Improving eye care follow-up adherence in diabetic patients with ocular abnormalities: the effectiveness of patient contracts in a free, pharmacy-based eye screening.

OBJECTIVES: Patient contracts are increasingly utilized in medical practice and have the potential to improve health outcomes in high-risk populations. However, as a relatively new tool, there has been limited research regarding the efficacy of patient contracts. Diabetic retinopathy (DR) is one of the leading causes of vision impairment in adults in the US and only 50-60% of adults with diabetes adhere to annual dilated fundus exam recommendations. This study aimed to evaluate the impact of patient contracts on follow-up adherence in diabetic patients with ocular abnormalities after a free, pharmacy-based eye screening. STUDY DESIGN: This prospective study implemented a non-invasive, non-mydriatic fundus camera in an urban, community-based pharmacy setting to screen for ocular diseases in patients with diabetes. Patients were assigned to the contract or non-contract group. Patients who signed a contract agreed to: 1) review their results with their primary care doctor, 2) follow-up with an ophthalmologist if their results were abnormal, and 3) inform research staff if/when they completed an eye care appointment. All study participants and their primary care doctors were notified of their results via mail. Follow-up questionnaires were administered to all patients by telephone three months after the screening results. RESULTS: 500 patients were screened and 113 (22.6%) had abnormal results. Of the patients who had abnormal results, 83 (74.3%) were able to be contacted. Of the 83 patients who were able to be contacted, the majority of patients were African American (73.5%) and female (56.6%). The mean age was 54.7 years. Of those, 34 (41.0%) adhered to follow-up recommendations. There was no significant difference in follow-up adherence between the contract (38.1%) and non-contract group (43.9%) (P = 0.59). In addition, 70.4% of patients did not comply with at least one measure of the contract agreement. CONCLUSION: Contracts did not increase follow-up adherence to eye appointments in diabetic patients with ocular abnormalities. The majority of patients did not comply with their contract and follow-up adherence was low in both groups. Most research has yielded mixed results regarding the efficacy of contracts in improving health outcomes. Therefore, different types of contracts or other patient-centered tools should be evaluated in order to increase follow-up adherence in patients at high risk for DR.

An exploratory study of the safety, tolerability and bioactivity of a single intravitreal injection of vascular endothelial growth factor Trap-Eye in patients with diabetic macular oedema.

AIM: The aim of the study was to assess the safety and bioactivity of a single intravitreal injection of vascular endothelial growth factor (VEGF) Trap-Eye in subjects with diabetic macular oedema (DMO). METHODS: Five subjects with DMO, foveal thickness > or =250 microm measured by optical coherence tomography (OCT), and best-corrected visual acuity (BCVA) between 20/40 and 20/320, were enrolled. Each participant received a single intravitreal injection of 4.0 mg of VEGF Trap-Eye followed by a 6-week observation period. Outcome measures included safety and biological activity, including changes in BCVA and excess retinal thickness assessed by OCT. RESULTS: Injections of VEGF Trap-Eye were well tolerated with no ocular toxicity. One patient had an unrelated serious adverse event: hospitalisation for cellulitis of the left foot 27 days after injection of VEGF Trap-Eye. Median baseline BCVA was 36 ETDRS letters read at 4 m (not ETDRS visual acuity score; Snellen equivalent: 20/50) and median baseline excess central 1 mm foveal thickness (FTH) was 108 microm. At 4 weeks after injection, the median excess FTH was 59 microm and the median improvement in BCVA was nine letters. At 6 weeks after injection, four of the five patients showed improvement in excess FTH (median 74 microm; 31% reduction from baseline, p = 0.0625) and four of the five showed improvement in BCVA (median improvement of three letters). CONCLUSIONS: A single intravitreal injection of 4.0 mg of VEGF Trap-Eye was well tolerated and preliminary evidence of bioactivity was detected. These findings support additional studies investigating multiple injections of VEGF Trap-Eye in patients with DMO.

Clinical protocol. An open-label, phase I, single administration, dose-escalation study of ADGVPEDF.11D (ADPEDF) in neovascular age-related macular degeneration (AMD).

