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Combined Keratoplasty and Cataract Extraction: Reply
522
AMERICAN JOURNAL OF OPHTHALMOLOGY
Editor : Bravo! for Dr. Burian's injecting some art appreciation into our scientific journal. I submit, however, that if Dr. Burian had watched the young lady's hands instead of her overacting superior oblique muscle he would have seen her clipping the young man's pendant and indeed her confederate is deftly picking his pocket ! All the nervous eye movements are a re sult of their fear of discovery while the old lady distracts him. The ladies are pretty enough, but obviously a nasty bunch. LEWIS C. GORDONSON,
M.D.
New Hyde Park, New York COMBINED KEHATOPLASTY AND
MARCH, 1975
zonulolysis, and see no reason to discontinue this practice but we would hesitate to recom mend "mechanical" zonulolysis as advocated by Dr. Kaufman; (3) as far as graft di ameter is concerned, corneal opening of 7.3 to 7.5 mm suffices for extraction of the lens provided of course the corneal problem does not require a larger graft. PROF. DR. H. SAUTTER PROF. DR. G. NAUMANN
Hamburg, Germany REFERENCES
1. Sautter, H., Naumann, G., and Démêler B. Über Erfahrungen mit gleichzeitiger perforierender Keratoplastik and Kataraktextraktion. Klin. Monatsbl. Augenheilkd. 163:290,1973. 2. : Proceedings of the 20th International Ophthalmological Congress, Paris 1974. In press.
CATARACT EXTRACTION REPLY
Editor: We read with interest the article, "Com bined keratoplasty and cataract extraction," by H. E. Kaufman (Am. J. Ophthalmol. 77: 824, 1974). Since 1968 we performed 86 simultaneous keratoplasties with intracapsular cataract ex tractions in often complicated eyes of pa tients aged 40 to 82. After at least six months' follow-up we achieved crystal-clear corneal grafts in 90% of cases. A reversible "immunological" clouding occurred in 15% but responded well to corticosteroid therapy. An anterior vitrectomy was performed in five eyes.1·2 In younger patients we routinely use 250 mg of acetazolamide, twice daily postoperatively. General anesthesia is preferred, but local anesthesia is adequate in elderly pa tients. Inasmuch as this has been a satisfac tory procedure for both the patient and sur geon we would like to stress the following: (1) It is not necessary or advantageous to use a simple or double ring if the corneal graft is preplaced with two to three tempo rary sutures below to facilitate closure of the eye immediately after lens extraction; (2) we always inject alpha-chymotrypsin for
Editor: The major point of my article was to in dicate that a modern technique in the hands of experienced surgeons, provides a safe combined corneal graft and cataract extrac tion. The results are approximately as good as those of phakic keratoplasty alone. I at tempted to stress the major aspects of suc cessful surgery, but attempted also to em phasize the many ways to accomplish them. Thus, in our hands, results are most success ful when the lens is removed intracapsularly. Alpha-chymotrypsin makes this possible, as does mechanical zonulolysis. The enzyme has occasionally been associated with unex plained corneal clouding as well as increased inflammation activity. With mechanical zonulolysis the enzyme is not necessary ; con versely, it does not present a serious hazard, can be supplemented by zonulolysis, and helps to accomplish the major goal of removing the lens in its capsule. Similarly, vitreous loss must be prevented, or if it occurs must be adequately handled by removing vitreous fluid from the wound. The use of a double ring is rapid, does not delay the operation, gives good support for
VOL. 79, NO. 3
CORRESPONDENCE
523
the eye for trephination and other pro the duration of follow-up and the condition cedures, and makes the operation simple. I of the eye initially, but this major point, believe it is simpler, more rapid, and less which has been questioned in the past, is sup hazardous than partially suturing in the ported by the more modest experience of the graft, and taking the chance that the delicate Hamburg group as well as any of our own. graft endothelium might be damaged either Separating such surgery into two operations by drying or abrasion during the cataract ex appears more hazardous and expensive and traction process. I have also tried pupillary submits the patient to much greater incon constriction and find that cataract extraction