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Radial Keratotomy Redux
beyond, there is a subtle tendency for some optics to be squeezed toward the 11 o'clock position. Ifpresent, the decentration seems always to be 0.4 mm or less, so excellent optical results are not compromised. The direction, though, is always superior, never inferior. I suspect that this kind of occasional, late, subtle decentration will still occur even if no anterior radial tears are created. If a more perfect anterior capsulotomy is created (like the one described by my associate, John Graether, M.D., Ocular Surgery News, July 1986, pages 30,31), decentration should be somewhat less in amount and more varied in its direction. Phacoemulsification is a marvelous operation in the hands of a skilled and expe,rienced surgeon. I feel that it is a vastly superior technique to nucleus expression. Refined techniques are often described, and while they represent continued improvement, they usually only help the advanced "phaco surgeon" because they assume a substantial baseline level of phacoemulsification experience. I believe that the problem with phacoemulsification lies not in its sophistication, but in its overall utilization. Many surgeons have found it somewhat difficult to learn, and even more difficult to justify, when they try to reconcile the risk/benefit ratio when applying it to their patients and friends. For these reasons, the majority of cataract surgeons do not use this superior technique. I am convinced that phacoemulsification is the best way to remove cataracts. I also believe that its popularity will increase because of its overall superiority. I hope that these writings will help those of you who are taking courses, practicing with laboratory models, and reading books and articles on phacoemulsification. Keep it up. It's worth it. James A. Davison, M.D.
cataract surgery. In Dr. Henry Hirschman's reply to the question as to his usual regimen, he stated that his patients receive oral haloperidol (Haldol®), 2 mg, for one week preoperatively and one month postoperatively. Haldol is a psychopharmacologic agent used to treat highly agitated patients, particularly in the older age group. Haldol, 1 mg every day, is sufficient to make most elderly people tranquil to the extent that they sleep all the time. I assume that the response by Dr. Hirschman contains a misprint, since I doubt the necessity or indication for using this drug routinely. I recommend that you ask Dr. Hirschman the question again and determine if this is his usual preoperative and postoperative drug management for cataract and intraocular lens patients. Kenneth R. Barasch, M.D. New York, New York
Dr. Henry Hirschman replies: Haldol, 1 mg everyday for one week preoperatively and one month postoperatively, was recommended by Ron Schachar, M.D., as innocuous and an effective preventative for cystoid macular edema (CME). I found it to be neither innocuous nor effective and no longer use it. In the great majority of patients there were no adverse side effects, but several patients complained of drowsiness to the point where they felt uncomfortable driving. I have abandoned the use of Haldol and in fact had done so just before the November issue. In his advocacy, Dr. Schachar indicated the pharmacological action of Haldol interfered with prostaglandin and thus prevented CME. It seemed like a good idea at the time, did no great harm, and insofar as I can see, has no benefit. Henry Hirschman, M.D.
Marshalltown. Iowa
Long Beach, California
REFERENCES 1. Davison JA: Minimal lift-multiple rotation technique for capsular bag phacoemulsification and intraocular lens fixation. J Cataract Refract Sllrg 14:25-34, 1988 2. Rosner M. Sharir M, Blumenthal M: Optical aberrations from a well-centered intraocular lens implant. Am J Ophthalmol 101:117-118, 1986 3. Landry RA: Unwanted optical effects caused by intraocular lens positioning holes. J Cataract Refract Sllrg 13:421-423. 1987 4. Sharir M. Rosner M, Blumenthal M: Choosing an intraocular lens for patiel1ts with large pupils. ] Cataract Refract Sllrg 14:88-89, 1988 5. Davison JA: Analysis of capsular bag defects and intraocular lens positions for consistent centration. ] Cataract Refract Surg 12:124-129, 1986
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USE OF HALOPERIDOL PREOPERATIVELY To the Editor: The consultation section of the November 1987 issue (pages 682-687) was devoted to the use of antibiotics in
RADIAL KERATOTOMY REDUX To the Editor: Unfortunately, in his comments in the March issue (page 234), Dr. Thomas Cravy has misstated the facts. Dr. Shepard has not engaged in the solicitation of patients for radial keratotomy (RK),and cataract advertising was not an issue in the rebuttal to Dr. Salz's letter. Radial keratotomy advertising by our organization is done on behalf of Dr. M. Harvey Rubin, our RK specialist. Dr. Shepard is our cataract-IOL specialist and Dr. Galas is our vitreoretinal specialist. Our office letterhead specifically states that, while our newspaper advertising and Yellow Pages listings reflect these three areas of subspecialization for the individual doctors.
