Comparison of 4% articaine and 0.5% levobupivacaine/2% lidocaine mixture for sub-Tenon's anaesthesia in phacoemulsification cataract surgery: a randomised controlled trial.

BACKGROUND/AIMS: [corrected] The aim of this study was to compare the efficacy and safety of 4% articaine with a mixture containing equal volumes of 2% lidocaine and 0.5% levobupivacaine without hyaluronidase for sub-Tenon's anaesthesia in phacoemulsification cataract surgery. METHODS: The study was a prospective, randomised double-masked clinical trial of 65 patients allocated to receive either 4% articaine or a mixture containing equal parts of 2% lidocaine and 0.5% levobupivacaine. All patients had pre- and postoperative Hess charting to document ocular motility dysfunction. Ocular and eyelid movements were scored at 2 min intervals from 2 to 10 min after injection of the anaesthetic agent, and at the end of surgery. Complications related to injection, including pain, chemosis and subconjunctival haemorrhage, were recorded. Patients rated pain (none/mild/moderate/severe) during surgery. The operating surgeon masked to the anaesthetic agent assessed proptosis/chemosis at the start of the operation and the degree of ocular akinesia and analgesia at the end of surgery. RESULTS: The articaine group demonstrated a rapid onset of ocular akinesia with a mean time to readiness for surgery (achieving a score of

Continuing emissions of methyl chloroform from Europe.

The consumption of methyl chloroform (1,1,1-trichloroethane), an industrial solvent, has been banned by the 1987 Montreal Protocol because of its ozone-depleting potential. During the 1990s, global emissions have decreased substantially and, since 1999, near-zero emissions have been estimated for Europe and the United States. Here we present measurements of methyl chloroform that are inconsistent with the assumption of small emissions. Using a tracer transport model, we estimate that European emissions were greater than 20 Gg in 2000. Although these emissions are not significant for stratospheric ozone depletion, they have important implications for estimates of global tropospheric hydroxyl radical (OH) concentrations, deduced from measurements of methyl chloroform. Ongoing emissions therefore cast doubt upon recent reports of a strong and unexpected negative trend in OH during the 1990s and a previously calculated higher OH abundance in the Southern Hemisphere compared to the Northern Hemisphere.

Comparison of articaine and bupivacaine/lidocaine for peribulbar anaesthesia by inferotemporal injection.

BACKGROUND: Articaine is a novel amide local anaesthetic with a shorter duration of action than prilocaine. METHODS: In a randomized, double-blind study we compared the efficacy of 2% articaine with epinephrine 1:200,000 with a mixture of 0.5% bupivacaine and 2% lidocaine with epinephrine 1:200,000 for peribulbar anaesthesia in cataract surgery using a single inferotemporal injection. Eighty-two patients were randomly allocated to one of two groups to receive peribulbar anaesthesia with 6-7 ml of articaine or a bupivacaine/lidocaine mixture. Both solutions contained hyaluronidase 30 iu ml(-1). Ocular movement was scored at 2 min intervals up to 10 min, at the end of surgery and at time of discharge from hospital. Time to readiness for surgery and any complications (proptosis, chemosis, pain) were recorded. RESULTS: The articaine group demonstrated a rapid onset of peribulbar block with mean time (SD) to readiness for surgery of 4.2 (4.5) min compared with 7.2 (5.7) min in the bupivacaine/lidocaine group (P=0.0095). The block obtained in the articaine group was dense with eye movement scores at 2, 4, 6, 8 and 10 min all significantly reduced (P<0.01 at each interval). There was also a faster offset of the block in the articaine group (P=0.0009). There was no difference in incidence of minor complications between the groups. CONCLUSIONS: Two per cent articaine is safe and effective for peribulbar anaesthesia by inferotemporal injection and is a suitable alternative to the traditional mixture of 0.5% bupivacaine and 2% lidocaine.

Comparison of articaine and bupivacaine/lidocaine for single medial canthus peribulbar anaesthesia.

In a single-centre, randomized, double-blind study, we compared the efficacy of 2% articaine with that of a mixture of 0.5% bupivacaine and 2% lidocaine for peribulbar anaesthesia in cataract surgery, using a single medial canthus injection technique. Eighty-two patients were allocated randomly to receive 7-9 ml of a mixture of 0.5% bupivacaine and 2% lidocaine or an equal volume of 2% articaine with 1:200,000 epinephrine. Hyaluronidase 30 iu ml(-1) was added to both solutions. The degree of akinesia was scored 1, 5 and 10 min after the block, at the end of surgery and at discharge from the day case unit. Primary outcome measures were the difference in ocular movement scores 5 min after block and the need for supplementary inferolateral injections. There was greater akinesia in the articaine group at 5 min (P=0.01). Ten patients (24%) in the articaine group and 21 patients (51%) in the bupivacaine/lidocaine group required a supplementary injection (P=0.02). The mean (SD) volume of local anaesthetic required to achieve adequate block for surgery was 9.7 (2.1) ml in the articaine group and 11.0 (2.2) ml in the bupivacaine/lidocaine group (P=0.01). There was a faster offset of akinesia after surgery in the articaine group (P=0.01). There were no differences between groups in the incidence of reported pain or of minor complications. In our study, 2% articaine with 1:200,000 epinephrine was safe and efficacious for single medial canthus peribulbar anaesthesia.

Chronic ocular ischaemia.

The ocular changes due to chronic ischaemia are described in seven patients, aged between 59 and 77 years, with severe carotid artery disease. Doppler sonography was used to confirm the presence of high-grade arterial stenosis or occlusion in all the patients. The treatment of chronic ocular ischaemia is discussed, including the role of carotid bypass surgery, which is mentioned briefly. Three patients died of cardiovascular or cerebrovascular disease within 6 to 18 months of presentation.

