Augmentation of local anesthesia during retinal detachment surgery.

Because the effect of local anesthesia from a retrobulbar injection diminishes with time, local anesthesia during prolonged retinal surgery may be difficult. A simple, safe, and effective technique for administration of supplemental intraoperative local anesthesia during retinal detachment surgery is described. After a limbal peritomy is performed and the quadrants are dissected bluntly, a 19-guage irrigating cannula is passed posterior to the globe to irrigate the recti muscles and the retrobulbar space with 4% lidocaine hydrochloride. Using this technique, even prolonged vitreoretinal surgery can be performed using local anesthesia with minimal patient discomfort.

A new culture method for infectious endophthalmitis.

We studied the use of blood culture bottles for culturing vitreous specimens obtained during vitrectomy for infectious endophthalmitis. In a retrospective review of 83 cases, blood culture bottles yielded a 91% incidence of positive cultures. A laboratory comparison of direct media inoculation, a membrane filter system, and three blood culture systems was undertaken using inocula of nine organisms in three different concentrations. The blood culture bottle systems became positive at the same time as, or within 24 hours of, the membrane filter system for nearly every organism tested. A prospective clinical comparison was also performed in 14 cases of endophthalmitis, confirming our laboratory findings. The direct inoculation of blood culture bottles may be an acceptable adjunct or alternative to more sophisticated laboratory techniques for vitreous cultures in infectious endophthalmitis.

Endophthalmitis caused by streptococcal species.

The medical records of 48 patients with culture-positive streptococcal endophthalmitis diagnosed between January 1977 and May 1990 were reviewed. The viridans group streptococci were isolated in 24 (50%) of the 48 cases, enterococci in 13 cases (27.1%), Streptococcus pneumoniae in six cases (12.5%), and beta-hemolytic streptococci in six (12.5%) of 48 cases. The clinical statuses of endophthalmitis cases by etiology were postoperative in 40 patients (83.3%), posttraumatic in six patients (12.5%), and miscellaneous in two patients (4.2%). Overall, 15 (31.2%) patients achieved 20/400 or better visual acuity. The streptococcal isolates demonstrated a 32.6% in vitro resistance to gentamicin sulfate, whereas all isolates were sensitive to vancomycin hydrochloride. The enterococci were often resistant to the cephalosporins, whereas the other streptococcal species were not.

Endophthalmitis caused by gram-negative organisms.

The medical records of 52 patients (53 eyes) with culture-proven gram-negative endophthalmitis between January 1982 and December 1990 were reviewed. Pseudomonas aeruginosa (23% [12/53]) and Haemophilus influenzae (19% [10/53]) were the most frequent isolates in this series. Overall, 26 (49%) of 53 treated patients achieved 20/400 or better visual acuity. Fifty-two (98%) of the original 53 gram-negative isolates were sensitive to the aminoglycoside antibiotics. To determine their sensitivity to recently developed antibiotics, 35 of the isolates were again grown on culture media and their sensitivities to ceftazidime, ciprofloxacin, and imipenem were obtained. Only ceftazidime demonstrated in vitro efficacy for all the organisms tested.

Subretinal "napkin-ring" membrane in proliferative vitreoretinopathy.

A "napkin-ring" subretinal membrane is an unusual expression of subretinal proliferation associated with retinal detachment. An 80-year-old man with a total funnel-shaped retinal detachment underwent pars plana vitrectomy, 360 degrees relaxing retinotomy, excision of a subretinal napkin-ring membrane, and silicone oil injection. Histopathologic examination of the removed napkin-ring subretinal membrane revealed the presence of retinal pigment epithelium (RPE) as the major source of cells within the membrane. Myofibroblasts were the most common cellular constituents; the total number of these cells may have correlated with the degree of clinical contraction, causing a funnel-shaped retinal detachment. Arch Ophthalmol. 2000;118:1287-1289

Asymptomatic rhegmatogenous retinal detachments.