venience. is much simpler with a dilated pupil, and yet HERBERT E. KAUFMAN, M.D. that it is difficult to bring a well-dilated pupil Gainesville, Florida down to good miosis, even with acetylcholine chloride (Miochol). In a less than maximally HYDROXYAMPHETAMINE TEST IN dilated pupil, extraction with the cryophake HOBNER'S SYNDROME is more difficult. The important goal, how ever, is to minimize the chance of vitreous Editor: loss, and certainly if Professors Naumann In separate letters to the editor, Drs. and Sautter find that, in their hands, small Thompson and Mensher (Am. J. Ophthalpupils and partial suturing of the graft give mol. 78:739, 1974) and Dr. Sears (Am. J. good results, this is an acceptable way to ac Ophthalmol. 78:740, 1974) expressed vary complish the same goal. It is not clear that ing opinions of the hydroxyamphetamine graft damage could as easily be avoided in test's value in Horner's syndrome. However, the hands of others with their technique and they seem to agree that this drug's mechanism that results would be as good. of action is clear cut: the release of norepineProfessors Naumann and Sautter do not phrine from nerve endings. Drs. Thompson mention postoperative glaucoma other than and Mensher state, "In our paper we empha the use of acetazolamide in some patients. sized that unlike cocaine, hydroxyampheta In our experience, in spite of acetazolamide, mine (Paredrine) could be depended upon pressures sometimes range above 50 mm H g to separate preganglionic from postgangand chronic glaucoma is not uncommon in lionic defects; only the postganglionic cases this group. I assume they use a Mackay- would fail to dilate, because the nerve endings Marg tonometer or other reliable device to had degenerated and there were no stores of measure postoperative pressures. Certainly, norepinephrine to be released." Dr. Sears even if grafts are not clouded by high pres states these authors "realized that hydroxy sure, pressure control may have a significant amphetamine dilates the pupil only when the effect on postoperative visual acuity and must iris contains norepinephrine because the action of hydroxyamphetamine is to displace be properly regulated. the endogenous transmitter, norepinephrine, The important point to be emphasized by from its storage site (in the axon) onto the this letter from experienced corneal surgeons, receptor (the smooth muscle cell)." Professors Sautter and Naumann, is not the There is the possibility of error in this small differences in technique to accomplish what are primary surgical goals but that we belief. Pharmacologically, the actions of the all find similar results. With careful tech amphetamines are not limited to releasing nique and modern surgery, in experienced norepinephrine from sympathetic nerve end hands, combined graft and cataract extrac ings. At least three other mechanisms of tion yields results as good as keratoplasty action1 have been investigated: direct stimu alone, even in patients who are phakic. The lation of smooth muscle adrenergic recep exact success rate will certainly depend on tors2"*; inhibition of catecholamine re-up-
AMERICAN JOURNAL OF OPHTHALMOLOGY
Editor : Bravo! for Dr. Burian's injecting some art appreciation into our scientific journal. I submit, however, that if Dr. Burian had watched the young lady's hands instead of her overacting superior oblique muscle he would have seen her clipping the young man's pendant and indeed her confederate is deftly picking his pocket ! All the nervous eye movements are a re sult of their fear of discovery while the old lady distracts him. The ladies are pretty enough, but obviously a nasty bunch. LEWIS C. GORDONSON,
M.D.
New Hyde Park, New York COMBINED KEHATOPLASTY AND
MARCH, 1975
zonulolysis, and see no reason to discontinue this practice but we would hesitate to recom mend "mechanical" zonulolysis as advocated by Dr. Kaufman; (3) as far as graft di ameter is concerned, corneal opening of 7.3 to 7.5 mm suffices for extraction of the lens provided of course the corneal problem does not require a larger graft. PROF. DR. H. SAUTTER PROF. DR. G. NAUMANN
Hamburg, Germany REFERENCES
1. Sautter, H., Naumann, G., and Démêler B. Über Erfahrungen mit gleichzeitiger perforierender Keratoplastik and Kataraktextraktion. Klin. Monatsbl. Augenheilkd. 163:290,1973. 2. : Proceedings of the 20th International Ophthalmological Congress, Paris 1974. In press.
