Persistent endophthalmitis after intravitreal antimicrobial therapy.

PURPOSE: To assess the frequency of persistent infection after injection of intravitreal antimicrobials as therapy for endophthalmitis and to determine if persistent infection influences the final visual outcome after treatment. METHODS: In a series of 42 eyes with culture-positive endophthalmitis of various types, the authors performed a second vitreous culture and injection of antimicrobial agents in 22 eyes. Repeat cultures were obtained 3 to 8 days after initial therapy in 20 of the 22 eyes. RESULTS: Twelve of the 22 eyes were persistently culture-positive. Organisms identified in the persistently culture-positive eyes included staphylococcal species (n = 4), Streptococcus (n = 4), Serratia (n = 1), Propionibacterium acnes (n = 1), and fungi (n = 2). Eyes in which the initial antimicrobial therapy failed to eradicate a bacterial infection had a worse outcome than those that were culture-negative on repeat sampling. Final visual acuity of 20/200 or better after repeat injection was attained in 4 of the 12 culture-positive eyes. CONCLUSION: A single injection of intravitreal antimicrobial agents may be insufficient to cure some cases of endophthalmitis, and a second injection should be considered in some circumstances.

Surgical management of submacular hemorrhage. A series of 47 consecutive cases.

BACKGROUND: The development of a thick submacular hemorrhage usually carries a poor visual prognosis. The surgical removal of submacular blood may improve the otherwise poor outlook in these cases. SUBJECTS AND METHODS: Forty-seven consecutive patients underwent vitrectomy with surgical removal of submacular hemorrhage. The patient population consisted of two consecutive groups. Group 1 (1989 to 1991) included 23 patients (20 with age-related macular degeneration [ARMD], one with idiopathic submacular hemorrhage, one with presumed ocular histoplasmosis syndrome [POHS], and one with angioid streaks) who underwent mechanical clot extraction. Group 2 (1991 to 1993) included 24 patients (19 with ARMD, two with POHS, two with arterial macroaneurysm, and one with angioid streaks) who underwent tissue plasminogen activator-assisted drainage of thick submacular hemorrhage. The dose of tissue plasminogen activator ranged from 10 to 40 micrograms. All patients had surgery within 72 hours of diagnosis. RESULTS: In group 1, the mean size of the submacular hemorrhage was 11 disc areas (range, 1 to 16 disc areas). Mean follow-up was 40 weeks. Mean postoperative visual acuity for eyes with ARMD was 20/200. (Visual acuity improved in six eyes, was stable in seven eyes, and deteriorated in seven eyes.) All three of the eyes without ARMD had visual improvement with a mean postoperative visual acuity of 20/70. Overall, visual acuity stabilized or improved in 13 (57%) of 23 patients and decreased in 10 (43%) patients. In group 2, the mean size of the submacular hemorrhage was 11 disc areas (range, 3 to 16 disc areas). Mean follow-up was 24 weeks. Mean postoperative visual acuity for eyes with ARMD was 20/480 (visual acuity was stable in 15 eyes, improved in two eyes, and deteriorated in two eyes). Four of five eyes without ARMD had visual improvement and one was stable, with a mean postoperative visual acuity of 20/60. Visual acuity stabilized or improved in 22 (92%) of 24 patients and decreased in two (8%). The degree of clot lysis was variable. CONCLUSIONS: Submacular hemorrhage secondary to ARMD has a poor visual prognosis, with or without surgical drainage. The addition of tissue plasminogen activator-assisted clot lysis does not appear to significantly improve the visual outcome following surgery. The determination of whether surgical intervention is appropriate in these cases requires a prospective, randomized clinical trial.

Visual results after surgical removal of subfoveal choroidal neovascular membranes.

