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Intraocular inflammation after cataract surgery
Letters to the Editor MATHEW W. MACCUMBER, MD, PHD KIRK H. PACKO, MD JOSEPH M. CIVANTOS, MD JASON B. GREENBERG, MD Chicago, Illinois
Intraorbital Foreign Bodies Dear Editor: Fulcher et al1 failed to mention alternative methods of inorganic foreign body removal which we have found useful. If a tract is evident on initial examination or in theatre it may be possible to use a surgical electromagnet to dislodge the metallic foreign body anteriorly, thereby reducing the need for more extensive dissection and potentially obscuring the operative field with blood making extraction increasingly difficult. The authors commonly approached the foreign body either through the entry wound, transconjunctivally or transseptally. We would suggest that an endoscopic approach should on occasion be considered, as in skilled hands it maybe a useful addition to the surgeons armamentarium. DAMIAN LAKE, MRCOPHTH ALI MEARZA, MRCOPHTH GRAHAM M. THOMPSON, FRCS, FRCOPHTH London, England Reference 1. Fulcher TP, McNab AA, Sullivan TJ. Clinical features and management of intraorbital foreign bodies. Ophthalmology 2002;109:494 –500.
Author reply Dear Editor: We have not had to use an electromagnet to facilitate removal of any intraorbital foreign body (IOrbFB). Using standard orbital surgical techniques we have not had a problem with intraoperative bleeding. We believe that endoscopy has little role to play in most
Figure 2. Axial bone-window computed tomographic scan demonstrating the wooden foreign body extending through the right orbit and ethmoid sinus into the sphenoid sinus
purely IOrbFBs but acknowledge that there may be rare circumstances that might benefit from an endoscopic approach. We have subsequently seen a case that illustrates this point. An elderly man fell on a shrub whilst intoxicated, resulting in an organic foreign body passing through his orbit and ethmoid sinus to enter his sphenoid sinus, closely related to the carotid vasculature (Figs 1 and 2). Prior to removing the IOrbFB, an oto-rhino-layngological colleague endoscopically removed debris and ethmoid sinus tissue to allow preplacement of sphenoid sinus packs to anticipate catastrophic carotid bleeding, should it have occurred. The IOrbFB was simply removed through the entry wound without complication. In addition to the role of endoscopic assistance, this case highlights another important aspect of management, which should be incorporated into our protocol. Should the IOrbFB extend beyond the orbit, consultation from the relevant service (e.g., neurosurgery or oto-rhino-laryngology) should be arranged. TIMOTHY SULLIVAN, FRANZCO TIMOTHY FULCHER, FRCOPHTH Brisbane, Australia ALAN MCNAB, FRANZCO Melbourne, Australia
Intraocular Inflammation after Cataract Surgery Dear Editor: In their recent article, Solomon et al investigated the efficacy and safety of ketorolac 0.5% ophthalmic solution in the treatment of ocular inflammation after cataract surgery and intraocular lens implantation (Ophthalmology 2001;108: 331–7). They found ketorolac to be significantly more effective than the vehicle alone. We would like to raise two issues with regard to the methods used in their study: Figure 1. Clinical photograph demonstrating a large intra-orbital foreign body, with extension into the sphenoid sinus.
1. Solomon et al used anterior chamber flare and anterior chamber cells as primary efficacy variables. However, we were surprised that they still utilized a time-
1269
Ophthalmology Volume 110, Number 6, June 2003 honored, subjective, semi-quantitative grading system for postoperative aqueous flare and aqueous cells that was described 42 years ago.1 In their scale, flare is was graded from 0 ⫽ none (no Tyndall effect) to ⫹4 ⫽ very severe (very severely intense Tyndall beam). Anterior chamber cells were similarly graded at the slit-lamp from 0 to ⫹4. With the development of the laser flare photometer,2 we have now an instrument that is much more exact, observer-independent and reproducible in quantifying aqueous flare and, with somewhat less precision, aqueous cells. A number of studies have shown the usefulness of the laser flare photometer to assess blood-aqueous barrier breakdown in many ophthalmologic and systemic diseases, and especially for exact and observer-independent measurements of postoperative intraocular inflammation following cataract surgery.3– 4 Furthermore, when taking into consideration that most of the flare values in the study group were between 0 ⫽ no flare and 1 ⫽ barely discernable Tyndall effect, we believe that subjective determination of intraocular inflammation by slit -lamp examination has its drawbacks and the study of Solomon et al might have profited from use of modern techniques to quantify postoperative blood-aqueous barrier breakdown. 2. Solomon et al enrolled patients if they exhibited anterior chamber cells and flare 24 hours after cataract surgery. Interestingly, the authors apparently did not analyze most causes or underlying diseases that may have led to increased pre- and postoperative bloodaqueous barrier breakdown in their patients. Thus, many factors besides surgical ocular trauma may cause or perpetuate postoperative inflammation, two of the most important being diabetes mellitus5– 6 (with or without rubeosis iridis) and pseudoexfoliation syndrome.7– 8 These factors may influence studies investigating the effects of antiinflammatory agents to treat postoperative inflammation in at least two ways: First, unequal distribution of major risk factors or under-
