Retained nuclei after cataract surgery.

The authors reviewed the medical records of 36 patients in whom the nucleus or nuclear fragments were retained in the eye after cataract surgery. In 4 patients, there was no further surgery, and visual acuity deteriorated to counting fingers or worse (mean follow-up time, 14 months). Thirty-two patients underwent vitrectomy to remove the retained, unencapsulated nuclear material. Sixty percent (6 of 10) of patients in whom vitrectomy was performed after 3 weeks had chronic glaucoma on long-term follow-up, whereas this complication developed in only 18% (4 of 22) of patients in whom vitrectomy was performed in less than 3 weeks. Sixty-three percent (21 of 32) of vitrectomy patients had final visual acuity of 20/200 or better after removal of the retained nuclear fragments. The causes of the poorest visual outcome (less than 20/200) included 1 or more of the following: corneal decompensation, chronic inflammation, chronic glaucoma with optic atrophy, and retinal detachment.

Diabetic retinopathy.

Macular edema can occur early, especially in maturity onset diabetics. These patients will usually have blurred vision. An examination (through dilated pupil) will reveal fuzziness or hard exudates in the central retina. The ETDRS proved focal laser treatment to leaking blood vessels reduces vision loss. Proliferative retinopathy occurs after 12-15 years or more of diabetes in juvenile diabetics and any time in maturity onset diabetics. Proliferative disease may be completely asymptomatic until there is a vitreous hemorrhage or retinal detachment. The DRS showed scatter laser treatment reduces severe visual loss by at least 50% in patients with proliferative disease. If proliferative disease is not treated, it almost always causes blindness. We must shout this message to all primary care physicians and diabetics. If we are successful, we can eliminate preventable blindness in Iowa's diabetics.

Long-term visual outcome in patients with optic nerve pit and serous retinal detachment of the macula.

Serous detachment of the macula is a well-known complication in patients with an optic nerve pit. Despite the many descriptions of this condition and possible treatment options, the long-term natural history is not well known. The authors identified 15 eyes of 15 consecutive patients seen over 21 years who were diagnosed with a serous detachment of the macula arising from an optic nerve pit. Average length of follow-up was 9 years. Twelve eyes lost three or more lines of vision, two eyes remained unchanged, and only one eye improved. All of the 12 eyes losing three or more lines of vision experienced this decrease within the first 6 months of follow-up. Although only two patients had a visual acuity of 20/200 or less initially, 12 of 15 patients had a visual acuity of 20/200 or less at the time of their last examination. The appearance of the macula at last examination included cystic changes of the neurosensory retina, full-thickness hole formation, retinal pigment epithelial mottling, and lamellar hole formation in the outer retinal layer. The long-term visual prognosis in patients with optic nerve pit and untreated serous retinal detachment of the macula is poor, and visual loss occurs within 6 months of the serous detachment.

Visual prognosis in macular retinoblastomas.

Since 1979, we have treated 11 patients who had macular retinoblastomas. Two patients eventually recovered 20/20 visual acuity despite the presence of subretinal fluid in the fovea at the time of diagnosis. The diagnosis was made at 11 and 14 months of age, and follow-up periods were ten and seven years, respectively. One case was sporadic and the other was hereditary. Both patients were treated with external radiation; one patient was also treated with chemotherapy. The lesions regressed markedly after treatment. These cases demonstrate that visual prognosis in macular retinoblastomas is not uniformly poor even when a foveal detachment is present. Visual acuity may be good in some cases, which supports the merits of medical treatment rather than enucleation in selected patients.

Direct and feeder vessel photocoagulation of retinal angiomas with dye yellow laser.

Dye yellow laser photocoagulation (577 nm) was used to treat 14 retinal angiomas in nine patients. Eight patients had von Hippel-Lindau disease. Treatment was applied either directly to the tumor surface or to the feeding artery. Seven of eight angiomas that were treated directly and five of six that had feeder vessel treatment only were ablated successfully using dye yellow laser alone (mean follow-up, 11.1 months). An average of 2.2 treatments for feeder vessel and 1.1 treatments for direct ablation was required. Neither treatment caused decreased vision or severe complications. Dye yellow laser photocoagulation allows for effective treatment of retinal angiomas even when applied to the feeder vessel alone.

