To 'Phaco'
or
Not?
To the Editor.\p=m-\Thephacoemulsification procedure has been available for cataract surgery in this country for nearly 20 years. During this time there have been several waves of popularity for the procedure. At present, we seem to be riding the crest of another of these waves, or so we are told. There have been major developments in equipment, instrumentation, and pharmaceutical agents intended to improve the outcome and ease of performance of this procedure. In addition, the procedure itself has been modified numerous times. Intraocular lenses have also been modified into oval shapes that will slip through a smaller incision. Foldable lenses of soft materials are also available to slip through a phaco incision. Many courses are taught by the masters throughout the United States on conversion to phaco. In addition, on at least a weekly basis, we receive slick throwaway tabloids containing information on surgical procedures, instrumentation, and intraocular lenses, many of which pertain to phacoemulsification. After 20 years, what has been the result of all of these factors, including the millions of dollars spent on promo¬ tion? Currently, phacoemulsification is the procedure of choice for 25% to 30% of the ophthalmic surgeons in the United States. Extracapsular cataract surgery, intraocular lens implantation, and argon trabeculoplasty have all gained almost universal acceptance among ophthalmic surgeons in a much shorter period. What is the reason for this discrepancy in acceptance? Could it be related to the difficulty in performing the procedure, the complication rate, or the overall surgical success rate? We do not have an answer.
We do know, however, on the basis of incomplete surveys published in throwaway journals, that high-volume sur¬ geons are most likely to use phacoemulsification as their procedure of choice. We also know, on the basis of the In¬
spector General's recent survey of cataract surgery in the
United States, that the results of surgery performed by high-volume surgeons are more likely to be unsatisfactory than those performed by the general ophthalmologist. Is there a correlation between these two findings? Again, we have no answers. Cataract surgery is the most frequently performed oper¬ ation in the United States. Is phacoemulsification the pro¬ cedure of choice for restoration of vision for patients with cataracts? Does the patient who undergoes phacoemulsifi¬ cation for a cataract have a greater risk of complications than one who undergoes standard extracapsular surgery? There are many attractive features of phacoemulsification, but the primary consideration should be whether the patient is better served by this procedure and, if so, why it has not been generally accepted among the community of
ophthalmic
surgeons.
For this reason, I propose that a national collaborative study be developed to evaluate the relative efficacy of these
Downloaded From: by a Tulane University User on 01/18/2019
two alternative surgical procedures for patients with cata¬ racts. We all know how valuable these types of studies have
been in guiding ophthalmic therapy. Probably none would have an impact on a greater number of patients than this study would. John M. Hattenhauer, MD Wausau, Wis
Sports Vision and Vision Training: Myth or Reality? To the Editor.\p=m-\Thereis a rising interest in sports vision. Articles describing the visual abilities in athletic performance are frequent. In the field of sports vision, there is a great possibility of misinterpreting the results of ocular examinations owing to our eagerness to be involved and prescribe answers to a new field of endeavor. Financial gain
precede modest, and may
or
follow
our
our efforts. Therefore, we should be interpretations should be controlled by
double-masked studies. Instruments that test and develop saccadic fixation and dynamic vision are worthwhile, but some skepticism involving the effectiveness of visual training will arise unless controlled studies are conducted. I hope such studies can be pursued by a joint effort monitored by the American Academy of Ophthalmology and the American Academy of Optometry. Perhaps this joint effort could be controlled by the National Institutes of Health. As previously demonstrated in the study of dyslexia and learning disabilities, it would be tragic and serve no useful purpose if our efforts to study sports vision ran separate ways. At a time when our professional worlds are subject to critical observation by politicians and our own profes¬ sional bodies, it is imperative that we join in a combined effort of research. It would be well to take heed before we proceed individually in this interesting field of endeavor. Herman K. Goldberg, MD Baltimore, Md Orbital Carcinoid Tumor
