[Local anesthesia in ophthalmic surgery]. / Lokalanästhesie in der Ophthalmochirurgie.

In recent years anesthesia modalities have changed in ophthalmic surgery. A growing trend toward the use of topical anesthesia in cataract surgery is apparent. The present-day techniques used in ophthalmic surgery are retrobulbar anesthesia, peribulbar anesthesia, subtenon anesthesia, and subconjunctival anesthesia as injection techniques, topical anesthesia using drops, gel, or sponge, and intracameral anesthesia. Injectable anesthesia (RBA, PBA, STA) provides a higher level of analgesia and globe akinesia. With injection techniques the risks of vis a tergo and anesthetic complications increase; the level of analgesia after topical anesthesia could be improved by supplementation with i.v. narcotics.

Oral premedication with low dose midazolam modifies the immunological stress reaction after the setting of retrobulbar anaesthesia.

BACKGROUND/AIMS: An acute immunological stress reaction was previously reported to occur after the painful setting of retrobulbar anaesthesia before intraocular surgery. This study was conducted to find out whether an oral low dose premedication with midazolam would modify the immunological stress reaction. METHODS: 32 patients undergoing intraocular surgery using retrobulbar anaesthesia were included in a randomised, double blind trial. They received premedication with either 3.75 mg midazolam or placebo 30 minutes before the retrobulbar injection. Counts of leucocyte subpopulations, cardiovascular, and psychometric parameters were measured repetitively before and after the retrobulbar injection. RESULTS: The numbers of leucocytes increased significantly in the placebo group after the setting of retrobulbar anaesthesia (before retrobulbar injection: 6687 (SD 1025) cells x10(6)/l; after injection: 7067 (1022) cells x10(6)/l, p=0.0009) caused by rising numbers of neutrophils (before injection: 4111 (1063) cells x10(6)/l; after injection: 4352 (1147) cells x10(6)/l, p=0.0007) and natural killer cells (before injection: 290 (84) cell x10(6)/l; after injection 354 (133) cells x10(6)/l, p=0.003). There was no significant increase in total leucocytes (before injection: 5997 (1288) cells x10(6)/l; after injection: 6189 (1215) cells x10(6)/l) or in any leucocyte subpopulation in the midazolam group. A significant rise in systolic blood pressure occurred in the placebo group, but not in the midazolam group. CONCLUSION: A low dose premedication with midazolam attenuates the immunological and cardiovascular stress reactions occurring with retrobulbar anaesthesia.

Painful regional anaesthesia induces an immunological stress reaction: the model of retrobulbar anaesthesia.

BACKGROUND AND OBJECTIVE: Laboratory stress studies found that acute psychological stresses may elicit changes in leukocyte numbers similar to those occurring in physical stresses. Both types of stress evoke - mainly by release of catecholamines - leukocytosis resulting from a release of natural killer cells (NK-cells), of CD8+ T-cells, of monocytes and of neutrophils. However, there is little proof that laboratory stress models can be applied to daily clinical routines. As a likely inductor of an immunological stress response the setting of retrobulbar anaesthesia prior to intraocular surgery permits the study of a short-term painful anaesthetic procedure under highly standardized conditions. This was examined in 16 female patients. METHODS: Counts of leukocyte subsets, serum cortisol and cardiovascular variables were measured 30 min and 1 min prior to retrobulbar anaesthesia as well as 2, 15 and 45 min afterwards. RESULTS: The setting of retrobulbar anaesthesia induced an increase in total leukocytes [+380 cells microL-1; P < 0.01 (means; significance level)] mainly due to rising counts of neutrophils (+241 cells microL-1, P < 0.01). Of all lymphocyte subpopulations, natural killer cells increased most markedly (+64 cells microL-1; P < 0.01). Furthermore, the retrobulbar block induced an increase in systolic arterial pressure (+15.2 mmHg; P < 0.01). CONCLUSION: These changes in immunological and cardiovascular variables are considered to be elements of a sympatho-adrenal stress reaction; catecholamines are considered to induce a demargination of leukocytes by binding to beta2-adrenoceptors and by modifying the avidity state of adhesion molecules.