OBJECTIVE: To describe the clinical characteristics and risk of progression of asymptomatic rhegmatogenous retinal detachments. METHODS: We retrospectively reviewed the clinical records of 28 patients (31 eyes) with asymptomatic rhegmatogenous retinal detachments followed up without surgery for 0.5 to 12.1 years (mean, 3.4 years). Tractional tears were present in six eyes and atrophic holes in 25 eyes. In five patients, the asymptomatic retinal detachment was noted when the patient presented with a symptomatic retinal detachment in the fellow eye. RESULTS: Twenty-nine of the 31 eyes remained asymptomatic without progression of the retinal detachment. Two eyes progressed to a symptomatic retinal detachment 2.25 and 3.3 years after the initial examination, underwent a successful scleral buckling procedure, and maintained 20/20 visual acuity. CONCLUSIONS: Observation can be considered a reasonable option in the treatment of patients with asymptomatic retinal detachments. Chart documentation of the risks and benefits of observation and instruction of the patient on self-monitoring of the peripheral visual field are necessary in such patients.

Pars plana vitrectomy in the management of complications of proliferative sickle retinopathy.

Ten patients (11 eyes) with sickle-C hemoglobinopathy with complications of proliferative sickle retinopathy were treated using pars plana vitrectomy with or without the use of a scleral buckle. Postoperative visual acuity was improved in ten of 11 cases. Three cases of retinal detachment were managed by internal vitreoretinal techniques alone without the use of a scleral buckle. Although exchange transfusions were used in only five of the 11 cases, no cases of recognized anterior segment ischemia occurred during the postoperative course of these patients. Because of exchange transfusion risks and awareness of intraoperative and postoperative measures to reduce this complication, the use of exchange transfusions probably should be discontinued as prophylaxis for vitreoretinal surgery in these patients.

Subretinal hemorrhage management by pars plana vitrectomy and internal drainage.

We reviewed 14 consecutive cases of subretinal hemorrhage involving the macula, in which surgery to remove the hemorrhage was performed by the authors between February 1984 and January 1989. All patients underwent pars plana vitrectomy and internal subretinal hemorrhage drainage. The causes of subretinal hemorrhages in group 1 were primary rhegmatogenous retinal detachments (three eyes), complications from scleral buckling procedures (three eyes), traumatic retinal detachments (two eyes), and sickle cell retinopathy associated with anticoagulation therapy after a pulmonary embolus (one eye). Group 2 consisted of five eyes with massive subretinal hemorrhage associated with age-related macular degeneration. In group 1, recurrent postoperative retinal detachment occurred in five eyes but reattachment was achieved in eight of the nine eyes, and final visual acuities were 20/400 or better in those eight eyes. In group 2, marked subretinal fibrosis occurred in two eyes. Although three eyes had improved visual acuities, final visual acuities were 5/200 or worse in all five eyes.

Transient hypopyon with marked anterior chamber fibrin following pars plana vitrectomy and silicone oil injection.

In a retrospective review of 30 cases of complex retinal detachment, which had been managed by pars plana vitrectomy techniques together with silicone oil injection, we found that two patients developed marked postoperative anterior chamber fibrin and hypopyon. In all 30 cases, the same silicone oil was used: purified and heat-sterilized trimethylsiloxy-terminated, polydimethylsiloxane of 1000-centistoke viscosity. Although the silicone oil itself remained clear and without emulsification, the differential diagnosis of this postoperative inflammation included microbial endophthalmitis. These two cases were treated with frequent topical steroids and antibiotics while we closely monitored the retraction of the anterior chamber fibrin. In both cases, clinical improvement and long-term retinal reattachment with satisfactory visual function were achieved. The use of intense scatter laser endophotocoagulation and the presence of impurities in the silicone oil may have contributed to the excessive postoperative inflammation in these cases.

Hypodermic stainless steel tacks and companion inserter designed for peripheral fixation of retina.

