- Email: [email protected]
Complications in Cataract Surgery*
ELECTROMYOGRAPHY AND
237
AKINESIA
22. Scheie, H. G , Ellis, R. A , Eckenhoff, J . E , and Spencer, R. \ Y . : Long-lasting local anesthetic agents in ophthalmic surgery. A M A Arch. Ophth, 53:177-190, 1955. 23. Burford, G. E.: Involuntary eyeball motion during anesthesia and sleep: Relationship to cortical rhythmic potentials. Anesth. & Analg, 20:191-199, 1941. Cited by Walsh, F. B.: Clinical Ν euro-ophthal mology. Baltimore, Williams & Wilkins, 1957, p. 189.
COMPLICATIONS FROM THE
IN
USE OF A L P H A
ULYSSES
M.
Manila, CLINICAL
CATARACT
SURGICAL
CHYMOTRYPSIN
CARBAJAL,
M.D.
Philippines TABLE
DATA
1
A G E DISTRIBUTION
This paper is based on a 36-month study of cataract extractions performed by me on 143 eyes (115 patients), Quimotrase* being used in 69 eyes. As shown in Table 1, most of these pa tients were past the age of 60 years. Of the 115 patients, 111 were Filipinos, two were Americans and two were Chinese. There were more females than males (67 females, 48 males).
QuiMOTRASE
SURGERY*
Age Groups (yr.)
No. Cases
No. Eyes
1-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90
2 2 7 2 7 18 42 25 10
2 2 8 2 7 23 50 34 15
115
143
TECHNIQUE
USED
A fornix-based conjunctival flap is made following O'Brien and Van Lint akinesia, retrobulbar injection of Xylocaine and digi tal pressure. A perilimbal groove is made extending from the 9- to 3-o'clock positions. Three preplaced black silk 6-0 sutures are cautiously inserted. Then with a keratome the anterior chamber is entered, avoiding sudden gush of aqueous fluid. The keratome incision is enlarged with corneal scissors. Then iridectomy is performed (peripheral iridectomy in 81 eyes). Quimotrase is then carefully irrigated into the posterior chamber through the iridectomy area as well as at the 6-o'clock position. As soon as the lens begins to bulge out, the excess Quimotrase is washed off by careful irriga tion with normal saline solution. With an * From the Manila Sanitarium and Hospital, t Quimotrase is alpha chymotrypsin distributed by Smith, Miller and Patch, Inc., New York.
erisophake the cataractous lens is delivered by the sliding method. Attempt is now made to make the pupil round and regular. The sutures are carefully tied over the conjunc tival flap. Two side sutures are used to tighten the conjunctival flap. Antibiotic oint ment is squeezed into the lower cul-de-sac before the eye is patched and protected with a shield. No
QUIMOTRASE
USED
The same technique as just described is used, except that the lens is delivered by tumbling. It should be noted that air injection into the anterior chamber is avoided except in cases in which vitreous is lost. HOSPITAL CARE AND
FOLLOW-UP
The operated eye, as well as the unoperated eye, is kept covered for 48 hours and is disturbed only after 24 hours when
238
U L Y S S E S
TABLE
Μ. C A R B A . I A L
2
COMPLICATIONS ΓΗΉΙΝΓ· SURGERY
Quiinotrase
Complications
Vitreous Loss: a. Threatened ^ b. Liquid vitreous 1. c. Formed vitreous Extracapsular Hyphema Difficulty in lens ex traction Sinking of lens into vit reous
7(
40%)
3(
33%)
No Quimo- γ trase 10(60%
)
|
(
17
6 ( 6 6 % )
1(100%) 1(100%) 1(100%)
