Biomedical subjects
Publications and source records attributed to A L Stern.
Ocular trauma is not uncommon. Because the tissues associated with visual function are delicate and remarkably specialized, care of ocular injuries is best left to well-trained specialists. Initial care, however, is often simply common sense. Irrigation of chemical burns, sterile techniques, and procedures that salvage tissue are good general principles.
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The incidence of clinically significant cystoid macular edema (CME) following cataract surgery has risen sharply with the widespread utilization of intraocular lenses. To evaluate the factors contributing to the incidence of CME, the senior author has divided 1808 of his own cataract cases into three groups according to procedures used: 1) intracapsular cataract extraction (ICCE) with no lens implantation; 2) ICCE with implantation of an iris-supported lens; and 3) extracapsular cataract extraction (ECCE) with implantation of a posterior chamber lens. The incidence of CME in these three groups was 2%, 9.9%, and 1.2%, respectively. Contributing factors and visual outcome in all three groups are reviewed. It is concluded that many of the problems associated with ICCE and iris-supported lens implantation seem to be eliminated with the ECCE-posterior chamber IOL procedure. However, it is emphasized that careful longterm follow-up is required to determine safety.
Pseudophakic bullous keratopathy (PBK) is a relatively new disease that is rapidly becoming the prime indication for penetrating keratoplasty. From 1977 thru 1981 we performed 81 corneal transplants on 66 eyes for this condition. In our experience, the incidence of PBK, with iris-supported lenses, is five times greater than aphakic bullous keratopathy (ABK). A series of 800 intracapsular cataract extractions (ICCE) with implantation of iris-supported lenses (1975-1979) were reviewed. Thirty-four patients (4.3%) developed PBK (average two years after surgery). In a series of 3,000 simple ICCEs (1955-1980), 24 patients (0.8%) developed ABK. Etiologic factors, methods of prevention, and the results of penetrating keratoplasty are considered. PBK following ICCE is a serious disease entity, usually of multifactorial origin. Though 88% of the patients have clear grafts, a high incidence of associated posterior segment disease tends to nullify the visual result. Planned extracapsular cataract extraction and posterior chamber lens insertion (1979-1982) has reduced our incidence of PBK to 0.3% (1/300). These results are promising but premature.
The incidence of clinical cystoid macular edema (CME) in routine cataract surgery is about 2%. Clinically significant pseudophakic maculopathy has a higher incidence and is more severe. Fifty cases of CME following intracapsular cataract extraction and intraocular lens implantation in a series of 821 consecutive cases were reviewed. The overall incidence of pseudophakic cystoid macular edema (PCME) was 6.1%. Several clinical observations were made: (1) Young patients, or those under 65, had a much higher incidence of PCME, approaching 20%; (2) chronic inflammation is responsible for pseudophakic cystoid maculopathy; (3) systemic steroid therapy of CME in the pseudophakic patient was beneficial in 80% of the cases, with a response within ten days; and (4) pseudophakic cystoid maculopathy is almost always recurrent and frequently requires maintenance suppression with daily steroid drops after recovery. Forty-four percent of these patients did not recover better than 20/40 visual acuity, suggesting that CME in the pseudophakic patient is not a benign, self-limited disease.
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The refractive keratoplasty techniques of keratomileusis and keratophakia require meticulous care to avoid intralamellar foreign particles. A portable High Efficiency Particular Air Filter Unit has been designed to meet the needs of those surgeons clinically performing this surgery. The unit, combined with amorphic techniques has minimized the clinical problem of particulate matter for the general hospital.
The keratophakia and keratomileusis procedures of Barraquer for the correction of aphakia have not gained acceptance in the United States because of thier inherent complexity and degree of difficulty. To determine the practicality, feasibility, and visual rehabilitation potential of these procedures, 13 secondary keratophakia operations were performed at a 500-bed community hospital between March 1980 and April 1981. The first ten cases are reported to allow 6- to 12-month follow-up. All patients in the series were resistant to contact lenses or were poor candidates for secondary intraocular lens implantation. The anatomic results were excellent. Complications were minimal consisting of surface drying problems in three patients related to the sudden steepening of the cornea or pseudo keratoconus effect. Seven patients achieved 20/30 to 20/40 vision with minimal spectacle correction. The keratophakia procedure of Barraquer shows promise and can be duplicated by experienced corneal surgeons, but is not yet a viable alternative to the use of primary intraocular lenses and continuous wear lenses for the general ophthalmologist.
Progressive corneal destruction of varying causes can result in pathologic changes that are incompatible with globe survival. Reconstructive keratoplasty and scleroplasty, in combination with other procedures, can be attempted as an alternative to enucleation, evisceration or spontaneous phthisis bulbi. The results of 50 reconstructive keratoplasties in 36 patients with severe corneal destruction are presented with one- to twenty-two year follow-up. Ninety-nine percent of the eyes were salvaged, 69% have clear grafts, 86% are visually improved and 51% achieved acuity of 20/100 or better.
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