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Round Pupil After Vitreous Loss
328
CORRESPONDENCE
CORRESPONDENCE LARGER RETROBULBAR INJECTIONS
Editor, American Journal of Ophthalmology: It is gratifying to see the favorable report of Drs. Van Bergen and Swets in the No vember, 1963, A JO on the use of larger retrobulbar injections. Although the injection of 4.0 cc. or more has been advocated for a number of years, many ophthalmic surgeons still limit the size of the retrobulbar injection to 1.5 cc. If hyaluronidase and epinephrine are added to the anesthetic solution and the injection is followed by digital pressure until there is akinesia of the rectus muscles, the tension will be lower than with the injection of 1.5 cc. There will also be more profound akinesia and anesthesia. As much as 8.0 cc. has been injected in the orbit without com plications. The authors mention making injections into the muscle tissue which may account for the high incidence of orbital hemor rhages reported. Since the motor nerve sup ply to the rectus muscles enters the muscles on the inner surface 15 mm. anterior to the apex of the orbit, an injection near the mus cle in that vicinity has in my experience blocked the nerves. To produce akinesia of the orbicularis muscle, the authors stated that they aug mented the van Lint method of injection with the O'Brien. If the directions of van Lint are followed, this would be unneces sary. However, if the O'Brien method is used first, then another injection would oc casionally be required since the course of the facial nerve varies and, as shown by Kline, may pass considerably below the condyloid process over the ramus of the lower mandible and so might not be reached by the injection. The purpose of the subconjunctival in jection at the 6- and 12-o'clock positions is not explained and seems unnecessary unless the eye is inflamed. Probably these injec
tions and the use of cocaine are measures carried over from earlier years before the routine use of retrobulbar injections and be fore better topical anesthetic agents were produced. I hope the authors will continue to empha size the value of larger retrobulbar injec tions. (Signed) Walter S. Atkinson, Watertown, New York.
ROUND PUPIL AFTER VITREOUS LOSS
Editor, American Journal of Ophthalmology: In recent years, ophthalmic surgeons have recognized the importance of so planning and executing indicated surgical procedures that further complications may be operated upon and corrected with greater facility. Glaucoma surgeons advise placing the filter ing bleb in the upper nasal quadrant and the peripheral iridectomy in the upper temporal quadrant, anticipating the expected lens changes and the ease of cataract extraction from the temporal side. Retinal detachment surgeons are doing more and more pro cedures which utilize intrascleral diathermy, anticipating a revised procedure and the avoidance of the necrotic sclera and adhe sions. It is generally conceded that vitreous loss in cataract extraction predisposes to retinal detachment. The incidence varies in differ ent series. Schepens,1 in reviewing 387 cases of retinal detachment, 88 of which were aphakic, concluded that loss of vitreous was not a frequent cause of detachment in his series ; however, Hughes and Owens 2 in 1943, in reviewing 2,086 cataract extrac tions at the Wilmer Institute, concluded that vitreous loss very definitely causes retinal detachment and the detachment incidence in creased with the amount of vitreous lost. Shapland3 concludes from his studies that retinal detachment occurs in 10 percent of aphakic subjects; and therefore aphakia must predispose to retinal detachment.
CORRESPONDENCE Regardless of the impressions gained from reviews of different series, it is logical to believe that vitreous loss does predispose to retinal detachment, and any disturbance of this body would make detachment more likely. Preservation of the round pupil has be come well established in cataract surgery and some even advocate preserving the round pupil after vitreous loss ; while others believe a sphincter-to-base iridectomy should be done and often a sphincterectomy at the 6-o'clock position. Maumenee4 and Castroviejo4 have suggested procedures which help to maintain a free and mobile pupil after vitreous loss. Many of the younger surgeons have adopted these procedures. If we believe vitreous loss in cataract sur gery predisposes the eye to retinal detach ment, it would seem more practical and better judgment to do a sphincter-to-base iridec tomy when this complication occurs. Brockhurst 5 and his group have stated the im portance of having a good view of the fundus in all detachments. Because even un complicated cataract extractions often result in fixed, small pupils, Brockhurst 5 believes that any patient who has had or who may have a retinal detachment, and who is to have a cataract extraction, should have a full iridec tomy. In as much as vitreous loss often results in fixed, eccentric, undilatable pupils, and because of the danger of detachment in such eyes, a sphincter-to-base iridectomy should be done in all cases of cataract extraction with vitreous loss. This is planning ahead for an expected complication. (Signed) Harold Beasley, Fort Worth, Texas.
