Ophthalmology
Volume 99, Number 12, December 1992
intraocular surgery, and development in fellow eyes). The necessity to craft concise case reports makes it difficult to include all the details of these complicated cases. We cer tainly can understand Dr. Fourman's reservations re garding some of the historical details. For example, the -4.25 + 4.50 X 163 refractive error of patient 6 seemed unusual to us as well. This prompted a preoperative A scan (axial length 21.2 mm) and keratometry (48.75/ 45.37), which provided insight into the presence of a my opic correction in an eye with ang]e-closure g]aucoma. Dr. Fourman is correct in stating that we did not in clude ciliary body spasm leading to ang]e-closure glau coma in our differential diagnosis. 1 However, a retro spective evaluation of our patients has failed to reveal large myopic shifts in refraction or symptoms of blurred vision relieved by myopic overcorrection during an attack. Dr. Fourman refers to his own interesting report of "Angle-closure Glaucoma Complicating Ciliochoroidal Detachment," with which we are familiar. 2 As discussed in the Comment section of our article, choroidal detach ment was actively and specifically searched for and not found in any of our patients. Ophthalmoscopy was the primary examination technique used. When corneal edema or other factors precluded an adequate view, an ultrasonic evaluation was performed. Malignant g]aucoma remains an incompletely under stood condition that must be diagnosed by exclusion. However, we hope that by reporting these six patients who developed malignant g]aucoma after laser iridotomy, we will contribute to the general awareness of malignant glaucoma and the persistent risk of its development after laser iridotomy. L. FRANK CASHWELL, JR., MD TIMOTHY J. MARTIN, MD
Winston-Salem, North Carolina
References
I. Phelps CD. Angle-closure glaucoma secondary to ciliary body swelling. Arch Ophthalmol 1974;92:287-90. 2. Fourman S. Angle-closure glaucoma complicating ciliocho roidal detachment. Ophthalmology 1989;96:646-53.
Accommodation with Monofocal IOLs Dear Editor: It may have escaped the notice of some readers of the article entitled, "A Prospective Randomized Double masked Comparison of A Zonal-Progressive Multifocal Intraocular Lens and A Monofocal Intraocular Lens" (Ophthalmology 1992;99:853-861) by Steinert et al that the point of greatest significance for this reader was not that "52% of patients with a multifocal IOL reported that they did not need spectacles at all or used them only for their fellow eye" but that 25% of the patients with mono focal intraocular lenses did not need spectacles at all or used them only for their fellow eye. It is this accommodative potential with monofocal in traocular lenses that I described and documented in the mid 1980's 1•2 and described in some detail in a textbook published in 1991. 3 In the mid 1980's, people scoffed at
1752
the idea that a monofocal intraocular lens could restore some degree of accommodation. It is interesting that within the past few years several other investigators have confirmed my findings and have designed other similar lenses to take advantage of this potential. SPENCER P. THORNTON, MD Nashville, Tennessee References
I. Thornton SP. Lens implantation with restored accommo dation. Curr Canadian Ophthalmic Pract 1986(2);60. 2. Thornton SP. An in-the-bag lens with potential accom modation. Contemp Views Ophthalmol Bellows, Randall T, editor, No. 26, Fall 1986. 3. Thornton SP. Accommodation in pseudophakia. In: Percival SPB, ed. A Colour Atlas of Lens Implantation, Mosby Yearbook Inc, St. Louis, 1991.
Author's reply Dear Editor: Dr. Thornton's careful reading of our article and inno vative interpretation is most appreciated. Regarding the response to the subjective question on postoperative spec tacle usage, the multitude of reasons for absence of spec tacle usage postoperatively were not elaborated. These range from personal preference and tolerance ofa blurred image through postoperative anisometropia yielding "monovision" to the pseudoaccommodative effects of low-level compound myopic astigmatism. Dr. Thornton has previously observed the possibility of some true post operative accommodation due to ciliary body contraction changing the position of the capsular bag. Our study did not directly examine for such an effect. If it were present, one might expect asymmetry of the "through-focus" curves for monofocal patients shown in Figure 2 of our article. In any case, the monofocal and multifocal IOL used in our study were completely identical in haptic structure and haptic-optic dimensions. Dr. Thornton's accommodation effect, if present, would therefore be ex pected to be equal in both groups, and the differences between the two groups attributable to the IOL optics alone.
