Vascular consequences of retinectomy.

OBJECTIVE: To define the vascular sequelae of retinectomy. DESIGN: Clinical and angiographic survey of patients who had undergone retinectomy procedures. PATIENTS: Twenty consecutive patients with ambulatory vision and attached posterior retina after retinectomy procedures underwent ophthalmic examination, including retinal biomicroscopy, indirect ophthalmoscopy with scleral indentation, and peripheral retinal fluorescein angiography. RESULTS: Ten eyes (50%) showed anterior retinal neovascularization (NV), with vessels derived from the ciliary body or posterior retina. Neovascularization occurred in residual anterior retina adjacent to the retinectomy, in detached anterior retina demarcated by laser in quadrants not involved by retinectomy, and in fibrinous membranes extending anterior to the retinectomy edge. This was associated with postoperative vitreous hemorrhages in two patients. Iris NV and inferior iridectomy occlusion were strongly associated with retinal NV (Fisher's exact test, P < .005). No patient had neovascular glaucoma or optic disc NV during a median follow-up of 250 days (range, 121 to 465). CONCLUSIONS: Retinectomy may have profound secondary effects on ocular vascular circulation, resulting in retinal NV in association with iris NV, occlusion of inferior iridectomies, and vitreous hemorrhage. Complete intraoperative removal of residual anterior retina to the ora serrata in quadrants involved by retinectomy, combined with prophylactic retinal laser treatment from the vitreous base to the ora in the remaining quadrants, is recommended to prevent the development of retinal NV and its associated complications.

The stability of perfluoro-N-octane during vitreoretinal procedures.

OBJECTIVES: To examine the propensity for intraoperative procedures, such as endolaser, to generate polar impurities in perfluorocarbon liquids, either by degradation of the compound or by dissolution of materials contacting the liquid, given the value of these liquids as adjuncts to vitreoretinal procedures and the importance of using pure and inert liquid. METHODS: Perfluoro-N-octane liquid recovered from patients after vitreoretinal procedures was analyzed by gas chromatography, nuclear magnetic resonance, ultraviolet spectroscopy, and a cell proliferation assay. Similar analyses were performed on pure and impure perfluoro-N-octane exposed in vitro to superclinical energy levels of argon and YAG laser, endodiathermy, and endoillumination. RESULTS: No change in chemical structure and only minor (parts per million) increases in dissolved contaminants were observed. The perfluoro-N-octane liquid retained its inertness as indicated by the inability of fibroblasts to attach and proliferate on its surface. CONCLUSION: The structure and biologic inactivity of perfluoro-N-octane are unaffected by vitreoretinal surgical manipulations.

Combined pars plana vitrectomy and sutured posterior chamber implant.

OBJECTIVE: To describe the surgical technique, visual acuity results, and complications of sutured posterior chamber intraocular lenses with complete pars plana vitrectomy. METHOD: A retrospective review of 63 eyes was combined with a telephone survey of the patients and their ophthalmologists. RESULTS: The preoperative diagnoses were trauma, 25 eyes; ectopia lentis, 24 eyes; aphakia following retinal detachment surgery, 7 eyes; cataract surgery, 6 eyes; and endophthalmitis, 1 eye. Mean follow-up was 20 months. Preoperative best-corrected visual acuity was 20/40 or better in 36% (23 of 63 eyes), 20/60 to 20/120 in 33% (21 of 63 eyes), and 20/200 or worse in 31% (19 of 63 eyes) improving to 20/40 or better in 76% (48 of 63 eyes), 20/60 to 20/120 in 18% (11 of 63 eyes), and 20/200 or worse in 6% (4 of 63 eyes) at final follow-up. Preoperative complications included iatrogenic retinal breaks in 3 cases, difficulty with a fixation suture in 1 case, and mild vitreous hemorrhage in 1 case. Postoperative complications included retinal detachment in 2 cases, choroidal hemorrhage in 1 case, intermittent pupil capture in 9 cases, self-limiting vitreous hemorrhage in 3 cases, and late intraocular lenses dislocation in 1 case. CONCLUSIONS: Suturing a posterior chamber implant concurrently, or following, a complete pars plana vitrectomy is a safe procedure. Complete vitrectomy may reduce the rate of long-term complications. Optimal visual rehabilitation can be achieved without the need for contact lens wear with an acceptable additional risk of surgical complications. Arch Ophthalmol. 2000;118:905-910

Arachnoid hyperplasia in optic nerve glioma: confusion with orbital meningioma.

A case is reported of an optic nerve glioma with a marked degree of arachnoid hyperplasia which was initially diagnosed as an optic nerve meningioma. Hyperplasia of the arachnoid was also the underlying cause for expansion of the optic canal. The relationship between arachnoid hyperplasia in optic nerve glioma and meningioma of the optic nerve sheath in childhood is discussed.

