340
AMERICAN JOURNAL OF OPHTHALMOLOGY
March, 1992
5. Sasamoto, K., Akagi, Y., Kodama, Y., and Itoi, M.: Corneal endothelial changes caused by ophthal mic drugs. Cornea 3:37, 1984.
A Simple, Inexpensive Technique for Punctal Occlusion L o u i s J. G i r a r d , M . D . , Laura B a r n e t t , B . S . , and Rosemary Rao, C O . A .
Figure (Satterfield, Mannis, and Glover). Multiple, fine, intraepithelial vesicles are in an annular pattern in the center of the left cornea. literature of p u n c t a t e k e r a t o p a t h y from a 3 % dipivefrin solution. 4 T h e r e are several r e p o r t s on the effect of the d r u g on the c o r n e a l s t r o m a and endothelium.6 C o r n e a l toxicity s e c o n d a r y to dipivefrin t h e r a p y is u n c o m m o n . This case of i n t r a e p i t h e l i a l corneal vesicles is, we believe, s e c o n d a r y to dipivefrin t h e r a p y . O u r p a t i e n t w a s u n w i l l i n g to r e i n s t i t u t e dipivefrin t h e r a p y to p r o v e a c a u s al r e l a t i o n s h i p b e t w e e n the d r u g a n d the findings. H o w e v e r , the t e m p o r a l s e q u e n c e of events in w h i c h corneal vesicles a n d m o n o c u l a r diplopia a p p e a r e d after i n i t i a t i o n of dipivefrin h y d r o c h l o r i d e t h e r a p y to the o n e eye only a n d d i s a p p e a r e d after d i s c o n t i n u a t i o n of t h e d r u g strongly s u g g e s t s a causal r e l a t i o n s h i p .
References 1. Cebon, L., West, R. H., and Gilles, W. E.: Expe rience with dipivalyl epinephrine, its effectiveness, alone or in combination, and its side effects. Aust. J. Ophthalmol. 11:159, 1983. 2. Wandel, T., and Spinak, M.: Toxicity of dipivalyl epinephrine. Ophthalmology 88:259, 1981. 3. Coleiro, J. A., Sigurdsson, H., and Lockyer, J. A.: Follicular conjunctivitis on dipivefrin therapy for glaucoma. Eye 2:440, 1988. 4. Boerner, C. F.: Total punctate keratopathy due to dipivefrin. A case report. Arch. Ophthalmol. 106:171, 1988.
Inquiries to Louis J. Girard, M.D., 4126 Southwest Freeway, Suite 1150, Houston, TX 77027. O c c l u s i o n of t h e lacrimal p u n c t a is i n d i c a t e d in p a t i e n t s w i t h dry eyes in w h o m occlusion of the lacrimal c a n a l i c u l u s h a s b e e n helpful. K n a p p a n d associates 1 c o n t r a s t e d superficial c a u t e r i z a t i o n of the lacrimal p u n c t a w i t h cau t e r i z a t i o n of t h e lacrimal p u n c t a a n d vertical p o r t i o n of the c a n a l i c u l u s . They f o u n d that, in 20 of 22 p a t i e n t s , the p u n c t a r e m a i n e d occlud ed after d e e p c a u t e r i z a t i o n . Ten of 22 lacrimal p u n c t a t h a t w e r e c a u t e r i z e d superficially r e m a i n e d closed o n e m o n t h later. We have f o u n d t h a t occlusion of the canalicu lus w i t h a collagen p l u g , c o m b i n e d w i t h cauter ization of the p u n c t u m a n d vertical c a n a l i c u l u s by u s i n g a d i s p o s a b l e c a u t e r y , gives excellent results. P a t i e n t s are selected in w h o m canalicular occlusion w i t h a collagen p l u g h a d b e e n helpful in r e d u c i n g t h e s y m p t o m s of d r y eyes. T h e p r o c e d u r e is s i m p l e . A collagen p l u g is i n s e r t e d in the c a n a l i c u l u s . The area is a n e s t h e t i z e d by instillation of 1 0 % cocaine twice at five-minute i n t e r v a l s . The area of the lacrimal p u n c t u m is t h e n dried. The t h e r m a l o u t p u t of a d i s p o s a b l e cautery is n o t variable b u t d e c r e a s e s w i t h r e p e a t e d u s e ; we u s e d a fresh d i s p o s a b l e cautery. The tip of the c a u t e r y is i n s e r t e d into the p u n c t u m a n d into the vertical c a n a l i c u l u s , a n d the tissues are c o a g u l a t e d . The tissues s h r i n k w i t h i n o n e to two s e c o n d s , a n d w h e n the a n a tomic l a n d m a r k s of t h e p u n c t u m are coagulat ed, the d i s p o s a b l e c a u t e r y is r e m o v e d . The collagen p l u g a b s o r b s s p o n t a n e o u s l y a n d p r e v e n t s the p a s s a g e of tears u n t i l cicatrization of the p u n c t u m a n d vertical c a n a l i c u l u s is com plete.
