We read with keen interest the article by Gogate et al. on
extracapsular cataract surgery (ECCE) compared with manual small
incision
cataract surgery(MSICS) in community eye care setting.[1]
We fully endorse their views that MSICS should be the choice for effective rehabilitation
of the cataract patients. They have rightly pointed out that the
conventional (ECCE) with posterior chamber int...
We read with keen interest the article by Gogate et al. on
extracapsular cataract surgery (ECCE) compared with manual small
incision
cataract surgery(MSICS) in community eye care setting.[1]
We fully endorse their views that MSICS should be the choice for effective rehabilitation
of the cataract patients. They have rightly pointed out that the
conventional (ECCE) with posterior chamber intraocular lens
implantation (PCIOL) is becoming less frequent as phacoemulsification
has
gained popularity worldwide. Further, they have made the scenario of
MSICS
more realistic for the developing countries to effectively manage the
large backlog of cataract blindness which is still a burning problem in
India. MSICS is a good quality alternative to both ECCE and Phaco as it
is
safe, quick, cost effective and produces less astigmatism and unlike
phacoemulsification it does not have a long learning curve . However, we
would like to comment on some areas of concern.
The authors have recommended either straight or frown incision. In our opinion, frown incision would be preferable as it induces lesser astigmatism and prevents sliding between the roof and floor of the tunnel as happens in straight incision.
Capsulorrhexis is a good method of capsulotomy, but it is not a
must
for MSICS as for phaco. One can perform MSICS safely with linear
capsulotomy which provides additional advantages: the anterior
capsular
flap prevents rubbing of the hard nucleus to the corneal endothelium,
allows aspiration in the bag, ensures in the bag placement of the IOL
and
almost behaves like capsulorrhexis at end.
The authors have also commented that mature and hypermature
cataracts
are more prevalent in India and the hardness of the nucleus has a
direct
correlation with both intra and postoperative complications. Therefore,
it
would have been better if the patients would have been grouped as per
the
maturity of the cataract.
It is mentioned that though the posterior capsular rent is a major
problem in their study especially in hypermature cataracts and with
hard
nuclei, incidence of vitreous loss is minimal in MSICS due to the self
sealing wound which helps to maintain the anterior chamber. In our
opinion
the size of the incision is an important factor in causation of
posterior
capsular rent besides the hardness of the nucleus. They have kept the
incision size constant between 6.5 and 7.5 mm. Hard nucleus requires a
larger incision than the conventional size for its easy delivery.
Further,
in hyper mature cataract with calcification dragging of entire lens
capsule is possible during nucleus delivery. Therefore, a good hydro
dissection and adequate quantity of viscoelastic injection in the bag
both infront and behind the nucleus is mandatory to ensure nuclear
separation and thus preventing dragging of entire capsule. Further, with all types of cataract, full nuclear rotation is mandetory.
The authors have mentioned about the two major advantages of this
method in terms of time and money which should have been elaborated.
Finally, the authors are to be congratulated for their effort to popularise MSICS which is a boon not only for the community setting but for the centres/ hospitals with limited resources.
Reference
(1) Gogate PM ,Deshpande M, Wormald RP, Deshpande R, Kulkarni SR. Extracapsular
cataract surgery compared with manual small incision cataract
surgery(MSICS) in community eye care setting. Br J Ophthalmol 2003;87:667-672 .
We read the article “Transcaruncular approach for the management of
frontoethmoidal mucocoeles” by Lai et al. [1] with interest.
The authors report a modification of the non-obliterative external
procedure that was first described by Lynch in 1921.[2] The Lynch-Howarth
procedure [2-4] involved trans-nasal stenting to prevent medial-ward
collapse of the orbit obstructing drainage from th...
We read the article “Transcaruncular approach for the management of
frontoethmoidal mucocoeles” by Lai et al. [1] with interest.
