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Benign orbital neoplasms comprise a wide spectrum of different entities. The origin of the tumours can be epithelial or mesenchymal. Epithelial neoplasms of the orbit originate from the lacrimal gland. The most important tumour is the pleomorphic adenoma, which should not be biopsied but resected in toto. The most common intraconal neoplasm in adults is the cavernous hemangioma. Symptomatic cavernous hemangiomas should be treated. The treatment of choice for most symptomatic benign neoplasms of the orbit is surgical resection. Suitable surgical approaches are anterior transconjunctival and lateral orbitotomy. Cryoextraction is a minimally invasive technique that is particularly suitable for cavernous hemangiomas.

A retrospective analysis of the results of surgical treatment of complicated uveal cataracts of different origin.The study analyzed the results of surgical treatment of uveal cataract in 30 patients (34 eyes) who were divided into three groups by uveitis etiology. The first group included 11 patients with spondyloarthritis associated with the HLA-B27 antigen; the second group included 10 patients with juvenile chronic arthritis and spondyloarthritis, negative for HLA-B27 antigen; the third group consisted of 9 patients with other systemic autoimmune diseases and uveitis of unknown etiology, also negative for the HLA-B27 antigen. The average age of the patients was 35.8±2.6; 30.8±3.8 and 34.0±2.3 years, respectively. Four patients (6 eyes) with juvenile chronic arthritis and severe ribbon-like corneal degeneration underwent standard intracapsular cataract cryoextraction with subsequent spectacle correction of aphakia. In other cases, ultrasound phacoemulsification with implantation of an intraocular lens (IOL) was used as a surgical aid.Regardless of the surgery technique and the cause of uveal cataract, a statistically significant decrease in the number of exacerbations per year (Surgical treatment of uveal cataracts of various etiologies with adequate pre- and postoperative therapy provides an improvement in visual acuity and a reduction in the frequency of inflammation recurrence. Considering the high likelihood of IOP decompensation in the long-term postoperative period, IOP control should be given attention in such cases.Ретроспективный анализ результатов хирургического лечения увеальных катаракт различного генеза.Проанализированы результаты хирургического лечения увеальной катаракты у 30 пациентов (34 глаза), которые были разделены на три группы по этиологии увеита. В 1-ю группу включены 11 пациентов со спондилоартритами, ассоциированными с HLA-B27 антигеном; 2-я группа — 10 пациентов с ювенильным хроническим артритом и спондилоартритами, отрицательными по HLA-B27 антигену; 3-я группа — 9 пациентов с другими системными аутоиммунными заболеваниями и увеитом неясной этиологии, также отрицательными по HLA-B27 антигену. Возраст пациентов в среднем составил 35,8±2,6; 30,8±3,8 и 34,0±2,3 года соответственно. Четырем пациентам (6 глаз) с ювенильным хроническим артритом и выраженной лентовидной дегенерацией роговицы была произведена стандартная интракапсулярная криоэкстракция катаракты с последующей очковой коррекцией афакии. В остальных случаях в качестве хирургического пособия использовали ультразвуковую факоэмульсификацию с имплантацией интраокулярной линзы.Независимо от методики операции и причины увеальной катаракты после ее удаления отмечено статистически достоверное уменьшение количества обострений в год (Хирургическое лечение увеальных катаракт различной этиологии при адекватной пред- и послеоперационной терапии обеспечивает улучшение остроты зрения и сокращение частоты рецидивов воспаления. Учитывая высокую вероятность декомпенсации офтальмотонуса в отдаленном послеоперационном периоде, следует уделять внимание контролю его уровня.

Tadeusz Krwawicz (1910–1988) pioneered the use of cryosurgery in, as ophthalmology. The idea arose in 1959 while experimenting because on lyophilization to store corneas and lenses for transplantation it was difficult to remove the lens without damage the capsule was usually torn. Subsequent experiments on rabbits revealed that touching the lens with a wire cooled to 203°K (–70°C) resulted in firm attachment of the lens capsule and subcapsular masses. A cryoextractor was developed and employed for clinical use in cataract extraction, likewise in intumescent cataracts and lens subluxation. Cataract surgery utilizing cryoextraction led to substantial progress to ophthalmology by reducing the number of complications, particularly capsule rupture, and resulted in achieving better outcome compared to other methods. This surgery soon and for almost 20 years became a routine method used all around the world in cataract removal. Simultaneously, Krwawicz developed techniques for corneal refractive surgery—partial lamellar removal of the corneal stroma and temporary interlaminar introduction of a plastic disk in order to change the corneal curvature. Krwawicz presented other ophthalmic interests—his research concerned immunology, histology, histochemistry, biochemistry of ocular tissue, and mainly corneal and experimental surgery with a particular focus on the pathology of the cornea.

