Eyeworld

MAR 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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18 EW NEWS & OPINION Sunken continued from page 17 possible so as not to worsen the glaucoma situation. I decided to do a pars plana vitrectomy using 25- gauge infusion and a 20-gauge vit- rector (large enough to digest the capsule and Soemmering's ring ma- terial) and to suture-fixate this IOL to the iris without disturbing the bleb or the existing scleral suture at 12 o'clock. A video of the procedure can be viewed at www.youtu.be/8-tqKVvXlMw. (TRYPAN BLUE OPHTHALMIC SOLUTION)VISIONBLUE TM BRIEF SUMMARY OF PRESCRIBING INFORMATION Indications and Usage VisionBlueTM capsule of the lens. Contraindications VisionBlueTM is contraindicated when a non-hydrated (dry state), hydrophilic acrylic intraocular lens (IOL) is planned to be inserted into the eye because the dye may be absorbed by the IOL and stain the IOL. Precautions General: It is recommended that after injection all excess VisionBlueTM the eye by thorough irrigation of the anterior chamber. be immediately removed from Carcinogenesis, mutagenesis, impairment of fertility: Trypan blue is carcinogenic in rats. Wister/Lewis rats developed lymphomas after receiving subcutaneous injections of 1% trypan blue dosed at 50 mg/kg every other week for 52 weeks (total dose approximately 1,250,000-fold the maximum recommended human dose of 0.06 mg per injection in a 60 kg person, assuming total absorption). Trypan blue was mutagenic in the Ames test and caused DNA strand breaks in vitro. Pregnancy: Teratogenic Effects: Pregnancy Category C: Trypan blue is teratogenic in rats, mice, rabbits, hamsters, dogs, guinea pigs, pigs, and chickens. The majority of teratogenicity studies performed involve intravenous, intraperitoneal, or subcutaneous administration in the rat. The teratogenic dose is 50 mg/ kg as a single dose or 25 mg/kg/day during embryogenesis in the rat. These doses are approximately 50,000- and 25,000-fold the maximum recommended human dose of 0.06 mg per injection based in a 60 kg person, assuming that the whole dose is completely absorbed. Characteristic anomalies included neural tube, cardiovascular, vertebral, tail, and eye defects. Trypan blue also caused an increase in post-implantation mortality, and decreased fetal weight. In the monkey, trypan blue caused abortions with single or two daily doses of 50 mg/kg between 20th to 25th days of pregnancy, but no apparent increase in birth defects (approximately 50,000-fold maximum recommended human dose of 0.06 mg per injection, assuming total absorption). There are no adequate and well-controlled studies in pregnant women. Trypan blue should be given to a pregnant woman only if the potential benefit justifies the potential risk to the fetus. Nursing mothers: It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when trypan blue is administered to a nursing woman. Pediatric use: The safety and effectiveness of trypan blue have been established in pediatric patients. Use of trypan blue is supported by evidence from an adequate and well-controlled study in pediatric patients. Geriatric use: No overall differences in safety and effectiveness have been observed between elderly and younger patients. Adverse Reactions Adverse reactions reported following use of VisionBlueTM include discoloration of high water content hydrogen intraocular lenses (see Contraindications) and inadvertent staining of the posterior lens capsule and vitreous face. Staining of the posterior lens capsule or staining of the vitreous face is generally self limited, lasting up to one week. Rx ONLY Revised: July 2005 Manufactured by: © Dutch Ophthalmic Research Center International b.v. Scheijdelveweg 2, 3214 VN Zuidland The Netherlands Distributed in the United States by: Dutch Ophthalmic USA 10 Continental Drive, Bldg 1 Exeter, NH 03833, U.S.A. Phone: 800-75-DUTCH or 603-778-6929 U.S. PAT. 6,367,480; 6,720,314 is indicated for use as an aid in ophthalmic surgery by staining the anterior Dr. Chang commented about what was done here, "Your video nicely demonstrates the benefit of the pars plana approach to the cap- sulectomy and vitrectomy. It is al- ways surprising how much cortical material is still present after being sequestered for so many years. Pin- ning the material against the IOL is a clever maneuver that seems to keep the fragments from falling pos- teriorly." One thing I've be- come impressed with over the years is how a little bit of cortex or a few lens epithelial cells left behind at the time of cataract sur- gery can increase over time to become a truly impressive amount of "junk in the trunk." In this case, because of the very floppy bag and weak zonules, it was impossible to strip all the cortex at the time of cataract sur- gery because the capsular cortical adhesions forces were greater than the strength of the re- maining zonules. It was these cortical fibers left behind that multiplied over time to become the impres- sive opacity seen in the video. I've long been a fan of the pars plana approach to vit- rectomy and have used this technique for almost all of my anterior vitrectomies done since 1992. This case is a clear example of how an assist from "down under" can be helpful. It should be noted that a 25-gauge vitrector is too small to remove this type of material so a 20-gauge vitrector is used with a self-retaining 25-gauge infusion line. With this combination you need to keep the bot- tle fairly high, about 80 mm, while you are using the vitrector and then bring it down (or shut the in- fusion off) as soon as you remove the vitrec- tor from the eye. The outcome of March 2012 The VF of the patient's OD this case was a well- centered implant with elimination of the myopic astigmatism caused by the lens tilt, improvement of vi- sion with removal of the opacity in the visual axis, and no change in the intraocular pressure from pre-opera- tive levels. EW The OCT study of the optic nerves showing marked glaucoma damage OD Source (all): Steven G. Safran, M.D. Editors' note: The doctors mentioned have no financial interests related to this article. Contact information Safran: safran12@comcast.net

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