Submacular surgery.

Modern vitreoretinal surgery is now one of the most effective tools for treating posterior segment diseases. In the last several years, there has been a surge of interest in submacular surgery which allows removal of submacular choroidal neovascular membranes and haematomas. Various aspects of this rapidly emerging modality of surgery are discussed in this review.

Managing recurrent neovascularization after subfoveal surgery in presumed ocular histoplasmosis syndrome.

PURPOSE: To report the authors' experience with recurrent neovascularization after subfoveal surgery in the presumed ocular histoplasmosis syndrome (POHS). METHODS: One-hundred seventeen patients with POHS and subfoveal choroidal neovascularization were followed a median of 13 months after submacular surgery. RESULTS: Recurrent neovascularization developed in 51 eyes (44%). The median time to recurrence was 3 months (range, 0.5-28 months). Recurrence location was extrafoveal in 16%, juxtafoveal in 18%, and subfoveal in 66%. Sixteen eyes were treated with laser photocoagulation, 17 eyes underwent repeat submacular surgery, and 18 eyes were observed. The visual outcome for patients with recurrences amenable to laser was better than that for patients who were observed or who underwent surgery. CONCLUSION: Recurrent neovascularization after surgery is common; prompt recognition may allow laser photocoagulation.

The surgical removal of subfoveal choroidal neovascularization. Ingrowth site as a predictor of visual outcome.

PURPOSE: The authors determine the significance of location of the ingrowth site of subfoveal choroidal neovascularization (CNV) as a preoperative indicator of postsurgical visual acuity. DESIGN: A retrospective review is given of preoperative fluorescein angiograms and color fundus photographs for 84 eyes with subfoveal CNV due to the following etiologies: presumed ocular histoplasmosis syndrome (POHS) = 67 eyes; multifocal choroiditis = 9 eyes; not identifiable. If identifiable, the ingrowth site was further classified as extrafoveal, juxtafoveal, or subfoveal. Correlations between CNV ingrowth site location and postoperative visual acuity were made. RESULTS: The ingrowth site for subfoveal CNV was identifiable preoperatively in 60 eyes (71%). Of 31 eyes with an extrafoveal ingrowth site, 18 (60%) had a final visual acuity of 20/40 or better. Of 12 eyes with a juxtafoveal ingrowth site and 18 eyes with a subfoveal ingrowth site, only 2 (7%) had a final visual acuity of 20/40 or better. If the ingrowth site was not identifiable or identifiable and subfoveal in location (N = 42), 76% of eyes had a final visual acuity of 20/200 or worse. CONCLUSION: The ingrowth site of subfoveal CNV can be identified in the majority of eyes with POHS, multifocal choroiditis, or idiopathic membranes. A significant number of subfoveal CNV will have an extrafoveal ingrowth site. Eyes with an extrafoveal ingrowth site have a favorable visual prognosis after the surgical removal of the CNV. If the ingrowth site is subfoveal or not identifiable, the visual prognosis after surgery is guarded.

Cotton-wool spots and the early diagnosis of giant cell arteritis.

BACKGROUND: Giant cell arteritis is a common cause of severe visual loss in older individuals. Patients often present to the ophthalmologist having already lost vision in one eye. Detection of early ophthalmoscopic signs that precede irreversible visual loss in giant cell arteritis would allow preventative treatment in an otherwise frequently blinding disease. METHODS: Case presentations. RESULTS: Seven patients with mild visual symptoms and results of an ophthalmologic examination significant for cotton-wool spots were found to have giant cell arteritis. On specific questioning, six of seven patients described constitutional symptoms consistent with giant cell arteritis. Six patients had an abnormally elevated Westergren erythrocyte sedimentation rate. Temporal artery biopsy confirmed giant cell arteritis in six patients. The seventh patient received a diagnosis of polymyalgia rheumatica. Prompt treatment with corticosteroids led to preservation of vision and uneventful resolution of the cotton-wool spots in all seven patients. CONCLUSION: Cotton-wool spots are an early ophthalmoscopic finding in giant cell arteritis and can precede severe visual loss. Recognition of the significance of cotton-wool spots, use of laboratory studies, and prompt treatment may preserve vision in an otherwise frequently blinding disease.

Nuclear sclerotic cataract after vitrectomy in patients younger than 50 years of age.

PURPOSE: To evaluate the occurrence of cataract formation after pars plana vitrectomy and gas-fluid exchange in patients younger than 50 years of age. METHODS: Twenty-eight patients younger than 50 years of age with bilaterally symmetric crystalline lenses underwent pars plana vitrectomy and gas-fluid exchange in one eye. Postoperatively, lens photographs were used to assess any asymmetry between the surgical and nonsurgical eye. Lens photographs were graded by three independent masked observers using the Lens Opacities Classification System III (LOCS III). Significant cataract progression was defined as either cataract extraction in the surgical eye or a greater than a 0.9 LOCS III unit difference in lens opacity between the surgical and nonsurgical eye. Results were compared with 28 patients older than 50 years of age who had undergone identical surgery. RESULTS: In only 7% of patients younger than 50 years of age (mean age, 36.5 years; range, 16-47 years) did significant lens opacity develop in the surgical eye compared with the nonsurgical eye during the follow-up period (mean follow-up, 25.4 months; range, 12-43 months). Of patients older than 50 years of age (mean age, 68.2 years; range, 51-85 years), 79% developed significant lens opacity in the surgical eye compared with the nonsurgical eye during the follow-up period (mean follow-up 27.3 months; range, 12-49 months). The difference in cataract progression between patients younger than 50 years of age and patients older than 50 years of age was statistically significant (P < 0.0000001). CONCLUSION: Pars plana vitrectomy with gas-fluid exchange is minimally cataractogenic within the first few years in patients younger than 50 years of age.