To the Editor.\p=m-\Wehad the opportunity to review representative slides from the exenteration specimen kindly sent to one of us (R.L.F.) by Dr Bullock from the tumor he and his colleagues1 interpreted as a "primary orbital neuroblastoma." On review of the slides, all four of us favored the diagnosis of orbital carcinoid tumor. By light microscopy, the tumor exhibited all four main patterns described previously in cases of carcinoid tumors: pattern A (solid basaloid lobules), pattern B (trabecular or cordlike), pattern C (tubular or rosettelike), and pattern D (mixed).2 The tumor also lacked the fine fibrillary background (neuropil) that is frequently observed in cases of neuroblastoma.3 We decided to study the tumor using the Krystalon procedure used by one of us (H.B.). Portions of the section from the exenteration specimen containing tumor tissue were
lifted off the slide, sectioned into 12 portions averaging 5\m=x\5 mm each, and mounted on individual glass slides. Immunostaining after protease digestion was performed using four antikeratin monoclonal antibodies to low-molecularweight keratins: AE„ UCD-PR 10/11, CAM 5.2, and 35 beta H 11. Although all antibodies gave positive results, stron¬ ger immunoreactivity was observed with antibodies that recognize keratin 18 (CAM 5.2 and 35 beta H 11), a finding common in cases of neuroendocrine carcinomas (including carcinoids).4 In addition, a strong and diffuse reactivity with an antibody to chromogranin A was noted. This finding is typical of carcinoid tumors and correlates well with the abundance of neurosecretory granules. Neuroblastomas, because they have fewer secretory
granules, are usually chromogranin negative or only focally and weakly positive. This immunohistochemical profile completely excludes neuroblastoma and strongly favors the diagnosis of carcinoid tumor. The most important finding is the abundant expression of cytokeratins, which, in the ex¬ perience of one of us (H.B.), is not found in cases of
neuroblastoma.4 We believe the record should be kept straight in this case for the benefit of those interested in oncology as well as for the ophthalmic community as a whole. We are convinced the correct diagnosis is carcinoid tumor in the orbit (primary vs metastatic). The majority of reported orbital métastases have developed from ileal carcinoid tumors.5 We recommend, therefore, periodic follow-up study of the patient with appropriate ancillary methods to exclude a primary occult carcinoid tumor, especially of the midgut (ileum or appendix). If all the study results continue to be negative, this case would be best classified as a primary or¬ bital carcinoid tumor similar to the one reported by Zimmerman and coworkers.6 Ramon L. Font, MD Hector Battifora, MD Frederick A. Jakobiec, MD Lorenz E. Zimmerman, MD Houston, Tex 1. Bullock JD, Goldberg SH, Rakes SM, Felder DS, Connelly PJ. Primary orbital neuroblastoma. Arch Ophthalmol. 1989;107:1031-1033. 2. Riddle PJ, Font RL, Zimmerman LE. Carcinoid tumor of the eye and orbit: a clinicopathologic study of 15 cases, with histochemical and electron microscopic observations. Hum Pathol. 1982;13:459-469. 3. Jakobiec FA, Klepach GL, Crissman JD, Spoor TC. Primary differentiated neuroblastoma of the orbit. Ophthalmology. 1987;94:255-266. 4. Battifora H. Clinical applications of the immunohistochemistry of filamentous proteins. Am J Surg Pathol. 1988;12(suppl):24-42. 5. Shetlar DJ, Font RL, Ordonez N, El-Naggar A, Boniuk M. A clinicopathologic study of three carcinoid tumors metastatic to the orbit. Ophthal-
mology. 1990;97:257-264. 6. Zimmerman LE, Stangl R, Riddle PJ. Primary carcinoid tumor of the orbit: a clinicopathologic study with histochemical and electron microscopic observations. Arch Ophthalmol. 1983;101:1395-1398.
In Reply.\p=m-\Wevery much appreciate the interest of Font et al in our article. When our patient was first seen in 1982, the slides were reviewed in consultation with numerous surgical pathologists, neuropathologists, and ophthalmic pathologists at six medical institutions across the country. There was a consensus that the tumor was neuroendocrine in nature. The diagnoses included esthesioneuroblastoma, metastatic carcinoid tumor, neuroblastoma, and paraganglioma, with the majority favoring a diagnosis of neuroblastoma. At that time, specific keratin antibody stains, as
performed by Dr Battifora, were not available. We reviewed Dr Battifora's slides and agree with his interpretation of the tumor's keratin positivity. A polyclonal
broad-spectrum antikeratin stain was questionably positive in our laboratory while our anti-AE1/AE3 was strongly
Downloaded From: by a Tulane University User on 01/18/2019
positive. The keratin positivity effectively includes a neuroblastoma and is very strong evidence in favor of a carcinoid tumor. In view of these new findings, we completely agree that this is a carcinoid tumor. Considering the 8-year asymptomatic period and the negative results of the sys¬ temic evaluation, it appears that this is another case of pri¬ mary orbital carcinoid tumor similar to the one reported by Zimmerman and coworkers.1 We are extremely grateful to Font et al for bringing this new information to our atten¬ tion. We especially appreciate Dr Battifora's immunologie expertise in resolving this controversial case. The utility and reliability of immunohistochemistry is continually in¬ creasing.
