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Perforation of Contact Lenses*
726
NOTES, CASES, INSTRUMENTS
2. François, J. : Syndromes with congenital cataract : XVI Jackson Memorial Lecture. Am. J. Ophth., 52:207, 1961. 3. Butterworth, T., and Strean, L. P.: Clinical Genodertnatology. Baltimore, Williams & Wilkins, 1962, p. 56. 4. Müller, S. A., and Brunsting, L. A. : Cataracts associated with dermatologie disorders. Arch. Derm., 88:330-339 (Sept.) 1963. 5. Marshall, D. : Ectodermal dysplasia : Report of a kindred with ocular abnormalities and hearing defect. Am. J. Ophth., 45:143 (Apr. Pt. I I ) , 1958. 6. Gregory, I. D. R. : Congenital ectodermal dysplasia. Brit. J. Ophth., 39:44, 1955. 7. Silver, H., and Robinson, A. : Rothmund-Thomson syndrome. To be published. 8. Rothmund, A. : Cataracts in association with a peculiar degeneration of the skin. Arch. f. Ophth., 14:159, 1868. 9. Thomson, M. S. : A hitherto undescribed familial disease. Brit. J. Derm., 35 :455-462, 1923. 10. Merz, E. H., Tausk, K., and Dukes, E.: Meso-ectodermal dysplasia and its variants: With particular reference to the Rothmund-Werner syndrome. Am. J. Ophth., 55 :488, 1963.
PERFORATION OF CONTACT LENSES*
(1) after the usual "loosening" processes fail, this is the last hope of success; (2) when lenses ride high or to one side so the FOR CORNEAL EDEMA patient sees the edge, a large lens that ordinarily would cause edema can be fitted with HERSCHELL H. BOYD, M.D. Bellevue, Washington holes; (3) a nonblinker can be successfully treated; (4) a heavy hyperopic lens which A method of treating corneal edema secrides inferiorly can be lightened by making ondary to contact lens wearing by perforateight to 10 holes so that it will center proping the lenses with holes, the causes of the erly; (5) air bubbles that do not disappear edema and a statistical analysis of 900 conwith the usual "loosening" technique may be secutive cases, from September, 1962, to removed by drilling holes in the area overlySeptember, 1964, is described. ing the bubbles. The causes of edema from contact lenses The disadvantages of perforated lenses are : ( 1 ) wrong base curve, size, peripheral are: (1) technically the perforating is a bevel, intermediary bevels, poor edge finishsomewhat tedious process, the usual "loosing; (2) incomplete blink; (3) insufficient ening" of lenses being far easier; (2) too rate of blinking; (4) lens does not rotate many holes and too large holes may make with blinking ; (5) squinting; (6) lens rides vision too watery for the patient to tolerate low, moves too much when patient blinks, the lenses; (3) if the holes are not well polcausing watery vision and, consequently, the ished, the plastic burrs scratch the cornea; patient does not blink shut. Even with the usual methods of dealing with this problem, by making lenses smaller, increasing bevels and providing steeper base curves, some patients still have corneal edema. The inadequate blinker must do one of three things: (1) give up wearing contact lenses; (2) begin to blink properly; (3) have holes drilled in the lenses. The advantages of perforated lenses are: * Presented at the annual meeting of the Contact Lens Association of Ophthalmologists, Chicago, October 19, 1964.
Fig. 1 (Boyd). Lens blanks, showing other possible configurations of the fenestrations.
NOTES, CASES, INSTRUMENTS if too much polishing is done, the optics become poor. Review of 900 consecutive contact lens patients showed that 7.5% had holes drilled in their lenses and that 0.5% who could not tolerate the holes were listed as failures. Of these 900 cases, 86% were myopic, 14% were hyperopic; 6.0% of the myopes and 14% of the hyperopes had holes drilled in their lenses. The increased number of hyperopic lenses drilled suggests that hyperopes do not blink their eyes completely shut and that something must be done to get oxygen to the cornea. In a previous report* on 1,000 consecutive contact lens cases, 5% were failures for
727
Hg. 4 (Boyd). Lens with five 0.30-mm holes.
