Visual sensation during phacoemulsification and intraocular lens implantation using topical and regional anesthesia

PURPOSE

To evaluate patients' visual sensations at different stages of phacoemulsification and posterior chamber intraocular lens (PC IOL) implantation under topical and regional anesthesia.

SETTING

Department of Ophthalmology, United Christian Hospital and Tseung Kwan O Hospital, Kowloon, Hong Kong, China.

METHODS

Seventy-six consecutive patients having phacoemulsification were randomized to a topical anesthesia group (n = 35) or regional anesthesia group (n = 41). The topical anesthesia group received lidocaine hydrochloride 2% gel (Xylocaine) and the regional anesthesia group, a peribulbar or retrobulbar injection of lignocaine 2%. The patients' visual sensations, including light and color sensations, shape of objects, and visual patterns, were evaluated at different stages of surgery.

RESULTS

Two patients (4.9%) in the regional anesthesia group and none in the topical anesthesia group experienced total loss of light sensation throughout surgery (P =.50). There was a significant association between color perception and the type of anesthesia at stages 1 and 2 (P<.05) but not at stages 3, 4, and 5 (P>.05). The perception of objects and visual patterns had no association with the type of anesthesia at any stage (P>.05). Of all patients in the study, 56 (73.7%) reported color changes as surgery proceeded. Both groups saw waves, defined as curves with periodic fluctuations in amplitude, at all stages. The perception of some colors and a rectangular moving object was significantly associated with the type of anesthesia at some or all stages (P<.05).

CONCLUSIONS

Patients having phacoemulsification and PC IOL implantation under topical or regional anesthesia had a wide spectrum of visual sensations that were similar at most stages of surgery. Patients in the topical anesthesia group perceived more colors at the early stages and more blue throughout surgery than patients in the regional anesthesia group.

Scanning laser polarimetry in patients with acute attack of primary angle closure

PURPOSE

To compare the retinal nerve fiber layer measurements of attacked eyes with their fellow eyes after a single unilateral attack of acute primary angle closure (APAC).

METHODS

Patients with a single episode of APAC in 1 eye, successfully treated with laser peripheral iridotomy, were recruited. Eyes with persistently raised intraocular pressure (IOP) after resolution of the acute attack were excluded. Scanning laser polarimetry was carried out at 6 months after remission of the acute attack. The various parameters between the attacked and the fellow eyes were compared using the Student t-test.

RESULTS

Twenty-six patients (24 female and 2 male, mean age 66.9+/-8.1 years) were recruited. The duration of the APAC ranged from 5 to 98 hours (mean, 36.3 hours). The mean presenting IOP during the acute attack was 62.0+/-9.4 mm Hg. Only the mean inferior ratio and the ellipse modulation showed a statistically significant difference between the attacked and the fellow eyes among the 12 standard scanning laser polarimetry measurement parameters.

CONCLUSION

No severe retinal nerve fiber layer damage was documented in eyes that suffered a single episode of APAC with duration of attack up to 48 hours. With duration of attack longer than 48 hours, retinal nerve fiber layer damage was detected.

Different optineurin mutation pattern in primary open-angle glaucoma

PURPOSE

The optineurin gene (OPTN) is the second gene besides MYOC in which mutations have been identified to be associated with primary open-angle glaucoma (POAG). In this study, sequence alterations in the OPTN gene associated with POAG in Chinese subjects were investigated.

METHODS

All the coding exons of OPTN were screened, including the intron-exon boundaries, for sequence alterations in a Chinese sample of 119 sporadic patients with POAG and 126 unrelated control subjects by polymerase chain reaction-conformation-sensitive gel electrophoresis and DNA sequencing.

RESULTS

Sixteen sequence changes were identified: 3 had been reported (T34T, M98K, and R545Q) and 13 were novel (T49T, E103D, V148V, P199P, T202T, H486R, IVS6-5T-->C, IVS6-10G-->A, IVS7+24G-->A, IVS8+20G-->A, IVS13+21C-->G, IVS15+10G-->A, and IVS15-48C-->A). Among them, only E103D, H486R, V148V, and IVS13+21C-->G were found exclusively in patients with POAG, whereas P199P, T202T, and IVS8+20G-->A were present only in control subjects. The genotype of IVS7+24G-->A showed a significant association with POAG (P = 0.02, Fisher two-tailed exact test) and with and increased cup-to-disc ratio in these patients (P = 0.005, Mann-Whitney test).

