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Visual defects in the uninjured eye of patients with unilateral eye injuries
CURRENTOPHTHALMOLOGY
355
of eyes were comfortable and pain-free. Failure of the Molten0 drainage implant to function result of inadequate postoperative management and consecutive external bleb scarring.
was primarily
the
Comment This paper describes the technique and results using one of a variety of implants which have been utilized for management of acute neovascular glaucoma. The technique attempts to avoid the problem of flat anterior chambers by first placing the acrylic episcleral plate posteriorly to allow it to encapsulate and later introducing the tube in the anterior chamber. In eyes with acute neovascular glaucoma this two-stage technique may not be possible. In addition, while the results reported are very impressive, they do not explain why Molten0 has subsequently modified the technique to use two or even three interlocking scleral plates rather than the one described in the present paper. A rather formidable combination of antiinflammatory agents is utilized to prevent excessive fibrosis although the actual mechanisms by which each of these agents accomplished this prevention is not clearly evident. Experience with implants indicates that the drainage tube placed about 3 mm into the anterior chamber does remain open in most patients with neovascular glaucoma. The procedure tends to fail because of encapsulation of the posterior edge of the tube by fibrous tissue. The present technique (as well as the modifications noted above) attempts to provide a large capsule which presumably is thin enough to be permeable to aqueous and thereby control the intraocular pressure. Efforts to reduce fibrosis using either the above technique or other medications may well permit the achievement of successful control of intraocular pressure in more of these difficult cases in the future. AI.I..w E. KoI.~~I:K ST I A)I’IS. M~ss<,r~t~r
Visual Defects in the Uninjured
Eye of Patients With Unilateral
Kaitz,
Ankava,
I.
53: 179-190,
Perlman,
N.
Ovadia,
D.
E.
Auerbach,
and
M.
Eye Injuries, by N. l)oc Ophthalmol
Feinsod.
1982
Intraocular foreign bodies have highly variable effects on the physiology and responsiveness of the injured eye. In addition to the damage incurred by the ocular media during penetration through the eye globe, the foreign body may cause secondary complications. Tests on the injured eye may reveal reduced sensitivity and/or abnormal transmission of the electrical signals within the retina or along the visual pathway. Disturbances in the contralateral eye as a result of the unilateral injury have been thought to be rare. The authors have examined the electroretinographic responses in 11 patients with unilateral intraocular foreign bodies. These patients were studied with electroretinograms, dark adaptation curves, and scotopic and photopic parametric evaluation. Most of the patients showed subnormal ERG amplitudes over a range of light intensities and subnormal light sensitivity and isolated retinal areas in the contralateral uninjured eye. The authors suggest that eyes not directly injured by unilateral traumatic ocular episode may show visual defects.
Comment after penetrating injury to one eye, the This report by Kaitz et al documents a surprising phenomenon: fellow eye may show subtle abnormalities of retinal function. The questions of clinical concern are whether these abnormalities are sufficient to alarm the patient (and physician), and whether an electrophysiologic work-up is necessary for every fellow eye. The authors found a reduced ERG in 70% of the fellow eyes, but this figure seems high relative to my own experience. Many of their cases are war injuries which may involve projectile velocities or blast forces different from those which commonly cause civilian injuries. Although the low ERGS are an objective finding, and not to be discounted, the damage was found, practically speaking, to be focal, peripheral and rather mild. The only symptom, and not a constant one, was difficulty with night vision. Since the patients were not disabled seriously, and the condition appears to be self-limited, these deficits in the fellow eye should probably be noted carefully but not made a focus of clinical concern unless the patient has spontaneous complaints.
