Intracameral anesthesia: a report by the American Academy of Ophthalmology.

OBJECTIVE: This document describes the technique of intracameral anesthesia and examines the available evidence to address questions about its effectiveness, possible corneal endothelial and retinal toxicity, and the optimal and maximal dose. METHODS: A literature search conducted for the years 1968 to 2000 retrieved over 180 citations that matched the search criteria. Panel members and a methodologist reviewed this information, and it was evaluated for the quality of the evidence presented. RESULTS: Some studies report effectiveness of intracameral anesthesia while others report no effect. In those studies showing an effect, levels of pain in the groups that were compared were low. Short-term studies seem to indicate that preservative (methylparaben)-free lidocaine 1% is well tolerated by the corneal endothelium but that higher concentrations of lidocaine are toxic. There is some evidence of electroretinogram changes after exposure to lidocaine or bupivacaine. CONCLUSIONS: The ideal timing and placement of intracameral anesthesia has not been determined. Because topical anesthesia alone is effective, surgeons may elect to use intracameral anesthesia for incremental pain control in patients who cannot be adequately managed with topical alone. Appropriate patient selection is important when using this method of anesthesia. While short-term studies seem to indicate safety, long-term effects are unknown. Patient preferences for anesthesia are not well studied.

Growth factor expression in corneal wound healing after excimer laser keratectomy.

PURPOSE: To develop a rabbit model of reproducible corneal haze after excimer laser keratectomy and to characterize expression of transforming growth factor beta (TGFbeta) and basic fibroblast growth factor (bFGF) in rabbit corneas during haze formation. METHODS: Seven rabbits underwent a 100 microm deep phototherapeutic keratectomy (PTK) in one eye and a 15-microm shallow PTK in the contralateral eye. Corneal haze was compared at 1-20 weeks after surgery. Subsequently, 16 rabbits underwent 100-microm PTK in one eye and 15-microm PTK in the contralateral eye. Four rabbits were killed at 1, 2, 3, and 4 weeks, respectively, after surgery. Immunohistochemistry was performed on the corneas to localize the expression of TGFbeta and bFGF. Control subjects were rabbits that underwent either epithelial debridement alone or no surgery. RESULTS: A 100-microm PTK resulted in significantly more corneal haze than a 15-microm PTK at every postoperative examination (p < 0.05). Both TGFbeta and bFGF were expressed in the scars at 1-4 weeks after deep and shallow excimer ablations. bFGF was expressed in the keratocytes of both treated and control corneas. Minimal TGFbeta was detected in the keratocytes of the control corneas, whereas prominent TGFbeta expression was noted in the keratocyte-like cells adjacent to the postkeratectomy scars. CONCLUSIONS: The 100-microm PTK ablation resulted in significantly more corneal scarring than the 15-microm PTK ablation. Even though there was no immunohistochemical difference in the pattern of TGFbeta and bFGF expression after deep and shallow ablations, there was an association between the expression of the growth factors and corneal scarring after excimer laser keratectomy.

Quantitative estimation of RNA transcripts suggests persistence of Pax-6 expression in the postembryonic chick retina.

Pax-6 is expressed during early embryonic development of the eye. Very little is known about its expression in the functionally mature retina. We have detected Pax-6 transcripts in the ganglion cell- and amacrine cell layers at days 3, 10, 17 and 31 posthatching and in 2- to 3-month-old chick retina by in situ hybridization. These observations were confirmed by a quantitative analysis. Competitive RT-PCR with a homologous internal control revealed a significant reduction (p < 0.001) in the number of Pax-6 transcripts in day 17 retina [(0.39 +/- 0.13) x 10(10)/mg tissue] compared to day 3 retina [(1.65 +/- 0.48) x 10(10)/mg tissue]. Although significantly lower than at day 3, the day 31 retina [(0.7 +/- 0.16) x 10(10)/mg tissue] and retina from 2- to 3-month-old chicks [(0.9 +/- 0.28) x 10(10)/mg tissue] contained an increased number of Pax-6 transcripts in comparison to day 17. On the basis of the amount of RNA, the number of Pax-6 transcripts in the day 3 retina [(0.45 +/- 0.14) x 10(10)/microg RNA] relative to day 17 retina [(0.4 +/- 0.08) x 10(10)/microg RNA] did not change significantly (p = 0.29). However, at day 31 and at 2-3 months of age an increased number of Pax-6 transcripts [(0.65 +/- 0.14) x 10(10)/microg RNA and (0.65 +/- 0.2) x 10(10)/microg RNA, respectively)] were found. In view of the known association of Pax-6 expression with proliferation and emergence of different cell types, these data suggest that cell types in ganglion and inner nuclear cell layers may retain proliferative potential for an extended period in the young adult retina.

