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Hyaluronate in the Identification of the Cut End in Lacerations of the Lacrimal Canaliculi
214
suppressive acidic protein in 32 patients with both Behget's disease and ocular manifesta tions, in 60 patients with other types of uveitis, and in 50 normal subjects. Single radial immunodiffusion assay was used to quantitate levels of the protein in sera. Agarose gel containing anti-immunosuppressive acidic protein goat serum was prepared on a glass plate, and wells 2.5 mm in diameter were punched out. Placed in each well was 5 ul of sample. After incubation for 48 hours at 37 C, the diameter of the precipitation ring was measured. The mean ± S.D. of the serum immunosuppressive acidic protein level in cases of Behget's disease was 596.9 ± 133.2 |xg/ml, which was significantly greater than that of other uveitis patients (376.5 ± 134.7 u.g/ml; P < .001) and normal subjects (381.4 ± 62.3 u.g/ml; P < .001). The serum immunosuppressive acidic pro tein level in cases of Behget's disease in a state of remission (521.5 ± 63.9 |xg/ml) was less than
1,000-
• •• •
?
• • •
■ *
%
en o
ive acidic
*L
3
that of patients with an active disease state (P < .01), but significantly higher than that in nor mal subjects (P < .001) (Figure). Shimakawa and Kogure 3 reported that serum acid-soluble protein is a useful indicator of activity in Behget's disease. In our study, the changes of immunosuppressive acidic protein levels were quantitatively correlated with the serum levels of a-l-acid glycoprotein. How ever, the level of protein showed a relatively higher response. This indicates that immuno suppressive acidic protein levels may be used as a marker for Behget's disease.
References 1. Tamura, K., Shibata, Y., Matsuda, M., and Ishida, N.: Isolation and characterization of an im munosuppressive acidic protein. Cancer Res. 41:3244, 1981. 2. Shibata, Y., Tamura, K., and Ishida, N.: Cul tured human monocytes, granulocytes, and a monoblastoid cell line (THP-1) synthesize and se crete immunosuppressive acidic protein (a type of a-1-acidic glycoprotein). Microbiol. Immunol. 28:99, 1984. 3. Shimakawa, M., and Kogure, M.: Acid-soluble protein in Behget's disease. Am. J. Ophthalmol. 102:281, 1986.
f
1
3 a
February, 1988
AMERICAN JOURNAL OF OPHTHALMOLOGY
11 • ! t
O
c
D
E
•t • •
i
r
— \ -
V
■
Hyaluronate in the Identification of the Cut End in Lacerations of the Lacrimal Canaliculi
t
i
t\
m T • •• •
• ••
Behpet s disease1
Other uveitis
Control
Figure (Yamaguchi and associates). Serum immu nosuppressive acidic protein levels in patients with Behget's disease, other types of uveitis, and in nor mal controls.
Alejandro Aguirre Vila-Coro, M . D . , Antonio Aguirre Vila-Coro, M . D . , and Pablo Zaragoza Garcia, M . D . Departamento de Oftalmologia, Hospital Clinico de San Carlos, Facultad de Medicina, Universidad Complutense (A.A.V.-C. and P.Z.G.); and the University of Texas Health Science Center at Houston, Hermann Eye Center (An.A.V.-C). Inquiries to Alejandro Aguirre Vila-Coro, M.D., Dracena 40, 28016 Madrid, Spain. Repair of a lacerated lacrimal canaliculus re quires exquisite microsurgery to obtain postop erative patency. Ideally, surgery should be per formed within 24 hours after trauma. Visual identification of the medial cut end of the lace rated canaliculus is often difficult, even through the operating microscope. Current
Letters to the Journal
Vol. 105, No. 2
methods of facilitating recognition of this cut end include injection of milk or of a white ophthalmic suspension through a blunt cannu la via the intact canaliculus, as well as injection of air under a pool of saline. 1 Colorants such as methylene blue should not be used, as they stain the surrounding tissues, rendering recog nition of the cut end more difficult. To recognize the medial cut end of the cana liculus, we have been using a mixture of hyaluronate with fluorescein. To prepare the mix ture, an ampulla of hyaluronate (0.4 ml) is emptied in a medicine glass, and two drops of 2% fluorescein solution are added. Stirring is followed by aspiration of the mixture in a sy ringe. The stained hyaluronate is then injected through the intact canaliculus. Injection causes filling of the lacrimal sac and reflux through the injured canaliculus. Viscoelastic properties of the hyaluronate and slow injection allow a controlled reflux. Thus, only a fraction of a drop is allowed to protrude through the medial cut end of the canaliculus. This end is thus easily recognized, while fluorescein tissue staining is avoided. A cobalt blue filter may be used to enhance visua lization.
