Management of persistent loculated subretinal fluid after pneumatic retinopexy.

AIM: To report on the incidence and management of a unique and troublesome complication of pneumatic retinopexy-localised, delayed subretinal fluid absorption (DSRFA). METHODS: A retrospective chart review was done for all patients who underwent pneumatic retinopexy for retinal detachment over a 5 year period to identify the patients with DSRFA. RESULTS: Seven phakic patients (five females, two males, age range 26-87 years) were identified with the phenomenon of delayed resolution of subretinal fluid after pneumatic retinopexy and cryotherapy. In four patients the subretinal fluid involved the macula. Time taken to complete absorption of the subretinal fluid ranged from 10 to 26 months. In one patient there was still residual fluid inferiorly at 18 months of follow up. During the follow up period additional procedures were performed--scleral buckling (five eyes), pars plana vitrectomy (one eye), and mild laser scatter to extramacular areas of shallow subretinal fluid (four eyes). None of these procedures appeared to influence the rate of fluid absorption. CONCLUSIONS: Loculated subretinal fluid following pneumatic retinopexy may persist for very long periods, extending up to more than 2 years. Additional surgical procedures or laser photocoagulation do not affect the rate of subretinal fluid absorption. Spontaneous reattachment eventually occurs in most eyes, and conservative management is indicated.

Reduced rate of retinal detachment following silicone oil removal.

PURPOSE: To investigate the rate of retinal redetachment and other complications after silicone oil removal over a 4-year period. METHODS: Retrospective analysis of charts of patients who underwent vitrectomy and silicone oil injection between January 1994 and June 1998 followed by oil removal. RESULTS: Sixty-eight eyes of 67 patients were included. The average follow-up time after oil removal was 15 months. Significant retinal redetachment developed in 6 eyes (8.8%). The redetachment rate was slightly higher in the 32 eyes with proliferative vitreoretinopathy (9.3%) than in the 36 eyes with other pathologies (8.3%). The average time to redetachment was 4.2 months. These eyes were reoperated and reattached, and at the end of the follow-up, three retained silicone oil. Two other eyes without redetachment were hypotonus after oil removal. Cataract extraction and intraocular lens implantation were performed at the time of oil removal in 18 eyes; 2 (11%) developed redetachment. Visual acuity improved significantly after oil removal (P < 0.001). CONCLUSION: The rate of retinal redetachment after removal of silicone oil in recent years is low compared with previous series. The authors attribute this reduction to the improved surgical management of complicated retinal detachments; particularly, the introduction of perfluorocarbon liquids and wide-field viewing systems and the widespread use of endolaser.

Management of glaucoma implants occluded by vitreous incarceration.

PURPOSE: To review the authors' experience in the management of aphakic or pseudophakic patients without an intact posterior capsule who had undergone glaucoma implant surgery complicated by vitreous incarceration in the tube, resulting in increased intraocular pressure or combined rhegmatogenous and tractional retinal detachment. METHODS: Retrospective review of the clinical features, treatment, and outcomes of eight patients who had vitreous incarceration in a glaucoma implant drainage tube. In each patient, a model 425 (7 patients) or model 350 (1 patient) Baerveldt glaucoma implant was used. RESULTS: Vitreous incarceration in the tube was first diagnosed 1 day to 49 weeks after surgery (mean, 7.5 weeks; median, 1 week). The interval between glaucoma implant surgery and pars plana vitrectomy ranged from 22 to 365 days (mean, 125 days). Before management with pars plana vitrectomy or neodymium:yttrium-aluminum-garnet laser vitreolysis, intraocular pressure ranged from 25 to 62 mm Hg (mean, 40 mm Hg). Four patients were initially treated with neodymium:yttrium-aluminum-garnet laser vitreolysis, which was successful in only one patient. Six patients were successfully treated with pars plana vitrectomy, and one patient declined surgery. Follow-up after treatment of the incarceration ranged from 5 weeks to 15 months (mean, 8.3 months). After pars plana vitrectomy, intraocular pressure ranged from 9 to 24 mm Hg (average, 14 mm Hg). Postoperative visual acuity remained within one line of the preoperative visual acuity in each of the six patients undergoing pars plana vitrectomy. CONCLUSIONS: Pars plana vitrectomy is effective in managing vitreous incarceration in glaucoma implant tubes. Previous anterior vitrectomy does not prevent incarceration.

