Use of silicone oil in the treatment of complicated retinal detachment: results from 1981 to 1994.

PURPOSE: To evaluate the advantages and disadvantages of the retention and removal of silicone oil in the treatment of complicated retinal detachments. METHODS: The records of 344 patients (348 eyes) that underwent vitrectomy and silicone oil injection for complicated retinal detachments were abstracted and analysed. The anatomical and functional results, complications and influencing factors are discussed. The outcome in eyes after removal of the silicone oil was compared with the outcome in a comparable group of eyes in which the silicone oil was retained. RESULTS: The overall retinal reattachment rate was 63% (220/348). The final vision of 5/300 or better was 52% (115/220) in those eyes with totally attached retinas. The silicone oil-related complications included keratopathy (23%) and secondary glaucoma (11%). Comparing removal of silicone oil with retention of silicone oil, we found: (i) there was no statistical difference in the redetachment rate (19 vs 17%); (ii) oil-removed eyes had a better final vision (P < 0.05); and (ii) keratopathy (13 vs 23%), secondary glaucoma (11 vs 25%) and optic nerve atrophy (4 vs 18%) were significantly lower in oil-removed eyes. CONCLUSION: Silicone oil injection is useful in the treatment of complicated retinal detachments. For reducing the incidence of complications, early removal of silicone oil is recommended in those cases in which the retina is attached, all breaks adequately closed and traction relieved.

Nanophthalmos with longstanding choroidal effusion and serous retinal detachment.

PURPOSE: To report a typical case of nanophthalmos with uveal effusion and local serous retinal detachment followed for 1 year. METHODS: Clinical ocular examinations included vision, refraction, corneal diameter, anterior chamber depth, intraocular pressure, fundoscopy, A/B scan ultrasonography and gonioscopy. RESULTS: Both eyes were hypermetropic with small corneas and shallow anterior chambers. Decreased axial length and thickened sclera were also found. There were peripheral choroidal effusions and local serous retinal detachments as well. The patient declined any surgery that was offered. No significant change in either eye was found after 1 year follow-up. CONCLUSION: This case illustrates that the progress of choroidal effusion and retinal detachment in nanophthalmos may be very slow and even non-progressive for at least 1 year. In these cases sclerectomy and or sclerotomy may be delayed without undue immediate risk to the vision.

Silicone oil insertion. A review of 127 consecutive cases.

Silicone oil was used in combination with vitrectomy to treat 127 cases of complicated retinal detachments. An initial anatomic success in 120 cases (94%) was reduced to 68 (54%) after an average follow-up of 32 months and was attributable to ongoing proliferative vitreo-retinopathy (PVR). The indications for the use of silicone oil were: 1. Retinal detachment complicated by PVR (107 cases), 20 of which required multiple operations. Anatomic success was achieved in 59 (55%) and of these 23 (40%) had a visual acuity of 6/60. 2. Giant retinal tears (GRT) (7 cases). Four (57%) of these remained attached, three (75%) having a final vision of 6/36. 3. GRTs complicated by PVR (8 cases). Four (50%) were anatomically successful and two had a final vision of 6/60. 4. Proliferative diabetic retinopathy (5 cases). Two (40%) remained attached and one of these (50%) had hand movements vision. The silicone oil was removed electively in 23 eyes, 16 (70%) of these being anatomically successful. Oil was removed in 43 eyes because of complications, and in 20 (46%) of these, the retina remained attached at the end of follow-up. Complications included cataract in all 14 phakic eyes; rubeosis in 19 eyes (15%); corneal opacification in 52 eyes (41%), there being no clear cut difference between those eyes with an inferior iridectomy (35 of 85 eyes--41%) and those without (12 of 29 eyes--41%); and raised intraocular pressure in 55 eyes (43%). We conclude that although far from being ideal, silicone oil appears to have played some part in achieving the successful results reported in this study.

Benign intracranial hypertension in chronic myeloid leukemia.

We present a patient with chronic myeloid leukemia (CML) who had marked bilateral disc swelling as part of his initial presentation. This occurred in the setting of raised intracranial pressure (ICP), with normal cerebrospinal fluid (CSF) composition and cell content, and normal neuroimaging. We discuss the possible mechanisms which could lead to disc swelling in CML and conclude that the raised ICP and subsequent papilloedema in our patient were the result of poor absorption of CSF into the dural venous sinuses. We propose that the very high white cell count (WCC) led to a hyperviscosity state which resulted in poor absorption of CSF and in so doing, created a clinical picture of benign intracranial hypertension (BIH).

