Do we operate too many cataracts? The referred cataract patients' own appraisal of their need for surgery

A questionnaire was sent to 379 patients referred for cataract extraction, asking them to assess their visual disability and their need for surgery. Two hundred and seventy-nine patients (73.6%) answered the questionnaire, this group being representative for the 379 patients regarding all relevant variables. The patient's answers were analyzed in relation to data extracted from their referral notes (visual acuity, monocular pseudophakia, age, sex, place of residence, referring ophthalmologist). The overall level of self-reported visual problems and need for cataract surgery were significantly correlated to a reduced best-eye visual acuity, although the correlation factor was low. A similar correlation between the subjective need for surgery and a worst-eye visual acuity < or = 6/24 was also found. Forty-seven patients (16.9%) answered that cataract surgery was not needed for the time being, and this attitude was not significantly correlated to the visual acuity, provided the acuity was > or = 6/24 in the best eye and > or = 6/36 in the worst eye. One hundred and twenty patients (43.0%) felt that their visual disability was so severe that they had to be operated within 1 month and 67 patients (24.0%) within 3 months, while 45 patients (16.1%) felt that surgery could be postponed for at least 6 months. Age, sex, place of residence and the presence of monocular pseudophakia were not found to significantly influence the level of self-reported visual problems. Only 18.3% preferred to be treated as out-patients.

Corneal astigmatism. The effect of transverse corneal incisions

The results of transverse or combined transverse and radial keratotomy in eyes with idiopathic corneal astigmatism (N = 11), astigmatism+myopia (N = 9) or early stages of keratoconus (N = 6) are presented. The corneal astigmatism was reduced in all our patients, the absolute reduction being significantly correlated to the degree of preoperative astigmatism (p = 0.007). In the whole study group the mean relative reduction of the corneal astigmatism was 52.7%. In eyes without keratoconus the astigmatism recorded at the last follow-up visit was very similar to that measured a few days after surgery, while greater changes occurred in the keratoconus group.

The refractive error after implantation of a posterior chamber intraocular lens. The accuracy of IOL power calculation in a hospital practice

The study included 188 patients, in which a posterior chamber intraocular lens was implanted after extracapsular cataract extraction. After modifications of the intraocular lens constants (SRK formula and SRK II formula) and correction of the axial length measurements (Colenbrander-Hoffer formula) had been made, the mean differences between the actual postoperative spherical equivalent and that predicted by the three formulas were -0.23D, -0.22D and -0.46D, respectively. More than +/-1.0D deviation from the predicted postoperative refraction occurred in about one-third of the cases. Inter-observed discrepancy regarding the accuracy of the preoperative measurement of the ocular axis length is suggested to be the main cause of unpredicted postoperative refractive errors.

Transverse keratotomy in postkeratoplasty astigmatism

Transverse relaxing incisions were made in 12 eyes with a mean corneal astigmatism of 10.7D following penetrating keratoplasty. A few days later the mean graft astigmatism had been reduced to 5.5D (p = 0.0022), the reduction being significantly correlated to the degree of astigmatism before the keratotomy was done (p = 0.0044). Thereafter the corneal contour remained fairly stable through a mean follow-up period of 28.1 months, although a tendency towards a further reduction of the astigmatism was indicated. The mean corrected visual acuity improved from 0.5 before the keratotomy to 0.7 at the last control visit (p = 0.0117).

Suture adjustment in penetrating keratoplasty

Postoperative adjustment of a single running penetrating corneal graft suture was done in 19 patients (22 adjustments). The short-term effect of this procedure was a mean reduction of corneal astigmatism of 4.39D (p < 0.0001). Thereafter, the corneal contour was fairly stable, provided that the running suture remained intact and tight. Localized loosening of the graft suture significantly increased the corneal astigmatism. Following removal of the graft suture no statistically significant mean change of corneal astigmatism was found. However, patients with a previously intact running suture tended to show increased astigmatism, while those with a previous localized suture loosening usually showed a decreased astigmatism after suture removal. The main benefit of suture adjustment is apparently the rapid and fairly stable reduction of postkeratoplasty astigmatism usually obtained, but unfortunately this effect seems chiefly to exist only as long as the graft suture remains intact and tight.