ICGA-guided laser photocoagulation of feeder vessels of choroidal neovascular membranes in age-related macular degeneration. Indocyanine green angiography.

PURPOSE: To report the ability of indocyanine green angiography (ICGA) with a confocal scanning laser ophthalmoscope (SLO) to identify feeder vessels of choroidal neovascular membranes (CNVM) secondary to age-related macular degeneration (ARMD) and to show the feasibility of inducing complete closure of the CNVM by photocoagulation targeted exclusively to the feeder vessels. METHODS: Five consecutive patients with exudative ARMD in whom ICGA with the confocal SLO showed extrafoveal feeder vessels supplying choroidal neovascular nets had laser photocoagulation done only to the feeder vessels. In two patients, two separate membranes were seen. RESULTS: Laser photocoagulation resulted in closure of the feeder vessels and the CNVM in four patients. Complete closure was achieved with one treatment in one patient and with two treatments in three patients. In one patient, two treatments failed to close the feeder vessel and the CNVM, but a third, more intense laser treatment resulted in temporary closure of the feeder vessel and CNVM, which recanalized 2 to 4 weeks later with development of a large rip in the retinal pigment epithelium. In one patient, two separate CNVMs grew from the edge of the laser scars, but they were not directly related to the original CNVM and its feeder vessel, and were treated successfully. The same eye later developed subfoveal occult CNVM with gradual deterioration of visual acuity. In the other four patients, visual acuity improved in two and was unchanged in two. CONCLUSIONS: Indocyanine green angiography with the confocal SLO can identify choroidal feeder vessels supplying CNVM secondary to ARMD. Laser treatment to such extrafoveal feeder vessels, particularly in membranes that are large or subfoveal, may be effective in closing the feeder vessel and CNVM with preservation of the fovea and central vision. More than one treatment may be required, however, and failures and complications may be expected with this treatment modality.

Spontaneous separation of an idiopathic macular pucker in a young girl.

PURPOSE: To report a young girl with spontaneous separation of an idiopathic epiretinal membrane and notable visual recovery. METHOD: Case report. RESULT: A 12-year-old girl had spontaneous improvement in visual acuity of the left eye from 20/100 to 20/40 attributable to spontaneous peeling of an idiopathic epiretinal membrane more than 2 years after it was diagnosed. CONCLUSION: Conservative treatment can be considered in young patients with epiretinal membrane because spontaneous separation may occur and result in good vision.

Refractive status in children after long-term follow up of cataract surgery with intraocular lens implantation.

PURPOSE: To evaluate the resultant refractive status in children 5 to 11 years after cataract surgery with a high power intraocular lens (IOL) implantation. METHODS: Charts of eight patients (10 eyes) who underwent cataract surgery with IOL implantation by the same technique were reviewed. Age at surgery was 2 months to 3 years. High-power IOL of 27.0 to 30.0 diopters (D) was implanted in seven eyes and lower IOL (between 19.0 D to 23.0 D) in three eyes. Follow-up period was between 5 and 11 years. RESULTS: In children who received a high-power IOL, the resultant refraction after 5 to 7 years was found to be between -5.50 and -12.00 D. In the group that had a lower power IOL implanted, the refraction was between -2.50 and +9.00 after 6 to 11 years. The results were plotted on a graph of refraction vs. IOL power and showed that the IOL power that may result in emmetropia in an older child is 23.2D. CONCLUSIONS: The implantation of a high-power IOL (27 D to 30 D) in eight young children resulted in refractive status within 3 D of emmetropia during the first year or two of life and in high myopia at age 5 to 12 years.

Congenital cataract surgery in children with cataract as an isolated defect and in children with a systemic syndrome: a comparative study.