Mechanical fixation of the torn or cut edge of retina with 30-gauge hypodermic stainless steel tacks has been performed in 15 patients at the Bascom Palmer Eye Institute, Miami, and Miami Veterans Administration Medical Center with six to 18 months of follow-up. The companion tack inserter allows the surgeon to select an angle for the shaft of the tack in relation to the inserter to allow the tack to be driven perpendicularly into sclera even when the insertion is anterior to the equator. If residual detachment remains following fluid-gas exchange after preliminary placement of the retinal tacks, a given tack may be removed and reinserted to facilitate complete retinal reattachment. This utilitarian feature allows the surgeon to eliminate residual anteroposterior traction following complete membrane peeling by extending relaxing retinotomies and tacking the posterior cut edge of the retina securely between the ora serrata and the equator.

Endophthalmitis after filtering surgery with mitomycin.

OBJECTIVE: To identify the incidence, causative organisms, and clinical outcomes of eyes with bleb-associated endophthalmitis after glaucoma filtering procedures with adjunctive mitomycin. METHODS: Retrospective analysis of 773 consecutive eyes that underwent glaucoma filtering surgery at the Bascom Palmer Eye Institute, Miami, Fla. The course of 609 eyes from 485 patients with a minimum of 3 months of follow-up were reviewed. RESULTS: Mean follow-up was 16.0 +/- 11.5 months (range, 3-48 months). Of the 609 eyes, 13 (2.1%) developed bleb-associated endophthalmitis an average of 18.5 +/- 13.2 months after surgery (range, 1-45 months). The incidence of bleb-associated endophthalmitis was significantly greater after inferior trabeculectomy (7.8% per patient-year) than after superior trabeculectomy (1.3% per patient-year) by Kaplan-Meier estimates (P = .02, log rank test). The cumulative incidence was 13% for inferior limbal blebs and 1.6% for superior limbal blebs. Nine (69.2%) of the 13 eyes were culture positive. Streptococcus sanguis and Haemophilus influenzae (6/13 [46.2%]) were the most frequent causative organisms. The mean increase in intraocular pressure after endophthalmitis treatment was 1.2 mm Hg, with a mean decrease in visual acuity of 1.42 logMAR units. Eight (61.5%) of the 13 eyes had a final acuity of 20/400 or better. CONCLUSIONS: The incidence of bleb-associated endophthalmitis after guarded filtering surgery performed with adjunctive mitomycin is higher than the reported rate in eyes undergoing filtering surgery without the use of antifibrotic agents (0.2%-1.5%). Inferior limbal trabeculectomy carries the highest risk of infection. Eyes with mitomycin blebs maintained excellent filtration capacity. However, after treatment of the infection, the visual outcomes were generally poor.

Vitrectomy with silicone oil or long-acting gas in eyes with severe proliferative vitreoretinopathy: results of additional and long-term follow-up. Silicone Study report 11.