PURPOSE: The authors report their experience with the surgical removal of subfoveal choroidal neovascularization. Correlations between preoperative characteristics and final postoperative visual acuity are explored. METHODS: A retrospective study of 159 consecutive patients was performed between February 1990 and August 1993. Follow-up of 2 or more months was available for 147 eyes: presumed ocular histoplasmosis syndrome, 67 eyes; age-related macular degeneration, 41 eyes; myopia, 10 eyes; multifocal choroiditis, 9 eyes; idiopathic, 8 eyes; angioid streaks, 4 eyes; and miscellaneous, 8 eyes. RESULTS: Sixty-seven eyes had presumed ocular histoplasmosis syndrome: mean follow-up was 10.5 months. Visual acuity was stable or improved in 56 (83%) eyes and 20/40 or greater in 21 (31%) eyes. Mean interval to best visual acuity was 3 months. A recurrence rate of 37% had no significant effect on final visual outcome (P = 0.952). Forty-one eyes had age-related macular degeneration: mean follow-up was 15 months. Visual acuity was improved in only five (12%) eyes and was 20/40 or greater in only two (5%) eyes. The interval to best visual acuity was 5 months. A recurrence rate of 27% had not significant effect on final visual outcome (P = 0.31). The visual results and recurrence rates for eyes with less common disorders are presented. CONCLUSION: The surgical excision of subfoveal choroidal neovascularization may stabilize or improve visual acuity in selected cases. Patients with focal disorders of the retinal pigment epithelium-Bruch's membrane complex appear to have a better surgical outcome than those with diffuse disease.

External argon laser choroidotomy versus needle drainage technique in primary scleral buckle procedures. A prospective randomized study.

PURPOSE: To compare the rates of intraoperative and postoperative complications of external argon laser choroidotomy and needle drainage techniques during scleral buckle procedures for primary retinal detachment. METHODS: A group of 175 patients undergoing scleral buckling for primary retinal detachment was randomly assigned to undergo either external argon laser choroidotomy or needle drainage. Complications associated with drainage of subretinal fluid were categorized as retinal break, retinal incarceration, or hemorrhage (dot, < or = 1 disc diameter [DD], or > 1 DD), and recorded during surgery and 24 hours after surgery. RESULTS: In the group that underwent laser choroidotomy, 12 (13%) of 92 patients had complications, including 4 dot hemorrhages, 3 hemorrhages 1 DD or smaller, 3 hemorrhages larger than 1 DD, 1 retinal incarceration, and 1 suprachoroidal hemorrhage. In the group that underwent needle drainage, 13 (16%) of 81 patients had complications, including 3 dot hemorrhages, 4 hemorrhages 1 DD or smaller, 5 hemorrhages larger than 1 DD, and 1 suprachoroidal hemorrhage. No significant difference was noted between the two groups in the incidence of complications (P = 0.657). CONCLUSION: External argon laser choroidotomy and needle choroidotomy are comparable, safe, and effective ways to drain subretinal fluid during scleral buckle surgery.

Magnetic resonance imaging findings in Vogt-Koyanagi-Harada syndrome.

BACKGROUND: Vogt-Koyanagi-Harada Syndrome (VKHS) is a systemic disorder consisting of bilateral panuveitis with associated cutaneous and neurologic findings. In the absence of extraocular manifestations, diagnosis of VKHS may be difficult. METHODS: The results of magnetic resonance imaging (MRI) in two patients with VKHS and of computed tomography (CT) in a third patient with VKHS are described. RESULTS: Bilateral, diffuse choroidal thickening with scleral sparing was the norm. Choroidal thickening was demonstrable, despite the normal fundus appearance and fluorescein angiogram, in one eye. Intense enhancement after administration of gadopentetate was seen in the acute stages, but not after corticosteroid treatment. High-intensity periventricular lesions were seen in one patient. CONCLUSION: MRI superbly discriminates the fibrous sclera from the choroid and allows for the detection of subclinical ocular and central nervous system disease. It is therefore a useful adjunct in the diagnosis and follow-up of VKHS.

Prospective evaluation of the effect of pseudophakic cystoid macula edema on contrast sensitivity.