Retrobulbar anesthesia with and without hyaluronidase in extracapsular cataract surgery. A prospective, randomized, double-blind study

Eighty patients with senile cataract were subjected to a planned extracapsular cataract extraction (ECCE) with implantation of a posterior chamber intraocular lens. Retrobulbar anesthesia was administered by injection of 4 mg lidocaine 2% with adrenalin. In 40 patients 150 I.U. hyaluronidase (Kinetin) was added to the anesthesia. The hyaluronidase group had a significantly lower frequency of iris prolapse, and deeper anterior chamber, both before and after expression of the lens nucleus. Possible mechanisms explaining the beneficial effect of hyaluronidase in extracapsular cataract surgery are discussed.

Epikeratophakia for keratoconus in mentally retarded patients. The use of fresh, free-hand made lamellar grafts

Epikeratophakia for keratoconus was done in 11 mentally retarded patients, using fresh, free-hand made lamellar grafts. The mean follow-up period was 31.5 months. The grafts remained clear and well adapted in 7 cases (63.6%). Necrosis of the lower part of the graft occurred in 3 eyes (27.3%), and was probably caused by persisting epithelial defects. Only one of these grafts had to be removed. Despite concurrent eye diseases, such as cataract and possible amblyopia, an improved overall visual function was reported in 5 of the 11 patients (45.5%). No vision-threatening complications related to the epikeratophakia surgery was found.

Trabeculectomy and gelatin implants. A retrospective, long-term follow-up study

In a retrospective follow-up study including 60 eyes with simple or capsular glaucoma, the results obtained by using a gelatin implant under the scleral flap during trabeculectomy were compared with those obtained without such implants. One month postoperatively the mean IOP was significantly lower in the gelatin group than in the control group (15.0 mmHg and 17.9 mmHg, respectively) (p = 0.024). At the long-term follow-up, however, the mean IOP in the two groups were very similar (13.6 mmHg and 14.8 mmHg, respectively).

Epikeratophakia for keratoconus. Long-term results using fresh, free-hand made lamellar grafts

Epikeratophakia using fresh, free-hand made corneal grafts was done in 16 patients with keratoconus. The follow-up period averaged 27.8 months (range 13-45 months). A significant improvement of visual acuity was obtained (p = 0.002), and 14 of the 16 eyes (87.5%) achieved a corrected visual acuity greater than or equal to 6/12. The spherical equivalent and the cylindrical refractive error were reduced (p less than 0.05), and a significant flattening of the central corneal curvature was obtained (p less than 0.002). The mean postoperative central corneal astigmatism was 4.25 D. Postoperatively, the mean central corneal thickness was 0.670 mm, and the mean central thickness of the epithelialized graft was 0.336 mm. Six patients reported some postoperative glare or blurring of vision, despite a visual acuity greater than or equal to 6/9 on the Snellen chart. No significant subjective or objective changes were noticed after the 6-month postoperative follow-up visit.

The central corneal thickness in keratoconjunctivitis sicca

The central corneal thickness of 17 patients with keratoconjunctivitis sicca was compared with the thickness recorded in a control group of 105 subjects with healthy eyes. A moderate, but highly statistically significant central corneal thinning was found in the keratoconjunctivitis sicca group. The possible etiology and clinical importance of this finding is briefly discussed.

Multiple-dose, dose-response relationship for the topical carbonic anhydrase inhibitor MK-927

The multiple-dose, dose-response curve of MK-927 was studied in a five-center, double-masked, randomized, placebo-controlled, parallel study of 2%, 1%, and 0.5% MK-927 in 76 patients with bilateral primary open angle glaucoma or ocular hypertension and intraocular pressure greater than 24 mm Hg following washout of ocular hypotensive medications. Patients received doses at 8 AM and 8 PM for 14 days, and parallel 12-hour intraocular pressure curves were performed prestudy and on day 14, with 4-hour curves on days 1 and 4. There was a significant dose-response relationship, with 0.5% MK-927 twice daily being a minimal-effect dose. Both 1% and 2% MK-927 were active through 12 hours postdose, and peak mean percent decrease in pressure at 2 hours postdose was 18.6% and 20.6%, respectively.

Keratoprosthesis. II. Results obtained after implantation of 27 dismountable two-piece prostheses. A retrospective, follow-up study

During the years 1974-1987 a total of 27 two-piece keratoprostheses were implanted in 25 eyes of 22 different patients with bilateral blinding anterior segment disease with no possibility for a successful corneal transplantation. The prosthesis design and the surgical procedures used are described. The healing in and fixation of the prostheses were initially good in all cases, but 9 prostheses were lost or removed because of complications during the postoperative period of observation. The prosthesis retention time was significantly longer than that earlier achieved by the use of a one-piece prosthesis. In 18 of 27 cases a visual acuity of 6/60 or better was obtained. Postoperative complications included necrosis of the tissues covering and supporting the prosthesis, infection around the prosthesis, overgrowth of the surrounding tissues and the development of dense retroprosthetic membranes. Despite the obvious risks, keratoprosthesis surgery in a small number of patients with severe corneal disease represents the only potential hope for a visual rehabilitation, and should therefore be considered.