The authors report a modification of the non-obliterative external
procedure that was first described by Lynch in 1921.[2] The Lynch-Howarth
procedure [2-4] involved trans-nasal stenting to prevent medial-ward
collapse of the orbit obstructing drainage from the frontal sinus into the
nose. Although the transcaruncular procedure uses a different external
approach, it nevertheless often involves removal of part of the lamina
papyracea for access to the sinuses. Hence, as with the Lynch approach,
prolapse of orbital contents into the defect may occur, increasing the
risk of re-stenosis. In addition, the cells in the frontal recess are not
formally cleared and thus drainage into the nasal cavity is not assured.
Stenting of sinus openings results in a significant fibrotic reaction in a
proportion of patients, and closure of such a previously stented opening
is likely. Furthermore, the follow-up period in this study is too short to
confirm the success or failure of this technique as recurrence often takes
years to manifest.[4]
Endoscopic management of mucocoeles protruding into the other sinuses
or nasal cavity has been an accepted treatment for years.[5-9] Frontoethmoidal mucocoeles are typical of such mucocoeles where the bony
wall surrounding the mucocoele is thin and therefore easily accessible
trans-nasally. The endoscopic procedure creates a large area clear of
cells which allows the greatest possible marsupialization of the
mucocoele. No stenting is required. Har et al.[9] reported the largest
series of 108 mucocoeles with a median follow-up of 4.[7] years with a
recurrence rate of only 0.9%. Therefore, we would recommend an endoscopic
approach for frontoethmoidal mucoceles as the integrity of the lamina
papyracea is maintained and the largest possible opening is created into
the mucocoele, which in turn minimizes the chances of recurrence.
References
(1) Lai PC, Liao SL, Jou JR et al. Transcaruncular approach for the
management of frontoethmoid mucoceles. Br J Ophthalmol 2003;87:699-703.
(2) Lynch RC. The technique of a radical frontal sinus operation which has
given me the best results. Laryngoscope 1921;31:1-5.
(3) Surgical procedures on the paranasal sinuses: the frontal sinus. In
The paranasal sinuses: surgery and technique, 2nd edition, Ritter FN (Ed). St.
Louis: Mosby, 1978: 136-45.
(4) Neel HB, McDonald TJ, Facer GW. Modified Lynch procedure for chronic
frontal sinus diseases: rationale, technique, and long-term results.
Laryngoscope 1987;97:1274-79.
(5) Kennedy DW, Josephson JS, Zinreich SJ et al. Endoscopic sinus surgery
for mucoceles: a viable alternative. Laryngoscope 1989;99:885-95.
(6) Schaefer SD, Close LG. Endoscopic management of frontal sinus disease.
Laryngoscope 1990;100:155-60.
(7) Har-EL G, Balwally AN, Lucente FE. Sinus mucoceles: is marsupialization
enough? Otolaryngol Head Neck Surg 1997;117:633-40.
We read, with interest the article 'Charles Bonnet Syndrome
precipitated by Brimonidine Tartrate eye drops' published in July 2003 BJO. Interest in Charles-Bonnet syndrome (CBS) has escalated of late,
highlighting the probable 15% [1] incidence of the condition in patients with significant visual impairment coupled with a clear sensorium.
The authors implied that CBS was induced in 4 patient...
We read, with interest the article 'Charles Bonnet Syndrome
precipitated by Brimonidine Tartrate eye drops' published in July 2003 BJO. Interest in Charles-Bonnet syndrome (CBS) has escalated of late,
highlighting the probable 15% [1] incidence of the condition in patients with significant visual impairment coupled with a clear sensorium.
The authors implied that CBS was induced in 4 patients by
Brimonidine
Tartrate (BT) on the basis of patient age and the instigation of BT
therapy, with discontinuation resulting in eventual resolution of the
hallucinations. Firstly, the diagnostic criteria proposed by Podell et
al,[2] and Gold and Rabins [3] quite rightly made no reference for age
being
indicative of CBS, although incidence certainly increases with age.
Schwartz [4] found that CBS also occurred in children following profound visual loss. This suggests that the high incidence in the elderly
population is possible be attributable to the increased incidence of
acquired visual loss occurring with age; therefore, age is not a
criteria for diagnosis.