Age-Related Macular Degeneration (AMD) is, together with Diabetic Retinopathy, the most common cause of vision loss among adults in the U.S. and other developed countries. In the U.S., at least 1.7 million people have impaired vision due to AMD. Every year, more than 165,000 people contract AMD and 16,000 go blind from it, predominantly from a rapidly progressing form of the disease called "wet" AMD. Wet AMD is characterized by serious or hemorrhagic detachment of the retinal pigment epithelium and choroidal neovascularization. The macula has the highest concentration of photoreceptors facilitating central vision and permitting high-resolution visual acuity. The damage caused by the leakage and fibrovascular scarring in wet AMD leads to profound loss of central vision and severe loss of visual acuity (usually 20/200 or worse). People with wet AMD have several limitations, including inability to read, inability to recognize faces or drive, and the disease often leads to blindness. The onset of severe visual changes in wet AMD can occur suddenly. More than 400,000 Americans are currently affected by this form of the disease, and the incidence is rising rapidly with the aging of the population. Therefore, the serious consequences of this disease along with the limited treatment options and their effectiveness make this a very good candidate for a gene transfer treatment approach. The investigational agent, Ad(GV)PEDF.11D, is an E1-, partial E3-, E4- deleted replication-deficient, adenovirus serotype 5, gene transfer vector. The transgene in this vector is the cDNA for human pigment epithelium-derived factor (PEDF). PEDF is one of the most potent known antiangiogenic proteins found in humans. While Ad(GV)PEDF.11D is able to transduce many somatic cell types, the natural barrier to other tissues created by the retina limits the ability of Ad(GV)PEDF.11D to affect tissues other than in the eye. Intravitreal administration of Ad(GV)PEDF.11D provides a convenient means of delivering PEDF to the relevant cells within the eye likely to result in a more prolonged duration of effect versus administration of the PEDF protein alone. In three murine disease models (the laser-induced choroidal neovascularization model, the VEGF transgenic model, and the retinopathy of prematurity model) significant inhibition of neovascularization (up to 85%) was demonstrated with doses of Ad(GV)PEDF vectors ranging from 1 x 10(8) to 1 x 10(9) pu. In toxicology studies performed in Cynomolgus monkeys, a dose-related inflammatory response was observed. A dose of 1 x 10(8) pu caused no adverse effects, while the inflammatory response observed at 1 x 10(9) pu was minimal and fully reversible. The observed inflammatory response at doses of 1 x 10(10) and 5 x 10(10) pu were increasingly severe. The proposed clinical trial is an open-label, dose-escalation, phase I study to investigate the safety, tolerability and potential activity of intravitreal injection of Ad(GV)PEDF.11D in patients with wet AMD. Ad(GV)PEDF.11D will be injected once via intravitreal injection into the eye with the most advanced AMD based on visual acuity. Subjects will be age 50 or over and have severe wet AMD in at least one eye defined by a best-corrected vision of 20/200 or worse. The primary objectives of this investigation are: (1) to assess the safety, tolerability and feasibility of intravitreal injection of Ad(GV)PEDF.11D in patients with severe, neovascular AMD, (2) to identify the maximum tolerated dose (MTD) of Ad(GV)PEDF.11D, and (3) to get some indication of potential activity of Ad(GV)PEDF.11D.

Cataract surgery by phacoemulsification in adults with retinopathy of prematurity.