Keratoprosthesis. I. Results obtained after implantation of 12 one-piece prostheses. A retrospective, follow-up study

A total of 12 one-piece keratoprostheses were implanted in 6 eyes of 6 different patients with bilateral blinding, severe corneal disease with no possibility for a successful corneal transplantation. The prosthesis and the surgical procedure used are described. The short-term results were good, with 4 of the 6 patients obtaining a substantial visual improvement. In the remaining 2 patients preexisting pathology in the posterior segment of the eye was strongly suspected. However, the long-term complication rate was high, the chief problems being tissue necrosis around the prosthesis with eventual prosthesis loss and the development of retroprosthetic membranes. Repeated replacements of keratoprostheses extruded or removed because of complications were possible with restoration of the vision obtained after the first implantation.

Twelve-hour IOP control obtained by a single dose of timolol/pilocarpine combination eye drops

The 12 h IOP control achieved by a single application of a newly developed ophthalmic solution containing 0.5% timolol and 2% resp. 4% pilocarpine was compared with that obtained by 1 dose of timolol 0.5% alone in 33 patients with manifest open angle glaucoma or ocular hypertension. The combined solutions gave a significantly better 12 h IOP control, evidenced by both a reduced mean diurnal IOP and a decreased frequency of larger pressure peaks.

The prognosis of patients with hysterical visual impairment

During the period 1962-1986, 54 patients received the diagnosis hysterical visual impairment, i.e. 1 out of every 631 patients admitted to our department. Isolated visual acuity impairment was the most common symptom, followed by combined visual acuity impairment and visual field constriction, whereas isolated visual field constriction occurred most infrequently. The mean age of the patients in the first group was significantly lower than that of the patients in the latter group. A questionnaire sent to all patients in 1987 was answered by 41 patients. Twenty-one of these (51%) felt that their visual function now was good, whereas 20 (49%) claimed that their visual function was still poor. Nine patients (22%) were disabled because of their visual problems. Twenty-nine of the patients who answered the questionnaire were re-examined. Sixteen of these (55%) still showed visual impairment at the follow-up, while 13 (45%) showed complete disappearance of visual complaints. The younger patients appeared to have a better prognosis than the older ones.

A comparison between acyclovir and trifluorothymidine ophthalmic ointment in the treatment of epithelial dendritic keratitis. A double blind, randomized parallel group trial

This report presents the results of a double blind randomized study comprising 50 patients with epithelial herpes simplex keratitis. Twenty-five patients received 3% acyclovir ophthalmic ointment, the other 25 patients 2% trifluorothymidine (TFT) ophthalmic ointment. The mean duration of treatment in the 2 study groups before healing of the epithelial ulceration was obtained was 6.7 days and 5.9 days, respectively (no statistically significant difference). Two patient (8%) in the acyclovir group and 1 patient (4%) in the TFT group failed to heal within 14 days of treatment. No clinically significant adverse effects were recorded.

Timolol/pilocarpine combination eye drops in open angle glaucoma and in ocular hypertension. A controlled randomized study

The effect of a newly developed ophthalmic solution containing both 0.5% timolol and 2% resp. 4% pilocarpine was compared with that of timolol 0.5% eye drops alone in 93 patients with manifest simple or capsular glaucoma or ocular hypertension. The medications were administered twice daily. The absolute additive effect of pilocarpine was small, although the combined solutions caused a statistically significantly greater reduction of the intraocular pressure than that achieved by timolol alone. This additional effect appeared to last at least 12 h. The effect of the test solutions containing 2% resp. 4% pilocarpine was very similar. Apart from the well-known effects of the pilocarpine-induced miosis, the combined test medications were generally well tolerated.