Acta Ophthalmol. 2010: 88: 675–680 Abstract. Purpose: To describe and evaluate a cryo-assisted, minimally invasive, anterior approach for orbital tumour surgery. Methods: Retrospective, non-comparative, consecutive, interventional case series of 103 patients who were operated on by the same surgeon for retroocular orbital tumours over the last 16 years. Results: A cryo-assisted, minimally invasive, anterior approach was employed in 63 out of the 103 patients (61.2%). In 37 patients (35.9%), anterior orbitotomy without the use of cryoprobe was employed for biopsy or excision of small, anteriorly located lesions. Lateral orbitotomy was used in three patients (2.9%). In a subgroup of 61 patients with circumscribed lesions (mainly cavernous haemangiomas and schwannomas), cryoextraction was used in 51 (83.6%). None of the procedures required conversion to lateral orbitotomy and there were no intraoperative complications. Conclusion: In contrast to other reports on the treatment of orbital lesions, in the current case series surgery of most solid tumours and many other cystic or infiltrative lesions was achieved here via an anterior, cryo-assisted approach, and thus with minimal trauma to the orbit. This approach warrants more favourable consideration because the combination of the anterior approach with the use of cryoprobe and surgical microscope can yield successful results, even in patients with large or deeply located tumours – obviating in most of them the need for lateral or transcranial orbitotomies with bone flaps.

Kecova, H. , A. Neaas: Phacoemulsification and Intraocular Lens Implantation: Recent Trends in Cataract Surgery. Acta Vet. Brno 2004, 73: 85-92. This review article summarizes the evolution of cataract surgery techniques and intraocular lens (IOL) implantation. It emphasizes the necessity of appropriate patient selection for the surgery and precise surgical technique for successful outcome of this procedure in dogs. The history of cataract surgery, factors critical for good outcome of the procedure, timing of surgery, preoperative medication, phacoemulsification technique and types of implanted intraocular lenses are discussed. Cataract, phacoemulsification, intraocular lens, dog Cataract (Plate XIII, Fig. 1) is a leading cause of unilateral and more often bilateral blindness in dogs. The only effective mean of its treatment is surgery – extraction of diseased lens (Dziezyc 1990) and its replacement by an artificial intraocular lens (IOL = “intraocular lens”). The opinions on cataract surgery have been changing continually with advancement of the procedure. The success rate of cataract surgery has risen significantly during last decades, especially thanks to development of more precise microsurgical techniques and with introduction of phacoemulsification (Boldy 1988; Dziezyc 1990) and IOL implantation. History of cataract surgery The initiation of “cataract surgery” is mentioned in ancient India as early as 2000 years B.C.; at that time the only attempt was to restore vision by iatrogenic posterior luxation of cataractous lens reclination. Until now reclination remains a method of choice of shamans in some parts of Africa (Ghana). In 1745 Daviel performed the first extracapsular cataract extraction (ECCE). In 1753 Sharp performed the first intracapsular cataract extraction (ICCE) by expression of the nucleus using a thumb. During the 17th, 19th and the beginning of 20th century, the most popular method of cataract extraction was ICCE (different methods of mechanical zonulolysis). After the 2nd World War, the ECCE became more popular with development of better operating microscopes. In 1949 Harold Ridley implanted first posterior chamber IOL in a 60-year-old woman after previous ECCE (Ridley 1952). However, due to a large degree of secondary cataract, glaucoma and anterior chamber inflammation following “primitive” ECCE (without irrigation/aspiration of remaining cortical material), this method was again replaced by intracapsular extraction. In 1957, Barraquer carried out the first ICCE using enzymatic zonulolysis (Barraquer 1958) and in 1961 first cryoextraction was done by Krawicz. In 1970s, with improved irrigation/aspiration devices and capsulotomy techniques, surgeons again returned to ECCE (now with complete removal of remaining cortical material). With the development of ultrasound machines creating low ACTA VET. BRNO 2004, 73: 85–92 Address for correspondence