* Boyd, H. H. : One thousand consecutive contact lens cases. Northwest Med. (Seattle), 61:933-936 (Nov.) 1962.
Fig. 5 (Boyd). Lens with nine 0.30-mm holes.
Fig. 2 (Boyd). Another group of lens blanks with other possible configurations.
Fig. 3 (Boyd). Lens with four 0.30-mm holes.
various reasons. In this series of cases 2.5% were failures for all reasons. If one assumes that ability in fitting remained the same, one can say that drilling holes in lenses gave a higher success rate in fitting contact lenses, the definition of success being ability to wear the lenses during waking hours with no damage to the cornea and with satisfaction. It should be noted that all of the patients in the present study who were considered failures could wear their lenses all day without damage to the cornea; they found that contact lenses were not what they had anticipated, for their visual and emotional problems remained unsolved. Usually four 0.30-mm holes are drilled in the periphery of the lens 1.0 mm inside the bevels. If this is not adequate a central hole of 0.30 mm is added. When this is not sue-
NOTES, CASES, INSTRUMENTS
728
U S E O F ACETYLCHOLINE IN P E R I P H E R A L IRIDECTOMY* RONNIE R. RAY,
M.D.
Brooklyn, Neiv York
Fig. 6 (Boyd). Lens with five 0.40-mm and four 0.30-mm holes. cessful, another four holes may be drilled. As a last resort four more holes may be added. Possible configurations of holes in contact lenses are shown in Figures 1 and 2. Some or all of the holes (figs. 1 and 2) may be enlarged to 0.40 mm. Need for this adjustment can be determined by viewing the cornea with the slitlamp to see which holes or which area of the lens needs "opening" to allow the tears to flow through the lens. Holes as small as 0.20 mm fill with mucus and are unsatisfactory. SUMMARY
Treatment of corneal edema due to contact lenses has been discussed. Holes of 0.30-mm and 0.40-mm diameter are drilled in the lenses. The advantages and disadvantages have been reviewed. Examples of several patients are shown (figs. 3, 4, 5 and 6). This method has improved my success rate from 95% to 97.5%. 1199 116th Avenue, N.E. (98004).
It is often found that the difficulties encountered in doing a peripheral iridectomy are not just those of causing the peripheral iris to prolapse but also those attendant upon repositing the iris into the anterior chamber. If after the iridectomy iris tissue remains incarcerated in the incision, the following methods may be tried : mechanical stroking of the cornea away from the wound, saline irrigation of the incision site, additional resection of iris tissue, substituting a light blepharostat for a solid-bladed blepharostat, thus reducing any possible pressure on the globe, or enlarging the original incision. Each or any combination of these methods may or may not lead to successful reposition of the iris. The use of a miotic agent to pull the iris away from the incision is another approach. However, it is disappointing to find that after the topical application of miotics other than acetylcholine, usually no rapid progress is made in changing the position of the iris. Acetylcholine is the chemical mediator of the postganglionic parasympathetic nerve fibers to the iris sphincter, and long clinical usage of this physiologic agent in the anterior chamber has shown that it induces no deleterious changes. For this reason, instead of resorting to pilocarpine, we have been irrigating the wound site with a 1:100 solution of acetylcholine through a blunt-tipped silver needle. This produces sufficient retraction of the prolapsing iris to permit irrigation of the anterior chamber with acetylcholine, thus exposing the entire iris sphincter to the action of the drug. An additional advantage of irrigation of the anterior chamber with acetylcholine is ♦From the Section of Ophthalmology (Chief: Dr. R. D. Binkhorst), Surgical Service (Chief: Dr. H. H. LeVeen) Brooklyn Veterans Administration Hospital.
