- Email: [email protected]
New Scleral Plugs for Use During Vitrectomy
VOL. 9 1 , NO. 6
NOTES, CASES, INSTRUMENTS
nique.1 An antibody titer of 1:256 in a bloo'd sample taken four weeks after the illness started was followed three weeks later by a drop in antibody titer to 1:64. Serologie tests for rubella by the hemagglutination inhibition technique2 were negative (1:8). IgG titers to herpes simplex virus in blood samples taken 19 and 25 days after the onset of clinical herpetic infec tion were 1:40 and 1:80 respectively, by the indirect immunoperoxidase antibody to membrane antigen technique.3 However, it should be noted that a 1:40 to 1:80 rise in antibody titer is not considered a significant rise diagnostically, and was probably the result of the serum samples being taken so close together. The diagnosis of herpes simplex viral infec tion was based on viral isolation. The removed comeal epithelium was cultured on human embryonic flbroblasts and herpes simplex was isolated and identified as type 1. DISCUSSION
Primary infection with herpes simplex is most common in the age groups be tween 6 months to 5 years and 16 to 25 years. The cornea is involved in 40% to 66% of cases of ocular infection, whereas bilateral comeal involvement is relatively uncommon (0.5% to 9.5% of cases).4"7 In our case, there was no history of herpes simplex infection in our patient or his family. Our patient was at the lower age limit of the high-risk group, and the main feature of his infection was bilateral corneal involvement accompanied by mild conjunctivitis. We know that there is a punctate keratitis with catarrhal conjunctivitis in many cases of measles.4 Bacterial conjunctivitis with bilateral corneal ulcers is possible in debilitated children.4 The possibility of bacterial secondary infection caused by the lowered immune response in measles has long been suspected.8,9 Recent stud ies of viral secondary infection caused by the altered immune response found in measles have implicated adenovirus and herpes simplex.10 In our case, the child developed an unusually severe bilateral corneal herpet ic infection that seemed to be related to his immunologie state. Possibly some of the reported cases of keratitis during measles or in malnourished children
797
were the result of herpes simplex virus infection. REFERENCES 1. Norrby, E., and Gollmar, Y.: Appearance and persistence of antibodies against different virus com ponents after regular measles infection. Infect. Immun. 6:240, 1972. 2. Rawls, W. E., and Chemesky, M. A.: Rubella virus. In Rose, N. R., and Friedman, H. (eds.): Man ual of Clinical Immunology. Washington, D.C., American Society for Microbiology, 1976, pp. 452455. 3. Haikin, H., Leventon-Kriss, S., and Sarov, I.: Antibody to varicella-zoster virus-induced mem brane antigen. Immunoperoxidase assay with airdried target cells. J. Infect. Dis. 140:601, 1979. 4. Duke-Elder, S.: Diseases of the Outer Eye. Conjunctiva. In System of Ophthalmology, vol. 8, pt. 1. St. Louis, C. V. Mosby, 1965, pp. 307-335. 5. Ostler, H. B.: Herpes simplex. The primary infection. Surv. Ophthalmol. 21:91, 1976. 6. Dawson, C. R., andTogmi, B.: Herpes simplex eye infections. Clinical manifestations, pathogenesis and management. Surv. Ophthalmol. 21:121, 1976. 7. Binder, P. S.: Herpes simplex keratitis. Surv. Ophthalmol. 21:313, 1977. 8. Morgan, E. M., and Rapp, F.: Measles virus and its associated diseases. Bacteriol. Rev. 41:636, 1977. 9. Jolly, H.: Diseases of Children, 2nd ed. Oxford, Blackwell Scientific Publications, 1974, pp. 464-467. 10. Coovadia, H. M., Wesley, A., Henderson, L. G., Brain, P., Vos, G. H., and Hallett, A. F.: Alterations in immune responsiveness in acute mea sles and chronic post-measles chest disease. Int. Arch. Allergy Appl. Immunol. 56:14, 1978.
NEW SCLERAL PLUGS FOR USE DURING VITRECTOMY EDWARD K. ISBEY III, M.D., DYSON HICKINGBOTHAM, AND MAURICE B. LANDERS III, M.D. Durham, North Carolina
We have devised two new scierai plugs for use in vitreous From the Duke University Eye Center, Durham, North Carolina. Reprint requests to Maurice B. Landers III, M.D., Duke Eye Center, Box 3802, Durham, NC 27710.