Patrick J. Connelly, MD John D. Bullock, MD Dayton, Ohio
1. Zimmerman LE, Stangl R, Riddle PJ. Primary carcinoid tumor of the orbit: a clinicopathologic study with histochemical and electron microscopic observations. Arch Ophthalmol. 1983;101:1395-1398.
Encroaching Lens Loops To the Editor.\p=m-\Iread with interest the letter in the June 1990 issue of the Archives by Olson and Brodstein.1 They describe a 20-year-old woman who underwent extracapsular cataract extraction with placement of a polypropylene looped posterior chamber intraocular lens (PC IOL). After
a period, the polypropylene loops were forced by capsular fibrosis to encroach on the edge of the IOL, and one appeared over the IOL and the other one under it. I might simply add that this would not occur if a one-piece polymethyl methacrylate (PMMA) PC IOL had been used.
ta 1. Olson
RJ,
Kennethfer,Hoffer, Monica, Calif
Brodsteinoaching lens loops.
Arch
OphthalmoOphthalmol.
L990;108:1990
In Reply.\p=m-\Dr Hoffersue that a one-piece PMMA PC IOL would avoid the problem of encroaching loops due to capsular fibrosis. Although many all-PMMA lenses are significantly stiffer and maintain their "memory"ch better than polypropylene, we still do not know the forces involved in capsular fibrosis. Therefore, it is too early to state that the problem would be totally eliminated one-pieceses. It is also important to note the by recent trend toward more flexible all-PMMAand so new lenses approach the flexibility of polypropylene loops. As a general rule, it is true that encroaching lens loops are generally polypropylene. It is also true, however, that polypropylene has been around much longer and the number of "in-IOLsh polypropylene patient years of all-PMMA Only time loops is many times that of the will tell which lens is better. Randallon, Olson, t Lake City, Utah Robert Brodstein, S. MD Rober Ogden, Utah Decentration of an hamber Intraocular Lens due to aocularation
To the Editor.\p=m-\Decentration of casalIPaoOmCtpeLlication of surgery has extracapsular cataract -2rature. erature.1-2. The mostcauseisthefrequent umented haptic in the capsular bag and theother placement of one in the ciliary sulcus. Subsequent contracturecoftahpseularg may deform the hapticltimately decenter the well been doc-
or
Not?
To the Editor.\p=m-\Thephacoemulsification procedure has been available for cataract surgery in this country for nearly 20 years. During this time there have been several waves of popularity for the procedure. At present, we seem to be riding the crest of another of these waves, or so we are told. There have been major developments in equipment, instrumentation, and pharmaceutical agents intended to improve the outcome and ease of performance of this procedure. In addition, the procedure itself has been modified numerous times. Intraocular lenses have also been modified into oval shapes that will slip through a smaller incision. Foldable lenses of soft materials are also available to slip through a phaco incision. Many courses are taught by the masters throughout the United States on conversion to phaco. In addition, on at least a weekly basis, we receive slick throwaway tabloids containing information on surgical procedures, instrumentation, and intraocular lenses, many of which pertain to phacoemulsification. After 20 years, what has been the result of all of these factors, including the millions of dollars spent on promo¬ tion? Currently, phacoemulsification is the procedure of choice for 25% to 30% of the ophthalmic surgeons in the United States. Extracapsular cataract surgery, intraocular lens implantation, and argon trabeculoplasty have all gained almost universal acceptance among ophthalmic surgeons in a much shorter period. What is the reason for this discrepancy in acceptance? Could it be related to the difficulty in performing the procedure, the complication rate, or the overall surgical success rate? We do not have an answer.
We do know, however, on the basis of incomplete surveys published in throwaway journals, that high-volume sur¬ geons are most likely to use phacoemulsification as their procedure of choice. We also know, on the basis of the In¬
spector General's recent survey of cataract surgery in the
United States, that the results of surgery performed by high-volume surgeons are more likely to be unsatisfactory than those performed by the general ophthalmologist. Is there a correlation between these two findings? Again, we have no answers. Cataract surgery is the most frequently performed oper¬ ation in the United States. Is phacoemulsification the pro¬ cedure of choice for restoration of vision for patients with cataracts? Does the patient who undergoes phacoemulsifi¬ cation for a cataract have a greater risk of complications than one who undergoes standard extracapsular surgery? There are many attractive features of phacoemulsification, but the primary consideration should be whether the patient is better served by this procedure and, if so, why it has not been generally accepted among the community of
ophthalmic
surgeons.
