Severe fibrinous reaction after cataract and intraocular lens implantation surgery requiring neodymium: YAG laser therapy
mentioned. 3 We report six cases that did not resolve with steroids; they required neodymium:YAG laser membranectomy or microsurgical excision.
John W. Norris, M.D. I. Allen Chirls, M. D. Joseph G. Santry, O.D. John W. Norris III, M.D.
All patients were scheduled for phacoemulsification with implantation of a modified C-style posterior chamber lens with 15-degree angulation unless the pupil would not dilate to 5 mm or the endothelial cell count was below 1,000 cells/mm. When a phacoem ulsifier was not available, a planned extracapsular cataract extraction (ECCE) was performed. During the period reviewed, lenses from two companies were used. Similar cases had not been reported to either company. All lenses had polypropylene (Prolene®) haptics. Most lenses were placed in the ciliary sulcus and the wound closed with 10-0 nylon sutures. Three operating rooms in two hospitals were used. Three phacoemulsifiers and two automated irrigation/aspiration (1/A) machines were used. A quality control audit, carried out by each hospital after the first reaction, showed all standards were upheld. Over 80% of the cases were performed by phacoemulsification and five of the six reactions occurred with phacoemulsification. Anterior chamber or vitreal taps were not performed because we did not believe infection would be the cause of a reaction that started at least ten days after surgery and appeared to have been managed with steroid therapy. All cataract extractions performed in this period are included.
ABSTRACT Fibrous membrane formation on the anterior surface of an intraocular lens with occlusion of the pupil was noted in five patients having phacoemulsification and one patient having planned extracapsular cataract extraction, Initial onset of pain and decreased vision ranged from eight to 36 postoperative days. Since these patients did not respond fully to steroid therapy, the neodymium:YAG laser was used to disrupt the fibl'inous membrane which occluded the pupil. In all but one case, the fibrinous l'eaction responded to laser therapy. Generally, less energy was required when laser therapy was initiated early in the treatment plan.
Key Words: fibrin , m mbranectomy, neodymium :YAG lase r
In a series of 1,041 consecutive extracapsular procedures with intraocular lens (IOL) implantation, six cases of severe fibrinous reaction were noted. The onset of this reaction ranged from the eighth to the 36th postoperative day and was accompanied by pain and occlusion of the pupil. Previous reports 1 ,2,3 show the onset of a fibrinous reaction occurring between the first and tenth postoperative day. These same reports show favorable response to steroid therapy, although use of a YAG laser was From the Northern New Jersey Eye Institute, South Orange, New Jersey. Reprint requests to John W Norris, M.D., Northern New Jersey Eye Institute, 71 Second Street, South Orange, New Jersey 07079.
MATERIALS AND METHODS
CASE REPORTS
Case 1 A 63-year-old black female whose medical history included hypertension, arteriosclerotic heart disease, diabetes mellitus, and possible glaucoma and whose medications included nitropatch, erythromycin, thioridazine and dilitiazem reported onset of pain and decreased visual acuity 22 days after phacoemulsification and posterior chamber IOL implantation. Slitlamp examination revealed an oval pupil, posterior synechias, fibrin clot, and 2 + flare and cells. Intraocular pressure was 30 mm Hg. No improvement was seen by the 25th postoperative day on topical steroids (prednisolone sodium phosphate 1% once every hour) and injections of methylprednisolone acetate (Depo-Medrol®). Neodymium:YAG laser membranectomy was performed with 102 bursts between 1.0 mJ and 1.6 mJ. Case 2 A 67-year-old white male with diabetes mellitus taking chlorpropamide reported onset of pain nine days after phacoemulsification and posterior cham-
J CATARACT REFRACT SURG- VOL
16, SEPTEMBER 1990
637
ber IOL implantation in the left eye. Visual acuity fell from 20/30 to finger counting at six feet on the 11th postoperative day. The eye was white. There were trace flare and cells and posterior synechias. Resolution of the process was seen by the 16th postoperative day with topical steroid use (dexamethasone 0.1 % every two hours) and cycloplegia. Seven months later phacoemulsification and posterior chamber IOL implantation were performed in the right eye. Onset of pain occurred 14 days later. A fibrin clot was noted. Topical steroid (fluoromethalone 1% once every hour) and cycloplegic therapy was initiated on the 14th postoperative day with no improvement by the 22nd postoperative day. Argon laser treatment of the fibrin clot showed no effect. Neodymium:YAG laser membranectomy was performed with 12 bursts at l.5 m] on the 22nd postoperative day. The eye was quiet on the 41st postoperative day.