the first postoperative dressing is done. Terra-Cortril ointment is instilled into the eye, although sometimes Cyclogyl is used when the pupil is somewhat constricted. The patient is allowed to ambulate freely after 48 hours and is discharged home on the sixth postoperative day. The patients are seen in the office every other day for one week and then twice a week as necessary. Glasses are prescribed not earlier than 10 weeks after the surgery. PKKSKXTATION
ΟΙ·" R E S U L T S
Inasmuch as the objective of this paper is to compare the results obtained when Quimotrase is used and when Quimotrase is not used, care was exercised in noting com T A B L E
T A B L E
3
Corneal haziness Hyphema Anterior chamber: ¡i. Shallow b. Collapsed Vitreous prolapsing into anterior chamber Iritis (dense aqueous Hare) Endophthalmitis Synechiae formation Occluded pupil 1 )escemet's membrane curled down Iris prolapse
Quimotrase
No Quimotrase
Tota
9( 6 0 % )
6( 4 0 % )
15
6( 7 5 % )
8
4( 6 6 % )
2( 2 5 % ) 2( 3 3 % )
2( 6 6 % ) 2( 6 6 % )
!( 3 3 % ) 1 ( 33%)
3(100%) 2(100%) 1( 5 0 % )
—
1(100%) 1 (100%)
none
Κ
— —
6 3 3 3
)
50%) 1(100%)
1
—
1
—
1
none
4
L A T E POSTOPERATIVE COMPLICATIONS
EARLY POSTOPERATIVE COMPLICATIONS
Complications
plications during surgery, immediately after surgery, and later on. The complications are classified a s : ( A ) operative; ( B ) postopera tive: ( 1 ) early and ( 2 ) late. Table 2 shows that the tendency to extra capsular extraction was minimized consider ably by the use of Quimotrase, and that the tendency to vitreous loss was diminished by the use of Quimotrase. The lone case of hyphema was associated with the use of Quimotrase and so was the lone case of the lens sinking into the vitreous. In the early postoperative period, that is during the first week of surgery (table 3 ) , there were more complications when Qui motrase was used. The incidence of corneal haziness, collapsed anterior chamber, iritis, prolapse of vitreous into the anterior cham ber and hyphema was definitely higher in the eyes where Quimotrase was used. There was one case of endophthalmitis in each group. It is interesting to note that, although the incidence of hyphema was negligible in each group during surgery, there was marked rise of incidence of hyphema during the early postoperative period in the eyes in which Quimotrase was used. During the late postoperative period, a number of complications were encountered, as shown in Table 4. The incidence of com plications appears nearly equal in each
—
Complications:
Quimo trase
Iris-vitreous adhesions 2 ( 5 0 % ) Glaucoma 2( 50%) Vitreous condensation 3(100%) Phthisis bulbi 2 ( 6 0 % ) Macular hemorrhage 1 ( 5 0 % ) Endothelial downgrowth and cyst 1(50%) Secondary membrane — Detached retina 1(100%) Hammock pupil 1(100%) Persistent pain 1(100%) Optic atrophy — Poor wound healing 1(100%) Slight hyphema — Pupillary membrane —
No Quimotrase 2 ( 5 0 % )
2( 50%) — 1 ( 3 3 % ) 1 ( 5 0 % )
1( 50%) 1(100%) — — — 1(100%) — 1(100%) 1(100%)
Total
COMPLICATIONS
FROM A L P H A
CHYMOTRYPSIX
239
TABLE 5 RELATIONSHIP: TYPE OF CATARACT TO COMPLICATIONS WITH USE OF
Quimotrase
Type of Cataract: Immature Mature Hypermature Secondary to: a. Trauma b. Endophthalmitis c. Glaucoma surgery d. Dislocation*
QLIMOTKASK
No Quimotrase Complicated
Uncomplicated
4 ( 30%) 13( 50%) 12( 50%)
9(70%) 13(50%) 12(50%)
10( 58%) M( 36%) 7( 44%)
7(42%) 20(64%) 9(56%)
30 57 40
3( 60%) 2(100%)
2(40%)
Κ 50%) 2(100%) Κ 25%)
H50%)
40 4 4 1
—
—
—
1(100%)
Uncomplicated
Total
Complicated
3(75%)
—
35
36
32
143
40
* Another case done recently; no Quimotrase used.