J CATARACT REFRACT SURG-VOL
14, MAY 1988
349
Dr. Shepard writes a weekly information column ("Eye Care") for various newspapers that mentions numerous advances in ophthalmology, including RK. He is often quoted in the media regarding these advances. He has written a monograph ("Know Your Eyes") that provides ophthalmic information and answers to his patients' questions. This information is similar to that found in the American Academy of Ophthalmology brochures that one can purchase and give to one's patients. If giving your patient information about an ophthalmic problem or procedure is "advertising," as Dr. Cravy would have you believe, then we are all engaged in advertising. Richard E. Gwyn, Marketing Director
Shepard Eye Center Santa Maria, California
ANTERIOR CHAMBER LENSES To the Editor: This is to address the letters from Dr. Kenneth J. Hoffer (Anterior chamber lens terminology. ] Cataract Refract Surg 13:460,1987) and Dr. Charles D. Kelman (In defense of the Omnifit lens. ] Cataract Refract Surg 14:lO0, 1988). Dr. Hoffer's notation that the Kelman Omnifit "... is not as tolerant to improper sizing. . ." is a geometric truism. Flexible anterior chamber lenses have virtually eliminated sizing problems when implanted with haptic diameters that are equal to or greater than chamber diameters. Regardless, whenever haptic diameter is less than chamber diameter, precisely the same geometric facts apply to flexible as to fixed length lenses, and an undersized tripod is a decided second to an undersized tetrapod for achievement of fixation. l With our current preference for posterior chamber lenses, it is still important to remain mindful of the distinguishing characteristics of anterior chamber lenses, for which a need will always exist, and to be aware of the past experiences of Choyce and others concerning anterior chamber lens stability.2,3 As tetrapods, both the Kelman M ultiflex I and Multiflex II designs afford greater probabilities of proper fixation than any tripod. The Multiflex II obviates the possibility of pupillary capture of the optic-as Dr. Hoffer indicates-and in extolling the Multiflex II, his petition for its individual evaluation is both well-founded and an acknowledgment of Dr. Kelman's contributions to the evolution of an ideal anterior chamber lens. Richard
J.
Broggi, M. D.
Worcester, Massachusetts
REFERENCES 1. Broggi RJ: Choyce's postulate. Am Intra-Ocular Implant Soc J 11:272-278, 1985 350
2. Strampelli B: Tolerance of acrylic lenses in the anterior chamber in aphakia and refractive error. Atti Soc Oftal Lombarda 8:292, 1953 3. Choyce DP: The Mark VI, Mark VII and Mark VIII fixed-length all-acrylic StrampellilChoyce anterior chamber implants. J Soc Sci Med Lisbon 128:665, 1964
RELIEF OF INTRAOCULAR PRESSURE BY APPLYING PRESSURE ON THE POSTERIOR SCLERAL WOUND To the Editor: A common occurrence following cataract surgery is elevation of intraocular pressure. Problems are frequently encountered when using medication to lower the pressure in elderly patients. Accordingly, pressure can be applied to the posterior scleral wound after planned extracapsular surgery and to the posterior lip of the stab incision after phacoemulsification. For phacoemulsification, a needle or any sharp instrument is simply placed on the anesthetized eye immediately posterior to the incision, and slight, gentle pressure is applied without entering the wound itself. This gentle pressure allows fluid to flow out of the eye and not into the eye. Concerns about infection have been voiced; however, we have not noticed any problems and do not expect any to occur since there is a normal leakage of aqueous from the wound in the first several days following surgery. This method simply allows the surgeon control of the aqueous egress. In summary, placing slight pressure on the posterior scleral wound between sutures from planned extracapsular surgery or on the stab incision from phacoemulsification allows release of intraocular pressure without use of glaucomatous medications. James P. Gills, M.D. Tarpon Springs, Florida