Case 3 A 66-year-old white female whose medical history included hypertension and ulcerative colitis and whose medications included atenolol, hydrochlorothiazide and sulfacolizides reported onset of pain eight days following phacoemulsification and posterior chamber IOL implantation in the right eye. Acuity was 20/100 and a fibrin clot was noted (Figure 1). Topical steroid (prednisolone sodium phosphate 1% every two hours) and cycloplegic therapy was begun; pain continued on the tenth postoperative day. Neodymium:YAG laser therapy (71 bursts between 0.9 m] and l.4 m]) was performed on the tenth postoperative day and medication was continued. Acuity was 20/20 on the 70th postoperative day, with mild inflammation continuing into the ninth postoperative month.
Fig. 1.
638
(Norris) Case 3. Fibrinous membrane on anterior IOL surface eight days postoperatively.
J CATARACT REFRACT
One year after this surgery the patient had phacoemulsification with implantation of the same style IOL in the left eye. The postoperative course was uneventful.
Case 4 A 66-year-old white female whose medical history included hypertension treated with propranolol hydrochloride reported onset of pain on the 36th day following phacoemulsification and posterior chamber IOL implantation. A fibrin clot was noted. Neodymium:YAG laser membranectomy was performed. Slight improvement was seen with prednisolone sodium phosphate 1 % and cycloplegic therapy. A second YAG membranectomy (41 bursts at 0.6 m]) was performed on the 39th day. Prednisone 5 mg by mouth and prednisolone acetate 1% every two hours were begun and gradually tapered. The eye was quiet five weeks following YAG therapy. Case 5 A 62-year-old black female whose medical history included diabetes mellitus and hypertenSion and whose medications included insulin, reserpine, and hydrochlorothiazide had a fibrin reaction eight days after planned ECCE with IOL implantation. A topical steroid (prednisolone sodium phosphate 1% four times a day) and cycloplegia were initiated. The eye responded well to treatment. At 55 days postoperatively pain was reported; a fibrin clot over the IOL and iris bombe were noted. Intraocular pressure was 34 mm Hg. The neodymium:YAG laser was used (100 bursts at l.0 m], 22 bursts at 1.5 m]) and a topical steroid (prednisolone acetate 1% every two hours), a cycloplegic, and a Depo-Medrol injection were given. The eye quieted. Case 6 A 67-year-old white male whose medical history included hypertenSion untreated by medication and advanced glaucoma had phacoemulsification with implantation of a posterior chamber IOL and a trabeculectomy. An inadvertent puncture of the posterior capsule did not result in vitreous loss. Cortical clean up was not thorough. Onset of pain with loss of visual acuity occurred 17 days after surgery. Pupillary capture, 3 + flare and cells, and fibrin clot over the anterior IOL surface were noted. Depo-Medrol injection, topical (prednisolone sodium phosphate 1%) and systemic (prednisone 80 mg orally every other day) steroids and cycloplegics were administered. The patient was scheduled for surgery to lyse the fibrin clot and release the iris capture. The patient did not return for 15 days. At 32 days postoperatively posterior capsular fibrosis and a white fibrous membrane on the anterior IOL surface were noted. At 55 SURG-VOL 16, SEPTEMBER 1990
days postoperatively a pars plana vitrectomy and excision ofthe anterior membrane by sharp discission were performed. Histologic examination showed the membrane to be fibrous connective tissue with speckles of hemosiderin-laden macrophages.
