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
Letters to the Editor room of every good contact lens department is the true artist, the technician who adjusts the lenses. The ultimate fit for these irregular corneas is not just a Soper lens or a to ric lens but the finely tuned lens with adjustments made after slit-lamp evaluation. Incidently, no mention was made of the McGuire lens, which has a good nomagram showing base curve and three intermediate and peripheral curves. Soft contact lens fitting in the majority of offices, large and small, has eliminated the skilled technician of poly methylmethacrylate days. RGP lenses for keratoconus may be fine-tuned only by a skilled technician with the touch of a jeweler or watchmaker. May I make a plea-the older contact lens technicians must pass on their art and expertise. The larger residency and training programs must add contact lens technicianry to their programs. The patients with corneal pathology deserve the care of a skilled contact lens team. ROBERT J. CROSSEN, MD Williamsburg, Virginia
Genetics of Granular Dystrophy Dear Editor: We congratulate Sajjadi and Javadi on their article entitled Superficial Juvenile Granular Dystrophy (Ophthalmology 1992; 99: We were interested in their table ofpreoperative data, for this gives a clue to their observations we reported that even though the genetic information therein is in complete. In our own study 1 we reported that the super ficial confluent form of granular dystrophy was probably due to the homozygous state. The concurrence by Sajjadi and Javadi of this peculiarly severe form of the disease with the ordinary variety within the same pedigree in a number of their cases confirms our contention. Our own observation ofa family in which both parents, who are first cousins, have simple granular dystrophy sug gests this, for their four offspring exhibit a complete Men delian "set" for dominant inheritance, there being one unaffected, two normally affected, and one severely af fected siblings. A further severely affected patient has re cently come under our care, and he also was the product of a consanguineous marriage having a cousin affected with simple granular dystrophy. He will be the subject of a further communication shortly. Many of the observations ofSajjadi and Javadi can be explained on the basis of simple Mendelian inheritance, although some of their pedigrees do not fit appropriately with our contention and we wonder whether the genetic information they were able to obtain was accurate, es pecially in view of the likely degree of consanguinity among their pedigrees. We have found it difficult to dis entangle the pedigree of our second patient with this syn drome for that reason. A. E. A. RIDGWAY, FRCS Manchester, United Kingdom H. U. MOLLER, MD Arhus, Denmark
Reference I. Muller HU, Ridgway AE. Granular corneal dystrophy
groenouw type I. A report ofa probable homozygous patient. Acta Ophthalmol (Copenh) 1990;68:97-I 0 I.
Propionibacterium Endophthalmitis Dear Editor: We read with interest the article entitled, "Propionibac terium acnes Endophthalmitis after Intracapsular Cataract Extraction" by Chien and co-workers as well as the other articles published in the Journal on the same topic. 1•2 Since all the described cases with intravitreal and/or intravenous antibiotic therapies have been treated after or concomitant to surgery, we would like to report our experience with successful oral treatment of a case of Propionibacterium acnes endophthalmitis. A 55-year-old woman developed a chronic indolent intraocular inflammation 2 months after an extracapsular cataract extraction with posterior chamber IOL implan tation. The inflammation was partially responsive to ste roids given by various routes (topically, subconjunctivally, sistemically), and because of the temporary effectiveness of this therapy in resolving the intraocular inflammation, an IOL removal, capsulectomy, and anterior vitrectomy were performed 7 months later. Nevertheless, severe uve itis recurrences (4+ flare and cells in anterior chamber, hypopion, 4+ vitreous cells, and haziness) reappeared ap proximately three times per year for the following 3 years. When the patient was seen by us for the first time at our Ocular Immunovirology Service (3 years after the first episode), a chronic uveitis with keratic precipitates, cor neal edema, 3+ cells and flare in anterior chamber, 3+ vitreous, and haziness were seen. Results of slit-lamp, ophthalmoscopic, and echographic examinations showed no white plaque or capsular residuals. Intraocular pressure was 32 mmHg. A bacterial postoperative endophthalmitis was presumed, and after unsuccessful treatment with ste roids and oral cephalexin (2 g/day), an anterior chamber diagnostic paracentesis was performed. The fluid was in oculated into appropriate media for aerobes, anaerobes, and fungi; after 16 days of anaerobic cultures (thiogly colate broth and blood agar) a growth of Propionibacter ium acnes was noted and, based on in vitro susceptibility patterns, chloramphenicol therapy (1 g/day) was admin istered orally for l month. In 20 days, complete recovery from uveitis was achieved and no recurrences appeared during 22 months of follow-up. The increased lOP, not completely controlled by medical therapy (acetazolamide and beta-blockers), was treated with argon laser trabe culoplasty (nearly I 00 bums, 50-~m spot size, 0.1-second power pulse, 800 m W, 360° of trabecular meshwork in two sessions) 4 months after the complete resolution of the uveitis; no further antiglacomatous treatment has been required during 18 months offollow-up, and the patient's corrected visual acuity is now 20/25. According to these and other authors, 1.2 we stress the importance of holding the ocular specimen cultures for more than 14 days to await the outcome of a Propioni
1753