PURPOSE: To report the preoperative, operative, and postoperative factors associated with phacoemulsification cataract surgery in adults with retinopathy of prematurity. METHODS: Records of patients with retinopathy of prematurity who underwent phacoemulsification at The Wilmer Institute between January 1990 and January 2000 were retrospectively searched. Seventeen adults (9 women, 8 men) with retinopathy of prematurity were identified who had undergone phacoemulsification for visually significant cataract or phacomorphic glaucoma and who had at least 6 months of postoperative follow-up. RESULTS: Cataract extraction by phacoemulsification was performed on 20 eyes. Follow-up ranged from 6 to 103 months (mean, 32 months). A posterior chamber intraocular lens was placed in 18 eyes; two eyes were left aphakic for refractive reasons. Zonular weakness was noted in two eyes in which the intraocular lens was suture fixated to the sclera. Concomitant trabeculectomy was performed in one eye. Visual acuity improved in 18 of 20 eyes and remained unchanged in two eyes. Postoperatively, visual acuity was worse than 5/200 in two eyes, 5/200 to worse than 20/100 in five eyes, 20/100 to 20/50 in five eyes, and 20/40 or better in eight eyes. One eye developed a rhegmatogenous retinal detachment 1 month after cataract surgery; the retina was successfully reattached. CONCLUSIONS: Although cataract extraction in eyes with regressed retinopathy of prematurity may present challenges, such as high myopia, monocularity, glaucoma, and previous ocular surgery, phacoemulsification in this series proved to be relatively safe as well as visually rehabilitating. The surgeon should be aware of the special considerations in this population, alert to potential zonular weakness intraoperatively, and careful of increased postoperative risks, including retinal detachment.

Dietary fat and risk for advanced age-related macular degeneration.

OBJECTIVE: To evaluate the relationship between intake of total and specific types of fat and risk for advanced age-related macular degeneration (AMD), the leading cause of irreversible blindness in adults. DESIGN: A multicenter eye disease case-control study. SETTING: Five US clinical ophthalmology centers. PATIENTS: Case subjects included 349 individuals (age range, 55-80 years) with the advanced, neovascular stage of AMD diagnosed within 1 year of their enrollment into the study who resided near a participating clinical center. Control subjects included 504 individuals without AMD but with other ocular diseases. Controls were from the same geographic areas as cases and were frequency-matched to cases by age and sex. MAIN OUTCOME MEASURES: Relative risk for AMD according to level of fat intake, controlling for cigarette smoking and other risk factors. RESULTS: Higher vegetable fat consumption was associated with an elevated risk for AMD. After adjusting for age, sex, education, cigarette smoking, and other risk factors, the odds ratio (OR) was 2.22 (95% confidence interval [CI], 1.32-3.74) for persons in the highest vs those in the lowest quintiles of intake (P for trend,.007). The risk for AMD was also significantly elevated for the highest vs lowest quintiles of intake of monounsaturated (OR, 1.71) and polyunsaturated (OR, 1.86) fats (Ps for trend,.03 and.03, respectively). Higher consumption of linoleic acid was also associated with a higher risk for AMD (P for trend,.02). Higher intake of omega-3 fatty acids was associated with a lower risk for AMD among individuals consuming diets low in linoleic acid, an omega-6 fatty acid (P for trend,.05; P for continuous variable,.03). Similarly, higher frequency of fish intake tended to reduce risk for AMD when the diet was low in linoleic acid (P for trend,.05). Conversely, neither omega-3 fatty acids nor fish intake were related to risk for AMD among people with high levels of linoleic acid intake. CONCLUSION: Higher intake of specific types of fat--including vegetable, monounsaturated, and polyunsaturated fats and linoleic acid--rather than total fat intake may be associated with a greater risk for advanced AMD. Diets high in omega-3 fatty acids and fish were inversely associated with risk for AMD when intake of linoleic acid was low.

Clinicopathologic findings in eyes with retained perfluoro-n-octane liquid.

OBJECTIVE: To describe the clinical and histopathologic findings in five eyes with retained perfluoro-n-octane (PFO) liquid after retinal reattachment surgery. DESIGN: Retrospective, noncomparative, clinicopathologic case series. PARTICIPANTS: Surgical specimens from five eyes were studied. METHODS: Surgical specimens from eyes with prior intraoperative PFO use submitted to the W. Richard Green Eye Pathology Laboratory at the Wilmer Ophthalmological Institute were identified and reviewed. MAIN OUTCOME MEASURES: Histopathologic analysis and energy dispersive spectroscopy identified intracellular vacuoles containing PFO. RESULTS: Five cases were identified. Three specimens were obtained at the time of further surgery for recurrent retinal detachment; one at repeat penetrating keratoplasty, and one at removal of retained PFO. Each eye had macroscopic white flake-like material on intraocular structures noted before or during surgery. Histopathologic analysis disclosed an inflammatory response featuring macrophages with intracellular vacuoles containing PFO. Removal of the PFO in all five eyes combined with repeat retinal reattachment surgery in three eyes resulted in resolution of the inflammatory response. CONCLUSIONS: Retention of PFO after surgery elicits an inflammatory response. We suspect that young patients, those with considerable residual vitreous gel, and eyes with larger amounts of retained PFO may be at higher risk for this complication.