CONCLUSIONS

The findings in the current study enrich the evidence on the OPTN gene as a causative gene for POAG and suggest a different mutation pattern of OPTN in Chinese than in whites. The wide spectrum of putative mutations detected in this study suggests that both structural and functional disruptions in OPTN may contribute to the pathogenesis of glaucoma.

Trabeculectomy with beta radiation: long-term follow-up

PURPOSE

To evaluate the long-term outcome and complications of trabeculectomy with beta radiation.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Forty-three patients with confirmed primary open-angle glaucoma (POAG), who received trabeculectomy with adjunctive beta radiation at the Prince of Wales Hospital between June 1991 and November 1994.

METHODS

Patients fulfilling the preceding criteria were followed up longitudinally. The visual acuity, intraocular pressure (IOP), bleb morphology, and complications were evaluated.

MAIN OUTCOME MEASURES

Visual acuity, IOP, bleb morphology, complications.

RESULTS

Forty-three eyes of 43 consecutive Chinese patients were recruited and successfully followed up for a minimum of 7 years. The mean age +/- 1 standard deviation (SD) was 60.9 +/- 13.0 years. There were 29 males and 14 females. The mean baseline IOP +/- 1 SD was 28.3 +/- 5.8 mmHg. The mean postoperative IOP +/- 1 SD after the initial trabeculectomy was 11.9 +/- 4.3 mmHg, and the mean number of preoperative IOP-lowering eyedrops +/- 1 SD was reduced from 2.8 +/- 0.5 to 0.7 +/- 1.0 at 7 years follow-up. The qualified success rate at 7 years follow-up, defined as IOP <or=21 mmHg with and without medication(s), was 88.4%. The complete success rate at 7 years defined as IOP <or=21 mmHg without medication was 60.7%. Two eyes developed blebitis, and one of them progressed to corneal decompensation after the infection. One eye had hypotony, and one eye had a traumatic ruptured bleb. Twelve eyes (27.9%) developed significant cataract. No corneal ulceration or scleral necrosis was encountered.

CONCLUSIONS

From this noncomparative study, trabeculectomy with a single dose of 1000 rad beta radiation used as an adjunctive measure for POAG in Chinese eyes had achieved a qualified success rate of 88.4% at 7 years.

Diode laser transscleral cyclophotocoagulation in the treatment of chronic angle-closure glaucoma: a preliminary study

PURPOSE

To evaluate the efficacy and safety of diode laser transscleral cyclophotocoagulation in the treatment of chronic angle-closure glaucoma.

PATIENTS AND METHODS

A prospective, non-comparative interventional pilot study was conducted. Fourteen eyes of 14 Chinese patients with chronic angle-closure glaucoma whose intraocular pressures were greater than 21 mm Hg on medications were treated with diode laser transscleral cyclophotocoagulation using the G-probe at the United Christian Hospital between February 2000 and May 2001. The inferior 270 degrees quadrant (from 2 to 11 o'clock for right eye and from 1 to 10 o'clock for left eye) was treated and the patients were followed up regularly. The initial laser energy was set at 2,000 mWatt with a duration of 2 seconds. The post-treatment anti-glaucoma medications were adjusted according to the intraocular pressure. If medications failed to lower the intraocular pressure to below 21 mm Hg, cyclophotocoagulation to the same inferior 270 degrees quadrant was repeated.

RESULTS

All patients completed a 12-month follow-up period. The total success rate defined as IOP < 21 mm Hg with or without medication(s) was 85.7% at 1 year of follow-up review. The mean +/- SD intraocular pressure decreased from pre-treatment level of 36.9 +/- 11.7 mm Hg to 18.9 +/- 6.5 mm Hg at 1 year after treatment. The difference was statistically significant (P < 0.001) (Paired t test). The mean +/- SD number of IOP-lowering eyedrops was significantly reduced from 1.9 +/- 0.7 before cyclophotocoagulation to 0.4 +/- 0.8 at 1 year after treatment (P = 0.0002) (Paired t test). Two eyes required repeat treatment. Seven eyes (50%) had atonic pupil following the laser treatment.

