Comparison of pain, motility, and preoperative sedation in cataract phacoemulsification patients receiving peribulbar or sub-Tenon's anesthesia.

BACKGROUND AND OBJECTIVES: The authors hoped to reduce the need for preoperative sedation and intravenous pain medication during cataract surgery by converting from peribulbar anesthesia to sub-Tenon's anesthesia. PATIENTS AND METHODS: A consecutive series of 2453 cataract patients' charts were reviewed. Each patient had previously watched a videotape explaining the anesthetic method to be used. Requests for preoperative sedation were compared between patients who received peribulbar or sub-Tenon's anesthesia. A sample of 200 charts of nonsedated patients were reviewed to compare intraoperative pain and motility. RESULTS: Intraoperative freedom from pain was reported by 91% of the peribulbar patients and 99% of the sub-Tenon's patients. Preoperative sedation was reduced from 26% of the peribulbar patients to 6.7% of the sub-Tenon's patients. CONCLUSIONS: Sub-Tenon's anesthesia provided excellent intraoperative pain relief and reduced the need for preoperative sedation, making it a satisfactory anesthetic technique for patients undergoing cataract phacoemulsification in an ambulatory surgery facility.

The results of ab interno laser thermal sclerostomy combined with cataract surgery versus trabeculectomy combined with cataract surgery 6 to 12 months postoperatively.

BACKGROUND AND OBJECTIVE: When cataract surgery and glaucoma surgery are combined, the theoretical advantages of pressure control, removal of the visual impairment, and protection against an increase in intraocular pressure (IOP) in the immediate postoperative period are gained. The authors' objective was to determine whether ab interno laser thermal sclerostomy (LTS) combined with cataract surgery would be as effective as trabeculectomy combined with cataract surgery. PATIENTS AND METHODS: Ab interno LTS was compared with trabeculectomy, retrospectively, for patients who had undergone combined cataract and glaucoma surgery. RESULTS: There was no significant difference in the numbers of patients using no medications or fewer medications at 6 and 12 months. There was a greater reduction in IOP in the LTS group. CONCLUSIONS: LTS may be better than trabeculectomy in combined cataract and glaucoma surgery because it reduces the IOP more. Compared with trabeculectomy, LTS is simpler to perform and adds less operating time to cataract surgery. Continued follow-up is recommended.

Combined cataract-glaucoma surgery using the THC:YAG (holmium) laser ab interno without gonioscopy.

We describe a simple method of combined cataract-glaucoma surgery, involving use of the THC:YAG (holmium) laser ab interno, without gonioscopy, in which the initial cataract incision remains small and the glaucoma filtering procedure can be completed relatively quickly, with minimal surgical manipulation of the conjunctiva. In a series of 15 eyes (13 patients) with visually significant cataracts and medically uncontrolled glaucoma, followed for an average of 14 weeks (range, 1 to 26 weeks), 13 of the 15 eyes had decreased IOP. Visual acuity was improved in 9 eyes, remained the same in 4 eyes (with age-related macular degeneration), and was worse in 2 eyes (with opacification of the posterior capsule sufficient to account for the decrease in acuity).

Expansion of contracted visual fields following treatment with pentoxifylline in two patients with coexistent peripheral vascular disease--case reports.

Pentoxifylline, a hemorheologic drug reputed to reduce blood viscosity, can be used to improve the microcirculation in peripheral vascular disease. The authors report on 2 patients who were being followed up for possible glaucoma and whose visual field constriction became worse at about the same time as their peripheral vascular symptoms began to increase in severity. Following initiation of treatment with oral pentoxifylline, their peripheral vascular complaints decreased and their visual fields gradually expanded over the next several months. This dual effect seemed more than a coincidence. It may in fact indicate that the same mechanism said to aggravate the peripheral ischemia (ie, increased blood viscosity) in patients with peripheral vascular disease may also have been the basis for the visual field contraction in these 2 patients, possibly by producing retinal ischemia. The reversal of the contracted visual fields would then seem to be due to the ameliorative effect of the pentoxifylline treatment on the blood viscosity.

Immunocytochemistry of mouse and human retina with antisera to insulin and S-100 protein.

Immunocytochemistry using peroxidase antiperoxidase (PAP) techniques showed insulin-like immunoreactivity in the human retina, and in the mouse retina and optic nerve. The immunoreaction product was seen in the inner nuclear, ganglion cell, outer and inner plexiform layers of the retinas, and in glial cell bodies of the optic nerve. A similar staining pattern using antiserum to S-100 protein, a marker for glial elements, was also seen in these tissues. This demonstrates that insulin or insulin-like immunoreactivity appears to be limited to glial cells of the retina and optic nerve. Our study suggests that the presence of insulin or a similar peptide in retina and optic nerve may be important for their normal function and metabolism.

The eye and face pain.

Because face pain may be referred from the eye, all patients with this complaint require a careful eye examination. Pain may also be referred to the eye and surrounding face by other structures innervated by the ophthalmic division of the fifth (trigeminal) cranial nerve. These structures include the paranasal sinuses, orbital contents, optic nerve, and meninges and vessels in the cavernous sinus and anterior cranial fossa.