Management of a floating sternum after repair of pectus excavatum.

PURPOSE: The aim of this study was to examine the authors' experience with patients who have floating sternum after correction of pectus excavatum via the classical Ravitch procedure. A floating sternum is defined as a sternum in which the only attachment to the chest wall is its superior (cranial) border, and in which the body is secured only by the manubrium and whatever lateral and inferior fibrous bands are present. Typically, a floating sternum is caused by either extensive resection of the costal cartilages and perichondrium during correction of pectus excavatum or failure of proper regrowth of these cartilages. METHODS: The authors retrospectively assessed the charts of all patients diagnosed with a floating sternum noting age at original correction of pectus excavatum, time from original correction of pectus excavatum to diagnosis of floating sternum, age at correction of floating sternum, complaints before stabilization of the sternum, methods of repair, and postoperative complications. RESULTS: Between July 1993 and June 1999, floating sternum was diagnosed in 7 patients. The mean age of patients who underwent operative correction of a floating sternum was 28.9 years (range, 16 to 42 years). The mean time interval between original correction of pectus excavatum, or "redo," and diagnosis of a floating sternum was 9.9 years (range, 2 to 20 years). Complaints before correction of the floating sternum included sternal pain and instability, exercise intolerance, and difficulty breathing. Operative repair consisted of mobilizing the lateral and inferior edges of the sternum, detaching the fibrous perichondrium, performing anterior sternal osteotomies, and finally supporting the sternum with substernal Adkins struts. All 7 patients had successful stabilization of the sternum. Two of 7 patients underwent 2 procedures to successfully stabilize the sternum. One patient has Adkins struts still in place because of hematopoetic malignancy. Six of 7 patients are now without symptoms. CONCLUSIONS: A floating sternum is a morbid phenomenon that may manifest many years after the original procedure. It can cause significant sternal pain, chest wall instability, and respiratory dysfunction, which are the hallmark indications for correction. Repair of a floating sternum can be accomplished successfully.

Eye pain after vitreoretinal surgery: a prospective study of 185 patients.

PURPOSE: To assess subjective levels of eye pain, nausea, and sedation following vitreoretinal surgery performed with intravenous sedation and retrobulbar anesthesia. METHODS: One hundred eighty-five consecutive patients who underwent vitreoretinal surgery and had access to a standard postoperative analgesic regimen prospectively quantified levels of eye pain, nausea, and sedation 2 hours and 5 hours after surgery by using a standard visual analog scale. Analgesic requests were recorded. Responses were statistically analyzed. RESULTS: Fifty-six percent of patients had some eye pain after vitreoretinal surgery; 48% of patients requested an analgesic within 5 hours after surgery. Twenty-seven percent of patients required narcotic analgesia. There was a significant relationship between the presence of eye pain and surgery duration of >2 hours (P < 0.02). Sixteen percent of patients had postoperative nausea, which more likely occurred in those who received a narcotic analgesic (P < 0.02). Eighty percent of patients had postoperative sedation, which more likely occurred in those who received a narcotic analgesic (P < 0.02). CONCLUSION: One half of individuals undergoing vitreoretinal surgery, especially those who have lengthy procedures (>2 hours), will request pain medication within 5 hours after surgery; one half of these patients will need narcotic analgesia for pain control. Narcotics may result in nausea and sedation.

Acute annular outer retinopathy: report of four cases.