PURPOSE: To compare visual acuity outcome in two groups of children who underwent congenital cataract surgery. The first group is one in which an isolated cataract occurred; the second group is one in which cataract occurred in conjunction with a systemic disease. METHODS: A review of 46 charts: 36 children (50 eyes) with congenital cataract as an isolated defect, and 10 children (16 eyes) with cataract as part of a systemic disease. RESULTS: One third of the eyes with isolated cataract had postoperative visual acuity better than 6/12, although none of the patients in the syndrome group had visual acuity better than 6/12. This difference was statistically significant (p = 0.01). Of the various ocular pathologies associated with congenital cataract, only nystagmus was found to be more prevalent in the syndrome group (40%) as compared with the isolated cataract group (11%) (p = 0.05). Surgery was performed during the first 2 years of life in 54% of the eyes in the isolated cataract group, and in 87% of the eyes in the syndrome group (p = 0.01). There was no difference in the prevalence of the postoperative complications between the two groups. CONCLUSION: Children who underwent congenital cataract surgery developed poorer visual acuity if the cataract was a part of a systemic disease as compared with children without a systemic syndrome.

A review of the role of visual problems in reading disabilities.

In this review we discuss the etiology of reading disturbances in children and adults. The majority of reading problems in children are either due to primary causes (dyslexia) or secondary to a variety of nonophthalmologic disorders or diseases. In adults the nature of reading difficulties is different to that in children and is defined as asthenopia. Asthenopia can develop as a result of uncorrected refractive errors or due to an imbalance of extraocular muscle action. The therapeutic approach to reading problems is reviewed and it will be seen to be different in children and in adults.

Anterior chamber hemorrhage during cataract surgery in Lowe syndrome.

This article reports a spontaneous intracameral bleeding at the end of cataract surgery in both eyes of two patients with Lowe syndrome. Extracapsular cataract extraction with anterior vitrectomy and posterior capsulotomy, using the anterior chamber maintainer (ACM), was performed in both eyes of two patients. At the conclusion of the surgery, when the ACM was removed, spontaneous bleeding occurred into the anterior chamber and spread into the vitreous cavity. The hemorrhage resolved spontaneously over varying periods of time. We propose that bleeding occurred from damage to iris vessels in the abnormal angle in our patients with Lowe syndrome when the ACM was removed with a concomitant decrease in intraocular pressure.

Bilateral exudative retinal detachment complicating systemic corticosteroid therapy in the presence of renal failure.

PURPOSE: We describe an elderly patient with chronic renal failure who developed bilateral exudative retinal detachments after initiation of systemic corticosteroid therapy, followed by prompt resolution of the retinal detachments after the corticosteroids were discontinued. METHODS: The medical record was examined and reviewed to document the clinical course, treatment, and therapeutic response. RESULTS: Two weeks after receiving systemic corticosteroids for deteriorating renal failure, the patient had painless bilateral visual loss. Rapid tapering of the corticosteroids concurrent with hemodialysis and subsequent improvement of renal failure resulted in resolution of the exudative retinal detachments. The right eye developed a 360-degree retinal pigment epithelial tear in the macula. CONCLUSIONS: Exudative retinal detachments may complicate systemic corticosteroid therapy.

Glaucoma and visual outcome in central retinal vein occlusion.

Glaucoma is a recognized risk factor for central retinal vein occlusion. The authors retrospectively reviewed charts of fifty patients with central vein occlusion examined over a 5-year period. The visual outcome and clinical characteristics of eyes with and without glaucoma were compared. There were 32 eyes without glaucoma and 18 eyes with glaucoma. Final visual acuity of 20/100 or better was obtained in 22% of eyes with glaucoma, compared with 34% of eyes without glaucoma, and final visual acuity of finger counting and less was found in 56% and 22%, respectively (p = 0.02). The rate of ischemic occlusion was higher in the glaucoma group, 44% and 28% respectively, but the difference did not reach statistical significance. There was no difference in the rate of neovascular complications and macular edema between the two groups. The results suggest that glaucoma has an adverse effect on the visual outcome of eyes with central vein occlusion.

Epileptic blindness in children: a localizing sign of various epileptic disorders.

