Pars plana vitrectomy without scleral buckle for pseudophakic retinal detachments.

OBJECTIVE: To report the anatomic and visual results of primary pars plana vitrectomy (PPV) without scleral buckling to repair primary rhegmatogenous retinal detachments in pseudophakic eyes. DESIGN: Nonrandomized, prospective, comparative clinical trial. PARTICIPANTS: Two hundred eighty-three consecutive patients (294 eyes) with pseudophakia, peripheral retinal tears, and new rhegmatogenous retinal detachments were treated according to the surgery protocol. INTERVENTION: Patients underwent PPV with fluid-gas exchange and endolaser to repair the retinal detachment. Two hundred sixty-four patients (275 eyes) were followed from 6 months to 6 years and 8 months with an average follow-up of 19 months. MAIN OUTCOME MEASURES: Reattachment of the retina and visual outcome were compared to previously published studies. RESULTS: Of 97 eyes with a macula-attached rhegmatogenous retinal detachment, 88 eyes (91%) were reattached with a single operation, and of the 178 eyes with a macula-detached retinal detachment, 153 (86%) eyes were reattached with a single operation. In 241 (88%) of 275 eyes, the retina was reattached with a single operation, and in 265 (96%) of 275 eyes, the retina was ultimately reattached with subsequent operations. The median initial visual acuity was 20/300, and the median final visual acuity was 20/40. The rate of reattachment with one operation was similar for eyes with an anterior chamber intraocular lens (91%) and for eyes with a posterior chamber intraocular lens (88%). Refractive error measurements obtained in 81 eyes were essentially unchanged. The mean change in refractive error was -0.15 diopter. Seventeen eyes (6%) developed macular puckers requiring surgery, 46 eyes (17%) developed cystoid macular edema, and 6 eyes (2%) developed full-thickness macular holes. CONCLUSION: Primary PPV with fluid-gas exchange and laser is a safe, effective method to repair primary pseudophakic retinal detachments. The anatomic reattachment rate and the visual acuity obtained with this technique appear to be at least as good as those reported in the literature for scleral buckling, PPV with scleral buckling, and pneumatic retinopexy.

Retinal periphlebitis in patients with acquired immunodeficiency syndrome with cytomegalovirus retinitis mimics acute frosted retinal periphlebitis.

Acute frosted retinal periphlebitis is an inflammatory condition of unknown origin characterized by marked perivenular infiltration in otherwise healthy patients. We encountered seven patients with acquired immunodeficiency syndrome who exhibited visual loss associated with an unusual diffuse retinal periphlebitis very similar in appearance to acute frosted retinal periphlebitis. Each patient developed a thick inflammatory infiltrate surrounding the retinal venules, creating a frosted appearance. Two cases were bilateral. All patients had areas of more typical cytomegalovirus retinitis in their involved eye(s). Five of six patients treated with ganciclovir sodium showed improvement not only of the cytomegalovirus retinitis but also of the periphlebitis. Although we do not have histopathologic evidence that cytomegalovirus was the cause of these cases of periphlebitis, we believe that periphlebitis may be a previously unrecognized finding of cytomegalovirus retinitis in patients with acquired immunodeficiency syndrome. So far, there is no evidence implicating cytomegalovirus as the cause of acute frosted retinal periphlebitis in healthy patients.

Vitrectomy for diabetic macular traction and edema associated with posterior hyaloidal traction.

Pars plana vitrectomy with separation of the posterior hyaloid was performed in 10 eyes with diabetic macular edema and traction associated with a thickened and taut premacular posterior hyaloid. Nine of the 10 eyes had previous macular photocoagulation. Preoperative fluorescein angiography showed a deep and diffuse pattern of leakage in the macula. Intraoperatively, the attached and thickened posterior hyaloid was lifted and separated from the retina. Postoperatively, vision improved in nine eyes. The macular traction and edema resolved in eight eyes and decreased in two. Complications included a vitreous hemorrhage, a rhegmatogenous retinal detachment, cataract formation, and a mild epimacular membrane, each occurring in one eye. Vitreous surgery can improve the visual prognosis of some eyes with diabetic macular traction and edema associated with a thickened and taut posterior hyaloid.