329
M., et al.: Advances in cataract surgery. High lights of Ophth., 3:243-247, 1959. 5. Brockhurst, R. J.: Cataract surgery, iridec tomy and retinal detachment. AMA Arch. Ophth., 69:1-2 (Jan.) 1963.
KERATOME WITH GUARD
Editor, American Journal of Ophthalmology: I wish to report an angulated keratome which I have designed, manufactured by the Storz Instrument Company, Saint Louis, Missouri. This instrument is unique in that it has a guard (stop), a feature that has not, to my knowledge, been placed on any kera tome in the past except on a straight one. About 30 years ago Wecker designed a kera tome with a guard but it was a straight one in two sizes. The Desmarres paracentesis needle is in effect a small keratome with a guard, but it too is straight. This stainless steel instrument can be manufactured in any of the conventional keratome sizes. The blade of the one illus trated (fig. 1) measures 7.5 by 9,5 mm. (wide) and it is suggested that it be used primarily for doing iridectomies when one does not wish to do an ab externo incision. The upper side of the blade is faceted and has hollow ground edges. The guard (stop) extends across the entire front of the blade just below the shank and measures 1.5 by 11 mm.
REFERENCES
1. Schepens, C. L. : Retinal detachment and aphakia. AMA Arch. Ophth, 45:1-17 (Jan.) 1951. 2. Hughes, W. T., and Owens, W. C : Extrac tion of senile cataract. Am. J. Ophth., 28:40-49 (Jan) 1945. 3. Shapland, C. D.: Detachment of the retina in the aphakic eye. Tr. Ophth. Soc. Australia, 21 : 61-65. 1961. 4. Boyd, B. F., Maumenee, A. E., McLean, J.
Fig. 1
CORRESPONDENCE
CORRESPONDENCE LARGER RETROBULBAR INJECTIONS
Editor, American Journal of Ophthalmology: It is gratifying to see the favorable report of Drs. Van Bergen and Swets in the No vember, 1963, A JO on the use of larger retrobulbar injections. Although the injection of 4.0 cc. or more has been advocated for a number of years, many ophthalmic surgeons still limit the size of the retrobulbar injection to 1.5 cc. If hyaluronidase and epinephrine are added to the anesthetic solution and the injection is followed by digital pressure until there is akinesia of the rectus muscles, the tension will be lower than with the injection of 1.5 cc. There will also be more profound akinesia and anesthesia. As much as 8.0 cc. has been injected in the orbit without com plications. The authors mention making injections into the muscle tissue which may account for the high incidence of orbital hemor rhages reported. Since the motor nerve sup ply to the rectus muscles enters the muscles on the inner surface 15 mm. anterior to the apex of the orbit, an injection near the mus cle in that vicinity has in my experience blocked the nerves. To produce akinesia of the orbicularis muscle, the authors stated that they aug mented the van Lint method of injection with the O'Brien. If the directions of van Lint are followed, this would be unneces sary. However, if the O'Brien method is used first, then another injection would oc casionally be required since the course of the facial nerve varies and, as shown by Kline, may pass considerably below the condyloid process over the ramus of the lower mandible and so might not be reached by the injection. The purpose of the subconjunctival in jection at the 6- and 12-o'clock positions is not explained and seems unnecessary unless the eye is inflamed. Probably these injec
tions and the use of cocaine are measures carried over from earlier years before the routine use of retrobulbar injections and be fore better topical anesthetic agents were produced. I hope the authors will continue to empha size the value of larger retrobulbar injec tions. (Signed) Walter S. Atkinson, Watertown, New York.