PURPOSE: To describe the clinical findings and course in four patients with acute annular outer retinopathy. METHODS: Four patients were evaluated during the course of acute annular outer retinopathy, and the historical and clinical findings were retrospectively collected. RESULTS: Four healthy patients developed the acute onset of visual field loss associated with a localized, white annular outer retinopathy. All patients were caucasian; two were women, aged 29 and 32 years, and two were men, aged 71 and 79 years. The mean follow-up was 3.9 years (range, 1 to 6 years). On presentation, four eyes had an irregular, incomplete, peripapillary, annular band of gray-white, deep retinal opacification with visual CONCLUSIONS: These four cases of acute annular outer retinopathy expand our knowledge of this disorder. Acute annular outer retinopathy may be a distinct entity or it may represent a variant of acute zonal occult outer retinopathy retinopathy. As more cases are recognized, the characteristic features of the disease spectrum, the etiology, and treatment options may be better elucidated.

Cardiorespiratory function is significantly improved following corrective surgery for severe pectus excavatum. Proposed treatment guidelines.

BACKGROUND: Pectus excavatum is a congenital chest abnormality which may become more marked during childhood and teenage growth. Young teenagers with severe PE deformities often become short of breath during strenuous exercise and complain of becoming easily fatigued. The pathophysiologic effects of PE remain controversial because they have been difficult to measure, especially in young children. Symptomatic patients often have significant subjective improvement during exercise following PE repair and there is a major cosmetic impact on teenagers with severe deformities. This study was designed to measure pulmonary and cardiac function with exercise before and after corrective surgery. METHODS: Pulmonary function testing and incremental exercise testing were performed in 36 adolescents with pectus excavatum (PE) and 10 age-matched, healthy control subjects. Six months after corrective surgery was performed, 15 of these PE patients and 6 control subjects were re-evaluated for pulmonary function. RESULTS: Before surgery, PE subjects had a lower forced vital capacity (FVC) than controls; there was no change in FVC after surgery. Before surgery, 58% of PE patients had subjective complaints of exercise limitation; 66% of the patients were significantly improved after surgery. PE subjects exercised at a similar workload to controls. Respiratory parameters during exercise were similar between the two groups before surgery, indicating that exercise was not limited by restrictive lung disease. After surgery, PE subjects exercised longer and had a higher oxygen pulse than before surgery, whereas controls showed no such changes. Although some PE subjects showed mild restrictive lung function, surgical repair did not influence this mild degree of restriction. CONCLUSIONS: After corrective surgery, PE patients have increased exercise tolerance and a higher oxygen pulse. Oxygen pulse is a measure of cardiac output. Results suggest that PE repair improves cardiopulmonary function during vigorous exercise. Based upon these studies, and our experience in the treatment of more than 700 surgical patients with pectus excavatum over a 40-year period, guidelines for the diagnosis and management of children with pectus excavatum are proposed.

Perfluoroperhydrophenanthrene versus perfluoro-n-octane in vitreoretinal surgery.

PURPOSE: To compare two perfluorocarbon liquids, perfluoroperhydrophenanthrene (Vitreon) and perfluoro-n-octane (PFO), regarding (1) ease of removal at the time of surgery and (2) efficacy and safety. DESIGN: Retrospective, nonrandomized, comparative trial. PARTICIPANTS: Two hundred sixty-four patients. METHODS: All medical records of patients who participated in either the Vitreon (n = 142) or the PFO (n = 122) multicenter trials at the Wilmer Eye Institute were reviewed. Patients in the two groups were compared with respect to presence and amount of postoperative perfluorocarbon. Safety and efficacy of the two perfluorocarbon liquids were evaluated in the subset of patients undergoing surgery for retinal detachment with PVR grade C or more, who had at least 6 months of postoperative follow-up (n = 46 in the Vitreon group and n = 55 in the PFO group). Best-corrected visual acuity, intraocular pressure, and status of the cornea, lens, and retina after 3, 6, and 12 months of follow-up were compared in the two groups. MAIN OUTCOME MEASURES: Percentage of eyes with retained perfluorocarbon, final visual acuity, final retinal attachment rate. RESULTS: At the 6-month postoperative visit, retained Vitreon or PFO was detected in 8.4% and 4% of the eyes, respectively (P < 0.05). No statistically significant difference was found between the two perfluorocarbons in attachment rate or visual acuity after 6 and 12 months. After 6 months, the retina was attached in 71.7% of the eyes in which Vitreon was used and in 78.3% of the eyes in which PFO was used (P = 0.81). Visual acuity improved or remained stable in 80% of the Vitreon group eyes and in 74.5% of the PFO group eyes (P = 0.75). No statistically significant difference was found in final visual acuity or intraocular pressure between the two groups after 6 or 12 months. There was a tendency at the 12-month follow-up examination for the cornea to remain clearer in the Vitreon group (P = 0.01). CONCLUSIONS: Although PFO was easier to visualize and remove completely from within the eye at the time of surgery, the efficacy in terms of retinal attachment and final visual outcome was similar between the Vitreon and PFO groups.

