Topical versus sub-Tenon's anesthesia without sedation in cataract surgery

PURPOSE

To compare pain control using topical anesthesia with that using sub-Tenon's anesthesia for clear corneal phacoemulsification cataract surgery and foldable intraocular lens (IOL) implantation.

SETTING

Departments of Ophthalmology, General Hospital Asklepeion Voulas and General Hospital of Athens, University of Athens, Athens, Greece.

METHODS

One hundred consecutive patients scheduled for bilateral cataract surgery 1 to 2 months apart were prospectively randomized to receive topical anesthesia (100 eyes) or sub-Tenon's anesthesia (100 eyes). The randomization was stratified so that one half of first-eye surgeries and one half of second-eye surgeries were assigned to each anesthesia group, with each patient receiving each type of anesthesia once. All patients had clear corneal phacoemulsification with foldable IOL implantation. Patients were asked to rate their pain level on a 10-point scale for 4 periods: during the administration of the anesthetic agent, during surgery, immediately after surgery, and 24 hours postoperatively. The surgeon recorded his subjective assessment of ease of surgery and surgical complications using a standardized template.

RESULTS

Eighty-one percent of patients who received topical anesthesia and 8% of patients who received sub-Tenon's anesthesia reported no pain during delivery of the anesthetic agent. The mean pain score was 0.19 +/- 0.39 (SD) in the topical group and 1.35 +/- 0.63 in the sub-Tenon's group. The difference between groups was statistically significant (P <.001). Seventy-two percent of patients in the topical anesthesia group and 86% in the sub-Tenon's anesthesia group reported no pain or slight discomfort during surgery (mean score 1.13 +/- 1.57 and 0.57 +/- 1.28, respectively) (P <.001). Ninety percent of topical anesthesia patients and 100% of sub-Tenon's anesthesia patients reported no pain or slight discomfort 30 minutes postoperatively (mean score 0.80 +/- 0.93 and 0.12 +/- 036, respectively) (P <.001). All patients in the topical anesthesia group and 77% in the sub-Tenon's group reported no pain 24 hours postoperatively (mean pain 0.00 +/- 0.00 and 0.23 +/- 0.40, respectively) (P <.001). Complications including prolonged akinesia of the globe, chemosis, and conjunctival hemorrhage occurred significantly more frequently in the sub-Tenon's than in the topical group (P <.001).

CONCLUSIONS

Patients having cataract surgery under topical anesthesia had more intraoperative and postoperative discomfort than patients receiving sub-Tenon's anesthesia. However, patients having topical anesthesia reported less pain during its administration and had fewer complications. Both anesthesia methods provided high levels of pain control without additional sedation.

Recurrent nodular scleritis associated with varicella zoster virus

PURPOSE

To describe a case of recurrent nodular scleritis that was apparently caused by reactivation of a varicella zoster virus infection.

METHODS

Case report. Immunohistochemistry and polymerase chain reaction were used to detect viral antigen and DNA in the biopsy specimen of inflamed sclera of a patient with a history of recurrent nodular scleritis.

High levels of interleukin-12 in the aqueous humor and vitreous of patients with uveitis

OBJECTIVE

This study aimed to investigate the role of interleukin-12 (IL-12) and interleukin-10 (IL-10) in initiation and maintenance of intraocular inflammation.

DESIGN

Case series.

PARTICIPANTS

Aqueous humor and vitreous levels of IL-12 and IL-10 were measured in 22 patients with uveitis undergoing cataract surgery, paracentesis of the anterior chamber, and/or vitrectomy for diagnostic reasons, and in 4 patients with cataract only.

INTERVENTION

Aqueous humor and vitreous levels of IL-12 and IL-10 were measured with specific enzyme-linked immunosorbent assays.

MAIN OUTCOME MEASURES

Disease activity was correlated to IL-12 levels in the aqueous humor and the vitreous of patients with uveitis.

RESULTS

Cytokine levels found in the anterior chamber and the vitreous are presented in picogram/milliliter (medium; range). The highest IL-12 levels were found in patients with active uveitis (108.5 pg/ml; 72-293 pg/ml). Interleukin-12 in patients with moderate uveitis or with their disease in remission was lower (32 pg/ml; 15-94 pg/ml) than in patients with active disease (P > 0.001) but higher than in the control group (10.5 pg/ml; 9-14 pg/ml). Interleukin-10 was detectable in only 3 of 22 patients with uveitis (12 pg/ml; 9-23 pg/ml).

CONCLUSION

The authors found statistically significant differences of IL-12 levels in the various patient groups (active vs. inactive vs. control). These results support the idea that these uveitis cases represent type 1 (Th1)-T lymphocyte-mediated diseases in which IL-12 plays a pivotal role in the initiation and maintenance of the intraocular inflammation. The high levels of IL-12 in the vitreous and/or aqueous humor of the patients with uveitis suggest that susceptibility or resistance to ocular autoimmunity may be connected to a genetic predisposition to an elevated Th1 response.

Ocular cicatricial pemphigoid antigen: partial sequence and biochemical characterization

Ocular cicatricial pemphigoid (OCP) is an autoimmune disease that affects mainly conjunctiva and other squamous epithelia. OCP is histologically characterized by a separation of the epithelium from underlying tissues within the basement membrane zone. Immunopathological studies demonstrate the deposition of anti-basement membrane zone autoantibodies in vivo. Purified IgG from sera of patients with active OCP identified a cDNA clone from a human keratinocyte cDNA library that had complete homology with the cytoplasmic domain of beta 4-integrin. The sera recognized a 205-kDa protein in human epidermal, human conjunctiva, and tumor cell lysates that was identified as beta 4-integrin by its reaction with polyclonal and monoclonal antibodies to human beta 4-integrin. Sera from patients with bullous pemphigoid, pemphigus vulgaris, and cicatricial pemphigoid-like diseases did not recognize the 205-kDa protein, indicating the specificity of the binding. These data strongly implicate a role for human beta 4-integrin in the pathogenesis of OCP. It should be emphasized that multiple antigens in the basement membrane zone of squamous epithelia may serve as targets for a wide spectrum of autoantibodies observed in vesiculobullous diseases. Molecular definition of these autoantigens will facilitate the classification and characterization of subsets of cicatricial pemphigoid and help distinguishing them from bullous pemphigoid. This study highlights the function and importance of beta 4-integrin in maintaining the attachment of epithelial cells to the basement membrane.