EMPIRICAL MODIFICATION OF THE THEORETICAL IOL POWER FORMULAS To the Editor: Intraocular lens power formulas have previously been constructed using two different approaches: a theoretical approach and an empirical one. Each of these formulas comprises various terms of axial length and corneal power, combined with some constants. Theoretical formulas use the nonlinear terms of axial length and corneal power, in combination with theoretical constants. The ability of these formulas to adjust to clinical results is limited. On the other hand, empirical formulas comprise mostly linear terms. The constants used in these formulas are obtained by statistical analysis and their ability to be modified is
J CATARACT REFRACT SURG-VOL
14, MAY 1988
cataract surgery. In Dr. Henry Hirschman's reply to the question as to his usual regimen, he stated that his patients receive oral haloperidol (Haldol®), 2 mg, for one week preoperatively and one month postoperatively. Haldol is a psychopharmacologic agent used to treat highly agitated patients, particularly in the older age group. Haldol, 1 mg every day, is sufficient to make most elderly people tranquil to the extent that they sleep all the time. I assume that the response by Dr. Hirschman contains a misprint, since I doubt the necessity or indication for using this drug routinely. I recommend that you ask Dr. Hirschman the question again and determine if this is his usual preoperative and postoperative drug management for cataract and intraocular lens patients. Kenneth R. Barasch, M.D. New York, New York
Dr. Henry Hirschman replies: Haldol, 1 mg everyday for one week preoperatively and one month postoperatively, was recommended by Ron Schachar, M.D., as innocuous and an effective preventative for cystoid macular edema (CME). I found it to be neither innocuous nor effective and no longer use it. In the great majority of patients there were no adverse side effects, but several patients complained of drowsiness to the point where they felt uncomfortable driving. I have abandoned the use of Haldol and in fact had done so just before the November issue. In his advocacy, Dr. Schachar indicated the pharmacological action of Haldol interfered with prostaglandin and thus prevented CME. It seemed like a good idea at the time, did no great harm, and insofar as I can see, has no benefit. Henry Hirschman, M.D.
Marshalltown. Iowa
Long Beach, California
REFERENCES 1. Davison JA: Minimal lift-multiple rotation technique for capsular bag phacoemulsification and intraocular lens fixation. J Cataract Refract Sllrg 14:25-34, 1988 2. Rosner M. Sharir M, Blumenthal M: Optical aberrations from a well-centered intraocular lens implant. Am J Ophthalmol 101:117-118, 1986 3. Landry RA: Unwanted optical effects caused by intraocular lens positioning holes. J Cataract Refract Sllrg 13:421-423. 1987 4. Sharir M. Rosner M, Blumenthal M: Choosing an intraocular lens for patiel1ts with large pupils. ] Cataract Refract Sllrg 14:88-89, 1988 5. Davison JA: Analysis of capsular bag defects and intraocular lens positions for consistent centration. ] Cataract Refract Surg 12:124-129, 1986
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USE OF HALOPERIDOL PREOPERATIVELY To the Editor: The consultation section of the November 1987 issue (pages 682-687) was devoted to the use of antibiotics in
RADIAL KERATOTOMY REDUX To the Editor: Unfortunately, in his comments in the March issue (page 234), Dr. Thomas Cravy has misstated the facts. Dr. Shepard has not engaged in the solicitation of patients for radial keratotomy (RK),and cataract advertising was not an issue in the rebuttal to Dr. Salz's letter. Radial keratotomy advertising by our organization is done on behalf of Dr. M. Harvey Rubin, our RK specialist. Dr. Shepard is our cataract-IOL specialist and Dr. Galas is our vitreoretinal specialist. Our office letterhead specifically states that, while our newspaper advertising and Yellow Pages listings reflect these three areas of subspecialization for the individual doctors.