1270
lying diseases may by itself lead to different clinical courses and therefore bias the study outcomes. Second, patients with underlying conditions or diseases may respond differently to individual pharmacological agents, thus modulating the effect of topical antiinflammatory substances. We believe that it might be useful to have more detailed patient data at hand to be able to analyze the results of the study in the context of possible underlying causes for postoperative bloodaqueous barrier breakdown. MICHAEL KU¨ CHLE, MD GOTTFRIED O. H. NAUMANN, MD Erlangen, Germany, EU References 1. Hogan MJ, Kimura SJ, Thygeson P. Signs and symptoms of uveitis. I. Anterior uveitis. Am J Ophthalmol 1959;47:155–70. 2. Sawa M, Tsurimaki Y, Tsuru T, Shimizu H. New quantitative method to determine protein concentration and cell number in aqueous in vivo. Jpn J Ophthalmol 1988;32:132– 42. 3. Shah SM, Spalton DJ. Changes in anterior chamber flare and cells following cataract surgery. Br J Ophthalmol 1994;78: 91– 4. 4. Dick HB, Schwenn O, Krummenauer F, et al. Inflammation after sclerocorneal versus clear corneal tunnel phacoemulsification. Ophthalmology 2000;107:241–7. 5. Ku¨ chle M, Scho¨ nherr U, Nguyen NX, et al. Quantitative measurement of aqueous flare and aqueous “cells” in eyes with diabetic retinopathy. Ger J Ophthalmol 1992;1:164 –9. 6. Ku¨ chle M, Ha¨ ndel A, Naumann GOH. Cataract extraction in eyes with diabetic iris neovascularization. Ophthalmic Surg Lasers 1998;29:28 –32. 7. Naumann GOH, Schlo¨ tzer-Schrehardt U, Ku¨ chle M. Pseudoexfoliation syndrome for the comprehensive ophthalmologist. Intraocular and systemic manifestations. Ophthalmology 1998;105:951– 68. 8. Schumacher S, Nguyen NX, Ku¨ chle M, Naumann GOH. Quantification of aqueous flare after phacoemulsification with intraocular lens implantation in eyes with pseudoexfoliation syndrome. Arch Ophthalmol 1999;117:733–5.
Intraorbital Foreign Bodies Dear Editor: Fulcher et al1 failed to mention alternative methods of inorganic foreign body removal which we have found useful. If a tract is evident on initial examination or in theatre it may be possible to use a surgical electromagnet to dislodge the metallic foreign body anteriorly, thereby reducing the need for more extensive dissection and potentially obscuring the operative field with blood making extraction increasingly difficult. The authors commonly approached the foreign body either through the entry wound, transconjunctivally or transseptally. We would suggest that an endoscopic approach should on occasion be considered, as in skilled hands it maybe a useful addition to the surgeons armamentarium. DAMIAN LAKE, MRCOPHTH ALI MEARZA, MRCOPHTH GRAHAM M. THOMPSON, FRCS, FRCOPHTH London, England Reference 1. Fulcher TP, McNab AA, Sullivan TJ. Clinical features and management of intraorbital foreign bodies. Ophthalmology 2002;109:494 –500.
Author reply Dear Editor: We have not had to use an electromagnet to facilitate removal of any intraorbital foreign body (IOrbFB). Using standard orbital surgical techniques we have not had a problem with intraoperative bleeding. We believe that endoscopy has little role to play in most
Figure 2. Axial bone-window computed tomographic scan demonstrating the wooden foreign body extending through the right orbit and ethmoid sinus into the sphenoid sinus
purely IOrbFBs but acknowledge that there may be rare circumstances that might benefit from an endoscopic approach. We have subsequently seen a case that illustrates this point. An elderly man fell on a shrub whilst intoxicated, resulting in an organic foreign body passing through his orbit and ethmoid sinus to enter his sphenoid sinus, closely related to the carotid vasculature (Figs 1 and 2). Prior to removing the IOrbFB, an oto-rhino-layngological colleague endoscopically removed debris and ethmoid sinus tissue to allow preplacement of sphenoid sinus packs to anticipate catastrophic carotid bleeding, should it have occurred. The IOrbFB was simply removed through the entry wound without complication. In addition to the role of endoscopic assistance, this case highlights another important aspect of management, which should be incorporated into our protocol. Should the IOrbFB extend beyond the orbit, consultation from the relevant service (e.g., neurosurgery or oto-rhino-laryngology) should be arranged. TIMOTHY SULLIVAN, FRANZCO TIMOTHY FULCHER, FRCOPHTH Brisbane, Australia ALAN MCNAB, FRANZCO Melbourne, Australia
Intraocular Inflammation after Cataract Surgery Dear Editor: In their recent article, Solomon et al investigated the efficacy and safety of ketorolac 0.5% ophthalmic solution in the treatment of ocular inflammation after cataract surgery and intraocular lens implantation (Ophthalmology 2001;108: 331–7). They found ketorolac to be significantly more effective than the vehicle alone. We would like to raise two issues with regard to the methods used in their study: Figure 1. Clinical photograph demonstrating a large intra-orbital foreign body, with extension into the sphenoid sinus.
