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Eyelid Taping for Comfortable Occlusion
256
AMERICAN JOURNAL OF OPHTHALMOLOGY
Cladiosporium infection. To the best of our knowledge, P. bubakii has been re ported as a suspected pathogen only in a renal transplant patient. The treatment of these cases is diffi cult. The patient described by Wilson, Sexton, and Ahearn 2 failed to respond to treatment with amphotericin B and cryotherapy and ultimately required a conjuctival flap. The patient described by Pol lack, Siverio, and Bresky 4 did not respond to natamycin and had to undergo keratoplasty. None of the previously reported cases responded favorably to the antifungal agents available at that time. Our case, however, responded to topical 1% flucytosine. Although in vitro laboratory testing of this compound indicated resist ance with regard to achievable serum levels, the concentration attained in the eyedrops was fungicidal (500 μg/ml). Ad ditionally, the presence of the corneal laceration probably enhanced the ocular penetration of the flucytosine. This case demonstrated the value of obtaining viable organisms from either the cornea or the anterior chamber. The problems incurred with the initial cul ture, primarily the production of sterile hyphae, showed that a nutritionally defi cient medium is needed to induce the sporulation required for complete identi fication. RICHARD A. E I F E R M A N , M.D. JAMES W. SNYDER, P H . D . J O H N V. BARBEE, J R . , M.D.
Louisville,
Kentucky
REFERENCES
1. Emmons, C. S., Binford, C. H., Utz, J. P., and Kwon-Chung, K. J.: Medical Mycology, 3rd ed. Philadelphia, Lea & Febiger, 1977, p. 40. 2. Wilson, A., Sexton, R. H., and Ahearn, D.: Keratochromomycosis. Arch. Ophthalmol. 76:811, 1966. 3. Jones, B. D., Sexton, R., and Revell, M.: Mycotic keratitis in South Florida. A review of thirty nine cases. Trans. Ophthalmol. Soc. U.K. 89:781, 1969.
FEBRUARY, 1983
4. Pollack, F. M., Siverio, C , and Bresky, R. H.: Corneal chromomycosis. Double infection by Phialophora verrucosa (Medlar) and Cladosporium dadosporiodes (Frescenius). Ann. Ophthalmol. 2:139, 1976.
Eyelid Taping for Comfortable Occlusion One significant problem we have en countered with eyelid occlusion is the movement of the eyelids beneath the patch. We believe that we have greatly decreased this problem by taping the eyelids shut. Patching for eyelid occlusion is routine in the treatment of corneal epithelial de fects. Usually a double patch is applied (two single patches or a folded inner patch). The patches are tightly taped to apply sufficient pressure on the upper eyelid to immobilize it. When the eye is tightly patched, the eyelids may open somewhat but the tightness of the patch prevents them from closing adequately. As the eyelid opens and moves across the cornea, the cornea may be abraded and brought into contact with the eye patch. This can delay the healing process and can also make the patient uncomfortable. 1 Patients treated in this manner often complain of irritation related to move ment of their eyelids beneath the patch es. For this reason one of us (D.R.M.) has been taping the eyelids before patching. The technique of taping the eyelids to gether was first described by Wolchok and Miller. 2 We have used both Transpore and Mi cropore tape successfully. We routinely instill a drop of a cycloplegic drug and either antibiotic solution or ointment be fore taping the eyelids. The eyelids are immobilized with a single vertical piece of tape extending approximately 1 inch above and 1 inch below the eyelash mar gin (Figure). On top of this, we place a single eye patch and tape it into position.
VOL. 95, NO. 2
CORRESPONDENCE
257
Suture Lysis by Laser and Goniolens
Figure (May and May). The eyelids are opposed and taped together with a single piece of tape.
The eyelids remain taped together without separating unless the patient has excessively oily skin, has been sweating profusely, has come in contact with water, or otherwise removes the tape. We routinely apply a single patch over the taped eyelids to absorb these fluids. The pad helps to keep the tape as dry as possible and we believe it promotes pro longed adhesion. We believe that taping the eyelids to gether, thus keeping them firmly op posed and immobilized, increases the pa tient's comfort and the rate of corneal epithelial healing. The mechanical trau ma of eyelid movement over the corneal epithelium is decreased, as is possible contact between the corneal epithelium and the eye patch or eyelashes. D O N A L D R. MAY, M.D. W I L L I A M N. MAY, B.S.
