Infusion Of Balanced Salt Solution Research Articles

A novel surgical technique for macular manipulation in highly myopic eyes with long axial length

Purpose: We developed a novel surgical technique tailored for highly myopic eyes characterized by extended axial lengths. Myopic eyes are prone to macular complications including macular schisis, full-thickness macular holes, and retinal detachment, which can cause severe vision loss. A pars plana vitrectomy is necessary in these cases. However, due to the considerable distance between the posterior pole and the cannula, regular forceps cannot reach the macula in some cases. To overcome this, we inserted a trocar more posteriorly after localizing the ora serrata. Methods: First, we placed two ports and performed partial vitrectomy without the infusion of balanced salt solution (BSS) to reduce the intraocular pressure. Subsequently, we observed the peripheral retina localized to the ora serrata by scleral indentation using forceps. Following the precise marking of the area, a third trocar was inserted and its position and placement confirmed intraoperatively. Results: Surgical maneuvers including a removal of the internal limiting membrane were safely performed using regular forceps through the posteriorly located cannula. Conclusions: The described technique offers a solution to the challenges posed by the extended axial lengths of highly myopic eyes during vitreoretinal surgery. By inserting the trocar more posteriorly, surgeons can enhance accessibility to the macula without requiring specialized equipment or extensive maneuvers.

Release and extraction of retained subfoveal perfluorocarbon liquid facilitated by subretinal BSS, vibration, and gravity: a case report

BackgroundPerfluorocarbon liquid (PFCL) is an effective surgical adjuvant in performing vitrectomy for severe vitreoretinal pathologies such as proliferative vitreoretinopathy and giant retinal tears. However, subretinal retention of PFCL can occur postoperatively and retained PFCL causes severe visual disorders, particularly when PFCL was retained under the fovea. Although several procedures have been proposed for subfoveal PFCL removal, such as direct aspiration or submacular injection of balanced salt solution (BSS) to dislodge the subfoveal PFCL, the retinal damage associated with these procedures has been a major problem. Here, we report a case of subfoveal retention of PFCL for which we performed a novel surgical technique that attempts to minimize retinal damage.Case presentationA 69-year-old man presented with subfoveal retained PFCL after surgery for retinal detachment. To remove the retained PFCL, the internal limiting membrane overlying the subretinal injection site is first peeled to allow low-pressure (8 psi) transretinal BSS infusion, using a 41-gauge cannula, to slowly detach the macula. A small drainage retinotomy is created with the diathermy tip at the inferior position of the macular bleb, sized to be slightly wider than that of the PFCL droplet. The head of the bed is then raised, and the surgeon gently vibrates the patient’s head to release the PFCL droplet to allow it to migrate inferiorly towards the drainage retinotomy. The bed is returned to the horizontal position, and the PFCL, now on the retinal surface, can be aspirated. The subfoveal PFCL is removed while minimizing iatrogenic foveal and macular damage. One month after PFCL removal, the foveal structure showed partial recovery on optical coherence tomography, and BCVA improved to 20/40.ConclusionCreating a macular bleb with low infusion pressure and using vibrational forces and gravity to migrate the PFCL towards a retinotomy can be considered as a relatively atraumatic technique to remove subfoveal retained PFCL.

Long-Term Outcomes from an Intraoperative Bleb Needling Procedure Augmented with Continuous Infusion