356
Surv Ophthalmol
28 (4) January-February
CURRENT
1984
OPHTHALMOLOGY
There has always been good reason to examine the fellow eye after uniocular injury. There may be clinical damage to the fellow eye. The fellow eye may have incidental disease. There may be sympathetic ophthalmia. Finally, physiologic test results on the injured eye can be better interpreted in terms ofa normal base line. This paper adds a new reason: the possibility of associated retinal damage. But how extensive an examination is necessary? When the injured eye, for its own sake, is subjected to electrophysiologic testing, then the fellow eye should always be tested and the question is moot. If the fellow eye is symptomatic, appropriate tests should be done. However, when testing is not planned for the injured eye, and there are no significant symptoms in the fellow eye, performing an expensive electrophysiologic work-up on the fellow eye to search for a subclinical condition is probably not warranted. The most interesting question, of course - but one left unanswered by this paper - is why the fellow eye becomes involved at all. The answer may provide important clues to other ophthalmic disorders, and the authors should be encouraged to extend their clinical observations and develop animal models. MICHAEI. MARMOR PALO AI-TO, CALJFORNIA
Day-Case Cataract Surgery, by R.M. Ingram, son. Br J Ophthalmol67:278-281, 1983
D. Banerjee,
M.J. Traynar
and R.K. Thomp-
The authors report on 276 patients who have had a total of 501 cataract extractions performed under local anesthetic as day cases in a district hospital in England. Two of the patients went to a convalescent home after operation, Twelve patients required general anesthesia and were retained in the hospital for one night after the operation. Two patients had bilateral cataract extractions under local anesthetic while they were in the hospital for medical conditions. One patient was retained in the hospital because bad weather prevented return home on the day of operation. One patient had had a previous expulsive hemorrhage in a previous series and was therefore retained in the hospital for one day. The authors contend that general anesthesia is not necessary for routine cataract surgery and that for the majority of patients cataract surgery may be done as outpatient surgical procedure. The authors have done day-case cataract surgery for over live years (more than 700 operations) and they submit it is now difficult to understand what benefit there is from hospitalization after cataract extraction for the vast majority ofpatients. Only 13% of the patients in this series stated that they would have preferred to stay in the hospital following surgery. Postoperative followup in this series included a change ofdressing three to four hours after operation with appropriate eyedrops instilled. Following this, the patient was discharged from the hospital. On the first postoperative day, a trained nurse visited patients in the home and examined the eye. Atropine 1% and prednisolone and neomycin drops were instilled. The patients then attended a hospital outpatient clinic at one week, three to four weeks, and seven to eight weeks following surgery. The authors submit that there is no increased incidence of postoperative complications as the result of this procedure.
Comment The topic of day-case cataract surgery is very timely, due to the present marked pressure in this country to reduce the cost of hospitalization and surgery. The surgery as described in this paper is used less and less in the United States, so the applicability of the paper may be somewhat limited for some readers. Only one to three sutures were used to close the scleral wound. This is considerably less suturing than is done in the United States. As intraocular lenses are now used in over 50% of United States cataract surgeries, conclusions drawn from a population group such as are described in this paper may similarly not be applicable. It is of interest that a trained nurse performed the one-day postoperative exam. It would similarly be of great interest to know how much medical advantage is gained by this one-day postoperative exam; it might be possible to eliminate it with proper patient education. And in a paper designed to measure the acceptance by the patients of outpatient surgery, it would be of interest to know the preoperative vision of these patients. For example, if all patients were essentially blind prior to surgery, their acceptance of almost any mode of therapy designed to return sight would presumably be considerably more enthusiastic than that of patients who only had mild impairment to their vision prior to cataract extraction. THOILIAS R. M~wzc~:co Los ANGEIXS, CAI.IFORNIA
355
of eyes were comfortable and pain-free. Failure of the Molten0 drainage implant to function result of inadequate postoperative management and consecutive external bleb scarring.
was primarily
the
Comment This paper describes the technique and results using one of a variety of implants which have been utilized for management of acute neovascular glaucoma. The technique attempts to avoid the problem of flat anterior chambers by first placing the acrylic episcleral plate posteriorly to allow it to encapsulate and later introducing the tube in the anterior chamber. In eyes with acute neovascular glaucoma this two-stage technique may not be possible. In addition, while the results reported are very impressive, they do not explain why Molten0 has subsequently modified the technique to use two or even three interlocking scleral plates rather than the one described in the present paper. A rather formidable combination of antiinflammatory agents is utilized to prevent excessive fibrosis although the actual mechanisms by which each of these agents accomplished this prevention is not clearly evident. Experience with implants indicates that the drainage tube placed about 3 mm into the anterior chamber does remain open in most patients with neovascular glaucoma. The procedure tends to fail because of encapsulation of the posterior edge of the tube by fibrous tissue. The present technique (as well as the modifications noted above) attempts to provide a large capsule which presumably is thin enough to be permeable to aqueous and thereby control the intraocular pressure. Efforts to reduce fibrosis using either the above technique or other medications may well permit the achievement of successful control of intraocular pressure in more of these difficult cases in the future. AI.I..w E. KoI.~~I:K ST I A)I’IS. M~ss<,r~t~r
Visual Defects in the Uninjured
Eye of Patients With Unilateral
Kaitz,
Ankava,
I.
53: 179-190,
Perlman,
N.
Ovadia,
D.
E.
Auerbach,
and
M.
Eye Injuries, by N. l)oc Ophthalmol
Feinsod.
1982
Intraocular foreign bodies have highly variable effects on the physiology and responsiveness of the injured eye. In addition to the damage incurred by the ocular media during penetration through the eye globe, the foreign body may cause secondary complications. Tests on the injured eye may reveal reduced sensitivity and/or abnormal transmission of the electrical signals within the retina or along the visual pathway. Disturbances in the contralateral eye as a result of the unilateral injury have been thought to be rare. The authors have examined the electroretinographic responses in 11 patients with unilateral intraocular foreign bodies. These patients were studied with electroretinograms, dark adaptation curves, and scotopic and photopic parametric evaluation. Most of the patients showed subnormal ERG amplitudes over a range of light intensities and subnormal light sensitivity and isolated retinal areas in the contralateral uninjured eye. The authors suggest that eyes not directly injured by unilateral traumatic ocular episode may show visual defects.
