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Aspiration Method of Hard Cataract
VOL. 76, NO. S
BOOK REVIEWS
reous. These are probably minor differences since all of us agree that meticulous toilet of the anterior chamber and incision is the key to success. Obviously this book will be of greatest benefit to those with a command of la belle langue. However the authors have thought fully provided an English summary at the end of each chapter and added similar trans lations of all the figure legends. The latter are largely line-drawings of a clarity and simplicity that is complementary to the or derliness of the text material. David Shoch ASPIRATION METHOD OF HARD CATARACT.
By Yasuharu Kuwahara. New York, Grune and Stratton, 1973. Clothbound, 139 pages, table of contents, index, 96 fig ures. $16.50 A method for ultrasonic fragmentation and aspiration of hard cataracts is stated to be applicable to 93% of senile cataracts. The technique consists of a 3-5 mm limbal inci sion at 12 o'clock followed by a large periph eral iridectomy and a Graefe-knife discission of the lens capsule in the anterior equatorial region. A 1-mm diameter hollow probe is in serted through the peripheral iridectomy and lens capsule opening. The probe fragments the lens by vibrating at 30,000 cycles per sec ond. A negative pressure is induced within the hollow probe which automatically aspi rates small lens particles. Suction is aug mented by the surgeon who presses his fin ger over a suction control hole on the handpiece. Danger of excessive suction with ante rior chamber collapse leading to corneal damage is emphasized. Irrigating fluid con tinuously enters the anterior chamber to help keep the chamber formed, as well as to cool the probe and to wash away lens debris. The amplitude of ultrasonic vibration is varied from 60-100 μ depending upon the hardness of the lens material. As much lens material as can be visualized is aspirated, while main taining the integrity of the anterior lens cap sule. The posterior lens capsule is stated to
859
be adherent to the lens material and is aspi rated. Fragmentation-aspiration is complete within 3-5 minutes. The incision is closed with a single virgin silk suture. The patient is allowed out of bed on the day of surgery or the following day. The suture is removed on the seventh postoperative day, and the pa tient is discharged from the hospital eight to ten days after surgery. The author is to be commended for the ex tensive and meticulous laboratory studies carried out in the development of this tech nique. That it has not yet reached the point of safe general applicability, however, is evi denced by the incidence of complications, which reads like a war-casualty list. Opera tive complications include vitreous loss in 22% of cases, and lens particles in the vitre ous in 7%. Postoperative complications with two months or more of follow-up include corneal opacity in 17%, folds in Descemet's membrane in 27%, chronic or recurrent iridocyclitis in 23%, vitreous opacities in 55%, retinal detachment in 3 % , and secondary glaucoma in 3 % . Sympathetic ophthalmia and phacoanaphylaxis have not been ob served. These figures are derived from the author's first 100 cases; an additional 200 cases were not included because of inade quate length of follow-up, but observations were thought to be similar for that group. It is discouraging to me that the last 200 cases show no fewer complications than the first 100 cases. The author states that postoperative visual acuities are similar to those obtained by intracapsular extraction, although attainment of maximal visual acuity is somewhat de layed with the new technique as compared with routine methods. Vision better than 20/40 was achieved in 64% of patients, with 27% reaching 20/20 or better. Pre-existing retinal or optic nerve disease reduced vision in 9% of patients. This technique appears to suffer from two major inherent disadvantages: (1) manual control of aspiration is imprecise, leading to a significant incidence of anterior chamber
860
AMERICAN JOURNAL OF OPHTHALMOLOGY
collapse with corneal damage; and (2) aspi ration of the posterior capsule leads to diffi culties with mechanical disturbance of the vitreous and mixing of lens material with vitreous. This book provides a fascinating account of how a dedicated research team has strug gled for ten years to devise a safe and effi cient method for fragmenting and aspirating a hard cataract through a small incision ; the results thus far indicate, however, that their goal has yet to be achieved. Jared M. Emery MODERN TRENDS IN OPHTHALMOLOGY, vol.
