Combined hamartoma of sensory retina and retinal pigment epithelium.

We report two cases of combined hamartoma of the sensory retina and retinal pigment epithelium (CHR-RPE) in which apparent growth of the lesion was observed. In case 1, the eye was enucleated with a presumed diagnosis of juxtapapillary malignant melanoma. Histopathologically, the enucleated globe showed an elevated peripapillary mass containing disorganized retinal tissue intermixed with vascular and glial elements as well as tubules of proliferating retinal pigment epithelium. We have summarized the clinical features of 53 patients with CHR-RPE reported between 1952 and 1988 excluding the cases compiled by the Macular Society Collaborative Study. While the latter study found an equal sex predilection among their cases, we found a 70% male preponderance among the 53 patients. Of the 54 lesions observed in 53 patients, 76% were juxtapapillary, 17% were macular, and 7% were peripheral. Furthermore, periodic follow-up examination disclosed apparent enlargement of the mass in six patients, five of whom underwent enucleation of the globe for suspected melanoma.

Treatment of juxtafoveal and parafoveal neovascular membranes with monochromatic green argon photocoagulation: green laser.

Sixty eyes in 58 patients with either juxtafoveal or parafoveal neovascular membranes were treated with monochromatic green argon photocoagulation. The visual acuity was stabilized or improved in 73.2% (22 eyes) in both the juxtafoveal and parafoveal groups. Total eradication of the neovascular membranes was possible in 86.6% (26 eyes) in the juxtafoveal group and 93.4% (28 eyes) of the parafoveal group. This study suggests that successful treatment of both juxtafoveal and parafoveal neovascular membranes can be accomplished with monochromatic green argon photocoagulation.

An interpretation of retinopathy of prematurity in terms of spindle cells: relationship to vitamin E prophylaxis and cryotherapy.

Spindle cells in the hyperoxygenated, avascular, vanguard retina are proposed to be the peripheral inducers of the neovascularization associated with retinopathy of prematurity (ROP). The induction of ROP is conceptualized in terms of three basic events. First, activation of spindle cells results initially in the increase in gap junctions between adjacent spindle cells, secondarily in the increase in cytoplasmic volume of rough endoplasmic reticulum, and ultimately in the synthesis and secretion of angiogenic factors Second, maturation of spindle cells is associated with a decrease in gap junctions, a diminished cytoplasmic volume of rough endoplasmic reticulum, and a cessation of synthesis and secretion of angiogenic factors. Third, myofibroblasts invade the vitreous concomitantly with spindle cell maturation and provide the tractional force that can produce retinal separation. The extent of interstitial retinol binding protein within the subretinal space explains the gestational-age-dependent efficacy of vitamin E in suppressing the development of severe ROP. The kinetics of both spindle cell activation/maturation and myofibroblast invasion predict the efficacy of appropriately timed and placed transretinal cryotherapy.

Malignant melanoma of the choroid: treatment with episcleral 198Au plaque and xenon-arc photocoagulation.

A method of treatment for posteriorly located malignant melanomas of the choroid is reviewed. Twenty-six patients have been treated either by radioactive gold (198Au) seed radiation plaque, alone or in combination with postradiation xenon-arc photocoagulation. Success, defined as the preservation of the globe with tumor ablated or regressed, was achieved in 92.3% of the treated eyes. These patients have been followed from 1 to 8.5 years, with an average follow-up of 44.84 months. Fifteen out of 26 patients (57.69%) had a final visual acuity of 20/50 or better. The main complications were radiation retinopathy (19.2%) and cystoid macular edema (19.2%). There were two enucleations, one after 29 months and one after 24 months following treatment.

Pigmented free-floating vitreous cysts in two young adults. Electron microscopic observations.

Pigmented free-floating vitreous cysts were observed in two young adults. In both patients, the cyst was in the visual axis; however, the size and extent of pigmentation of the cyst wall compromised the visual acuity only in case 1. In this case, the vitreous cyst was aspirated through the pars plana and studied by light and electron microscopy. Histopathologically, the cyst was lined by a heavily pigmented layer of cuboidal cells intermixed with sheets of nonpigmented cells forming papillae. Ultrastructurally, the pigmented cells contained predominantly large, mature melanosomes (0.9-2.2 micron). Scattered immature melanosomes with a scarcity of mitochondria and other cytoplasmic organelles were present. Additionally, the cells were invested by a thin polarized basement membrane and displayed apical microvilli. Numerous microvillous processes were noted under the plasmalemmae and between adjacent cells. The results of the light and ultrastructural studies provide support for the hypothesis that the cyst in case 1 originated from the pigment epithelium. The possibility of a traumatic etiology is proposed for these pigmented vitreous cysts. If significant visual impairment is present, surgical removal of the cyst through a pars plana approach can be safely performed as in our case 1.

