780
December, 1992
AMERICAN JOURNAL OF OPHTHALMOLOGY
with a No. 15 blade, carefully avoiding these areas, and then the incision is carried into the superficial submucosal palatine gland layer. It is important to avoid incising the mucoperiosteum, as mentioned in the article. Even more crucial, one should avoid incising the fat-gland layer (located between mucoperiosteum and the mucochondral tissue), which often con tains larger vessels responsible for significant bleeding. Hemostasis is then obtained in three steps. The first step is to coagulate all bleeding ves sels with unipolar cautery. The settings re quired are usually higher than for convention al eyelid surgery. The assistant alternates the suction between the soft palate, to protect the airway, and the operative field. Secondly, once hemostasis is complete, ferric subsulfate solu tion (Monsel's solution) is applied sparingly and gently to the bed. Lastly, equal parts of dental paste (Coe-Pak) base and accelerator are mixed for approximately one minute along with one drop of eugenol (a topical anesthet ic), until the soft paste reaches the consistency of putty. The surgeon's gloves are lubricated with an ointment to aid in handling the sticky substance. By using a combination of digital pressure and wet cotton applicators, the putty is packed into the site so as to lie flush with the wound edges. Putting in a mound will cause the stent to fit improperly. Denture ad hesive cream is applied to the side of the stent that contacts the hard palate mucosa, except in the area of the graft site, in order to help maintain its position for several days. The longer the packing stays in place, the more comfortable is the patient. Our experience does not support the statement that the pack ing will control bleeding. Postoperatively, the patient is instructed to leave the stent in place two days, then to rinse with chlorhexidene gluconate oral rinse. Thereafter, the stent can be worn or omitted, depending on each patient's preference. All hot beverages and foods are avoided for one week. The patients are instructed that if any oral bleeding occurs, to place the ball of the thumb against the graft site and suck the thumb for 30 minutes. The graft site is usually fully healed within two to three weeks. The hard palate mucochondral graft is an excellent composite tissue for use in eyelid re construction. One might conclude, based on the study of Maurilio and associates that sig nificant bleeding is an anticipated complica tion associated with harvesting the grafts. We
appreciate the excellent review of how to man age this problem, and the useful modification of a mouthguard to keep pressure on the bleeding site. Based on over 100 cases since 1989, we have never encountered a problem which did not respond to conventional treat ment. We hope this correspondence puts a per spective on how infrequently uncontrollable hemorrhaging is encountered. NORMAN SHORR, M.D. YOASH R. ENZER, M.D.
Los Angeles, California Reply EDITOR:
We agree with Drs. Shorr and Enzer that bleeding rarely occurs after harvesting of the hard palate grafts; indeed, our patient was un usual in that he had severe bleeding from sub sequent oral surgery on the cheek area. After extensive hématologie reexamination, he was found to have a mild platelet abnormality de spite normal bleeding, prothrombin, and par tial thromboplastin times. We discovered the acrylic mouthguard was an extremely simple and effective method for controlling bleeding in this difficult unusual circumstance. J. A. MAURILLO, JR., M.D. B. WASSERMAN, B.A. S. ALLEE, B.A. L. ROBINSON, D.M.D.
