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Unusual corneal ring
1551
LETTERS
In the industrialized world, intumescent cataracts are very rare. In Europe, most patients have cataract surgery earlier. Given that fact, a study of 41 eyes with intumescent white cataract is certainly not small, but rather as good as it gets. We agree that it was not our prime intention to use the soft-shell technique introduced by Arshinoff. To abstain from using a dispersive OVD results in a rapid outflow without the need for major irrigation maneuvers. Protecting the endothelium was not the major concern since in these eyes, the liquefied cortex and the lens material can be easily aspirated or drain off themselves. Applying a cohesive OVD in these cases is absolutely sufficient, as the study shows nicely. Adding Healon5 to create a central indentation of the anterior lens capsule leads to better results (as shown). It should not, however, be considered a soft-shell technique but rather a limited approach to specifically indent the central part of the lens capsule. A study of the advantages of soft-shell techniques (whichever variant) would be valuable, and we strongly encourage surgeons to contribute to our knowledge.2 We are completely content with the findings in our study, which showed the efficiency of selectively injecting an OVD of high viscosity centrally and targeting the anterior lens capsule in providing very satisfactoryd or rather outright gooddclinical results. It should be noted that in Europe the soft-shell technique is not widely used. We fully agree with Dr. Arshinoff that there is some confusion. Numerous OVDs currently available are marketed with conflicting claims about their properties. We strongly encourage all colleagues to use the accepted classification categories.3 This confusion was fortunately avoidable in this trial because we used the Healon family, which has been exceptionally well investigated in regard to physicochemical and other properties for a given task.4,5 We cordially acknowledge and congratulate Dr. Arshinoff on his great scientific work and teaching endeavors on OVDs. His contributions are landmarks in this field; there is by far not enough room here to honor his research appropriately. We would like to encourage other researchers worldwide to conduct prospective clinical trials to evaluate the value of the suggested (tri) soft-shell technique.2 One of the authors (H.B.D.) would also like to take the opportunity to express his appreciation (and fond memories) of the many courses and lectures at international meetings during which he had the honor to meet with Dr. Arshinoff, whose research and impressive didactical qualities cannot be valued highly enough. The current study deals with a simplified surgical technique that led to surprisingly good results in
complex situations. Future clinical studies comparing this method with optimized techniques will certainly contribute to making cataract surgery even safer for a rare breed of patients; that is, those with the almost “extinct” intumescent cataract.dFritz H. Hengerer, MD, PhD, H. Burkhard Dick, MD, PhD, Thomas Kohnen, MD, PhD, Ina Conrad-Hengerer, MD REFERENCES 1. Arshinoff SA. Dispersive-cohesive viscoelastic soft shell technique. J Cataract Refract Surg 1999; 25:167–173 2. Arshinoff SA, Norman R. Tri-soft shell technique. J Cataract Refract Surg 2013; 39:1196–1203 3. Arshinoff SA, Jafari M. New classification of ophthalmic viscosurgical devicesd2005. J Cataract Refract Surg 2005; 31:2167–2171 4. Dick HB, Schwenn O. Viscoelastics in Ophthalmic Surgery. Berlin, Springer-Verlag, 2000 5. Dick HB, Krummenauer F, Augustin AJ, Pakula T, Pfeiffer N. Healon5 viscoadaptive formulation: comparison to Healon and Healon GV. J Cataract Refract Surg 2001; 27:320–326
Unusual corneal ring In the April 2015 consultation section,1 several responses stated that this condition was first described by Ascher et al. in 1964. For the sake of historical correctness, this condition was first described in 1963 at the 65th Deutsche Ophthalmologischen Gesellschaft held in Heidelberg in 1963.2 The confusion arises because the proceedings of the conference were not published until 1964. Dr. Ascher was the only presenter, so “et al.” is also incorrect. Reva Hurtes Miami, Florida, USA REFERENCES 1. Moshirfar M. Corneal surgical problem. J Cataract Refract Surg 2015; 41:895–899 €hnliche Hornhautringe [Unusual corneal 2. Ascher KW. Ungewo ring]. Dtsch Ophthalmol Ges 1963; 65:44–46
Note: The errors regarding the Ascher reference in the consultation section were editorial oversights, not a mistake by any of the respondents or by the section editor, Dr. Moshirfar.dWendy Veselick Pacheco
Corneal ectasia after femtosecond laser–assisted small-incision lenticule extraction in eyes with subclinical keratoconus/forme fruste keratoconus In the case report by El-Naggar,1 a patient with “subclinical keratoconus/forme fruste keratoconus” who developed “bilateral ectasia following
