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Acute Intraoperative Suprachoroidal Hemorrhage
method as well as with the modified SRK method to the axial length, the corneal power, and the postoperative chamber depth, but found no significant association. Probably a random combination of measurement errors accounts for the large error, when it occurs.
ACUTE INTRAOPERATIVE SUPRACHOROIDAL HEMORRHAGE To the Editor: I would like to add my congratulations to Dr. James Davison regarding his article ''Acute Intraoperative Suprachoroidal Hemorrhage in Extracapsular Cataract Surgery" U Cataract Refract Surg 12:606-622, 1986). With an experience extending to over 12,000 cases of extracapsular surgery in the past 12 years, I have encountered the same problem with a relatively common frequency. I would like to contribute two points from my experience with this problem: Of all the factors that seem to be involved, one that Dr. Davison refers to seems to be by far the most significant; that is, this problem seems to occur almost entirely in the very elderly patient, increasing in incidence in proportion to the number of patients in the 80s and 90s, but it certainly can occur in patients in the 70s. It seems to be extremelv uncommon below the age of70. One thing I have don~ to attempt to decrease this incidence in the quite elderly is that although I do not routinely use sodium hyaluronate (Healon®) or other viscoeleastic material in most of my cases, when I am operating on a patient over the age of 8.5 or 90, I usually fill the anterior chamber with Healon® as soon as it is opened. My goal is to dampen or suppress the marked fluctuations in intraocular pressure which I believe can contribute to vascular leakage behind the eye. The second point I would like to make is that Dr. Lindstrom refers to using phacoemulsification because it reduces the risk of severe damage from this problem (Acute intraoperative suprachoroidal hemorrhage, ] Cataract Refract Surg 13:215-216, 1987). I believe that it would be difficult to argue that a small incision is probably easier to control than a larger one. Nevertheless, using a planned extracapsular type of incision and procedure in the majority of my cases, I have always been able to abort these episodes by a very rapid installation of sutures at the first sign of a pressure problem. It is certainly correct that with some experience you can pick this up quite early as you become alert to its first signs. My point is that ifone is using phaco, this is probably of slight additional benefit, but I believe that to use this as a reason for teaching phaco, which in my opinion has some additional risks that are not referred to by Dr. Lindstrom, is perhaps not a valid reason. David D. Dulaney, M.D.
Sun City, Arizona
ANTERIOR CHAMBER MAINTAINER DEVICE To the Editor: I read with interest an article published in the March 1987 issue entitled ''Anterior Chamber Maintainer for Extracapsular Cataract Extraction and Intraocular Lens Implantation" by Drs. Michael Blumenthal and Joseph Moisseiev (pages 204-206). The reason for my letter is to point out that this anterior chamber maintainer device is merely a reinvention and copy of an anterior chamber maintainer device developed by Spencer P. Thornton, M.D., of Nashville, Tennessee, in the early 1970s. Not only do I feel that Dr. Thornton should receive credit for his work 15 years ago on this product, but also Concept, Inc., should be acknowledged for marketing this "old, new idea" to ophthalmologists over the years. Patrick A. Brady Concept, Inc. Clearwater, Florida
INJECTABLE PROSTAGLANDIN INHIBITORS PRIOR TO CATARACT SURGERY To the Editor: Indomethacin (1 mg vials indomethacin; add 2 cc water; 1 mgl2 cc; add .4 vials (8 cc) to 52 cc of xylocaine with 1 % epinephrine = total volume 60 cc (mixture). Inject 1.5 cc xylocaine = 0.1 mg indocin; injection subconj.) was injected prior to cataract surgery in 200 eyes. The inhibition of intraoperative miosis and antiinflammatory effect was greater than with the prostaglandin inhibitor drops, Ocufen® (fluriproben sodium). Indomethacin 1 mm vials were divided so that 1/10 mg was given in each retrobulbar injection one hour prior to surgery. The following changes were noted as compared to the eyes not injected: 1. Dilation of the pupil was marked. This allowed phacoemulsification in a greater percentage of cases than was possible prior to this regimen. 2. Postoperative flare and cell were seen much less frequently and to a lesser degree than before the injectable was used. Adverse effects (that may be related to the drug) are slight chemosis and minimal ecchymosis. This is the first report I know of injection of nonsteroidal anti-inflammatory protaglandin inhibitors for the prevention of inflammation at cataract surgery. I would like to encourage others to study this with various drugs and techniques. I believe the development of the concept holds great opportunity for