Xenon-arc photocoagulation of medium-sized malignant melanomas.

Sixteen cases of medium-sized malignant melanomas were treated with xenon-arc photocoagulation. Early follow-up results are encouraging. Only minimal complications were encountered, and there was no evidence of metastasis. Meticulous follow-up of ocular malignant melanoma patients is strongly suggested, especially in cases in which the tumor is situated in the posterior pole.

Adverse reactions in intravenous fluorescein angiography.

Adverse reactions were noted in 241 (4.82%) of 5,000 consecutive intravenous fluorescein angiographies of the retina. The most frequent adverse reactions were nausea (2.24%), vomiting (1.78%), and urticaria/pruritus (0.34%). No life-threatening reactions were noted. No significant difference in the rate of adverse reactions was found when angiography using 10% fluorescein was compared with angiography using 25% fluorescein.

Retinal detachment following late posterior capsulotomy.

When we compared the incidence of retinal detachment in 27 eyes after extracapsular cataract surgery and late posterior capsulotomy with the incidence of general aphakic detachment, we found no relationship between the onset of retinal detachment and the numbers, types, or locations of breaks. The interval between cataract extraction and discission had a significant effect on recovery of visual acuity. Final visual acuities of 20/400 or better were attained in 22 of 23 eyes in which discission followed cataract extraction by one year or more but in only one of four eyes in which the procedures were separated by less than one year. Delaying discission for more than 12 months may reduce the extent of retinal detachment and produce the best functional results. Detachments that occurred less than one year after discission were more extensive but achieved better functional results than those that occurred later.

Retinal detachment in young premature infants with acute retrolental fibroplasia. Thirty-two new cases.

Experience with scleral buckling for exudative and tractional retinal detachments in very young premature infants who have acute retrolental fibroplasia (RLF) is reported. In this series, surgery was successful in 24 of 32 eyes (75%) of 23 infants, (age at surgery ranged from 1.75 months to 6 months, average age of 3 months). We attribute the 15% improvement in the success rate over our 1979 series in part to closer screening with emphasis on the examination at age 8 weeks, to earlier referral for treatment, and to our observation that these fragile eyes can withstand reoperation if buckle revision is necessary to combat persistent retinal traction. We encountered no serious complications either at surgery or immediately after surgery. We stress that (1) because of the high incidence of spontaneous remission, buckling surgery should not be performed until the detachment has progressed well posterior to the equator and remission is obviously unlikely (Grade IV or V); (2) excessive cryotherapy and undue surgical trauma should be avoided; and (3) because scleral erosion is certain as the eyes grow, the encircling band should be transected six months to one year after surgery.

Visual acuity after surgery for retinal detachment with macular involvement.

The records for a group of 2,054 patients who had undergone surgery fur rhegmatogenous retinal detachment with macular involvement were analyzed to ascertain the relative influence of the following five specific factors on postoperative visual acuity: (1) patient age, (2) degree of preoperative macular elevation, (3) duration of preoperative macular detachment, (4) extent of retinal detachment, and (5) drainage of subretinal fluid. Increasing patient age, increasing preoperative macular elevation, increasing duration of macular detachment, and increasing extent of retinal detachment were all found to be associated in general with decreasing postoperative visual acuity. Drainage, or nondrainage, or subretinal fluid appeared to be unassociated with postoperative visual acuity.

Spontaneous vitreous hemorrhage.

The causes of 653 cases of spontaneous vitreous hemorrhage were evaluated. The four most common causes, accounting for over 84% of the cases, were diabetic retinopathy (34.1%), retinal break without retinal detachment (22.4%), rhegmatogenous retinal detachment (14.9%), and retinal vein occlusion (13.0%). Other diagnoses accounting for a significant number of cases of spontaneous vitreous hemorrhage included posterior vitreous detachment, retinal vasculitis, senescent macular degeneration, intraocular tumor, and retinopathy of prematurity. The remaining, uncommon, diagnoses accounted for less than 5% of the cases.

Anterior segment abnormalities in cicatricial retinopathy of prematurity.

Abnormalities that occur in the anterior segments of patients with retinopathy of prematurity have been studied in 72 eyes of 36 patients. The anterior chamber depth, the placido disc image on the cornea, the distortion of polarized light by corneal stress, and keratometry readings were recorded. There was a highly significant correlation between anterior chamber depth, retinopathy of prematurity, and keratometry readings (p less than .001). These findings emphasize the importance of careful follow-up examinations of the anterior segment in retinopathy of prematurity because cataracts, band keratopathy, acute hydrops, and angle-closure glaucoma can progressively occur as complications.