Unexplained vision loss following removal of epiretinal membrane.

PURPOSE: To report unexplained severe central vision loss accompanied by a dense central scotoma as an uncommon complication following epiretinal membrane removal. METHODS: Retrospective, multicentred, case series. RESULTS: Six patients underwent uncomplicated vitrectomy surgery between 2000 and 2007 at four separate retina practices for removal of an epiretinal membrane. Preoperative vision ranged from 20/60 to 20/100, with a median of 20/70. On the first day postoperatively, all patients noted decreased vision ranging from counting fingers to light perception and were found to have a dense central scotoma. Posterior segment examination revealed a white, oedematous macula in all affected eyes. Vision improved minimally during the follow-up period, which ranged from 2 months to 5 years. The final vision ranged from 20/200 to hand movements. No anatomic or physiologic cause for the decreased vision and central scotoma was identified. CONCLUSIONS: While uncommon, severe, permanent, central vision loss accompanied by a dense central scotoma can occur following epiretinal membrane removal and should be considered when assessing the risks and benefits of such surgery.

Massive suprachoroidal hemorrhage during pars plana vitrectomy associated with Valsalva maneuver.

PURPOSE: To report the intraoperative occurrence of massive intraocular suprachoroidal hemorrhage associated with Valsalva maneuver. METHODS: Retrospective, multicenter study of patients who developed massive choroidal hemorrhage associated with Valsalva maneuver during vitrectomy. RESULTS: Massive intraoperative suprachoroidal hemorrhage in seven patients (seven eyes) involved three men and four women with a median age of 52 years (range, 26 to 82 years). General anesthesia was used in six of seven cases. Coughing or "bucking" on the endotracheal tube during general anesthesia or severe coughing during the one vitrectomy performed under local anesthesia was associated with massive suprachoroidal hemorrhage. In five of seven eyes, this occurred near the end of surgery, after air-fluid exchange but before sclerotomy closure. Scleral plugs were immediately placed, and sclerotomy closure was performed exigently. Immediate posterior sclerotomy was performed on five of seven eyes; an additional patient underwent posterior sclerotomy postoperatively. After median follow-up of 18 months (range, 3 to 36 months), final visual acuity was no light perception in four eyes, light perception in one eye, 20/250 in one eye, and 20/20 in one eye. Four eyes became phthisical. CONCLUSIONS: Valsalva maneuver during pars plana vitrectomy may result in massive suprachoroidal hemorrhage with disastrous visual consequences. Precautionary measures to prevent coughing or "bucking" on the endotracheal tube during general anesthesia, or a prolonged episode of coughing during local anesthesia, may prevent this potentially devastating complication.

Traumatic macular hole: observations, pathogenesis, and results of vitrectomy surgery.

PURPOSE: To review our experience with vitrectomy surgery techniques for the treatment of traumatic macular holes and the biomicroscopic and surgical findings. DESIGN: Retrospective noncomparative, multicenter, case series. PARTICIPANTS AND INTERVENTION: Twenty-five patients with traumatic macular hole underwent surgical repair. INTERVENTION: Vitrectomy with membrane peeling and gas injection followed by prone positioning for 7 to 14 days. MAIN OUTCOME MEASURES: Postoperative evaluation included visual acuity testing, closure of the macular hole, and ocular complications. RESULTS: The macular hole was successfully closed in 24 of 25 cases (96%). The visual acuity improved two or more lines in 21 (84%) cases, and 16 (64%) achieved 20/50 or better vision. CONCLUSIONS: Vitrectomy surgery can successfully close macular holes associated with trauma and improve vision.

Sympathetic ophthalmia associated with pars plana vitrectomy without antecedent penetrating trauma.

PURPOSE: To evaluate, describe, and categorize the clinical presentation, clinical course, histopathology, and response to therapy in patients without a history of penetrating ocular trauma who developed sympathetic ophthalmia following pars plana vitrectomy. METHODS: The records of patients without a history of trauma who underwent pars plana vitrectomy and developed sympathetic ophthalmia were retrospectively reviewed. Cases were analyzed with respect to clinical presentation, fluorescein angiographic findings, anatomic and visual outcomes, histopathology, and response to therapy. RESULTS: Eight eyes were identified. The median age at presentation was 55 years, with a range of 14 to 62 years. The time from vitrectomy to diagnosis of sympathetic ophthalmia ranged from 2 months to greater than 2 years, with a median of 7 months. Six of eight patients (75%) presented with anterior chamber reaction. All eight patients presented with a vitreous inflammatory response. The optic nerve was inflamed clinically or angiographically in four of eight cases (50%). Small yellow-white sub-retinal pigment epithelial deposits were present in four of eight cases (50%). Two eyes had lesions characterized as multifocal choroiditis. One eye had larger yellow placoid-like lesions. One eye presented with vitritis but no retinal lesions. Subretinal choroidal neovascularization was noted in the inciting eye of one patient. Vision improved in the sympathizing eye with immunosuppressive therapy in five of eight cases (62.5%). CONCLUSIONS: Sympathetic ophthalmia can be seen following pars plana vitrectomy in patients without penetrating injuries or a history of trauma. Indeed, it may be seen after successful vitrectomy for retinal detachment. Diverse clinical presentations are possible, and persistent or atypical uveitis following vitrectomy should alert the surgeon to the development of sympathetic ophthalmia.