Further, although the Snellen acuity of all 4 patients was reasonably
good
in at least one eye of each patient, it may be surmised that severe
visual
impairment may have been due to visual field loss secondary to
glaucomatous damage. Although this is not clear from the article, the
cause
of visual impairment and bilaterality are important in the diagnosis of
CBS. Indeed, bilateral advanced visual field defects induced by
glaucoma
and homonymous hemianopia have resulted in CBS.[5,6] A prevailing
theory suggests sensory visual deprivation as an integral causative
factor
in CBS. Interestingly, and supportive of this theory, is that musical
pseudohallucinations have been documented in cases of acquired deafness.[7] Sensory deprivation in the presence of a clear sensorium will
necessary bilaterally to induce CBS, although no lower limit of Snellen
visual acuity has been defined as a level for which CBS symptoms are
stimulated. In the article case 4 seems to have sufficiently
adequate visual function in the right eye to justify a definite
misdiagnosis of CBS.
Secondly, as mentioned by the authors, alpha-2 agonists have been
shown to cause systemic and neuropsychiatric phenomena.[8] As with any medication, the expectation would be resolution of induced symptoms, and as such we believe the hallucinations may easily be explained as a side
effect of the medication. BT is a known lipophilic compound able to
penetrate the blood-brain barrier. Through the accompanying package
insert, neurological side effects such as depression and dizziness are
well known. There is, therefore, little doubt that in the aged
population
in whom pharmacokinetics is often unpredictable, likelihood of greater
systemic absorption and distribution may well lead to neuropsychiatric
phenomena. Consequently, we believe that CBS was not the cause of the
complex visual hallucinations experienced by these patients and may be
attributed to a rarer side-effect of BT, which should now be included in the patient information leaflet.
References
(1) Menon GJ, Rahman I, Menon SJ, Dutton GN. Complex visual
hallucinations in the visually impaired: the Charles Bonnet Syndrome. Surv of Ophthalmol 2003: 48;58-72 (Major Review)
(2) Gold K, Rabins PV: Isolated visual hallucinations and the
Charles-
Bonnet Syndrome: A review of the literature and presentation of six
cases. Compr Psychiatry 1989; 30:90-98.
(3) Podoll K, Osterheider M, Noth J: Das Charles Bonnet Syndrom.
Fortschr Neurol Psychiat 1989;57:43-60.
(4) Schwartz TL, Vahgei L: Charles Bonnet syndrome in children. J
AAPOS 1998;2:310-3.
(5) Damas-Mora J, Skelton-Robinson M, Jenner FA: The Charles Bonnet Syndrome in perspective. Psychol Med 1982; 12:251-61.
(6) Dodd J, Heffernan A, Blake J: Visual hallucinations associated with Charles Bonnet Syndrome - an ever increasing diagnosis. Ir Med J 1999;92:344-345.
(7) Griffiths TD: Musical hallucinosis in acquired deafness:
Phenomenology and brain substrate. Brain 2000;123:2065-2076.
(8) Kim DD, Bay G. A case of suspected Alphagan-induced Psychosis. Arch Ophthalmol 2000;118:1132-33.
I read with great interest the article by Okada et al,[1]
reporting the efficacy and complications of trans-tenon’s retrobulbar
infusion of triamcinolone acetonide for posterior uveitic inflammation.
The authors have to be commended for the excellent description of this
novel technique.
The efficacy of various modalities of corticosteroid injection has
always been a matter of debate w...
I read with great interest the article by Okada et al,[1]
reporting the efficacy and complications of trans-tenon’s retrobulbar
infusion of triamcinolone acetonide for posterior uveitic inflammation.
The authors have to be commended for the excellent description of this
novel technique.