UNLABELLED: The ictal manifestations, EEG, CT, and MRI correlates, as well as the management and outcome of 11 children with epileptic blindness are presented. Seven males and four females, aged 3 months to 12 years, experienced single or recurrent episodes of acute visual obscuration. Ictal blindness was the solitary epileptic phenomenon in only two children. The rest had other focal or generalized motor epileptic manifestations. Six children had either focal motor phenomena and/or unilateral EEG disturbances, with a normal head CT. The drug of choice in this group was carbamazepine and all became asymptomatic. Two patients had structural abnormalities of the brain, of which one had a low-grade occipital astrocytoma which was resected. His blindness abated shortly following initiation of carbamazepine, even prior to surgery. Status epilepticus amauroticus and focal motor seizures, secondary to focal cortical dysplasia, was detected in another 3-month-old infant. These required cortical resection and she regained full vision. Three patients had generalized epileptiform discharges on EEG, of which two were photic-induced. Blindness was accompanied with motor seizures and myoclonic jerks. Full seizure control could be achieved in only one child. CONCLUSION: our data suggest a relatively benign nature and a favorable outcome in most children with ictal blindness. Resection of a secondary temporo-parietal focus, as occurred in an infant with status epilepticus amauroticus which originated in the occipital region, may result in complete cessation of seizures and visual recovery.

Treatment of clinically resistant cytomegalovirus retinitis with combined intravitreal injections of ganciclovir and foscarnet.

PURPOSE: To determine the efficacy of combined ganciclovir and foscarnet intravitreal injections in controlling clinically resistant cytomegalovirus retinitis in a 37-year-old man with the acquired immunodeficiency syndrome who refused systemic therapy. METHODS: The patient refused systemic therapy and was treated with intravitreal injections of ganciclovir and foscarnet, which were then combined when the retinitis became resistant to either drug alone. RESULTS: The retinitis was initially controlled with bilateral intravitreal ganciclovir injections. After reactivation of retinitis in the left eye, intravitreal foscarnet was effective until recurrent retinitis threatened the center of the fovea. The retinitis continued to progress until combined intravitreal injections of ganciclovir and foscarnet were administered. CONCLUSIONS: Combined intravitreal injections of ganciclovir and foscarnet may be effective in treating cytomegalovirus retinitis when the infection is clinically resistant to either intravitreal drug alone. Intravitreal injections can be effective in controlling cytomegalovirus retinitis in patients who are intolerant of or refuse systemic therapy.

Early postoperative intraocular pressure pattern in glaucomatous and nonglaucomatous patients.

PURPOSE: To evaluate intraocular pressure (IOP) changes in the 24 hours following cataract extraction in glaucomatous and nonglaucomatous patients. SETTING: General Eye Service and Glaucoma Service of the Goldschleger Eye Institute, Tel Hashomer, Israel. METHODS: Twenty-six nonglaucomatous patients and 13 glaucomatous patients scheduled for routine cataract extraction and intraocular lens implantation were evaluated. In each patient, IOP was measured before cataract surgery and every 4 hours for 24 hours postoperatively. Thirteen of the nonglaucomatous patients were randomly treated with one drop of timolol maleate at the end of surgery (NG-T group). The other 13 nonglaucomatous patients (NG group) and all glaucoma patients (G group) were not treated. RESULTS: In the NG group, mean preoperative IOP was 13.9 mm Hg. Following surgery, IOP rose steadily to 22.2 mm Hg at 12 hours; it returned to almost presurgical levels at 24 hours. The IOP exceeded 35 mm Hg in only one patient. In the NG-T group, mean preoperative IOP was 16.5 mm Hg and increased to 21.2 mm Hg at 12 hours. The IOP returned to almost presurgical levels at 24 hours. In the G group, mean IOP was 18.8 mm Hg preoperatively and rose to 29.9 mm Hg at 8 hours after surgery. In seven eyes the IOP exceeded 35 mm Hg. COMMENTS: Our findings of elevated IOP emphasize the need for prophylactic treatment (medical or combined cataract and glaucoma surgery) to prevent IOP spikes in high-risk patients.