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
Letters to the Editor room of every good contact lens department is the true artist, the technician who adjusts the lenses. The ultimate fit for these irregular corneas is not just a Soper lens or a to ric lens but the finely tuned lens with adjustments made after slit-lamp evaluation. Incidently, no mention was made of the McGuire lens, which has a good nomagram showing base curve and three intermediate and peripheral curves. Soft contact lens fitting in the majority of offices, large and small, has eliminated the skilled technician of poly methylmethacrylate days. RGP lenses for keratoconus may be fine-tuned only by a skilled technician with the touch of a jeweler or watchmaker. May I make a plea-the older contact lens technicians must pass on their art and expertise. The larger residency and training programs must add contact lens technicianry to their programs. The patients with corneal pathology deserve the care of a skilled contact lens team. ROBERT J. CROSSEN, MD Williamsburg, Virginia
Genetics of Granular Dystrophy Dear Editor: We congratulate Sajjadi and Javadi on their article entitled Superficial Juvenile Granular Dystrophy (Ophthalmology 1992; 99: We were interested in their table ofpreoperative data, for this gives a clue to their observations we reported that even though the genetic information therein is in complete. In our own study 1 we reported that the super ficial confluent form of granular dystrophy was probably due to the homozygous state. The concurrence by Sajjadi and Javadi of this peculiarly severe form of the disease with the ordinary variety within the same pedigree in a number of their cases confirms our contention. Our own observation ofa family in which both parents, who are first cousins, have simple granular dystrophy sug gests this, for their four offspring exhibit a complete Men delian "set" for dominant inheritance, there being one unaffected, two normally affected, and one severely af fected siblings. A further severely affected patient has re cently come under our care, and he also was the product of a consanguineous marriage having a cousin affected with simple granular dystrophy. He will be the subject of a further communication shortly. Many of the observations ofSajjadi and Javadi can be explained on the basis of simple Mendelian inheritance, although some of their pedigrees do not fit appropriately with our contention and we wonder whether the genetic information they were able to obtain was accurate, es pecially in view of the likely degree of consanguinity among their pedigrees. We have found it difficult to dis entangle the pedigree of our second patient with this syn drome for that reason. A. E. A. RIDGWAY, FRCS Manchester, United Kingdom H. U. MOLLER, MD Arhus, Denmark
Reference I. Muller HU, Ridgway AE. Granular corneal dystrophy
groenouw type I. A report ofa probable homozygous patient. Acta Ophthalmol (Copenh) 1990;68:97-I 0 I.
Propionibacterium Endophthalmitis Dear Editor: We read with interest the article entitled, "Propionibac terium acnes Endophthalmitis after Intracapsular Cataract Extraction" by Chien and co-workers as well as the other articles published in the Journal on the same topic. 1•2 Since all the described cases with intravitreal and/or intravenous antibiotic therapies have been treated after or concomitant to surgery, we would like to report our experience with successful oral treatment of a case of Propionibacterium acnes endophthalmitis. A 55-year-old woman developed a chronic indolent intraocular inflammation 2 months after an extracapsular cataract extraction with posterior chamber IOL implan tation. The inflammation was partially responsive to ste roids given by various routes (topically, subconjunctivally, sistemically), and because of the temporary effectiveness of this therapy in resolving the intraocular inflammation, an IOL removal, capsulectomy, and anterior vitrectomy were performed 7 months later. Nevertheless, severe uve itis recurrences (4+ flare and cells in anterior chamber, hypopion, 4+ vitreous cells, and haziness) reappeared ap proximately three times per year for the following 3 years. When the patient was seen by us for the first time at our Ocular Immunovirology Service (3 years after the first episode), a chronic uveitis with keratic precipitates, cor neal edema, 3+ cells and flare in anterior chamber, 3+ vitreous, and haziness were seen. Results of slit-lamp, ophthalmoscopic, and echographic examinations showed no white plaque or capsular residuals. Intraocular pressure was 32 mmHg. A bacterial postoperative endophthalmitis was presumed, and after unsuccessful treatment with ste roids and oral cephalexin (2 g/day), an anterior chamber diagnostic paracentesis was performed. The fluid was in oculated into appropriate media for aerobes, anaerobes, and fungi; after 16 days of anaerobic cultures (thiogly colate broth and blood agar) a growth of Propionibacter ium acnes was noted and, based on in vitro susceptibility patterns, chloramphenicol therapy (1 g/day) was admin istered orally for l month. In 20 days, complete recovery from uveitis was achieved and no recurrences appeared during 22 months of follow-up. The increased lOP, not completely controlled by medical therapy (acetazolamide and beta-blockers), was treated with argon laser trabe culoplasty (nearly I 00 bums, 50-~m spot size, 0.1-second power pulse, 800 m W, 360° of trabecular meshwork in two sessions) 4 months after the complete resolution of the uveitis; no further antiglacomatous treatment has been required during 18 months offollow-up, and the patient's corrected visual acuity is now 20/25. According to these and other authors, 1.2 we stress the importance of holding the ocular specimen cultures for more than 14 days to await the outcome of a Propioni
1753
