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Argon Laser Endophotocoagulator Closure of Cyclodialysis Clefts
748
AMERICAN JOURNAL OF OPHTHALMOLOGY
two of these eight patients was pressure controlled without further therapy. Two patients required additional medicines within three months, one progressed to laser trabeculoplasty, and one required trabeculectomy. One was lost to long-term follow-up, and one discontinued carbachol because of side effects despite improved pressure control. Additionally, three other patients discontinued the carbachol before the first follow-up pressure check because of browache or decreased vision, not experienced with pilocarpine. No correlation could be found between the strength of pilocarpine before the switch and the resulting pressure change. These data suggest that switching from pilocarpine to carbachol offers a low chance of improved long-term pressure control, as well as an increased chance of side effects with resulting poor compliance. Furthermore, the risk of further optic nerve damage while delaying more definitive laser or conventional surgical therapy must be kept in mind when contemplating a switch from pilocarpine to carbachol in the hope of improving pressure control in the management of glaucoma.
December, 1988
ined him. Best-corrected visual acuity was R.E.: 20/400 and L.E. : 20/20. The right eye had a shallow anterior chamber and a small superior iridodialysis with vitreous prolapse. Intraocular pressure by pneumotonometry was R.E.: <5 mm Hg and L.E.: 17 mm Hg. Visualization of the right anterior chamber angle by gonioscopy was impossible because of anterior chamber shallowing. The right eye also had a swollen optic nerve head and macular striae. The left eye was normal. A diagnosis of cyclodialysis cleft was considered and the patient was treated with atropine sulfate 0.5%. The hypotony did not improve and we therefore examined him again after administration of general anesthesia. Because we could not visualize the angle we deepened the anterior chamber with sodium hyaluronate instilled through a paracentesis tract. This permitted an excellent view of the angle, and we identified a wide cyclodialysis cleft superiorly and two small clefts nasally.
Argon Laser Endophotocoagulator Closure of Cyclodialysis Clefts Wallace L. M. Alward, M . D . , Elizabeth A. H o d a p p , M . D . , Jean-Marie Parel, Ing. ETS-G., and D o u g l a s R. A n d e r s o n , M . D . Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami. Inquiries to Elizabeth A. Hodapp, M.D., Bascom Palmer Eye Institute, P.O. Box 016880, Miami, FL 33101. Although argon laser energy can close a cyclodialysis cleft,1,2 cleft localization and treatment is often difficult in the hypotonous eye with a shallow anterior chamber. 2 · 3 After deepening the anterior chamber in the operating room, we used a modified endophotocoag ulator probe as an external source of argon laser light to overcome this problem in a child. Figure (Alward and associates). Condensing lens A 7-year-old boy was struck in the right eye (CL) in plastic sleeve (S) permits focusing of laser by a bottle cap. Hypotony and poor vision had light from fiberoptic tip (FT) through Swan Jacobs persisted for three months when we first examlens (SJ) into cyclodialysis cleft.
Letters to the Journal
Vol. 106, No. 6
We treated the clefts using an argon laser endophotocoagulator. We developed a plastic sleeve with a condensing lens that fit over the fiberoptic probe of the endophotocoagulator (Figure). This adapter permitted us to focus the laser light through a Swan Jabobs gonioscopic lens into the cyclodialysis clefts and along their margins. We applied 91 burns with a mean energy output of 450 mW, a duration of 1 second, and a spot diameter of approximately 300 μιη. The paracentesis tract did not require suturing. On postoperative day 1, intraocular pressure was 50 mm Hg. Atropine sulfate 0.5% and timolol maleate 0.25% were given topically, and over the next two days the intraocular pressure dropped to 8 mm Hg. Nine months after surgery the patient was taking no medica tions, visual acuity was 20/400, and intraocular pressure was 9 mm Hg. The anterior chamber was deep, and the clefts were covered with pigment. The optic nerve head was no longer swollen but was somewhat pale. The macular folds had resolved. By using this simple adapter on the endophotocoagulator we were able to treat di rectly the cyclodialysis clefts in this child and avoid a more extensive operation.