A 55-year-old Caucasian woman presented with an orbital cavernous haemangioma superior to the optic nerve in the orbital apex. Preoperative imaging demonstrated a mass involving the superomedial and superolateral quadrants of the posterior orbit. A stereotactic fronto-orbital approach was performed by the neurosurgical team, and cryoextraction of the lesion was accomplished by the ocular plastic surgical team.

Purpose The aim of this course is to share our experience with transconjunctival or transcutaneous anterior orbitotomy using surgical microscope and cryoextraction approach for surgery of retroocular orbital tumors. Methods Data regarding the used of this anterior surgical approach to retro-ocular orbital tumors was collected from our case series of 103 patients who, over 16 years, were operated on for retroocular orbital tumors and from a newer case series of 24 patients who, over the last 5 years were operated on for orbital cavernous hemangioma. Results A cryo-assisted, minimally invasive, anterior approach was employed in most patients. During more than 20 years lateral orbitotomy was needed only in 3 patients. The operations with anterior approach lasted 57.9 + 15.0 minutes. In none there was need for transformation into lateral orbitotomy and there were no intra-operative complications. No post operative deterioration of visual acuity was evident. Conclusion In contrast to other reports on treatment of orbital lesions, in our experience, surgery of most solid tumors and of many other cystic or infiltrative lesions can be achieved via an anterior, cryo-assisted approach, and thus with minimal trauma to the orbit. This approach warrants more favorable consideration as it can yield successful results even in cases with large or deeply located tumors. In most cases it obviates the need for extra-ocular muscle disinsersion and lateral or transcranial orbitotomies with bone flaps.

Vitreoretinal surgery allows the effective removal of soft to moderately dense crystalline lens fragments, using the vitrectomy probe and the ultrasonic fragmentation probe. Hard lenses cannot be removed with these instruments. Previously described techniques for removal of hard lenses include trapping the lens anteriorly with needles, cryoextraction of the lens in an air-filled eye, and manipulation with sodium hyaluronate. These methods are difficult and dangerous in some cases. We used perfluorocarbon liquid to facilitate the safe removal of a surgically luxated hard crystalline lens. Injection of the perfluorocarbon liquid floated the lens off the retinal surface and into the anterior vitreous cavity. In this location, the lens was delivered by using standard extracapsular cataract extraction techniques. This technique allowed removal of the hard crystalline lens with minimal manipulation, and was helpful in the setting of poor media clarity.

BACKGROUND The cavernous haemangioma (cavernoma) is the most common orbital tumour in adults. Various surgical approaches have been described so far. We prefer a transconjunctival approach and analyse herein how our outcomes compare with those of transcutaneous or transosseous approaches. METHODS A retrospective series of 10 cases was analysed with regard to surgical success and complications. RESULTS The tumour could be completely removed in all cases. In one case, preoperative diplopia disappeared after surgery. Another case suffered from postoperative diplopia, which resolved within two months. Two cases developed a long-lasting partial tonic pupil. CONCLUSION A retrobulbar cavernoma can be safely removed via a transconjunctival approach through shrinkage by coagulation and subsequent cryoextraction.

Patient A 35-years-old female patient with Marfan's syndrome presented with fast progressive reduction of visual acuity (hand movements) of her right eye and lens-related glaucoma on both eyes. On examination, subluxation of the lens and nuclear cataract were seen on both eyes. Diurnal pressure curve showed great fluctuations in pressure with normal IOP in the morning and elevated pressure in the evening. Pressure measurement revealed great fluctuations depending on positioning. Because of cataractous lens in the right eye blocking the visual axis and uncontrollable, phacogenic glaucoma removal of the lens by cryoextraction was necessary. Visual acuity increased to 0.5 and IOP was normal after three weeks. To improve safety of topical medication of lens-related glaucoma in Marfan's syndrome regular measurement of IOP at different times of the day is especially important. Measurement of IOP at different positions seems to be an effective provocation test in cases of phacogenic glaucoma in Marfan's syndrome. Examination of all members of a family with Marfan's syndrome should include regular measurement of IOP at different times of the day. In suspected cases, measurement of IOP at different positions that may provoce IOP-increase could be useful in the early detection of lens-related glaucoma.

