Accommodation of an endocapsular silicone lens (Phaco-Ersatz) in the nonhuman primate.

In owl monkeys, as a model of endocapsular cataract extraction, the lens material was removed through a small hole in the capsule and was replaced with a silicone polymeric gel. The ability of this endocapsular implant (Phaco-Ersatz) to accommodate was documented when pilocarpine produced an increase in the curvature of the lens surface and a decrease in the anterior chamber depth, just as occurs with the untouched natural lens. Refinements of the surgical technique are required to achieve a controlled degree of filling of the capsular bag and inhibit postoperative epithelial proliferation on the inner capsular surface.

Phaco-Ersatz: cataract surgery designed to preserve accommodation.

Phaco-Ersatz represents a new approach to cataract surgery and the correction of aphakia. The procedure involves the removal of the cataractous cortex and nucleus while preserving the lens capsule and its zonular attachments. The empty lens capsule is then refilled with biocompatible and optically suitable clear gel. A physiologic lens is recreated in situ. Experimental work with human cadaver eyes and rabbit and cat eyes in vivo demonstrates this surgical feasibility. A review of the literature reveals contradicting theories regarding the physical laws and lens properties governing accommodation. The accommodative potential of the ersatz lens has not been tested, but it may be speculated that this recreated lens may, in fact, possess some accommodative properties. Experimental investigations in this area represent the logical extension of intraocular lens implant development.

5-fluorouracil: new applications in complicated retinal detachment for an established antimetabolite.

Long-term reattachment of the retina following the development of proliferative vitreoretinopathy is often prevented by the occurrence of cellular reproliferation. 5-fluorouracil, a synthetic pyrimidine analog, is a potent inhibitor of fibroblast proliferation in cell culture and an animal model of tractional retinal detachment. Doses of up to 1.0 mg, when administered intravitreally to rabbits, result in no demonstrable retinal toxicity by microscopic and electrophysiologic criteria. The first 22 consecutive patients with advanced forms of proliferative vitreoretinopathy were treated with a combination of periocular and intraocular 5-fluorouracil, in addition to scleral buckling and vitrectomy. Retinal reattachment was achieved in 60% of patients at 6 months postoperatively. No serious systemic or ocular complications were observed although delayed healing of corneal epithelial defects occurred in 18% of cases and subtle subepithelial scarring in 31.8%. In combination with standard vitrectomy techniques, post-operative fluid gas exchange, and photocoagulation, periocular and subconjunctival 5-fluorouracil appears to improve the prognosis for longterm retinal reattachment following the development of proliferative vitreoretinopathy.

Recurrence of choroidal melanoma after photocoagulation therapy.

A 40-year-old man had a small choroidal melanoma in his left eye. The tumor was seemingly erradicated by xenon arc photocoagulation; however, eight years later the tumor recurred along the inferior edge of the chorioretinal scar, and the eye was enucleated. Histopathologic examination of the lesion revealed a spindle B-cell melanoma.

Split-frame stereoscopy. A new projection system.

The viewing of projected stereo-slides can be achieved by either prismatic or polarized modalities. Two new projection lenses were designed for polarized split-frame stereoscopy. These lenses fit any of the commonly available (35 mm) projectors.

The acute retinal necrosis syndrome. Part 2: Histopathology and etiology.

The acute retinal necrosis syndrome is manifested by diffuse uveitis, vitritis, retinal vasculitis, and acute necrotizing retinitis (see Part 1). We studied the histopathology and electron microscopic findings of an eye enucleated from a 67-year-old man with typical acute retinal necrosis. Histology showed profound acute necrosis of the retina, retinal arteritis, and eosinophilic intranuclear inclusions in retinal cells. Electron microscopy demonstrated a herpes group virus in all layers of affected retina. The implications of these findings for antiviral and other treatments are discussed.

The acute retinal necrosis syndrome. Part 1: Clinical manifestations.

The acute retinal necrosis syndrome is characterized by necrotizing retinitis, vitritis, and retinal vasculitis occurring in otherwise healthy patients. Experience with 11 cases and the review of 30 additional cases in the literature are presented. In this series, 50% of the affected eyes developed retinal detachments, and 64% had a final visual acuity of less than 20/200. The natural history, diagnosis, postulated etiology, and suggestions for management will be discussed.

Exudative retinal detachment in Wegener's granulomatosis: case report.