Sensitivity, specificity, and predictive values of screening tests for eye conditions in a clinic-based population.

PURPOSE: To assess four commonly available visual function tests to detect visually disabling or vision-threatening eye conditions among new patients of a large, urban, public, general ophthalmology clinic. METHODS: Three hundred seventeen patients were tested for contrast sensitivity, Amsler grid abnormalities, and visual acuity at near and at distance. A complete eye evaluation found the prevalence of serious eye diseases, allowing determination of the sensitivity (Sn), specificity (Sp), likelihood ratio (LR), and other characteristics of each test. RESULTS: Of 317 patients, most were Hispanic (77%), women (60%), and middle-aged (44 +/- 17 years). Normal findings were reported in 18%; refractive error in 43%; cataracts in 16%; glaucoma in 7.3%; and macular degeneration in 4.1%. Near visual acuity of 20/40 or worse (Sn = 0.75; Sp = 0.74; LR = 2.8); and distance visual acuity testing of 20/30 or worse (Sn = 0.74; Sp = 0.73; LR = 2.7) correlated significantly with ocular disease, whereas contrast sensitivity testing (Sn = 0.62; Sp = 0.41; LR = 1.1) and Amsler grid test (Sn = 0.19; Sp = 0.92; LR = 2.4) did not. Test performance decreased when refractive errors were excluded and among those younger than 40 years of age relative to those 40 years of age or older. CONCLUSION: Of the four screening tests studied, distance and near threshold visual acuities as defined above were judged to have the best correlations of an abnormal result with ocular disease, both including or excluding refractive error. Different combinations of tests did not result in more accurate detection of ocular disease. More efficient screening tools for detecting ocular disease need to be developed.

A randomized trial comparing mitomycin C and conjunctival autograft after excision of primary pterygium.

PURPOSE: To determine the rate of recurrence and complications after bare sclera excision of primary pterygia followed by low-dose mitomycin C (0.2 mg/ml twice daily for five days), placebo (balanced saline solution), or conjunctival autograft. METHODS: We performed a prospective, double-masked clinical trial of 64 patients (60 Hispanic) randomly assigned to a treatment group. Twenty-four patients received mitomycin C, 23 conjunctival autograft, and 17 placebo. Recurrence was defined as fibrovascular tissue over the corneoscleral limbus onto clear cornea in the area of previous pterygium excision. RESULTS: The recurrence rate after mitomycin C and conjunctival autograft was 38% and 39% of eyes, respectively, after mean follow-up (in recurrence-free patients) of 12.3 and 13.5 months, respectively. The recurrence rate after placebo treatment was significantly higher (P = .002), 88%, after mean follow-up (in recurrence-free patients) of 9.3 months. Increasing age was associated with significantly fewer recurrences (P = .006) after controlling for pterygium type (atrophic, noninflamed, or inflamed) and treatment group. The mean time to recurrence varied from 3.7 to 4.8 months; only 6% of recurrences were noted after the sixth postoperative month. Major complications included symblepharon (two), loose autograft (one), and pyogenic granuloma (two). No group had significantly more complications. CONCLUSIONS: Conjunctival autograft and low-dose topical mitomycin C are equally effective as adjunctive treatment after excision of primary pterygia in this young, southern California, predominantly Hispanic population. Both methods have significantly lower rates of recurrence than bare sclera excision alone, and neither is associated with severe complications after one year of follow-up. Increasing patient age is associated with significantly less risk of recurrence.

Microorganisms cultured from the anterior chamber of ruptured globes at the time of repair.

PURPOSE: We studied events leading to the development of posttraumatic endophthalmitis by examining the significance of 15 factors on microbial contamination of injured eyes. METHODS: A prospective study was done of 30 ruptured globes in patients admitted to an urban medical center. Cultures were taken from the conjunctiva before and after preoperative disinfection and from the anterior chamber at the beginning and end of wound repair. Twenty-five of 30 patients received a three-day regimen of intravenous antibiotics that were begun before surgery. RESULTS: Anterior chamber samples grew microorganisms in ten (33%) of 30 eyes, with positive cultures recovered from specimens taken at the beginning of wound repair in eight eyes and at the end of wound repair in six eyes. Contamination with indigenous flora may have occurred at the time of injury in one eye and during repair in another eye. Microbes recovered included Staphylococcus, Corynebacterium, and Aspergillus species. No patient developed endophthalmitis. Of the 15 factors studied, only intravenous antibiotics significantly decreased the incidence of positive anterior chamber cultures in eyes treated before wound repair compared with eyes not receiving such therapy (P = .002). CONCLUSIONS: Despite the frequency of anterior chamber microbial contamination during injury or repair of the wound, with our treatment protocol and the presence of physiologic mechanisms to reduce intraocular microbes, no eyes developed clinical endophthalmitis. With our limited sample size only intravenous antibiotic therapy was found significantly to reduce anterior chamber microorganisms at the time of surgical repair, supporting their prophylactic use against the development of posttraumatic endophthalmitis.