5. Edited by Arnold Sorsby and Stephen J. H. Miller. Glasgow, Butterworths, 1973. Clothbound, 206 pages. $20.40 The Modern Trend in Ophthalmology se ries, the previous four edited by the indefati gable Arnold Sorsby, appears in a fifth vol ume, with Dr. Sorsby joined by Stephen Miller, the new editor of our fellow publica tion, the British Journal of Ophthalmology. The volume consists of some 17 review arti cles covering diagnostic, clinical, and thera peutic ophthalmology. The articles follow the general pattern of previous Modern Trend books in which an expert in a particular field briefly discusses its present position and speculates on the fu ture. Thus, visual field screening, screening for glaucoma, prospects in fluorescein angiography, and biomicroscopy are discussed. Keeney provides an up-to-date discussion of the diagnosis of proptosis and ultrasonography. Miller describes unusual forms of secon dary glaucoma and chromosomal abnormali ties-. Sorsby discusses some newer genetic disorders, and Armaly, polygenic determina tion of glaucoma. The complications of car bonic anhydrase inhibitors and osmotic agents are described. Lincoff describes cryosurgical treatment of detachment. Birge de scribes cataract fistulizing combination. Binkhorst describes his lens, and Skydsgaard, visual aids.
NOVEMBER, 1973
The broadly read reader of ophthalmology is familiar with most topics. Others will find much that is new. All will find it stimulating to have many topics brought together in a single place. Frank W. Newell DIE
FUNKTIONSPRUFUNG
MEDIENTRUBUNGEN
DES
BEIN
DICHTEN
AUGES.
By
Dietrich W. Comberg and Prof. Wulf Ehrich. Leipzig, George Thiem, 1973. Pa perback, 75 pages, table of contents, in dex, 43 black and white figures. $9.20 The authors describe the evaluation of the visual function when the optical media are cloudy and do not allow an ophthalmoscopic examination of the fundus. They coin a term for this type of visual evaluation and call it the "visual function sub opacitate" which stands for "function under an opacity" (f.s.o.). The examination can be broken down into three aspects: 1. The light sense: The simplest way of examining the light sense is by determining light perception. This is certainly the most fundamental examination, but can be mis leading, e.g., in dense vitreous hemorrhages. More sophisticated are the various methods of examining the light sense by illuminating the entire eye through the closed eyelid. This transpalpebral method was first de scribed by the elder Comberg and has been widely accepted. It can also be used in a dif ferential way by comparing the light sense as perceived through the closed eyelids in one eye against the other eye. This method can be more quantitatively determined by using a standard source of illumination and a dia phragm. With adjusting the diaphragm the minimum of light can be determined which, perceived through the closed eyelids, still elic its a light sensation. 2. The visual field: The coarsest method is testing the light projection. A more elegant method is testing for pressure phosphenes. This is an entoptic phenomenon where the stimulation is produced by mechanical pres sure. The authors prefer using slightly bent
BOOK REVIEWS
reous. These are probably minor differences since all of us agree that meticulous toilet of the anterior chamber and incision is the key to success. Obviously this book will be of greatest benefit to those with a command of la belle langue. However the authors have thought fully provided an English summary at the end of each chapter and added similar trans lations of all the figure legends. The latter are largely line-drawings of a clarity and simplicity that is complementary to the or derliness of the text material. David Shoch ASPIRATION METHOD OF HARD CATARACT.
By Yasuharu Kuwahara. New York, Grune and Stratton, 1973. Clothbound, 139 pages, table of contents, index, 96 fig ures. $16.50 A method for ultrasonic fragmentation and aspiration of hard cataracts is stated to be applicable to 93% of senile cataracts. The technique consists of a 3-5 mm limbal inci sion at 12 o'clock followed by a large periph eral iridectomy and a Graefe-knife discission of the lens capsule in the anterior equatorial region. A 1-mm diameter hollow probe is in serted through the peripheral iridectomy and lens capsule opening. The probe fragments the lens by vibrating at 30,000 cycles per sec ond. A negative pressure is induced within the hollow probe which automatically aspi rates small lens particles. Suction is aug mented by the surgeon who presses his fin ger over a suction control hole on the handpiece. Danger of excessive suction with ante rior chamber collapse leading to corneal damage is emphasized. Irrigating fluid con tinuously enters the anterior chamber to help keep the chamber formed, as well as to cool the probe and to wash away lens debris. The amplitude of ultrasonic vibration is varied from 60-100 μ depending upon the hardness of the lens material. As much lens material as can be visualized is aspirated, while main taining the integrity of the anterior lens cap sule. The posterior lens capsule is stated to
859