group, except that there were three cases of vitreous condensation after Quimotrase in comparison to that of none when Quimotrase was not used. In this study an attempt is also made to clarify the relationship between the type of cataract and complications in the two groups: ( a ) Quimotrase used ( b ) Quimotrase not used. A glance at Table 5 will reveal quickly that Quimotrase diminished complications in extraction of immature cataracts. When Quimotrase was used in mature and hyper mature cataracts, complications were more likely to occur. In cataracts secondary to trauma, endophthalmitis and glaucoma, it was doubtful whether or not Quimotrase was of any help. It might have even been better not to use Quimotrase. In regard to the relationship between age and cataract extraction with or without Qui
motrase, it is noteworthy (table 6 ) that the use of this enzyme did not alter the inci dence of complications in those patients 20 years of age or younger. However, in the age group of 20 to 40 years, it appeared that the use of Quimotrase greatly helped di minish the incidence of complications. In the higher age groups, the complications did not seem related to age but more to the cause and the stage of the cataract. It is remark able that in the age period 81 to 90 years, Quimotrase was associated with complica tions but there were none when Quimotrase was not used. VISUAL
RESULT
The visual result in all cases without com plications was 20/20 with proper classes. Vision was poorest in those cases in which there was vitreous loss, vitreous condensa tion and adhesion between iris and vitreous
TABLE 6 RELATIONSHIP: ACE, USE OF QUIMOTRASE, COMPLICATIONS
Age Group (yr.) 1-20 21-40 41-60 61-up«
Quimotrase
No Quimotrase
Complicated
Uncomplicated
2(100%1 6( 75%) 10( 52%) 18( 42%)
2(25%) 9(48%) 25(58%)
2(100%) If 50%) 3( 28%) 26( 47%)
1 (50%) 8(72%) 30(53%)
36
36
32
39
Complicated
Lincomplicated
Total 4 10 30 99 143
* In the age group 81-90 years, Quimotrase was used in 11 patients and not used in three patients. In the first group, six patients had complications but, in the latter, not one had any complication.
240
U L Y S S E S Μ. CARBA.IAL
face. In the cases with collapsed anterior chamber, vision was eventually good except in one case that developed secondary glau coma. The transient corneal haziness in the early postoperative stage in both groups (with or without Quimotrase) did not mate rially affect the final vision. Those cases with hyphema cleared nicely with no ill-effect on the vision, including the case that had to undergo washing of the an terior chamber 10 days after cataract ex traction. COMMENT
Despite the use of a fornix-based conjuctival flap, there was still greater tendency to collapsed chamber when Quimotrase was used, indicating that this enzyme (1:5,000 dilution) tended to delay wound healing, in accordance with Rarraquer's conclusion. Moreover, mild corneal haziness tended to be more frequent when this enzyme was used. Fortunately, this was only transient. This could be due to trauma from the erisophake or Arruga capsule forceps as a re sult of the shallowing of the anterior cham ber following the dislodgement of the lens from rapid zonulolysis. This could be mini mized by applying the erisophake or capsule forceps before the lens begins to bulge out. The increased secondary hyphema when Quimotrase was used was a corollary to (he tendency to delay in wound healing, and did not bear any relation to defects in the blood coagulation mechanism. The tendency to condensation of the vit reous and even its adherence to the iris \vere other complications that lowered the boon of the use of alpha chymotrypsin. This con densation, however, occurred mostly in those patients giving a history of attacks of iritis and/or glaucoma in the past. This could have been prevented, or at least mini mized, by the use of systemic steroids and controlled mydriatics. This studv bears out thai care should be exercised in using this enzyme or its use should even be avoided in the presence of structural alterations brought about by a 1
previous iritis or a previous glaucoma or r currently dislocated lens. O'Malley, et al. emphasized that this enzyme should not be used in the presence of vitreous disinsertion, rupture of vitreous face and possibly extreme degeneration of vitreous. Kennedy, et al. do not believe that alpha chymotrypsin should be used in (1) anyone under 20 years of age, (2) in cases of subluxated lenses and ( 3 ) in the presence of corneal dystrophy. Ciirard, Xeely and Sampson* declare that one of the major postoperative problems in intracapsular cataract in infants and chil dren is impaired conical healing, probably the result of the cytotoxicity of alpha chy motrypsin. Although in this study the enzyme was used in only four children, there is reason to conclude that its use does not prevent the complications brought about by the lentieulovitreal adhesions and pliancy of the sclera. Wilson" in his review of the congenital cata ract extractions in Childrens Hospital, l.os Angeles, states that the results obtained there leave much to be desired. The tendency to delay in wound healing according to Hill" and Ilarraquer is either due to the imperfect incision or to the method of wound closure rather than to the enzyme itself. Moreover, they feel that postplaced sutures are more likely to result in a leaking wound than sutures carefully preplaced in a groove in the firm unopened eye ball. However, in this study, it is demon strated that despite the use of ;i conjunctival flap and preplaced sutures, there was greater tendency to leaky wounds in the group in which alpha chymotrypsin was used. One bright note here is that alpha chymo trypsin diminishes the incidence of capsule tearing in patients with immature cataracts, especially in the age group 40 to 60 years. It is not, however, recommended in age groups bevoiul 80 years, especially when the cata ract is mature or hvpermature. The reasons behind this are Í1) the zonules in these pa tients are already very weak and (2) there 2
3
COMPLICATIONS
FROM A L P H A
is possibility that the vitreous in these pa tients may have degenerated to some degree. SUM
MARY
In this study, 143 eyes undergoing cata ract extraction are divided into two cate gories; in one group (69 eyes), Quimotrase was used; in the other group the enzyme was not used. The same surgical technique was done in each group except that the lens was delivered by the sliding method in the first group and by the tumbling method in the latter.