Davis,
California
REFERENCES 1, Patton, D., and Goldberg, M. F.: Management of Ocular Injuries. Philadelphia, W. B. Saunders, 1976, pp. 265 and 266. 2. Wolchok, E. G., and Miller, D.: A new type of eye patch for corneal abrasions. Trans. Am. Acad. Ophthalmol. Otolaryngol. 76:542, 1972.
I would like to share a technique that is proving useful in the postoperative man agement of patients with cataract and glaucoma patients. During my residency, I was taught one could occasionally use the argon laser to lyse black nylon sutures at the corneoscleral limbus. Usually, how ever, the thick postoperative edema and injection of the conjunctiva permitted only one shot, so this technique has been of limited usefulness. I currently seat the patient at the laser and administer one drop of topical proparacaine HC1 to the eye to be treated. I then apply a four-mirror Goldmann goniolens. When the patient looks down, the superior corneoscleral limbus, where sutures are to be treated, is centered in the circular glass at the center of the lens. This usually puts the sutures themselves at the junction of the angled mirror and the center lens. The goniolens has two advantages: it not only prevents blinking, but allows a mild compression of the boggy and inject ed conjunctiva, providing excellent visu alization of the small (No. 9-0 or No. 10-0) nylon sutures. With a spot size of 100 μπι, a duration of 0.2 second, and a setting of 400 to 600 mW, only two to four burns are needed to lyse the suture. There is minimal conjunctival blanching and no perforation of the conjunctiva. Perhaps there is a heat-sink effect with the lens that spares the conjunctiva excessive thermal energy. Ocular discomfort is minimal. This technique is particularly useful in patients who have undergone trabeculectomies alone or trabeculectomies in combination with cataract extraction or intraocular lens implantation. In such eyes, the nonappearance of a bleb postoperatively is sometimes caused by ex cessive tightening of the scierai flap by the sutures. This simple laser lysis allows
AMERICAN JOURNAL OF OPHTHALMOLOGY
Cladiosporium infection. To the best of our knowledge, P. bubakii has been re ported as a suspected pathogen only in a renal transplant patient. The treatment of these cases is diffi cult. The patient described by Wilson, Sexton, and Ahearn 2 failed to respond to treatment with amphotericin B and cryotherapy and ultimately required a conjuctival flap. The patient described by Pol lack, Siverio, and Bresky 4 did not respond to natamycin and had to undergo keratoplasty. None of the previously reported cases responded favorably to the antifungal agents available at that time. Our case, however, responded to topical 1% flucytosine. Although in vitro laboratory testing of this compound indicated resist ance with regard to achievable serum levels, the concentration attained in the eyedrops was fungicidal (500 μg/ml). Ad ditionally, the presence of the corneal laceration probably enhanced the ocular penetration of the flucytosine. This case demonstrated the value of obtaining viable organisms from either the cornea or the anterior chamber. The problems incurred with the initial cul ture, primarily the production of sterile hyphae, showed that a nutritionally defi cient medium is needed to induce the sporulation required for complete identi fication. RICHARD A. E I F E R M A N , M.D. JAMES W. SNYDER, P H . D . J O H N V. BARBEE, J R . , M.D.
Louisville,
Kentucky
REFERENCES
1. Emmons, C. S., Binford, C. H., Utz, J. P., and Kwon-Chung, K. J.: Medical Mycology, 3rd ed. Philadelphia, Lea & Febiger, 1977, p. 40. 2. Wilson, A., Sexton, R. H., and Ahearn, D.: Keratochromomycosis. Arch. Ophthalmol. 76:811, 1966. 3. Jones, B. D., Sexton, R., and Revell, M.: Mycotic keratitis in South Florida. A review of thirty nine cases. Trans. Ophthalmol. Soc. U.K. 89:781, 1969.
FEBRUARY, 1983
4. Pollack, F. M., Siverio, C , and Bresky, R. H.: Corneal chromomycosis. Double infection by Phialophora verrucosa (Medlar) and Cladosporium dadosporiodes (Frescenius). Ann. Ophthalmol. 2:139, 1976.