The efficacy of various modalities of corticosteroid injection has
always been a matter of debate with different studies giving different
results. McCartney et al.[2] showed that the major route of penetration of
steroids after subconjunctival injection was directly through the adjacent
sclera, choroid and retina. In addition, the authors described methods to
inject steroids in the sub-tenon’s space and concluded that the injections
should be placed immediately adjacent to the site of intraocular
inflammation that was under treatment. In contrast, in a study on rabbit
eyes, Wilson et al.[3] have elegantly demonstrated that injection of
corticosteroids by the sub-tenon’s route does not show a significant
effect on the blood-retinal barrier owing to inadequate penetration. The
authors analysed the severity of blood-retinal barrier breakdown following
panretinal photocoagulation, using rapid sequential MRI with contrast. Of
note, in this study the authors have taken particular care to ensure the
accurate placement of the needle in the sub-tenon’s space. A similar
result was obtained in a study on the efficacy of posterior sub-tenon’s
injections in patients with cystoid macular edema due to uveitis by
Jennings et al.[4] The authors found that the injection of steroids by the
sub-tenon’s route did not consistently affect the blood-retinal barrier
permeability in such patients and that there was no diffusion of the
steroids into the eye in therapeutically meaningful concentrations. This
is of particular concern since it is the breakdown in the blood-retinal
barrier that leads to influx of serum/serum components leading to macular
edema, epiretinal membrane and other sequelae.
Sub-tenon’s injections when compared to intravitreal injections have
the disadvantage of probably a decreased and difficult drug penetration
through the sclera and choroid and a rapid removal of the drug by the
choroidal circulation after penetration with the resultant shortened
duration of action. This is probably the reason why sub-tenon’s route of
injection of steroids has not become popular in diabetic macular edema in
contrast to the gaining popularity of the intravitreal steroid injections.
Interestingly, Freeman et al.[5] have postulated that the lack of
therapeutic response to sub-tenon’s corticosteroids may be because of
placement at a site relatively far from the target zone. They determined
the location of repository corticosteroid after sub-tenon’s injection by
echography and showed that the steroid was deposited within the sub-
tenon’s space over the macula in only 11 of 24 cases. They hence concluded
that the therapeutic response manifested by improvement in macular
function may be related to the proximity of the corticosteroid to the
macular area. The impressive efficacy reported in the study by Okada et
al.[1] could probably be due to reliable drug placement thanks to the visual
confirmation of cannula entry into sub-tenon’s space, as the authors
speculate. However, it is important to note that most of the patients in
this study continued to receive topical steroid drops. Whether these drops
had an additive effect is unclear.
It would probably be worthwhile to consider a planned, primary
intravitreal injection of corticosteroids under aseptic conditions that
has the distinct advantage of getting distributed into a much larger
volume for selected conditions. There would be no cases of “therapeutic
failures” that are seen after injection of steroids into the sub-tenon’s
space and the resultant confusion as to whether the unsatisfactory
response is secondary to the disease process or failure to inject the
steroid into the sub-tenon’s space or the debated lower efficacy of this
route of injection. The procedure is simpler than the described trans-
tenon’s retrobulbar infusion (no special cannula is required), but the
risk of endophthalmitis is daunting.[6]
References
(1) AA Okada, T Wakabayashi, Y Morimura, S Kawahara, E Kojima, Y
Asano and T Hida. Trans-Tenon’s retrobulbar triamcinolone infusion for the
treatment of uveitis. Br J Ophthalmol 2003;87:968-971.
(2) McCartney HJ, Drysdale IO,Gornall AG, Basu PK. An
autoradiographic study of the penetration of subconjunctivally injected hydrocortisone into normal and inflamed rabbit eyes. Invest Ophthalmol
1965;4: 297.
(3) Wilson CA, Berkowitz BA, Sato Y, Ando N, Handa JT, deJuan E. Treatment
with intravitreal steroid reduces blood-retinal barrier breakdown due to
retinal photocoagulation. Arch Ophthalmol 1992;110:1155-9.
(4) Jennings T, Rusin MM, Tessler HH, Cunhavaz JG. Posterior sub-tenon’s
injections of corticosteroids in uveitis patients with cystoid macular
edema. Jpn J Ophthalmol 1988;32:385-391.
(5) Freeman WR, Green RL, Smith RE. Echographic localization of
corticosteroids after periocular injection. Am J Ophthalmol 1987 Mar;
15;103(3 Pt 1):281-8.
(6) Benz MS, Murray TG, Dubovy SR, Katz RS, Eifrig CW. Endophthalmitis
caused by Mycobacterium chelonae abscessus after intravitreal injection of
triamcinolone. Arch Ophthalmol 2003;121(2):271-3.