CHYMOTRYPSIN
241
The complications in each group are clas sified, analyzed, and compared. In brief, during the surgery, complications were min imized with the use of Quimotrase. How ever, in the early postoperative period, more complications were encountered when this enzyme was used. Quimotrase was helpful in cases of immature cataract especially at the ages of 40 to 60 years. It was not of much use in the age group 80 to 90 years, and even proved harmful when the cataract was hypermature. 789 Vita Cruz, Malaie.
REFERENCES
1. Barraquer, J . : Enzymatic zonulolysis in lens extraction. A M A Arch. Ophth, 66:6, 1961. 2. O'Malley, C , Moskovitz, M., and Straatsma, B. R.: Experimentally induced adverse effects of alpha chymotrypsin. A M A Arch. Ophth, 66:544, 1961. 3. Kennedy, P. J , Jordan, Morrison, Mulbcrger, and Bolaml: Enzvmatic zonulolysis as an aid in cataract surgery. A M A Arch. Ophth, 65 :803-804, 1961. 4. Girard, L. I , Nellv, VY, and Sampson, \Y. G.: Cataract extraction in children. Am. I. Ophth, 6 4 : 1072-1073, 1962.' 5. Wilson, W . Α . : Congenital cataracts. A M A Arch. Ophth, 67:147, 1962. 6. Hill, H. F , and Barraquer, J . : Enzymatic zonulolysis. Am. J . Ophth, 54:94-95, 1962.
I N J E C T A B L E S I L A S T I C FOR . EVISCERATION RICHARD
A.
ELLIS,
M.D, A N D
Philadelphia,
It is now possible to inject liquid silastic (medical Silastic 382; previously called Sil astic RTV502) into the body where the ma terial forms a spongy rubber in a few min utes. It is the purpose of this paper to report the use of this material in evisceration sur gery. Medical Silastic base 382 (manufactured by Dow Corning) in a thick white liquid form will vulcanize (harden) to form sili con rubber at room or body temperature from one to six minutes after catalyst (Dow Corning M-Stannous Octoate) is added. It is also possible to vary the viscosity and set up time by varying the amount of base and catalyst added to the mixture. The base and catalyst may be autoclaved separately before * Presented at the Wills Eye Conference, ruary 15, 1964.
Feb
JOHN
J.
COYLE,
SURGERY* M.D.