This article is dedicated to the life and work (research, medical, educational) of V.V. Shmeleva, professor and Great Patriotic War participant. She was the head of ophthalmology department at the City Clinical Hospital No 67 and promoted the implementation of cataract cryoextraction into clinical practice. As a professor at the Order of Lenin Central Institute of Advanced Medical Training she was engaged in postgraduate training of ophthalmologists. V.V. Shmeleva is the author of Cataract monograph and many scientific articles. She was also the senior secretary of the Vestnik oftal'mologii journal for more than 25 years.

Four patients with relatively large orbital tumors are described. These patients had superomedial rhabdomyosarcoma, inferomedial cavernous hemangioma, lateral primitive neuroectodermal tumor, and superior neurofibroma, respectively. Continuing enlargement and encroachment upon vital ocular structures and suspicion of malignancy warranted surgical intervention. Following exposure of the anterior portions of these tumors, a cryoprobe was used for the complete removal of the mass. Cryoextraction greatly facilitates the excision of well-defined, solid, encapsulated, benign or malignant tumors excluding the lacrimal gland and thus minimizes trauma to adjacent tissues. More importantly, the tumor can be removed intact without capsular rupture and risk of tumor spill-over or hemorrhage. At the histopathological level, the application of a cryoprobe did not alter the microscopic structures of the lesions and did not cause any difficulty for histopathologic interpretation.

In India are approximately 4 million blind people by advanced or mature cataract. For only 10 US$ one patient can be operated in eye camps in the villages by an intracapsular cataract cryoextraction an + 12.00 dptr. aphakia glasses. Also estimated four million people are blind by xerophthalmia. The project is to examine all the babies and little children in the villages and to give them for 2 years each month vitamin-A-medication. On the other side the parents of children suffering from xerophthalmia are instructed to plant vegetables rich in vitamin A. The goal of both projects is to make a cataract and xerophthalmia free zone in Uttar Pradesh, which should spread over the entire country. Both projects are sponsored by Combat Blindness Foundation, P.O. Box 5, 332 Madison Wisconsin 53705 USA, Professor Suresh Chandra, chairman.

Owing to the use of wide-angle observation systems 1,2 the lens can be preserved during the vast majority of pars plana vitrectomies. When such lenses later develop cataracts, they frequently exhibit nuclear sclerosis of such a degree that phacoemulsification would no longer be a safe procedure, even for experienced anterior-segment surgeons who are more and more comfortable emulsifying denser and denser lenses. The vitreous cavity of these eyes is filled with aqueous or silicone oil. This fact renders standard extracapsular cataract extraction with expression of the lens nucleus potentially hazardous because pressure on the globe may lead to collapse of the posterior segment in eyes filled with aqueous or to a localized rupture of the zonule and subsequent formation of a persistent pathway through which silicone oil can pass from the vitreous cavity into the anterior chamber. To avoid such complications, extracapsular cryoextraction, followed by an irrigation-aspiration procedure, has proven

A surgical technique is described for cryoextraction of the inner germinal layer of orbital hydatid cysts. The technique was adopted in two cases. It is simple and effective and causes minimal postoperative reaction or complications. There were no recurrences over a period of 24 and 18 months respectively.

In 123 cases of lens luxation the lens was removed from the vitreous by cryoextraction. It was a success in 119 cases, always intracapsular, and in the majority of cases without or only with a minimal loss of vitreous. A vitrectomy or vitreous suction was never necessary. Evaluating these results, one would advise to employ this procedure early before an advanced vitreous destruction may occur.

A case of Serratia marcescens endophthalmitis following an intracapsular cataract cryoextraction in a diabetic patient is delineated. Appropriate antibiotic therapy failed to control the infection. Intravitreal administration in rabbit eyes of the culture of live bacteria, broth suspension of the dead-disrupted form of the organism, or the bacteria-free culture filtrates produced an infection that mimics the case presented.