798
AMERICAN JOURNAL OF OPHTHALMOLOGY
JUNE, 1981
surgery when intraocular pres sure is not maintained by the orig inal 20-gauge plug as the incision stretches. Modification of the con figuration of the heads of the plugs facilitates their identification dur ing surgery, without hindering the surgeon's ability to handle them with scierai plug forceps.
We have devised two new selfretaining scierai incision plugs that ex pand the capacities of the scierai plugs designed by O'Malley and Tripp 1 for closed-eye intraocular surgery including vitrectomy. These new plugs, with shafts of 19-gauge and 18-gauge diameter, also have different head sizes to facilitate their identification during the surgical proce dure. The plugs vary in dimension (Fig. 1). The original 20-gauge plug has a head 2 mm in diameter. The new 19-gauge plug has a head 2.4 mm in diameter and the new 18-gauge plug has a head 2.8 mm in diameter. The shaft of all three plugs is 3 mm in length (Fig. 2). The diameter of the 20-gauge plug shaft is 0.9 mm; the 19-gauge shaft is 1.1 mm and the 18-gauge shaft 1.3 mm in diameter. They are made of a high-grade (No. 316) stain less steel. All the plugs fit in the autoclavable silicone plug holder. All three can be grasped and inserted with standard cap sule forceps or with scierai plug forceps.
Fig. 1 (Isbey, Hickingbotham, and Landers). Heads of 20-gauge (left), 19-gauge (middle), and 18-gauge (right) scierai plugs. The head of the 20-gauge plug is 2 mm in diameter, that of the 19-gauge plug is 2.4 mm, and that of the 18-gauge plug is 2.8 mm.
Fig. 2 (Isbey, Hickingbotham, and Landers). Head and shaft of new 19-gauge plug. The shaft has a length of 3 mm and a diameter of 1.1 mm.
The scierai plugs are used during vit rectomy and other types of closed-eye intraocular surgery whenever the inci sion sites need to be closed temporarily, such as when the eye is to be examined by indirect ophthalmoscopy during a vit rectomy. In long operations the scierai incisions tend to stretch and widen. The 20-gauge scierai plugs fit loosely into 20-gauge openings, but cannot withstand increased intraocular pressures. One solution to
VOL. 91, NO. 6
NOTES, CASES, INSTRUMENTS
this problem is a suture at one end of the incision with insertion of the 20-gauge plug. However, this procedure slows the operation and often does not completely solve the problem, because fluid can leak around the suture. The 19-gauge scierai plug can be inserted instead of the 20gauge plug and will maintain the intraoc ular pressure. If the original 20-gauge incision has become extremely stretched, it can be firmly plugged with an 18-gauge plug. The 18-gauge plugs can also be used to plug stretched incisions originally made for 19-gauge instruments. REFERENCE 1. O'Malley, C , and Tripp, R. M.: Plugs and stiletto. Entry incisions for a 20-gauge instrument system. Ophthalmic Surg. 8:76, 1977.
INCISION SPREADER FOR RADIAL KERATOTOMY JAMES P. G I L L S , M.D., DENNIS L. WILLIAMS, M.D., BRUCE M. KISKADDON, M.D., AND RANDY SPENCER New Port Rickey, Florida
We devised Colibri forceps with reversed points that allow the sur geon to determine the depth of an incision by direct visualization. Al though designed for radial kera-
From the St. Luke's Cataract and Intraocular Lens Clinic, New Port Richey, Florida. Reprint requests to James P. Gills, M.D., St. Luke's Cataract and Intraocular Lens Clinic, 118 High St., New Port Richey, FL 33552.
799
Fig. 1 (Gills and associates). Gills incision spread er (X9).
totomies, the forceps can be used in other procedures as well. In radial keratotomy it is essential that the incision extend to the proper depth if the correction obtained is to remain per manent. To ensure that the correct depth is reached, we devised forceps* that al low the surgeon to look into the kera totomy wound and determine the depth of the incision by direct visualization (Fig. 1). These Colibri forceps, which can also be used in other surgical procedures, have reversed points that spread the tis sues around the wound apart (Fig. 2). When the bottom of the incision is in the middle of the stroma, it looks cloudy. As the incision extends deeper, the bot tom of the wound becomes glistening and clear, indicating that further cutting is unnecessary. * Available from Storz Instrument Co., 3365 Tree Court Ind. Blvd., St. Louis, MO 63122 (No. E9015).