Retinal detachment in congenital glaucoma.

This paper reports the occurrence of retinal detachment in 18 patients suffering from congenital glaucoma. Difficulty in establishing control of the glaucoma and the presence of high myopia were common findings. The poor results of detachment surgery were related to opacites in the media preventing evaluation of the renal details and the development of massive preretinal retraction.

Primary care and ophthalmology in the United Kingdom.

The National Health Service is now primary care led. There are different definitions for primary care and in this review they are analysed and related to ophthalmology to produce a working definition for ophthalmic primary care, summarised as the provision of first contact care for all ophthalmic conditions and follow up, preventive, and rehabilitative care of selected ophthalmic conditions, in a variety of settings, by a diverse workforce. The attributes of primary care are first contact, accessibility, continuity, longitudinality, comprehensiveness, coordination, equity, and accountability. The delivery of ophthalmic primary care should be governed by these and evaluated accordingly. The clinical content of primary care consists of the first presentation of disease, the management of minor illness and trauma, the recurrence of disease, the follow up and support of some chronic conditions, and the delivery of preventive health care. Planning for ophthalmic primary care needs to take service requirements of these categories of disease into account. Primary care research is abundant in ophthalmology but needs to be more structured and targeted. Ophthalmic primary care itself is urgently in need of recognition and formal adoption by the profession.

Retinal detachment following anterior chamber lens implantation for the correction of ultra-high myopia in phakic eyes.

The development of retinal detachment is reported in three eyes, of two patients, following implantation of an anterior chamber intraocular lens (AC-IOL) in phakic eyes for the correction of ultra-high myopia. The presence of an AC-IOL may hamper the identification of retinal breaks and removal of the intraocular lens may prove necessary to improve visualisation. Shallowing of the anterior chamber may also occur during, or following, vitreoretinal surgery with risk of endothelial contact. The risks and relative contraindications of AC-IOL implantation into phakic eyes are discussed.

Retinal detachment following excimer laser.

AIM: To report the clinical presentation, surgical management, and outcome of retinal detachment following excimer laser. METHODS: Retrospective analysis of retinal detachments observed in 11 eyes of 10 myopic patients who had previously undergone photorefractive keratectomy (PRK) or phototherapeutic keratectomy (PTK) by excimer laser. RESULTS: Symptoms of visual loss in two eyes were initially attributed to corneal haze. In 10 of 11 eyes visualisation of the retinal detachment and causative break was possible despite mild corneal haze and optical aberrations caused by the refractive laser procedure. Retinal reattachment was achieved in all 11 eyes though one eye required four surgical interventions. CONCLUSION: This is the first published report to describe an association between retinal detachment and previous excimer laser treatment. The association would appear to reflect the predisposition of myopes to retinal detachment. Clinicians should be aware of potential retinal pathology in patients undergoing PRK.

Fluorescein angiography of anterior uveal melanocytic tumours.

A retrospective analysis of 32 cases of anterior uveal melanocytic tumours included 14 cases in which the tumours could be categorised histologically as malignant, of intermediate cytology with equivocal features of malignancy, or as benign progressive naevi. An additional eight cases without a histological diagnosis were included as benign naevi, because there had been no change in their clinical characteristics after a minimum follow-up of four years. Clinical features and iris fluorescein angiographic (IFA) findings were analysed with respect to these groups in an attempt to identify features predictive of malignant or locally invasive behaviour. Very small tumours were more likely to be benign (p = 0.029). Glaucoma and episcleral vascular dilatation occurred in ciliary body tumours only. Tumours involving the anterior chamber angle proved more likely to be malignant (p = 0.019). IFA showed a disorganised vasculature and gross late leakage in 4/7 (56%) malignant melanomas as well as in 2/6 (33%) tumours with intermediate cytology. No benign tumours showed these features. Four out of nine (44%) benign tumours, but no tumours with malignant or intermediate cytology, showed complete masking of fluorescence. Early leakage of dye from tumour vessels and a geometric tumour vasculature were not specific features of any tumour category. IFA correlated with the cytology and behaviour of anterior uveal melanocytic tumours in 11/22 (50%) of our cases.

Retinal detachment and herpesvirus retinitis in patients with AIDS.