This correspondence is regarding the article by JF Jordan et al.[1]
This is a very exciting new approach to wound modulation in glaucoma
surgery, & looked very promising at the outset. However, the study
reported a complete success rate of only 59.5% as compared with a success
rate of 60-80% with standard trabeculectomy at 1 year, 65% with MMC at 2
years,[2] & 73% with 5 FU...
This correspondence is regarding the article by JF Jordan et al.[1]
This is a very exciting new approach to wound modulation in glaucoma
surgery, & looked very promising at the outset. However, the study
reported a complete success rate of only 59.5% as compared with a success
rate of 60-80% with standard trabeculectomy at 1 year, 65% with MMC at 2
years,[2] & 73% with 5 FU after 1 year.[3]
This study was undertaken in patients undergoing their first glaucoma
surgery rather than repeat surgery which is generally the case in patients
in whom antimetabolites are used so it cannot be compared with
trabeculectomy using MMC or 5 FU very satisfactorily.
There were no significant post-op complications including
endophthalmitis which is a major risk with antimetabolites. However, the
authors did not mention whether they studied the toxic effects if any, of
the chemical (BECEF) or the light on the cornea or sclera, particularly
limbal stem cells which may be exceptionally sensitive to the free
radicals which are produced by this procedure. Grisanti et al. used BECEF
in rabbits & studied the post-op effects histologically, and they
report that there was a yellow discolouration of the conjunctiva at the
injection site 1 week post-operatively which could be because of the decay
of the BECEF probe. However they also have not commented upon the presence
or absence of corneal or scleral damage.[4]
Laser suture lysis of the scleral sutures was used as part of the
technique which could have influenced the outcome.
The follow up period was adequate (> 1 year) in only 23 of the 42
patients studied while in the remainder some were followed up for as less
as 15 days.
The patients were not distributed according to ethnicity so that
differences in results between black and white races could not be
studied.
References
(1) Jordan JF, Diestelhorst M, Grisanti S, Krieglstein GK. Photodynamic modulation of wound healing in glaucoma filtration surgery. Br J Ophthalmol 2003;87: 870-875.
(2) Shin DH, Ren J, Juzych MS, et al. Primary glaucoma triple
procedure in patients with primary open angle glaucoma: the effect of
mitomycin C in patients with and without prognostic factors for filtration
failure. Am J Ophthalmol 1998;125:346-52.
(3)The Fluorouracil Filtering Surgery Study Group. Fluorouracil
Filtering Surgery Study one year follow up. Am J Ophthalmol 1989;108:625-635.
(4) Grisanti S, Diestelhorst M, Heimann K, Gunter K. Cellular
photoablation to control postoperative fibrosis in a rabbit model of
filtration surgery. Br J Ophthalmol 1999;83:1353-1359.
Khan et al. reported a patient with Rosai Dorfman disease (RDD) and
massive
lymphadenopathy in the orbit.[1] The encapsulated tumor was surgically
removed and histology confirmed immunohistochemistry stained positive
for
S-100 as well as CD68, a marker for macrophage. Unfortunately the
authors do not report their functional results in terms of visual acuity
(VA) or visual fields.
We recently als...
Khan et al. reported a patient with Rosai Dorfman disease (RDD) and
massive
lymphadenopathy in the orbit.[1] The encapsulated tumor was surgically
removed and histology confirmed immunohistochemistry stained positive
for
S-100 as well as CD68, a marker for macrophage. Unfortunately the
authors do not report their functional results in terms of visual acuity
(VA) or visual fields.
We recently also published a patient with RDD, who complained about
decreased VA. On examination his VA was 0.2 OU and we determined
bilateral uveitis with a massive serous retinal detachment. Cross-
sectional images on optical coherent tomography (OCT) and B-scan
ultrasound demonstrated infiltrations in the retina and choroid. After
treatment with 50mg oral prednisolone and topical cyclosporine 2% eye
drops for 10 weeks the retina reattached and vision improved to 0.4 OU.