Eyelid Taping for Comfortable Occlusion One significant problem we have en countered with eyelid occlusion is the movement of the eyelids beneath the patch. We believe that we have greatly decreased this problem by taping the eyelids shut. Patching for eyelid occlusion is routine in the treatment of corneal epithelial de fects. Usually a double patch is applied (two single patches or a folded inner patch). The patches are tightly taped to apply sufficient pressure on the upper eyelid to immobilize it. When the eye is tightly patched, the eyelids may open somewhat but the tightness of the patch prevents them from closing adequately. As the eyelid opens and moves across the cornea, the cornea may be abraded and brought into contact with the eye patch. This can delay the healing process and can also make the patient uncomfortable. 1 Patients treated in this manner often complain of irritation related to move ment of their eyelids beneath the patch es. For this reason one of us (D.R.M.) has been taping the eyelids before patching. The technique of taping the eyelids to gether was first described by Wolchok and Miller. 2 We have used both Transpore and Mi cropore tape successfully. We routinely instill a drop of a cycloplegic drug and either antibiotic solution or ointment be fore taping the eyelids. The eyelids are immobilized with a single vertical piece of tape extending approximately 1 inch above and 1 inch below the eyelash mar gin (Figure). On top of this, we place a single eye patch and tape it into position.
VOL. 95, NO. 2
CORRESPONDENCE
257
Suture Lysis by Laser and Goniolens
Figure (May and May). The eyelids are opposed and taped together with a single piece of tape.
The eyelids remain taped together without separating unless the patient has excessively oily skin, has been sweating profusely, has come in contact with water, or otherwise removes the tape. We routinely apply a single patch over the taped eyelids to absorb these fluids. The pad helps to keep the tape as dry as possible and we believe it promotes pro longed adhesion. We believe that taping the eyelids to gether, thus keeping them firmly op posed and immobilized, increases the pa tient's comfort and the rate of corneal epithelial healing. The mechanical trau ma of eyelid movement over the corneal epithelium is decreased, as is possible contact between the corneal epithelium and the eye patch or eyelashes. D O N A L D R. MAY, M.D. W I L L I A M N. MAY, B.S.
Davis,
California
REFERENCES 1, Patton, D., and Goldberg, M. F.: Management of Ocular Injuries. Philadelphia, W. B. Saunders, 1976, pp. 265 and 266. 2. Wolchok, E. G., and Miller, D.: A new type of eye patch for corneal abrasions. Trans. Am. Acad. Ophthalmol. Otolaryngol. 76:542, 1972.
I would like to share a technique that is proving useful in the postoperative man agement of patients with cataract and glaucoma patients. During my residency, I was taught one could occasionally use the argon laser to lyse black nylon sutures at the corneoscleral limbus. Usually, how ever, the thick postoperative edema and injection of the conjunctiva permitted only one shot, so this technique has been of limited usefulness. I currently seat the patient at the laser and administer one drop of topical proparacaine HC1 to the eye to be treated. I then apply a four-mirror Goldmann goniolens. When the patient looks down, the superior corneoscleral limbus, where sutures are to be treated, is centered in the circular glass at the center of the lens. This usually puts the sutures themselves at the junction of the angled mirror and the center lens. The goniolens has two advantages: it not only prevents blinking, but allows a mild compression of the boggy and inject ed conjunctiva, providing excellent visu alization of the small (No. 9-0 or No. 10-0) nylon sutures. With a spot size of 100 μπι, a duration of 0.2 second, and a setting of 400 to 600 mW, only two to four burns are needed to lyse the suture. There is minimal conjunctival blanching and no perforation of the conjunctiva. Perhaps there is a heat-sink effect with the lens that spares the conjunctiva excessive thermal energy. Ocular discomfort is minimal. This technique is particularly useful in patients who have undergone trabeculectomies alone or trabeculectomies in combination with cataract extraction or intraocular lens implantation. In such eyes, the nonappearance of a bleb postoperatively is sometimes caused by ex cessive tightening of the scierai flap by the sutures. This simple laser lysis allows