For generations, ophthalmic surgeons have worked toward perfecting the intracapsular extraction of cataracts. Yet, on occasion, even the most experienced and dexterous of surgeons unavoidably ruptures the capsule. Cryoextraction, in contrast to extraction by means of erisophake or forceps, by placing the tractive stress not on the fragile capsule but on the whole lens invariably assures a successful intracapsular operation. It is rather surprising that cryoextraction has found little acceptance in this country since Krwawicz first reported his technique in 1961. 1,2 Perhaps this has been due to a lack of completely satisfactory instrumentation. Krwawicz merely immersed a metal probe into a mixture of alcohol and solid carbon dioxide, lowering the temperature effectively but for a relatively short period that made rapid surgery (or repeated immersions and applications) necessary. Other instruments that are now available are the liquid nitrogen unit originally developed for brain surgery (involving a massive monitoring unit)

The size of the crushed cataractous bag was determined by measuring the diameters and widths of 50 cataracts removed by cryoextraction and then mathematically determining their individual areas and crushed bag size. These lenses had a collapsed bag size of 10.8 +/- 1.4 mm.

The presently employed methods for cataract operations are characterized by a high success quota. Some details from the fields of anesthesia, separation of the lids, cutting and stitching form, stitching material, cryoextraction which contribute to this success quota are discussed.

A case of electrical shock occurred with a heater-equipped cataract cryopencil. The short circuit resulted from apparent mistreatment of the cataract probe. Steps are listed for the prevention of such an occurrence. The probe tip should be grounded. Any evidence of muscle contraction when the probe is activated constitutes a danger signal.

THE APPLICATION of low temperatures to ocular surgery has resulted in numerous reports of the value of this modality in the treatment of cataract, retinal detachment, and to a lesser degree, glaucoma. Other ocular conditions have been treated by cryosurgical techniques 1 and currently constitute "minor" indications for the use of this modality. Recent favorable experience with cryoextraction of clotted blood in cases of total hyphema prompts the present report. Total hyphema carries a grave prognosis. Its deleterious effects require surgical removal of the blood from the anterior chamber when secondary glaucoma in uncontrollable by medical means or when corneal hemosiderosis occurs. Fibrinolytic agents and aspiration have been advocated by some investigators, 2 while others have recommended removal of the anterior chamber clot by forceps or the erysiphake. 3-4 All of these techniques have been successful, but all have their drawbacks. Cryosurgery, although not ideal, appears to offer some advantages

Traumatic cataracts occurring after ocular trauma were removed by phacoemulsification, cryoextraction or extracapsular cataract extraction, depending on the degree of lens absorption. All eyes received sputnik-style iridocapsular lenses. Most cases were complicated by the presence of synechiae and/or the need for iridoplasty. The surgical technique varied with the specific nature of the ocular pathology. Eyes with penetrating injuries had a higher complication rate. Anterior chamber shallowing or collapse was the most frequent intraoperative complication, and was directly related to the incidence of postoperative complications. Most postoperative complications were typical of those associated with cataract surgery in complicated situations.

Lens capsule thickness was measured in 105 cataractous lenses with and without exfoliation syndrome. The lenses were removed by intracapsular cryoextraction. Forty lenses (38%) showed exfoliation, while 65 (62%) were exfoliation negative. Thickness values were measured by light microscopy from the central anterior capsule, central posterior capsule and from the equator. The mean thickness values were for the central anterior capsule 8.2 ± 3.2 μ, for the central posterior capsule 3.2 ± 1.4 and for the equator 3.9 ± 1.3. There was no statistical difference between the exfoliation-positive and exfoliation-negative lenses. The capsule thickness varied greatly throughout the present material. The highest value, 22.4 μ, was measured from an exfoliation-negative central anterior lens capsule of a male patient aged 33 years. The lowest value, 0.6 μ, was measured from an exfoliation-positive central posterior capsule of a male patient aged 64 years. The central posterior capsule is the thinnest area of the lens capsule. The findings call for great caution in polishing the posterior capsule during extracapsular cataract surgery. The higher complication rate in eyes with exfoliation syndrome cannot be explained by thinner lens capsules but rather on the more friable zonules.