Laser photocoagulation treatment of choroidal melanoma.

Ten cases of choroidal melanoma were treated with Argon and/or Krypton laser photocoagulation in this retrospective study. Each patient received an average of 9.6 laser treatment sessions. Three female and seven male patients were treated and followed for an average of 69.9 months. Clinical regression was observed in seven cases (70%). Tumour size in these successfully treated cases ranged from 4.5 x 5.0 x 1.5 mm to 7.0 x 7.0 x 3.5 mm. Continued growth occurred in one case (10%), tumour recurrence which failed to respond to additional laser treatment in another (10%), and although a recurrence appeared to respond to additional laser in a third case (the largest tumour in the series 11.0 x 9.0 x 2.5 mm) extraocular extension was found at enucleation (10%). Complications of laser treatment included cystoid macular oedema (Case 5), branch retinal vein occlusion (Cases 3 and 6), vitreous haemorrhage from neovascularisation at the edge of the scar, optic atrophy and thrombotic glaucoma (Case 8), and macular involvement by laser (Cases 4, 7 and 10). All patients remain alive without any clinical evidence of metastatic disease at the end of the follow-up period. These results suggest that laser photocoagulation treatment is a useful option in the management of small choroidal melanomas. It avoids the psychological trauma of enucleation, and maintains some vision, without compromising life expectancy.

[Laser photocoagulation treatment of small malignant choroidal melanomas].

8 cases of malignant choroidal melanoma were treated with argon and krypton laser photocoagulation of average 11 sessions and followed up an average 56 months. Clinical complete regression was observed in 5 cases (62.5%), in whom the tumors measured from 1.0mm x 1.2mm x 1.5mm to 6.0mm x 4.5mm x 2.5mm. The other 3 cases (37.5%) recurred, in whom the tumors measured from 4.0mm x 2.0mm x 3.5mm to 11.5mm x 12.5mm x 3.5mm. The complications of treatment included branch retinal vein occlusion, retinal neovascularization, vitreous hemorrhage, macular edema and optic atrophy. These results suggested that laser photocoagulation was useful in the treatment of small malignant choroidal melanomas.

Needle drainage of subretinal fluid. A randomized clinical trial.

Needle drainage of subretinal fluid with simultaneous observation using the indirect ophthalmoscope has been reported to have a very low complication rate. The technique was evaluated by a prospective clinical trial. The study group consisted of 100 patients undergoing scleral buckling for rhegmatogenous retinal detachment who were randomly assigned to groups treated with needle drainage or conventional two-stage drainage. At 1 month, the retina was anatomically flat in 88% of all cases. Subretinal hemorrhage occurred in 10 of 45 patients (22.2%) after needle drainage and in 7 of 55 patients (12.7%) after conventional drainage. The difference was not statistically significant. Retinal puncture occurred during conventional drainage in one case and in no cases during needle drainage. There were no cases of retinal incarceration. The results showed that subretinal hemorrhage was more common after needle drainage, but a larger study would be required to show whether this difference was statistically significant. The fear that the retina would be damaged by placement of a needle in the subretinal space throughout the drainage procedure was unfounded.

The quadrate suture. A new technique for temporary intraoperative mydriasis.

A simple, quick, effective, and atraumatic closed suturing technique for producing and maintaining intraoperative pupillary dilation is described. Readily available sutures, needles, and syringes are used in a way that eliminates the need for paracenteses, sclerotomies, and special equipment.

Persistent ectopic syndrome.

Persistent ectopic syndrome is a complication of conservative surgery for tubal pregnancy. This study is directed toward the escalating conservatism in the treatment of tubal ectopic pregnancy and its possible sequelae. Residual trophoblast propagation after initial surgery is becoming more frequent. Two cases are reported. The first woman was admitted with an acute abdomen; salpingectomy was performed to control hemorrhage from tubal rupture at the site of the previous salpingostomy. The second woman was treated by fimbrial expression. Because of the recurrence of pain, the beta human chorionic gonadotropin (BHCG) levels were measured; they indicated fresh trophoblastic activity. She was treated with methotrexate orally, 10 mg/d for 5 days. The need for BHCG surveillance of conservatively managed tubal ectopic pregnancy is stressed. The value of using methotrexate when tubal integrity persists is discussed in the light of its traditional role against trophoblastic tumours.