CONCLUSION

Diode laser transscleral cyclophotocoagulation is effective in lowering the intraocular pressure in chronic angle-closure glaucoma and its effect lasts for at least 1 year.

Efficacy of lignocaine 2% gel in chalazion surgery

BACKGROUND/AIMS

To determine whether topical 2% lignocaine (lidocaine) gel is an effective anaesthetic agent for chalazion surgery.

METHODS

In a randomised controlled clinical trial, 57 subjects aged 12 years or over requiring incision and curettage for chalazion were recruited over an 8 month period. Patients were randomised into two groups. One group received 1.5 ml of lignocaine 2% injection and the other 1.5 ml of lignocaine 2% gel topically. Standard incision and curettage was then performed. The primary outcome of interest was the total pain experienced during the entire procedure including anaesthetic administration as well as incision and curettage. The pain from the local anaesthetic administration and during incision and curettage was assessed independently using a visual analogue scale (0-100). The sum of these two scores would be the total pain score out of 200. "Fear of injection" score (0-100) was also assessed.

RESULTS

There was a statistically significant difference in the mean total pain scores between the injection and the gel groups (95.6 v 57.0) (p <0.001) (alpha = 0.05) (1 - beta = 0.9394). There was a statistically significant difference in the mean scores on "pain of anaesthetic administration" (47.0 v 5.5) (p <0.000). There was no statistically significant differences in the mean scores on "fear of injection" (43.9 v 47.7) (p = 0.668) and "pain during incision and curettage" (48.28 v 51.4) (p=0.679).

CONCLUSIONS

Lignocaine 2% gel is effective in chalazion surgery especially in lowering the pain caused by anaesthetic administration.

In vivo confocal microscopy of corneal insect foreign body

PURPOSE

To report a case of insect corneal foreign body with in vivo confocal microscopy performed.

METHODS

Clinical presentation, clinical pictures, and treatment are discussed. Confocal microscopy of the injured cornea was performed in areas showing foreign bodies with and without infiltrations seen under the slit-lamp.

CONCLUSION

Confocal microscopy is useful in detection of subtle inflammatory reaction, monitoring the progress of the injury and decision of treatment plans.

Laser peripheral iridoplasty as initial treatment of acute attack of primary angle-closure: a long-term follow-up study

PURPOSE

To study the long-term clinical course and complications of patients with acute primary angle-closure treated with immediate laser peripheral iridoplasty followed by laser peripheral iridotomy.

PATIENTS AND METHODS

Consecutive patients with acute primary angle closure treated with immediate laser peripheral iridoplasty, followed by laser peripheral iridotomy, at the Prince of Wales Hospital from July 1997 through January 2000 were followed up to document the clinical course of their disease and any complications from the laser treatment. Visual acuity, intraocular pressure, gonioscopic findings, corneal and lens clarity, iris appearance, pupillary reaction, and progression of glaucomatous optic neuropathy were evaluated.

RESULTS

Thirty eyes of 29 Chinese patients with acute primary angle closure treated initially with either argon or diode laser peripheral iridoplasty were recruited. The mean follow-up period was 33.0 +/- 9.3 months. Twenty-one eyes (70%) had no further attack and maintained normal intraocular pressure without medications, and 9 eyes (30%) developed chronic angle-closure glaucoma with peripheral anterior synechiae. All eyes had pigmented laser marks on the peripheral iris, but none had peripheral corneal burn.

CONCLUSIONS

Long-term follow-up data indicated that 30% of Chinese eyes with acute primary angle closure successfully treated with immediate laser peripheral iridoplasty followed by laser peripheral iridotomy developed peripheral anterior synechiae and an increase in intraocular pressure. There were minimal long-term complications on the cornea and the lens from the laser treatment.

Nausea and vomiting after phacoemulsification using topical or retrobulbar anesthesia

PURPOSE

To determine and compare the incidence of postoperative nausea and vomiting in patients having phacoemulsification under topical or retrobulbar anesthesia.

SETTING

Department of Ophthalmology, United Christian Hospital, Hong Kong, China.