Pennsyhania
combining. The resultant silicone rubber maintains its properties over a large tempera ture range and resists moisture and oxida tion. This material has been used successfully to form plastic jackets around intracranial aneurysms where it could be precisely molded and yet allow pulsatile flow because of its elastic property. It has also been used as a prosthesis for the newborn infant with a cleft palate. Clinical work using injectable silicone has also been done on patients with micrognathia, facial hemiatrophy, post-trau matic deformities and in those requiring augmentation mammoplastv and testicular prostheses. No untoward reactions were noted in these cases. This material has also been successfully used in the correction of vclvopharyngeal insufficiency. 1
2
3,4
5
237
AKINESIA
22. Scheie, H. G , Ellis, R. A , Eckenhoff, J . E , and Spencer, R. \ Y . : Long-lasting local anesthetic agents in ophthalmic surgery. A M A Arch. Ophth, 53:177-190, 1955. 23. Burford, G. E.: Involuntary eyeball motion during anesthesia and sleep: Relationship to cortical rhythmic potentials. Anesth. & Analg, 20:191-199, 1941. Cited by Walsh, F. B.: Clinical Ν euro-ophthal mology. Baltimore, Williams & Wilkins, 1957, p. 189.
COMPLICATIONS FROM THE
IN
USE OF A L P H A
ULYSSES
M.
Manila, CLINICAL
CATARACT
SURGICAL
CHYMOTRYPSIN
CARBAJAL,
M.D.
Philippines TABLE
DATA
1
A G E DISTRIBUTION
This paper is based on a 36-month study of cataract extractions performed by me on 143 eyes (115 patients), Quimotrase* being used in 69 eyes. As shown in Table 1, most of these pa tients were past the age of 60 years. Of the 115 patients, 111 were Filipinos, two were Americans and two were Chinese. There were more females than males (67 females, 48 males).
QuiMOTRASE
SURGERY*
Age Groups (yr.)
No. Cases
No. Eyes
1-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90
2 2 7 2 7 18 42 25 10
2 2 8 2 7 23 50 34 15
115
143
TECHNIQUE
USED
A fornix-based conjunctival flap is made following O'Brien and Van Lint akinesia, retrobulbar injection of Xylocaine and digi tal pressure. A perilimbal groove is made extending from the 9- to 3-o'clock positions. Three preplaced black silk 6-0 sutures are cautiously inserted. Then with a keratome the anterior chamber is entered, avoiding sudden gush of aqueous fluid. The keratome incision is enlarged with corneal scissors. Then iridectomy is performed (peripheral iridectomy in 81 eyes). Quimotrase is then carefully irrigated into the posterior chamber through the iridectomy area as well as at the 6-o'clock position. As soon as the lens begins to bulge out, the excess Quimotrase is washed off by careful irriga tion with normal saline solution. With an * From the Manila Sanitarium and Hospital, t Quimotrase is alpha chymotrypsin distributed by Smith, Miller and Patch, Inc., New York.
erisophake the cataractous lens is delivered by the sliding method. Attempt is now made to make the pupil round and regular. The sutures are carefully tied over the conjunc tival flap. Two side sutures are used to tighten the conjunctival flap. Antibiotic oint ment is squeezed into the lower cul-de-sac before the eye is patched and protected with a shield. No
QUIMOTRASE
USED
The same technique as just described is used, except that the lens is delivered by tumbling. It should be noted that air injection into the anterior chamber is avoided except in cases in which vitreous is lost. HOSPITAL CARE AND
FOLLOW-UP
The operated eye, as well as the unoperated eye, is kept covered for 48 hours and is disturbed only after 24 hours when
238
U L Y S S E S
TABLE
Μ. C A R B A . I A L
2
COMPLICATIONS ΓΗΉΙΝΓ· SURGERY
Quiinotrase
Complications
Vitreous Loss: a. Threatened ^ b. Liquid vitreous 1. c. Formed vitreous Extracapsular Hyphema Difficulty in lens ex traction Sinking of lens into vit reous