Routine use of cryosurgery in a series of 200 cataract extractions resulted in a marked increase in the incidence of irreversible corneal edema when compared with a series of 900 deliveries by conventional methods (increase from 0.66% to 4¼%). This is presumably due to inadvertent freezing and lysis of a critical number of endothelial cells. These clinical observations are consistent with laboratory findings of other workers who induced irreversible corneal edema in rabbits by surface freezing techniques. Further research appears indicated before cryosurgery can be routinely adopted as a safe method of cataract extraction. Until such time caution is urged.

Severe complications associated with the extraction of the dislocated lens have made many surgeons hesitant to operate in such cases. However, with cryoextraction of the lens, using a controllable probe inserted into the eye at ambient (room) temperature, the operative risk is greatly reduced. Previous work in cryoextraction of the dislocated lens 1 described the use of a double-pronged needle, which was inserted with the patient in a prone position, to trap and support the lens prior to cryoextraction. Frequently, the probe had to be applied a few times before good contact with the lens was obtained. This was due to refraction of light rays by the vitreous anterior to the lens, disturbing the operator's judgment of depth. The technique was not entirely satisfactory mainly because of the damage inflicted to the pars plana by insertion of the double-pronged needle. It was impossible to remove a lens fixed to the

TWO papers in this issue of theArchives(pp 3-9) report on cataract cryoextraction and the complications encountered. Both agree that the incidence of capsular rupture is reduced by cryoextraction. On the other hand, one paper reports an alarmingly high incidence of irreversible corneal edema following cataract cryosurgery while the other paper scarcely mentions any problem concerned with the cornea. In view of the increasing popularity of this technique, this apparent discrepancy deserves further explanation. Taylor and Dalburg report an incidence of 4.5% of postoperative corneal edema, often progressing to severe bullous keratopathy, in a series of 200 cases employing one of three types of cryoextractors. In a larger control series, the authors report an incidence of corneal edema of only 0.66%. Their speculation based on certain animal experimentation in the literature, is that freezing or excessive chilling of the corneal endothelium was the factor responsible for the greater incidence

Because cryoextraction is a technique of cataract surgery that is still on trial, it is important that those who are testing the method should put their experiences on record. For that reason, we are publishing the account of 100 consecutive extractions performed by this technique, by the residents in ophthalmology on the ophthalmologic service of Louisiana State University School of Medicine at Charity Hospital of Louisiana at New Orleans, with an instrument devised by one of us (D.L.) for this purpose. A new epoch in cataract extraction—for so we believe it to be—began in 1961, when Krwawicz1described the simple, functional instrument he had devised for cryoextraction of cataracts. His extractor was a pencilshaped, nickel-plated copper instrument, which was cooled in a mixture of solidified carbon dioxide (Dry Ice) and methyl alcohol at -79 C. With it, he had been able to perform intracapsular extraction of 48 of 50

THE RAPID increase in use of electromedical apparatus in clinical medicine and medical research has, for the most part, resulted in significant benefits for the patient and, in general, improved medical care. However, the introduction of these instruments into the hospital environment has created new patient hazards which must be recognized by both the clinical user and the electronic designer-manufacturer. There are two distinct types of electrical hazards in the hospital environment: "macroshock" and "microshock." Macroshock is the familiar hazard of superficial contact shocks that we face every day. Microshock, however, is a new hazard, peculiar to the hospital environment. This type of shock cannot be felt by the operator and may occur without warning. Your patient is increasingly surrounded by and connected to many instruments carrying electric currents. If these instruments are not well grounded, small currents, called leakage currents, can result in undesirable side effects. They will be

Intralenticular foreign bodies are neither unequivocal antecedents of cataract nor indications for immediate lens extraction. Minute foreign bodies either chemically active or nonmagnetic are preferably left in the lens. Small to medium size magnetic foreign bodies should be extracted with minimal magnetic gauss carefully along the entrance pathway. Capsular tears under 2 mm tend to seal, whereas those of 3 mm or larger may lead to opacity. Major foreign bodies causing extensive cataract should be removed by cryoextraction of the lens, unless multiple capsular tears or perforations are present. Under these conditions, the lens may be allowed to absorb unless glaucoma or uveitis require removal. Foreign bodies should be placed in culture broth after extraction rather than taped to the chart.