Visual field loss after pars plana vitrectomy with air/fluid exchange.

PURPOSE: To report the postoperative finding of a dense, permanent, peripheral temporal visual field defect in the treated eyes of three patients who underwent pars plana vitrectomy with air/fluid exchange. METHODS: The patient's charts were reviewed. RESULTS: Visual field loss after pars plana vitrectomy and air/fluid exchange occurs and may be caused by mechanical trauma to the optic nerve head. CONCLUSION: Great caution is advised when aspirating directly over the optic nerve with any extrusion instrument.

The impact of acute lymphocytic leukemia on diabetic retinopathy.

PATIENTS AND METHODS: A 16 year-old girl with a 9-year history of insulin-dependent diabetes mellitus developed acute lymphocytic leukemia. RESULTS: The patient's vision deteriorated from normal to legal blindness within 6 months as her ophthalmologic examination progressed from minimal background diabetic retinopathy to severe proliferative diabetic retinopathy. The accelerated course of diabetic eye disease is attributable to the moderate anemia resulting from the leukemia and its treatment. CONCLUSIONS: Although anemia is usually well tolerated by young patients, it is not well tolerated by the diabetic retina. Diabetic patients require close ophthalmologic follow-up and aggressive management to maintain normal hemoglobin levels.

Vitrectomy for vitreomacular traction syndrome with macular detachment.

PURPOSE: To describe the clinical characteristics of the vitreomacular traction syndrome with macular detachment and to report our surgical experience with this condition. METHODS: A retrospective chart and photographic review was performed on nine patients (nine eyes) who had a symptomatic decrease in visual acuity from a macular traction retinal detachment caused by vitreomacular traction syndrome. Vitrectomy was performed in each eye to reattach the retina. RESULTS: Intraoperative observation confirmed partial posterior vitreous separation with adherence of the posterior hyaloid to the detached retina and separation of the posterior hyaloid from the attached retina. After surgery the macula was reattached in seven eyes (78%). Visual acuity was improved in four eyes, stable in four eyes, and worse in one eye. CONCLUSION: Macular detachment may occur secondary to vitreomacular traction syndrome. Although the retina may be reattached surgically in these cases, visual improvement may be limited by chronic detachment, premacular fibrosis, cystoid macular edema, or macular schisis.

Visual results after surgical removal of subfoveal choroidal neovascular membranes.

PURPOSE: The authors report their experience with the surgical removal of subfoveal choroidal neovascularization. Correlations between preoperative characteristics and final postoperative visual acuity are explored. METHODS: A retrospective study of 159 consecutive patients was performed between February 1990 and August 1993. Follow-up of 2 or more months was available for 147 eyes: presumed ocular histoplasmosis syndrome, 67 eyes; age-related macular degeneration, 41 eyes; myopia, 10 eyes; multifocal choroiditis, 9 eyes; idiopathic, 8 eyes; angioid streaks, 4 eyes; and miscellaneous, 8 eyes. RESULTS: Sixty-seven eyes had presumed ocular histoplasmosis syndrome: mean follow-up was 10.5 months. Visual acuity was stable or improved in 56 (83%) eyes and 20/40 or greater in 21 (31%) eyes. Mean interval to best visual acuity was 3 months. A recurrence rate of 37% had no significant effect on final visual outcome (P = 0.952). Forty-one eyes had age-related macular degeneration: mean follow-up was 15 months. Visual acuity was improved in only five (12%) eyes and was 20/40 or greater in only two (5%) eyes. The interval to best visual acuity was 5 months. A recurrence rate of 27% had not significant effect on final visual outcome (P = 0.31). The visual results and recurrence rates for eyes with less common disorders are presented. CONCLUSION: The surgical excision of subfoveal choroidal neovascularization may stabilize or improve visual acuity in selected cases. Patients with focal disorders of the retinal pigment epithelium-Bruch's membrane complex appear to have a better surgical outcome than those with diffuse disease.

Corticosteroid-induced ocular hypertension in the treatment of aphakic or pseudophakic cystoid macular edema.

PURPOSE: To examine the relationship between corticosteroid-induced ocular hypertension and the reduction and/or resolution of chronic aphakic or pseudophakic cystoid macular edema (CME). METHODS: The authors retrospectively reviewed 454 cases coded for CME between 1971 and 1991 and identified 21 patients with aphakic or pseudophakic CME greater than 6 months' duration who experienced a documented rise in intraocular pressure (IOP) on corticosteroid therapy. These patients were compared with similarly treated controls who did not experience a rise in IOP, and visual acuity and the biomicroscopic appearance of CME were examined. RESULTS: Sixteen of 21 patients showed improved visual acuity and reduction and/or resolution of CME. In all five cases of treatment failure, there was evidence of vitreous attachment to anterior segment structures. This is statistically significant compared with controls, in which 4 of 14 patients with normal vitreous anatomy showed similar improvement (P = 0.00003). CONCLUSION: This small retrospective series suggests that in the absence of vitreous traction, corticosteroid-induced ocular hypertension possibly leads to reduction and/or resolution of chronic aphakic or pseudophakic cystoid macular edema.