[Vascular and ocular complications in a child with homocystinuria]. / Vaskuläre und okuläre Komplikationen bei einem Kind mit Homocystinurie.

Homocystinuria, only partially responsive to pyridoxine, was first diagnosed at the age of 14 years in a boy with high myopia, spherophakia and subluxated lenses, when surgical removal of a dislocated lens became necessary. 2 years previously a fracture of the left tibia, treated conservatively, had been followed by ischemia of the leg necessitating amputation. Postoperatively, deep vein thrombosis had developed in the right leg. Plasma homocysteine was lowered to undetectable levels by treatment with betaine in addition to pyridoxine, folic acid and reduction of protein intake. During the two years on treatment no further thromboembolic complications have occurred.

Lattice corneal dystrophy: a source of confusion.

Published descriptions of families with lattice dystrophy of the cornea reveal a much more varied clinical course and a more pleomorphic corneal picture than the rather stereotyped textbook descriptions would suggest. This report describes a family with lattice dystrophy of unusually late onset with retention of useful vision into the 7th decade. Herpes simplex keratitis was misdiagnosed in 5 members of the family by different ophthalmologists, probably because the typical lattice lines were fine and visible only by retroillumination.

[Cogan-Reese syndrome]. / Zur Kenntnis des Cogan-Reese-Syndroms.

The clinical, histological and ultrastructural findings in a case of Cogan-Reese syndrome (iris nevus) are presented. The typical iris nodules first appeared 14 years after a unilateral, juvenile, open-angle glaucoma was diagnosed. No lasting regulation of the intermittently elevated pressure was possible either medically or surgically. The failure of two filtering operations was due to the histologically verified endothelialization of the blebs. Endothelialization and deposition of Descemet's membrane on the anterior surface of the lens and on the zonule is described for the first time in this syndrome. The histological findings support the view that the peripheral anterior synechiae and iris nodules are secondary to the endothelialization. Hence the diagnosis of Cogan-Reese syndrome cannot be made until relatively late in the course of this disease. Cytological similarities between the proliferating endothelium in this case and in Chandler syndrome support the recent hypothesis that the Cogan-Reese syndrome belongs to the irido-corneal-endothelial group of syndromes.

[Corona serrata at the root of the iris]. / Corona serrata der Irisbasis.

In certain blue-eyed patients with shallow anterior chambers an irregular whitish saw-tooth pattern is visible at the root of the iris, especially on the temporal side. This finding does not appear to have been described previously. The anatomical reasons for this iris root pattern are discussed.

Specular microscopy of the corneal endothelium.

The endothelium of the normal corneas of 67 human subjects was studied in vivo with the specular microscope in order to quantify the method as a means of sampling the cell density of the tissue. It was found that (1) axial cell counts of the endothelium are reproducible in the same cornea after an interval of time; (2) the cell counts of the centre and periphery of the same cornea are similar; (3) the axial cell counts of pairs of eyes are similar; and (4) there is a gradual reduction of cell number with increasing age. The significance of these data is discussed.

Endothelial cell loss and corneal thickness after intracapsular extraction and iris clip lens implantation: a randomised controlled trial (interim report).

Patients in a randomised controlled trial were chosen either to have iris clip lens implantation after intracapsular cataract extraction or intracapsular extraction only. They were assessed in terms of corneal thickness, postoperative epithelial oedema, and endothelial cell counts. All patients had 1 eye submitted to operation, which was carried out by the same surgeon. There was significantly greater increase in corneal thickness (P less than 0.05) on the 5th postoperative day in eyes which had lens implants (23 patients with intracapsular extraction and 19 with implant), but the difference between the 2 groups became insignificant at 1 month (17 patients in each group). Daily corneal thickness measurements and observations of epithelial oedema in a subgroup (20 patients divided equally into 2 groups) showed that postoperatively there was greater and more widespread corneal oedema after implant surgery. When the operated eye was compared with the unoperated eye, endothelial cell loss was significantly greater in those with implants (P less than 0.01) than in those with simple intracapsular extraction.

An improved objective slit-lamp fluorophotometer using tungsten-halogen lamp excitation and synchronous detection.

A new design of fluorophotometer is described. The instrument can measure lower concentrations of fluorescent dye with greater accuracy than previous models.

Corneal oedema and endothelial cell loss after iris-clip lens implantation.

Lens implantation as a form of replacement surgery has some clear advantages over other forms of aphakic correction. The most feared complication of this type of operation is bullous keratopathy. A short-term study was carried out in two comparable groups of patients to assess corneal oedema and endothelial cell loss after simple cataract extraction and after iris-clip lens implantation following intracapsular extraction as a primary procedure. All patients were randomly chosen to have one or other procedure. The results indicate that lens implantation causes greater postoperative corneal oedema and greater endothelial cell loss. It is therefore important for implant surgeons to bear in mind the possible harm they may be inflicting and the need both for stringent criteria of selection and for the adoption of techniques which will minimize endothelial trauma.

Pigmented lens striae.

The clinical features of pigmented lens striae were studied biomicroscopically in seven patients. The lenses of three of these, obtained by cataract surgery, were examined by electron microscopy to determine the structure of the striae. We concluded that the striae are not formed by remnants of tunica vasculosa lentis, as earlier workers believed, but consist of fine fibrils of zonular bundles entrapping pigment granules of uveal origin.

Nocturnal lagophthalmos and recurrent erosion.

The symptoms and corneal changes caused by sleeping with one or both eyes open are described in 102 patients. The clinical picture is identical to that of the microform recurrent erosion. The close relationship between the micro- and macro-forms of recurrent corneal erosion suggests that the latter condition is also precipitated by nocturnal lagophthalmos.