METHODS

In this prospective randomized clinical trial, patients scheduled for routine phacoemulsification with posterior chamber intraocular lens implantation under local anesthesia without sedation were randomized to receive topical anesthesia or retrobulbar anesthesia. One hundred seven eyes of 107 Chinese patients were included. There were 49 patients and 58 patients of similar age and sex distribution in the retrobulbar group and topical group, respectively. Postoperative nausea and vomiting (PONV), the need for an antiemetic, and intraocular pressure (IOP) were recorded 1 day after surgery. Also recorded were the patient's preexisting risk factors for PONV (if any), fasting time, duration of surgery, and intraoperative complications or need for supplementary anesthesia or analgesia.

RESULTS

The overall incidence of PONV in the entire study group was 3.7% (4 patients). No statistically significant differences in PONV were found between the 2 anesthesia techniques, although 6.1% (3 of 49) in the topical group had nausea compared with 1.7% (1 of 58) in the retrobulbar group. No significant differences were found in the fasting time, duration of surgery, or postoperative IOP between patients who had PONV and those who did not.

CONCLUSIONS

Topical and retrobulbar anesthesia were associated with a low incidence of PONV in routine phacoemulsification. There were no statistically significant differences in PONV between the 2 anesthesia techniques. No significant correlation was found between the incidence of PONV and the duration of surgery, presence of complications, fasting time, postoperative IOP, or history of PONV or motion sickness.

Descemet membrane detachment after sequential argon-neodymium:YAG laser peripheral iridotomy

PURPOSE

To report a case of Descemet membrane detachment after sequential argon-neodymium (Nd):yttrium-aluminum-garnet (YAG) laser peripheral iridotomy.

DESIGN

Interventional case report.

METHODS

A 72-year-old Chinese man presented with acute primary angle-closure in the left eye. In the fellow right eye, a localized Descemet membrane detachment developed after prophylactic sequential argon-Nd:YAG laser peripheral iridotomy. Ultrasound biomicroscopy pictures were taken.

RESULTS

The Descemet membrane detachment reattached gradually without intervention. The cornea remained clear and the vision was unchanged.

CONCLUSION

In sequential argon-Nd:YAG laser peripheral iridotomy, the shock wave formed during photodisruption may produce linear cracks at the level of Descemet membrane, resulting in detachment. This complication can occur irrespective of the color of the iris.

Intracameral lidocaine in trabeculectomy. A preliminary safety and efficacy study

PURPOSE

To study the safety and efficacy of intracameral lidocaine as anaesthesia in trabeculectomy for primary open-angle glaucoma.

METHODS

Trabeculectomy under intracameral anaesthesia using 1% preservative-free lidocaine was performed in 10 patients with primary open-angle glaucoma. Intraoperative pain score, postoperative intraocular pressure (IOP) and endothelial cell count at 3 months were recorded.

RESULTS

The mean pain score was 1.70 +/- 1.34. The mean IOP was lowered from 24.60 +/- 8.28 mmHg preoperatively to 14.1 +/- 3.11 mm Hg postoperatively. There was no significant decrease in the mean endothelial cell count 3 months after the surgery (P = 0.375).

CONCLUSION

Intracameral lidocaine may be a safe and effective alternative anaesthesia method in trabeculectomy for uncomplicated primary open-angle glaucoma.

Argon laser peripheral iridoplasty versus conventional systemic medical therapy in treatment of acute primary angle-closure glaucoma : a prospective, randomized, controlled trial

OBJECTIVE

To study whether argon laser peripheral iridoplasty (ALPI) is as effective and safe as conventional systemic medications in treatment of acute primary angle-closure glaucoma (PACG) when immediate laser peripheral iridotomy is neither possible nor safe.

DESIGN

Prospective, randomized, controlled trial.

PARTICIPANTS

Seventy-three eyes of 64 consecutive patients with their first presentation of acute PACG, with intraocular pressure (IOP) levels of 40 mmHg or more, were recruited into the study.

INTERVENTION

The acute PACG eye of each consenting patient received topical pilocarpine (4%) and topical timolol (0.5%). The patients were then randomized into one of two treatment groups. The ALPI group received immediate ALPI under topical anesthesia. The medical treatment group was given 500 mg of intravenous acetazolamide, followed by oral acetazolamide 250 mg four times daily, and an oral potassium supplement until IOP levels normalized. Intravenous mannitol also was administered to the latter group if the presenting IOP was higher than 60 mmHg. The acute PACG eye of both groups continued to receive topical pilocarpine (1%) until peripheral iridotomy could be performed.

