- Email: [email protected]
Carbachol Dose Response
456
October, 1989
AMERICAN JOURNAL OF OPHTHALMOLOGY
Inquiries to Lluis Puig, M.D., ,Department of Dermatology, Hospital de la Santa Creu I Sant Pau, Avda. S. Ant. M. Claret 167, 08025 Barcelona, Spain.
A 64-year-old man with chronic simple glaucoma of the left eye, who had been treated twice daily with 0.5% timolol eye drops in t~e affected eye for nine months, consulted his dermatologist in October 1987 because of t~e appearance of fissurated red patches on his groin and red scaly plaques on his scalp. There was no personal or family history of psoriasis. The lesions progressively spread to involve the glans penis, the elbows, and. the trunk, wher~ the lesions were especially thick and scaly. Nail plates became dystrophic, with pitting and ridging, and subunguinal hyperkeratosi~ .appeared. Psoriasis was diagnosed on chm~al grounds and topical treatment, together With discontinuation of timolol, eventually led to complete blanching. In September 1988, despite trabeculectomy, 0.5% timolol eyedrops were required for the treatment of glaucoma. One month later similar dermatologic lesions reappeared in the same areas. Histopathologic studies confirmed the diagnosis of psoriasis. The skin condition responded to topical treatment with coal tar and corticosteroids, thus allowing continuation of timolol eyedrop treatment. Several beta-blockers have been implicated in the initiation or aggravation of psoriasis, the occurrence of psoriasiform lesions, or the development of refractoriness of psoriasis to treatment;' and several series illustrate the diversity of potential causes.>' Oral timolol has been associated with triggering of palmoplantar psoriasis (without histologic confirmation)," but we believe our case of psoriasis associated with ophthalmic timolol preparations is unique.
References 1. Abel, E. A., DiCicco, L. M., Orenberg, E. K., Fraki, J. E., and Farber, E. M.: Drugs in exacerbation of psoriasis. J. Am. Acad. Dermatol. 15:1007, 1986. 2. Arntzen, N., Kavli, G., and Volden, G.: Psoriasis provoked by beta-blocking agents. Acta Derm. Venereol. (Stockh.) 64:346, 1984. 3. SavoIa, J., Vehvilainen, 0., and Vaatainen, N. J.: Psoriasis as a side effect of J3 blockers. Br. Med. J. 295:637, 1987. 4. Gold, M. H., Holy, A. K., and Roenigk, H. H., [r.: Beta-blocking drugs and psoriasis. A review of
cutaneous side effects and retrospective analysis of their effects on psoriasis. J. Am. Acad. Dermatol. 19:837, 1988.
Carbachol Dose Response Thom J. Zimmerman, M. D., Umar Dukar, M.D., George F. Nardin, M.D., Richard Patchett, M.D., and Meg Fuqua University of Louisville School of Medicine.
Inquiries to Thom J. ZimJ!!~rman, M. D., l!niversity of LIOns Eye .ReLouisville, School of MediCine, Kentu~ky search Institute, 301 E. Muhammad All Blvd., LOUisville, KY 40202.
We recently published a dose-response study of intracameral carbachol and postoperative intraocular pressure increase after cataract surgery.' We studied the patients in the early postoperative period and one month postoperatively. Because of the potential adverse effects from this intracameral carbachol injection we elected to do a one-year follow-up of the' same patients. This comparison between control eyes and treated eyes might delineate any long-term adverse effects from the carbachol injection. All patients had best corrected visual acuity of 20/40 or better at the one-year examination. Only one patient of the a.25-ml treatment group (at the one-month interval) had a visual acuity worse than 20150 with angiegraphic evidence of cystoid macular edema. Intraocular pressures measured at one month and one year were less than 20 mm Hg in both treatment and control groups. There was no evidence of corneal opacities or posterior synechiae in either group. Furthermore, the degree of postoperative inflammation at each examination during the one-year period was comparable. Two patients in the treatme~t group showed mild opacification of the posterior capsular membrane. Intracameral carbachol as used in our study appears to be safe with no short-term or long-term adverse effects. Reference 1. Linn, D. K., Zimmerman, T. J., Nardin, G. F., Yung, R., Berberich, S., DuBiner, H., and Fuqua, M.:
Vol. 108, No.4
Letters to the Journal
457
Effect of intracameral carbachol on intraocular pressure after cataract extraction. Am. J. Ophthalmol.
107:133, 1989.
Protector
.-----:::=4~--'OpOQlle
ClIl'votur, (r-7.45"",,1
~"'--Corneol
Scl,ra I Slope
""'-----
A Contact Lens for Transscleral Nd:YAG Cyclophotocoagulation M. Bruce Shields, M.D., Marino Blasini, M.D., Ruthanne Simmons, M.D., and Phillip J. Erickson, M.S. Duke University Eye Center, Durham (M.B.S., M.B., R.S.), and Ocular Instruments, Inc., Bellevue, Washington (Mr. Erickson).