Reference 1. Katowitz, J. A.: Lacrimal drainage surgery. In Duane, T. (ed.): Clinical Ophthalmology, Vol. 5, Chapter 11. Philadelphia, Harper and Row Publish ers, 1983, p. 27.
215
various techniques. 1 Drainage may be accom plished by a posterior intentional retinotomy with subsequent drainage of subretinal fluid by an extrusion needle. 2 When an open peripheral break is present, a flexible cannula up to 18 mm can be introduced into the break to allow drain age of posterior subretinal fluid.3 The standard 20-gauge extrusion needle can be modified simply by attaching a short flexible cannula to the tapered metal tip (Fig. 1). The silicone cannula tubing* can be attached to the end of the tapered extrusion needle without adhesives. This flexible, 24-gauge tubing can be cut in variable lengths, depending on the ex pected extension into the subretinal space. The flexible cannula can be folded over to facilitate entry into a 20-gauge pars plana sclerotomy site (Fig. 2). The flexible cannula can be introduced into an existing peripheral or posterior iatrogenic retinal break and guided into the subretinal space. During simultaneous fluid/gas ex change, 4 the subretinal fluid will passively leave the eye through the extrusion needle cannula. If a peripheral retinal break is used, complete removal of posterior subretinal fluid may not be possible, but reattachment of the peripheral retinal break can be achieved. This would allow laser endophotocoagulation treat ment around the retinal break. In addition to internal drainage of subretinal fluid, the extrusion needle with flexible cannu la tip has many applications in vitreoretinal microsurgery. In association with the vacuum cleaning/extrusion technique, the soft, flexible *The silicone cannula tubing is manufactured by Dow Corning (HH075305).
A Simple Extrusion Needle With Flexible Cannula Tip for Vitreoretinal Microsurgery Harry W. Flynn, Jr., M . D . , William G. Lee, and Jean-Marie Parel, Ing. ETS-G Bascom Palmer Eye Institute, Department of Oph thalmology, University of Miami School of Medicine. Inquiries to Harry W. Flynn, ]r., M.D., Bascom Palmer Eye Institute, 900 N.W. 17th St., Miami, FL 33136. In eyes with a complex retinal detachment requiring pars plana vitrectomy, internal drain age of subretinal fluid may be performed by
Fig. 1 (Flynn, Lee, and Parel). A flexible cannula is attached to the end of a tapered 20-gauge extrusion needle.
suppressive acidic protein in 32 patients with both Behget's disease and ocular manifesta tions, in 60 patients with other types of uveitis, and in 50 normal subjects. Single radial immunodiffusion assay was used to quantitate levels of the protein in sera. Agarose gel containing anti-immunosuppressive acidic protein goat serum was prepared on a glass plate, and wells 2.5 mm in diameter were punched out. Placed in each well was 5 ul of sample. After incubation for 48 hours at 37 C, the diameter of the precipitation ring was measured. The mean ± S.D. of the serum immunosuppressive acidic protein level in cases of Behget's disease was 596.9 ± 133.2 |xg/ml, which was significantly greater than that of other uveitis patients (376.5 ± 134.7 u.g/ml; P < .001) and normal subjects (381.4 ± 62.3 u.g/ml; P < .001). The serum immunosuppressive acidic pro tein level in cases of Behget's disease in a state of remission (521.5 ± 63.9 |xg/ml) was less than
1,000-
• •• •
?
• • •
■ *
%
en o
ive acidic
*L
3
that of patients with an active disease state (P < .01), but significantly higher than that in nor mal subjects (P < .001) (Figure). Shimakawa and Kogure 3 reported that serum acid-soluble protein is a useful indicator of activity in Behget's disease. In our study, the changes of immunosuppressive acidic protein levels were quantitatively correlated with the serum levels of a-l-acid glycoprotein. How ever, the level of protein showed a relatively higher response. This indicates that immuno suppressive acidic protein levels may be used as a marker for Behget's disease.
References 1. Tamura, K., Shibata, Y., Matsuda, M., and Ishida, N.: Isolation and characterization of an im munosuppressive acidic protein. Cancer Res. 41:3244, 1981. 2. Shibata, Y., Tamura, K., and Ishida, N.: Cul tured human monocytes, granulocytes, and a monoblastoid cell line (THP-1) synthesize and se crete immunosuppressive acidic protein (a type of a-1-acidic glycoprotein). Microbiol. Immunol. 28:99, 1984. 3. Shimakawa, M., and Kogure, M.: Acid-soluble protein in Behget's disease. Am. J. Ophthalmol. 102:281, 1986.
f
1
3 a
February, 1988
AMERICAN JOURNAL OF OPHTHALMOLOGY
11 • ! t
O
c
D
E
•t • •
i
r
— \ -
V
■
Hyaluronate in the Identification of the Cut End in Lacerations of the Lacrimal Canaliculi
t
i
t\
m T • •• •
• ••
Behpet s disease1
Other uveitis
Control
Figure (Yamaguchi and associates). Serum immu nosuppressive acidic protein levels in patients with Behget's disease, other types of uveitis, and in nor mal controls.