Vol. 113, No. 3
Letters to The Journal
We have used this technique successfully in 15 patients.
Reference 1. Knapp, M. E., Frueh, B. R., Nelson, C. C , and Musch, D. C: A comparison of two methods of punctal occlusion. Am. J. Ophthalmol. 108:315, 1989.
Improved, Reusable, Autopsy Eye Model Container for Laser Trabeculoplasty and Iridectomy D o n S. Minckler, M.D., D o u g l a s Gaasterland, M.D., and P h i l i p J. Erickson, M.S. Estelle Doheny Eye Institute (D.S.M.), and George town University (D.G.), and Ocular Instruments, Inc. (P.J.E.). Mr. Erickson has proprietary interest in the device described. Inquiries to Don S. Minckler, M.D., Estelle Doheny Eye Institute, 1355 San Pablo St., Los Angeles, CA 90033. In a previous communication, we described a container to hold autopsy eye specimens in a model for practicing or teaching laser trabecu loplasty and laser iridotomy. The model was made of a short section of plastic plumbing pipe and glass end-plates. 1 The original containers were not reusable. In cooperation with Ocular Instruments of Bellevue, Washington, we have developed a reusable eye model container, which has been extensively tested during the last two years in hands-on instruction courses at the annual meeting of the American Acade my of Ophthalmology. A single model can serve several students during instruction cours es, depending on the number of laser burns placed. A universal slit-lamp holding clamp has also been developed to simplify stationary po sitioning of the models for use, which is pre ferred by most students rather than hand-hold ing the models. Models for both trabeculoplasty and iridecto my are constructed by suspending appropriate sections of formalin-fixed human autopsy eyes in 100% anhydrous glycerin and orienting the tissue sections to display the trabecular mesh work or iris through a glass window (antireflective coated for laser light) (Figs. 1 and 2). The
341
preferable assembly techniques for either mod el include placing the tissue sections to display the desired structure in the holder with just enough glycerin for a bubble-free view. Melted paraffin can be added onto the top of the glycer in and exposed tissue sufficient to cover the tissue and lock it in place as cooling occurs. Usually, only about V* to Vi inch of paraffin is required. Before securing the lid, the remainder of the container can be packed with sponges or tissue paper to hold the tissue and paraffin in place. Minimizing the amount of paraffin facili tates cleaning and reusing the model. Laser trabeculoplasty—For laser trabeculo plasty models, divide the fixed globe through the cornea and posterior pole into two equal parts. Remove the lens. Next, gently tear the iris from its ciliary body insertion. Inspect both hemispheres with a dissecting microscope to ensure that the trabecular meshwork is intact. If fixation has been poor, the angle landmarks may be distorted and tissue consistency too abnormal for use. Ideally, the pigmented tra becular meshwork should be well defined and the pigment preserved in place. Usually, two trabeculoplasty models can be made from one well-fixed autopsy eye. Immerse in bubble-free glycerin in the container. Place the half-globe
Fig. 1 (Minckler, Gaasterland, and Erickson). The component parts of the laser eye model container include the eye cup, sponge, and lid along with the universal, slit-lamp holder.