BACKGROUND: The Silicone Study evaluated the outcomes of vitreoretinal surgery for retinal detachment with proliferative vitreoretinopathy (PVR). OBJECTIVE: To evaluate short-term (up to 36 months) outcomes in eyes randomized to silicone oil or perfluoropropane gas and long-term (up to 72 months) outcomes in eyes with attached maculas at 36 months. DESIGN: Prospective, randomized, multicentered surgical trial. SETTING: Community- and university-based vitreoretinal practices. PATIENTS: Two-hundred sixty-five eyes with PVR randomized to perfluoropropane gas and silicone oil with follow-up through 3 years (cohort 1) and 249 eyes with attached maculas at 36 months (121 eyes randomized to long-acting gas [either sulfur hexafluoride or perfluoropropane] and 128 eyes randomized to silicone oil) with follow-up up to 6 years (cohort 2). Both cohorts consisted of eyes that had and had not undergone vitrectomy for PVR (groups 1 and 2, respectively) before randomization. Of the 265 eyes in cohort 1, 24-month follow-up data were available for 218 eyes (82%) and 36-month follow-up data were available for 196 eyes (74%). Of 208 eyes in cohort 2, 48-month follow-up data were available for 146 eyes (70%), 60-month follow-up data for 119 eyes (57%), and 72-month follow-up data for 73 eyes (35%). INTERVENTIONS: Vitrectomy surgery for PVR with a long-acting gas or silicone oil as the intraocular tamponade. MAIN OUTCOME MEASURES: Changes in visual acuity, recurrent retinal detachment, and incidence of complications. RESULTS: In group 1 of cohort 1, compared with oil-treated eyes, gas-treated eyes had a higher rate of complete retinal reattachment from 18 to 36 months (P < .05). No other differences were found. In group 2 of cohort 1, no notable differences were found between treatment arms. In cohort 2, during 6 years of follow-up, attachment of the macula was maintained for all eyes. No notable differences in the rates of complete retinal attachment, visual acuity of 5/200 or better, or glaucoma were found between treatment groups. In contrast, gas-treated eyes had more hypotony (P < .001). Silicone oil-treated eyes that underwent subsequent surgery were more likely to have the oil retained (P = .02). Compared with oil-retained eyes, oil-removed eyes had higher rates of complete posterior attachment (P = .01) and of a visual acuity of 5/200 or better (P < .001) and less keratopathy (P < .05). Compared with oil-removed eyes, gas-treated eyes had a worse visual acuity outcome (P < .05) and more hypotony (P < .01). CONCLUSION: The Silicone Study showed that silicone oil and perfluoropropane gas were equal in most respects for the management of retinal detachments with PVR. Success in the first surgery for PVR is paramount for obtaining better visual results. Overall, surgery for PVR had a high likelihood of retinal reattachment, and if anatomically and visually successful at 3 years, there is an excellent chance that the results will be maintained over the long-term.

Nonsurgical management of macular hemorrhage secondary to retinal artery macroaneurysms.

OBJECTIVE: To report visual acuity outcomes of nonsurgical management of macular hemorrhage secondary to retinal artery macroaneurysms. METHODS: Forty-one patients at multiple centers with macular hemorrhage secondary to retinal artery macroaneurysms managed with observation alone were reviewed. Time to clearance of macular hemorrhage, visual acuity at final follow-up, and presence or absence of macular pigmentary changes after absorption of the hemorrhage were recorded for each patient. RESULTS: On initial examination, visual acuity was 20/200 or worse in all except 4 patients (3 with 20/70, 1 with 20/80). At an average follow-up of 15. 7 months, a final visual acuity of 20/40 or better was achieved in 15 eyes (37%), between 20/50 and 20/100 in 12 (29%), and 20/200 or worse in 14 (34%). Macular pigmentary abnormalities were noted after clearance of the hemorrhage in 23 (56%) of 41 cases, and these eyes generally had worse visual acuity outcomes. CONCLUSIONS: In eyes with macular hemorrhage secondary to retinal artery macroaneurysms managed with observation alone, good visual acuity outcomes can often be achieved. Poorer visual acuity outcomes are associated with macular pigmentary changes after resorption of blood. Arch Ophthalmol. 2000;118:780-785

Elevated intraocular pressure and hypotony following silicone oil retinal tamponade for complex retinal detachment: incidence and risk factors.