For this reason, I propose that a national collaborative study be developed to evaluate the relative efficacy of these
Downloaded From: by a Tulane University User on 01/18/2019
two alternative surgical procedures for patients with cata¬ racts. We all know how valuable these types of studies have
been in guiding ophthalmic therapy. Probably none would have an impact on a greater number of patients than this study would. John M. Hattenhauer, MD Wausau, Wis
Sports Vision and Vision Training: Myth or Reality? To the Editor.\p=m-\Thereis a rising interest in sports vision. Articles describing the visual abilities in athletic performance are frequent. In the field of sports vision, there is a great possibility of misinterpreting the results of ocular examinations owing to our eagerness to be involved and prescribe answers to a new field of endeavor. Financial gain
precede modest, and may
or
follow
our
our efforts. Therefore, we should be interpretations should be controlled by
double-masked studies. Instruments that test and develop saccadic fixation and dynamic vision are worthwhile, but some skepticism involving the effectiveness of visual training will arise unless controlled studies are conducted. I hope such studies can be pursued by a joint effort monitored by the American Academy of Ophthalmology and the American Academy of Optometry. Perhaps this joint effort could be controlled by the National Institutes of Health. As previously demonstrated in the study of dyslexia and learning disabilities, it would be tragic and serve no useful purpose if our efforts to study sports vision ran separate ways. At a time when our professional worlds are subject to critical observation by politicians and our own profes¬ sional bodies, it is imperative that we join in a combined effort of research. It would be well to take heed before we proceed individually in this interesting field of endeavor. Herman K. Goldberg, MD Baltimore, Md Orbital Carcinoid Tumor
To the Editor.\p=m-\Wehad the opportunity to review representative slides from the exenteration specimen kindly sent to one of us (R.L.F.) by Dr Bullock from the tumor he and his colleagues1 interpreted as a "primary orbital neuroblastoma." On review of the slides, all four of us favored the diagnosis of orbital carcinoid tumor. By light microscopy, the tumor exhibited all four main patterns described previously in cases of carcinoid tumors: pattern A (solid basaloid lobules), pattern B (trabecular or cordlike), pattern C (tubular or rosettelike), and pattern D (mixed).2 The tumor also lacked the fine fibrillary background (neuropil) that is frequently observed in cases of neuroblastoma.3 We decided to study the tumor using the Krystalon procedure used by one of us (H.B.). Portions of the section from the exenteration specimen containing tumor tissue were
lifted off the slide, sectioned into 12 portions averaging 5\m=x\5 mm each, and mounted on individual glass slides. Immunostaining after protease digestion was performed using four antikeratin monoclonal antibodies to low-molecularweight keratins: AE„ UCD-PR 10/11, CAM 5.2, and 35 beta H 11. Although all antibodies gave positive results, stron¬ ger immunoreactivity was observed with antibodies that recognize keratin 18 (CAM 5.2 and 35 beta H 11), a finding common in cases of neuroendocrine carcinomas (including carcinoids).4 In addition, a strong and diffuse reactivity with an antibody to chromogranin A was noted. This finding is typical of carcinoid tumors and correlates well with the abundance of neurosecretory granules. Neuroblastomas, because they have fewer secretory
granules, are usually chromogranin negative or only focally and weakly positive. This immunohistochemical profile completely excludes neuroblastoma and strongly favors the diagnosis of carcinoid tumor. The most important finding is the abundant expression of cytokeratins, which, in the ex¬ perience of one of us (H.B.), is not found in cases of
neuroblastoma.4 We believe the record should be kept straight in this case for the benefit of those interested in oncology as well as for the ophthalmic community as a whole. We are convinced the correct diagnosis is carcinoid tumor in the orbit (primary vs metastatic). The majority of reported orbital métastases have developed from ileal carcinoid tumors.5 We recommend, therefore, periodic follow-up study of the patient with appropriate ancillary methods to exclude a primary occult carcinoid tumor, especially of the midgut (ileum or appendix). If all the study results continue to be negative, this case would be best classified as a primary or¬ bital carcinoid tumor similar to the one reported by Zimmerman and coworkers.6 Ramon L. Font, MD Hector Battifora, MD Frederick A. Jakobiec, MD Lorenz E. Zimmerman, MD Houston, Tex 1. Bullock JD, Goldberg SH, Rakes SM, Felder DS, Connelly PJ. Primary orbital neuroblastoma. Arch Ophthalmol. 1989;107:1031-1033. 2. Riddle PJ, Font RL, Zimmerman LE. Carcinoid tumor of the eye and orbit: a clinicopathologic study of 15 cases, with histochemical and electron microscopic observations. Hum Pathol. 1982;13:459-469. 3. Jakobiec FA, Klepach GL, Crissman JD, Spoor TC. Primary differentiated neuroblastoma of the orbit. Ophthalmology. 1987;94:255-266. 4. Battifora H. Clinical applications of the immunohistochemistry of filamentous proteins. Am J Surg Pathol. 1988;12(suppl):24-42. 5. Shetlar DJ, Font RL, Ordonez N, El-Naggar A, Boniuk M. A clinicopathologic study of three carcinoid tumors metastatic to the orbit. Ophthal-
mology. 1990;97:257-264. 6. Zimmerman LE, Stangl R, Riddle PJ. Primary carcinoid tumor of the orbit: a clinicopathologic study with histochemical and electron microscopic observations. Arch Ophthalmol. 1983;101:1395-1398.