J CATARACT REFRACT SURG-VOL 13, JULY 1987
459
ACUTE INTRAOPERATIVE SUPRACHOROIDAL HEMORRHAGE To the Editor: I would like to add my congratulations to Dr. James Davison regarding his article ''Acute Intraoperative Suprachoroidal Hemorrhage in Extracapsular Cataract Surgery" U Cataract Refract Surg 12:606-622, 1986). With an experience extending to over 12,000 cases of extracapsular surgery in the past 12 years, I have encountered the same problem with a relatively common frequency. I would like to contribute two points from my experience with this problem: Of all the factors that seem to be involved, one that Dr. Davison refers to seems to be by far the most significant; that is, this problem seems to occur almost entirely in the very elderly patient, increasing in incidence in proportion to the number of patients in the 80s and 90s, but it certainly can occur in patients in the 70s. It seems to be extremelv uncommon below the age of70. One thing I have don~ to attempt to decrease this incidence in the quite elderly is that although I do not routinely use sodium hyaluronate (Healon®) or other viscoeleastic material in most of my cases, when I am operating on a patient over the age of 8.5 or 90, I usually fill the anterior chamber with Healon® as soon as it is opened. My goal is to dampen or suppress the marked fluctuations in intraocular pressure which I believe can contribute to vascular leakage behind the eye. The second point I would like to make is that Dr. Lindstrom refers to using phacoemulsification because it reduces the risk of severe damage from this problem (Acute intraoperative suprachoroidal hemorrhage, ] Cataract Refract Surg 13:215-216, 1987). I believe that it would be difficult to argue that a small incision is probably easier to control than a larger one. Nevertheless, using a planned extracapsular type of incision and procedure in the majority of my cases, I have always been able to abort these episodes by a very rapid installation of sutures at the first sign of a pressure problem. It is certainly correct that with some experience you can pick this up quite early as you become alert to its first signs. My point is that ifone is using phaco, this is probably of slight additional benefit, but I believe that to use this as a reason for teaching phaco, which in my opinion has some additional risks that are not referred to by Dr. Lindstrom, is perhaps not a valid reason. David D. Dulaney, M.D.
Sun City, Arizona
ANTERIOR CHAMBER MAINTAINER DEVICE To the Editor: I read with interest an article published in the March 1987 issue entitled ''Anterior Chamber Maintainer for Extracapsular Cataract Extraction and Intraocular Lens Implantation" by Drs. Michael Blumenthal and Joseph Moisseiev (pages 204-206). The reason for my letter is to point out that this anterior chamber maintainer device is merely a reinvention and copy of an anterior chamber maintainer device developed by Spencer P. Thornton, M.D., of Nashville, Tennessee, in the early 1970s. Not only do I feel that Dr. Thornton should receive credit for his work 15 years ago on this product, but also Concept, Inc., should be acknowledged for marketing this "old, new idea" to ophthalmologists over the years. Patrick A. Brady Concept, Inc. Clearwater, Florida
INJECTABLE PROSTAGLANDIN INHIBITORS PRIOR TO CATARACT SURGERY To the Editor: Indomethacin (1 mg vials indomethacin; add 2 cc water; 1 mgl2 cc; add .4 vials (8 cc) to 52 cc of xylocaine with 1 % epinephrine = total volume 60 cc (mixture). Inject 1.5 cc xylocaine = 0.1 mg indocin; injection subconj.) was injected prior to cataract surgery in 200 eyes. The inhibition of intraoperative miosis and antiinflammatory effect was greater than with the prostaglandin inhibitor drops, Ocufen® (fluriproben sodium). Indomethacin 1 mm vials were divided so that 1/10 mg was given in each retrobulbar injection one hour prior to surgery. The following changes were noted as compared to the eyes not injected: 1. Dilation of the pupil was marked. This allowed phacoemulsification in a greater percentage of cases than was possible prior to this regimen. 2. Postoperative flare and cell were seen much less frequently and to a lesser degree than before the injectable was used. Adverse effects (that may be related to the drug) are slight chemosis and minimal ecchymosis. This is the first report I know of injection of nonsteroidal anti-inflammatory protaglandin inhibitors for the prevention of inflammation at cataract surgery. I would like to encourage others to study this with various drugs and techniques. I believe the development of the concept holds great opportunity for
J CATARACT REFRACT SURG-VOL 13, JULY 1987
459