Dynamic angle closure following pars plana vitrectomy with perfluoropropane gas.

Purpose: To report the clinical course of an aphakic patient who developed positional secondary angle closure glaucoma following pars plana vitrectomy (PPV) with perfluoropropane (C3F8) gas tamponade. Observations: A 23-year-old male presented due to a two-year history of vision loss in the left eye. Best-corrected visual acuity (BCVA) was 20/200 and intraocular pressure (IOP) was 12 mm Hg OS. Exam revealed iridodonesis and aphakia of both eyes, and a total RRD in the left eye. The patient underwent scleral buckle plus PPV with 15 % C3F8 gas and was instructed to maintain face-down positioning for 5 days. On post-operative day 1, IOP was 32 mm Hg and exam revealed significant diffuse corneal edema, a large epithelial defect, and 85 % C3F8 fill of the vitreous cavity. Patient was started on IOP-lowering drops but continued to have elevated IOP and corneal epithelial sloughing over the next 3 weeks. He was taken for a superficial keratectomy, but when placed supine under the microscope, a large new gas bubble was visualized overlying the pupil in a now shallow anterior chamber (AC) and IOP was 52 mm Hg. The patient was positioned back upright and the gas bubble migrated posteriorly out of the AC with return of IOP to 25 mm Hg. The dynamic nature of his IOP raised concerns for intermittent angle closure by C3F8 induced by supine positioning. Thus, a pars plana aspiration of the C3F8 gas was performed and resulted in normalization of the IOP. Conclusions and importance: Dynamic, positional secondary angle closure glaucoma can occur after vitrectomy with C3F8 in the setting of aphakia. This is the first report to capture C3F8 gas migration causing intermittent acute angle closure in real-time. Due to its intermittent nature however, the diagnosis may not be initially apparent at the slit lamp. Thus, we suggest this potential complication should be carefully monitored for and discussed when advising post-vitrectomy positioning in aphakic patients.

Incidence of presumed iatrogenic graft failure in Descemet stripping automated endothelial keratoplasty.

PURPOSE: To evaluate presumed iatrogenic graft failure (PIGF) in Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS: Deidentified data were collected retrospectively from the Illinois Eye Bank between April 2007 and May 2010. PIGF was defined as cases in which a repeat corneal transplant was performed <8 weeks after an initial DSAEK. Data collected for each case included days between initial DSAEK and regraft, regraft type (DSAEK vs. penetrating keratoplasty), precut versus surgeon-cut tissue, and number of DSAEKs distributed to individual surgeons. Ninety-three cases of PIGF were identified for a group of 46 surgeons who received 2504 corneas. Nine PIGF cases from 4 surgeons in cornea fellowships were analyzed separately. Individual surgeon failure rate and overall failure rate were calculated. Analysis of the overall failure rate was conducted without cases performed by surgeons who train fellows. Effect of surgical experience on PIGF was analyzed. RESULTS: Overall presumed iatrogenic DSAEK failure rate was 3.66% (84 PIGF cases divided by 2294 corneas). Within the group of 4 surgeons that trained fellows, the failure rate was 4.29% (9 cases PIGF divided by 210 corneas). Average time to regraft was 27.5 ± 17.4 days. Initial diagnoses included Fuchs dystrophy, pseudophakic bullous keratopathy, edema, and other disease states. Average donor and recipient ages were 54.3 ± 13.0 and 71.7 ± 11.3 years, respectively. Use of precut versus surgeon-cut tissue did not affect overall failure rates. Failure rates of less experienced surgeons (21.8% ± 10.8%) were higher than more experienced surgeons (1.5% ± 1.4%). CONCLUSIONS: Overall, DSAEK failure rates improve as surgeons gain experience. Failure rates in cornea fellowship programs are not excessive.

Indocyanine green toxicity of the retina after cataract surgery: a case report.

PURPOSE: To report a single case of indocyanine green (ICG) toxicity of the retina after cataract surgery. METHODS: A patient from an academic clinical practice was observed with visual field testing, fundus photography, optical coherence tomography, and electroretinography (ERG) following the occurrence of ICG toxicity of the retina after cataract surgery. The main outcomes were final visual acuity, visual fields, and ERG result. RESULTS: ERG revealed initial subnormal dark-adapted response with normalization 6 months after surgery. The pericentral scotoma found by visual field testing disappeared. Fundus photography of the affected eye showed clearing of ICG stains. CONCLUSIONS: The patient had substantial improvement of ICG-mediated retinal toxicity.