Vitrectomy techniques in the treatment of giant retinal tears: a flexible approach.

We describe a flexible approach employing vitrectomy, scleral buckling and intraocular tamponading agents in the treatment of giant retinal tears. Intraocular gas without a buckle was used in the 10 least complicated cases. In five eyes we considered a scleral buckle to be necessary in addition to gas tamponade. Silicone oil was selected as the primary tamponading agent in the six most complex cases with PVR and in five re-operations. The overall anatomical success rate was 71% of which 73% had a final visual acuity of at least 6/60 and 60% achieved 6/18 or better.

Microholes of the fovea centralis.

Foveal microholes are a possible cause of unilateral or bilateral small central visual defects in the absence of other macular pathology. In 18 eyes of 17 patients we noted the following features: small, dark-reddish holes in the centre of the fovea ranging from 50 to 150 micron in size; normal adjacent retinal pigment epithelium and neuroepithelium; unilateral in most cases; males and females are equally affected; mean age 40 years; insidious onset; no history of direct eye trauma or sungazing; non-progressive; relatively favourable visual outcome; no relationship with regular macular holes; aetiology unknown. These distinctive features justify reporting these patients as an important separate group.

Contusion injuries of the optic nerve.

Indirect trauma to the optic nerve with secondary optic atrophy may result from minor trauma and has traditionally been associated with a poor visual prognosis. The case of a 32-year-old man who suffered a blow to his left supraorbital region and eyebrow in an automatic closing door is reported to draw attention to the uncommon but trivial nature of this injury which may result in profound visual loss. He suffered an initial inferonasal visual field loss which was related to vascular changes in the optic nerve head. Over the ensuing year there was deterioration in his central vision and visual field due to arachnoiditis. Current trends in the management of optic nerve contusion injuries are discussed. There is currently a move towards primary medical management with high-dose corticosteroids as in this case; surgery is reserved for those patients who fail to respond to steroids or deteriorate as the steroid dose is reduced.

Combined vitrectomy, intraocular microsurgery and liquid silicone in the treatment of proliferative vitreoretinopathy.

This study investigates the effectiveness of combining vitrectomy, scleral buckling, intraocular microsurgery and liquid silicone injection for the treatment of retinal detachment complicated by proliferative vitreoretinopathy: 48 eyes were treated using these techniques combined. Complete attachment was achieved in 16 eyes (33%), partial attachment in 20 eyes (42%), and 12 eyes (25%) remained detached. Vision was improved in 17 eyes (35%), unchanged in 17 eyes (35%), and worse in 14 eyes (30%). Complications included emulsification of the silicone, glaucoma, cataract, band degeneration of the cornea, reproliferation of membranes and passage of silicone into the subretinal space. Significant preservation of mobility vision was achieved. A larger series of patients with longer follow-up will ultimately determine the place of this technique in the management of this complicated problem.

Vitreous cytology in primary cerebroretinal malignant lymphoma.

We report the case of a 72-year-old woman who presented with vitreous opacities of unknown cause. A pars plana vitrectomy yielded material in which there were atypical lymphoid cells consistent with malignant lymphoma. Five months after the vitrectomy, the patient re-presented with cerebral lymphoma. Our report emphasizes the value of cytological examination of the vitreous in selected cases. We also review the features of malignant lymphoma of the retina and stress the cerebroretinal axis of involvement in this disease.

Malacoplakia of the female genital tract.

Malacoplakia is an uncommon chronic granulomatous inflammation which most frequently involves the urinary bladder of middle-aged women and rarely affects the genital tract. In this paper 10 cases of female genital malacoplakia are reviewed, seven of which have been reported previously in the literature. Genital malacoplakia usually occurs in women 60 years of age or older and most frequently affects the vagina. Vaginal bleeding is a common presenting complaint and the lesion may simulate a malignancy. Four of the 10 patients were receiving corticosteroids at the time of diagnosis. Escherichia coli was cultured from urine or from the lesion itself in half of the cases. The disease appears to be an acquired defect in bactericidal function of histiocytes. Antibiotic therapy and surgical excision are effective, although a recurrence developed in one patient and was successfully re-excised.