Inquiries to M. Bruce Shields, M.D., Duke University Eye Center, Box 3802, Durham, NC 27710.
Transscleral cyclophotocoagulation with the Nd: YAG laser in the thermal mode is typically performed with a slit-lamp delivery system by spreading the eyelids and applying the laser energy directly to the eye. We have developed a contact lens that facilitates several aspects of this operation. The lens is constructed of polymethylmethacrylate with an antireflective coating (Fig. 1). The central, corneal portion has a diameter of 12 mm and a 7.45-mm radius of curvature, which provides a shallow vault over the average cornea (Fig. 2). A central opaque disk, 1 mm thick and 8 mm in diameter, helps to prevent the trans pupillary entrance of stray
Fig. 1 (Shields and associates). Contact lens for transscleral cyclophotocoagulation.
Imbul
Fig. 2 (Shields and associates). Side and top schematic views of contact lens for transscleral cyclophotocoagula tion.
light into the eye. A flat scleral flange, angled at 35 degrees, extends 3 mm beyond the corneal portion. This is the optical interface of the lens, which can be used to compress the conjunctiva and blanch blood vessels. Four sets of etched marks, spaced 90 degrees apart, consist of three circumferential lines at l -mm intervals. The center-most line in each set is located at the junction of the corneal and scleral portions, with the second and third lines in the scleral surface. These marks help to place the laser applications more accurately in relation to the corneosclerallimbus. A knurled holding flange extends out from the scleral portion of the lens. It has been cut away in one section to facilitate upward rotation of the lens, which is otherwise difficult in a patient with a prominent brow. Preliminary experience in 75 patients supports the usefulness of the lens. Although the contact portion has a larger diameter than most lenses, it has been possible to apply the lens in all patients with normal palpebral fissures. The ability to compress the conjunctiva, especially when there is chemosis or anterior extravasation of the anesthesia, helps to thin out and standardize the width of the tissues through which the therapeutic laser beam must pass. Additionally, the ability to blanch conjunctival and episcleral vessels creates an ischemic bed of external ocular tissue for transmission of the beam, which results in smaller conjunctival burns and more rapid conjunctival healing, in contrast to eyes treated without the lens.
October, 1989
AMERICAN JOURNAL OF OPHTHALMOLOGY
Inquiries to Lluis Puig, M.D., ,Department of Dermatology, Hospital de la Santa Creu I Sant Pau, Avda. S. Ant. M. Claret 167, 08025 Barcelona, Spain.
A 64-year-old man with chronic simple glaucoma of the left eye, who had been treated twice daily with 0.5% timolol eye drops in t~e affected eye for nine months, consulted his dermatologist in October 1987 because of t~e appearance of fissurated red patches on his groin and red scaly plaques on his scalp. There was no personal or family history of psoriasis. The lesions progressively spread to involve the glans penis, the elbows, and. the trunk, wher~ the lesions were especially thick and scaly. Nail plates became dystrophic, with pitting and ridging, and subunguinal hyperkeratosi~ .appeared. Psoriasis was diagnosed on chm~al grounds and topical treatment, together With discontinuation of timolol, eventually led to complete blanching. In September 1988, despite trabeculectomy, 0.5% timolol eyedrops were required for the treatment of glaucoma. One month later similar dermatologic lesions reappeared in the same areas. Histopathologic studies confirmed the diagnosis of psoriasis. The skin condition responded to topical treatment with coal tar and corticosteroids, thus allowing continuation of timolol eyedrop treatment. Several beta-blockers have been implicated in the initiation or aggravation of psoriasis, the occurrence of psoriasiform lesions, or the development of refractoriness of psoriasis to treatment;' and several series illustrate the diversity of potential causes.>' Oral timolol has been associated with triggering of palmoplantar psoriasis (without histologic confirmation)," but we believe our case of psoriasis associated with ophthalmic timolol preparations is unique.
References 1. Abel, E. A., DiCicco, L. M., Orenberg, E. K., Fraki, J. E., and Farber, E. M.: Drugs in exacerbation of psoriasis. J. Am. Acad. Dermatol. 15:1007, 1986. 2. Arntzen, N., Kavli, G., and Volden, G.: Psoriasis provoked by beta-blocking agents. Acta Derm. Venereol. (Stockh.) 64:346, 1984. 3. SavoIa, J., Vehvilainen, 0., and Vaatainen, N. J.: Psoriasis as a side effect of J3 blockers. Br. Med. J. 295:637, 1987. 4. Gold, M. H., Holy, A. K., and Roenigk, H. H., [r.: Beta-blocking drugs and psoriasis. A review of
cutaneous side effects and retrospective analysis of their effects on psoriasis. J. Am. Acad. Dermatol. 19:837, 1988.