DISCUSSION Fibrin deposition on the IOL has been shown to occur as a response to toxic agents such as residual ethylene oxide 4 or polyvinyl alcohol 5 coating the IOL. A 4.4% incidence of pupillary fibrin membrane after posterior chamber lens implantation was reported in Japan. 3 Lenses incubated in whole blood developed a proteinaceous film containing leucocytes and macrophages. 6 Fibrous strands were seen in rabbit eyes with iris plane lenses. 7 Talcum powder from surgical gloves was shown to cause granulomatous reactions. 8 Diabetes was implicated as a predisposing factor in one study, 1 while infusion of heparin intravenously during surgery was shown to inhibit postoperative fibrin formation in diabetic eyes. 9 An indolent, persistent uveitis not responsive to steroid therapy has been associated with Propionibacterium acnes endophthalmitis.lO,ll Hypopyon usually accompanies pain and inflammation with P. acnes. 12 Granulomatous inflammation with or without a sterile hypopyon is characteristic of phacoanaphylactic endophthalmitis.l 3 ,14 Fibrin formation did not occur in 110 consecutive eyes whose anterior capsules had been stripped ultrasonically. 2 The present study shows the occurrence of fibrin clots after both phacoemulsification and planned ECCE. Three phacoemulsifiers and two automated IIA machines were used. All lenses had Prolene haptics. Onset of fibrin reaction ranged from eight days to 36 days postoperatively. This range differs from earlier reports 1 ,2 of fibrin formation occurring within the first ten days postoperatively. Of the six cases, one (case 5) showed an exacerbation of the fibrinous reaction well after initiation of steroid therapy. Except where noted in case 1 and case 5, all patients had normal intraocular pressures on each visit. Two were being treated for glaucoma at the time. One patient had a trabeculectomy performed at the time of surgery. All patients have had quiet eyes for over one year. Previous reports note the efficacy of steroid therapy in the resolution of fibrin reactions. The present study details the persistence of the membrane in some cases despite steroid use. The absence of hypopyon, keratic precipitates, or other signs of granulomatous reaction made a diagnosis of anaerJ CATARACT
obic endophthalmitis or phacoantigenic uveitis unlikely. Toxic lens syndrome is unlikely since similar reactions did not occur with other lenses from the same lens lots. Neodymium:YAG laser bursts of between 0.6 mJ and 1.6 mJ were sufficient to disrupt the membranes. Less energy was needed to disrupt the fibrin membrane if laser therapy was performed early in the course of membrane formation. In the case in which laser treatment was delayed, a membrane which required sharp discission formed. REFERENCES
1. Chee CKL, Lim ASM. Severe fibrinous membrane formation after extracapsular cataract extraction. Implants Ophthalmol 1988; 2:140-147 2. Nishi O. Fibrinous membrane formation on the posterior chamber lens during the early postoperative period. J Cataract Refract Surg 1988; 14:73-77 3. Miyake K, Maekubo K, Miyake Y, Nishi O. Pupillary fibrin membrane: a frequent early complication after posterior chamber lens implantation in Japan. Ophthalmology 1989; 96: 1228-1233 4. Murata T. Capsular bag intraocular lens fixation with retention of the anterior capsule. J Cataract Refract Surg 1987; 13:438-441 5. Kraff MC, Sanders DR, Lieberman HL, et al. Membrane formation after implantation of polyvinyl alcohol-coated intraocular lenses. Am Intra-Ocular Implant Soc J 6: 129-136 6. Wolter JR, Till GO. Protein deposition and leucocyte accumulation on lens implants: following exposure to whole blood in vitro. Implants Ophthalmol1988; 2:159-163 7. Hiles DA, Johnson BL. The role of the crystalline lens epithelium in postpseudophakos membrane formation. Am Intra-Ocular Implant Soc J 1980; 6:141-147 8. Karcioglu ZA, Aran AJ, Holmes DL, et al. Inflammation due to surgical glove powders in the rabbit eye. Arch Ophthalmol 1988; 6:808-811 9. Johnson RN, Blankenship G. A prospective, randomized, clinical trial of heparin therapy for postoperative intraocular fibrin. Ophthalmology 1988; 95:312-317 10. Sawusch MR, Michels RG, Stark WJ, et al. Endophthalmitis due to Propionibacterium acnes sequestered between IOL optic and posterior capsule. Ophthalmic Surg 1989; 20:90-92 11. Beatty RF, Robin JB, Trousdale MD, Smith RE. Anaerobic endophthalmitis caused by Propionibacterium acnes. Am J Ophthalmol 1986; 101:114-116 12. Meisler DM, Palestine AG, Vastine DW, et al. Chronic Propionibacterium endophthalmitis after extracapsular cataract extraction and intraocular lens implantation. Am J Ophthalmol1986; 102:733-739 13. Apple DJ, Mamalis N, Steinmetz RL, et al. Phacoanaphylactic endophthalmitis associated with extracapsular cataract extraction and posterior chamber intraocular lens. Arch Ophthalmol 1984; 102:1528-1532 14. McMahon MS, Weiss JS, Riedel KG, Albert DM. Clinically unsuspected phacoanaphylaxis after extracapsular cataract extraction with intraocular lens implantation. Br J Ophthalmol 1985; 69:836-840
REFRACT SURG-VOL 16, SEPTEMBER 1990
639
mentioned. 3 We report six cases that did not resolve with steroids; they required neodymium:YAG laser membranectomy or microsurgical excision.