To investigate long-term outcomes of a modified bleb needling technique performed in the operating room in controlling intraocular pressure (IOP) and to report risk factors for procedure failure. Retrospective, observational cohort study. One hundred six eyes of 98 consecutive patients undergoing intraoperative bleb needling with a continuous infusion of balanced salt solution at the Wilmer Eye Institute, Johns Hopkins Hospital, in the setting of a failed trabeculectomy or express shunt, between May 2011 and December2015. Postoperative data were collected between May 2011 and August 2019. Success was defined as achieving a previously determined target IOP regardless of (qualified success) or without (complete success) glaucoma medications. Patients who underwent additional glaucoma surgery were censored in the survival analysis. Primary outcome measures included IOP, attainment of target IOP, and number of glaucoma medications used at different time points pre- and post-operatively. Needling was performed in 106 eyes at an average of 4.3 years from the time of trabeculectomy (standard deviation [SD], 6.5 years) and an average baseline IOP of 20.7 mmHg (SD, 7.2 mmHg). Further glaucoma surgery was required for 33 eyes. We observed a 70% qualified success rate with a mean IOP lowering of 25% (95% confidence interval [CI], 13.8%-36.4%) at 1 year after surgery and a 52% qualified success rate and 44.3% reduction in IOP (95% CI, 34.9%-53.6%) at 5 years after surgery. Nearly half and a third of the eyes did not require medications after 1 and 5 years, respectively. The average medication reduction was 0.8 at year 1 (95% CI, 0.5-1.1) and 0.4 at year 5 (95% CI, -0.2 to 1.0). Postoperative complications were uncommon. Poorer outcomes were not associated with the age of the bleb but were more likely in Black patients. Reductions in IOP were maintained in most patients over the long term using a modified bleb needling technique, despite an average time from trabeculectomy of over 4 years. No significant adverse events were observed. Bleb needling may defer or avoid more invasive procedures such as tube-shunts or repeat trabeculectomy.

One-port vitreous cavity lavage with hybrid 27G infusion and 23G cannula.

To describe a new surgical technique for performing vitreous cavity lavage. After a 23G trocar cannula was inserted into the vitreous cavity at the lowest point of the eyeball 3.5 or 4 mm posterior to the limbus, a 27G infusion line with balanced salt solution was attached to the cannula. The infusion tube was partially withdrawn and the vitreous fluid with blood flowed out through the space between the larger lumen of the cannula and the smaller infusion tube. Meanwhile, vitreous cavity was irrigated with fresh balanced salt solution through the infusion line and the intraocular pressure (IOP) was maintained. The vitreous clarity was checked by indirect ophthalmoscopy. A total of 14 eyes of 14 patients with postvitrectomy hemorrhage were treated with the lavage technique. The vision improved and the fundus could be sufficiently viewed next day in all cases. This fluid/fluid exchange procedure was also performed in fluid/air exchange in two cases of unclosed idiopathic macular hole with switching to air infusion instead of balanced salt solution infusion. This minimally invasive technique is a simple, safe, and efficient way of performing postvitrectomy vitreous cavity fluid/fluid or fluid/air exchange.

Results From a Modified Bleb Needling Procedure With Continuous Infusion Performed in the Operating Room

Needling of a scarred trabeculectomy bleb is often performed in the office using a slit-lamp microscope as an alternative to additional surgery to lower intraocular pressure (IOP). However, the success rate in an office setting is highly variable, with reported success rates as low as 13%. We report a retrospective assessment of an intraoperative needling technique for reviving failed blebs. A retrospective chart review. Patients undergoing the intraoperative modified bleb revision technique in the setting of a failed trabeculectomy due to scarring at the Wilmer Eye Institute, Johns Hopkins Hospital between August 16, 2010 and August 29, 2012. Patients with uncontrolled IOP were operated on using a modified bleb needling technique. In this technique, a 25-G infusion cannula is placed in the anterior chamber and fibrotic adhesions within the bleb are lysed with a 25-G needle. The continuous infusion of balanced salt solution from the anterior chamber causes bleb elevation, which helps to guide the endpoint of lysis for the procedure. A subconjunctival injection of 5-fluorouracil is given at the conclusion of each case. IOP reduction and number of glaucoma medications at postoperative day 1, week 1, month 1, month 3, month 6, and month 12. A total of 33 eyes of 30 patients were included. At the visit before the procedure, the mean (±SD) IOP was 22.1±9.2 (range, 11 to 58) and subjects were using an average of 2.3±1.4 (range, 0 to 4) glaucoma medications. The mean IOP reduction was 8.7 mm Hg [95% confidence interval (CI), 5.6-11.8] at postoperative day 1, 8.1 mm Hg (95% CI, 4.0-12.3) at week 1, 8.9 mm Hg (95% CI, 5.3-12.5) at month 1, 8.1 mm Hg (95% CI, 4.2-12.0) at month 3, 8.2 mm Hg (95% CI, 3.9-12.5) at month 6, and 6.2 mm Hg (95% CI, 3.6-8.7) at month 12. IOP was reduced about 30% to 40% compared with baseline at each time point (P<0.05). The average reduction in medications used was 1.7 at day 1, 1.0 at month 1, 1.2 at month 3, 1.5 at month 6, and 0.5 at month 12. Seven patients underwent repeat needling. Overall, 64% of subjects maintained IOP at or below their target after 12 months. A modified bleb needling procedure performed in the operating room can successfully lower IOP in the setting of a previous trabeculectomy in over 60% of subjects a year after the procedure.