be adherent to the lens material and is aspi rated. Fragmentation-aspiration is complete within 3-5 minutes. The incision is closed with a single virgin silk suture. The patient is allowed out of bed on the day of surgery or the following day. The suture is removed on the seventh postoperative day, and the pa tient is discharged from the hospital eight to ten days after surgery. The author is to be commended for the ex tensive and meticulous laboratory studies carried out in the development of this tech nique. That it has not yet reached the point of safe general applicability, however, is evi denced by the incidence of complications, which reads like a war-casualty list. Opera tive complications include vitreous loss in 22% of cases, and lens particles in the vitre ous in 7%. Postoperative complications with two months or more of follow-up include corneal opacity in 17%, folds in Descemet's membrane in 27%, chronic or recurrent iridocyclitis in 23%, vitreous opacities in 55%, retinal detachment in 3 % , and secondary glaucoma in 3 % . Sympathetic ophthalmia and phacoanaphylaxis have not been ob served. These figures are derived from the author's first 100 cases; an additional 200 cases were not included because of inade quate length of follow-up, but observations were thought to be similar for that group. It is discouraging to me that the last 200 cases show no fewer complications than the first 100 cases. The author states that postoperative visual acuities are similar to those obtained by intracapsular extraction, although attainment of maximal visual acuity is somewhat de layed with the new technique as compared with routine methods. Vision better than 20/40 was achieved in 64% of patients, with 27% reaching 20/20 or better. Pre-existing retinal or optic nerve disease reduced vision in 9% of patients. This technique appears to suffer from two major inherent disadvantages: (1) manual control of aspiration is imprecise, leading to a significant incidence of anterior chamber
860
AMERICAN JOURNAL OF OPHTHALMOLOGY
collapse with corneal damage; and (2) aspi ration of the posterior capsule leads to diffi culties with mechanical disturbance of the vitreous and mixing of lens material with vitreous. This book provides a fascinating account of how a dedicated research team has strug gled for ten years to devise a safe and effi cient method for fragmenting and aspirating a hard cataract through a small incision ; the results thus far indicate, however, that their goal has yet to be achieved. Jared M. Emery MODERN TRENDS IN OPHTHALMOLOGY, vol.
5. Edited by Arnold Sorsby and Stephen J. H. Miller. Glasgow, Butterworths, 1973. Clothbound, 206 pages. $20.40 The Modern Trend in Ophthalmology se ries, the previous four edited by the indefati gable Arnold Sorsby, appears in a fifth vol ume, with Dr. Sorsby joined by Stephen Miller, the new editor of our fellow publica tion, the British Journal of Ophthalmology. The volume consists of some 17 review arti cles covering diagnostic, clinical, and thera peutic ophthalmology. The articles follow the general pattern of previous Modern Trend books in which an expert in a particular field briefly discusses its present position and speculates on the fu ture. Thus, visual field screening, screening for glaucoma, prospects in fluorescein angiography, and biomicroscopy are discussed. Keeney provides an up-to-date discussion of the diagnosis of proptosis and ultrasonography. Miller describes unusual forms of secon dary glaucoma and chromosomal abnormali ties-. Sorsby discusses some newer genetic disorders, and Armaly, polygenic determina tion of glaucoma. The complications of car bonic anhydrase inhibitors and osmotic agents are described. Lincoff describes cryosurgical treatment of detachment. Birge de scribes cataract fistulizing combination. Binkhorst describes his lens, and Skydsgaard, visual aids.
NOVEMBER, 1973
The broadly read reader of ophthalmology is familiar with most topics. Others will find much that is new. All will find it stimulating to have many topics brought together in a single place. Frank W. Newell DIE
FUNKTIONSPRUFUNG
MEDIENTRUBUNGEN
DES
BEIN
DICHTEN
AUGES.
By
Dietrich W. Comberg and Prof. Wulf Ehrich. Leipzig, George Thiem, 1973. Pa perback, 75 pages, table of contents, in dex, 43 black and white figures. $9.20 The authors describe the evaluation of the visual function when the optical media are cloudy and do not allow an ophthalmoscopic examination of the fundus. They coin a term for this type of visual evaluation and call it the "visual function sub opacitate" which stands for "function under an opacity" (f.s.o.). The examination can be broken down into three aspects: 1. The light sense: The simplest way of examining the light sense is by determining light perception. This is certainly the most fundamental examination, but can be mis leading, e.g., in dense vitreous hemorrhages. More sophisticated are the various methods of examining the light sense by illuminating the entire eye through the closed eyelid. This transpalpebral method was first de scribed by the elder Comberg and has been widely accepted. It can also be used in a dif ferential way by comparing the light sense as perceived through the closed eyelids in one eye against the other eye. This method can be more quantitatively determined by using a standard source of illumination and a dia phragm. With adjusting the diaphragm the minimum of light can be determined which, perceived through the closed eyelids, still elic its a light sensation. 2. The visual field: The coarsest method is testing the light projection. A more elegant method is testing for pressure phosphenes. This is an entoptic phenomenon where the stimulation is produced by mechanical pres sure. The authors prefer using slightly bent