JAN 2013

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

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January 2013 Insights DUOVISC® Viscoelastic System is designed to give two viscoelastic materials with different physicochemical properties that can be used differently and/or sequentially to perform specific tasks during a cataract procedure. DUOVISC® Viscoelastic System consists of VISCOAT® Ophthalmic Viscosurgical Device and PROVISC® Ophthalmic Viscosurgical Device. Sex, drugs, and Melville's Whale CAUTION: Federal law restricts this device to sale by or on the order of a physician. by J.C. Noreika, M.D., M.B.A. VISCOAT® OVD (Sodium Chondroitin Sulfate – Sodium Hyaluronate) Ophthalmic Viscosurgical Device INDICATIONS: VISCOAT® OVD is indicated for use as an ophthalmic surgical aid in anterior segment procedures including cataract extraction and intraocular lens (IOL) implantation. Viscoat maintains a deep anterior chamber during anterior segment surgeries, enhances visualization during the surgical procedure, and protects the corneal endothelium and other ocular tissues. The viscoelasticity of the solution maintains the normal position of the vitreous face and prevents formation of a flat chamber during surgery. WARNINGS: Failure to follow assembly instructions or use of an alternate cannula may result in cannula detachment and potential patient injury. PRECAUTIONS: Precautions are limited to those normally associated with the surgical procedure being performed. Although sodium hyaluronate and sodium chondroitin sulfate are highly purified biological polymers, the physician should be aware of the potential allergic risks inherent in the use of any biological material. ADVERSE REACTIONS: VISCOAT® OVD has been extremely well tolerated in human and animal studies. A transient rise in intraocular pressure in the early postoperative period may be expected due to the presence of sodium hyaluronate, which has been shown to effect such a rise. It is therefore recommended that Viscoat be removed from the anterior chamber by thorough irrigation and/or aspiration at the end of surgery to minimize postoperative IOP increases. Do not overfill anterior chamber. ATTENTION: Reference the Physician Labeling/Directions for Use for a complete listing of indications, warnings and precautions. PROVISC® OVD (Sodium Hyaluronate) Ophthalmic Viscosurgical Device INDICATIONS: ProVisc® OVD is indicated for use as an ophthalmic surgical aid in the anterior segment during cataract extraction and intraocular lens (IOL) implantation. Ophthalmic viscoelastics serve to maintain a deep anterior chamber during anterior segment surgery allowing reduced trauma to the corneal endothelium and surrounding ocular tissues. They help push back the vitreous face and prevent formation of a flat chamber during surgery. PRECAUTIONS: Postoperative increases in intraocular pressure have been reported with sodium hyaluronate products. The IOP should be carefully monitored and appropriate therapy instituted if significant increases should occur. It is recommended that PROVISC® OVD be removed by irrigation and/or aspiration at the close of surgery. Do not overfill anterior chamber. Although sodium hyaluronate is a highly purified biological polymer, the physician should be aware of the potential allergic risks inherent in the use of any biological material; care should be used in patients with hypersensitivity to any components in this material. Cannula assembly instructions should be followed to prevent patient injury. ADVERSE REACTIONS: Postoperative inflammatory reactions such as hypopyon and iritis have been reported with the use of ophthalmic viscoelastics, as well as incidents of corneal edema, corneal decompensation, and a transient rise in intraocular pressure. ATTENTION: Reference the Physician Labeling/Directions for Use for a complete listing of indications, warnings and precautions. © 2013 Novartis 1/13 VIS13003JAD-PI A review of Shakespeare's Tremor and Orwell's Cough I t is no surprise that recent bestseller lists and book reviews are populated with the offerings of doctors. Finding a sinecure outside of Medicare reimbursement is a sound strategy. John J. Ross, M.D., is a graduate of McGill University Medical School, a hospitalist in the Harvard system, and crafter of an impressive, if not altogether groundbreaking, list of publications, most notably in the New England Journal of Medicine. He