Bilateral massive painless enlargement of lymph nodes were biopsied by
us
and RDD was diagnosed by Professor Rosai.[2]
Intraocular manifestations with uveitis are extremely rare in patients
with RDD. Foucar et al. reported the microscopic findings from 13
enucleated eyes with RDD and found only in 1 eye extensive infiltration
of
predominant histiocytes in the entire uvea.[3] Our OCT-image assessed the
anatomical morphology in-vivo and confirmed intraretinal and choroidal
infiltrates in RDD. The rare nature of the disease and the
self-limiting
course reduces the knowledge about effective treatment. However, our
patient responded quickly to a combined therapy with topical
cyclosporine
and systemic coricosteroids.
RDD-patients may also develop intraocular infiltrates. If their VA
decreases, a full ophthalmic examination is required to determine if
this rare intraocular manifestation is present. These infiltrates may
be treated by topical cyclosporine and systemic coricosteroids to
improve their vision.
References
(1) Khan R, Moriarty P, Kennedy S. Rosai Dorfman disease or sinus
histiocytosis with massive lymphadenopathy of the orbit. Br J Ophthalmol 2003;87:1054.
(2) Meyer CH, Sel S, Horle S, Burg J, Kroll P. Rosai-Dorfman disease with bilateral serous retinal detachment. Arch Ophthalmol 2003;121:733-5.
(3) Foucar E, Rosai J, Dorfman RF. The ophthalmic manifestations of
sinus
histiocytosis with massive lymphadenopathy. Am Journal Ophthalmol 1979;87:354-367.
I read with great interest the article by Okada et al.[1] I would like to
make the following comments: (1) The authors describe three patients of tubercular uveitis who are being
treated with isoniazid and rifampicin for a month prior to their treatment
with trans-tenons triamcinolone. However, current WHO guidelines
recommend an initial phase of 2 months with four drugs (iso...
I read with great interest the article by Okada et al.[1] I would like to
make the following comments: (1) The authors describe three patients of tubercular uveitis who are being
treated with isoniazid and rifampicin for a month prior to their treatment
with trans-tenons triamcinolone. However, current WHO guidelines
recommend an initial phase of 2 months with four drugs (isoniazid,
rifampicin, ethambutol and pyrazinamide )followed by a longer continuation
phase (four months of isoniazid and rifampicin or six months of isoniazid
and ethambutol) for both the severe and the less severe forms of
extrapulmonary tuberculosis.[2] Could the non-resolution of their uveitis
be due to inadequate anti-tubercular therapy?
(2) 16 of the described 37 patients were on systemic immunomodulators
(corticosteroids/cyclosporine) prior to their treatment with
triamcinolone. Did the authors notice any differences in the outcome
between those patients who were being treated with systemic drugs
initially versus those who were not?
References
(1) A A Okada, T Wakabayashi, Y Morimura, S Kawahara, E Kojima, Y
Asano, and T Hida. Trans-Tenon’s retrobulbar triamcinolone infusion for the treatment of
uveitis. Br J Ophthalmol 2003;87:968-971.
(2) World Health Organization. Standardized treatment regimes, Chapter 4:27-38. In Treatment of tuberculosis: guidelines for national
programmes (WHO/CDS/TB/2003.13) Third Edition. Available Online Accessed on 31
July 2003.
Geneva: World Health Organization.
Sutter and Gillies described in their paper four cases of
endophthalmitis-like reaction after an intravitreal injection of
triamcinolone acetonide (Kenacort A-40, Bristol-Myers Squibb
Pharmaceuticals, Australia) as a distinct clinical entity.[1] We would
like to point out some issues that could help to explain their findings
at least in part.
We strongly believe that the endophthalmitis-like...
Sutter and Gillies described in their paper four cases of
endophthalmitis-like reaction after an intravitreal injection of
triamcinolone acetonide (Kenacort A-40, Bristol-Myers Squibb
Pharmaceuticals, Australia) as a distinct clinical entity.[1] We would
like to point out some issues that could help to explain their findings
at least in part.