NOTES, CASES, INSTRUMENTS
2. François, J. : Syndromes with congenital cataract : XVI Jackson Memorial Lecture. Am. J. Ophth., 52:207, 1961. 3. Butterworth, T., and Strean, L. P.: Clinical Genodertnatology. Baltimore, Williams & Wilkins, 1962, p. 56. 4. Müller, S. A., and Brunsting, L. A. : Cataracts associated with dermatologie disorders. Arch. Derm., 88:330-339 (Sept.) 1963. 5. Marshall, D. : Ectodermal dysplasia : Report of a kindred with ocular abnormalities and hearing defect. Am. J. Ophth., 45:143 (Apr. Pt. I I ) , 1958. 6. Gregory, I. D. R. : Congenital ectodermal dysplasia. Brit. J. Ophth., 39:44, 1955. 7. Silver, H., and Robinson, A. : Rothmund-Thomson syndrome. To be published. 8. Rothmund, A. : Cataracts in association with a peculiar degeneration of the skin. Arch. f. Ophth., 14:159, 1868. 9. Thomson, M. S. : A hitherto undescribed familial disease. Brit. J. Derm., 35 :455-462, 1923. 10. Merz, E. H., Tausk, K., and Dukes, E.: Meso-ectodermal dysplasia and its variants: With particular reference to the Rothmund-Werner syndrome. Am. J. Ophth., 55 :488, 1963.
PERFORATION OF CONTACT LENSES*
(1) after the usual "loosening" processes fail, this is the last hope of success; (2) when lenses ride high or to one side so the FOR CORNEAL EDEMA patient sees the edge, a large lens that ordinarily would cause edema can be fitted with HERSCHELL H. BOYD, M.D. Bellevue, Washington holes; (3) a nonblinker can be successfully treated; (4) a heavy hyperopic lens which A method of treating corneal edema secrides inferiorly can be lightened by making ondary to contact lens wearing by perforateight to 10 holes so that it will center proping the lenses with holes, the causes of the erly; (5) air bubbles that do not disappear edema and a statistical analysis of 900 conwith the usual "loosening" technique may be secutive cases, from September, 1962, to removed by drilling holes in the area overlySeptember, 1964, is described. ing the bubbles. The causes of edema from contact lenses The disadvantages of perforated lenses are : ( 1 ) wrong base curve, size, peripheral are: (1) technically the perforating is a bevel, intermediary bevels, poor edge finishsomewhat tedious process, the usual "loosing; (2) incomplete blink; (3) insufficient ening" of lenses being far easier; (2) too rate of blinking; (4) lens does not rotate many holes and too large holes may make with blinking ; (5) squinting; (6) lens rides vision too watery for the patient to tolerate low, moves too much when patient blinks, the lenses; (3) if the holes are not well polcausing watery vision and, consequently, the ished, the plastic burrs scratch the cornea; patient does not blink shut. Even with the usual methods of dealing with this problem, by making lenses smaller, increasing bevels and providing steeper base curves, some patients still have corneal edema. The inadequate blinker must do one of three things: (1) give up wearing contact lenses; (2) begin to blink properly; (3) have holes drilled in the lenses. The advantages of perforated lenses are: * Presented at the annual meeting of the Contact Lens Association of Ophthalmologists, Chicago, October 19, 1964.
Fig. 1 (Boyd). Lens blanks, showing other possible configurations of the fenestrations.
NOTES, CASES, INSTRUMENTS if too much polishing is done, the optics become poor. Review of 900 consecutive contact lens patients showed that 7.5% had holes drilled in their lenses and that 0.5% who could not tolerate the holes were listed as failures. Of these 900 cases, 86% were myopic, 14% were hyperopic; 6.0% of the myopes and 14% of the hyperopes had holes drilled in their lenses. The increased number of hyperopic lenses drilled suggests that hyperopes do not blink their eyes completely shut and that something must be done to get oxygen to the cornea. In a previous report* on 1,000 consecutive contact lens cases, 5% were failures for
727
Hg. 4 (Boyd). Lens with five 0.30-mm holes.