Penetrating keratoplasty in infants with congenital glaucoma.

The efficacy of corneal transplantation in infants with corneal opacity secondary to congenital glaucoma has not been established. We retrospectively reviewed our results of nine penetrating keratoplasties performed on eight eyes of six infants who had multiple risk factors for poor prognosis: age < 2 years at the time of grafting; uncontrolled glaucoma in four eyes; concurrent lensectomy, retinal, or glaucoma surgery in five eyes; aphakia in five eyes; and an acute perforation in one eye. Six of the nine grafts (67%) remained clear during a mean follow-up of 24 months (30 months in eyes with clear grafts). Development of ambulatory vision or better occurred in six of eight (75%) eyes after corneal transplantation and treatment of refractive errors and amblyopia. Graft failure occurred in three eyes--two from corneal decompensation, and one from homograft rejection. Complications included one total retinal detachment, one case of Streptococcus pneumoniae keratitis, and three cases that lost intraocular pressure control, requiring further glaucoma surgery. We conclude that useful vision can be achieved after penetrating keratoplasty even in some high-risk infants with congenital glaucoma.

Intraoperative bacterial contamination of the aqueous humor.

Indigenous ocular flora has been presumed to be a source of infectious organisms in postoperative bacterial endophthalmitis. While bacteria have been recovered from the anterior chamber at the time of cataract wound closure in a significant percentage of cases, and bacteria from the vitreous of endophthalmitis cases have appeared genetically to be very similar to bacteria recovered from the adnexa and/or nares at the time of vitrectomy for endophthalmitis, no study has examined the relationship between organisms isolated from the eyelid and conjunctiva, and organisms recovered from the aqueous humor at the time of wound closure. This study examined 59 eyes undergoing cataract and other intraocular surgeries. Cultures of the eyelids and conjunctiva were taken before and after routine preparation with povidone-iodine solution. Cultures also were taken of the aqueous humor at the time of incision into the anterior chamber and at the time of wound closure. No organisms grew from aqueous humor samples taken at the time of incision. However, 13 eyes (22%) grew gram-positive organisms from samples taken at the time of wound closure. Eight of the 13 eyes (62%) had organisms with identical typing and antibiotic sensitivities to organisms isolated from the eyelids and conjunctiva before or after disinfection. This study suggests that a significant number of cases had inoperative bacterial contamination of the aqueous humor by the time of wound closure and that organisms from the eyelids and conjunctiva are an important source of contamination in these cases.

Distribution of (Na+ + K+)ATPase and sodium channels in skeletal muscle and electroplax.

The distributions of (Na+ + K+)ATPase and sodium channels in skeletal muscle fibres and electrocytes were determined by immunofluorescent and immunoelectron microscopic techniques using antibodies against rat and eel (Na+ + K+)ATPase and the eel electric organ sodium channel. The extrajunctional sarcolemma of skeletal muscle was uniformly stained by polyclonal antibodies against (Na+ + K+)ATPase and the sodium channel. The T-tubule system of skeletal muscle was also labelled heavily for both (Na+ + K+)ATPase and the sodium channel. The terminal cisternae of the sarcoplasmic reticulum was stained for (Na+ + K+)ATPase but not sodium channels. At the motor endplate, (Na+ + K+)ATPase-like immunoreactivity was present along the plasmalemma of motor nerve terminals but not along the postsynaptic junctional sarcolemma. Paradoxically, a monoclonal antibody that binds to the alpha form of the catalytic subunit of (Na+ + K+)ATPase from rat hepatocytes and renal tubule cells did not label the enzyme in rat skeletal muscle. In electrocytes, (Na+ + K+)ATPase-like immunoreactivity was concentrated primarily along the plasmalemma and calveolae of the non-innervated face. In contrast, sodium channel-like immunoreactivity was concentrated along the plasmalemma of the innervated face except in the clefts of the postsynaptic membrane. Thus, we conclude that at endplates both the (Na+ + K+)ATPase of rat skeletal muscle and sodium channels of eel electrocytes are not concentrated in the juxtaneuronal postsynaptic membrane. We also interpret the failure of the monoclonal anti-alpha (Na+ + K+)ATPase antibodies to bind to the enzyme in muscle to indicate that the catalytic subunit of skeletal muscle (Na+ + K+)ATPase displays different epitopes than does the alpha subunit of kidney and liver.