Comment after penetrating injury to one eye, the This report by Kaitz et al documents a surprising phenomenon: fellow eye may show subtle abnormalities of retinal function. The questions of clinical concern are whether these abnormalities are sufficient to alarm the patient (and physician), and whether an electrophysiologic work-up is necessary for every fellow eye. The authors found a reduced ERG in 70% of the fellow eyes, but this figure seems high relative to my own experience. Many of their cases are war injuries which may involve projectile velocities or blast forces different from those which commonly cause civilian injuries. Although the low ERGS are an objective finding, and not to be discounted, the damage was found, practically speaking, to be focal, peripheral and rather mild. The only symptom, and not a constant one, was difficulty with night vision. Since the patients were not disabled seriously, and the condition appears to be self-limited, these deficits in the fellow eye should probably be noted carefully but not made a focus of clinical concern unless the patient has spontaneous complaints.
356
Surv Ophthalmol
28 (4) January-February
CURRENT
1984
OPHTHALMOLOGY
There has always been good reason to examine the fellow eye after uniocular injury. There may be clinical damage to the fellow eye. The fellow eye may have incidental disease. There may be sympathetic ophthalmia. Finally, physiologic test results on the injured eye can be better interpreted in terms ofa normal base line. This paper adds a new reason: the possibility of associated retinal damage. But how extensive an examination is necessary? When the injured eye, for its own sake, is subjected to electrophysiologic testing, then the fellow eye should always be tested and the question is moot. If the fellow eye is symptomatic, appropriate tests should be done. However, when testing is not planned for the injured eye, and there are no significant symptoms in the fellow eye, performing an expensive electrophysiologic work-up on the fellow eye to search for a subclinical condition is probably not warranted. The most interesting question, of course - but one left unanswered by this paper - is why the fellow eye becomes involved at all. The answer may provide important clues to other ophthalmic disorders, and the authors should be encouraged to extend their clinical observations and develop animal models. MICHAEI. MARMOR PALO AI-TO, CALJFORNIA
Day-Case Cataract Surgery, by R.M. Ingram, son. Br J Ophthalmol67:278-281, 1983
D. Banerjee,
M.J. Traynar
and R.K. Thomp-
The authors report on 276 patients who have had a total of 501 cataract extractions performed under local anesthetic as day cases in a district hospital in England. Two of the patients went to a convalescent home after operation, Twelve patients required general anesthesia and were retained in the hospital for one night after the operation. Two patients had bilateral cataract extractions under local anesthetic while they were in the hospital for medical conditions. One patient was retained in the hospital because bad weather prevented return home on the day of operation. One patient had had a previous expulsive hemorrhage in a previous series and was therefore retained in the hospital for one day. The authors contend that general anesthesia is not necessary for routine cataract surgery and that for the majority of patients cataract surgery may be done as outpatient surgical procedure. The authors have done day-case cataract surgery for over live years (more than 700 operations) and they submit it is now difficult to understand what benefit there is from hospitalization after cataract extraction for the vast majority ofpatients. Only 13% of the patients in this series stated that they would have preferred to stay in the hospital following surgery. Postoperative followup in this series included a change ofdressing three to four hours after operation with appropriate eyedrops instilled. Following this, the patient was discharged from the hospital. On the first postoperative day, a trained nurse visited patients in the home and examined the eye. Atropine 1% and prednisolone and neomycin drops were instilled. The patients then attended a hospital outpatient clinic at one week, three to four weeks, and seven to eight weeks following surgery. The authors submit that there is no increased incidence of postoperative complications as the result of this procedure.
Comment The topic of day-case cataract surgery is very timely, due to the present marked pressure in this country to reduce the cost of hospitalization and surgery. The surgery as described in this paper is used less and less in the United States, so the applicability of the paper may be somewhat limited for some readers. Only one to three sutures were used to close the scleral wound. This is considerably less suturing than is done in the United States. As intraocular lenses are now used in over 50% of United States cataract surgeries, conclusions drawn from a population group such as are described in this paper may similarly not be applicable. It is of interest that a trained nurse performed the one-day postoperative exam. It would similarly be of great interest to know how much medical advantage is gained by this one-day postoperative exam; it might be possible to eliminate it with proper patient education. And in a paper designed to measure the acceptance by the patients of outpatient surgery, it would be of interest to know the preoperative vision of these patients. For example, if all patients were essentially blind prior to surgery, their acceptance of almost any mode of therapy designed to return sight would presumably be considerably more enthusiastic than that of patients who only had mild impairment to their vision prior to cataract extraction. THOILIAS R. M~wzc~:co Los ANGEIXS, CAI.IFORNIA