Changes in corneal endothelium cell characteristics after cataract surgery with and without use of viscoelastic substances during intraocular lens implantation.

PurposeTo evaluate whether the use of balanced salt solution (BSS) or an ophthalmic viscoelastic device (OVD) during hydrophilic acrylic intraocular lens (IOL) implantation variously impacts corneal endothelial cell characteristics in eyes undergoing uneventful phacoemulsifications.MethodsProspective nonrandomized observational clinical trial. Patients were assigned either to the BSS plus® or to the OVD Z-Celcoat™ group depending on the substance used during IOL implantation. Corneal endothelium cell characteristics were obtained before, 1 week, and 6 weeks after surgery. Intraoperative parameters (eg, surgery time, phacoemulsification energy) were recorded.ResultsNinety-seven eyes were assigned to the BSS plus and 86 eyes to the Z-Celcoat group. Preoperative corneal endothelium cell density (ECD) and endothelium cell size were 2,506±310 cells/mm2/2,433±261 cells/mm2 and 406±47 µm2/416±50 µm2 (P=0.107/P=0.09). After 1 and 6 weeks, ECD decreased and endothelium cell size increased significantly in both groups (each P<0.001) without significant differences between both groups (each P>0.05). Irrigation–aspiration suction time (30.3±16.6 versus 36.3±14.5 seconds) and overall surgical time (7.2±1.2 versus 8.0±1.4 minutes) were significantly longer in the OVD Z-Celcoat group (each P<0.001). No complications or serious side effects occurred.ConclusionImplantation of a hydrophilic acrylic IOL under BSS infusion seems to be a useful and faster alternative in experienced hands without generating higher ECD loss rates.

Preliminary study on implantable inductive-type sensor for continuous monitoring of intraocular pressure.

This study aims to validate the performance and biocompatibility of an implantable inductive-type sensor for continuous monitoring of intraocular pressure (IOP) METHODS: The sensor is composed of a top layer integrated with an inductor and capacitor circuit, and a bottom layer integrated with ferrite. With IOP change, the sensor's bottom layer is mechanically deflected, which changes the distance between the bottom-layer ferrite and top-layer inductor, resulting in an alteration of inductance magnitude and the resonant frequency (RF). In-vitro measurement was conducted via air pressurization in a sealing jig (n = 3). Subsequently, the sensor was implanted into the anterior chamber of a rabbit eye. In-vivo measurement was performed while the IOP was elevated by infusion of balanced salt solution (BSS, 6 μL/min). Smaller-sized sensors later were implanted into two rabbit eyes, which were microscopically examined at 2, 4 and 8 weeks post-implantation. The eyes were then immediately enucleated for histological examination. The in-vitro measurement showed a significant RF shift as pressure in the jig was increased from 0 mmHg to 60 mmHg (average initial frequency: 10.86 MHz, average shift: 403 kHz). The in-vivo measurement also showed an RF decrease, from 12.80 MHz to 12.67 MHz, as the pressure was increased from 10 mmHg to 20 mmHg. Microscopic in-vivo evaluations and histological exams, performed at intervals up to 8 weeks post-implantation, showed no evidence of significant inflammation or deformity of the ocular-tissue structures. The implantable inductive-type IOP sensor demonstrated wireless pressure-sensing ability and favourable biocompatibility in the rabbit eye.

Analysis of the intraocular jet flows and pressure gradients induced by air and fluid infusion: mechanism of focal chorioretinal damage.