J CATARACT REFRACT SURG-VOL
14, MAY 1988
349
Dr. Shepard writes a weekly information column ("Eye Care") for various newspapers that mentions numerous advances in ophthalmology, including RK. He is often quoted in the media regarding these advances. He has written a monograph ("Know Your Eyes") that provides ophthalmic information and answers to his patients' questions. This information is similar to that found in the American Academy of Ophthalmology brochures that one can purchase and give to one's patients. If giving your patient information about an ophthalmic problem or procedure is "advertising," as Dr. Cravy would have you believe, then we are all engaged in advertising. Richard E. Gwyn, Marketing Director
Shepard Eye Center Santa Maria, California
ANTERIOR CHAMBER LENSES To the Editor: This is to address the letters from Dr. Kenneth J. Hoffer (Anterior chamber lens terminology. ] Cataract Refract Surg 13:460,1987) and Dr. Charles D. Kelman (In defense of the Omnifit lens. ] Cataract Refract Surg 14:lO0, 1988). Dr. Hoffer's notation that the Kelman Omnifit "... is not as tolerant to improper sizing. . ." is a geometric truism. Flexible anterior chamber lenses have virtually eliminated sizing problems when implanted with haptic diameters that are equal to or greater than chamber diameters. Regardless, whenever haptic diameter is less than chamber diameter, precisely the same geometric facts apply to flexible as to fixed length lenses, and an undersized tripod is a decided second to an undersized tetrapod for achievement of fixation. l With our current preference for posterior chamber lenses, it is still important to remain mindful of the distinguishing characteristics of anterior chamber lenses, for which a need will always exist, and to be aware of the past experiences of Choyce and others concerning anterior chamber lens stability.2,3 As tetrapods, both the Kelman M ultiflex I and Multiflex II designs afford greater probabilities of proper fixation than any tripod. The Multiflex II obviates the possibility of pupillary capture of the optic-as Dr. Hoffer indicates-and in extolling the Multiflex II, his petition for its individual evaluation is both well-founded and an acknowledgment of Dr. Kelman's contributions to the evolution of an ideal anterior chamber lens. Richard
J.
Broggi, M. D.
Worcester, Massachusetts
REFERENCES 1. Broggi RJ: Choyce's postulate. Am Intra-Ocular Implant Soc J 11:272-278, 1985 350
2. Strampelli B: Tolerance of acrylic lenses in the anterior chamber in aphakia and refractive error. Atti Soc Oftal Lombarda 8:292, 1953 3. Choyce DP: The Mark VI, Mark VII and Mark VIII fixed-length all-acrylic StrampellilChoyce anterior chamber implants. J Soc Sci Med Lisbon 128:665, 1964
RELIEF OF INTRAOCULAR PRESSURE BY APPLYING PRESSURE ON THE POSTERIOR SCLERAL WOUND To the Editor: A common occurrence following cataract surgery is elevation of intraocular pressure. Problems are frequently encountered when using medication to lower the pressure in elderly patients. Accordingly, pressure can be applied to the posterior scleral wound after planned extracapsular surgery and to the posterior lip of the stab incision after phacoemulsification. For phacoemulsification, a needle or any sharp instrument is simply placed on the anesthetized eye immediately posterior to the incision, and slight, gentle pressure is applied without entering the wound itself. This gentle pressure allows fluid to flow out of the eye and not into the eye. Concerns about infection have been voiced; however, we have not noticed any problems and do not expect any to occur since there is a normal leakage of aqueous from the wound in the first several days following surgery. This method simply allows the surgeon control of the aqueous egress. In summary, placing slight pressure on the posterior scleral wound between sutures from planned extracapsular surgery or on the stab incision from phacoemulsification allows release of intraocular pressure without use of glaucomatous medications. James P. Gills, M.D. Tarpon Springs, Florida
EMPIRICAL MODIFICATION OF THE THEORETICAL IOL POWER FORMULAS To the Editor: Intraocular lens power formulas have previously been constructed using two different approaches: a theoretical approach and an empirical one. Each of these formulas comprises various terms of axial length and corneal power, combined with some constants. Theoretical formulas use the nonlinear terms of axial length and corneal power, in combination with theoretical constants. The ability of these formulas to adjust to clinical results is limited. On the other hand, empirical formulas comprise mostly linear terms. The constants used in these formulas are obtained by statistical analysis and their ability to be modified is
J CATARACT REFRACT SURG-VOL
14, MAY 1988