Alejandro Aguirre Vila-Coro, M . D . , Antonio Aguirre Vila-Coro, M . D . , and Pablo Zaragoza Garcia, M . D . Departamento de Oftalmologia, Hospital Clinico de San Carlos, Facultad de Medicina, Universidad Complutense (A.A.V.-C. and P.Z.G.); and the University of Texas Health Science Center at Houston, Hermann Eye Center (An.A.V.-C). Inquiries to Alejandro Aguirre Vila-Coro, M.D., Dracena 40, 28016 Madrid, Spain. Repair of a lacerated lacrimal canaliculus re quires exquisite microsurgery to obtain postop erative patency. Ideally, surgery should be per formed within 24 hours after trauma. Visual identification of the medial cut end of the lace rated canaliculus is often difficult, even through the operating microscope. Current
Letters to the Journal
Vol. 105, No. 2
methods of facilitating recognition of this cut end include injection of milk or of a white ophthalmic suspension through a blunt cannu la via the intact canaliculus, as well as injection of air under a pool of saline. 1 Colorants such as methylene blue should not be used, as they stain the surrounding tissues, rendering recog nition of the cut end more difficult. To recognize the medial cut end of the cana liculus, we have been using a mixture of hyaluronate with fluorescein. To prepare the mix ture, an ampulla of hyaluronate (0.4 ml) is emptied in a medicine glass, and two drops of 2% fluorescein solution are added. Stirring is followed by aspiration of the mixture in a sy ringe. The stained hyaluronate is then injected through the intact canaliculus. Injection causes filling of the lacrimal sac and reflux through the injured canaliculus. Viscoelastic properties of the hyaluronate and slow injection allow a controlled reflux. Thus, only a fraction of a drop is allowed to protrude through the medial cut end of the canaliculus. This end is thus easily recognized, while fluorescein tissue staining is avoided. A cobalt blue filter may be used to enhance visua lization.
Reference 1. Katowitz, J. A.: Lacrimal drainage surgery. In Duane, T. (ed.): Clinical Ophthalmology, Vol. 5, Chapter 11. Philadelphia, Harper and Row Publish ers, 1983, p. 27.
215
various techniques. 1 Drainage may be accom plished by a posterior intentional retinotomy with subsequent drainage of subretinal fluid by an extrusion needle. 2 When an open peripheral break is present, a flexible cannula up to 18 mm can be introduced into the break to allow drain age of posterior subretinal fluid.3 The standard 20-gauge extrusion needle can be modified simply by attaching a short flexible cannula to the tapered metal tip (Fig. 1). The silicone cannula tubing* can be attached to the end of the tapered extrusion needle without adhesives. This flexible, 24-gauge tubing can be cut in variable lengths, depending on the ex pected extension into the subretinal space. The flexible cannula can be folded over to facilitate entry into a 20-gauge pars plana sclerotomy site (Fig. 2). The flexible cannula can be introduced into an existing peripheral or posterior iatrogenic retinal break and guided into the subretinal space. During simultaneous fluid/gas ex change, 4 the subretinal fluid will passively leave the eye through the extrusion needle cannula. If a peripheral retinal break is used, complete removal of posterior subretinal fluid may not be possible, but reattachment of the peripheral retinal break can be achieved. This would allow laser endophotocoagulation treat ment around the retinal break. In addition to internal drainage of subretinal fluid, the extrusion needle with flexible cannu la tip has many applications in vitreoretinal microsurgery. In association with the vacuum cleaning/extrusion technique, the soft, flexible *The silicone cannula tubing is manufactured by Dow Corning (HH075305).
A Simple Extrusion Needle With Flexible Cannula Tip for Vitreoretinal Microsurgery Harry W. Flynn, Jr., M . D . , William G. Lee, and Jean-Marie Parel, Ing. ETS-G Bascom Palmer Eye Institute, Department of Oph thalmology, University of Miami School of Medicine. Inquiries to Harry W. Flynn, ]r., M.D., Bascom Palmer Eye Institute, 900 N.W. 17th St., Miami, FL 33136. In eyes with a complex retinal detachment requiring pars plana vitrectomy, internal drain age of subretinal fluid may be performed by
Fig. 1 (Flynn, Lee, and Parel). A flexible cannula is attached to the end of a tapered 20-gauge extrusion needle.