Newark, New Jersey
Sudden Retinal Manifestations of Intranasal Cocaine and Methamphetamine Abuse EDITOR:
In the article "Sudden retinal manifestations of intranasal cocaine and methamphetamine abuse," by R. T. Wallace, G. C. Brown, W. Benson, and A. Sivalingham (Am. J. Ophthalmol. 114:158, August 1992), the authors de scribed a patient who developed a central reti nal artery occlusion after using cocaine intranasally. They speculated that either arteri al spasm or severe transient hypertension may have led to occlusion of the retinal artery. We have seen a similar case that occurred shortly after a man smoked crack cocaine. A 42-year-old man had painless loss of vi-
Vol. 114, No. 6
Correspondence
781
ent pupillary defect was present in the left eye. The anterior segment was normal in each eye, and the intraocular pressure by applanation tonometry was R.E.: 17 mm Hg in the right eye and 18 mm Hg in the left eye. Ophthalmoscopy disclosed a normal right fundus and an edematous optic nerve with whitening of the posterior pole and a foveal cherry-red spot in the left fundus (Figure). Fluorescein angiography of the left eye showed nonperfusion of the retinal vasculature, confirming the diagno sis of central retinal artery occlusion. Cocaine use has been associated with a number of medical problems, many of which are life-threatening. 1 Abuse of crack cocaine, the alkaloid form of cocaine, has now reached epidemic proportions in most large urban are as and has been found to have several ocular complications. 24 Crack cocaine and intranasal cocaine abuse should be considered as part of the differential diagnosis for retinal vascular occlusion, especially in relatively young, other wise healthy patients. JOHN H. ZEITER, M.D. Stockton, California DONNA M. CORDER, M.D. Dearborn, Michigan MATHEW P. MADION, M.D. Traverse City, Michigan JOHN G. McHENRY, M.D. Lavonia, Michigan
References
Figure (Zeiter and associates). Fundus photo graphs of the left eye of a crack cocaine user show edematous optic nerve (top) and whitening of the posterior pole with a foveal cherry-red spot (bottom). sion in his left eye one hour after smoking crack cocaine. His ocular and medical histories were unremarkable. Visual acuity was R.E.: 20/20 and L.E.: hand motions. A relative affer
1. Cregler, L. L., and Mark, H.: Medical complica tions of cocaine abuse. N. Engl. J. Med. 315:1495, 1986. 2. McHenry, J. G., Zeiter, J. H., Madion, M. P., and Cowden, J. W.: Corneal epithelial defects after smoking crack cocaine. Am. J. Ophthalmol. 108:732, 1989. 3. Strominger, M. B., Sachs, R., and Hersh, P. S.: Microbial keratitis with crack cocaine. Arch. Oph thalmol. 108:1672, 1990. 4. Zagelbaum, B. M., Tannenbaum N. H., and Hersh, P. S.: Candida albicans corneal ulcer associat ed with crack cocaine. Am. J. Ophthalmol. 111:248, 1991.
December, 1992
AMERICAN JOURNAL OF OPHTHALMOLOGY
with a No. 15 blade, carefully avoiding these areas, and then the incision is carried into the superficial submucosal palatine gland layer. It is important to avoid incising the mucoperiosteum, as mentioned in the article. Even more crucial, one should avoid incising the fat-gland layer (located between mucoperiosteum and the mucochondral tissue), which often con tains larger vessels responsible for significant bleeding. Hemostasis is then obtained in three steps. The first step is to coagulate all bleeding ves sels with unipolar cautery. The settings re quired are usually higher than for convention al eyelid surgery. The assistant alternates the suction between the soft palate, to protect the airway, and the operative field. Secondly, once hemostasis is complete, ferric subsulfate solu tion (Monsel's solution) is applied sparingly and gently to the bed. Lastly, equal parts of dental paste (Coe-Pak) base and accelerator are mixed for approximately one minute along with one drop of eugenol (a topical anesthet ic), until the soft paste reaches the consistency of putty. The surgeon's gloves are lubricated with an ointment to aid in handling the sticky substance. By using a combination of digital pressure and wet cotton applicators, the putty is packed into the site so as to lie flush with the wound edges. Putting in a mound will cause the stent to fit improperly. Denture ad hesive cream is applied to the side of the stent that contacts the hard palate mucosa, except in the area of the graft site, in order to help maintain its position for several days. The longer the packing stays in place, the more comfortable is the patient. Our experience does not support the statement that the pack ing will control bleeding. Postoperatively, the patient is instructed to leave the stent in place two days, then to rinse with chlorhexidene gluconate oral rinse. Thereafter, the stent can be worn or omitted, depending on each patient's preference. All hot beverages and foods are avoided for one week. The patients are instructed that if any oral bleeding occurs, to place the ball of the thumb against the graft site and suck the thumb for 30 minutes. The graft site is usually fully healed within two to three weeks. The hard palate mucochondral graft is an excellent composite tissue for use in eyelid re construction. One might conclude, based on the study of Maurilio and associates that sig nificant bleeding is an anticipated complica tion associated with harvesting the grafts. We
appreciate the excellent review of how to man age this problem, and the useful modification of a mouthguard to keep pressure on the bleeding site. Based on over 100 cases since 1989, we have never encountered a problem which did not respond to conventional treat ment. We hope this correspondence puts a per spective on how infrequently uncontrollable hemorrhaging is encountered. NORMAN SHORR, M.D. YOASH R. ENZER, M.D.