To comprehend the mechanism of focal chorioretinal damage by analysis of the pressure distribution and dynamic pressure induced by infused air during fluid-air exchange. A precise simulation featuring a model eye and a fluid circuit was designed to analyze fluid-air exchange. The pressure distribution, flow velocity, and dynamic pressure induced by infusion of air into an air-filled eye were analyzed using an approach based on fluid dynamics. The size of the port and the infusion pressure were varied during simulated iterations. We simulated infusion of an air-filled eye with balanced salt solution (BSS) to better understand the mechanism of chorioretinal damage induced by infused air. Infused air was projected straight toward a point on the retina contralateral to the infusion port (the "vulnerable point"). The highest pressure was evident at the vulnerable point, and the lowest pressure was recorded on most retinal areas. Simulations using greater infusion pressure and a port of larger size were associated with elevations in dynamic pressure and the pressure gradient. The pressure gradients were 2.8 and 5.1 mm Hg, respectively, when infusion pressures of 30 and 50 mm Hg were delivered through a 20-gauge port. The pressure gradient associated with BSS infusion was greater than that created by air, but lasted for only a moment. Our simulation explains the mechanism of focal chorioretinal damage in numerical terms. Infused air induces a prolonged increase in focal pressure on the vulnerable point, and this may be responsible for visual field defects arising after fluid-air exchange.

Macular Detachment for Treatment of Persistent Macular Hole

The authors report a technique for treatment of persistent macular holes in cases refractory to traditional surgical techniques. With a standard pars plana vitrectomy approach, subretinal infusion of balanced salt solution was performed and followed by a fluid-air exchange. This intervention resulted in hole closure despite poor prognosis and may be considered as a treatment option for patients with persistent flat macular holes.

The Use of Continuous Silicone Oil Infusion as a Peroperative Tool to Facilitate Break Localisation, Vitreous Base Dissection and Drainage of Subretinal Fluid

Introduction: We introduce the use of low-molecular-weight silicone oil as an infusion and as a peroperative tool to facilitate three specific surgical steps, namely internal search for retinal breaks, vitreous base shaving and drainage of subretinal fluid. Method and Patients: Ethics committee approval was obtained to test this novel agent in a small number of cases as a pilot study. Following vitrectomy the posterior retina was reattached and stabilised using perfluorocarbon liquid (PFCL). The infusion of balanced salt solution was then stopped and replaced with 5 mPas silicone oil. Subsequent surgery was assessed as to whether the infusion was helpful in the three surgical steps. Five cases were selected for this pilot study. Three presented with long-standing rhegmatogenous retinal detachment (RRD) of 2 or more months: 1 had dense vitreous haemorrhage and no fundal view at presentation; 2 had proliferative vitreoretinopathy. Of the remaining 2 cases, 1 had a giant retinal break and the other case had a combined diabetic tractional retinal detachment and RRD. Results: Additional retinal breaks were found in 2 patients. The silicone oil joined with the PFCL to form a single bubble. The vitreous base along with the operculum of any retinal break was reflected anteriorly. The infusion of oil stabilised the anterior retina, making it possible to shave the vitreous closely in all 5 patients. Visualisation of the vitreous gel was also improved. There was a clear interface between vitreous and oil because of the large difference between the refractive indices of vitreous and oil. Four of the 5 patients had a total reattachment with one procedure. In the 2 cases in which 5,000 mPas silicone oil was used for long-term postoperative tamponade, no emulsification was observed. Follow-up of patients ranged from 6 to 13 months. There were no additional serious adverse reactions recorded. Conclusion: We found that the experience of using silicone oil was very highly positive.