The distribution of (Na+ + K+)ATPase is continuous along the axolemma of unensheathed axons from spinal roots of 'dystrophic' mice.

(Na+ + K+)ATPase-like immunoreactivity along the axolemma of sensory and motor neurons and the plasmalemma of Schwann cells from spinal roots of dystrophic mice (129 ReJ Dy/Dy) was determined using polyclonal antibodies specific for guinea pig renal (Na+ + K+)ATPase (GP-17), along with polyclonal (439-2) and monoclonal (9A5) antibodies specific for rat renal (Na+ + K+)ATPase. In normal and dystrophic mice, (Na+ + K+)ATPase-like immunoreactivity was observed along the axolemma at nodes of Ranvier using GP-17 and 439-2, each of which binds to isozymes of (Na+ + K+)ATPase composed of the alpha and alpha + forms of the catalytic subunit. Staining was not seen along the nodal axolemma with 9A5, a preparation that binds to the alpha form of the catalytic subunit. The terminal processes and microvilli of Schwann cells were stained using all three antibody probes. The axolemma of unensheathed axons in dystrophic mice was continuously and uniformly labelled with GP-17 and 439-2, but not 9A5. Concentrations of (Na+ + K+)ATPase-like immunoreactivity along Schwann cell processes were observed most often in areas adjacent to unensheathed axolemma. At heminodes, staining abruptly decreased along Schwann cell processes in areas that were separated from the unensheathed axolemma by other intervening Schwann cell processes. It was concluded from these data that in dystrophic mice (Na+ + K+)ATPase is uniformly distributed along unensheathed portions of axons without evidence of detectable focal concentrations of the enzyme, and that the catalytic subunit of (Na+ + K+)ATPase along unensheathed axons is distinct from the alpha form found in Schwann cells and other organs. In addition, (Na+ + K+)ATPase is concentrated along the plasmalemma of Schwann cells in regions of close apposition to axolemmal areas associated with large ionic fluxes.

Localization of sodium/potassium adenosine triphosphatase in multiple cell types of the murine nervous system with antibodies raised against the enzyme from kidney.

This report describes the development and characterization of a battery of highly specific antibodies to sodium/potassium (Na+ + K+)-ATPase and their use in localizing this enzyme in nervous tissue. The immunolabeling characteristics of polyclonal antibodies and monoclonal antibodies (Schenk, D. B., and H. L. Leffert (1983) Proc. Natl. Acad. Sci. U. S. A. 80: 5281-5285) raised against rat renal (Na+ + K+)-ATPase were compared. The interspecies cross-reactivity of the polyclonal anti-rat antibodies was examined by determining their binding to purified rat, eel, or dog enzyme. The immunostaining characteristics of the IgG fraction of the polyclonal antibody preparations, their affinity-purified derivatives, and the monoclonal antibodies were compared. The results obtained with each of these were similar, providing information about where focal concentrations of the enzyme exist within nervous tissue. The IgG fraction of the polyclonal antibody preparations provided the most sensitive probe, facilitating localization of the (Na+ + K+)-ATPase in the tissue sections from various regions of the nervous system. (Na+ + K+)-ATPase-like immunoreactivity was observed along the plasmalemma of alpha-motor neurons and at the nodal axolemma of myelinated axons from the central or peripheral nervous system. It was determined that the absence of labeling for the enzyme along the paranodal or internodal regions of the axolemma was not an artifact due to a limited accessibility of antibody to these regions. Some central nervous system glial cells demonstrated abundant amounts of plasmalemmal and intracellular (Na+ + K+)-ATPase-like immunoreactivity. These cells were identified as astroglia by positive labeling of cells in serial sections for glial fibrillary acid protein immunoreactivity in the soma and radial processes in optic nerve, or velous processes in the cerebellum. Astrocyte processes overlying the nodal axolemma also stained positively for the enzyme. (Na+ + K+)-ATPase-like immunoreactivity was not observed in association with oligodendroglia cell bodies or their processes forming myelin sheaths. In contrast, the plasmalemma of myelinating Schwann cells showed greatest immunoreactivity in the region of the node of Ranvier. Although a focal concentration of immunoreactivity was observed along node- and paranode-associated regions of Schwann cells, a lower level of uniform staining was noted along the entire Schwann cell surface membrane.(ABSTRACT TRUNCATED AT 400 WORDS)