Los Angeles, California Reply EDITOR:
We agree with Drs. Shorr and Enzer that bleeding rarely occurs after harvesting of the hard palate grafts; indeed, our patient was un usual in that he had severe bleeding from sub sequent oral surgery on the cheek area. After extensive hématologie reexamination, he was found to have a mild platelet abnormality de spite normal bleeding, prothrombin, and par tial thromboplastin times. We discovered the acrylic mouthguard was an extremely simple and effective method for controlling bleeding in this difficult unusual circumstance. J. A. MAURILLO, JR., M.D. B. WASSERMAN, B.A. S. ALLEE, B.A. L. ROBINSON, D.M.D.
Newark, New Jersey
Sudden Retinal Manifestations of Intranasal Cocaine and Methamphetamine Abuse EDITOR:
In the article "Sudden retinal manifestations of intranasal cocaine and methamphetamine abuse," by R. T. Wallace, G. C. Brown, W. Benson, and A. Sivalingham (Am. J. Ophthalmol. 114:158, August 1992), the authors de scribed a patient who developed a central reti nal artery occlusion after using cocaine intranasally. They speculated that either arteri al spasm or severe transient hypertension may have led to occlusion of the retinal artery. We have seen a similar case that occurred shortly after a man smoked crack cocaine. A 42-year-old man had painless loss of vi-
Vol. 114, No. 6
Correspondence
781
ent pupillary defect was present in the left eye. The anterior segment was normal in each eye, and the intraocular pressure by applanation tonometry was R.E.: 17 mm Hg in the right eye and 18 mm Hg in the left eye. Ophthalmoscopy disclosed a normal right fundus and an edematous optic nerve with whitening of the posterior pole and a foveal cherry-red spot in the left fundus (Figure). Fluorescein angiography of the left eye showed nonperfusion of the retinal vasculature, confirming the diagno sis of central retinal artery occlusion. Cocaine use has been associated with a number of medical problems, many of which are life-threatening. 1 Abuse of crack cocaine, the alkaloid form of cocaine, has now reached epidemic proportions in most large urban are as and has been found to have several ocular complications. 24 Crack cocaine and intranasal cocaine abuse should be considered as part of the differential diagnosis for retinal vascular occlusion, especially in relatively young, other wise healthy patients. JOHN H. ZEITER, M.D. Stockton, California DONNA M. CORDER, M.D. Dearborn, Michigan MATHEW P. MADION, M.D. Traverse City, Michigan JOHN G. McHENRY, M.D. Lavonia, Michigan
References
Figure (Zeiter and associates). Fundus photo graphs of the left eye of a crack cocaine user show edematous optic nerve (top) and whitening of the posterior pole with a foveal cherry-red spot (bottom). sion in his left eye one hour after smoking crack cocaine. His ocular and medical histories were unremarkable. Visual acuity was R.E.: 20/20 and L.E.: hand motions. A relative affer
1. Cregler, L. L., and Mark, H.: Medical complica tions of cocaine abuse. N. Engl. J. Med. 315:1495, 1986. 2. McHenry, J. G., Zeiter, J. H., Madion, M. P., and Cowden, J. W.: Corneal epithelial defects after smoking crack cocaine. Am. J. Ophthalmol. 108:732, 1989. 3. Strominger, M. B., Sachs, R., and Hersh, P. S.: Microbial keratitis with crack cocaine. Arch. Oph thalmol. 108:1672, 1990. 4. Zagelbaum, B. M., Tannenbaum N. H., and Hersh, P. S.: Candida albicans corneal ulcer associat ed with crack cocaine. Am. J. Ophthalmol. 111:248, 1991.