Intraluminal Pressure Response in Baerveldt Tube Shunts

To design an apparatus for in vitro quantification of effects of modifications to nonvalved tube shunts, and to compare the effects of these modifications done to prevent early postoperative hypotony. A testing apparatus was designed and constructed to measure intraluminal pressure (ILP) during constant infusion of balanced salt solution at 2 microL/min through Baerveldt tube shunts mounted on cadaver eyes. Three different modifications were performed and 3 shunts were used for each modification. The modifications were partial tube occlusion with a 3-0 Supramid suture, tube perforation with a 27-gauge needle on an occluded tube, and a 1.2 mm longitudinal venting slit on an occluded tube. The final steady state ILP for the 3-0 Supramid partially occluded tube ranged between 1.6 and 2.8 mm Hg over 3 trials with an average final steady state ILP of 2.0 mm Hg. The 27-gauge needle perforation produced ILPs of 4.6 to 8.2 mm Hg over 3 trials with an average final steady state pressure of 5.9 mm Hg. The 1.2 mm longitudinal venting slit produced an ILP range of 12.6 to 17.3 mm Hg over 3 trials with an average final steady state ILP of 14.8 mm Hg. The differences in final steady state ILP between the 3 modification techniques were statistically significant (P=0.00036). The 3-0 Supramid occlusion and the 27-gauge perforation techniques produced hypotony, whereas the 1.2 mm longitudinal venting slit produced acceptable pressures in vitro.

Nonvitrectomizing Vitreous Surgery for Epiretinal Membrane: Long-term Follow-up

To report the long-term follow-up results of nonvitrectomizing vitreous surgery for idiopathic epiretinal membrane (ERM). Nonrandomized comparative case series. Thirty patients were followed up for at least 5 years after nonvitrectomizing vitreous surgery. Epiretinal membranes were peeled without infusion of balanced salt solution and removal of the vitreous. The data from the fellow eye was the control data. We examined the visual acuities (VAs), objective refractions, and slit-lamp and Scheimpflug photographs from the preoperative and the final examinations of both eyes. Quantitative assessment of the progression of nuclear sclerosis was performed by densitometry analysis using Scheimpflug photography. The recurrence rate of ERM was determined. The follow-up periods ranged from 60 to 102 months (mean+/-standard deviation, 72.2+/-11.0 months). The patient ages ranged from 52 to 76 years (68.8+/-6.3 years). The final VA improved or stabilized within 2 lines in 29 of 30 eyes (96.7%). No unilateral progression of nuclear sclerosis occurred in any cases. The mean preoperative and postoperative refractions without additional surgery were -0.4+/-2.9 diopters (D) and -0.2+/-3.0 D in the operated eyes, respectively, and -0.2+/-2.5 D and 0.1+/-2.4 D, respectively, in the unoperated fellow eyes. The mean differences in the refractive error between both eyes (operated eye data minus fellow eye data) were -0.2+/-0.7 D before surgery and -0.3+/-0.8 D after surgery (P = 0.319, paired t test). The mean preoperative and postoperative nuclear densities in 16 patients were 69+/-14 nuclear density units (NDUs) and 76+/-12 NDUs in the operated eyes and 71+/-14 NDUs and 78+/-14 NDUs in the fellow eyes, respectively. The mean preoperative and postoperative differences in nuclear densities in both eyes were -2+/-2 NDUs and -2+/-5 NDUs, respectively (P = 0.836, paired t test). The ERM recurred in 10 eyes (33%), and 3 eyes underwent conventional vitrectomy combined with cataract surgery. Unilateral nuclear sclerosis did not progress for at least 5 years after nonvitrectomizing vitreous surgery. The recurrence rate of ERM appeared to be higher than that after conventional vitreous surgery.

In vivo retinal vascular cannulation in rabbits.

To perform in vivo cannulation of retinal vessels for local application of pharmacotherapy to treat central retinal vein occlusion (CRVO), a new method was tested using rabbits. Changes following cannulation were studied histologically. The micropipette used for cannulation was constructed from a glass tube. The outer diameter of the tip was 30-40 microm. Rabbits for the experiment were anesthetized; each had its head stabilized with fixing equipment designed for that purpose. After preparing a port for infusion of balanced salt solution (BSS), the specially designed micropipette was inserted at the pars plana of the ciliary body to puncture the major retinal vein, through which BSS was injected. We were able to puncture the major retinal vein with the micropipette without causing any serious incident, after which we injected approximately 100 microl of BSS. A small amount of vitreous hemorrhage that appeared after removing the micropipette could be stopped by increasing intraocular pressure by elevating the infusion bottle. Postoperative observation by indirect ophthalmoscopy showed no obstruction in the vein at the puncture site. Light microscopy showed only a slight narrowing of the venous lumen at the site. Cannulation into the retinal vein of rabbits was possible, and invasion was not significant, as determined histologically. Our findings endorse a method of restoring blood flow that involves direct injection of tissue plasminogen activator into the retinal vein of patients with CRVO to dissolve a thrombus.