References 1. Joondeph, H. C : Management of postoperative and post-traumatic cyclodialysis clefts with argon laser photocoagulation. Ophthalmic Surg. 11:186, 1980. 2. Harbin, T. S.: Treatment of cyclodialysis clefts with argon laser photocoagulation. Ophthalmology 89:1082, 1982. 3. Partamian, L. G.: Treatment of a cyclodialysis cleft with argon laser photocoagulation in a patient with a shallow anterior chamber. Am. J. Ophthalmol. 99:5, 1985.
Hepatic Métastases of Diffuse Iris Melanoma 17 Years After Enucleation Jerry A. Shields, M.D., and Carol L. Shields, M.D. Oncology Service, Wills Eye Hospital, Jefferson Medical College. Supported in part by the Ocular Oncolo-
749
gy Fund and the Oncology Research Fund, Wills Eye Hospital, Philadelphia, and in part by the Black Patch Invitational Golf Tournament, Downingtown, Pennsylvania. Inquiries to Jerry A. Shields, M.D., Director, Oncology Service, Wills Eye Hospital, Ninth and Walnut Sts., Philadelphia, PA 19107. Melanocytic tumors of the iris are generally recognized to be very low-grade tumors that can be managed initially by simple observation. If growth is unequivocally documented, then most of them can be removed by iridectomy and the affected patient usually has an excellent prognosis. 1 " 4 Diffuse malignant melanoma of the iris is a distinct variant of this tumor, which characteristically produces unilateral acquired hyperchromic heterochromia and secondary glaucoma. 1 · 5 This type of iris melanoma still carries an excellent prognosis and metastatic disease is extremely rare. 5 Our patient, who underwent enucleation for a diffuse iris melanoma, remained well for 17 years before developing hepatic métastases. Histopathologically the lesion was a very low-grade spindle cell tumor that would not be expected to metastasize. In April 1969, a 52-year-old man was seen because of unilateral glaucoma. He related a nine-month history of progressive hyperchromic heterochromia (Fig. 1) and visual loss in the affected right eye. Examination disclosed a visual acuity of hand motions, intraocular pressure of 55 mm Hg, and marked glaucomatous cupping and atrophy of the optic disk in the right eye. The iris of the right eye was dark brown, thickened, and showed dense irregular pigment in the trabecular meshwork. The left
Fig. 1 (Shields and Shields). Facial photograph shows heterochromia, with right iris darker than the left.
AMERICAN JOURNAL OF OPHTHALMOLOGY
two of these eight patients was pressure controlled without further therapy. Two patients required additional medicines within three months, one progressed to laser trabeculoplasty, and one required trabeculectomy. One was lost to long-term follow-up, and one discontinued carbachol because of side effects despite improved pressure control. Additionally, three other patients discontinued the carbachol before the first follow-up pressure check because of browache or decreased vision, not experienced with pilocarpine. No correlation could be found between the strength of pilocarpine before the switch and the resulting pressure change. These data suggest that switching from pilocarpine to carbachol offers a low chance of improved long-term pressure control, as well as an increased chance of side effects with resulting poor compliance. Furthermore, the risk of further optic nerve damage while delaying more definitive laser or conventional surgical therapy must be kept in mind when contemplating a switch from pilocarpine to carbachol in the hope of improving pressure control in the management of glaucoma.
December, 1988
ined him. Best-corrected visual acuity was R.E.: 20/400 and L.E. : 20/20. The right eye had a shallow anterior chamber and a small superior iridodialysis with vitreous prolapse. Intraocular pressure by pneumotonometry was R.E.: <5 mm Hg and L.E.: 17 mm Hg. Visualization of the right anterior chamber angle by gonioscopy was impossible because of anterior chamber shallowing. The right eye also had a swollen optic nerve head and macular striae. The left eye was normal. A diagnosis of cyclodialysis cleft was considered and the patient was treated with atropine sulfate 0.5%. The hypotony did not improve and we therefore examined him again after administration of general anesthesia. Because we could not visualize the angle we deepened the anterior chamber with sodium hyaluronate instilled through a paracentesis tract. This permitted an excellent view of the angle, and we identified a wide cyclodialysis cleft superiorly and two small clefts nasally.