We have presented a case of Wegener's granulomatosis with characteristic systemic and ocular manifestations. The diagnosis was determined pathologically by thoracotomy and lung biopsy. Our patient's ocular complications included an intense vitritis, exudative retinal detachment, choroiditis, and other corneoscleral manifestations. Exudative retinal detachment is a finding not previously described clinically, but alluded to in pathologic descriptions from case reports. Both systemic and ocular response were obtained within weeks after the patient started cyclophosphamide and prednisone. In addition to recording this new finding, we have reviewed the pathology and ocular manifestations of this uncommon disorder, outlined a modern therapeutic protocol, and updated the present-day prognosis of Wegener's granulomatosis.

Periodic alternating nystagmus clearing after vitrectomy.

Periodic alternating nystagmus 1) may be related to vestibulocerebellar system disease, 2) may occur with loss of vision, and 3) may be congenital in origin. We report the case of a patient with acquired periodic alternating nystagmus in whom the nystagmus followed bilateral vitreous hemorrhages. Upbeating nystagmus was interposed between the right beating and left beating phases. Bilateral vitrectomy resulted in the prompt disappearance of the nystagmus. The importance of visual function in relation to periodic alternating nystagmus and associated motility disturbances is emphasized.

The use of intraocular gases. The results of sulfur hexafluoride gas in retinal detachment surgery.

The results of SF6 gas in 69 retinal detachment cases managed with nonvitrectomy techniques are presented. Of 57 cases followed six months, 64.9% were reattached and 61.4% showed stabilization of visual acuity at 20/60 or better or improvement in vision from the preoperative level. Visual and anatomical results were similar between 16 giant tear cases managed with SF6 and a similar previous series from the same institution managed with air. Complications possibly attributable to gas were development or progression of mild cataract changes in 27% of phakic patients and transient elevation of intraocular pressure in 26% of all patients on the first preoperative day. Presumed central retinal artery occlusion occurred in four patients with elevated pressure, with permanent loss of light perception in three diabetic patients. In selected cases where other methods or air will not suffice, SF6 can be useful if used cautiously.

Fluorescein angiography of optociliary shunt vessels.

Progressive loss of vision, optic disc pallor, and optociliary shunt vessels (the Hoyt-Spencer sign) constitute the clinical triad of optic nerve sheath meningiomas. However, optociliary shunt vessels may also follow central vein occlusions, and less commonly occur with a few other conditions. This report presents a comparative study of fluorescein angiograms performed on eight patients with optociliary shunt vessels. Four patients had optic nerve sheath meningiomas, and four patients had central retinal vein occlusions. The following differences in the fluorescein angiograms were noted in the two groups. In the optic nerve sheath meningioma group, the shunt vessels fill earlier (in the arteriovenous phase), the flow drains to central venous tributaries, and the late staining is hyperfluorescent to other veins. However, in the central vein occlusion group, the shunts fill later (in the venous phase), show a flow draining to the outer disc margin, and late staining is eufluorescent with other veins. Although optic nerve sheath meningiomas and old vein occlusions are usually rather easily differentiated by a complete examination, the fluorescein angiographic patterns are not only pertinent with regards to the pathogenesis of optociliary vessels, but in certain cases may be clinically helpful in making an important clinical differentiation.

Doyne memorial lecture, 1981. Fluorescein angiography. Twenty years later.

A new method to study and permanently record function and structure in the living eye became available with the introduction of fluorescein angiography by Novotny and Alvis (1961). Flow and permeability in the retinal and choroidal vessels could now be correlated with anatomical changes. This presentation will review some of the major advances in our knowledge resulting from this technique.

Ocular quinine toxicity.

A 25-year-old woman had no light perception in either eye 14.5 hours after ingesting 3.7 to 4.7 g of quinine. Fundus photographs showed mild venous distention and retinal haziness, but normal arteries. The electroretinogram, electrooculogram, and visual-evoked potential were all mildly abnormal. Two days after the patient ingested quinine, her visual acuity returned to 6/6 (20/20) with a markedly constricted visual field. The classic late fundus appearance of quinine toxicity, marked vascular narrowing, and disk pallor developed within six months. Visual fields remained constricted to 12 degrees with small temporal islands.

Simultaneous stereophotogrammetric and angiographic fundus camera.

We developed an apparatus for serial, simultaneous stereophotogrammetric fundus angiography by modifying a fundus camera. The paired stereoangiograms obtained by this system provided satisfactory stereoscopy and fair depth of field. With this system, mounting and filing of slides were easy. Accurate photogrammetric analysis of the fundus can be performed. Clinical results were impressive in both young and old subjects with fully dilated pupils.

The influence of changing cataract techniques on the ophthalmologist concerned with retinal diseases.

This paper briefly presents a review of some of the retinal problems the ophthalmologist faces because of changing techniques in cataract surgery. It emphasizes the need for controlled clinical trials to properly evaluate the benefits or disadvantages of these changing techniques.