Intraocular distribution of intravitreally administered amphotericin B in normal and vitrectomized eyes.

A study was performed to determine how amphotericin B is distributed in the eye after direct intravitreal injection. Radiolabeled amphotericin B was administered by direct injection into the vitreous space of unmodified phakic control or vitrectomized aphakic eyes in the rabbit model. The eyes were removed at different post-injection times, frozen and dissected into anatomical subparts of cornea, aqueous, iris, lens, vitreous and sclera-choroid-retina. The parts were assayed for total radioactivity (expressed as remaining amphotericin B). No accumulation of drug was observed in the cornea, lens, iris or aqueous region. The majority of drug was found in the vitreous cavity. The rate of disappearance of radiolabeled drug or radiolabeled drug degradation products from the vitreous space was similar to the rate of disappearance from the eye. However, progressive accumulation of radioactivity was observed in the sclera-choroid-retina tissue in the unmodified phakic eyes. This was not observed in vitrectomized aphakic eyes. The accumulated radioactivity could have represented drug degradation products or active drug. These results shed light on the distribution of amphotericin B in the eye after direct intravitreal injection, a procedure often employed clinically for fungal endophthalmitis.

Silicone oil for progressive anterior ocular neovascularization after failed diabetic vitrectomy.

We have performed revision of vitrectomy and silicone oil injection in 18 eyes that developed advanced iris neovascularization and/or anterior hyaloidal fibrovascular proliferation complicated by retinal detachment or media opacity after vitreous surgery for the complications of proliferative diabetic retinopathy. Stabilization or regression of the anterior ocular neovascular changes was noted in 83% of the eyes. Sustained retinal attachment was achieved in 56% of the eyes, with visual acuity improving to 20/400 or better in 28% of the eyes. Posterior segment vascular and avascular reproliferation was the major cause of anatomic failure, while generalized retinal vascular ischemia was felt to be the principal cause of poor visual results despite retinal attachment. Revision of vitrectomy with silicone oil injection is of limited value in the management of complicated and advanced anterior ocular neovascularization after unsuccessful vitrectomy for diabetic retinopathy.

Slit-lamp fluid-gas exchange and other office procedures following vitreoretinal surgery.

Many complicated postoperative vitreoretinal cases require reoperations. It is possible to perform some of these procedures outside the operating room. We describe examining room techniques for fluid-gas exchange, fluid and gas aspiration, and adherent vitreous strand removal. We also discuss a slit-lamp technique for using sodium hyaluronate (Healon) following fluid-gas exchange to eliminate optical distortion from endothelial striae.

Management of ocular penetration from injection of local anesthesia preceding cataract surgery.

We herein describe 12 patients who suffered penetration or perforation of the globe during injection of a local anesthetic before cataract surgery. Minimum follow-up was 6 months. Six eyes had a final visual acuity of 20/50 or better and an attached retina. Four eyes had an attached retina with a visual acuity of 20/80 to 2/200. Two eyes were anatomic failures because of a recurrent retinal detachment complicated by proliferative vitreoretinopathy. These cases show that retinal penetrations without retinal detachment may be treated effectively with photocoagulation. Vitreous surgery is recommended when the retinal penetration is associated with a retinal detachment. Eyes with a dense vitreous hemorrhage and a suspicion of a penetrating injury should either be followed up closely with echography or should undergo vitreous surgery since the extent of the injury cannot be determined.

Temperature-dependent light damage to the retina.

We examined the ability of hypothermic infusion fluid to reduce the risk of light damage to the retina from the intraocular fiberoptic probe during vitreous surgery. Following vitrectomy, we exposed the retina of rabbits to light from an intraocular fiberoptic probe during infusion of fluid at body temperature (39 C) and compared this with exposures during infusion of room temperature fluid (22 C). Retinal irradiance was 0.33 W/cm2. Damage was determined ophthalmoscopically and histologically. Cooling the infusion fluid from body to room temperature extended the damage threshold from approximately 25 to 60 minutes. A 35-minute exposure to body temperature fluid was compared with the same exposure during infusion of room temperature fluid. While retinal and retinal pigment epithelium damage was present after the body temperature exposure, no damage was detected after the room temperature exposure. Vitreoretinal surgeons should avoid warming intraocular infusion fluids to levels above room temperature.

Silicone oil for retinal detachment with advanced proliferative vitreoretinopathy following failed vitrectomy for proliferative diabetic retinopathy.

We used sophisticated vitreous surgical techniques in conjunction with silicone oil injection in ten eyes of ten patients with rhegmatogenous retinal detachment complicated by advanced proliferative vitreoretinopathy following failed vitrectomy for proliferative diabetic retinopathy. After a minimum follow-up of one year, three patients achieved total retinal reattachment and two patients regained ambulatory vision (5/200 or better). Maintenance of low to normal intraocular pressure was observed in nine of the ten eyes despite some cases of progressive anterior segment neovascularization and retinal detachment. Although treatment was more difficult and less successful than in either retinal detachment with proliferative diabetic retinopathy or proliferative vitreoretinopathy alone, these techniques allowed some success in eyes that otherwise would have a poor prognosis.

Neurological manifestations of acute posterior multifocal placoid pigment epitheliopathy.

BACKGROUND: Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) is a chorioretinal disease that causes acute visual symptoms with characteristic fundus findings. Although this entity has been associated with a variety of neurological complications, it has received little attention in the neurological literature. We wanted to emphasize the spectrum of neurological involvement, in particular the occurrence and management of strokes in patients with APMPPE. CASE DESCRIPTIONS: We report three patients with APMPPE and neurological disease. All three presented with marked visual disturbances and headaches. One patient developed recurrent strokes involving different vascular territories of the brain and required immunosuppressive treatment for presumed cerebral vasculitis. The other two patients had cerebrospinal fluid pleocytosis and persistent headaches but recovered spontaneously. The review of the literature demonstrates a particular pattern of neurological complications in a subgroup of patients with APMPPE. CONCLUSIONS: APMPPE should be considered among the causes of stroke and aseptic meningitis in young adults. The diagnosis is critically dependent on a thorough ophthalmologic examination. Severe neurological complications are difficult to predict at the onset of the ophthalmologic disease. The patients should be monitored closely. If investigations suggest cerebral vasculitis, immunosuppressive treatment may be helpful to prevent recurrences.

Treatment of endophthalmitis after cataract extraction.

BACKGROUND: A series of 34 patients was prospectively treated for postoperative endophthalmitis according to a specific protocol. The data are from the pilot study performed before initiation of the Endophthalmitis Vitrectomy Study (EVS). METHODS: Patients with bacterial endophthalmitis that developed within 6 weeks of cataract extraction received intravitreal amikacin and vancomycin, subconjunctival and topical antimicrobials and corticosteroids, and systemic corticosteroids. All patients had diagnostic samples removed from the aqueous and vitreous, with randomized assignment to immediate vitrectomy versus vitreous tap and treatment with or without intravenous antibiotics. Outcome was evaluated 3 and 9 months after treatment. RESULTS: At the 9-month visit, visual acuity was 20/50 or better in 49% of all eyes, 20/200 or better in 79%, and 5/200 or better in 91%. Media clarity was such that a "20/40 or better view" of the retina was present in 71% of patients at 3 months and in 97% at 9 months. CONCLUSION: This is one of the largest series of patients with postoperative endophthalmitis treated and evaluated under a prospective protocol and without selection bias. Each of the options used in this study to treat postoperative endophthalmitis may result in good visual results.