ROUND PUPIL AFTER VITREOUS LOSS
Editor, American Journal of Ophthalmology: In recent years, ophthalmic surgeons have recognized the importance of so planning and executing indicated surgical procedures that further complications may be operated upon and corrected with greater facility. Glaucoma surgeons advise placing the filter ing bleb in the upper nasal quadrant and the peripheral iridectomy in the upper temporal quadrant, anticipating the expected lens changes and the ease of cataract extraction from the temporal side. Retinal detachment surgeons are doing more and more pro cedures which utilize intrascleral diathermy, anticipating a revised procedure and the avoidance of the necrotic sclera and adhe sions. It is generally conceded that vitreous loss in cataract extraction predisposes to retinal detachment. The incidence varies in differ ent series. Schepens,1 in reviewing 387 cases of retinal detachment, 88 of which were aphakic, concluded that loss of vitreous was not a frequent cause of detachment in his series ; however, Hughes and Owens 2 in 1943, in reviewing 2,086 cataract extrac tions at the Wilmer Institute, concluded that vitreous loss very definitely causes retinal detachment and the detachment incidence in creased with the amount of vitreous lost. Shapland3 concludes from his studies that retinal detachment occurs in 10 percent of aphakic subjects; and therefore aphakia must predispose to retinal detachment.
CORRESPONDENCE Regardless of the impressions gained from reviews of different series, it is logical to believe that vitreous loss does predispose to retinal detachment, and any disturbance of this body would make detachment more likely. Preservation of the round pupil has be come well established in cataract surgery and some even advocate preserving the round pupil after vitreous loss ; while others believe a sphincter-to-base iridectomy should be done and often a sphincterectomy at the 6-o'clock position. Maumenee4 and Castroviejo4 have suggested procedures which help to maintain a free and mobile pupil after vitreous loss. Many of the younger surgeons have adopted these procedures. If we believe vitreous loss in cataract sur gery predisposes the eye to retinal detach ment, it would seem more practical and better judgment to do a sphincter-to-base iridec tomy when this complication occurs. Brockhurst 5 and his group have stated the im portance of having a good view of the fundus in all detachments. Because even un complicated cataract extractions often result in fixed, small pupils, Brockhurst 5 believes that any patient who has had or who may have a retinal detachment, and who is to have a cataract extraction, should have a full iridec tomy. In as much as vitreous loss often results in fixed, eccentric, undilatable pupils, and because of the danger of detachment in such eyes, a sphincter-to-base iridectomy should be done in all cases of cataract extraction with vitreous loss. This is planning ahead for an expected complication. (Signed) Harold Beasley, Fort Worth, Texas.
329
M., et al.: Advances in cataract surgery. High lights of Ophth., 3:243-247, 1959. 5. Brockhurst, R. J.: Cataract surgery, iridec tomy and retinal detachment. AMA Arch. Ophth., 69:1-2 (Jan.) 1963.
KERATOME WITH GUARD
Editor, American Journal of Ophthalmology: I wish to report an angulated keratome which I have designed, manufactured by the Storz Instrument Company, Saint Louis, Missouri. This instrument is unique in that it has a guard (stop), a feature that has not, to my knowledge, been placed on any kera tome in the past except on a straight one. About 30 years ago Wecker designed a kera tome with a guard but it was a straight one in two sizes. The Desmarres paracentesis needle is in effect a small keratome with a guard, but it too is straight. This stainless steel instrument can be manufactured in any of the conventional keratome sizes. The blade of the one illus trated (fig. 1) measures 7.5 by 9,5 mm. (wide) and it is suggested that it be used primarily for doing iridectomies when one does not wish to do an ab externo incision. The upper side of the blade is faceted and has hollow ground edges. The guard (stop) extends across the entire front of the blade just below the shank and measures 1.5 by 11 mm.
REFERENCES
1. Schepens, C. L. : Retinal detachment and aphakia. AMA Arch. Ophth, 45:1-17 (Jan.) 1951. 2. Hughes, W. T., and Owens, W. C : Extrac tion of senile cataract. Am. J. Ophth., 28:40-49 (Jan) 1945. 3. Shapland, C. D.: Detachment of the retina in the aphakic eye. Tr. Ophth. Soc. Australia, 21 : 61-65. 1961. 4. Boyd, B. F., Maumenee, A. E., McLean, J.
Fig. 1