AMERICAN JOURNAL OF OPHTHALMOLOGY
March, 1992
5. Sasamoto, K., Akagi, Y., Kodama, Y., and Itoi, M.: Corneal endothelial changes caused by ophthal mic drugs. Cornea 3:37, 1984.
A Simple, Inexpensive Technique for Punctal Occlusion L o u i s J. G i r a r d , M . D . , Laura B a r n e t t , B . S . , and Rosemary Rao, C O . A .
Figure (Satterfield, Mannis, and Glover). Multiple, fine, intraepithelial vesicles are in an annular pattern in the center of the left cornea. literature of p u n c t a t e k e r a t o p a t h y from a 3 % dipivefrin solution. 4 T h e r e are several r e p o r t s on the effect of the d r u g on the c o r n e a l s t r o m a and endothelium.6 C o r n e a l toxicity s e c o n d a r y to dipivefrin t h e r a p y is u n c o m m o n . This case of i n t r a e p i t h e l i a l corneal vesicles is, we believe, s e c o n d a r y to dipivefrin t h e r a p y . O u r p a t i e n t w a s u n w i l l i n g to r e i n s t i t u t e dipivefrin t h e r a p y to p r o v e a c a u s al r e l a t i o n s h i p b e t w e e n the d r u g a n d the findings. H o w e v e r , the t e m p o r a l s e q u e n c e of events in w h i c h corneal vesicles a n d m o n o c u l a r diplopia a p p e a r e d after i n i t i a t i o n of dipivefrin h y d r o c h l o r i d e t h e r a p y to the o n e eye only a n d d i s a p p e a r e d after d i s c o n t i n u a t i o n of t h e d r u g strongly s u g g e s t s a causal r e l a t i o n s h i p .
References 1. Cebon, L., West, R. H., and Gilles, W. E.: Expe rience with dipivalyl epinephrine, its effectiveness, alone or in combination, and its side effects. Aust. J. Ophthalmol. 11:159, 1983. 2. Wandel, T., and Spinak, M.: Toxicity of dipivalyl epinephrine. Ophthalmology 88:259, 1981. 3. Coleiro, J. A., Sigurdsson, H., and Lockyer, J. A.: Follicular conjunctivitis on dipivefrin therapy for glaucoma. Eye 2:440, 1988. 4. Boerner, C. F.: Total punctate keratopathy due to dipivefrin. A case report. Arch. Ophthalmol. 106:171, 1988.
Inquiries to Louis J. Girard, M.D., 4126 Southwest Freeway, Suite 1150, Houston, TX 77027. O c c l u s i o n of t h e lacrimal p u n c t a is i n d i c a t e d in p a t i e n t s w i t h dry eyes in w h o m occlusion of the lacrimal c a n a l i c u l u s h a s b e e n helpful. K n a p p a n d associates 1 c o n t r a s t e d superficial c a u t e r i z a t i o n of the lacrimal p u n c t a w i t h cau t e r i z a t i o n of t h e lacrimal p u n c t a a n d vertical p o r t i o n of the c a n a l i c u l u s . They f o u n d that, in 20 of 22 p a t i e n t s , the p u n c t a r e m a i n e d occlud ed after d e e p c a u t e r i z a t i o n . Ten of 22 lacrimal p u n c t a t h a t w e r e c a u t e r i z e d superficially r e m a i n e d closed o n e m o n t h later. We have f o u n d t h a t occlusion of the canalicu lus w i t h a collagen p l u g , c o m b i n e d w i t h cauter ization of the p u n c t u m a n d vertical c a n a l i c u l u s by u s i n g a d i s p o s a b l e c a u t e r y , gives excellent results. P a t i e n t s are selected in w h o m canalicular occlusion w i t h a collagen p l u g h a d b e e n helpful in r e d u c i n g t h e s y m p t o m s of d r y eyes. T h e p r o c e d u r e is s i m p l e . A collagen p l u g is i n s e r t e d in the c a n a l i c u l u s . The area is a n e s t h e t i z e d by instillation of 1 0 % cocaine twice at five-minute i n t e r v a l s . The area of the lacrimal p u n c t u m is t h e n dried. The t h e r m a l o u t p u t of a d i s p o s a b l e cautery is n o t variable b u t d e c r e a s e s w i t h r e p e a t e d u s e ; we u s e d a fresh d i s p o s a b l e cautery. The tip of the c a u t e r y is i n s e r t e d into the p u n c t u m a n d into the vertical c a n a l i c u l u s , a n d the tissues are c o a g u l a t e d . The tissues s h r i n k w i t h i n o n e to two s e c o n d s , a n d w h e n the a n a tomic l a n d m a r k s of t h e p u n c t u m are coagulat ed, the d i s p o s a b l e c a u t e r y is r e m o v e d . The collagen p l u g a b s o r b s s p o n t a n e o u s l y a n d p r e v e n t s the p a s s a g e of tears u n t i l cicatrization of the p u n c t u m a n d vertical c a n a l i c u l u s is com plete.
