Improved surgical treatment of familial exudative vitreoretinopathy in children.

PURPOSE: To evaluate current surgical results in patients with familial exudative vitreoretinopathy and study the histologic findings of epiretinal membranes obtained at the time of surgery. METHODS: We performed phakic pars plana vitrectomy and membrane peeling on five patients (six eyes) with familial exudative vitreoretinopathy, who ranged in age from 18 months to 9 years and had traction retinal detachment. Membranes from two eyes (two patients) were analyzed by light and electron microscopy. RESULTS: The macula was reattached in all six eyes. Visual acuity improved after surgery in five of the six eyes, with two eyes improving from a preoperative visual acuity of 20/400 to a postoperative visual acuity of 20/25 and 20/60. Electron microscopic analysis of the membranes from two patients disclosed thick fibrocellular fragments with vascular elements and astrocytes. CONCLUSION: With current surgical techniques, there appears to be improvement in the anatomic reattachment rate and visual outcome in patients with familial exudative vitreoretinopathy. Amblyopia, reproliferation, and vitreous hemorrhage may limit long-term improvement in vision.

Comparison of xenon arc and argon laser photocoagulation in the treatment of choroidal melanomas.

We analyzed the follow-up data in 38 consecutive patients with selected choroidal melanomas that were treated by photocoagulation between 1971 and 1980. Indications for treatment included photographic documentation of tumor growth or an unequivocally positive radioactive phosphorus uptake test, or both. Xenon arc photocoagulation was used in 22 patients (58%) and argon laser was used in 16 patients (42%). At the time of data analysis, the length of follow-up was at least 58 months in all patients. Although all treated tumors were initially eradicated according to ophthalmoscopic and fluorescein angiographic criteria, there was subsequent regrowth in three of the 22 patients (14%) treated with xenon photocoagulation and in ten of the 16 patients (64%) treated with argon laser. The recurrences were observed on an average of 71 months after completion of treatment in the xenon-treated group and on an average of 30 months in the argon-treated group. More treatment sessions were required in the argon laser group to achieve tumor control. Complications of vitreous hemorrhage, cystoid macular edema, and retinal detachment were greater in the xenon photocoagulation group.

Choroidal rupture and optic atrophy.

The association between post-traumatic optic disc pallor and traumatic choroidal rupture is poorly understood. To further define this relationship, nine cases of indirect traumatic choroidal rupture and post-traumatic optic disc pallor were compared with cases of indirect choroidal rupture without disc pallor in terms of severity of ocular injury, fundus findings, and visual outcome. The type and severity of the injury did not appear to influence the risk of optic disc pallor. Optic disc pallor was associated with a slightly poorer long term visual acuity than eyes without pallor (p = 0.059). The presence of a relative afferent pupillary defect was strongly associated with optic disc pallor (p = 0.016). Peripapillary retinal pigment epithelial abnormalities were a common finding, suggesting peripapillary trauma as a cause for optic disc pallor.

Hemorrhage associated with localization of melanoma margins during radioactive plaque placement.

Accurate placement of a radioactive plaque is essential in brachytherapy of choroidal melanoma. Various localization techniques, including transillumination of anteriorly located tumours and scleral indentation to mark the anterior margin of posteriorly located tumours, have been used in initially placing a plaque over the base of the tumour. Of 40 consecutive patients treated for choroidal melanoma between 1986 and 1990, 8 had posteriorly located tumours, all localized by means of scleral indentation; subretinal hemorrhage occurred in 3 of the 8 during marking of the tumour margins. No hemorrhages occurred in the 32 patients with tumours localized by means of transillumination (p less than 0.01). It is not clear whether the method of marking or the location of the tumour itself contributed to the development of the hemorrhage. Hemorrhage around the base of a tumour may mask the tumour margins, making assessment of the response to therapy difficult. Caution should be used when marking posteriorly located tumours.

Favourable outcome of traumatic endophthalmitis with associated retinal breaks or detachment.

Traumatic endophthalmitis in association with retinal breaks or detachments is reported to have uniformly poor visual and anatomic outcomes. We describe two cases of culture-positive traumatic endophthalmitis with retinal breaks or detachment in which the final visual result was 20/70 in one case and 20/40 in the other. Factors that may improve the prognosis in such cases include attention to the possibility of infection, selective use of broad-spectrum antibiotics, prompt surgical intervention and improvement in vitreous surgical techniques. Modification of intravitreal antibiotic regimens may be indicated in eyes in which the vitreous cavity is partially filled with air or gas.