The efficacy of postoperative incentive spirometry is influenced by the device-specific imposed work of breathing.

STUDY OBJECTIVES: The study evaluated the impact of the additional imposed work of breathing (WBimp) generated by two different spirometers on postoperative incentive spirometry performance in patients at high risk and moderate risk for postoperative pulmonary complications (PPCs). Additionally, we investigated whether maximal inspiratory pressure (PImax) is an easy estimate of the WBimp imposed by incentive spirometers. DESIGN: Prospective, randomized, single-blind clinical trial. SETTING: ICU of a university hospital. INTERVENTIONS AND MEASUREMENTS: Thirty male patients were assigned to a group at high risk for PPCs (group A; inspiratory capacity [IC], < 1.6 L) or to a group at moderate risk for PPCs (group B; IC, 1.6 to 2.5 L) after upper-abdominal, thoracic, or two-cavity surgery. On the first or second postoperative day WBimp, IC, and PImax were recorded without spirometers (baseline) and during incentive spirometry with the Mediflo spirometer (Medimex; Hamburg, Germany) (high WBimp) and the Coach spirometer (Kendall; Neustadt, Germany) (low WBimp) using a pneumotachograph. In group A, the baseline and the ICs for both spirometers only differed slightly. In group B, the IC was significantly reduced for the Mediflo (p < 0.05), which imposed a WBimp twice as high as the Coach (p < 0.01). PImax was significantly increased for both the Mediflo and the Coach (p < 0.01). PImax was positively correlated with WBimp (r = 0.8). CONCLUSIONS: Incentive spirometers differ considerably in their additional Wbimp with a potential impact on the efficacy of postoperative incentive spirometry performance. PImax might be an easy clinical estimate for the WBimp during incentive spirometry. Incentive spirometers with low WBimp permit increased maximal sustained inspiration and, thus, enhanced incentive spirometry performance, and, therefore, it might be more suitable for use in postoperative respiratory care.

Low-dose oral clonidine as premedication before intraocular surgery in retrobulbar anesthesia.

PURPOSE: We investigated whether low-dosed oral clonidine premedication before elective intraocular surgery in retrobulbar anesthesia is effective in terms of anxiolysis, sedation, stable hemodynamics, lower intraocular pressure and perioperative endocrine stress response. METHODS: In a prospective, randomised, double-blind study, 44 patients scheduled for elective intraocular surgery received either 0.15 mg clonidine (n=22) or a matched placebo (n=22) orally 60 minutes before retrobulbar anesthesia. The main study parameters were sedation, anxiolysis, hemodynamics and intraocular pressure. Additionally, mediators of endocrine stress responses were measured five times, in 13 patients after clonidine and 12 after placebo. RESULTS: After clonidine 86% of the patients showed sedation and after placebo 90.9% showed no sedation (p<0.01). Clonidine produced effective anxiolysis (Erlanger-Anxiety-Scale: 31.6 +/- 2.6 points vs. 38.1 +/- 8.5 points) before the operation (p<0.01). Systolic blood pressure was significantly lower after clonidine. Effects on mean and diastolic blood pressure were small but statistically significant. Norepinephrine and cortisol plasma concentrations were significantly lower after clonidine. Intraocular pressure was significantly lower too (p<0.05). No clinically relevant adverse effects were observed e.g. inappropriate sedation, hypotension (<100 mmHg), bradycardia (<50 bpm) or hypoxemia (SpO2<90%). CONCLUSIONS: Oral low-dose clonidine produces light sedation, significant anxiolysis and stable hemodynamics, and attenuates the endocrine response to perioperative stress. Thus, clonidine seems sufficient to increase patient comfort for intraocular surgery and might even offer clinically worthwhile benefits such as stable hemodynamics and a reduced response to perioperative stress.

Comparison of analgesia and akinesia after retrobulbar injections at different speeds.

