An investigation of the hospital charges related to the treatment of endophthalmitis in the Endophthalmitis Vitrectomy Study.

PURPOSE: The purpose of the study is to assess the hospital charges associated with the treatment of endophthalmitis using a sample of patients from the Endophthalmitis Vitrectomy Study (EVS). METHODS: The Endophthalmitis Vitrectomy Study was a multicenter, randomized clinical trial with a two-by-two factorial design to compare immediate pars plana vitrectomy to tap-biopsy and to compare the use of systemic antibiotics (intravenous) to no intravenous antibiotics in the management of postoperative endophthalmitis. Hospital charge data were collected retrospectively from 129 patients from the 4 clinical centers participating in this ancillary study. This represents 31% of the total Endophthalmitis Vitrectomy Study population. An analysis of variance was used to compare hospital charges across center and treatment. A charge-effectiveness analysis compared measures the effectiveness across treatment groups. The annual savings of hospital charges in the United States was estimated for a range of annual incidence rates of endophthalmitis. RESULTS: The use of intravenous antibiotics significantly increased hospital charges. Patients undergoing vitrectomy had significantly higher hospital charges than did patients undergoing tap-biopsy. The most charge-effective treatment for patients presenting with light perception only vision was immediate vitrectomy, whereas the most charge-effective treatment for patients presenting with better vision was tap-biopsy. Factors other than treatment independently associated with hospital charges were female sex, history of diabetes, symptom of red eye, and baseline vision of light perception only. CONCLUSIONS: Assuming the results of the Endophthalmitis Vitrectomy Study were used as a guide for the treatment of endophthalmitis, the estimated annual nationwide reduction of hospital charges would be between $7.6 million and $40.0 million.

Office repair of retinal detachment using a Lincoff Temporary balloon buckle.

PURPOSE: The purpose of the study is to report on a series of patients with retinal detachments that were repaired in an office setting using a temporary Lincoff balloon scleral buckle. METHODS: A retrospective review was performed on 162 consecutive casepatients with retinal detachment repaired in the authors' office between January 1989 and June 1995 using a temporary Lincoff balloon scleral buckle. All procedures were performed using local anesthesia and minimal equipment. RESULTS: The retina was attached completely with a single procedure in 88% of patients. Of the 19 retinas (12%) that failed primary surgery, all except 1 ultimately were reattached using traditional scleral buckling in 14, combined scleral buckling and vitrectomy in 3, and pneumatic retinopexy in 1, for a total success rate of 99.4%. Complications were minimal. CONCLUSION: A temporary Lincoff balloon scleral buckle can be used safely and effectively in an office setting for retinal detachment repair. The results are comparable to other available methods that take more time, involve greater risk, have higher complication rates, and are more costly. This technique represents a viable alternative, particularly in a managed care environment.

Eye care: diabetic retinopathy.

Diabetic retinopathy is the leading cause of blindness in the United States for adults, ages 20 to 74 years. Yet, the strict control of blood glucose may help ameliorate the potentially catastrophic effects of diabetes on vision. Physicians need a working knowledge of diabetic retinopathy.

Nocardia choroidal abscess.

Nocardia is a Gram positive, aerobic, filamentous branching micro-organism that rarely causes human infection. When infection does occur it usually takes the form of a subcutaneous abscess or a pneumonia-like illness. We describe a case of a patient with chronic lymphocytic leukaemia who developed painless loss of vision in the right eye secondary to a choroidal abscess after a prolonged course of treatment on several immunosuppressive agents. The patient also complained of right shoulder pain that was unresponsive to conventional therapy, and had been admitted and treated for several episodes of 'pneumonia'. A diagnostic transvitreal fine-needle aspiration biopsy of the ocular lesion was performed which demonstrated Nocardia asteroides. This allowed for appropriate antibiotic therapy to be instituted early in the course of the infection and prompted the systemic work-up which also demonstrated central nervous system and arthropic nocardial infection.

Vitreous haemorrhage as a complication of HELLP syndrome.

In the last trimester of an uncomplicated pregnancy a woman developed a spontaneous vitreous haemorrhage. She was later diagnosed as having HELLP syndrome, a recently described disorder comprising haemolytic anaemia, elevated liver enzymes, and a low platelet count in women with severe pre-eclampsia or eclampsia. We believe this rare complication of pregnancy to be the cause of the intraocular bleeding.

Retinal hemangioma-like lesions in eyes with retinitis pigmentosa.

The authors report two patients with bilateral vascular masses of the peripheral retina associated with primary pigmentary dystrophy of the retina (retinitis pigmentosa). Although they are most similar to the retinal capillary hemangiomas of von Hippel, the affected patients had no clinical history or clinical findings suggestive of that syndrome. They differ from the calcified retinal hamartomas that have been associated with retinitis pigmentosa because they do not show the extensive telangiectasia and exudation seen with the exudative retinopathy that has been described with retinitis pigmentosa. They do not show the fluorescein angiographic pattern that characterizes peripheral choroidal neovascularization. Their main complication seems to be vitreous hemorrhage rather than exudative retinopathy. The authors discuss the possible relationship of these acquired retinal vascular masses to the retinitis pigmentosa.

Tumor-associated retinal pigment epithelial proliferation simulating retinal pigment epithelial tear.

A lesion with both the clinical and fluorescein angiographic appearance of the classical retinal pigment epithelial (RPE) tear was discovered over the dome of an actively growing metastatic choroidal tumor in a patient with a previous history of breast carcinoma. However, our patient exhibited no evidence of pigment epithelial detachment or age-related macular degeneration, the underlying cause of the RPE tear. Although we cannot be sure that a true RPE tear did not exist over our patient's tumor, more likely, we are observing a tumor induced zone of RPE dehiscence accompanied by RPE proliferation at its border, giving a very similar fundus appearance. Possible pathogenic mechanisms for the finding in our patient, and a comparison to those mechanisms responsible for the classical RPE tear, are discussed.

Intracranial extension of choroidal melanoma via the optic nerve.

A 62-year-old woman was treated with cyclocryotherapy for neovascular glaucoma of uncertain origin. Fifteen months later she was diagnosed as having a choroidal melanoma, which extended extrasclerally to fill the orbit and invaded the optic nerve intracranially to the chiasm. She was treated by orbital exenteration and neurosurgical resection of the intracranial portion of the optic nerve. The patient is alive and clinically free of metastasis five years after the onset of neovascular glaucoma and almost four years after surgical resection. The significance of this highly unusual growth pattern of uveal melanoma is discussed.

Monocular diplopia of retinal origin.

A 68-year-old man experienced monocular diplopia related to a subretinal choroidal neovascular membrane. His symptom resolved with laser photocoagulation of the choroidal membrane. Retinal disease is an uncommon cause of this uncommon symptom.

A mimic of the "exact diagnostic sign" of Foster Kennedy.

We observed a patient with bilateral nonarteritic ischemic optic neuropathy presenting with gradual loss of vision in the right eye and initially asymptomatic disk swelling in the left. This atypical picture may create diagnostic difficulty, since sudden visual loss, the major distinguishing feature between Foster Kennedy's original syndrome and "pseudo-Foster Kennedy syndrome" of ischemic optic neuropathy, is lacking.