In Reply.\p=m-\Wevery much appreciate the interest of Font et al in our article. When our patient was first seen in 1982, the slides were reviewed in consultation with numerous surgical pathologists, neuropathologists, and ophthalmic pathologists at six medical institutions across the country. There was a consensus that the tumor was neuroendocrine in nature. The diagnoses included esthesioneuroblastoma, metastatic carcinoid tumor, neuroblastoma, and paraganglioma, with the majority favoring a diagnosis of neuroblastoma. At that time, specific keratin antibody stains, as
performed by Dr Battifora, were not available. We reviewed Dr Battifora's slides and agree with his interpretation of the tumor's keratin positivity. A polyclonal
broad-spectrum antikeratin stain was questionably positive in our laboratory while our anti-AE1/AE3 was strongly
Downloaded From: by a Tulane University User on 01/18/2019
positive. The keratin positivity effectively includes a neuroblastoma and is very strong evidence in favor of a carcinoid tumor. In view of these new findings, we completely agree that this is a carcinoid tumor. Considering the 8-year asymptomatic period and the negative results of the sys¬ temic evaluation, it appears that this is another case of pri¬ mary orbital carcinoid tumor similar to the one reported by Zimmerman and coworkers.1 We are extremely grateful to Font et al for bringing this new information to our atten¬ tion. We especially appreciate Dr Battifora's immunologie expertise in resolving this controversial case. The utility and reliability of immunohistochemistry is continually in¬ creasing.
Patrick J. Connelly, MD John D. Bullock, MD Dayton, Ohio
1. Zimmerman LE, Stangl R, Riddle PJ. Primary carcinoid tumor of the orbit: a clinicopathologic study with histochemical and electron microscopic observations. Arch Ophthalmol. 1983;101:1395-1398.
Encroaching Lens Loops To the Editor.\p=m-\Iread with interest the letter in the June 1990 issue of the Archives by Olson and Brodstein.1 They describe a 20-year-old woman who underwent extracapsular cataract extraction with placement of a polypropylene looped posterior chamber intraocular lens (PC IOL). After
a period, the polypropylene loops were forced by capsular fibrosis to encroach on the edge of the IOL, and one appeared over the IOL and the other one under it. I might simply add that this would not occur if a one-piece polymethyl methacrylate (PMMA) PC IOL had been used.
ta 1. Olson
RJ,
Kennethfer,Hoffer, Monica, Calif
Brodsteinoaching lens loops.
Arch
OphthalmoOphthalmol.
L990;108:1990
In Reply.\p=m-\Dr Hoffersue that a one-piece PMMA PC IOL would avoid the problem of encroaching loops due to capsular fibrosis. Although many all-PMMA lenses are significantly stiffer and maintain their "memory"ch better than polypropylene, we still do not know the forces involved in capsular fibrosis. Therefore, it is too early to state that the problem would be totally eliminated one-pieceses. It is also important to note the by recent trend toward more flexible all-PMMAand so new lenses approach the flexibility of polypropylene loops. As a general rule, it is true that encroaching lens loops are generally polypropylene. It is also true, however, that polypropylene has been around much longer and the number of "in-IOLsh polypropylene patient years of all-PMMA Only time loops is many times that of the will tell which lens is better. Randallon, Olson, t Lake City, Utah Robert Brodstein, S. MD Rober Ogden, Utah Decentration of an hamber Intraocular Lens due to aocularation
To the Editor.\p=m-\Decentration of casalIPaoOmCtpeLlication of surgery has extracapsular cataract -2rature. erature.1-2. The mostcauseisthefrequent umented haptic in the capsular bag and theother placement of one in the ciliary sulcus. Subsequent contracturecoftahpseularg may deform the hapticltimately decenter the well been doc-