7(
40%)
3(
33%)
No Quimo- γ trase 10(60%
)
|
(
17
6 ( 6 6 % )
1(100%) 1(100%) 1(100%)
the first postoperative dressing is done. Terra-Cortril ointment is instilled into the eye, although sometimes Cyclogyl is used when the pupil is somewhat constricted. The patient is allowed to ambulate freely after 48 hours and is discharged home on the sixth postoperative day. The patients are seen in the office every other day for one week and then twice a week as necessary. Glasses are prescribed not earlier than 10 weeks after the surgery. PKKSKXTATION
ΟΙ·" R E S U L T S
Inasmuch as the objective of this paper is to compare the results obtained when Quimotrase is used and when Quimotrase is not used, care was exercised in noting com T A B L E
T A B L E
3
Corneal haziness Hyphema Anterior chamber: ¡i. Shallow b. Collapsed Vitreous prolapsing into anterior chamber Iritis (dense aqueous Hare) Endophthalmitis Synechiae formation Occluded pupil 1 )escemet's membrane curled down Iris prolapse
Quimotrase
No Quimotrase
Tota
9( 6 0 % )
6( 4 0 % )
15
6( 7 5 % )
8
4( 6 6 % )
2( 2 5 % ) 2( 3 3 % )
2( 6 6 % ) 2( 6 6 % )
!( 3 3 % ) 1 ( 33%)
3(100%) 2(100%) 1( 5 0 % )
—
1(100%) 1 (100%)
none
Κ
— —
6 3 3 3
)
50%) 1(100%)
1
—
1
—
1
none
4
L A T E POSTOPERATIVE COMPLICATIONS
EARLY POSTOPERATIVE COMPLICATIONS
Complications
plications during surgery, immediately after surgery, and later on. The complications are classified a s : ( A ) operative; ( B ) postopera tive: ( 1 ) early and ( 2 ) late. Table 2 shows that the tendency to extra capsular extraction was minimized consider ably by the use of Quimotrase, and that the tendency to vitreous loss was diminished by the use of Quimotrase. The lone case of hyphema was associated with the use of Quimotrase and so was the lone case of the lens sinking into the vitreous. In the early postoperative period, that is during the first week of surgery (table 3 ) , there were more complications when Qui motrase was used. The incidence of corneal haziness, collapsed anterior chamber, iritis, prolapse of vitreous into the anterior cham ber and hyphema was definitely higher in the eyes where Quimotrase was used. There was one case of endophthalmitis in each group. It is interesting to note that, although the incidence of hyphema was negligible in each group during surgery, there was marked rise of incidence of hyphema during the early postoperative period in the eyes in which Quimotrase was used. During the late postoperative period, a number of complications were encountered, as shown in Table 4. The incidence of com plications appears nearly equal in each
—
Complications:
Quimo trase
Iris-vitreous adhesions 2 ( 5 0 % ) Glaucoma 2( 50%) Vitreous condensation 3(100%) Phthisis bulbi 2 ( 6 0 % ) Macular hemorrhage 1 ( 5 0 % ) Endothelial downgrowth and cyst 1(50%) Secondary membrane — Detached retina 1(100%) Hammock pupil 1(100%) Persistent pain 1(100%) Optic atrophy — Poor wound healing 1(100%) Slight hyphema — Pupillary membrane —
No Quimotrase 2 ( 5 0 % )
2( 50%) — 1 ( 3 3 % ) 1 ( 5 0 % )
1( 50%) 1(100%) — — — 1(100%) — 1(100%) 1(100%)
Total
COMPLICATIONS
FROM A L P H A
CHYMOTRYPSIX
239
TABLE 5 RELATIONSHIP: TYPE OF CATARACT TO COMPLICATIONS WITH USE OF
Quimotrase
Type of Cataract: Immature Mature Hypermature Secondary to: a. Trauma b. Endophthalmitis c. Glaucoma surgery d. Dislocation*
QLIMOTKASK
No Quimotrase Complicated
Uncomplicated
4 ( 30%) 13( 50%) 12( 50%)
9(70%) 13(50%) 12(50%)
10( 58%) M( 36%) 7( 44%)
7(42%) 20(64%) 9(56%)
30 57 40
3( 60%) 2(100%)
2(40%)
Κ 50%) 2(100%) Κ 25%)
H50%)
40 4 4 1
—
—
—
1(100%)
Uncomplicated
Total
Complicated
3(75%)
—
35
36
32
143
40
* Another case done recently; no Quimotrase used.