Hemorrhagic glaucoma in an infant with hemophilia, spontaneous hyphema, aniridia, and persistent iris vessels

J AAPOS 2001;5:129-30.

Effects of ethacrynic acid on intraocular pressure of anesthetized rats.

Ethacrynic acid (ECA) lowers intraocular pressure (i.o.p.) by an effect usually ascribed to increased drainage of aqueous humor by the trabecular meshwork. Here, we describe the effects of a continuous 2-hr intracameral infusion of balanced salt solution (BSS), with or without 2 mM ECA (sodium salt), on IOP of pentobarbital anesthetized rats. The infusion was divided into a constant (0.05 microliter/min) and a periodic (0.25 microliter/min) component that cycled 4 min on then 4 min off. This permitted the calculation of dynamic changes in resistive (trabecular and uveoslceral drainage) and nonresistive (aqueous synthesis, episcleral venous pressure) components of IOP by fitting a second-order transfer function to the responses. ECA markedly blunted the BSS-induced rise in IOP (P < 0.01). The rise in resistive mechanisms (ocular impedance) was transiently blunted by ECA (P < 0.05) during the third and fourth 8-min cycles, and nonresistive mechanisms were reduced by ECA from cycles 3-10 (P < 0.05). Then, at the end of the infusion, the control and ECA dynamic values were similar (P < 0.05), although IOP of ECA-treated rats was still slightly reduced (P < 0.05). The most likely explanation is a summation of small changes in both resistive and nonresistive components of IOP dynamics. Systemic blood pressure was unchanged within either group. The well-known effects of ECA on the trabecular meshwork, alone, are insufficient to explain the dynamic changes in IOP observed in this model.

Effects of Ethacrynic Acid on Intraocular Pressure of Anesthetized Rats

Ethacrynic acid (ECA) lowers intraocular pressure (IOP) by an effect usually ascribed to increased drainage of aqueous humor by the trabecular meshwork. Here, we describe the effects of a continuous 2-hr intracameral infusion of balanced salt solution (BSS), with or without 2 mM ECA (sodium salt), on IOP of pentobarbital anesthetized rats. The infusion was divided into a constant (0.05 μl/min) and a periodic (0.25 μl/min) component that cycled 4 min on then 4 min off. This permitted the calculation of dynamic changes in resistive (trabecular and uveoslceral drainage) and nonresistive (aqueous synthesis, episcleral venous pressure) components of IOP by fitting a second-order transfer function to the responses. ECA markedly blunted the BSS-induced rise in IOP (P < 0.01). The rise in resistive mechanisms (ocular impedance) was transiently blunted by ECA (P < 0.05) during the third and fourth 8-min cycles, and nonresistive mechanisms were reduced by ECA from cycles 3-10 (P < 0.05). Then, at the end of the infusion, the control and ECA dynamic values were similar (P > 0.05), although IOP of ECA-treated rats was still slightly reduced (P < 0.05). The most likely explanation is a summation of small changes in both resistive and nonresistive components of IOP dynamics. Systemic blood pressure was unchanged within either group. The well-known effects of ECA on the trabecular meshwork, alone, are insufficient to explain the dynamic changes in IOP observed in this model.