OBJECTIVE: To evaluate the effect of pseudophakic cystoid macular edema (PCME) on contrast sensitivity. DESIGN: Best-corrected visual acuity, fluorescein angiogram, and contrast sensitivity measurements were obtained before surgery and at 8 weeks and 8.5 months after surgery. Eyes were classified as having no PCME, transient PCME, or persistent PCME. PARTICIPANTS: The study population consisted of 31 consecutive patients undergoing extracapsular cataract extraction with posterior chamber intraocular lens implantation between September 1990 and March 1991. MAIN OUTCOME MEASUREMENTS: Outcomes were best-corrected visual acuity and contrast sensitivity. RESULTS: Analysis of variance showed a significant decrease for all spatial frequencies at 8 weeks (P < .005) and for higher frequencies at 8.5 months (P < .05) in both PCME groups and for higher frequencies at 8 weeks in the transient PCME group. CONCLUSION: Decrease in contrast sensitivity associated with PCME may account for persistent visual difficulties despite good Snellen visual acuity.

Exuberant conjunctival pseudopolyposis in a patient with dermatomyositis.

Dermatomyositis is a disease of unknown cause, characterized by a diffuse inflammatory myopathy and skin changes consisting of heliotrope eruption, Gottron's papules, periungual telangiectasia with dystrophic cuticles, skin telangiectasia, and atrophy. Ocular involvement may consist of conjunctival edema, nystagmus, extraocular muscle imbalance (when associated with myasthenia gravis), iritis, cotton-wool spots, and optic atrophy. Conjunctival avascularity and membranous conjunctivitis also have been reported. We describe an unusual conjunctival finding with secondary corneal surface disturbances in a patient with dermatomyositis.

Subretinal endophotocoagulation in the treatment of choroidal neovascularization.

The development of subfoveal choroidal neovascularization is a major cause of visual loss in age-related macular degeneration and other disorders of the retinal pigment epithelium-Bruch's membrane complex. We designed a new subretinal laser delivery system and used it to treat subfoveal neovascular membranes in three eyes with age-related macular degeneration. Preoperative visual acuities were 20/200, 20/80, and 20/300, respectively. With a mean follow-up of seven months, postoperative visual acuities were 20/80, 20/400, and 20/300, respectively. One eye developed recurrent neovascularization, which was adequately treated with slit lamp-delivered laser photocoagulation. Another eye continued to lose visual acuity because of progressive atrophy of the retinal pigment epithelium. Although ablation of choroidal neovascular membranes was possible with this technique, visual results were disappointing, probably because of damage of the underlying retinal pigment epithelium and choriocapillaris.

Interferon alfa-2a in the treatment of subfoveal choroidal neovascularization.

We prospectively evaluated the effect of interferon alfa-2a on subfoveal choroidal neovascularization. Eight patients with recurrent subfoveal choroidal neovascularization after surgical excision and 12 patients with subfoveal choroidal neovascularization without previous surgical excision received interferon alfa-2a (3.0 to 6.0 million U/m2 of body surface area), every other night for an average of 12 weeks. Mean follow-up was nine months. Visual acuity improved in two of 20 (10%), remained stable in seven of 20 (35%), and worsened in 11 of 20 (55%) patients. The fluorescein angiogram improved in two of 20 (10%), remained stable in three of 20 (15%), and deteriorated in 15 of 20 (75%) patients. All patients had side effects, which led to the discontinuation of therapy in five of 20 (25%) patients. Side effects included flulike symptoms, leukopenia, thrombocytopenia, increased liver enzymes, alopecia, fever, nausea, and suicidal depression. Interferon alfa-2a failed to improve visual acuity or the fluorescein angiographic appearance of subfoveal neovascular membranes in 90% of cases and was associated with marked side effects. We discourage the widespread use of interferon alfa-2a in the treatment of choroidal neovascularization.

A new presentation of disseminated histoplasmosis in a homosexual man with AIDS.

The clinical and histopathological features and the therapeutic response of a pustular eruption occurring in a homosexual man with Acquired Immune Deficiency Syndrome (AIDS) is reported. The rare cutaneous presentation consisted of mostly circumscribed, tender, tense pustules, associated with erythema, confined to the face and neck. Biopsy of these lesions revealed intracellular round to oval bodies surrounded by a clear space, consistent with Histoplasma capsulatum. Prompt resolution was observed after initiation of amphotericin B therapy. Clinicians are alerted to the occurrence of exotic presentations of this entity and emphasis is given to the need for skin biopsy and culture to avoid delay in diagnosis and failure to initiate appropriate therapy.