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The Pic-Forceps for Removal of Epiretinal Membranes
518
AMERICAN JOURNAL OF OPHTHALMOLOGY
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OCTOBER, 1984
Fig. 2 (Ferry). Cross-section of the retrobulbar portion of the second ciliary nerve exhibiting exten sion of tumor within its substance from the main choroidal mass to the orbit (hematoxylin and eosin, X400). REFERENCES
Fig. 1 (Ferry). Longitudinal section of the eye shows the choroidal melanoma extending across the sciera within the substance of a short posterior ciliary nerve (hematoxylin and eosin, x 40). the cross-sectional area of both ciliary nerves was replaced by deeply pigmented tumor. This case points out the importance of the surgeon examining carefully in the operating room an eye he has just enucle ated. 3 The patient had two small transscleral extensions of tumor that were obvious at the time of gross examina tion in the laboratory. They should also have been detectable in the operat ing room. Failure to examine the eye im mediately after enucleation resulted in the surgeon's first learning about the presence of extraocular extension when he received the pathologic report from our laboratory.
1. Wolter, J. R.: Orbital extension of choroidal melanoma within a long posterior ciliary nerve. Trans. Am. Ophthalmol. Soc. 81:47, 1983. 2. Starr, H. J., and Zimmerman, L. E.: Extrascleral extension and orbital recurrence of malignant melanomas of the choroid and ciliary body. Int. Ophthalmol. Clin. 2:369, 1962. 3. Ferry, A. P.: Unsuspected extraocular exten sion of malignant melanoma. Am. J. Ophthalmol. 57:814, 1964.
T H E PIC-FORCEPS FOR REMOVAL OF EPIRETINAL MEMBRANES E U G E N E D E JUAN, J R . , M.D., DYSON HICKINGBOTHAM, BROOKS W . M C C U E N II, M . D . , AND R O B E R T M A C H E M E R , M . D .
Department of Ophthalmology, Duke University Eye Center. This study was supported by grant ΕΥ02903 from the National Eye Institute and by Research to Prevent Blindness, Inc. Dr. de Juan is a Heed Foundation Fellow (1983-1984).
VOL. 98, NO. 4
LETTERS TO T H E
Inquiries to Eugene de Juan, Jr., M.D., Duke University Eye Center, Box 3802, Durham, NC 27710.
Removal of epiretinal membranes ac counts for a major portion of vitreous surgery. This is particularly true for dis eases such as proliferative vitreoretinopathy, macular pucker, and proliferative diabetic retinopathy. Various instruments have been developed to dissect tissue planes, including the hooked needle 1 and small vitreoretinal pics. 2 Recently forceps for removal of epiretinal membranes have been developed (Zivojnovic, personal communication). We have combined both the pic function and forceps function into a single instrument (Figure). This innova tion avoids repeated changes of instru ments and thus saves time and increases safety. The pic-forceps are modified from a Sutherland intraocular forceps. They con sist of 20-gauge horizontally acting for ceps shaped to form a slightly blunt pic. The pic function is usually used with the forceps closed but when the forceps are opened a sharper and smaller edge for the pic is achieved. The top of the pic-forceps can be easily rotated 360 degrees without changing the hand position because of an enlarged rotation wheel on the instru ment shaft. The pic-forceps remain in the closed position when not activated. Once the epiretinal tissue is engaged
JOURNAL
519
by the pic and the membrane is elevated, it can then be grasped securely by the forceps and microscissors used to delaminate the membrane from the retina. This avoids excessive traction with consequent retinal hole formation. The pic-forceps may be used to increase small tunnels by placing the closed pic beneath a mem brane, as within a fold of retina, and by slowly opening the forceps the overlying epiretinal membrane is dissected free. The forceps are very useful obtaining biopsy specimens. REFERENCES 1. Machender, R. : A new concept for vitreous surgery. Two-instrument techniques in pars plana vitrectomy. Arch. Ophthalmol. 92:407, 1974 2. Michels, R. G.: Vitreous Surgery. St. Louis, C. V. Mosby, 1981, p. 80.
CHORIORETINAL DAMAGE IN ONCHOCERCIASIS R O B E R T P. M U R P H Y ,
M.D.,
H U G H TAYLOR, M.D., AND B R U C E M. G R E E N E ,
M.D.
From the Wilmer Ophthalmological Institute, Johns Hopkins University (R.P.M. and H.R.T.), and the Department of Medicine, Case Western Reserve University (B.M.G.). Inquiries to Robert P. Murjyhy, M. D., Wilmer Ophthalmological Institute, Johns Hopkins University, Baltimore, MD 21205.
Figure (de Juan and associates). The pic-forceps. By pressing the handle, the branches of the pic can be opened for use as forceps. An enlarged wheel allows easier rotation of the tip. Inset, Scanning electron micrograph of the pic-forceps.