Physiological Responses to Intramammary or Intravenous Treatment with Endotoxin in Lactating Dairy Cows

Twenty-one, middle to late lactation Holstein cows were assigned to one of three treatments in a completely randomized design to examine physiological changes associated with intramammary or intravenous administration of Escherichia coli endotoxin. Treatments were 1) Hank's balanced salt solution infusion in two contralateral quarters (control), 2) E. coli endotoxin infusion in two contralateral quarters, and 3) intravenous infusion of E. coli endotoxin. Blood was sampled and rectal temperature was measured at 30-min intervals. Endotoxin treatment was at 0900h and sampling continued until 1700h. Serum prolactin, cortisol, and 13,14-dihydro-15-keto-prostaglandin F2α were measured.A pyretic response was observed in intravenous and intramammary treatment groups after endotoxin treatment. Response peak was higher (41.1 vs. 40.3°C) and occurred later (6 vs. 4.5h posttreatment) in the intramammary than the intravenous treatment group. Significant prolactin peaks were observed also in intravenous and intramammary endotoxin treatment groups. Prolacrin peaked higher (288 vs. 112ng/ml) and occurred sooner (1 vs. 4h posttreatment) in the intravenous than in the intramammary treatment group. Cortisol followed a trend similar to prolaclin. Cortisol peaked higher (100 vs. 82ng/ml) and sooner (2.5 vs. 4.5h posttreatment) in the intravenous than in the intramammary treatment group. Concentrations of 13,14-dihydro-15-keto-prostaglandin F2α increased rapidly post-treatment in the intravenous group only.

Vitrectomy and Fluid Infusion in the Treatment of Delayed Suprachoroidal Hemorrhage After Combined Cataract and Glaucoma Filtration Surgery

I report the successful treatment of one case of massive, delayed suprachoroidal hemorrhage that occurred after combined intracapsular cataract extraction and trabeculectomy. Significant vitreous incarceration in the filtration site and consequent vitreoretinal traction were present so that a limbal approach anterior vitrectomy was necessary before choroidal drainage could be accomplished safely. An infusion of balanced salt solution through a limbal infusion cannula was employed during vitrectomy and also during drainage of suprachoroidal blood. The simultaneous intravitreal infusion helped to create an efficient, controlled choroidal drainage procedure. In addition to relieving vitreoretinal traction, this technique helps prevent the periods of extreme hypotony experienced when choroidal drainage and anterior chamber reformation are accomplished serially in step-wise fashion. This use of this method also obviates the compromised view of the peripheral retina which occurs when air is introduced into the vitreous cavity.

A Case of Localized Cutaneous Mucormycosis

A 76 days-old female baby was hospitalized to the Pediatric Clinic of the Tajimi Prefectual Hospital on January 31 in 1973, because of “Cerebral cry”, anemia, vomitting, diarrhea and fever. She was kept in incubator and treated with infusion of balanced salt solution and antibiotics.Several days after removal of the splint for infusion, a crateriform ulcer covered with brownish black necrotic tissue and two erythematous nodules were noticed, close to the site of infusion on the left leg.Microscopical examination of the ulcer revealed necrosis in the dermis and subcutis surrounded with leucocytic infiltrate, and in the necrotic tissue many large non-septate mycelial fragments were observed. The fungus isolated from the lesion was identified as Rhizopus oryzae.The lesions were resected surgically followed by compress of Amphotericin B solution with satisfactory result. But, she accidentaly died of dyspnoe on March 18. Autopsy findings revealed no fungus infection in the internal organs.Intravenous and intraperitoneal inoculation of the fungus to guinea pigs and rabbits revealed same kinds of necrotic lesions and fungus proliferations in the liver, kidney, small intestine and colon as the patients.

A Problem in Anesthesiology

ABSTRACT To the Editor:— Dr. Carter's points are well taken if one assumes that the hypotension was caused by sympathetic denervation from the spinal block. However, there are cogent arguments against this belief. First, severe hypotension due to sympathetic denervation is usually associated with bradycardia because of vagal preponderance. Yet, this patient showed tachycardia. Second, evidence is accumulating that hypotension due to regional blockadeeven with levels higher than T-4— can be successfully prevented or treated with rapid intravenous infusion of balanced salt solution with or without the intravenous injection of small doses of ephedrine (Cosmi and Marx, Amer J Obstet Gynec102:378, 1968; F.W. Hehre, personal communication). Yet, this patient's blood pressure did not respond to such intravenous therapy. Third, the blood pressure rose immediately upon delivery of the infant and before delivery of the placenta and administration of oxytocics. If the hypotension had been caused by sympathetic blockade, the