Argon Laser Endophotocoagulator Closure of Cyclodialysis Clefts Wallace L. M. Alward, M . D . , Elizabeth A. H o d a p p , M . D . , Jean-Marie Parel, Ing. ETS-G., and D o u g l a s R. A n d e r s o n , M . D . Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami. Inquiries to Elizabeth A. Hodapp, M.D., Bascom Palmer Eye Institute, P.O. Box 016880, Miami, FL 33101. Although argon laser energy can close a cyclodialysis cleft,1,2 cleft localization and treatment is often difficult in the hypotonous eye with a shallow anterior chamber. 2 · 3 After deepening the anterior chamber in the operating room, we used a modified endophotocoag ulator probe as an external source of argon laser light to overcome this problem in a child. Figure (Alward and associates). Condensing lens A 7-year-old boy was struck in the right eye (CL) in plastic sleeve (S) permits focusing of laser by a bottle cap. Hypotony and poor vision had light from fiberoptic tip (FT) through Swan Jacobs persisted for three months when we first examlens (SJ) into cyclodialysis cleft.
Letters to the Journal
Vol. 106, No. 6
We treated the clefts using an argon laser endophotocoagulator. We developed a plastic sleeve with a condensing lens that fit over the fiberoptic probe of the endophotocoagulator (Figure). This adapter permitted us to focus the laser light through a Swan Jabobs gonioscopic lens into the cyclodialysis clefts and along their margins. We applied 91 burns with a mean energy output of 450 mW, a duration of 1 second, and a spot diameter of approximately 300 μιη. The paracentesis tract did not require suturing. On postoperative day 1, intraocular pressure was 50 mm Hg. Atropine sulfate 0.5% and timolol maleate 0.25% were given topically, and over the next two days the intraocular pressure dropped to 8 mm Hg. Nine months after surgery the patient was taking no medica tions, visual acuity was 20/400, and intraocular pressure was 9 mm Hg. The anterior chamber was deep, and the clefts were covered with pigment. The optic nerve head was no longer swollen but was somewhat pale. The macular folds had resolved. By using this simple adapter on the endophotocoagulator we were able to treat di rectly the cyclodialysis clefts in this child and avoid a more extensive operation.
References 1. Joondeph, H. C : Management of postoperative and post-traumatic cyclodialysis clefts with argon laser photocoagulation. Ophthalmic Surg. 11:186, 1980. 2. Harbin, T. S.: Treatment of cyclodialysis clefts with argon laser photocoagulation. Ophthalmology 89:1082, 1982. 3. Partamian, L. G.: Treatment of a cyclodialysis cleft with argon laser photocoagulation in a patient with a shallow anterior chamber. Am. J. Ophthalmol. 99:5, 1985.
Hepatic Métastases of Diffuse Iris Melanoma 17 Years After Enucleation Jerry A. Shields, M.D., and Carol L. Shields, M.D. Oncology Service, Wills Eye Hospital, Jefferson Medical College. Supported in part by the Ocular Oncolo-
749
gy Fund and the Oncology Research Fund, Wills Eye Hospital, Philadelphia, and in part by the Black Patch Invitational Golf Tournament, Downingtown, Pennsylvania. Inquiries to Jerry A. Shields, M.D., Director, Oncology Service, Wills Eye Hospital, Ninth and Walnut Sts., Philadelphia, PA 19107. Melanocytic tumors of the iris are generally recognized to be very low-grade tumors that can be managed initially by simple observation. If growth is unequivocally documented, then most of them can be removed by iridectomy and the affected patient usually has an excellent prognosis. 1 " 4 Diffuse malignant melanoma of the iris is a distinct variant of this tumor, which characteristically produces unilateral acquired hyperchromic heterochromia and secondary glaucoma. 1 · 5 This type of iris melanoma still carries an excellent prognosis and metastatic disease is extremely rare. 5 Our patient, who underwent enucleation for a diffuse iris melanoma, remained well for 17 years before developing hepatic métastases. Histopathologically the lesion was a very low-grade spindle cell tumor that would not be expected to metastasize. In April 1969, a 52-year-old man was seen because of unilateral glaucoma. He related a nine-month history of progressive hyperchromic heterochromia (Fig. 1) and visual loss in the affected right eye. Examination disclosed a visual acuity of hand motions, intraocular pressure of 55 mm Hg, and marked glaucomatous cupping and atrophy of the optic disk in the right eye. The iris of the right eye was dark brown, thickened, and showed dense irregular pigment in the trabecular meshwork. The left
Fig. 1 (Shields and Shields). Facial photograph shows heterochromia, with right iris darker than the left.