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Hyaluronidase omission and diplopia
LETTERS
nylon suture. Once 360 degree full-thickness trephination is completed, the host button remains attached to the host bed by as many as 8 sutures. The donor button is then laid over the host and sutured to the host bed after the sutures attaching the host button to the host bed have been removed. Prior to placing the last cardinal suture, the host button is extracted from under the donor. The technique described by us is considerably simpler. Instead of excising the host button completely, suturing it back to the host bed, then cutting the sutures and removing the host button as the donor is sutured to the recipient, we leave the recipient button partially attached to the bed at the 6 and 9 o’clock positions. The donor is then sutured to the recipient, the host attachments are severed, and the host button is removed from beneath the donor. Both techniques appear to prevent unopposed movement of the lens–iris diaphragm during PKP. Our work was written prior to the date Loden and Price’s article was published. Had our paper been written after publication, it would certainly have been cited considering the similarity of the 2 techniques.—Ella G. Faktorovich, MD, Yaron S. Rabinowitz, MD
anesthesia was done. Retrobulbar blocks of a 50:50 mixture of lidocaine 2% and bupivacaine 0.5% with epinephrine were used in all cases. In 97 charts, there was preoperative prediction of postoperative diplopia (thyroid, strabismus, fractures), and these patients were omitted. Seventeen patients died within 2 months of surgery of unrelated causes. Four patients had diplopia following retinal detachment surgery. Forty-two charts could not be found. Of the 7040 remaining consecutive nonselected patients, there were no cases of diplopia reported beyond the 3 week postoperative visit. All patients were followed for a minimum of 10 weeks, and follow-up ranged up to 18 years. All patients had blocks without hyaluronidase. Although cases of postoperative restrictive diplopia can occur and are well referenced in the article by Brown et al., I suggest that the cluster of cases referred to the authors in 1998 is not explained by the temporary unavailability of hyaluronidase. Omitting hyaluronidase from periocular anesthesia does not lead to an increase in restrictive diplopia. RONALD D. MILLER, MD Mattoon, Illinois, USA
Hyaluronidase Omission and Diplopia n 1998, Brown et al.1 noted a sharp increase in the number of referrals for diplopia after cataract extraction. They contacted the referring cataract surgeons and were generally told that unexpected postoperative restrictive diplopia was not seen in their practices before 1998. The authors suggest the explanation was a temporary unavailability of hyaluronidase as a component of the anesthetic block, resulting in more diplopia. This simply does not match with my experience in over 7000 cases of anesthetic blocks without hyaluronidase. Because of a pilot study that came out of my residency at the University of Texas Medical Branch in Galveston in the late 1970s suggesting that hyaluronidase increased cystoid macular edema,2 this extra ingredient was never part of my training. Although a later study showed this was not true,3 I have never used hyaluronidase and blocks have been quite excellent without it. I also cannot recall an unanticipated diplopia case. A chart review of 7200 consecutive cataract surgeries performed by me over a 19 year period under local
I
References 1. Brown SM, Brooks SE, Mazow ML, et al. Cluster of diplopia cases after periocular anesthesia without hyaluronidase. J Cataract Refract Surg 1999; 25:1245–1249 2. Roper DL, Nisbet RM. Effect of hyaluronidase on the incidence of cystoid macular edema. Ann Ophthalmol 1978; 10:1673– 1678 3. Kraff MC, Sanders DR, Jampol LM, Lieberman HL. Effect of retrobulbar hyaluronidase on pseudophakic cystoid macular edema. Am Intra-Ocular Implant Soc J 1983; 9:184 –185
Reply: We appreciate Dr. Miller’s comments and applaud his excellent anesthetic technique. Dr. Miller has never used hyaluronidase, and it may be that in his hands muscle palsies are exceptionally rare events with or without hyaluronidase. The fact that several surgeons, practicing in widely separated areas geographically and with different training backgrounds, experienced a spike in the incidence of motility complications during a particular time period suggests a common denominator. The omission of hyaluronidase from the anesthetic mixtures, during the brief period when it was unavailable, seems a plausible explanation. Dr. Miller’s review of his own experience, in which the anesthetic technique and mixture were identical for all 7200 cases, does not alter the conclusions of our report.—Sandra M. Brown, MD, Steven E. Brooks, MD