Improvement in visual acuity in chronic aphakic and pseudophakic cystoid macular edema after treatment with topical 0.5% ketorolac tromethamine.

Ketorolac tromethamine 0.5% ophthalmic solution treatment was compared to placebo treatment in 120 patients with chronic aphakic or pseudophakic cystoid macular edema (six-month or more duration of distance visual acuity of 20/40 or less and angiographic evidence of cystoid changes) during a four- to five-month double-masked, multicenter study in which patients were randomly assigned. A statistically significant improvement in distance visual acuity (two lines or more) was observed in the ketorolac-treated group as compared to the placebo-treated group after 30 days (P = .038), 60 days (P = .017), and 90 days (P = .008) of treatment. This improvement in visual acuity remained statistically significant one month after cessation of treatment (P = .001). Nine ketorolac-treated patients and two placebo-treated patients demonstrated a decrease in visual acuity one month after treatment was discontinued. Seven of the nine ketorolac-treated patients experienced an improvement in visual acuity after retreatment as compared to none of the placebo-treated patients. This study offers evidence for a more optimistic outlook in the medical treatment of chronic aphakic and pseudophakic cystoid macular edema.

Pars plana vitrectomy in the management of dislocated posterior chamber lenses.

We used pars plana vitrectomy techniques in the management of pseudophakia and a dislocated posterior chamber lens in 17 patients. In six patients, the implant was decentered with the optic axis still located in the visual axis. In nine patients, the implant was rotated inferiorly and posteriorly but with the haptic still adherent to the vitreous base. In two patients, the implant was dislocated into the vitreous cavity. Surgical repositioning of the implant was indicated in 12 (71%) patients because of retained lens material, vitritis, vitreous adhesion to the cataract wound, vitreous hemorrhage, or retinal detachment. Preoperatively, visual acuity ranged from 20/30 to hand motions. Postoperatively, visual acuity ranged from 20/20 to 20/400. In eight patients, visual acuity was improved to 20/25 or better.

Pneumatic retinopexy. Surgical results.

We reviewed 55 consecutive cases of rhegmatogenous retinal detachment treated with pneumatic retinopexy. Eyes with inferior retinal breaks from the 4- to 8-o'clock positions or macular holes with retinal detachment were excluded. Forty-five eyes (82%) were reattached with one operation. Although ten operations failed, nine retinas were subsequently reattached surgically, a 98% overall reattachment rate. Thirty-three (92%) of 36 phakic eyes, eight (66%) of 12 pseudophakic eyes, and four (57%) of seven aphakic retinas were reattached with one operation. In macula-off cases, phakic patients tended to have greater improvement in visual acuity. New breaks occurred in six eyes (11%), five (83%) of which were pseudophakic or aphakic. The safety, efficacy, and indications for pneumatic retinopexy remain to be established by a randomized, controlled, prospective study.

Recurrences and bilaterality in the multiple evanescent white-dot syndrome.

Multiple evanescent white-dot syndrome recurred in two men (23 and 44 years of age, respectively). One patient had a recurrence in the previously affected eye three years after the initial visual loss; the other patient had two recurrences in the contralateral eye, each separated by two years. Two additional patients (a 28-year-old woman and a 21-year-old man) had bilateral but asymmetric acute involvement. Computerized visual study showed a loss of retinal sensitivity in both eyes, correlating poorly with the clinically observed lesions. Results of electro-oculography were abnormal in the patients with bilateral involvement; results of electro-retinography were abnormal only in the more severely involved eye. Systemic investigation in the two bilateral cases was unrevealing. None of the four patients had experienced a preceding influenza-like illness and all had complete recovery of vision within four to six weeks.