OBJECTIVE: To evaluate the incidence of and risk factors for persistently elevated intraocular pressure (IOP) and hypotony in patients who have undergone pars plana vitrectomy with silicone oil injection for the management of complex retinal detachment. SUBJECTS AND METHODS: The medical records of 532 patients who underwent silicone oil injection for the management of complex retinal detachments between January 1, 1991, and December 31, 1996, at the Bascom Palmer Eye Institute, Miami, Fla, were reviewed. Elevated IOP was defined as elevated IOP requiring an operation at any time postoperatively or a persistently elevated IOP of greater than 25 mm Hg at or after the 6-month visit. Hypotony was defined as a persistent IOP of 5 mm Hg or less at or after the 6-month visit. Patients with transient perioperative IOP fluctuations were not counted. RESULTS: Survival analysis for patients without cytomegalovirus retinitis (n = 383) revealed that 12.9% had an elevated IOP and 14.1% had hypotony by 6 months, 21% had an elevated IOP and 20.3% had hypotony by 1 year, and 29.5% had an elevated IOP and 27.3% had hypotony by 2 years. Among patients with cytomegalovirus retinitis (n = 149), none had a persistently elevated IOP, 10% had hypotony by 6 months, and 5.9% had persistently elevated IOP and 10% developed chronic hypotony by 1 year. A history of glaucoma before silicone oil retinal tamponade (P = .03), diabetes mellitus (P = .02), and a high IOP on the first postoperative day (P = .006) were risk factors for elevated postoperative IOP in patients without cytomegalovirus retinitis. Risk factors for postoperative hypotony in patients without cytomegalovirus retinitis included preoperative hypotony (P<.001) and aphakia (P = .03). CONCLUSIONS: An elevated or low IOP often develops postoperatively in patients without cytomegalovirus retinitis who undergo silicone oil injection for the management of complex retinal detachment. Risk factors for an elevated postoperative IOP include a history of glaucoma, diabetes mellitus, and a high IOP on the first postoperative day. Risk factors for hypotony include preoperative hypotony and aphakia.

The effects of silicone oil removal. Silicone Study Report 6.

OBJECTIVE: To evaluate the advisability of removing silicone oil from eyes after surgery for severe (with a classification of at least C-3) proliferative vitreoretinopathy. DESIGN: Subgroup analysis of the Silicone Study, a randomized, multicentered, surgical trial. SETTING: Community- and university-based clinics. PATIENTS: Two hundred twenty-two eyes with severe proliferative vitreoretinopathy followed up in the Silicone Study. INTERVENTIONS: Vitrectomy for proliferative vitreoretinopathy with silicone oil as the intraocular tamponade. OUTCOME MEASURES: Changes in visual acuity, recurrent retinal detachment, and incidence of complications. RESULTS: Ninety-nine (45%) of 222 eyes had surgery for silicone oil removal (oil-removed eyes). Compared with the eyes that did not undergo silicone oil removal (oil-retained eyes) evaluated at a comparable time after oil injection, oil-removed eyes at the examination prior to oil removal were more likely to be attached (85% vs 40%; P < .0001), have a visual acuity of 5/200 or greater (63% vs 35%; P < .0001), and not be hypotonous (5% vs 22%; P < .001). There was no association between the length of oil retention and incidence of recurrent retinal detachment after oil removal. Eyes with attached retinas at the time of oil removal generally improved in visual acuity at the last follow-up examination (P < .0001), which was not evident in eyes with detached retinas at the time of oil removal. In a matched-pair cohort analysis comparing both sets of eyes, there was an increased risk for recurrent retinal detachment at the last follow-up examination in the oil-removed eyes (odds ratio [OR], 2.1; P = .09). However, overall visual acuity improved for oil-removed eyes in 19 (29%) of 66 pairs and for oil-retained eyes in one (2%) of 66 pairs (OR, 19.0; P < .0001). Although nonsignificant, incidence rates of keratopathy (OR, 0.5) and hypotony (OR, 0.5) were lower in oil-removed eyes. CONCLUSION: Removal of silicone oil in anatomically successful eyes significantly increases the likelihood of improved visual acuity with a slight increase in the likelihood of recurrent retinal redetachment. There was a trend for a reduction in the incidence of complications in the oil-removed eyes.

Baerveldt drainage implants in eyes with a preexisting scleral buckle.

