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CORNEAL DAMAGE SECONDARY TO BENZALKONIUM CHLORIDE INTRAOCULAR USE
The goal to eliminate human error from health care is laudable but obviously impossible to achieve. That human error will continue to be part of the problems facing healthcare delivery is obvious. That we learn from the events of human error is not always certain. It is for that reason that Liu and co-workers are to be congratulated for candidly and openly describing the inadvertent use of benzalkonium chloride during cataract surgery and the corneal damage that resulted. Nineteen patients received hydroxypropyl methylcellulose preserved with benzalkonium chloride during phacoemulsification. This resulted in severe corneal oedema. In most cases this striate keratopathy spontaneously cleared. However, varying degrees of stromal thickening persisted. Penetrating keratoplasty was necessary in two patients and postoperative results were good. This study reminds us how important it is to clearly label all solutions and medications used in the operating room and to have in place as much redundancy as possible in our oversight procedures. See p 299
A NEW FINDING IN NEUROFIBROMATOSIS TYPE 1
Evaluation of patients with neurofibromatosis is of interest to most ophthalmologists. A distinctly separate set of associated findings occurs in patients with neurofibromatosis type 1 (NF-1) than in those with NF-2. In the case of NF-1 associated findings include changes in the cornea, angle structures, iris, retina, optic nerve, and orbital wall structures. In many centres all patients with NF-1 are screened by ophthalmologists as a matter of routine. It is perhaps surprising, therefore, that Muci-Mendoza and co-workers now report a new finding associated with NF-1—corkscrew retinal vessels. In a study of 32 patients with NF-1, 12 were found to have a spectrum of retinal microvascular anomalies that ranged from quite mild to dramatic in their manifestation. These anomalies consisted of retinal microvascular tortuosity without evidence of leakage on fluorescein angiography. This appears to be yet one more associated finding that occurs in NF-1. Can it really be true that one third of patients with NF-1 demonstrate these anomalies and we have only just now recognised them? See p 282
TRACHOMATOUS TRICHIASIS NEEDS BOTH SURGICAL AND MEDICAL TREATMENT
There are encouraging signs that the incidence of new cases of trachoma is decreasing in most endemic areas throughout the world. Nevertheless, trichiasis associated with previous infections remains a significant problem because of its associated risk for developing corneal opacities. Bowman and co-workers report the result of a self epilation and surgical treatment programme for trichiasis in the Gambia. They emphasise that despite the decline in trachoma in the Gambia the problem of trichiasis remains. Moreover, active trachomatis inflammation and infection may accelerate the damaging processes associated with trichiasis. They recommend, therefore, both surgical treatment of the trichiasis as well as antibiotic therapy. The workload associated with previous trachomatis infection remains high throughout many parts of the world. See p 339
NYSTAGMUS SURGERY: HOW MANY MUSCLES?
That one can reduce, at least in the short term, an anomalous face position associated with nystagmus by operating on extraocular muscle cannot be denied. That these procedures are of significant benefit for the long term remains more in question. Many ingenious procedures have been developed to address anomalous face turns, chin up, and chin down positions, and head tilts associated with nystagmus. Arroyo-Yllnes and co-workers challenge us with their study. They suggest that in patients with congenital nystagmus one needs only to operate on the horizontal rectus muscles when trying to eliminate anomalous head positions even when significant chin up and chin down or head tilt anomalies are present. Moreover, they operated on only two horizontal rectus muscles in a modified Anderson procedure. This minimalist approach to the problem of anomalous head position in patients with congenital nystagmus is provocative and thought provoking. In a series of 21 patients with relatively short follow up (averaging 18.5 months) the modified Anderson procedure was successful in reducing both the vertical and torsional components of anomalous head positions as well as the horizontal one. We look forward to seeing the results of long term studies using this modified Anderson two horizontal muscle procedure to address anomalous head positions in patients with congenital nystagmus. See p 267
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