CATARACT EXTRACTION REPLY
Editor: We read with interest the article, "Com bined keratoplasty and cataract extraction," by H. E. Kaufman (Am. J. Ophthalmol. 77: 824, 1974). Since 1968 we performed 86 simultaneous keratoplasties with intracapsular cataract ex tractions in often complicated eyes of pa tients aged 40 to 82. After at least six months' follow-up we achieved crystal-clear corneal grafts in 90% of cases. A reversible "immunological" clouding occurred in 15% but responded well to corticosteroid therapy. An anterior vitrectomy was performed in five eyes.1·2 In younger patients we routinely use 250 mg of acetazolamide, twice daily postoperatively. General anesthesia is preferred, but local anesthesia is adequate in elderly pa tients. Inasmuch as this has been a satisfac tory procedure for both the patient and sur geon we would like to stress the following: (1) It is not necessary or advantageous to use a simple or double ring if the corneal graft is preplaced with two to three tempo rary sutures below to facilitate closure of the eye immediately after lens extraction; (2) we always inject alpha-chymotrypsin for
Editor: The major point of my article was to in dicate that a modern technique in the hands of experienced surgeons, provides a safe combined corneal graft and cataract extrac tion. The results are approximately as good as those of phakic keratoplasty alone. I at tempted to stress the major aspects of suc cessful surgery, but attempted also to em phasize the many ways to accomplish them. Thus, in our hands, results are most success ful when the lens is removed intracapsularly. Alpha-chymotrypsin makes this possible, as does mechanical zonulolysis. The enzyme has occasionally been associated with unex plained corneal clouding as well as increased inflammation activity. With mechanical zonulolysis the enzyme is not necessary ; con versely, it does not present a serious hazard, can be supplemented by zonulolysis, and helps to accomplish the major goal of removing the lens in its capsule. Similarly, vitreous loss must be prevented, or if it occurs must be adequately handled by removing vitreous fluid from the wound. The use of a double ring is rapid, does not delay the operation, gives good support for
VOL. 79, NO. 3
CORRESPONDENCE
523
the eye for trephination and other pro the duration of follow-up and the condition cedures, and makes the operation simple. I of the eye initially, but this major point, believe it is simpler, more rapid, and less which has been questioned in the past, is sup hazardous than partially suturing in the ported by the more modest experience of the graft, and taking the chance that the delicate Hamburg group as well as any of our own. graft endothelium might be damaged either Separating such surgery into two operations by drying or abrasion during the cataract ex appears more hazardous and expensive and traction process. I have also tried pupillary submits the patient to much greater incon constriction and find that cataract extraction venience. is much simpler with a dilated pupil, and yet HERBERT E. KAUFMAN, M.D. that it is difficult to bring a well-dilated pupil Gainesville, Florida down to good miosis, even with acetylcholine chloride (Miochol). In a less than maximally HYDROXYAMPHETAMINE TEST IN dilated pupil, extraction with the cryophake HOBNER'S SYNDROME is more difficult. The important goal, how ever, is to minimize the chance of vitreous Editor: loss, and certainly if Professors Naumann In separate letters to the editor, Drs. and Sautter find that, in their hands, small Thompson and Mensher (Am. J. Ophthalpupils and partial suturing of the graft give mol. 78:739, 1974) and Dr. Sears (Am. J. good results, this is an acceptable way to ac Ophthalmol. 78:740, 1974) expressed vary complish the same goal. It is not clear that ing opinions of the hydroxyamphetamine graft damage could as easily be avoided in test's value in Horner's syndrome. However, the hands of others with their technique and they seem to agree that this drug's mechanism that results would be as good. of action is clear cut: the release of norepineProfessors Naumann and Sautter do not phrine from nerve endings. Drs. Thompson mention postoperative glaucoma other than and Mensher state, "In our paper we empha the use of acetazolamide in some patients. sized that unlike cocaine, hydroxyampheta In our experience, in spite of acetazolamide, mine (Paredrine) could be depended upon pressures sometimes range above 50 mm H g to separate preganglionic from postgangand chronic glaucoma is not uncommon in lionic defects; only the postganglionic cases this group. I assume they use a Mackay- would fail to dilate, because the nerve endings Marg tonometer or other reliable device to had degenerated and there were no stores of measure postoperative pressures. Certainly, norepinephrine to be released." Dr. Sears even if grafts are not clouded by high pres states these authors "realized that hydroxy sure, pressure control may have a significant amphetamine dilates the pupil only when the effect on postoperative visual acuity and must iris contains norepinephrine because the action of hydroxyamphetamine is to displace be properly regulated. the endogenous transmitter, norepinephrine, The important point to be emphasized by from its storage site (in the axon) onto the this letter from experienced corneal surgeons, receptor (the smooth muscle cell)." Professors Sautter and Naumann, is not the There is the possibility of error in this small differences in technique to accomplish what are primary surgical goals but that we belief. Pharmacologically, the actions of the all find similar results. With careful tech amphetamines are not limited to releasing nique and modern surgery, in experienced norepinephrine from sympathetic nerve end hands, combined graft and cataract extrac ings. At least three other mechanisms of tion yields results as good as keratoplasty action1 have been investigated: direct stimu alone, even in patients who are phakic. The lation of smooth muscle adrenergic recep exact success rate will certainly depend on tors2"*; inhibition of catecholamine re-up-