John W. Norris, M.D. I. Allen Chirls, M. D. Joseph G. Santry, O.D. John W. Norris III, M.D.
All patients were scheduled for phacoemulsification with implantation of a modified C-style posterior chamber lens with 15-degree angulation unless the pupil would not dilate to 5 mm or the endothelial cell count was below 1,000 cells/mm. When a phacoem ulsifier was not available, a planned extracapsular cataract extraction (ECCE) was performed. During the period reviewed, lenses from two companies were used. Similar cases had not been reported to either company. All lenses had polypropylene (Prolene®) haptics. Most lenses were placed in the ciliary sulcus and the wound closed with 10-0 nylon sutures. Three operating rooms in two hospitals were used. Three phacoemulsifiers and two automated irrigation/aspiration (1/A) machines were used. A quality control audit, carried out by each hospital after the first reaction, showed all standards were upheld. Over 80% of the cases were performed by phacoemulsification and five of the six reactions occurred with phacoemulsification. Anterior chamber or vitreal taps were not performed because we did not believe infection would be the cause of a reaction that started at least ten days after surgery and appeared to have been managed with steroid therapy. All cataract extractions performed in this period are included.
ABSTRACT Fibrous membrane formation on the anterior surface of an intraocular lens with occlusion of the pupil was noted in five patients having phacoemulsification and one patient having planned extracapsular cataract extraction, Initial onset of pain and decreased vision ranged from eight to 36 postoperative days. Since these patients did not respond fully to steroid therapy, the neodymium:YAG laser was used to disrupt the fibl'inous membrane which occluded the pupil. In all but one case, the fibrinous l'eaction responded to laser therapy. Generally, less energy was required when laser therapy was initiated early in the treatment plan.
Key Words: fibrin , m mbranectomy, neodymium :YAG lase r
In a series of 1,041 consecutive extracapsular procedures with intraocular lens (IOL) implantation, six cases of severe fibrinous reaction were noted. The onset of this reaction ranged from the eighth to the 36th postoperative day and was accompanied by pain and occlusion of the pupil. Previous reports 1 ,2,3 show the onset of a fibrinous reaction occurring between the first and tenth postoperative day. These same reports show favorable response to steroid therapy, although use of a YAG laser was From the Northern New Jersey Eye Institute, South Orange, New Jersey. Reprint requests to John W Norris, M.D., Northern New Jersey Eye Institute, 71 Second Street, South Orange, New Jersey 07079.
MATERIALS AND METHODS
CASE REPORTS
Case 1 A 63-year-old black female whose medical history included hypertension, arteriosclerotic heart disease, diabetes mellitus, and possible glaucoma and whose medications included nitropatch, erythromycin, thioridazine and dilitiazem reported onset of pain and decreased visual acuity 22 days after phacoemulsification and posterior chamber IOL implantation. Slitlamp examination revealed an oval pupil, posterior synechias, fibrin clot, and 2 + flare and cells. Intraocular pressure was 30 mm Hg. No improvement was seen by the 25th postoperative day on topical steroids (prednisolone sodium phosphate 1% once every hour) and injections of methylprednisolone acetate (Depo-Medrol®). Neodymium:YAG laser membranectomy was performed with 102 bursts between 1.0 mJ and 1.6 mJ. Case 2 A 67-year-old white male with diabetes mellitus taking chlorpropamide reported onset of pain nine days after phacoemulsification and posterior cham-
J CATARACT REFRACT SURG- VOL
16, SEPTEMBER 1990
637
ber IOL implantation in the left eye. Visual acuity fell from 20/30 to finger counting at six feet on the 11th postoperative day. The eye was white. There were trace flare and cells and posterior synechias. Resolution of the process was seen by the 16th postoperative day with topical steroid use (dexamethasone 0.1 % every two hours) and cycloplegia. Seven months later phacoemulsification and posterior chamber IOL implantation were performed in the right eye. Onset of pain occurred 14 days later. A fibrin clot was noted. Topical steroid (fluoromethalone 1% once every hour) and cycloplegic therapy was initiated on the 14th postoperative day with no improvement by the 22nd postoperative day. Argon laser treatment of the fibrin clot showed no effect. Neodymium:YAG laser membranectomy was performed with 12 bursts at l.5 m] on the 22nd postoperative day. The eye was quiet on the 41st postoperative day.