PURPOSE: To assess how the speed of injection of local anesthetic solutions affected pain of injection, bulbar akinesia and analgesia with retrobulbar anesthesia (RBA). METHODS: 70 patients undergoing RBA for cataract surgery were enrolled in a prospective masked trial. They were allocated randomly to receive 5 ml anesthetic solution injected either within 20 seconds (group A) or within 60 seconds (group B). Additionally, akinesia of the orbicularis muscle was created according to O'Brien's technique. The pain of injection was registered on an ordinal analogue scale immediately before and after RBA. The following data were collected before and 20 minutes after retrobulbar injection: eye motility (Kestenbaum test), and corneal sensitivity (0: no sensitivity; 1: sensitivity remaining). Data were also collected on age, sex, and bulbar length, and any side effects of the intervention. RESULTS: Injection pain did not differ in the two groups. After RBA horizontal and vertical eye motility was slightly lower in group A than group B. Persistent motility was found in 18 patients in group A and 16 in group B. Median horizontal and vertical motility was 0 mm in both groups. Four patients in group A and five in group B had corneal sensitivity persisting after RBA. CONCLUSIONS: This comparison of different injection velocities brought to light no significant differences regarding bulbar analgesia and akinesia after RBA.

Ablation of vitreous tissue with erbium:YAG laser.

PURPOSE: Using a noncontact erbium (Er):yttrium--aluminium--garnet (YAG) laser, ablation of vitreous was compared to distilled water in vitro. METHODS: The porcine vitreous body and distilled water were ablated in vitro at different pulse lengths and pulse energies. Selected pulse energies were 25, 35, 45, 75, and 100 mJ (pulse rate: 1 Hz; laser beam diameter at the surface of the sample: 2 mm). Pulse lengths were at 140 +/- 3 microsec, 190 +/- 4 microsec, and 240 +/- 5 microsec. The loss of weight in vitreous tissue and distilled water was measured using precision scales and corrected for evaporation, respectively. The Mann-Whitney U test was used to assess the significance of differences in ablation rates of water and vitreous. P < 0.05 was considered statistically significant. RESULTS: Reproducible and constant ablation rates were found in both vitreous and distilled water in each of 10 consecutive series of 50 laser pulses at constant laser parameters. Ablation rates per pulse (microg/microsec) of vitreous tissue were as follows: 3.0 microg to 45.8 microg (140 microsec), 10.4 microg to 53.8 microg (190 microsec), and 17.9 microg to 24.2 microg (240 microsec). The ablation rates exhibited a linear correlation with increasing pulse energies and also with decreasing pulse lengths. Considering the pulse lengths of 190 microsec and 240 microsec with all pulse energies tested, the ablation rates of distilled water were significantly higher (P < 0.05) than ablation of vitreous tissue. The ablation rates at a pulse length of 140 microsec were not significantly different. The differences per pulse were as follows: 0.5 microg to 2.1 microg (140 microsec), 1.9 microg to 6.0 microg (190 microsec), and 3.5 microg to 8.7 microg (240 microsec). CONCLUSIONS: Vitreous ablation is possible using Er:YAG laser. The ablation characteristics of vitreous have proved to be similar but not equal to that of water.

Ocular changes in mucopolysaccharidosis IV A (Morquio A syndrome) and long-term results of perforating keratoplasty.

BACKGROUND: The mucopolysaccharidoses (MPS) are an inhomogeneous group of disorders of errors in the carbohydrate metabolism with severe ocular involvement (corneal opacification, retinal degeneration, optic atrophy). PATIENT PRESENTATION: We report on a boy aged 12 years, with Morquio A (MPS IV A) syndrome. Ocular findings: progressive pseudoexophthalmus due to shallow orbits, increasing corneal stromal clouding, intermittent dissociated manifest nystagmus of the left eye, nyctalopia. Visual acuity OD cc = 0.16, OS cc = 0.05. Electrophysiology: changes suggesting a symptomatic tapetoretinal degeneration and optic atrophy. TREATMENT AND COURSE OF DISEASE: OS: perforating keratoplasty. Postoperative improvement of visual acuity to 0.25 for nearly a year, followed by progressive reopacification of the corneal graft. Both eyes: progressive signs of tapetoretinal degeneration and optic atrophy. Visual acuity now reduced to OD 0.05, OS 0.1. CONCLUSIONS: Success of a keratoplasty is limited by (1) reopacification of the cornea, (2) visual impairment due to (a) retinal degeneration and (b) optic atrophy. The indication for perforating keratoplasty has to be thought about very carefully in these multimorbid patients. In our patient, beside progressive visual impairment there is a progressive deafness which dominates his social and school life. Attending school is severely complicated by the double handicap. Perforating keratoplasty enabled the boy to attend a school for physically handicapped without a special low-vision care for another year. Progressive visual loss without further treatment options now renders optical and electronic low-vision aids necessary. Although the time of improved visual acuity lasted less than a year, we think patients with a life expectancy of less than 20 years should have every possible improvement of their situation - even if it does not last permanently. We therefore propose perforating keratoplasty in spite of insufficient long-term results.