1. Solomon et al used anterior chamber flare and anterior chamber cells as primary efficacy variables. However, we were surprised that they still utilized a time-
1269
Ophthalmology Volume 110, Number 6, June 2003 honored, subjective, semi-quantitative grading system for postoperative aqueous flare and aqueous cells that was described 42 years ago.1 In their scale, flare is was graded from 0 ⫽ none (no Tyndall effect) to ⫹4 ⫽ very severe (very severely intense Tyndall beam). Anterior chamber cells were similarly graded at the slit-lamp from 0 to ⫹4. With the development of the laser flare photometer,2 we have now an instrument that is much more exact, observer-independent and reproducible in quantifying aqueous flare and, with somewhat less precision, aqueous cells. A number of studies have shown the usefulness of the laser flare photometer to assess blood-aqueous barrier breakdown in many ophthalmologic and systemic diseases, and especially for exact and observer-independent measurements of postoperative intraocular inflammation following cataract surgery.3– 4 Furthermore, when taking into consideration that most of the flare values in the study group were between 0 ⫽ no flare and 1 ⫽ barely discernable Tyndall effect, we believe that subjective determination of intraocular inflammation by slit -lamp examination has its drawbacks and the study of Solomon et al might have profited from use of modern techniques to quantify postoperative blood-aqueous barrier breakdown. 2. Solomon et al enrolled patients if they exhibited anterior chamber cells and flare 24 hours after cataract surgery. Interestingly, the authors apparently did not analyze most causes or underlying diseases that may have led to increased pre- and postoperative bloodaqueous barrier breakdown in their patients. Thus, many factors besides surgical ocular trauma may cause or perpetuate postoperative inflammation, two of the most important being diabetes mellitus5– 6 (with or without rubeosis iridis) and pseudoexfoliation syndrome.7– 8 These factors may influence studies investigating the effects of antiinflammatory agents to treat postoperative inflammation in at least two ways: First, unequal distribution of major risk factors or under-
1270
lying diseases may by itself lead to different clinical courses and therefore bias the study outcomes. Second, patients with underlying conditions or diseases may respond differently to individual pharmacological agents, thus modulating the effect of topical antiinflammatory substances. We believe that it might be useful to have more detailed patient data at hand to be able to analyze the results of the study in the context of possible underlying causes for postoperative bloodaqueous barrier breakdown. MICHAEL KU¨ CHLE, MD GOTTFRIED O. H. NAUMANN, MD Erlangen, Germany, EU References 1. Hogan MJ, Kimura SJ, Thygeson P. Signs and symptoms of uveitis. I. Anterior uveitis. Am J Ophthalmol 1959;47:155–70. 2. Sawa M, Tsurimaki Y, Tsuru T, Shimizu H. New quantitative method to determine protein concentration and cell number in aqueous in vivo. Jpn J Ophthalmol 1988;32:132– 42. 3. Shah SM, Spalton DJ. Changes in anterior chamber flare and cells following cataract surgery. Br J Ophthalmol 1994;78: 91– 4. 4. Dick HB, Schwenn O, Krummenauer F, et al. Inflammation after sclerocorneal versus clear corneal tunnel phacoemulsification. Ophthalmology 2000;107:241–7. 5. Ku¨ chle M, Scho¨ nherr U, Nguyen NX, et al. Quantitative measurement of aqueous flare and aqueous “cells” in eyes with diabetic retinopathy. Ger J Ophthalmol 1992;1:164 –9. 6. Ku¨ chle M, Ha¨ ndel A, Naumann GOH. Cataract extraction in eyes with diabetic iris neovascularization. Ophthalmic Surg Lasers 1998;29:28 –32. 7. Naumann GOH, Schlo¨ tzer-Schrehardt U, Ku¨ chle M. Pseudoexfoliation syndrome for the comprehensive ophthalmologist. Intraocular and systemic manifestations. Ophthalmology 1998;105:951– 68. 8. Schumacher S, Nguyen NX, Ku¨ chle M, Naumann GOH. Quantification of aqueous flare after phacoemulsification with intraocular lens implantation in eyes with pseudoexfoliation syndrome. Arch Ophthalmol 1999;117:733–5.