Fig. 2 (Gills and associates). Magnified view of the teeth of the Gills incision spreader (xll.5).
NOTES, CASES, INSTRUMENTS
nique.1 An antibody titer of 1:256 in a bloo'd sample taken four weeks after the illness started was followed three weeks later by a drop in antibody titer to 1:64. Serologie tests for rubella by the hemagglutination inhibition technique2 were negative (1:8). IgG titers to herpes simplex virus in blood samples taken 19 and 25 days after the onset of clinical herpetic infec tion were 1:40 and 1:80 respectively, by the indirect immunoperoxidase antibody to membrane antigen technique.3 However, it should be noted that a 1:40 to 1:80 rise in antibody titer is not considered a significant rise diagnostically, and was probably the result of the serum samples being taken so close together. The diagnosis of herpes simplex viral infec tion was based on viral isolation. The removed comeal epithelium was cultured on human embryonic flbroblasts and herpes simplex was isolated and identified as type 1. DISCUSSION
Primary infection with herpes simplex is most common in the age groups be tween 6 months to 5 years and 16 to 25 years. The cornea is involved in 40% to 66% of cases of ocular infection, whereas bilateral comeal involvement is relatively uncommon (0.5% to 9.5% of cases).4"7 In our case, there was no history of herpes simplex infection in our patient or his family. Our patient was at the lower age limit of the high-risk group, and the main feature of his infection was bilateral corneal involvement accompanied by mild conjunctivitis. We know that there is a punctate keratitis with catarrhal conjunctivitis in many cases of measles.4 Bacterial conjunctivitis with bilateral corneal ulcers is possible in debilitated children.4 The possibility of bacterial secondary infection caused by the lowered immune response in measles has long been suspected.8,9 Recent stud ies of viral secondary infection caused by the altered immune response found in measles have implicated adenovirus and herpes simplex.10 In our case, the child developed an unusually severe bilateral corneal herpet ic infection that seemed to be related to his immunologie state. Possibly some of the reported cases of keratitis during measles or in malnourished children
797
were the result of herpes simplex virus infection. REFERENCES 1. Norrby, E., and Gollmar, Y.: Appearance and persistence of antibodies against different virus com ponents after regular measles infection. Infect. Immun. 6:240, 1972. 2. Rawls, W. E., and Chemesky, M. A.: Rubella virus. In Rose, N. R., and Friedman, H. (eds.): Man ual of Clinical Immunology. Washington, D.C., American Society for Microbiology, 1976, pp. 452455. 3. Haikin, H., Leventon-Kriss, S., and Sarov, I.: Antibody to varicella-zoster virus-induced mem brane antigen. Immunoperoxidase assay with airdried target cells. J. Infect. Dis. 140:601, 1979. 4. Duke-Elder, S.: Diseases of the Outer Eye. Conjunctiva. In System of Ophthalmology, vol. 8, pt. 1. St. Louis, C. V. Mosby, 1965, pp. 307-335. 5. Ostler, H. B.: Herpes simplex. The primary infection. Surv. Ophthalmol. 21:91, 1976. 6. Dawson, C. R., andTogmi, B.: Herpes simplex eye infections. Clinical manifestations, pathogenesis and management. Surv. Ophthalmol. 21:121, 1976. 7. Binder, P. S.: Herpes simplex keratitis. Surv. Ophthalmol. 21:313, 1977. 8. Morgan, E. M., and Rapp, F.: Measles virus and its associated diseases. Bacteriol. Rev. 41:636, 1977. 9. Jolly, H.: Diseases of Children, 2nd ed. Oxford, Blackwell Scientific Publications, 1974, pp. 464-467. 10. Coovadia, H. M., Wesley, A., Henderson, L. G., Brain, P., Vos, G. H., and Hallett, A. F.: Alterations in immune responsiveness in acute mea sles and chronic post-measles chest disease. Int. Arch. Allergy Appl. Immunol. 56:14, 1978.
NEW SCLERAL PLUGS FOR USE DURING VITRECTOMY EDWARD K. ISBEY III, M.D., DYSON HICKINGBOTHAM, AND MAURICE B. LANDERS III, M.D. Durham, North Carolina
We have devised two new scierai plugs for use in vitreous From the Duke University Eye Center, Durham, North Carolina. Reprint requests to Maurice B. Landers III, M.D., Duke Eye Center, Box 3802, Durham, NC 27710.