OBJECTIVE: To describe the surgical insertion of a Baerveldt drainage implant and postoperative visual acuity and intraocular pressure (IOP) outcomes in patients with a preexisting scleral buckle. METHODS: Medical records of all patients with a preexisting scleral buckle who underwent insertion of a Baerveldt drainage implant at Bascom Palmer Eye Institute, Miami, Fla, from January 1, 1994, through December 31, 1998, were reviewed. Outcome measures included visual acuity and IOP at 1 year. RESULTS: At 1 year postoperatively, 14 (88%) of 16 patients had stable or improved visual acuity. Preoperatively, mean IOP was 30.9 mm Hg and the mean number of antiglaucoma medications was 3.4; at 1 year postoperatively, mean IOP was 12.0 mm Hg and the mean number of antiglaucoma medications was 0.8 (P<.001). Nine patients (56%) achieved an IOP of greater than 5 and no greater than 21 mm Hg without medication, and an additional 7 (44%) achieved this level of IOP control with medication. No patient required further surgery for uncontrolled IOP during the follow-up interval, which ranged from 19. 1 to 45.5 months. CONCLUSION: Baerveldt drainage device insertion behind or over a preexisting encircling band is often successful in managing refractory glaucoma in patients who have undergone previous scleral buckling procedures. Arch Ophthalmol. 2000;118:1509-1513

Antibiotic selection in the treatment of endophthalmitis: the significance of drug combinations and synergy.

Emerging resistance of organisms to standard antibiotic therapy has forced clinicians to continually evaluate the best intraocular antibiotics for the treatment of endophthalmitis. Early diagnosis and appropriate treatment with intraocular antibiotics are important factors in the successful management of endophthalmitis. Although drug combinations are necessary to cover the full range of bacteria causing endophthalmitis, antimicrobial synergy is probably less important in endophthalmitis treatment because of the high intravitreal concentration of individual antibiotics achieved by intravitreal injection. In the treatment of bacterial endophthalmitis, the combination of intravitreal vancomycin (1 mg/0.1 cc) and ceftazidime (2.25 mg/ 0.1 cc) is a reasonable alternative to the combination vancomycin and amikacin (0.4 mg/ 0.1 cc).

Vitrectomy in the management of diabetic retinopathy.

According to the Early Treatment Diabetic Retinopathy Study, at least 5% of eyes receiving optimal medical treatment will still have progressive retinopathy that requires laser treatment and pars plana vitrectomy. During the past decade, improvements in instrumentation and surgical techniques have allowed more difficult cases of diabetic retinopathy to be candidates for vitrectomy. However, although the thresholds for performing surgery within established indicated situations have been lowered, only a few additional indications have been established. Although vitrectomy improves the prognosis for a favorable visual outcome, preventive measures, such as improved control of glucose levels and timely application of panretinal photocoagulation, produce better results. The authors review the indications, techniques, and results of vitrectomy in the management of diabetic retinopathy.

Vitrectomy in the management of diabetic eye disease.

Vitrectomy techniques including endolaser photocoagulation allow visual rehabilitation in many eyes that are otherwise untreatable. Discerning the indications and timing for diabetic vitrectomy is increasingly important as the treatment of complications of diabetic retinopathy continues to undergo modification and redefinition. The most common indications for diabetic vitrectomy include: 1) severe nonclearing vitreous hemorrhage; 2) traction retinal detachment recently involving the macula; 3) combined traction and rhegmatogenous detachment; 4) progressive fibrovascular proliferation; and 5) rubeosis iridis and vitreous hemorrhage for eyes in which the media opacity has prevented adequate laser photocoagulation. Other less common indications in selected cases include dense premacular hemorrhage, ghost cell glaucoma, macular edema with premacular traction, cataract preventing treatment of severe, proliferative diabetic retinopathy, anterior hyaloidal fibrovascular proliferation, and fibrinoid syndrome with retinal detachment. The rationale and surgical objectives are discussed and results are summarized.

Infectious endophthalmitis.

The internist or family medicine consultant can have an important role in the management of endophthalmitis. Even though intraocular antimicrobial therapy is the most effective method of treatment, the consultant can assist in the selection of systemic antibiotic agents and in the monitoring of systemic side effects of the treatment. In addition, the consultant can be called on to evaluate patients with endogenous endophthalmitis for systemic involvement. The joint efforts of the ophthalmologist and consultant should allow optimal treatment in an attempt to improve the visual prognosis for these devastating ocular infections.