Retrobulbar Hemorrhage

For an aphakic patient, a 6 mm incision is performed at the superior limbus. A special injector is used to help pass two needles through the ciliaI'y body, out on the sclera at the 4 0' clock and 8 0' clock positions. The third curved needle is passed with the needle holder at the 12 o'clock position. The sutures, after being passed through , are pulled and the lens drawn in . The three sutures are pulled to adjust the centration of the lens and then the ne edles are used to anchor the sutures at the sclera. This lens will be most stable and complication free ifthe surgical procedure has been correct and clean. This lens cannot tiIt. It will also not rub against the posterior surface of the iris if correctly passed through the pars plana. Because it has been demonstrated that even polypropylene shows degenerative changes after many years, the polypropylene loops are being replaced by Teflon sutures. My choice of an IOL in cases that lack capsular support is the iris claw lens. It has a 5.5 mm optic with claw mechanisms at diagonally opposite ends that hold the iris in two places. The lens can be used for a variety of cases. At Dr. Daljit Singh Eye Hospital we have implanted approximately 50,000 lenses. The surgery is completely atraumatic, under complete visual control, and there is no me_ssing with sutures. It is strange that while we try more and more to prevent contact between the ciliary body and the IOL and confine ourselves to the capsular bag, we continue to pierce the ciliary body with needles and sutures. Also, the procedure for passing the sutures through the ciliary body is not quite atraumatic and can have complications. Ravijit Singh , M.D.

Amritsar, India

REFERENCE 1. Smiddy WE, Sawusch MR, O'Brien TP, et al. Implantation of scleral-fixated posterior chamber intraocular lenses. J Cataract Refract Surg 1990; 16:691-696 .

William E. Smiddy, M.D. , replies: We appreciate the very pertinent comments that Dr. Singh has shared. While we have found a tendency for rotation along the axis of fixation of the suture in some cases, we feel that this is most related to the need for sulcus fixation. This can be avoided by ensuring that the suture is passed no more than 1 mm posterior to the surgical limbus. In our experience, it is usually advisable to perform at least an anterior vitrectomy to avoid migration of vitreous anteriorly. Certainly, the information regarding the biodegradability of nylon monofilament sutures is disturb-

ing and a reference would be welcome. The Maggie lens does sound like it would maximize the centrahon and lack ofIOL torsion, but I have no personal experience with it. Dr. Singh's statements have confirmed that the search for the ideal method of dealing with implantation of posterior chamber implants in the absence of capsular support is an ongoing process.

RETROBULBAR HEMORRHAGE To the Editor: I found the discussion of retrobulbar hemorrhage in the consuItation section of the November 1990 issue (pages 766-774) very intereshng. I have given over 5,000 retrobulbar injections and concur with most views outlined. However, with full appreciation of Dr. Gills' expertise, I cannot understand why " ... no pressure is applied unless there is evidence of retrobulbar hemorrhage. After five minutes, the Super Pinky is applied .... " Would it not be too late then? I apply instantaneous pressure, rather than waiting and possibly allowing any imperceptible albeit dangerous 1 build up of oozing, as do Drs. Maloney, Siepser, and Fechner. I also avoid mechanical devices as balloons and pinkys for reported complications, besides depriving the patient of the support and reassurance of "vocal" anesthesia during digital pressure and massage. 2,3 Further, I wonder why Dr. Frazzelli uses an "extremely" sharp ne edle despite all controversy. Dr. Thornton cautiously tempers the sharpness of his needle by a "non-cutting" quality. I use rather blunt needles for retrobulbar, but sharp ones for akinesia. This preference has been developed over the years by observing master surgeons, worldwide, after I had the good fortune of working under H. Stallard and H. Ridley in Moorfields Hospital, London University, 1965. In my consecutive cases, Idid not have immediate retrobulbar hemorrhages, but I did have a 1% incidence of oozing, or bleeding, of two types: (1) mild hemorrhage - which slowly builds up during surgery to cause a gradual increase in intraorbital pressure that is manifest only at the critical moment of extraction by vitreous loss andlor rupture of the capsulelzonule. Usually this pressure increase goes unnoticed amidst the sequence of events on which the surgeon is focused, until he or she is unpleasantly surprised by the prolapsing vitreous. If the problem is detected earlier, good judgment may dictate immediate closure of the wound and postponing