[Two contact lens holders for vitreoretinal surgery]. / Zwei Kontaktglashalter für vitreoretinale Chirurgie.

Two new lens holders for contact lens use in vitreoretinal surgery were developed: (1) a flexible hand-fixed lens holder and (2) a lid-retractor-fixed lens holder. Advantages are: better stabilization and centering of the lens, reduction of air bubbles and blood in the interface between cornea and contact lens.

[Indocyanine green angiography in acute posterior multifocal placoid pigment epithelial disease]. / Indozyanin-Grün-Angiographie bei der akuten posterioren multifokalen plakoiden Pigmentepitheliopathie.

BACKGROUND: Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) is an idiopathic posterior segment inflammatory disorder of young adults. The pathogenesis remains unsettled. The placoid lesions and characteristic findings on fluorescein angiography have been interpreted as representing a primary pigment epithelial disorder or a choroidal vascular disease. PATIENT: Using Fluorescein and Indocyanine green angiography we examined one patient with APMPPE. RESULTS: In the acute phase, the fluorescein angiogram showed early hypofluorescence of the ophthalmoscopically visible lesions followed by late hyperfluorescence with centripetal staining of fluorescein at the level of the pigment epithelium. Indocyanine green angiograms showed in the acute stage of this disease areas of hypofluorescence in both the early and late pictures that nearly correlated with the placoid lesions. Three weeks later we saw apart from involution of the initial lesions, new angiographic hypofluorescent lesions at the posterior pole of the left eye, which were ophthalmoscopically not visible. During the next four weeks the older and newer lesions went smaller and left scars. Also the choroidal blood flow was restored partially. CONCLUSIONS: Indocyanine green choroidal videoangiography has shown hypofluorescence of the placoid lesions. This may be explained by choroidal hypoperfusion as the pathogenesis of acute posterior multifocal placoid pigment epitheliopathy.

The endocrine stress response after oral premedication with low-dose midazolam for intraocular surgery in retrobulbar anaesthesia.

PURPOSE: It was the purpose of this study to examine the endocrine stess response in patients undergoing elective intraocular surgery in retrobulbar anaesthesia (RBA), and the effect of an oral premedication with 3.75 mg midazolam on this reaction. METHODS: In a prospective double-blind study, 23 patients were randomly assigned to either group I (n = 12), receiving 3.75 mg midazolam, or group II (n = 11), receiving a matched placebo 60 min before RBA. Plasma concentrations of known mediators of the endocrinological stress response were analysed at five perioperative times: adrenocorticotropic hormone (ACTH), cortisole (CORT), somatotropic hormone (STH), epinephrine (EPI), norepinephrine (NOR), and dopamine (DOP). RESULTS: The observed endocrinological reaction was moderate. Perioperative anxiety and, above all, RBA were the main stressors. The endocrine stress response could best be seen within the fast-reacting sympathoadrenergic system. Midazolam significantly suppressed the epinephrine and the cortisole answer (p < 0.01). After RBA an ACTH plasma peak only was observed after placebo. Plasma-STH showed extreme variability. An STH-peak after midazolam is presumably due to a gonadotropic hormone-releasing hormone (GHRH) secretion directly stimulated by midazolam. Midazolam had no significant effect upon norepinephrine. A significant (p < 0.01) increase for plasma-cortisole was seen 60 min after the operation when compared to preoperative values. CONCLUSIONS: The results indicate that even at a low dose midazolam positively influences the endocrine stress response. The combination of this stress-reducing effect with the well-known hemodynamic stability, the distinct anxiolytic and sedative action, suggest low-dose midazolam as a favourable premedication for intraocular surgery.