MAIN OUTCOME MEASURES

Intraocular pressure profile, corneal clarity, symptoms, visual acuity, angle status by indentation gonioscopy, and complications of treatment.

RESULTS

Thirty-three acute PACG eyes of 32 patients were randomized to receive immediate ALPI, whereas 40 acute PACG eyes of 32 patients had conventional systemic medical therapy. Both treatment groups were matched for age, duration of attack, and IOP at presentation. The ALPI-treated group had lower IOP levels than the medically treated group at 15 minutes, 30 minutes, and 1 hour after the start of treatment. The differences were statistically significant. The difference in IOP levels became statistically insignificant from 2 hours onward. The duration of attack did not affect the efficacy of ALPI in reducing IOP in acute PACG. No serious laser complications occurred, at least in the early postlaser period.

CONCLUSIONS

Argon laser peripheral iridoplasty significantly is more effective than conventional systemic medications in reducing IOP levels in acute PACG in eyes not suitable for immediate laser peripheral iridotomy within the first 2 hours from the initiation of treatment. Argon laser peripheral iridoplasty is a safe and more effective alternative to conventional systemic medications in the management of acute PACG not amenable to immediate laser peripheral iridotomy.

Argon laser suture lysis using Ritch lens following cataract surgery

Argon laser suture lysis using the Ritch lens provides a safe and effective means for correction of post--ECCE suture--induced astigmatism.

Traumatic subluxation causing variable position of the crystalline lens

We present a case of traumatic lens subluxation that was evident only when the patient was in the supine position. This case illustrates that a crystalline lens with traumatic zonular rupture can change its position depending on the posture of the patient. If such a lens is suspended by the remaining zonules at the superior quadrant while the patient is erect, phacodonesis may be present while the lens remains in its normal position. However, when the patient is in the supine position, the lens drops back into the vitreous cavity. Examination in erect and supine positions is important in the preoperative assessment of patients with traumatic phacodonesis or iridodonesis.

Topical anesthesia in phacotrabeculectomy

PURPOSE

To study the safety and efficacy of topical anesthesia alone, without systemic sedation, in phacotrabeculectomy for cataract and primary open-angle glaucoma.

METHODS

In this prospective study, topical anesthesia with 2% lidocaine hydrochloride jelly without systemic sedation was used for combined phacoemulsification, posterior chamber intraocular lens implantation, and trabeculectomy in consecutive patients with primary open-angle glaucoma and concurrent cataract at the United Christian Hospital, Kowloon, Hong Kong, from September 2000 to May 2001. Visual analog pain score and change in vital signs were used to assess the intraoperative pain experience. Other outcome measures included postoperative visual acuity and intraocular pressure at 3 months.

RESULTS

Twenty-two eyes of 22 consecutive patients were included in the study. The mean intraoperative pain score was 0.9 (range, 0-3). Three patients reported discomfort intraoperatively. No injection of supplementary anesthetic was required in any of the eyes. None of the patients had significant increase of pulse rate or blood pressure during the whole surgical procedure. Six patients required oral analgesic for postoperative discomfort. The mean preoperative medically treated IOP was 20.3 +/- 5.9 mm Hg and the mean postoperative IOP at 3 months was 14.4 +/- 4.7 mm Hg. All except two patients had improved visual acuity. There was no serious intraoperative or postoperative complication.

CONCLUSION

Topical 2% lidocaine hydrochloride jelly without systemic sedation may be a safe and effective anesthetic method in phacotrabeculectomy for patients with primary open-angle glaucoma with coexisting cataract.

Topical chloramphenicol for eye infections

Topical chloramphenicol has been widely used in the treatment and prevention of superficial eye infections due to its broad spectrum of activity and low cost. The use of this drug has decreased considerably in the United States since the first case of aplastic anaemia associated with topical chloramphenicol was reported in the 1960s. This medication, however, is still widely used in many other countries. This paper evaluates the evidence for and against the use of topical chloramphenicol in ocular diseases.