Vol. 113, No. 3
Letters to The Journal
We have used this technique successfully in 15 patients.
Reference 1. Knapp, M. E., Frueh, B. R., Nelson, C. C , and Musch, D. C: A comparison of two methods of punctal occlusion. Am. J. Ophthalmol. 108:315, 1989.
Improved, Reusable, Autopsy Eye Model Container for Laser Trabeculoplasty and Iridectomy D o n S. Minckler, M.D., D o u g l a s Gaasterland, M.D., and P h i l i p J. Erickson, M.S. Estelle Doheny Eye Institute (D.S.M.), and George town University (D.G.), and Ocular Instruments, Inc. (P.J.E.). Mr. Erickson has proprietary interest in the device described. Inquiries to Don S. Minckler, M.D., Estelle Doheny Eye Institute, 1355 San Pablo St., Los Angeles, CA 90033. In a previous communication, we described a container to hold autopsy eye specimens in a model for practicing or teaching laser trabecu loplasty and laser iridotomy. The model was made of a short section of plastic plumbing pipe and glass end-plates. 1 The original containers were not reusable. In cooperation with Ocular Instruments of Bellevue, Washington, we have developed a reusable eye model container, which has been extensively tested during the last two years in hands-on instruction courses at the annual meeting of the American Acade my of Ophthalmology. A single model can serve several students during instruction cours es, depending on the number of laser burns placed. A universal slit-lamp holding clamp has also been developed to simplify stationary po sitioning of the models for use, which is pre ferred by most students rather than hand-hold ing the models. Models for both trabeculoplasty and iridecto my are constructed by suspending appropriate sections of formalin-fixed human autopsy eyes in 100% anhydrous glycerin and orienting the tissue sections to display the trabecular mesh work or iris through a glass window (antireflective coated for laser light) (Figs. 1 and 2). The
341
preferable assembly techniques for either mod el include placing the tissue sections to display the desired structure in the holder with just enough glycerin for a bubble-free view. Melted paraffin can be added onto the top of the glycer in and exposed tissue sufficient to cover the tissue and lock it in place as cooling occurs. Usually, only about V* to Vi inch of paraffin is required. Before securing the lid, the remainder of the container can be packed with sponges or tissue paper to hold the tissue and paraffin in place. Minimizing the amount of paraffin facili tates cleaning and reusing the model. Laser trabeculoplasty—For laser trabeculo plasty models, divide the fixed globe through the cornea and posterior pole into two equal parts. Remove the lens. Next, gently tear the iris from its ciliary body insertion. Inspect both hemispheres with a dissecting microscope to ensure that the trabecular meshwork is intact. If fixation has been poor, the angle landmarks may be distorted and tissue consistency too abnormal for use. Ideally, the pigmented tra becular meshwork should be well defined and the pigment preserved in place. Usually, two trabeculoplasty models can be made from one well-fixed autopsy eye. Immerse in bubble-free glycerin in the container. Place the half-globe
Fig. 1 (Minckler, Gaasterland, and Erickson). The component parts of the laser eye model container include the eye cup, sponge, and lid along with the universal, slit-lamp holder.