J CATARACT REFRACT SURG—VOL 26, JANUARY 2000
7
nylon suture. Once 360 degree full-thickness trephination is completed, the host button remains attached to the host bed by as many as 8 sutures. The donor button is then laid over the host and sutured to the host bed after the sutures attaching the host button to the host bed have been removed. Prior to placing the last cardinal suture, the host button is extracted from under the donor. The technique described by us is considerably simpler. Instead of excising the host button completely, suturing it back to the host bed, then cutting the sutures and removing the host button as the donor is sutured to the recipient, we leave the recipient button partially attached to the bed at the 6 and 9 o’clock positions. The donor is then sutured to the recipient, the host attachments are severed, and the host button is removed from beneath the donor. Both techniques appear to prevent unopposed movement of the lens–iris diaphragm during PKP. Our work was written prior to the date Loden and Price’s article was published. Had our paper been written after publication, it would certainly have been cited considering the similarity of the 2 techniques.—Ella G. Faktorovich, MD, Yaron S. Rabinowitz, MD
anesthesia was done. Retrobulbar blocks of a 50:50 mixture of lidocaine 2% and bupivacaine 0.5% with epinephrine were used in all cases. In 97 charts, there was preoperative prediction of postoperative diplopia (thyroid, strabismus, fractures), and these patients were omitted. Seventeen patients died within 2 months of surgery of unrelated causes. Four patients had diplopia following retinal detachment surgery. Forty-two charts could not be found. Of the 7040 remaining consecutive nonselected patients, there were no cases of diplopia reported beyond the 3 week postoperative visit. All patients were followed for a minimum of 10 weeks, and follow-up ranged up to 18 years. All patients had blocks without hyaluronidase. Although cases of postoperative restrictive diplopia can occur and are well referenced in the article by Brown et al., I suggest that the cluster of cases referred to the authors in 1998 is not explained by the temporary unavailability of hyaluronidase. Omitting hyaluronidase from periocular anesthesia does not lead to an increase in restrictive diplopia. RONALD D. MILLER, MD Mattoon, Illinois, USA
Hyaluronidase Omission and Diplopia n 1998, Brown et al.1 noted a sharp increase in the number of referrals for diplopia after cataract extraction. They contacted the referring cataract surgeons and were generally told that unexpected postoperative restrictive diplopia was not seen in their practices before 1998. The authors suggest the explanation was a temporary unavailability of hyaluronidase as a component of the anesthetic block, resulting in more diplopia. This simply does not match with my experience in over 7000 cases of anesthetic blocks without hyaluronidase. Because of a pilot study that came out of my residency at the University of Texas Medical Branch in Galveston in the late 1970s suggesting that hyaluronidase increased cystoid macular edema,2 this extra ingredient was never part of my training. Although a later study showed this was not true,3 I have never used hyaluronidase and blocks have been quite excellent without it. I also cannot recall an unanticipated diplopia case. A chart review of 7200 consecutive cataract surgeries performed by me over a 19 year period under local
I
References 1. Brown SM, Brooks SE, Mazow ML, et al. Cluster of diplopia cases after periocular anesthesia without hyaluronidase. J Cataract Refract Surg 1999; 25:1245–1249 2. Roper DL, Nisbet RM. Effect of hyaluronidase on the incidence of cystoid macular edema. Ann Ophthalmol 1978; 10:1673– 1678 3. Kraff MC, Sanders DR, Jampol LM, Lieberman HL. Effect of retrobulbar hyaluronidase on pseudophakic cystoid macular edema. Am Intra-Ocular Implant Soc J 1983; 9:184 –185
Reply: We appreciate Dr. Miller’s comments and applaud his excellent anesthetic technique. Dr. Miller has never used hyaluronidase, and it may be that in his hands muscle palsies are exceptionally rare events with or without hyaluronidase. The fact that several surgeons, practicing in widely separated areas geographically and with different training backgrounds, experienced a spike in the incidence of motility complications during a particular time period suggests a common denominator. The omission of hyaluronidase from the anesthetic mixtures, during the brief period when it was unavailable, seems a plausible explanation. Dr. Miller’s review of his own experience, in which the anesthetic technique and mixture were identical for all 7200 cases, does not alter the conclusions of our report.—Sandra M. Brown, MD, Steven E. Brooks, MD
J CATARACT REFRACT SURG—VOL 26, JANUARY 2000
7