* Boyd, H. H. : One thousand consecutive contact lens cases. Northwest Med. (Seattle), 61:933-936 (Nov.) 1962.
Fig. 5 (Boyd). Lens with nine 0.30-mm holes.
Fig. 2 (Boyd). Another group of lens blanks with other possible configurations.
Fig. 3 (Boyd). Lens with four 0.30-mm holes.
various reasons. In this series of cases 2.5% were failures for all reasons. If one assumes that ability in fitting remained the same, one can say that drilling holes in lenses gave a higher success rate in fitting contact lenses, the definition of success being ability to wear the lenses during waking hours with no damage to the cornea and with satisfaction. It should be noted that all of the patients in the present study who were considered failures could wear their lenses all day without damage to the cornea; they found that contact lenses were not what they had anticipated, for their visual and emotional problems remained unsolved. Usually four 0.30-mm holes are drilled in the periphery of the lens 1.0 mm inside the bevels. If this is not adequate a central hole of 0.30 mm is added. When this is not sue-
NOTES, CASES, INSTRUMENTS
728
U S E O F ACETYLCHOLINE IN P E R I P H E R A L IRIDECTOMY* RONNIE R. RAY,
M.D.
Brooklyn, Neiv York
Fig. 6 (Boyd). Lens with five 0.40-mm and four 0.30-mm holes. cessful, another four holes may be drilled. As a last resort four more holes may be added. Possible configurations of holes in contact lenses are shown in Figures 1 and 2. Some or all of the holes (figs. 1 and 2) may be enlarged to 0.40 mm. Need for this adjustment can be determined by viewing the cornea with the slitlamp to see which holes or which area of the lens needs "opening" to allow the tears to flow through the lens. Holes as small as 0.20 mm fill with mucus and are unsatisfactory. SUMMARY
Treatment of corneal edema due to contact lenses has been discussed. Holes of 0.30-mm and 0.40-mm diameter are drilled in the lenses. The advantages and disadvantages have been reviewed. Examples of several patients are shown (figs. 3, 4, 5 and 6). This method has improved my success rate from 95% to 97.5%. 1199 116th Avenue, N.E. (98004).
It is often found that the difficulties encountered in doing a peripheral iridectomy are not just those of causing the peripheral iris to prolapse but also those attendant upon repositing the iris into the anterior chamber. If after the iridectomy iris tissue remains incarcerated in the incision, the following methods may be tried : mechanical stroking of the cornea away from the wound, saline irrigation of the incision site, additional resection of iris tissue, substituting a light blepharostat for a solid-bladed blepharostat, thus reducing any possible pressure on the globe, or enlarging the original incision. Each or any combination of these methods may or may not lead to successful reposition of the iris. The use of a miotic agent to pull the iris away from the incision is another approach. However, it is disappointing to find that after the topical application of miotics other than acetylcholine, usually no rapid progress is made in changing the position of the iris. Acetylcholine is the chemical mediator of the postganglionic parasympathetic nerve fibers to the iris sphincter, and long clinical usage of this physiologic agent in the anterior chamber has shown that it induces no deleterious changes. For this reason, instead of resorting to pilocarpine, we have been irrigating the wound site with a 1:100 solution of acetylcholine through a blunt-tipped silver needle. This produces sufficient retraction of the prolapsing iris to permit irrigation of the anterior chamber with acetylcholine, thus exposing the entire iris sphincter to the action of the drug. An additional advantage of irrigation of the anterior chamber with acetylcholine is ♦From the Section of Ophthalmology (Chief: Dr. R. D. Binkhorst), Surgical Service (Chief: Dr. H. H. LeVeen) Brooklyn Veterans Administration Hospital.