[Calcifying pseudotumor of the orbits]. / Kalzifizierender Pseudotumor der Orbita.

Orbital pseudotumor can be divided histopathologically into three basic types: lymphoid, granulomatous and sclerosing. Chronic lymphoid and granulomatous types may eventually transform into the sclerosing type. The calcifying orbital pseudotumor is a very rare disorder due to a chronic, idiopathic inflammatory process of the orbit. The granulomatous type shows a good response to steroids while radiotherapy is the method of choice for lymphoid lesions. In general, calcifying pseudotumors can be treated only by operative exploration and tumor removal. We report a patient with a calcifying pseudotumor of the orbital apex that was removed through an endonasal approach. Preoperative diagnostic procedures and differential diagnosis are discussed.

[Transcutaneous or transconjunctival peribulbar anesthesia?]. / Peribulbäranästhesie transkutan oder transkonjunktival?

BACKGROUND: Transconjunctival peribulbar anesthesia is reported to permit better identification of the bulbar limits because of a better view into the fornix; it is also said to be less painful compared to transcutaneous peribulbar anesthesia. The aim of our study was to compare the two injection techniques. PATIENTS AND METHODS: This study comprised 46 patients undergoing eye operations under local anesthesia. They were allocated randomly in a prospective and simple masked study. Twenty-three patients received transconjunctival injections and 23 patients transcutaneous peribulbar injections. Before injection, all patients received Oxybuprocain eyedrops for anesthesia of the conjunctiva. In all cases no separate injections for lid akinesia were performed. Before and 20 min after the injection, the following parameters were assessed: pain score (visual analog scale), frequency of conjunctival chemosis and the necessity for supplemental anesthesia. For identification of the bulbar limits we checked if it was possible to see the caudal and the cranial fornix. RESULTS: The transconjunctival injection was significantly (P = 0.05) more painful (5.6 +/- 2.4) than the transcutaneous injection (4.2 +/- 2.4). Among the patients with transconjunctival injection, in 66.6% the cranial fornix could not or was only poorly seen. CONCLUSIONS: Transconjunctival peribulbar anesthesia appears not to be more advantageous than transcutaneous peribulbar anesthesia.

Oral low-dose midazolam as premedication for intraocular surgery in retrobulbar anesthesia: cardiovascular effects and relief of perioperative anxiety.

The aim was to investigate the efficacy and practicability of oral low-dose premedication with 3.75 mg midazolam (1/2 tablet Dormicum 7.5 mg) for selective intraocular surgery with retrobulbar anesthesia. Forty-six ASA II-III patients were randomly assigned to either group I: midazolam (n = 24) or group II: placebo (n = 22). Sedation was objectively quantified with a scale derived from the Glasgow-Coma-Scale and a verbal self-rating scale. Trait-anxiety was studied with the State-Trait Inventory by Spielberger, perioperative situative anxiety with the Erlanger Anxiety Scale. Cardiovascular variables and oxygenation were automatically monitored. Midazolam produced significant and sufficient sedation and significant anxiolysis. Systolic, diastolic and mean blood pressure were moderately but significantly, reduced. The effect on diastolic pressure was more pronounced. There was no effect on heart-rate. Oxygenation at all times remained well above 90% SpO2. In conclusion low-dose oral midazolam proved to be a single and effective premedication before intraocular surgery under local anesthesia.

Does warming of anesthetic solutions improve analgesia and akinesia in retrobulbar anesthesia?