Carbachol Dose Response Thom J. Zimmerman, M. D., Umar Dukar, M.D., George F. Nardin, M.D., Richard Patchett, M.D., and Meg Fuqua University of Louisville School of Medicine.
Inquiries to Thom J. ZimJ!!~rman, M. D., l!niversity of LIOns Eye .ReLouisville, School of MediCine, Kentu~ky search Institute, 301 E. Muhammad All Blvd., LOUisville, KY 40202.
We recently published a dose-response study of intracameral carbachol and postoperative intraocular pressure increase after cataract surgery.' We studied the patients in the early postoperative period and one month postoperatively. Because of the potential adverse effects from this intracameral carbachol injection we elected to do a one-year follow-up of the' same patients. This comparison between control eyes and treated eyes might delineate any long-term adverse effects from the carbachol injection. All patients had best corrected visual acuity of 20/40 or better at the one-year examination. Only one patient of the a.25-ml treatment group (at the one-month interval) had a visual acuity worse than 20150 with angiegraphic evidence of cystoid macular edema. Intraocular pressures measured at one month and one year were less than 20 mm Hg in both treatment and control groups. There was no evidence of corneal opacities or posterior synechiae in either group. Furthermore, the degree of postoperative inflammation at each examination during the one-year period was comparable. Two patients in the treatme~t group showed mild opacification of the posterior capsular membrane. Intracameral carbachol as used in our study appears to be safe with no short-term or long-term adverse effects. Reference 1. Linn, D. K., Zimmerman, T. J., Nardin, G. F., Yung, R., Berberich, S., DuBiner, H., and Fuqua, M.:
Vol. 108, No.4
Letters to the Journal
457
Effect of intracameral carbachol on intraocular pressure after cataract extraction. Am. J. Ophthalmol.
107:133, 1989.
Protector
.-----:::=4~--'OpOQlle
ClIl'votur, (r-7.45"",,1
~"'--Corneol
Scl,ra I Slope
""'-----
A Contact Lens for Transscleral Nd:YAG Cyclophotocoagulation M. Bruce Shields, M.D., Marino Blasini, M.D., Ruthanne Simmons, M.D., and Phillip J. Erickson, M.S. Duke University Eye Center, Durham (M.B.S., M.B., R.S.), and Ocular Instruments, Inc., Bellevue, Washington (Mr. Erickson).
Inquiries to M. Bruce Shields, M.D., Duke University Eye Center, Box 3802, Durham, NC 27710.
Transscleral cyclophotocoagulation with the Nd: YAG laser in the thermal mode is typically performed with a slit-lamp delivery system by spreading the eyelids and applying the laser energy directly to the eye. We have developed a contact lens that facilitates several aspects of this operation. The lens is constructed of polymethylmethacrylate with an antireflective coating (Fig. 1). The central, corneal portion has a diameter of 12 mm and a 7.45-mm radius of curvature, which provides a shallow vault over the average cornea (Fig. 2). A central opaque disk, 1 mm thick and 8 mm in diameter, helps to prevent the trans pupillary entrance of stray
Fig. 1 (Shields and associates). Contact lens for transscleral cyclophotocoagulation.
Imbul
Fig. 2 (Shields and associates). Side and top schematic views of contact lens for transscleral cyclophotocoagula tion.
light into the eye. A flat scleral flange, angled at 35 degrees, extends 3 mm beyond the corneal portion. This is the optical interface of the lens, which can be used to compress the conjunctiva and blanch blood vessels. Four sets of etched marks, spaced 90 degrees apart, consist of three circumferential lines at l -mm intervals. The center-most line in each set is located at the junction of the corneal and scleral portions, with the second and third lines in the scleral surface. These marks help to place the laser applications more accurately in relation to the corneosclerallimbus. A knurled holding flange extends out from the scleral portion of the lens. It has been cut away in one section to facilitate upward rotation of the lens, which is otherwise difficult in a patient with a prominent brow. Preliminary experience in 75 patients supports the usefulness of the lens. Although the contact portion has a larger diameter than most lenses, it has been possible to apply the lens in all patients with normal palpebral fissures. The ability to compress the conjunctiva, especially when there is chemosis or anterior extravasation of the anesthesia, helps to thin out and standardize the width of the tissues through which the therapeutic laser beam must pass. Additionally, the ability to blanch conjunctival and episcleral vessels creates an ischemic bed of external ocular tissue for transmission of the beam, which results in smaller conjunctival burns and more rapid conjunctival healing, in contrast to eyes treated without the lens.