the total pupillary capture was reduced in the clinic by positioning with the dilated pupil. The inferior one half of the lens remained captured. She returned to the clinic the succeeding day for another attempt at medi­cal repositioning of the lens, which was again unsuc­cessful. . The pupil was dilated well beyond the margin of the lens, but the lens never came posterior to the pupil plane. She was sent home on 1 % Mydriacyl four times per day and told to lie down as much as possible and was scheduled for operative repositioning of the lens. Her pressure remained controlled in the low 30' s. She returned for preoperative examination a few days later at which time it was seen that the pupillary cap­ture had completely reduced. The pupil returned to about a 4 mm size anterior to the lens and on no medication has remained in proper position with a normal pressure. The vision has returned to 20/25+.

We learned several things from this case: l. Total pupillary capture with pupillary block glau­

coma is possible even in a myopic eye with a posterior chamber lens.

2. Patients should have their dilation reversed with pilocarpine prior to leaving the clinic, even with posterior chamber lenses.

3. A peripheral iridectomy may not be a bad idea if one is using a nonangulated lens. An angulated posterior chamber lens may not need peripheral iridectomy.

4. When one does obtain pupillary capture, it is possible to reduce capture at home by putting the patient on chronic dilation and asking him or her to remain supine.

Stephen D. Miller, M.D. Honolulu, Hawaii

PERIORBITAL INJECTION FOR CATARACT EXTRACTION

To the Editor: We read with interest the letter from Brad Pazan­

dak, M.D. and Gerald Faulkner, M.D., "Omission of Injection for Lid Akinesia," (Am Intra-Ocular Implant Soc] 9:48-49, 1983) describing cataract extraction using only retrobulbar anesthesia. This spares the pa­tient the pain of a separate lid block.

For the past two years, we have also used only one injection, but it is periorbital rather than retrobulbar.

No preoperative sedation is used. A solution of20 cc of bupivacaine 0.75% and 150 USP units of hyaluronidase is made up. A one-inch #25-gauge disposable needle is passed to its full extent through the lower lid inferior and temporal to the globe parallel to the lateral orbital wall. Four to five cubic centimeters is injected at that depth and a similar amount as the needle is withdrawn. Usually the fluid can be seen passing around the orbit giving a fullness to the lids, and we purposely pause in the lower cul-de-sac to blow up the inferior conjunc­tiva. We then apply a Honan pressure reducer for 20 to 30 minutes.

We can judge the effectiveness of the injection by dilation of the pupil, akinesia of the lids, akinesia of the extraocular muscles, and lack of pain when the superior rectus or conjunctiva is grasped. In most cases, all of these are present and there is profound pressure re­duction as well. Occasionally one or more areas escape the full effect and a supplemental injection locally is required.

Our reasoning is that it is equally effective and safer for the anesthetic to diffuse into the retrobulbar space from the periorbital space than the other way around. This reduces the chance of serious side effects such as direct needling of the optic nerve, retrobulbar hemor­rhage, or inadvertent injection into the optic nerve sheaths with retrograde diffusion into the brain.

John W. Norris, M.D. I. Allen Chirls, M.D. Vidya B. Bhardwaj, M.D. South Orange, New Jersey

PROTECTING THE LENS FROM LID CONTACT

To the Editor: Every effort should be made to avoid having an

implant come into contact with the lids or lashes while inserting the lens into the eye. A simple maneuver to facilitate protection of the lens is to cut out of the 3M Steri-Drape 1020 at one of the corners a rectangular piece measuring about 3 x 4 cm. This piece is placed over the upper lid margin, lashes, superior blade of the speculum, and the upper portion of the globe superior to the surgical incision. Moistening the material holds it in position better. The lens can then be inserted without touching the lids.

Frank J. Beasley, M. D. Fort Lauderdale, Florida

AM INTRA-OCULAR IMPLANT SOC J-VOL 9, SPRING 1983 193