Surgical repair of retinal detachment secondary to cytomegalovirus retinitis.

BACKGROUND AND OBJECTIVE: This study was conducted to determine preoperative predictors of postoperative visual acuity in patients with acquired immunodeficiency syndrome (AIDS) and cytomegalovirus (CMV) retinitis and retinal detachment. PATIENTS AND METHODS: The study design was a retrospective chart review of 38 eyes in 33 patients with AIDS and CMV retinitis who had retinal reattachment surgery by pars plana vitrectomy with the use of silicone oil tamponade. Factors considered included: preoperative visual acuity, macular attachment status and CMV activity at the time of surgery, and length of time from diagnosis of retinal detachment to surgical repair. RESULTS: Retinal reattachment was achieved in 37 of 38 eyes. Mean interval from surgery to best corrected visual acuity (VA) was 9 weeks. The mean best corrected post-op VA was 20/70. Approximately half of the patients died within 7 months of the surgery. There was good correlation between preoperative VA and best attained postoperative VA (Spearman's: r = 0.5139, P = 0.001). The interval from retinal detachment to surgery, and best attained postoperative VA did not correlate (Spearman's: r = 0.2339, P=0.158). The lack of macular CMV retinitis correlated well with postoperative VA (P = 0.0066, Wilcoxon rank-sum test). CONCLUSIONS: Preoperative visual acuity and macular attachment status correlates with better postoperative visual acuity results, whereas early surgical repair of retinal detachment does not.

Methods for determination of optic nerve blood flow.

A variety of studies have been conducted over the past two decades to determine if decreased optic nerve blood flow has a role in the etiology of glaucomatous nerve damage. Five basic methods have been employed in examining blood flow. Invasive studies, utilizing electrodes placed in the optic nerve head, represent one of the first attempts to measure blood flow. More recently, the methodologies have included axoplasmic flow analysis, microspheres, radioactive tracers such as iodoantipyrine, and laser doppler measurements. The results of these studies are inconclusive and frequently contradictory. When the studies are grouped by methodology, only the iodoantipyrine data are consistent. While each of the experimental techniques has limitations, iodoantipyrine appears to have better resolution than either invasive studies or microspheres.

Orbital metastasis as the presenting sign of adenocarcinoma of the breast.

A 64-year-old woman presented with periorbital induration of 6 months' duration. Computed tomography (CT) revealed enlargement of extraocular muscles. A biopsy specimen of the orbicularis muscle and indurated preaponeurotic fat demonstrated an infiltrating carcinoma, and immunoperoxidase studies for surface antigens suggested a metastatic adenocarcinoma. Extensive evaluation revealed a 1-cm subareolar breast mass, with histopathological features identical to those of the orbital lesion. Orbital metastasis presenting before the diagnosis of a primary breast cancer is unusual, particularly in the absence of other disseminated disease.

Complications of primary scleral buckling procedures in high myopia.

Repair of retinal detachments in high myopia may be associated with numerous intraoperative complications. Included are complications involved with the drainage of subretinal fluid as well as those arising from thin sclera. Highly myopic eyes tend to be more prone to these complications than less myopic or nonmyopic eyes. A retrospective study of 51 consecutive highly myopic eyes (six diopters (D) or greater) undergoing primary scleral buckling procedures was performed. Intraoperative complications occurred in a total of six eyes (12%). The complications were related to drainage of subretinal fluid in four eyes (8%) and associated with thin sclera in two eyes (4%). Despite the above-noted complications, there was no adverse effect on the final level of visual acuity or on the anatomic status of the retina. In the comparison of the incidence of drainage-related complications with previously published studies not preselected according to refractive status, there appears to be no added risk of complications based on the degree of myopia.

Mechanisms of visual loss in severe proptosis.

Vision loss in orbital hypertension secondary to sudden space-occupying lesions is usually attributed to one of three causes: central retinal artery occlusion, direct compressive optic neuropathy, or compression of optic nerve vasculature. Accepted modes of decompressive therapy include lateral canthotomy and cantholysis; drainage of localized orbital air, hematoma, or abscess; and bony wall decompression. Five cases are presented in which orbital hypertension caused severe proptosis with traction on the optic nerve and tenting of the posterior globe. Another mechanism contributing to visual loss is proposed in these cases: ischemic optic neuropathy due to stretching of nutrient vessels. In these cases, rapid posterior decompression should theoretically be favored to reduce orbital pressure and relieve traction on the optic nerve vasculature.