has written a clever book depicting "the medical lives of famous writers." Shakespeare's Tremor and Orwell's Cough (St. Martin's Press, N.Y., 2012) coalesces diagnostic speculation, curious anecdotes, and voyeuristic sleuthing into an amalgam satisfying both literary fan and inquisitive physician. Each of the book's 10 chapters explores what is known or surmised about the health of a worldrenowned author, dramatist, or poet. Spanning 400 years, nine of the 10 subjects are men. (Recall that Mary Anne Evans was still writing as George Eliot as late as the 1870s. Ross omits my favorite manic-depressive, Virginia Woolf.) The first chapter hypothesizes that a tremor may have caused Shakespeare to prematurely quit his illustrious writing. The bard provides fodder for a treatise on the history of syphilis and its treatments. Lost to history is why anyone thought that raising the body temperature to 106 degrees F in a "seething bath" to treat neurosyphilis was salutary. With "a mortality rate of only 1 to 2 percent," it was preferred to treatment with arsenic, mercury, or malaria. Ross insinuates that misogynistic themes in the sonnets, Hamlet and Macbeth germinated within a spirochete-afflicted mistress. Perhaps, but we are assured that Shakespeare's death was due to neither syphilis nor the complications of mercury therapy. He may have contracted typhoid fever after an otherwise quotidian drinking bout, an occupational hazard. Alcohol, opiates, mercury, arsenic, and lead poisoning compete with diseases such as tuberculosis (the Bronte sisters), brucellosis (William Butler Yeats), and cancer (Hawthorne). Mental illnesses, especially bipolar disease (Melville and Jack London), depression (Swift), social phobia (Hawthorne), and Asperger syndrome (the Brontes again) seem prerequisites for literary immortality. There are anecdotes regarding the sensory systems of literary greats. For example, Jonathan Swift probably suffered from Meniere's disease, tinnitus, and eventual deafness. His hearing loss was not due to syphilis as "there is no evidence that Swift had sex with anyone ever." Mercury toxicity is a recurring topic. A sidebar notes that Isaac Newton's obsession with alchemy may have contributed to his eventual paranoia, insomnia, and social withdrawal. Hair samples have shown mercury levels of 197 parts per million, exponentially above normal. Ophthalmologists such as Trevor-Roper, Ravin, and, especially, Marmor have contributed to understanding the import of visual debility on the work of painters such as Monet, Degas, O'Keefe, and Mary Cassatt. Edvard Munch's depictions of an evolving scotoma due to retinal hemorrhage continue to fascinate. Some of Ross' writers were affected by ocular pathology. Yeats had keratoconus in his left eye that "gave him a curious look of 'peering into infinity'" befitting the oracle of "The Second Coming." Melville's career-ending vision problems have been linked to the iritis of ankylosing spondylitis. But the ophthalmic literary stars are John Milton and James Joyce. The purblind Milton began losing sight at age 36. Eight years later he was sightless yet completed Paradise Lost. Ross posits a differential diagnosis and concludes Milton was genetically myopic and developed bilateral retinal detachments. Three hundred years later, Joyce became the literary poster child for ophthalmic infirmity. He exhibited symptoms of anterior uveitis resulting in multiple operations. Because of alcoholism, exposure to sexually transmitted disease, and, perhaps, Irish Catholic guilt, specialists needed to reassure him that he did not have an Argyll Robertson pupil. Alfred Vogt performed an ophthalmic procedure in 1930 that occasioned the use of leeches to drain blood from the eye. The vision-challenged Joyce employed a young scribe and proofreader named Samuel Beckett. Leopold Bloom portending Godot? And Orwell? He lived to publish Animal Farm and 1984 after a bullet traversed his neck during the Spanish Civil War. Bypassing critical anatomic structures, trauma to his recurrent laryngeal nerve affected his speech but not his fanatical antifascism. Alas, there is no report of Horner's syndrome, i.e., no ptosis, miosis, or anhidrosis. EW Editors' note: Dr. Noreika has practiced ophthalmology in Medina, Ohio, since 1983. He has been a member of ASCRS for more than 30 years. Contact information Noreika: JCNMD@aol.com

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