Subcutaneous steroid injection as treatment for chalazion: prospective case series

OBJECTIVE

To study the efficacy of subcutaneous steroid injection in the treatment of chalazion.

DESIGN

Prospective consecutive case series.

SETTING

University teaching hospital, Hong Kong.

PATIENTS

Patients with chalazion presenting to the out-patient clinic of the Department of Ophthalmology at the Prince of Wales Hospital from January to June 1998.

MAIN OUTCOME MEASURES

Size of the chalazion after steroid injection treatment.

RESULTS

Forty-eight consecutive patients with chalazion were treated with injection of triamcinolone into the subcutaneous tissue around the lesion. In 43 (89.6%) patients, the lesion subsided completely. Twenty-six (54.2%) patients had lesions that subsided with one injection. The size and duration of the chalazion at presentation did not significantly affect the outcome of the treatment. Two patients developed depigmentation of the skin at the site of injection. No other major complications were encountered.

CONCLUSION

Subcutaneous injection of the steroid triamcinolone acetonide appears to be a simple and effective treatment for chalazion. Further comparative clinical trials are indicated.

Physical effects of reuse and repeated ethylene oxide sterilization on transscleral cyclophotocoagulation laser G-probes

PURPOSE

The authors documented the physical effects of reuse and repeated ethylene oxide sterilization on transscleral cyclophotocoagulation laser G-probes.

METHODS

Transscleral cyclophotocoagulation was performed using G-probes on fresh porcine eyes. Each of two G-probes was used for four transscleral cyclophotocoagulation procedures, with three cycles of ethylene oxide sterilization in between. The power output from the G-probes was measured by a laser output meter before and after each transscleral cyclophotocoagulation procedure. The G-probes were also examined under a slit lamp for signs of physical damage.

RESULTS

Repeated use of the G-probe in transscleral cyclophotocoagulation, with ethylene oxide sterilization in between, resulted in an average decrease of 3% in laser energy delivered per repeated cycle of use up to the fourth cycle. No signs of physical damage were found.

CONCLUSIONS

Laser G-probes remain functional after repeated use and ethylene oxide resterilization for up to four cycles. No visible physical damage to the probes was identified. It is safe and cost-effective to reuse G-probe for transscleral cyclophotocoagulation with ethylene oxide sterilization, provided the surgeon stays alert for signs of probe damage. This alertness should be retained regardless of whether new or old G-probes are used.

Efficacy and safety of immediate anterior chamber paracentesis in the treatment of acute primary angle-closure glaucoma: a pilot study

OBJECTIVE

To study the safety and effectiveness of immediate anterior chamber paracentesis, combined with antiglaucomatous medications, in the intraocular pressure control and relief of symptoms of acute primary angle-closure glaucoma (PACG).

DESIGN

Prospective noncomparative case series.

PARTICIPANTS

Eight consecutive patients with their first attack of acute PACG, with intraocular pressure > or =50 mmHg, were recruited into the study.

INTERVENTION

On presentation, each patient received topical pilocarpine (4%) and timolol (0.5%), immediate anterior chamber paracentesis, and systemic acetazolamide and mannitol as primary treatment. The intraocular pressures at 15 and 30 minutes, and then at 1, 2, 3, 12, and 24 hours, were documented by applanation tonometry.

MAIN OUTCOME MEASURES

Symptoms, visual acuity, intraocular pressure, corneal edema, angle status on gonioscopy, pupillary size, and reaction.

RESULTS

Ten eyes of eight patients seen with acute PACG were recruited. The mean intraocular pressure was reduced from 66.6 +/- 9.1 mmHg to 15.1 +/- 3.5 mmHg immediately after paracentesis, and then to 17.1 +/- 7.0 mmHg at 15 minutes, 21.7 +/- 10.2 mmHg at 30 minutes, 22.7 +/- 11.0 mmHg at 1 hour, and 20.1 +/- 14.6 mmHg at 2 hours after paracentesis. The mean intraocular pressure was less than 21 mmHg at 2 hours and beyond. There was instant symptomatic relief for all patients. No complications from the paracentesis were encountered.

CONCLUSIONS

From this preliminary study, immediate paracentesis seems to be safe and effective in controlling the intraocular pressure and eliminating symptoms in acute PACG.