History of the operative management of pectus deformities.

This article examines the history of the operative management of pectus deformities, tracing the surgical innovations of such pioneers as Drs. Ochsner, Ravitch, Sanger, and Wada. Guidelines for the selection of patients for operative correction are also discussed.

Complications of surgery for pectus excavatum.

The article describes the various acute and late complications of surgery for pectus excavatum. Because the acute complications are well known and easily managed and the late complications can be prevented, operative correction of pectus excavatum can be recommended to parents and their children with severe deformities with very little risk and a realistic expectation of good long-term correction.

Limited macular translocation for neovascular maculopathy.

Subfoveal choroidal neovascularization presents one of the most difficult challenges to vision. No treatment option has yet solved the problem of subretinal hemorrhage and fibrovascular scarring causing permanent photoreceptor degeneration and loss. Limited macular translocation provides a surgical approach to this challenge by moving the fovea onto an adjacent area of relatively normal subretinal space and pigment epithelium in a selected group of patients. The choroidal neovascularization, thus, becomes extrafoveal or juxtafoveal and can be treated with focal laser photocoagulation. This article describes the current technique of limited macular translocation and reviews early results. The procedure offers selected patients a chance to retain useful central vision. About 40% of patients at 6 months are able to read and drive (visual acuity >20/100). Complications including retinal detachment, hemorrhage, and macular folds have decreased with experience. Limited macular translocation is a promising approach to neovascular maculopathy, but needs ongoing careful evaluation.

Histopathological features of vitreous removed at macular hole surgery.

OBJECTIVE: To describe the histopathological features of the vitreous removed at surgery for macular holes in 200 consecutive cases. METHODS: The complete vitrectomy specimen in each case was concentrated by means of cellulose membrane filters and stained for light microscopy. The cases were organized into 5 categories: (1) all cases (N = 200), (2) eyes without previous vitrectomy (n = 174), (3) eyes with previous vitrectomy (n = 26), (4) idiopathic cases (n = 143), and (5) traumatic (accidental or surgical) cases (n = 31). The type and frequency of tissue fragments present in the vitreous were determined for each case. RESULTS: Fibrocellular and cellular membrane fragments were found in a minority of cases in all categories. Retinal fragments were a rare finding, present in only 4 cases. Inflammation was present in 57 (28.5%) of all cases. CONCLUSIONS: The absence of fibrocellular and cellular membrane fragments in the majority of cases suggests that mechanisms other than cellular proliferation are important in the pathogenesis of macular holes. These fragments are, however, the likely histopathological correlate of the opercula that are often observed clinically in patients with macular hole. Opercula rarely if ever contain retinal fragments, and thus are better termed pseudo-opercula, as has been previously suggested. The cellular proliferation and inflammation that are observed in some of the cases are likely a secondary or reactive process.

Clinical course of macular holes: the Eye Disease Case-Control Study.