We strongly believe that the endophthalmitis-like reaction appeared
as an acute reaction to the preservative of the drug (i.e. benzyl
alcohol). Hida et al. found that the vehicle, and not the crystalline
cortisone itself, could be toxic to the intraocular tissue.[2] Although
no ocular toxicity has been proved in humans, intravenous use of solutions
containing this alcohol are known to have caused a fetal toxic syndrome in
premature infants.[3] Approximately 25 percent of all commercially
available ophthalmic solutions are preserved with chlorobutanol. Benzyl
alcohol is rarely used because of its low activity, irritation, and
capacity for disolving polystyrene.[4] In fact, experience has
demonstrated that many vehicles meet all the criteria to become a suitable
one but do not have the proper feel to make them acceptable to the human
patient.
On the other hand, the authors stated that the site of injection was
at the superior-temporal quadrant. It is well-known that this injection
method will completely obscure the view of the fundus and increase the
vitreous reaction (i.e. injected suspension will drop from up to down
throughout the vitreous gel).
We recommend the use of triamcinolone acetonide suspension for
intravitreal injection with most of the vehicle removed as suggested by
others.[5] We also suggest the introduction of the needle into the eye at
the inferior-temporal quadrant in an effort to keep the suspension in the
inferior vitreous region to reduce the vitreous reaction, and out of the
visual axis.
References
(1) Sutter FKP, Gillies MC. Pseudo-endophthalmitis after intravitreal
injection of triamcinolone. Br J Ophthalmol 2003; 87:972-974.
(2) Hida T, Chandler D, Arena JE, Machemer R. Experimental and
clinical observations of the intraocular toxicity of commercial
corticosteroid preparations. Am J Ophthalmol 1986;101:190-195.
(3) Brown WJ, Buits NR, Cory Gipson,HT, Huston RK, Kennaway NG. Fatal
benzyl alcohol poisoning in a neonatal intensive care unit. Lancet 1982;1(8283):1250.
(4) Mullen W, Shepherd W, Labovitz J. Ophthalmic preservatives and
vehicles. Surv Ophthalmol 1973;17(6):469-483.
(5) Jonas JB, Hayler JK, Söfker A, Panda-Jonas S. Intravitreal
injection of crystalline cortisone as adjunctive treatment of
proliferative diabetic retinopathy. Am J Ophthalmol 2001;131:468-471.
We would like to thank Dr Rodrigues and colleagues for bringing up this interesting point of what exactly trypan blue (TB) stains.
In our study, immunohistochemistry was performed to determine the
nature of cells involved in the epiretinal membranes (ERM) - not to
determine the presence or absence of the ERM. Presence or absence of ERM
was determined by examining routinely stained sections (H...
We would like to thank Dr Rodrigues and colleagues for bringing up this interesting point of what exactly trypan blue (TB) stains.
In our study, immunohistochemistry was performed to determine the
nature of cells involved in the epiretinal membranes (ERM) - not to
determine the presence or absence of the ERM. Presence or absence of ERM
was determined by examining routinely stained sections (H&E, PAS) for
cytoplasm/nuclei of epiretinal cell elements. All four of the macular
hole internal limiting membrane (ILM) specimens were examined in this way.[1] Furthermore TB (in low concentrations) stains the anterior lens
capsule.[2] Since this capsule lacks glia, we do not believe that the
evidence supports the contention of the correspondents that the staining
of our ILM specimens is due to undetected "glial cell elements of the
highly cellular ERM" rather than ILM.
Clinically two features are observed with the use of TB. Firstly, the
whole posterior pole that comes into contact with TB is stained a faint
blue in all cases. The staining pattern is diffuse and not patchy,
suggesting TB straining is indiscriminate of ERM or ILM. Secondly, in
cases of macular pucker, the TB stained ERM can be removed separately,
leaving intact ILM behind, which can be further stained and removed. In
cases of macular hole where a clinical ERM is not present, it appears that
only the ILM is stained and peeled. We have harvested these membranes and
confirmed that the membranes only consist of ILM and without a secondary
ERM.