group, except that there were three cases of vitreous condensation after Quimotrase in comparison to that of none when Quimotrase was not used. In this study an attempt is also made to clarify the relationship between the type of cataract and complications in the two groups: ( a ) Quimotrase used ( b ) Quimotrase not used. A glance at Table 5 will reveal quickly that Quimotrase diminished complications in extraction of immature cataracts. When Quimotrase was used in mature and hyper mature cataracts, complications were more likely to occur. In cataracts secondary to trauma, endophthalmitis and glaucoma, it was doubtful whether or not Quimotrase was of any help. It might have even been better not to use Quimotrase. In regard to the relationship between age and cataract extraction with or without Qui
motrase, it is noteworthy (table 6 ) that the use of this enzyme did not alter the inci dence of complications in those patients 20 years of age or younger. However, in the age group of 20 to 40 years, it appeared that the use of Quimotrase greatly helped di minish the incidence of complications. In the higher age groups, the complications did not seem related to age but more to the cause and the stage of the cataract. It is remark able that in the age period 81 to 90 years, Quimotrase was associated with complica tions but there were none when Quimotrase was not used. VISUAL
RESULT
The visual result in all cases without com plications was 20/20 with proper classes. Vision was poorest in those cases in which there was vitreous loss, vitreous condensa tion and adhesion between iris and vitreous
TABLE 6 RELATIONSHIP: ACE, USE OF QUIMOTRASE, COMPLICATIONS
Age Group (yr.) 1-20 21-40 41-60 61-up«
Quimotrase
No Quimotrase
Complicated
Uncomplicated
2(100%1 6( 75%) 10( 52%) 18( 42%)
2(25%) 9(48%) 25(58%)
2(100%) If 50%) 3( 28%) 26( 47%)
1 (50%) 8(72%) 30(53%)
36
36
32
39
Complicated
Lincomplicated
Total 4 10 30 99 143
* In the age group 81-90 years, Quimotrase was used in 11 patients and not used in three patients. In the first group, six patients had complications but, in the latter, not one had any complication.
240
U L Y S S E S Μ. CARBA.IAL
face. In the cases with collapsed anterior chamber, vision was eventually good except in one case that developed secondary glau coma. The transient corneal haziness in the early postoperative stage in both groups (with or without Quimotrase) did not mate rially affect the final vision. Those cases with hyphema cleared nicely with no ill-effect on the vision, including the case that had to undergo washing of the an terior chamber 10 days after cataract ex traction. COMMENT
Despite the use of a fornix-based conjuctival flap, there was still greater tendency to collapsed chamber when Quimotrase was used, indicating that this enzyme (1:5,000 dilution) tended to delay wound healing, in accordance with Rarraquer's conclusion. Moreover, mild corneal haziness tended to be more frequent when this enzyme was used. Fortunately, this was only transient. This could be due to trauma from the erisophake or Arruga capsule forceps as a re sult of the shallowing of the anterior cham ber following the dislodgement of the lens from rapid zonulolysis. This could be mini mized by applying the erisophake or capsule forceps before the lens begins to bulge out. The increased secondary hyphema when Quimotrase was used was a corollary to (he tendency to delay in wound healing, and did not bear any relation to defects in the blood coagulation mechanism. The tendency to condensation of the vit reous and even its adherence to the iris \vere other complications that lowered the boon of the use of alpha chymotrypsin. This con densation, however, occurred mostly in those patients giving a history of attacks of iritis and/or glaucoma in the past. This could have been prevented, or at least mini mized, by the use of systemic steroids and controlled mydriatics. This studv bears out thai care should be exercised in using this enzyme or its use should even be avoided in the presence of structural alterations brought about by a 1
previous iritis or a previous glaucoma or r currently dislocated lens. O'Malley, et al. emphasized that this enzyme should not be used in the presence of vitreous disinsertion, rupture of vitreous face and possibly extreme degeneration of vitreous. Kennedy, et al. do not believe that alpha chymotrypsin should be used in (1) anyone under 20 years of age, (2) in cases of subluxated lenses and ( 3 ) in the presence of corneal dystrophy. Ciirard, Xeely and Sampson* declare that one of the major postoperative problems in intracapsular cataract in infants and chil dren is impaired conical healing, probably the result of the cytotoxicity of alpha chy motrypsin. Although in this study the enzyme was used in only four children, there is reason to conclude that its use does not prevent the complications brought about by the lentieulovitreal adhesions and pliancy of the sclera. Wilson" in his review of the congenital cata ract extractions in Childrens Hospital, l.os Angeles, states that the results obtained there leave much to be desired. The tendency to delay in wound healing according to Hill" and Ilarraquer is either due to the imperfect incision or to the method of wound closure rather than to the enzyme itself. Moreover, they feel that postplaced sutures are more likely to result in a leaking wound than sutures carefully preplaced in a groove in the firm unopened eye ball. However, in this study, it is demon strated that despite the use of ;i conjunctival flap and preplaced sutures, there was greater tendency to leaky wounds in the group in which alpha chymotrypsin was used. One bright note here is that alpha chymo trypsin diminishes the incidence of capsule tearing in patients with immature cataracts, especially in the age group 40 to 60 years. It is not, however, recommended in age groups bevoiul 80 years, especially when the cata ract is mature or hvpermature. The reasons behind this are Í1) the zonules in these pa tients are already very weak and (2) there 2
3
COMPLICATIONS
FROM A L P H A
is possibility that the vitreous in these pa tients may have degenerated to some degree. SUM
MARY
In this study, 143 eyes undergoing cata ract extraction are divided into two cate gories; in one group (69 eyes), Quimotrase was used; in the other group the enzyme was not used. The same surgical technique was done in each group except that the lens was delivered by the sliding method in the first group and by the tumbling method in the latter.