Diabetic retinopathy and insulin therapy in a rural diabetic population.

The prevalence of diabetic retinopathy was lower in a rural diabetic population when compared to the prevalence of diabetic retinopathy in medical center clinic populations. Adult-onset (Type II) diabetics were at greater risk for developing diabetic retinopathy shortly after diagnosis than newly diagnosed cases of juvenile diabetes (Type I). The use of insulin positively correlated with the prevalence of diabetic retinopathy in this rural population.

Spontaneous regression of parafoveal exudates and serous retinal detachment in a patient with tuberous sclerosis and retinal astrocytomas.

The authors describe an unusual case of a serous detachment of the fovea and decreased vision with parafoveal exudates from a retinal astrocytoma with subsequent spontaneous resolution and return of central vision in a patient with tuberous sclerosis.

Chromograms of color normals and multiple sclerosis patients.

The Gunkel chromograph was tested on 81 volunteers with normal color vision as indicated by screening with Ishihara plates and the panel D-15. Most of these color normals located their neutral area superior to the geometric center of the chromogram. A minority located their neutral area at the geometric center. Recognition of this variation may prevent misdiagnosis of chromographs of patients suspected of having color vision defects. All 29 eyes with history and VEP findings consistent with optic nerve demyelinization had enlargement of the neutral area, even though visual acuity could be corrected to 20/20.

HLA-A1 and steroid-induced cataracts in renal transplant patients.

Posterior subcapsular (PSC) lens changes were found in 32 of 33 steroid-treated renal transplant patients examined with the slit lamp techniques of direct and retroillumination. Only one of 33 age-matched controls had any PSC changes. Six (18%) of the renal transplant patients were bilaterally surgically aphakic because of PSC cataracts that developed while the patient was receiving steroid therapy after transplant surgery. Steroid-induced PSC cataracts were associated with the presence of human leukocyte antigen (HLA) A1, but not with the patient's age, cause of renal failure, total dose of steroids, or duration of steroid therapy.

Von Hippel tumors in siblings with retinitis pigmentosa.

The conditions of three siblings with concurrent retinitis pigmentosa and von Hippel tumors were evaluated. Their eyes showed the characteristic arteriolar attenuation expected in retinitis pigmentosa, except in the retinal sectors containing von Hippel tumors, where large feeder vessels supplied each tumor. Two of the siblings suffered further loss of vision as a result of large exudative retinal detachments associated with the von Hippel tumors. Both patients had satisfactory resolution of the retinal detachments following cryotherapy and laser therapy of their retinal tumors. The third sibling has a small retinal detachment that should te amenable to therapy. Visually handicapped patients require routine follow-up examinations to detect new diseases that may result in low of the remaining vision.

The pupil dark response in normal volunteers.

A new semi-automatic videopupillometer with a two-channel video integrator uses prismatic displacement of pupil images for binocular recording with a single infrared-sensitive video camera. The video integrator graphically records pupil area or diameter during testing and can reanalyze and plot information from videotape recordings of pupil responses. This new pupillometer was used to evaluate the pupil dark response in 178 eyes of 89 normal human volunteers (ages 18-75 years). The time course of pupil dilation was similar in volunteers of all ages, even though the average pupil area became progressively smaller with increasing age.

The pupil dark response in narcolepsy.

The pupil dark response and maintenance of pupil area in darkness were compared in seven narcoleptic patients and 14 age-matched normal volunteers. Onset and degree of miosis after maximal pupil dilation in darkness were similar in the two groups, although three narcoleptic patients and no normal volunteers fell asleep during the experiment. The results of this study contradict earlier suggestions that pupillography can be used to distinguish normal individuals in family studies of narcoleptic patients.

Norepinephrine therapy of ischemic optic neuropathy.

Two monocular normotensive patients with nonarteritic ischemic optic neuropathy and retinal ischemia unresponsive to steroid therapy were treated with intravenous norepinephrine. In both patients, improvement in vision began within minutes after moderate hypertension was produced. A third patient showed no response to this therapy in one eye with established ischemic optic neuropathy, but had prompt recovery of vision in the second eye early in the course of ischemic optic neuropathy. This patient returned with recurrent ischemic optic neuropathy more than 1 year later. At that time she was found to have essential hypertension. One patient could not be weaned from the norepinephrine infusion without recurrent visual loss. In the second patient, controlled hypertensive therapy restored visual acuity to 20/30 during two separate recurrences of ischemic optic neuropathy. Therapy of a later episode of ischemic optic neuropathy was delayed for 2 days, and vision did not improve with norepinephrine infusion. This eye subsequently became painful and required enucleation. Histopathological evaluation showed combined arterial and venous occlusions within the optic nerve and evidence of previous peripapillary choroidal vascular occlusion. Selected normotensive patients with ischemic optic neuropathy and retinal ischemia may benefit from controlled hypertensive therapy induced by norepinephrine infusion.