Soccer ball-related retinal injuries: a report of 13 cases.

PURPOSE: To describe the clinical characteristics and management of retinal injuries caused by soccer ball impact as well as the mechanism of injury, prognostic features, risk factors, and possible prevention strategies. METHODS: Thirteen cases of soccer ball injuries from retina referral practices were retrospectively reviewed, with attention to the mechanism of associated ocular complications and the anatomic and visual outcomes. RESULTS: Soccer ball injuries occurred in both male and female patients (9 male, 4 female) with ages ranging from 8 to 21 years (median 14 years). These patients were observed from 0 to 64 months (median follow-up, 8 months). Four patients had traumatic macular holes, two eyes had retinal detachment associated with retinal dialysis, two had retinal tears associated with hemorrhage, one had a choroidal rupture, and one had only vitreous hemorrhage and Berlin's edema. Although six eyes had some degree of traumatic retinal pigment epitheliopathy, it was the primary diagnosis in only three. Visual acuity at presentation ranged from 20/20 to count fingers, with 7/13 (54%) having 20/200 or worse vision. Seven eyes underwent surgical procedures; the remainder were observed. Final visions ranged from 20/20 to count fingers, with 3/13 (23%) having 20/200 or worse vision. Six eyes (46%) improved by two or more lines by the last follow-up. CONCLUSION: Soccer ball-related ocular injuries disproportionately affect young players, are more frequent in females than previously reported, and have more severe visual consequences than previously recognized. Injury prevention strategies to minimize contact between the eye and the soccer ball may reduce the incidence and severity of eye injuries.

Juxtapapillary capillary hemangiomas. Clinical features and visual acuity outcomes.

OBJECTIVE: To describe the clinical features, association with von Hippel-Lindau (VHL) disease and visual acuity outcomes of patients with a juxtapapillary capillary hemangioma. DESIGN: Retrospective observational case series. PARTICIPANTS: Seventy-two eyes of 68 patients identified with a juxtapapillary capillary hemangioma. Follow-up data of at least 6 months duration were available for 60 eyes. METHODS: A retrospective chart review of patients diagnosed with a juxtapapillary capillary hemangioma examined at four medical centers. MAIN OUTCOME MEASURES: Age at diagnosis, visual acuity (VA) at first examination and at last follow-up, tumor growth pattern and location, associated clinical features, type of treatment, association with VHL, and presence of peripheral hemangiomas were recorded for each patient. RESULTS: On initial examination, VA was >/=20/40 in 43 of 70 eyes (61%) and was >/=20/200 in 60 eyes (86%). At an average follow-up of 5.4 years (range, 0.5-19 years), VA of >/=20/40 was achieved in 21 eyes (35%) and >/=20/200 in 33 eyes (55%). Patients with VHL had poorer initial VA (48% vs. 70% with VA >/=20/40, and 74% vs. 93% with VA >/=20/200) and final VA (26% vs. 41% with VA >/=20/40, and 39% vs. 65% with VA >/=20/200) compared with patients without VHL. Patients with VHL more commonly were seen at an earlier age (average, 20 vs. 44 years, P: < 0.001), with bilateral (17% vs. 0%), and/or peripheral (39% vs. 0%) (P: < 0.001) tumors that more often had an endophytic growth pattern (63% vs. 22%, P: = 0.001) compared with patients without VHL. Patients selected for laser treatment generally had poorer initial (52% vs. 74% with VA >/=20/40, 79% vs. 96% with VA >/=20/200) and final VAs (18% vs. 56% with VA >/=20/40, 45% vs. 67% with VA >/=20/200) compared with patients not treated with laser. CONCLUSIONS: On long-term follow-up of patients with a juxtapapillary capillary hemangioma, the VA generally worsens. Patients with VHL and a juxtapapillary hemangioma more often present at a younger age, have tumors with an endophytic growth pattern, and have bilateral, multiple tumors. Treatment with laser photocoagulation results in variable VA outcomes.