Ophthalmology

Volume 99, Number 9, September 1992

by vitrectomy and removal of retained lens fragments. We included four patients who had no surgery for the retained unencapsulated lens nucleus, all with poor visual outcome on long-term follow up. Patients with a small chip of nuclear material after phacoemulsification were not included in the current series. Complications from pars plana vitrectomy may occur. However, the majority of ocular complications in this series were a result of the initial cataract surgery and the complications secondary to the retained lens material. We agree with Dr. Marak that there are no established standards of care for managing posteriorly dislocated lens fragments, and we agree that eyes with a small piece of cortex or very small nuclear chip may do well without surgical intervention. Again, such cases were not included in this series. Our recommendations are certainly not "inflexible rules" but represent general guidelines for the anterior segment surgeon regarding a reasonable plan of action when this complication occurs. Because of the great variability in the type of cataract surgery performed, the amount of nuclear fragment retained, and the broad spectrum of coexisting ocular diseases in these eyes, we do not believe that a multicentered study would provide meaningful information necessary to establish standards of care. BARBARA BLODI, MD HARRY W. FLYNN, Jr., MD Miami, Florida Reference

1. Annitage P. Statistical Methods in Medical Research. Oxford and Edinburgh: Blackwell Scientific Publications, 1971; 134-8.

Swab Culture of Corneal Ulcers Dear Editor: Benson and Lanier are to be congratulated for their report entitled, "Comparison of Techniques for Culturing Corneal Ulcers" (Ophthalmology 1992;99:800-804), which dispels a long-held myth in external eye disease teaching that one must always use a platinum (Kimura) spatula to obtain material from a suspected infectious corneal ulcer. We have believed for some time that the stylized ritual of flaming the spatula has prevented many non specialty ophthalmologists from obtaining cultures when indicated and has frightened many patients. After hearing the preliminary results of the work of Benson and Lanier at the Ocular Microbiology and Immunology Group meeting in Anaheim (October 1991), we changed the procedures for culturing suspected infectious keratitis in our referral clinic at the Dean A. McGee Eye Institute. Our regimen involved removing adherent mucous and debris from the ulcer with a dry swab; scraping the ulcer once with a sterile Kimura spatula and streaking this on appropriate media; and finally, several swabbings of the ulcer with Dacron (or rayon) sterile swabs soaked in thioglycollate broth using multiple "C" streaks on appropriate media. Our results were similar to those

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of Benson and Lanier with more growth on the streaks from the swabs than from the spatula in nearly 100% of our cases-now 43 consecutive culture proven cases of bacterial keratitis. In many cases, the swab streaks showed diagnostic growth when the spatula streaks did not. Because the Dacron/rayon swabs are readily found in most clinics and hospital wards (where the spatula and alginate swabs are often scarce), we strongly urge others to use this simpler technique for corneal cultures. The larger Dacron/rayon swabs are easy to handle and work well for all except the smallest (1 mm) ulcers. It also is easy to break off the tip of the swab into the liquid media. The use of the synthetic swab as part of our corneal ulcer culture protocol seems to have decreased our incidence of culture negative ulcers as well as being simpler to perform than the conventional techniques with the spatula. JOHN H. VARGA, MD THOMAS C. WOLF, MD HAROLD G. JENSEN, PhD Oklahoma City, Oklahoma

Pseudotumor Cerebri from Venous Obstruction Dear Editor: Woodhall, in 1939, suggested that certain cases of obstruction of the transverse dural sinuses cause pseudotumor cerebri, benign intracranial hypertension. He investigated this condition, as recorded in a 1936 issue of Archives of Surgery, and additionally in Laryngoscope, in 1939. Further study, conducted by Dr. F. B. Walsh, was recorded in Archives of Ophthalmology in 1936. Drs. Odom, Kapp, and I I reported cases 25 years ago, with rather crude radiologic evidence. More recently, Lam et al, in their article entitled "Pseudotumor Cerebri from Cranial Venous Obstruction" (Ophthalmology 1992;99: 706-12), have presented a report of 6 cases of pseudotumor cerebri associated with venous outflow obstruction. We congratulate them. More than 50 years later, their more advanced and elaborate radiologic evidence has shown that Dr. Woodhall's idea was correct. Dr. Woodhall was one of the best neurosurgeons and clinicians that I have ever known or under whom I have ever had the privilege to study. Dr. Woodhall was Chief of the Division of Neurosurgery at Duke University from 1946 to 1960. He was president of the American Association of Neurological Surgery and other neurologic associations for a number of years. I believe that this new study by Lam et al is a fine tribute to Dr. Woodhall, a pioneer in this field. JAMES P. GILLS, MD Tarpon Springs, Florida

Reference 1. Gills JP, Kapp JP, Odom GL. Benign intracranial hyper-

tension: pseudotumor cerebri from obstruction of dural sinuses. Arch Ophthal 1967;78:592-5.

Pseudotumor cerebri from venous obstruction.

Ophthalmology Volume 99, Number 9, September 1992 by vitrectomy and removal of retained lens fragments. We included four patients who had no surgery...
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