ROGER F. STEINERT, MD
Boston, Massachusetts
Contact Lens Fallure in Keratoconus Dear Editor: I read the article entitled "Contact Lens Failure in Ker atoconus Management" with empathy and understand ing. Thirty years of contact lens fitting as a subspecialty demonstrated regularly that keratoconus contact lens evaluation is a labor of love. My reward was gratification rather than remuneration when a patient referred to The University of Michigan Department of Ophthalmology for corneal graft surgery could be successfully fitted or refitted for contact lens wear. The authors did not mention the importance of the team needed for successful keratoconus fitting. In the back
Volume 99, Number 12, December 1992
intraocular surgery, and development in fellow eyes). The necessity to craft concise case reports makes it difficult to include all the details of these complicated cases. We cer tainly can understand Dr. Fourman's reservations re garding some of the historical details. For example, the -4.25 + 4.50 X 163 refractive error of patient 6 seemed unusual to us as well. This prompted a preoperative A scan (axial length 21.2 mm) and keratometry (48.75/ 45.37), which provided insight into the presence of a my opic correction in an eye with ang]e-closure g]aucoma. Dr. Fourman is correct in stating that we did not in clude ciliary body spasm leading to ang]e-closure glau coma in our differential diagnosis. 1 However, a retro spective evaluation of our patients has failed to reveal large myopic shifts in refraction or symptoms of blurred vision relieved by myopic overcorrection during an attack. Dr. Fourman refers to his own interesting report of "Angle-closure Glaucoma Complicating Ciliochoroidal Detachment," with which we are familiar. 2 As discussed in the Comment section of our article, choroidal detach ment was actively and specifically searched for and not found in any of our patients. Ophthalmoscopy was the primary examination technique used. When corneal edema or other factors precluded an adequate view, an ultrasonic evaluation was performed. Malignant g]aucoma remains an incompletely under stood condition that must be diagnosed by exclusion. However, we hope that by reporting these six patients who developed malignant g]aucoma after laser iridotomy, we will contribute to the general awareness of malignant glaucoma and the persistent risk of its development after laser iridotomy. L. FRANK CASHWELL, JR., MD TIMOTHY J. MARTIN, MD
Winston-Salem, North Carolina
References
I. Phelps CD. Angle-closure glaucoma secondary to ciliary body swelling. Arch Ophthalmol 1974;92:287-90. 2. Fourman S. Angle-closure glaucoma complicating ciliocho roidal detachment. Ophthalmology 1989;96:646-53.
Accommodation with Monofocal IOLs Dear Editor: It may have escaped the notice of some readers of the article entitled, "A Prospective Randomized Double masked Comparison of A Zonal-Progressive Multifocal Intraocular Lens and A Monofocal Intraocular Lens" (Ophthalmology 1992;99:853-861) by Steinert et al that the point of greatest significance for this reader was not that "52% of patients with a multifocal IOL reported that they did not need spectacles at all or used them only for their fellow eye" but that 25% of the patients with mono focal intraocular lenses did not need spectacles at all or used them only for their fellow eye. It is this accommodative potential with monofocal in traocular lenses that I described and documented in the mid 1980's 1•2 and described in some detail in a textbook published in 1991. 3 In the mid 1980's, people scoffed at
1752
the idea that a monofocal intraocular lens could restore some degree of accommodation. It is interesting that within the past few years several other investigators have confirmed my findings and have designed other similar lenses to take advantage of this potential. SPENCER P. THORNTON, MD Nashville, Tennessee References
I. Thornton SP. Lens implantation with restored accommo dation. Curr Canadian Ophthalmic Pract 1986(2);60. 2. Thornton SP. An in-the-bag lens with potential accom modation. Contemp Views Ophthalmol Bellows, Randall T, editor, No. 26, Fall 1986. 3. Thornton SP. Accommodation in pseudophakia. In: Percival SPB, ed. A Colour Atlas of Lens Implantation, Mosby Yearbook Inc, St. Louis, 1991.
Author's reply Dear Editor: Dr. Thornton's careful reading of our article and inno vative interpretation is most appreciated. Regarding the response to the subjective question on postoperative spec tacle usage, the multitude of reasons for absence of spec tacle usage postoperatively were not elaborated. These range from personal preference and tolerance ofa blurred image through postoperative anisometropia yielding "monovision" to the pseudoaccommodative effects of low-level compound myopic astigmatism. Dr. Thornton has previously observed the possibility of some true post operative accommodation due to ciliary body contraction changing the position of the capsular bag. Our study did not directly examine for such an effect. If it were present, one might expect asymmetry of the "through-focus" curves for monofocal patients shown in Figure 2 of our article. In any case, the monofocal and multifocal IOL used in our study were completely identical in haptic structure and haptic-optic dimensions. Dr. Thornton's accommodation effect, if present, would therefore be ex pected to be equal in both groups, and the differences between the two groups attributable to the IOL optics alone.
ROGER F. STEINERT, MD
Boston, Massachusetts
Contact Lens Fallure in Keratoconus Dear Editor: I read the article entitled "Contact Lens Failure in Ker atoconus Management" with empathy and understand ing. Thirty years of contact lens fitting as a subspecialty demonstrated regularly that keratoconus contact lens evaluation is a labor of love. My reward was gratification rather than remuneration when a patient referred to The University of Michigan Department of Ophthalmology for corneal graft surgery could be successfully fitted or refitted for contact lens wear. The authors did not mention the importance of the team needed for successful keratoconus fitting. In the back