Study of central retinal ganglion cell loss in experimental glaucoma in monkey eyes.

PURPOSE: The objective of this research was to compare the loss of retinal ganglion cells subserving the fovea to that of the ganglion cells in the surrounding perifoveal region in eyes with experimental glaucoma. METHODS: Ganglion cell nucleoli were counted using light microscopy from vertically oriented retinal, strips and the cell density was calculated using the modified Abercombie formula. Percent ganglion cell loss in glaucomatous eyes from five monkeys was determined for each of up to five contiguous areas within the central 12 degrees of the retina by comparison to normal fellow eyes. RESULTS: Loss of central ganglion cells was present even in eyes with mild glaucomatous damage. The percent ganglion cell loss in glaucomatous eyes at five adjacent areas within the central 12 degrees of the retina did not differ significantly (ANOVA, p = 0.77, n = 8). Cell loss in areas nearest to the fovea was indistinguishable from that in more peripheral perifoveal areas. CONCLUSIONS: Foveal ganglion cells appear to be susceptible to experimental glaucoma injury. Psychophysical testing of foveal functions may deserve renewed attention in glaucoma diagnosis and follow-up.

Comparison of ganglion cell loss and cone loss in experimental glaucoma.

PURPOSE: To compare the loss of ganglion cells to cone loss in the macular area of monkey eyes with experimental glaucoma. METHODS: Experimental glaucoma was induced in eyes of three cynomolgus monkeys by argon laser applications to the trabecular meshwork. The average duration +/- S.D. of glaucoma in the experimental animals was 3.8 +/- 0.5 months. Glaucomatous damage was estimated, before the animals were killed, by evaluating stereoscopic photographs of the optic disk and red-free photographs of the nerve fiber layer. Ganglion cell nucleoli and cone pedicles were counted by using light microscopy from slides containing strips of retinal tissue. Cell density was then calculated by using the modified Abercrombie formula. Percent loss of ganglion cells and cones was determined from three eyes of three monkeys in 300-micron segments that were 900 to 1,200 microns superior and inferior to the foveal center. RESULTS: Cone loss was not found at 4.5 to 6 degrees eccentricity above and below the fovea, whether damage was mild or severe. The average loss +/- S.D. of ganglion cells was 81.1% +/- 10.7%, whereas the average cone loss was only 3.5% +/- 6.4%. CONCLUSIONS: Marked parafoveal cone loss was not found in experimental glaucoma in which extensive damage to ganglion cells occurred.

Angiogenic activity of vitreous extract obtained from rabbit eyes with endotoxin-induced uveitis.

The effect of rabbit vitreous with endotoxin-induced uveitis was investigated for its role in the modulation of rat corneal neovascularization (NV). Elvax pellets implanted into at cornea contained either uveitic vitreous, intact vitreous or Elvax alone. The latter two kinds of pellets did not elicit NV. Uveitic vitreous pellets caused, in 100% of eyes, a persistent NV with maximal growth on the 10th day post implantation. Prostaglandin E2 and leukotriene B4 levels in the uveitic rabbit vitreous at 36 h postendotoxin injection were 7- and 5-fold higher than baseline, respectively. Histopathologically, the neovascularized cornea showed a significant inflammatory reaction attributable to the uveitic vitreous extract.

[Secondary glaucoma after congenital cataract surgery].

In a retrospective study, the incidence of secondary glaucoma after congenital cataract extraction was evaluated. Causes of this type of secondary glaucoma include peripheral anterior adhesions which obstruct the anterior chamber angle and prevent normal outflow of aqueous humor, pupillary block, intraocular hemorrhage, and chronic uveitis, among others. During the past 12 years 41 children (57 eyes) were operated for congenital cataract. Secondary glaucoma was found in a 1-month-old boy and a 1-month-old girl (5.3%; 3 eyes). Follow-up in most patients was less than 5 years. A similar incidence of secondary glaucoma has been reported by others. In spite of the low incidence of this complication, secondary glaucoma should be excluded during routine follow-up of these children.