J CATARACT REFRACT SURG - VOL 41, JULY 2015
LETTERS
In the industrialized world, intumescent cataracts are very rare. In Europe, most patients have cataract surgery earlier. Given that fact, a study of 41 eyes with intumescent white cataract is certainly not small, but rather as good as it gets. We agree that it was not our prime intention to use the soft-shell technique introduced by Arshinoff. To abstain from using a dispersive OVD results in a rapid outflow without the need for major irrigation maneuvers. Protecting the endothelium was not the major concern since in these eyes, the liquefied cortex and the lens material can be easily aspirated or drain off themselves. Applying a cohesive OVD in these cases is absolutely sufficient, as the study shows nicely. Adding Healon5 to create a central indentation of the anterior lens capsule leads to better results (as shown). It should not, however, be considered a soft-shell technique but rather a limited approach to specifically indent the central part of the lens capsule. A study of the advantages of soft-shell techniques (whichever variant) would be valuable, and we strongly encourage surgeons to contribute to our knowledge.2 We are completely content with the findings in our study, which showed the efficiency of selectively injecting an OVD of high viscosity centrally and targeting the anterior lens capsule in providing very satisfactoryd or rather outright gooddclinical results. It should be noted that in Europe the soft-shell technique is not widely used. We fully agree with Dr. Arshinoff that there is some confusion. Numerous OVDs currently available are marketed with conflicting claims about their properties. We strongly encourage all colleagues to use the accepted classification categories.3 This confusion was fortunately avoidable in this trial because we used the Healon family, which has been exceptionally well investigated in regard to physicochemical and other properties for a given task.4,5 We cordially acknowledge and congratulate Dr. Arshinoff on his great scientific work and teaching endeavors on OVDs. His contributions are landmarks in this field; there is by far not enough room here to honor his research appropriately. We would like to encourage other researchers worldwide to conduct prospective clinical trials to evaluate the value of the suggested (tri) soft-shell technique.2 One of the authors (H.B.D.) would also like to take the opportunity to express his appreciation (and fond memories) of the many courses and lectures at international meetings during which he had the honor to meet with Dr. Arshinoff, whose research and impressive didactical qualities cannot be valued highly enough. The current study deals with a simplified surgical technique that led to surprisingly good results in
complex situations. Future clinical studies comparing this method with optimized techniques will certainly contribute to making cataract surgery even safer for a rare breed of patients; that is, those with the almost “extinct” intumescent cataract.dFritz H. Hengerer, MD, PhD, H. Burkhard Dick, MD, PhD, Thomas Kohnen, MD, PhD, Ina Conrad-Hengerer, MD REFERENCES 1. Arshinoff SA. Dispersive-cohesive viscoelastic soft shell technique. J Cataract Refract Surg 1999; 25:167–173 2. Arshinoff SA, Norman R. Tri-soft shell technique. J Cataract Refract Surg 2013; 39:1196–1203 3. Arshinoff SA, Jafari M. New classification of ophthalmic viscosurgical devicesd2005. J Cataract Refract Surg 2005; 31:2167–2171 4. Dick HB, Schwenn O. Viscoelastics in Ophthalmic Surgery. Berlin, Springer-Verlag, 2000 5. Dick HB, Krummenauer F, Augustin AJ, Pakula T, Pfeiffer N. Healon5 viscoadaptive formulation: comparison to Healon and Healon GV. J Cataract Refract Surg 2001; 27:320–326
Unusual corneal ring In the April 2015 consultation section,1 several responses stated that this condition was first described by Ascher et al. in 1964. For the sake of historical correctness, this condition was first described in 1963 at the 65th Deutsche Ophthalmologischen Gesellschaft held in Heidelberg in 1963.2 The confusion arises because the proceedings of the conference were not published until 1964. Dr. Ascher was the only presenter, so “et al.” is also incorrect. Reva Hurtes Miami, Florida, USA REFERENCES 1. Moshirfar M. Corneal surgical problem. J Cataract Refract Surg 2015; 41:895–899 €hnliche Hornhautringe [Unusual corneal 2. Ascher KW. Ungewo ring]. Dtsch Ophthalmol Ges 1963; 65:44–46
Note: The errors regarding the Ascher reference in the consultation section were editorial oversights, not a mistake by any of the respondents or by the section editor, Dr. Moshirfar.dWendy Veselick Pacheco
Corneal ectasia after femtosecond laser–assisted small-incision lenticule extraction in eyes with subclinical keratoconus/forme fruste keratoconus In the case report by El-Naggar,1 a patient with “subclinical keratoconus/forme fruste keratoconus” who developed “bilateral ectasia following
J CATARACT REFRACT SURG - VOL 41, JULY 2015