Although much of the blindness caused by Onchocerca volvulus is attributable to chorioretinal scarring, relatively little is known about the mechanism of chorioret inal damage in this major blinding dis ease. Histopathologic studies have dem onstrated microfilariae in the retina and choroid, but microfilariae have not previ ously been documented in the living reti na.1_4 In contrast, correlations among anterior segment changes such as scleros-
AMERICAN JOURNAL OF OPHTHALMOLOGY
■»*·*,
OCTOBER, 1984
Fig. 2 (Ferry). Cross-section of the retrobulbar portion of the second ciliary nerve exhibiting exten sion of tumor within its substance from the main choroidal mass to the orbit (hematoxylin and eosin, X400). REFERENCES
Fig. 1 (Ferry). Longitudinal section of the eye shows the choroidal melanoma extending across the sciera within the substance of a short posterior ciliary nerve (hematoxylin and eosin, x 40). the cross-sectional area of both ciliary nerves was replaced by deeply pigmented tumor. This case points out the importance of the surgeon examining carefully in the operating room an eye he has just enucle ated. 3 The patient had two small transscleral extensions of tumor that were obvious at the time of gross examina tion in the laboratory. They should also have been detectable in the operat ing room. Failure to examine the eye im mediately after enucleation resulted in the surgeon's first learning about the presence of extraocular extension when he received the pathologic report from our laboratory.
1. Wolter, J. R.: Orbital extension of choroidal melanoma within a long posterior ciliary nerve. Trans. Am. Ophthalmol. Soc. 81:47, 1983. 2. Starr, H. J., and Zimmerman, L. E.: Extrascleral extension and orbital recurrence of malignant melanomas of the choroid and ciliary body. Int. Ophthalmol. Clin. 2:369, 1962. 3. Ferry, A. P.: Unsuspected extraocular exten sion of malignant melanoma. Am. J. Ophthalmol. 57:814, 1964.
T H E PIC-FORCEPS FOR REMOVAL OF EPIRETINAL MEMBRANES E U G E N E D E JUAN, J R . , M.D., DYSON HICKINGBOTHAM, BROOKS W . M C C U E N II, M . D . , AND R O B E R T M A C H E M E R , M . D .
Department of Ophthalmology, Duke University Eye Center. This study was supported by grant ΕΥ02903 from the National Eye Institute and by Research to Prevent Blindness, Inc. Dr. de Juan is a Heed Foundation Fellow (1983-1984).
VOL. 98, NO. 4
LETTERS TO T H E
Inquiries to Eugene de Juan, Jr., M.D., Duke University Eye Center, Box 3802, Durham, NC 27710.
Removal of epiretinal membranes ac counts for a major portion of vitreous surgery. This is particularly true for dis eases such as proliferative vitreoretinopathy, macular pucker, and proliferative diabetic retinopathy. Various instruments have been developed to dissect tissue planes, including the hooked needle 1 and small vitreoretinal pics. 2 Recently forceps for removal of epiretinal membranes have been developed (Zivojnovic, personal communication). We have combined both the pic function and forceps function into a single instrument (Figure). This innova tion avoids repeated changes of instru ments and thus saves time and increases safety. The pic-forceps are modified from a Sutherland intraocular forceps. They con sist of 20-gauge horizontally acting for ceps shaped to form a slightly blunt pic. The pic function is usually used with the forceps closed but when the forceps are opened a sharper and smaller edge for the pic is achieved. The top of the pic-forceps can be easily rotated 360 degrees without changing the hand position because of an enlarged rotation wheel on the instru ment shaft. The pic-forceps remain in the closed position when not activated. Once the epiretinal tissue is engaged
JOURNAL
519
by the pic and the membrane is elevated, it can then be grasped securely by the forceps and microscissors used to delaminate the membrane from the retina. This avoids excessive traction with consequent retinal hole formation. The pic-forceps may be used to increase small tunnels by placing the closed pic beneath a mem brane, as within a fold of retina, and by slowly opening the forceps the overlying epiretinal membrane is dissected free. The forceps are very useful obtaining biopsy specimens. REFERENCES 1. Machender, R. : A new concept for vitreous surgery. Two-instrument techniques in pars plana vitrectomy. Arch. Ophthalmol. 92:407, 1974 2. Michels, R. G.: Vitreous Surgery. St. Louis, C. V. Mosby, 1981, p. 80.
CHORIORETINAL DAMAGE IN ONCHOCERCIASIS R O B E R T P. M U R P H Y ,
M.D.,
H U G H TAYLOR, M.D., AND B R U C E M. G R E E N E ,
M.D.
From the Wilmer Ophthalmological Institute, Johns Hopkins University (R.P.M. and H.R.T.), and the Department of Medicine, Case Western Reserve University (B.M.G.). Inquiries to Robert P. Murjyhy, M. D., Wilmer Ophthalmological Institute, Johns Hopkins University, Baltimore, MD 21205.
Figure (de Juan and associates). The pic-forceps. By pressing the handle, the branches of the pic can be opened for use as forceps. An enlarged wheel allows easier rotation of the tip. Inset, Scanning electron micrograph of the pic-forceps.
Although much of the blindness caused by Onchocerca volvulus is attributable to chorioretinal scarring, relatively little is known about the mechanism of chorioret inal damage in this major blinding dis ease. Histopathologic studies have dem onstrated microfilariae in the retina and choroid, but microfilariae have not previ ously been documented in the living reti na.1_4 In contrast, correlations among anterior segment changes such as scleros-