Prognostic factors in the development of manifest open angle glaucoma. A long-term follow-up study of hypertensive and normotensive eyes

Ninety-three patients, who during a mass screening for glaucoma in 1962-63 attended a thorough ophthalmological examination, were re-examined in 1980-82. At the mass screening 42 patients had IOP greater than or equal to 21 mmHg in at least 1 eye, but none of the 93 patients had glaucomatous optic disc excavations or visual field defects. At the re-examination, 28 patients (30.1%) had developed manifest open angle glaucoma in at least 1 eye. This development was significantly correlated to the height of the IOP, both at the mass screening, during the period of observation and at the follow-up study (P less than 0.05-P less than 0.002). A reduced outflow facility measured at the mass screening was also significantly associated with the later development of manifest glaucomatous damage (P less than 0.05-P less than 0.01). In addition, fibrillopathy (pseudoexfoliation), manifest glaucoma in the 'fellow eye' and a positive family history for glaucoma were found to be important risk factors.

Deposits on hydrophilic 'bandage' lenses. A scanning electronmicroscopic and x-ray microanalytic study

Scanning electronmicroscopy of 34 continuously worn Sauflon PW 'bandage' lenses showed an initial deposition of cellular debris, followed by an increasing, general, non-penetrating, organic coating, particularly on the anterior lens surface. No microorganisms were found. X-ray microanalysis of the 34 Sauflon PW lenses as well as 11 daily worn Hydroflex m lenses showed that elements may be added to or 'washed out' from the lenses during storage before preparation for microscopy. The elements obtained were constituents of both normal tear fluid and lens storage solutions. Only sulphur appeared firmly bound in the deposits, probably as sulphur-containing macromolecules of ocular mucus. Calcium was only detected in a few cases.

Hydrophilic contact lenses in corneal disorders

Hydrophilic 'bandage' lenses were fitted in 107 patients with corneal disorders not satisfactorily responding to conventional medical treatment. An over-all beneficial effect on both ocular discomfort, visual acuity and corneal disorder was found (P less than 0.002). Regarding each group separately only patients with bullous keratopathy and those with corneal ulcers achieved a significant reduction of ocular discomfort (P less than 0.002) and a significant improvement of visual acuity (P less than 0.05 - P less than 0.01). In bullous keratopathy corneal oedema was significantly reduced by concomitant use of contact lenses and 5% NaCl eye drops (P less than 0.01). Significant improvement of corneal disorder occurred in patients with corneal ulcers and in those with corneal lacerations (P less than 0.002 and P less than 0.01, respectively). Complications included corneal vascularization (7.5%) and keratitis/keratoconjunctivitis (5.6%). Prophylactic use of topical antibiotics appeared necessary only in dry eye disease.

The fluid content of hydrophilic contact lenses on the eye

Hydroflex m, Hydroflex 72 and Sauflon PW lenses were tested (declared fluid content 38.4%, 72% and 79%, respectively). At room temperature in vitro the mean fluid content of Hydroflex m and Sauflon PW was significantly higher than declared (P less than 0.002), but this might be due to insufficient blotting of the lens surface. The mean fluid content of Hydroflex 72 was about 2.5% lower than declared (P less than 0.002). During wear the fluid content of Hydroflex m did not differ significantly from the in vitro recordings at room temperature, while the fluid content of worn Hydroflex 72 and Sauflon PW was about 2% lower than in vitro (P less than 0.002). This difference was mainly due to the greater temperature susceptibility of these lens materials. Apart from a slight decrease during the first few h after insertion (P less than 0.05), the fluid content of the lenses was not significantly influenced by the duration of wear. The mean contact lens surface temperature during wear was 30.7 degrees C.

Light-induced release of protoporphyrin, but not of zinc protoporphyrin, from erythrocytes in a patient with greatly elevated erythrocyte protoporphyrin

A patient with greatly increased erythrocyte protoporphyrin, but normal porphyrins in urine and feces, is described. The patient later developed a malignant lymphoma, and the reason why she accumulated protoporphyrin in her erythrocytes is not known. The protoporphyrin in the erythrocytes consisted of two types of protoporphyrin, free protoporphyrin (30%) and zinc protoporphyrin (70%). Upon irradiation of erythrocytes in the absence of albumin, protoporphyrin and zinc protoporphyrin, which were both bound to hemoglobin, were released. In contrast, when the irradiation was carried out in the presence of albumin, the photohemolysis was negligible, and there was release of free protoporphyrin, but not of zinc protoporphyrin, from the erythrocytes. In vivo albumin is present in the plasma and the results may help to explain why patients with erythropoietic protoporphyria (erythrocytes containing free protoporphyrin) are photosensitive, whereas patients with lead intoxication and iron deficiency (erythrocytes containing zinc protoporphyrin) are not.