Case 3 A 66-year-old white female whose medical history included hypertension and ulcerative colitis and whose medications included atenolol, hydrochlorothiazide and sulfacolizides reported onset of pain eight days following phacoemulsification and posterior chamber IOL implantation in the right eye. Acuity was 20/100 and a fibrin clot was noted (Figure 1). Topical steroid (prednisolone sodium phosphate 1% every two hours) and cycloplegic therapy was begun; pain continued on the tenth postoperative day. Neodymium:YAG laser therapy (71 bursts between 0.9 m] and l.4 m]) was performed on the tenth postoperative day and medication was continued. Acuity was 20/20 on the 70th postoperative day, with mild inflammation continuing into the ninth postoperative month.
Fig. 1.
638
(Norris) Case 3. Fibrinous membrane on anterior IOL surface eight days postoperatively.
J CATARACT REFRACT
One year after this surgery the patient had phacoemulsification with implantation of the same style IOL in the left eye. The postoperative course was uneventful.
Case 4 A 66-year-old white female whose medical history included hypertension treated with propranolol hydrochloride reported onset of pain on the 36th day following phacoemulsification and posterior chamber IOL implantation. A fibrin clot was noted. Neodymium:YAG laser membranectomy was performed. Slight improvement was seen with prednisolone sodium phosphate 1 % and cycloplegic therapy. A second YAG membranectomy (41 bursts at 0.6 m]) was performed on the 39th day. Prednisone 5 mg by mouth and prednisolone acetate 1% every two hours were begun and gradually tapered. The eye was quiet five weeks following YAG therapy. Case 5 A 62-year-old black female whose medical history included diabetes mellitus and hypertenSion and whose medications included insulin, reserpine, and hydrochlorothiazide had a fibrin reaction eight days after planned ECCE with IOL implantation. A topical steroid (prednisolone sodium phosphate 1% four times a day) and cycloplegia were initiated. The eye responded well to treatment. At 55 days postoperatively pain was reported; a fibrin clot over the IOL and iris bombe were noted. Intraocular pressure was 34 mm Hg. The neodymium:YAG laser was used (100 bursts at l.0 m], 22 bursts at 1.5 m]) and a topical steroid (prednisolone acetate 1% every two hours), a cycloplegic, and a Depo-Medrol injection were given. The eye quieted. Case 6 A 67-year-old white male whose medical history included hypertenSion untreated by medication and advanced glaucoma had phacoemulsification with implantation of a posterior chamber IOL and a trabeculectomy. An inadvertent puncture of the posterior capsule did not result in vitreous loss. Cortical clean up was not thorough. Onset of pain with loss of visual acuity occurred 17 days after surgery. Pupillary capture, 3 + flare and cells, and fibrin clot over the anterior IOL surface were noted. Depo-Medrol injection, topical (prednisolone sodium phosphate 1%) and systemic (prednisone 80 mg orally every other day) steroids and cycloplegics were administered. The patient was scheduled for surgery to lyse the fibrin clot and release the iris capture. The patient did not return for 15 days. At 32 days postoperatively posterior capsular fibrosis and a white fibrous membrane on the anterior IOL surface were noted. At 55 SURG-VOL 16, SEPTEMBER 1990
days postoperatively a pars plana vitrectomy and excision ofthe anterior membrane by sharp discission were performed. Histologic examination showed the membrane to be fibrous connective tissue with speckles of hemosiderin-laden macrophages.