PURPOSE: The authors assess the effect of warming local anesthetic solutions on pain of injection and on bulbar akinesia and analgesia of retrobulbar anesthesia (RBA). METHODS: Seventy patients undergoing RBA for cataract surgery were enrolled in a prospective, double-blind trial. They were allocated randomly to receive 5 ml either warm (37 degrees C) or cold (20 degrees C) anesthetic solution for RBA. Additionally, O'Brien's method was used to create an akinesia of the orbicularis oculi muscle. The following data were collected before and 20 minutes after retrobulbar injection: pain of injection, eye motility (Kestenbaum test), and corneal sensitivity (0: no sensitivity; 1: sensitivity remaining) at four different sites. The pain of injection was registered using an ordinal analogous scale before and immediately after the injection. Furthermore, data acquisition included any possible side effects and the bulbar length, measured with ultrasound. RESULTS: The score for injection pain (4.5 +/- 2.3 points), horizontal eye motility (0.2 +/- 0.8 mm), vertical eye motility (0.9 +/- 2.1 mm) all were lower for the warm group in comparison to the cold group (average pain score: 5.2 +/- 2.6 points; horizontal eye motility: 0.7 +/- 1.6 mm; vertical eye motility: 1.2 +/- 2.0 mm). Two patients in the warm group and four patients in the cold group had remaining corneal sensitivity. None of the differences were significant. CONCLUSIONS: Data indicate no significant difference in bulbar analgesia and akinesia after RBA between injections of warm and cold anesthetic solutions.

[Perioperative physiological and cognitive functions following oral premedication with 3.75 mg midazolam in operations with retrobulbar anesthesia]. / Perioperativer Verlauf von physiologischen und kognitiven Funktionen nach oraler Prämedikation von 3,75 mg Midazolam bei Operationen in Retrobulbäranästhesie.

UNLABELLED: The number of surgical procedures performed as day surgery has significantly increased in recent years. Therefore, a safe and short postoperative recovery period has become increasingly important. The aim of the present study was to investigate perioperative cognitive and physiological function after oral premedication with low-dose midazolam (3.75 mg), especially during the postoperative period. METHODS: Forty-seven men (age > 69 years, weight 50-90 kg) scheduled for elective cataract surgery under retrobulbar anaesthesia (RBA) were included in the study. The patients were randomly assigned to either group 1 (n = 28), receiving 3.75 mg midazolam p.o. (Dormicum), or group 2 (n = 19), receiving a placebo orally 30 min before RBA. We measured the following parameters: sedation (modified Glasgow coma scale); anxiety (visual analogue scale); numerical and verbal memory (digit span and reproduction of previously presented words); concentration (Revisions test of Stender/Marschner). To identify depression of ventilation, pulse oximetry and nasal end-tidal PCO2 were monitored intraoperatively. RESULTS: After premedication with 3.75 mg midazolam, patients were significantly more sedated (P < 0.01) and systolic blood pressures were significantly reduced (P < 0.05); 30 min after midazolam premedication only concentration was significantly (P < 0.05) decreased. The results of the other cognitive functions did not differ. No differences in cognitive and physiological functions between and groups could be found 2 h after the operation (293 +/- min after premedication). Intraoperatively, there were no significant differences in end-tidal PCO2 and oxygenation between the groups. In both groups anxiety and blood pressure were significantly higher pre- than postoperatively. CONCLUSION: Oral administration of low-dose midazolam (0.049 +/- mg/kg) seems to be appropriate for premedication before ambulatory surgical procedures in elderly patients. In the interest of patient safety, standardised oral premedication with 3.75 mg midazolam may not be sufficient for some of the patients.

[Comparison of classical keratometry and computer-assisted corneal topography in high grade postoperative astigmatism after perforating keratoplasty]. / Vergleich von klassischer Keratometrie und computergestützter Hornhauttopographie bei hohem postoperativem Astigmatismus nach perforierender Keratoplastik.