BACKGROUND: The prolongation of survival of patients with herpesvirus retinitis and AIDS has been associated with a rise in the incidence of retinal detachment. In such cases, however, retinal reattachment may be difficult to achieve, and postoperative visual acuity may be poor despite anatomically successful surgery. METHODS: In order to examine factors affecting the visual outcome of surgery, a retrospective review of 29 patients with retinal detachment, herpesvirus retinitis, and AIDS was performed. Retinal reattachment surgery (32 procedures) or prophylactic laser demarcation (five procedures) was performed in 28 eyes of 23 patients. RESULTS: The macula was attached in 23/28 (82%) eyes at the last outpatient visit. Best postoperative visual acuity (median 6/18, range 6/6-hand movements) was significantly greater than final postoperative acuity (median counting fingers, range 6/6-no perception of light) (Wilcoxon sign rank test, p = 0.003), and was retained for a median of 3 months (1-91 weeks) after surgery. Poor visual outcome as evidenced by submedian final visual acuity was invariably associated with persistence of macular detachment, and significantly associated with the occurrence of optic atrophy (odds ratio = 5, p = 0.02). CONCLUSION: Retinal reattachment surgery appears justified in patients with herpesvirus retinitis and AIDS, but postoperative visual deterioration may occur in association with optic atrophy.

Identification of FBN1 gene mutations in patients with ectopia lentis and marfanoid habitus.

BACKGROUND: Marfan syndrome (MFS), inherited as an autosomal dominant trait, typically affects the cardiovascular, skeletal, and ocular systems. Ectopia lentis (EL) is a clinical manifestation of MFS, with stretching or disruption of the lenticular zonular filaments, leading to displacement of the lenses. EL, with or without minor skeletal changes, exists as an independent autosomal dominant phenotype linked to the same FBN1 locus. METHODS: A consecutive series of 11 patients, affected predominantly by EL, was analysed for FBN1 mutations using PCR, SSCA, and sequencing. RESULTS: Six mutations were identified, of which three are novel and one is recurrent in two patients, thus establishing a mutation incidence in this group of 7/11 (63%). CONCLUSION: The FBN1 variants reported are clustered in the first 15 exons of the gene, while FBN1 mutations reported in the literature are distributed throughout the entire length of the gene. A different type of FBN1 mutation presents in this group of patients, compared with MFS, with arginine to cysteine substitutions appearing frequently.

Vitrectomy and fluid/silicone-oil exchange for giant retinal tears: results at six months.

The results of vitrectomy combined with fluid/silicone-oil exchange in 73 eyes with giant retinal tears are reported at six months after surgery. Initial anatomical success was achieved in 71 out of 73 eyes (97%) and, prior to removal of silicone-oil, in 66 out of 73 eyes (90%). In 63 eyes (86%) the retina remained attached six months after surgery. Of these visual acuity was 6/60 or better in 44 (70%). The high proportion of eyes with macular detachment before surgery and the frequency of macular abnormalities are thought to account for reduced vision in many of the anatomically successful cases.

Systemic steroid prophylaxis for cataract surgery in patients with posterior uveitis.

Cataract remains difficult to manage in patients with uveitis affecting the posterior segment of the eye due to the high risk of postoperative complications, especially cystoid macular oedema, even in eyes in which inflammation has been completely suppressed preoperatively. A standard regimen of preoperative and perioperative systemic steroid prophylaxis was introduced into the uveitis clinic in order to prevent uveitis-related cystoid macular oedema in the postoperative period. The aim of this study was to assess if this policy resulted in an improvement in the visual recovery. Data from a single consecutive clinical series of 30 extracapsular cataract extraction procedures performed in 24 patients with posterior uveitis were collected retrospectively. Nineteen procedures were performed before and 11 after the introduction of the regimen of steroid prophylaxis. Success was graded according to the Snellen acuity at six months, the number of lines improvement in visual acuity by six months and the time from the operation date for acuity to recover to its best postoperative level. The median visual acuity after six months was 20/30 in the prophylaxis group compared with 20/80 in the controls (p = 0.052), representing a median improvement of five lines in the prophylaxis group and three lines in the controls (not significant). The eyes receiving prophylaxis achieved their best acuity in 1.8 months (median) compared with 5.9 months for the control group (p<0.01). This was not attributable to the longer period of follow-up in the control group and was independent of IOL implantation or the influence of any individual postoperative complication. When pseudophakic eyes were considered in isolation, the median acuity at six months was also better in the prophylaxis group (p = 0.023). The results suggest that preoperative systemic steroid prophylaxis may benefit the patient by hastening postoperative visual recovery independently of IOL implantation.

Traumatic retinal detachment--mechanisms and management.

Experience has shown that the overwhelming majority of traumatic retinal detachments are rhegmatogenous in origin. Retinal breaks are predominantly located within the vitreous base region but may occur at sites of focal scleral impact or from posterior vitreous avulsion. Although the use of scleral buckling techniques alone may be sufficient, closed microsurgery may be required to relieve trans-gel or surface retinal traction and to facilitate the identification and permanent closure of retinal breaks. Prophylactic measures including the use of closed microsurgery play a vital role in the management of traumatic retinal breaks and prevention of complex retinal detachment.