Pars plana vitrectomy in the management of retinal detachments associated with degenerative retinoschisis.

Pars plana vitrectomy and gas-fluid exchange were used to successfully reattach eyes of 12 patients who had symptomatic retinoschisis retinal detachments (RDs) associated with large or posterior outer-layer holes. Visual acuity improved postoperatively in seven (58%) eyes, was unchanged in two (17%) eyes, and decreased in three (25%) eyes. Loss of vision was secondary to a mild posterior subcapsular cataract in one eye and to epiretinal membranes in the other two. In two other eyes, cataracts developed that subsequently required an extracapsular cataract extraction (ECCE) and posterior chamber intraocular lens (PC IOL) implantation with 20/20 visual acuity in both eyes after cataract surgery. All eyes with a macula-involved RD stabilized or improved in visual acuity. Surgical indications, techniques, and results in the management of these retinoschisis RDs are discussed.

Best's vitelliform dystrophy.

Best's vitelliform dystrophy is an autosomal dominant disease that pathologically affects the retinal pigment epithelium and symmetrically affects the macula of patients at a very young age. Visual acuity tends to remain quite good for long periods of time. In the later stages of the disease, atrophic changes of the retinal pigment epithelium or scarring secondary to subretinal neovascular membranes with hemorrhage may cause a loss of central visual acuity. An abnormal diminished light to dark ratio of the electrooculogram is the hallmark of the disease. No other significant ocular abnormalities or systemic problems have been associated with this genetic disorder. No therapy exists for halting the progression of the disease with the possible exception of laser photocoagulation treatment used to ablate subretinal neovascular membranes in an attempt to avoid complications of subretinal hemorrhages. However, an accurate diagnosis and pedigree analysis is important for allowing the physician to perform adequate family and genetic counseling to affected patients.

Surgical management of late-onset retinal detachments associated with regressed retinopathy of prematurity.

The authors report their experience in managing 16 cases of late-onset retinal detachments (RDs) associated with regressed retinopathy of prematurity (ROP). Fourteen (88%) of the 16 eyes were successfully reattached. An initial scleral buckling procedure was successful in 6 of 12 eyes. A pars plana vitrectomy was necessary in a total of eight eyes that either initially presented with proliferative vitreoretinopathy (1 case), posterior retinal breaks (1 case), subretinal fibrosis (1 case), vitreoretinal traction bands (1 case), or had persistent vitreoretinal traction after failed scleral buckling procedures (4 cases). Visual acuity stabilized or improved in 13 of the 14 eyes with successful retinal reattachment. Because these cases often have significant vitreoretinal traction and/or posterior retinal breaks, pars plana vitrectomy in conjunction with scleral buckling may be necessary in order to achieve long-term retinal reattachment.

Myopia induced by vitreous hemorrhage.

Six of 11 children developed myopia in one eye after vitreous hemorrhage. None had retinopathy of prematurity, glaucoma, aphakia, or scleral buckling. In seven children developing vitreous hemorrhage before 1 year of age, six exhibited a myopic anisometropia in the affected eye of 1.37 to 12.00 diopters (mean, -4.7 diopters; S.D., 4.0). The degree of myopia correlated with the age of onset and duration of media opacification. In the child without myopia, the hemorrhage did not obscure the posterior pole. None of the four children whose hemorrhage occurred after 2 1/2 years of age showed myopic anisometropia (mean, +0.16 diopters; S.D., 0.24). We conclude that vitreous hemorrhage occurring in infancy is strongly associated with the development of myopia in the affected eye.

Factors prognostic of visual outcome in patients with subretinal hemorrhage.