UNLABELLED: The standard keratometry measures the central corneal refractive power by only four sample points. there is a risk for poor or incorrect measurements in high irregular postoperative astigmatism following penetrating keratoplasty. Therefore we compared the standard keratometry with the computer assisted corneal topography. METHOD: In the study 43 consecutive measurements after penetrating keratoplasty, with an astigmatism > 4 dpt measured with standard keratometry (Zeiss Ophthalmometer), were analyzed. A computer assisted corneal topography (Eye Sys) was performed simultaneously. 22 measurements were received before, 21 measurements after T-incisions. The astigmatism value and axis measured by keratometry and corneal topography were compared and the correlation coefficient were calculated. As a simple index for the asymmetry of the resulting corneal cylinder measured by corneal topography, the frequency and the axis difference of both steep hemimeridians within the 3 mm zone were determined. RESULTS: The astigmatism values measured by standard keratometry (8.1 +/- 2.7 dpt) were significantly higher than the values measured by the computer assisted corneal topography (6.1 +/- 2.2 dpt). The difference of the cylinder axis measured by standard keratometry and corneal topography was 19 +/- 23 degrees; 10 +/- 15 degrees before and 29 degrees +/- 26 degrees after T-incision. The comparison of the astigmatism values showed a correlation coefficient of 0.82 in the total group, of 0.84 before and of 0.83 after T-incisions. In 26% of all measurements the axis difference of both steep hemimeridians (3-mm zone) was more than 30 degrees. After T-incisions this difference increased. CONCLUSIONS: Based on the results of this study, it seems reliable to identificate patients with high postoperative astigmatism following penetrating keratoplasty by standard keratometry.

[Is cranial corneoscleral 6 mm "no-stitch" tunnel incision contraindicated in against-the-rule astigmatism?]. / Ist eine kraniale korneosklerale 6 mm "No-stitch"-Tunnelinzision bei einem Astigmatismus gegen die Regel kontraindiziert?

BACKGROUND: There is a risk to increase a preexisting astigmatism against the rule by performing the incision at the 12 o'clock position. PATIENTS AND METHODS: In the prospective study 15 patients with a preoperative astigmatism over 0.25 D axis 90 degrees +/- 15 degrees the first cataract extraction was performed by a cranial, the operation of the other eye by a temporal 6-mm no-stitch tunnel incision. RESULTS: The mean corneal astigmatism against the rule preoperatively was 1.02 +/- 0.5 D with cranial incision and 1.27 +/- 0.8 D with temporal incision. Postoperatively the corneal astigmatism was 2.18 +/- 0.9 D with cranial incision and 0.71 +/- 0.7 D with temporal incision. In comparison to the pre-existing astigmatism, there was an increase of the astigmatism with cranial incision more than double, with temporal incision the astigmatism was significant lowered. Postoperatively the astigmatism with temporal wound location was significant lower than with cranial incision. CONCLUSION: Under the aspect of a 1.5 D higher average astigmatism postoperatively, we conclude that a cranial 6-mm no-stitch tunnel incision in preoperative astigmatism against the rule is contraindicated.

[Drug side-effects of the eye--a contribution to quality assurance in ophthalmology]. / Unerwünschte Arzneimittelwirkungen am Auge-ein Beitrag zur Qualitätssicherung in der Augenheilkunde.

BACKGROUND: The aim of this research is to catalogue the increasing number of side effects of medications on the eyes and, by putting this catalogue into a data bank, to make it available for use in hospitals. Here a deliberate search is made for medications, which could possibly cause certain side effects as well as a list of possible undesired side effects caused by a certain group of medications analogous to the main groups in the so-called "Rote Liste". METHODS: With the use of the medical literature data bank MEDLINE (CD-ROM) and a search strategy suitable to the topic, German or English publications are included in the data bank, when dose, duration and method of application has been stated, and there had to be a definite or at least possible connection between the side effects observed and the substance causing the side effects. The relevant datas in each article, for example, details about the substance, its application, the publication reference, the individual side effects, categorized according to anatomical or functional aspects, and, if necessary, details about reversibility and therapy were registrated on the data bank. RESULTS: The most common side effects in systemic therapy relate to conjunctiva, cornea/sclera, retina as well as a large number of changes in vision. In external application the undesired side effects were also mainly on conjunctiva, cornea/sclera, as well as on eyelids, uvea, and changes in visual acuity. In medications taken externally ophthalmological side effects were most frequently caused by cytostatics, dermatics, corticoids and antibiotics. In the case of external application on the eye, by far the most undesired side effects were caused by glaucoma medications, followed by antibiotics, mydriatics and corticoids. CONCLUSION: In future, with the use of the data bank, it should be possible to quickly observe a relation between undesired side effects and medications which could possibly cause these side effects.