Inflow of Ocular Surface Fluid Into the Anterior Chamber After Phacoemulsification Through Sutureless Corneal Cataract Wounds

We also agree that some of the higher success rates reported for endonasal DCRs come from surgeons who have spent a considerable number of years in learning this new technique and can not be extrapolated to the majority of oculoplastic surgeons, who are not equally experienced in performing endonasal lacrimal surgery. External DCR conversely gives consistently good results in most hands. We agree that “new is not always the best” and we must weigh the advantages carefully before switching to a new procedure and discarding the tried and tested method. We believe that since scarring is not a big issue with most external DCR patients, surgeons and patients should not feel pressured into the endonasal approach for the sole purpose of avoiding a scar. However, we recognize that the endonasal approach does have some advantages like the ease of releasing adhesions under direct visualization for failed DCRs3 and the avoidance of any external facial wound or bruising, no matter how short-lived. The need then is to carefully weigh the advantages of each approach against the cost and the learning curve involved. VIDUSHI SHARMA, MD, FRCS PETER A. MARTIN, FRANZCO ROSS BENGER, FRANZCO GINA KOURT, FRANZCO JENNY DANKS, FRANZCO

Sydney, Australia

Temporal clear corneal incisions were introduced in 1992. This technique popularized the use of topical anesthesia, which rapidly replaced block anesthesia as the method of choice.2 Topical anesthesia produces good anesthesia without akinesia of the extraocular muscles. Temporal clear corneal wounds can leak in the first 30 minutes after surgery, possibly as a result of digital pressure or forced blinking.3 A systematic review indicates that the incidence of endophthalmitis associated with cataract extraction has increased over the last decade. This upward trend in endophthalmitis frequency coincides temporally with the development of sutureless clear corneal incisions.4 Is the temporal relationship due to use of sutureless wounds or to use of topical anesthesia without akinesia, or both? If so, a return to block anesthesia with long-acting agents, with the resulting ocular muscle akinesia, may help solve the forced blink problem in the first few hours after surgery. Medical students learn in their third year the surgical principle of immobilizing a wound. Temporary immobilization of the corneal wound with extraocular muscle akinesia should give enough time for better wound sealing and epithelialization of the site. Use of a Fox shield overnight should protect the eye from digital pressure. These steps could allow phacoemulsification surgeons to continue, safely and in good conscience, the use of the preferred temporal clear corneal incision. WADE FAULKNER, MD

Mobile, Alabama REFERENCES

1. Barnes EA, Abou-Rayyah Y, Rose GE. Pediatric dacryocystorhinostomy for nasolacrimal duct obstruction. Ophthalmology 2001;108:1562–1564. 2. Sharma V, Martin PA, Benger R, et al. Evaluation of the cosmetic significance of external dacryocystorhinostomy scars. Am J Ophthalmol 2005;140:359 –362. 3. Benger R, Forer M. Endonasal dacryocystorhinostomy—primary and secondary. Aust N Z J Ophthalmol 1993;21:157– 159.

Inflow of Ocular Surface Fluid Into the Anterior Chamber After Phacoemulsification Through Sutureless Corneal Cataract Wounds

REFERENCES

1. Herretes S, Stark WJ, Pirouzmanesh A, et al. Inflow of ocular surface fluid into the anterior chamber after phacoemulsification through sutureless corneal cataract wounds. Am J Ophthalmol 2005;140:737–740. 2. Fine IH. Clear corneal incisions. Int Ophthalmol Clin 1994; 34:59 –72. 3. Shingleton BJ, Wadhwani RA, O’Donaghue MW, et al. Evaluation of intraocular pressure in the immediate period after phacoemulsification. J Cataract Refract Surg 2001;27:1709 –1710. 4. Taban M, Behrens A, Newcomb RL, et al. Acute endophthalmitis following cataract surgery; a systematic review of the literature. Arch Ophthalmol 2005;123:613– 620.

REPLY

EDITOR:

WE THANK DR FAULKNER FOR HIS INTEREST IN OUR RE-

THE REPORT OF HERRETES AND ASSOCIATES1 CONCERNING

port. He raises an interesting point in the use of topical anesthesia for cataract surgery as a potential variable to consider in the increased risk of endophthalmitis. We have also addressed this issue in a previously published systematic review of endophthalmitis after cataract surgery.1 Unfortunately, it was difficult in that evaluation to analyze this variable, because most of the authors did not report the anesthetic approach used in the series.

possible mechanisms for leakage and ingress of ocular surface fluid in the first several hours after surgery before wound healing for postoperative clear corneal phacoemulsification wounds is thought-provoking. A cannula was used to exert external pressure for one second on the scleral side of the wound and then abruptly released which simulated digital pressure or forced blinking. VOL. 141, NO. 4

CORRESPONDENCE

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