CHYMOTRYPSIN
241
The complications in each group are clas sified, analyzed, and compared. In brief, during the surgery, complications were min imized with the use of Quimotrase. How ever, in the early postoperative period, more complications were encountered when this enzyme was used. Quimotrase was helpful in cases of immature cataract especially at the ages of 40 to 60 years. It was not of much use in the age group 80 to 90 years, and even proved harmful when the cataract was hypermature. 789 Vita Cruz, Malaie.
REFERENCES
1. Barraquer, J . : Enzymatic zonulolysis in lens extraction. A M A Arch. Ophth, 66:6, 1961. 2. O'Malley, C , Moskovitz, M., and Straatsma, B. R.: Experimentally induced adverse effects of alpha chymotrypsin. A M A Arch. Ophth, 66:544, 1961. 3. Kennedy, P. J , Jordan, Morrison, Mulbcrger, and Bolaml: Enzvmatic zonulolysis as an aid in cataract surgery. A M A Arch. Ophth, 65 :803-804, 1961. 4. Girard, L. I , Nellv, VY, and Sampson, \Y. G.: Cataract extraction in children. Am. I. Ophth, 6 4 : 1072-1073, 1962.' 5. Wilson, W . Α . : Congenital cataracts. A M A Arch. Ophth, 67:147, 1962. 6. Hill, H. F , and Barraquer, J . : Enzymatic zonulolysis. Am. J . Ophth, 54:94-95, 1962.
I N J E C T A B L E S I L A S T I C FOR . EVISCERATION RICHARD
A.
ELLIS,
M.D, A N D
Philadelphia,
It is now possible to inject liquid silastic (medical Silastic 382; previously called Sil astic RTV502) into the body where the ma terial forms a spongy rubber in a few min utes. It is the purpose of this paper to report the use of this material in evisceration sur gery. Medical Silastic base 382 (manufactured by Dow Corning) in a thick white liquid form will vulcanize (harden) to form sili con rubber at room or body temperature from one to six minutes after catalyst (Dow Corning M-Stannous Octoate) is added. It is also possible to vary the viscosity and set up time by varying the amount of base and catalyst added to the mixture. The base and catalyst may be autoclaved separately before * Presented at the Wills Eye Conference, ruary 15, 1964.
Feb
JOHN
J.
COYLE,
SURGERY* M.D.
Pennsyhania
combining. The resultant silicone rubber maintains its properties over a large tempera ture range and resists moisture and oxida tion. This material has been used successfully to form plastic jackets around intracranial aneurysms where it could be precisely molded and yet allow pulsatile flow because of its elastic property. It has also been used as a prosthesis for the newborn infant with a cleft palate. Clinical work using injectable silicone has also been done on patients with micrognathia, facial hemiatrophy, post-trau matic deformities and in those requiring augmentation mammoplastv and testicular prostheses. No untoward reactions were noted in these cases. This material has also been successfully used in the correction of vclvopharyngeal insufficiency. 1
2
3,4
5