Choroidal granuloma in sarcoidosis.

We examined two patients--a 33-year-old black man and a 62-year-old white woman--who had pale yellow choroidal tumefactions with subretinal fluid and reduced vision. One patient had a history of granulomatous iritis; both patients were initially thought to have metastatic choroidal carcinoma. Systemic investigation yielded positive tissue diagnosis for sarcoidosis, leading to the diagnosis of presumed sarcoid choroidal infiltration. There was striking absence of inflammation of the retina, retinal vessels, and vitreous cavities. Fluorescein angiography disclosed initial hypofluorescence and late hyperfluorescence and ultrasonography demonstrated medium internal reflectivity. Neither study could exclude metastatic choroidal carcinoma. One patient had an increased level of angiotensin-converting enzyme on serial determinations through 15 months of observation and during treatment with corticosteroids, indicating a good correlation with improved vision and flattening of the choroidal granuloma. In both cases there was only partial resolution of the choroidal granuloma with corticosteroids. We conclude that choroidal granuloma can be the sole ocular manifestation of sarcoidosis and in this context is likely to be confused with metastatic choroidal carcinoma. We also believe that biopsy confirmation is needed because noninvasive tests such as gallium scans and angiotensin-converting enzyme cannot be relied on for diagnosing sarcoidosis and excluding carcinoma.

Arcuate pigment epithelial dystrophy.

Five cases of an atypical pigmentary retinopathy are described. Findings consisted of a pigment epithelial atrophy occurring in an arcuate fashion, with corresponding visual field and angiographic transmission defects. The pigment epithelial atrophy was subtle, bilateral, and symmetrical. A familial pattern was not present. Electrophysiologic findings were normal or mildly subnormal. The process usually spared the macula. However, two patients demonstrated centrocecal scotomata with an associated significant decrease in visual acuity--a finding not previously described.

Digital subtraction angiography in the diagnosis of retinal vascular disease.

Digital subtraction angiography is a safe, inexpensive method of investigating systemic vascular disease in patients for whom conventional carotid angiography is too risky. We used this technique in five patients with a variety of retinal vascular conditions--a 55-year-old woman with occlusion of the right internal carotid artery, a 63-year-old man with bilateral occlusion of the internal carotid arteries, a 72-year-old man with occlusion of the stem of the left subclavian artery and an irregularity of the proximal portion of the innominate artery, a 77-year-old man with optic nerve head neovascularization and stenosis of the left internal and external and right internal carotid arteries, and a 74-year-old man with recurrent stenosis of the left internal carotid artery. In all five cases, digital subtraction angiography was helpful in determining the diagnosis and course of treatment.

Retinal telangiectasia secondary to bilateral carotid artery occlusion.

A man complaining of blurred vision had diffuse retinal capillary telangiectasia as a primary retinal finding. Evaluation of the carotid arteries by a noninvasive angiographic method revealed bilateral, silent occlusions of both common carotid arteries. Thus, some cases of "idiopathic retinal capillary telangiectasia" may in fact be harbingers of underlying carotid artery disease.

Vascular leakage, neovascularization, and vitreous hemorrhage in senile bullous retinoschisis.

Retinal detachment is the primary complication of bullous retinoschisis, a benign abnormality of the peripheral retina. We examined three patients (all women, 43, 55, and 56 years old) with typical bullous retinoschisis who had vitreous hemorrhage. In each case, there were sclerotic retinal vessels over the surface of the schisis cavity along with neovascularization above the central portion of the cyst. In one case there was also neovascularization of the peripheral retina in an area distant from the schisis. These findings were confirmed by fluorescein angiography in one case; the other two cases demonstrated similar changes by fluorescein angioscopy. Fluorescein angiography, also demonstrated intraretinal dye leakage from vessels along the posterior extent of the schisis, as well as from an adjacent area of white without pressure.