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surgery. OccasionaIly, surgery is continued, at the risk of complications, possibly beyond control at this stage, although an urgent canthotomy may temper the loss. Such subtle bleeding is further proved by lid ecchymosis later4 ; (2) minor oozing - that is revealed only in the first dressing as it reaches the skin. Although it raises no problem intraoperatively, it may cause postoperative anxiety, so that lid ecchymosis mandates explanation and reassurance. 3 This wider spectrum of slow imperceptible retrobulbar hemorrhages that is more serious than the early ones which postpone surgery is weIl asserted by three respondents. Dr. Olander says, "The classic presentation of retrobulbar hemorrhage is seen less often than subclinical hemorrhage (which) makes surgery harder with difficulty in exposure, increased pressure on the vitreous .. . . " Likewise, Drs. Wallace and Fechner report postoperative lid ecchymosis as "disconcerting sequelae." In view of the relative frequency of such subtle hemorrhages, we must be alert throughout the entire procedure for their possible late build-up that could then challenge all skills. If surgery is postponed, I prefer general anesthesia,5.6 also for its advantage of inducing hypocapnea when urgently needed intraoperatively in cases of choroidal vasodilation andlor transudationl hemorrhage. 7 In gratitude, I recall Ridley's receptive creativity in capturing questions even of medical students, and StaIlard's admonition to "focus on our mistakes as from them we leam most."8 M. Tadros, M.D.

New York, New York REFERENCES 1. Tadros M, Gadallah A, Dwairy H. The place ofiridotomies in modern cataract surgery. XX Concilium Ophthalmologieum, Munich , 1966; Pars I Excerpta Medica, 812-814 2. Tadros M. Psycho-ophthalmology and eye surgery. XXIII Concilium Ophthalmogicum, Kyoto, 1978; Pars 11 Excerpta Medica, 1443-1447 3. Tadros M. Surgical psycho-ophthalmology and contracted sockets. In: Bosniak S, ed, Advanees in Ophthalmie Plastie and Reconstruetive Surgery, vol 8. New York, Pergamon Press, 1990; 274-279 4. Tadros MA . Psico-oftalmologia, afaquia y seudofaquia. Anales Soc Mex De Oft 1981; 55:416 5. Duncalf D, Rhodes D. Anesthesia in Clinical Ophthalmology. BaItimore, Williams & Wilkins, 1984; 34 6. Meyers EF. Anesthetic complieations in ophthalmological patients. In: Waltman S, Krupin T, eds, Complications of Ophthalmie Surgery. Philadelphia, JB Lippincott, 1980; 13 7. Tadros MA. Hypocapnea in saving intra-operative crises. XXVI Concilium Ophthalmologicum , Singapore, 1990. In press 8. Stallard H. Eye Surgery, 4th ed. Baltimore, Williams & Wilkins, 1965; 1-3, 68-70 244

VISUAL DISABILITY INVENTORY: DOCUMENTING FUNCTIONAL IMPAIRMENT CAUSED BY CATARACT To the Editor: We practice ophthalmology in an age of increasing governmental regulation and control. In light of peer review evaluation, documentation of the indications for cataract surgery is important. To establish the disability caused by cataract, methods have progressed from Snellen visual acuity measurements to contrast sensitivity, glare testing, and PAM testing. 1-4 These advances in documentation of cataract-related disability have tended to involve various devices that may significantly add to the overall costs incurred. We have developed a simple check-list-type questionnaire to be completed by VISUAL DIS ABILITY INVENTORY Patient's Name l. Reading impairment

A. B. C. G.

Newspaper D. Medicine bottles _ __ Mai! E. Writing checks _ _ __ F. Paying bills _ _ _ __ Bible Hold things close, need good light, 01' use a magnifier _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

2. Household activities A. Cooking, able to see stove knobs , read labels, recipes _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ B. Climbing stairs, holding banister _ _ _ _ _ __ C. Walking, unable to see uneven pavement _ _ __ D. Falling _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ E . Shaving _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ F. Bathing _________________~_ G. Cleaning cloth es _ _ _ _ _ _ _ _ _ _ _ __ H. Washing dishes _ _ _ _ _ _ _ _ _ _ _ _ __ I. Cleaning house _ _ _ _ _ _ _ _ _ _ _ _ __ J. Yard work - _ _ _ _ _ _ _ _ _ _ _ _ __ K. Care of other familv members _ _ _ _ _ _ __ L. Trouble getting to doctor _ _ _ _ _ _ _ _ __ M. Diffieulty shopping _ _ _ _ _ _ _ _ _ _ __ N. Lives alone _ _ _ _ _ _ _ _ _ _ _ _ _ __ 3. Driving A. Daytime: Glare of sun B. Night time: Headlights from ear 4. Recognizing people (ex: identify person at dOOf) A. Difficulty with depth perception 5. Hobbies A. Sewing _ _ _ __ B. Stamps _ _ _ __ C. Gardening _ _ __ D. Coins _______

E. F. G. H.

Sports _ _ _ __ Lawn eare ______ Recreation activity _ Watehing TV ____

6. Employment A. Unable to perform _ _ _ _ _ _ _ _ _ _ _ _ __ B. Injury risk __________________ C. Cannot drive to work ______________

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