798
AMERICAN JOURNAL OF OPHTHALMOLOGY
JUNE, 1981
surgery when intraocular pres sure is not maintained by the orig inal 20-gauge plug as the incision stretches. Modification of the con figuration of the heads of the plugs facilitates their identification dur ing surgery, without hindering the surgeon's ability to handle them with scierai plug forceps.
We have devised two new selfretaining scierai incision plugs that ex pand the capacities of the scierai plugs designed by O'Malley and Tripp 1 for closed-eye intraocular surgery including vitrectomy. These new plugs, with shafts of 19-gauge and 18-gauge diameter, also have different head sizes to facilitate their identification during the surgical proce dure. The plugs vary in dimension (Fig. 1). The original 20-gauge plug has a head 2 mm in diameter. The new 19-gauge plug has a head 2.4 mm in diameter and the new 18-gauge plug has a head 2.8 mm in diameter. The shaft of all three plugs is 3 mm in length (Fig. 2). The diameter of the 20-gauge plug shaft is 0.9 mm; the 19-gauge shaft is 1.1 mm and the 18-gauge shaft 1.3 mm in diameter. They are made of a high-grade (No. 316) stain less steel. All the plugs fit in the autoclavable silicone plug holder. All three can be grasped and inserted with standard cap sule forceps or with scierai plug forceps.
Fig. 1 (Isbey, Hickingbotham, and Landers). Heads of 20-gauge (left), 19-gauge (middle), and 18-gauge (right) scierai plugs. The head of the 20-gauge plug is 2 mm in diameter, that of the 19-gauge plug is 2.4 mm, and that of the 18-gauge plug is 2.8 mm.
Fig. 2 (Isbey, Hickingbotham, and Landers). Head and shaft of new 19-gauge plug. The shaft has a length of 3 mm and a diameter of 1.1 mm.
The scierai plugs are used during vit rectomy and other types of closed-eye intraocular surgery whenever the inci sion sites need to be closed temporarily, such as when the eye is to be examined by indirect ophthalmoscopy during a vit rectomy. In long operations the scierai incisions tend to stretch and widen. The 20-gauge scierai plugs fit loosely into 20-gauge openings, but cannot withstand increased intraocular pressures. One solution to
VOL. 91, NO. 6
NOTES, CASES, INSTRUMENTS
this problem is a suture at one end of the incision with insertion of the 20-gauge plug. However, this procedure slows the operation and often does not completely solve the problem, because fluid can leak around the suture. The 19-gauge scierai plug can be inserted instead of the 20gauge plug and will maintain the intraoc ular pressure. If the original 20-gauge incision has become extremely stretched, it can be firmly plugged with an 18-gauge plug. The 18-gauge plugs can also be used to plug stretched incisions originally made for 19-gauge instruments. REFERENCE 1. O'Malley, C , and Tripp, R. M.: Plugs and stiletto. Entry incisions for a 20-gauge instrument system. Ophthalmic Surg. 8:76, 1977.
INCISION SPREADER FOR RADIAL KERATOTOMY JAMES P. G I L L S , M.D., DENNIS L. WILLIAMS, M.D., BRUCE M. KISKADDON, M.D., AND RANDY SPENCER New Port Rickey, Florida
We devised Colibri forceps with reversed points that allow the sur geon to determine the depth of an incision by direct visualization. Al though designed for radial kera-
From the St. Luke's Cataract and Intraocular Lens Clinic, New Port Richey, Florida. Reprint requests to James P. Gills, M.D., St. Luke's Cataract and Intraocular Lens Clinic, 118 High St., New Port Richey, FL 33552.
799
Fig. 1 (Gills and associates). Gills incision spread er (X9).
totomies, the forceps can be used in other procedures as well. In radial keratotomy it is essential that the incision extend to the proper depth if the correction obtained is to remain per manent. To ensure that the correct depth is reached, we devised forceps* that al low the surgeon to look into the kera totomy wound and determine the depth of the incision by direct visualization (Fig. 1). These Colibri forceps, which can also be used in other surgical procedures, have reversed points that spread the tis sues around the wound apart (Fig. 2). When the bottom of the incision is in the middle of the stroma, it looks cloudy. As the incision extends deeper, the bot tom of the wound becomes glistening and clear, indicating that further cutting is unnecessary. * Available from Storz Instrument Co., 3365 Tree Court Ind. Blvd., St. Louis, MO 63122 (No. E9015).
Fig. 2 (Gills and associates). Magnified view of the teeth of the Gills incision spreader (xll.5).