We reviewed the charts of 29 patients with large subretinal hemorrhages involving the center of the fovea to evaluate factors that might be prognostic of visual outcome. The average final visual acuity was 20/480 with a mean follow-up of three years. Patients with thick hemorrhages (causing an obvious elevation of the fovea) had worse final visual acuity than patients with thin hemorrhages (P = .02). The diameter of the hemorrhage was not a significant predictor of outcome. Patients with aging macular degeneration had poorer final visual acuity (mean, 20/1,700, P = .002), and patients with choroidal ruptures had better final visual acuity, (mean 20/35, P less than .001) than the remainder of the patients. We found that the presence of aging macular degeneration was a more important predictor of the outcome of legal blindness than the thickness of the hemorrhage (P = .03). Although the prognosis in patients with subfoveal blood is generally poor, some patients have excellent return of vision.

Rural endophthalmitis.

The antibiotic regimens recommended for empiric use in posttraumatic endophthalmitis are based on data collected from medical centers in large metropolitan areas. In rural areas, trauma resulting in endophthalmitis frequently involves injuries with perforating objects that are contaminated with organic matter. These rural cases therefore may not be comparable with endophthalmitis occurring after nonrural injuries. A 10-year retrospective analysis was performed to investigate the incidence of rural endophthalmitis as well as determine the type of causative organisms. Endophthalmitis developed in 24 (30%) of 80 patients with rural penetrating trauma, compared with 23 (11%) of 204 patients with nonrural penetrating trauma. Of 24 patients, Bacillus spp were isolated in 11 (46%), followed by gram-negative rods in 7, Staphylococcus epidermidis in 6, and streptococcal species in 5. In 10 (42%) of these 24 patients with rural trauma, more than one organism was isolated. Bacillus spp were involved in six (60%) of ten of these mixed infections. Based on these findings, the authors suggest an intravitreal regimen of gentamicin along with either vancomycin or clindamycin for the empiric therapy of rural endophthalmitis.

Idiopathic premacular gliosis in children and adolescents.

We treated three patients under 20 years of age who had idiopathic premacular gliosis, a disorder found primarily in patients older than 50 years of age. Initial visual acuity ranged from 20/20 to 20/50, remained unchanged in one patient, improved in one patient, and decreased in one patient. Final visual acuity ranged from 20/15 to 20/500 with an average follow-up of 60 months (range, ten to 102 months). Included in this series is a 6-year-old boy with idiopathic premacular gliosis. Children and adolescents with idiopathic premacular gliosis may develop progressive visual loss to a level where vitrectomy should be considered.

Vitrectomy for complicated retinal detachments secondary to branch retinal vein occlusions.

Combined rhegmatogenous and traction retinal detachments associated with branch vein occlusions occurred in five eyes of five patients between Jan. 1, 1986 and Dec. 31, 1987. Four patients underwent surgery with pars plana vitrectomy and intravitreal gas, with or without scleral buckling. One patient refused treatment. All operated on eyes had attached retinas at a mean follow-up of seven months. Because posterior traction plays an important role in these unusual detachments, consideration should be given to pars plana vitrectomy and air-fluid exchange rather than scleral buckling alone.

The treatment of serous macular detachment secondary to choroidal melanomas and nevi.

The authors successfully treated with laser photocoagulation five patients who had a serous macular detachment secondary to leakage from a pigmented choroidal tumor. Three patients had dye leakage on fluorescein angiography from a choroidal neovascular membrane. The subretinal fluid resolved in all three patients after the neovascular membrane was obliterated by either krypton red (2 patients) or argon green (1 patient) laser photocoagulation. The other two patients had prominent leakage from a localized choroidal neovascular membrane as well as mild diffuse leakage over the entire tumor. Focal argon laser treatment to the neovascular membrane alone did not cause permanent resolution of the subretinal fluid. The fluid did resolve, however, after the entire area of diffuse leakage was retreated with photocoagulation. In one of the patients who received both focal and confluent laser treatment, the choroidal tumor grew in a collar-button fashion through Bruch's membrane at the original site of focal treatment. This eye was enucleated, and results of histopathologic examination showed a choroidal melanoma.