DISCUSSION Fibrin deposition on the IOL has been shown to occur as a response to toxic agents such as residual ethylene oxide 4 or polyvinyl alcohol 5 coating the IOL. A 4.4% incidence of pupillary fibrin membrane after posterior chamber lens implantation was reported in Japan. 3 Lenses incubated in whole blood developed a proteinaceous film containing leucocytes and macrophages. 6 Fibrous strands were seen in rabbit eyes with iris plane lenses. 7 Talcum powder from surgical gloves was shown to cause granulomatous reactions. 8 Diabetes was implicated as a predisposing factor in one study, 1 while infusion of heparin intravenously during surgery was shown to inhibit postoperative fibrin formation in diabetic eyes. 9 An indolent, persistent uveitis not responsive to steroid therapy has been associated with Propionibacterium acnes endophthalmitis.lO,ll Hypopyon usually accompanies pain and inflammation with P. acnes. 12 Granulomatous inflammation with or without a sterile hypopyon is characteristic of phacoanaphylactic endophthalmitis.l 3 ,14 Fibrin formation did not occur in 110 consecutive eyes whose anterior capsules had been stripped ultrasonically. 2 The present study shows the occurrence of fibrin clots after both phacoemulsification and planned ECCE. Three phacoemulsifiers and two automated IIA machines were used. All lenses had Prolene haptics. Onset of fibrin reaction ranged from eight days to 36 days postoperatively. This range differs from earlier reports 1 ,2 of fibrin formation occurring within the first ten days postoperatively. Of the six cases, one (case 5) showed an exacerbation of the fibrinous reaction well after initiation of steroid therapy. Except where noted in case 1 and case 5, all patients had normal intraocular pressures on each visit. Two were being treated for glaucoma at the time. One patient had a trabeculectomy performed at the time of surgery. All patients have had quiet eyes for over one year. Previous reports note the efficacy of steroid therapy in the resolution of fibrin reactions. The present study details the persistence of the membrane in some cases despite steroid use. The absence of hypopyon, keratic precipitates, or other signs of granulomatous reaction made a diagnosis of anaerJ CATARACT
obic endophthalmitis or phacoantigenic uveitis unlikely. Toxic lens syndrome is unlikely since similar reactions did not occur with other lenses from the same lens lots. Neodymium:YAG laser bursts of between 0.6 mJ and 1.6 mJ were sufficient to disrupt the membranes. Less energy was needed to disrupt the fibrin membrane if laser therapy was performed early in the course of membrane formation. In the case in which laser treatment was delayed, a membrane which required sharp discission formed. REFERENCES
1. Chee CKL, Lim ASM. Severe fibrinous membrane formation after extracapsular cataract extraction. Implants Ophthalmol 1988; 2:140-147 2. Nishi O. Fibrinous membrane formation on the posterior chamber lens during the early postoperative period. J Cataract Refract Surg 1988; 14:73-77 3. Miyake K, Maekubo K, Miyake Y, Nishi O. Pupillary fibrin membrane: a frequent early complication after posterior chamber lens implantation in Japan. Ophthalmology 1989; 96: 1228-1233 4. Murata T. Capsular bag intraocular lens fixation with retention of the anterior capsule. J Cataract Refract Surg 1987; 13:438-441 5. Kraff MC, Sanders DR, Lieberman HL, et al. Membrane formation after implantation of polyvinyl alcohol-coated intraocular lenses. Am Intra-Ocular Implant Soc J 6: 129-136 6. Wolter JR, Till GO. Protein deposition and leucocyte accumulation on lens implants: following exposure to whole blood in vitro. Implants Ophthalmol1988; 2:159-163 7. Hiles DA, Johnson BL. The role of the crystalline lens epithelium in postpseudophakos membrane formation. Am Intra-Ocular Implant Soc J 1980; 6:141-147 8. Karcioglu ZA, Aran AJ, Holmes DL, et al. Inflammation due to surgical glove powders in the rabbit eye. Arch Ophthalmol 1988; 6:808-811 9. Johnson RN, Blankenship G. A prospective, randomized, clinical trial of heparin therapy for postoperative intraocular fibrin. Ophthalmology 1988; 95:312-317 10. Sawusch MR, Michels RG, Stark WJ, et al. Endophthalmitis due to Propionibacterium acnes sequestered between IOL optic and posterior capsule. Ophthalmic Surg 1989; 20:90-92 11. Beatty RF, Robin JB, Trousdale MD, Smith RE. Anaerobic endophthalmitis caused by Propionibacterium acnes. Am J Ophthalmol 1986; 101:114-116 12. Meisler DM, Palestine AG, Vastine DW, et al. Chronic Propionibacterium endophthalmitis after extracapsular cataract extraction and intraocular lens implantation. Am J Ophthalmol1986; 102:733-739 13. Apple DJ, Mamalis N, Steinmetz RL, et al. Phacoanaphylactic endophthalmitis associated with extracapsular cataract extraction and posterior chamber intraocular lens. Arch Ophthalmol 1984; 102:1528-1532 14. McMahon MS, Weiss JS, Riedel KG, Albert DM. Clinically unsuspected phacoanaphylaxis after extracapsular cataract extraction with intraocular lens implantation. Br J Ophthalmol 1985; 69:836-840
REFRACT SURG-VOL 16, SEPTEMBER 1990
639