OBJECTIVE: To describe the clinical course of affected and unaffected eyes in patients with idiopathic macular holes. PATIENTS: Prospective study of patients with macular holes enrolled in the Eye Disease Case-Control Study. MAIN OUTCOME MEASURES: The best-corrected visual acuity at follow-up was compared with that at baseline. Changes in the macular holes, including increases in size or spontaneous regression, were assessed. The rates of development of new macular holes in fellow unaffected eyes were estimated. RESULTS: Of the 198 patients examined at baseline, 28 (14.1%) died before reevaluation. Of those who survived, 122 (71.8%) had a follow-up examination. Approximately 34% (34.4%) of all eyes with macular holes had an increase in the size of the macular hole. Forty-five percent of eyes had a decrease in visual acuity of 2 or more lines and 27.8%, of 3 or more lines; 40.9% remained stable, with a gain or loss of fewer than 2 lines. The rate of development of a new macular hole during follow-up in fellow eyes that were unaffected at baseline was 4.3% for 3 or fewer years of follow-up, 6.5% for 4 to 5 years of follow-up, and 7.1% for 6 or more years of follow-up. Spontaneous regression of the macular hole occurred in 3 (8.6%) of 35 patients with a follow-up interval of 6 or more years, whereas no regression occurred in patients with a shorter follow-up. CONCLUSIONS: The visual acuity of 45.0% of eyes with macular holes deteriorated by 2 or more lines during follow-up. The rate of development of macular holes in unaffected fellow eyes was low.

Transscleral diode laser retinopexy in retinal detachment surgery: results of a multicenter trial.

PURPOSE: To evaluate the safety and efficacy of transscleral diode laser for retinopexy in rhegmatogenous retinal detachment surgery in a multicenter trial. METHODS: Seventy-two patients with primary rhegmatogenous retinal detachments were enrolled. No patient with chronic detachment, a retinal break greater than 90 degrees, history of uveitis or infectious retinopathy, or proliferative vitreoretinopathy was enrolled. RESULTS: Information from follow-up of 6 months or longer was available on 65 eyes. Retinas were attached at 6 months with a single operation in 58 (89%) of these eyes. Complications included apparent pinpoint breaks in Bruch's membrane in 15 eyes, scleral-thermal effect in 14 eyes, and limited hemorrhage, which was intraretinal in 10 eyes and extended into the vitreous in 3 eyes. In one case, hemorrhage was judged perhaps to have contributed to initial surgical failure. The other complications had no known adverse effects. Complications were significantly associated with the physician's experience in using transscleral laser retinopexy. CONCLUSIONS: In this multicenter study, transscleral diode laser retinopexy served as a safe and effective means of creating chorioretinal adhesion during retinal reattachment surgery. Minor complications were minimized by increasing experience with the technique.

Effect of scleral indentation on diode laser transscleral retinal photocoagulation.

BACKGROUND AND OBJECTIVE: To evaluate the effect of the degree of scleral indentation with a modified AlGaAs diode laser for transscleral retinopexy in the rabbit. MATERIALS AND METHODS: Transscleral diode laser photocoagulation was performed on the eyes of Dutch-belted rabbits using a modified AlGaAs diode laser with a wider base and various prism protrusions. RESULTS: The transscleral photocoagulation generally became more efficient with an increasing amount of scleral indentation. Effectiveness increased up to a prism protrusion of 1.5 mm. CONCLUSION: This study shows that a wide-based AlGaAs diode laser with a 1.5-mm protrusion provides a more easily oriented probe for creating more efficient chorioretinal burns.

Spiral CT with 3D reconstruction in children requiring reoperation for failure of chest wall growth after pectus excavatum surgery. Preliminary observations.

Pectus excavatum is the most common congenital chest wall deformity. Extensive corrective surgery prior to age 3 may disturb chest wall growth and result in a constricted thorax. We describe our surgical and radiologic experience with eight such cases, paying particular attention to the role of spiral computed tomography (CT) with 3D reconstruction in patient management. Spiral CT was performed on children who had developed restrictive chest walls following pectus excavatum surgery. These children then underwent a unique operation to elevate the sternum and attempt to correct their restrictive chest wall defects. In several cases, postoperative spiral CT was performed. Spiral CT with 3D reconstruction defined the orientation of the ribs and costal cartilages and their relationship to the sternum, allowing exact preoperative measurement of the bony rib cage and guiding individualized operative correction. Computed thoracic volumes in select cases correlated well with subjective patient reports of increased exercise capacity. Repair of pectus excavatum defects prior to age 3 may result in constrictive thoracic abnormalities. Surgical correction can increase thoracic volume and improve prospects for normal thoracic function. Three-dimensional reconstruction of spiral CT data is useful in both preoperative and postoperative evaluation.