There is no doubt that TB stains both ERM and ILM. We however, have
no knowledge as to what the structural elements of these membrane that the
dye is attached to. We concede that staining of ILM with TB can be
variable and sometimes rather faint. Since our publication, Dr. Perrier
and Dr. Sebag have also reported their experience with TB in staining ILM
and ERM.[3,4] Although histological findings were not given in these
studies, clinically the authors found the dye to be useful in both types
of membranes. Given the many concerns regarding the use of indocyanine
green,[5] we believe it is a positive development that an alternative
clinically useful dye is available.
References
(1) Li K, Wong D, Hiscott, et al. Trypan blue staining of internal limiting membrane and epiretinal membrane during vitrectomy: visual
results and histopathological findings. Br J Ophthalmol 2003;87:216-19.
(2) Melles GR, de Waard PW, Pameyer JH, et al. Typan blue capsule
staining to visualize the capsulorhexis in cataract surgery. J Cataract
Refract Surg 1999;25:7–9.
(3) Perrier M, Sebag M. Trypan blue-assisted peeling of the internal
limiting membrane during macular hole surgery. Am J Ophthalmol 2003;135(6): 903-05.
(4) Perrier M, Sebag M. Epiretinal membrane surgery assited by typan blue. Am J Ophthalmol 2003;135(6):909-11.
(5) Gandorfer A, Haritoglou C, Gass CA, et al. Indocyanine green-
assisted peeling of the internal limiting membrane may cause retinal
damage. Am J Ophthalmol 2001;132:431–3.
I read with interest the article by Teng et al.[1] reporting the
influence of tight neckties on intraocular pressure (IOP) measurement by
Goldman applanation tonometry. They show that elevated IOP may be
associated with a tightly worn necktie.
For comprehensive ophthalmologists tight collars, maybe owing to
tight neckties, are a virtual cause for erroneous high IOP measurements.[2] As sug...
I read with interest the article by Teng et al.[1] reporting the
influence of tight neckties on intraocular pressure (IOP) measurement by
Goldman applanation tonometry. They show that elevated IOP may be
associated with a tightly worn necktie.
For comprehensive ophthalmologists tight collars, maybe owing to
tight neckties, are a virtual cause for erroneous high IOP measurements.[2] As suggested by Teng et al.[1] tight collars may affect venous
blood
flow and, consequently, raise episcleral venous pressure, thus causing
elevated IOP. Another source for elevated IOP in patients with tight
neckties may be a mechanism similar to valsalva manoeuvre as reported by
Schuman et al.[3]
There are two conclusions from the article by Teng et al.:
First, ophthalmologists must be alert that tight neckties may
affect
IOP measurements. So, if the patient enters the office the slogan
must be: "Baby, take off your tie."
However, one has to bear in mind that the patient's position during
Goldmann applanation tonometry is the not physiologic and, consequently,
a
tight necktie then might even be tighter. Conversely, the necktie will
be
looser when the patient is in a more physiologic pose.
Therefore, it is uncertain if a tight necktie will be a risk factor
for glaucoma. So, the preliminary motto for our patients' everyday life
may
be: "You can leave your tie on."
References
(1) Teng C, Gurses-Ozden R, Liebmann JM, Tello C, Ritch R. Effect of a tight necktie on intraocular pressure. Br J Ophthamol 2003;87:946-948.
(2) The American Academy of Ophthalmology. Clinical measurement of
intraocular pressure. In Basic and clinical science course; Section 10: Glaucoma. Liesegang TJ, Deutsch TA, Grand MG, (Eds). San Francisco: American
Academy of Ophthalmology, 2002:20-23.
(3) Schuman JS, Massicotte EC, Connolly S, et al. Increased
intraocular
pressure and visual field defects in high resistance wind instrument
players. Ophthalmology 2000;107:127-133.
Dear Editor
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Dear Editor
I read with interest the article by Teng et al.[1] reporting the influence of tight neckties on intraocular pressure (IOP) measurement by Goldman applanation tonometry. They show that elevated IOP may be associated with a tightly worn necktie.
For comprehensive ophthalmologists tight collars, maybe owing to tight neckties, are a virtual cause for erroneous high IOP measurements.[2] As sug...
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