The effects of silicone oil removal. Silicone Study Report 6.

OBJECTIVE: To evaluate the advisability of removing silicone oil from eyes after surgery for severe (with a classification of at least C-3) proliferative vitreoretinopathy. DESIGN: Subgroup analysis of the Silicone Study, a randomized, multicentered, surgical trial. SETTING: Community- and university-based clinics. PATIENTS: Two hundred twenty-two eyes with severe proliferative vitreoretinopathy followed up in the Silicone Study. INTERVENTIONS: Vitrectomy for proliferative vitreoretinopathy with silicone oil as the intraocular tamponade. OUTCOME MEASURES: Changes in visual acuity, recurrent retinal detachment, and incidence of complications. RESULTS: Ninety-nine (45%) of 222 eyes had surgery for silicone oil removal (oil-removed eyes). Compared with the eyes that did not undergo silicone oil removal (oil-retained eyes) evaluated at a comparable time after oil injection, oil-removed eyes at the examination prior to oil removal were more likely to be attached (85% vs 40%; P < .0001), have a visual acuity of 5/200 or greater (63% vs 35%; P < .0001), and not be hypotonous (5% vs 22%; P < .001). There was no association between the length of oil retention and incidence of recurrent retinal detachment after oil removal. Eyes with attached retinas at the time of oil removal generally improved in visual acuity at the last follow-up examination (P < .0001), which was not evident in eyes with detached retinas at the time of oil removal. In a matched-pair cohort analysis comparing both sets of eyes, there was an increased risk for recurrent retinal detachment at the last follow-up examination in the oil-removed eyes (odds ratio [OR], 2.1; P = .09). However, overall visual acuity improved for oil-removed eyes in 19 (29%) of 66 pairs and for oil-retained eyes in one (2%) of 66 pairs (OR, 19.0; P < .0001). Although nonsignificant, incidence rates of keratopathy (OR, 0.5) and hypotony (OR, 0.5) were lower in oil-removed eyes. CONCLUSION: Removal of silicone oil in anatomically successful eyes significantly increases the likelihood of improved visual acuity with a slight increase in the likelihood of recurrent retinal redetachment. There was a trend for a reduction in the incidence of complications in the oil-removed eyes.

Relationship between retinal and glomerular lesions in IDDM patients.

Current knowledge regarding the concordance and discordance of the eye and kidney complications of diabetes is based on observations by ophthalmoscopy of retinal structural changes, which may be present at early stages of the disorder, and renal functional changes, which only become apparent at the later stages of the disease. For this reason we investigated the relationship between retinal structural lesions and quantitative measures of glomerular structure in patients with insulin-dependent diabetes mellitus (IDDM). Renal biopsies were evaluated using morphometric techniques, and retinopathy classification was determined by retinal fundus photography in 86 patients with IDDM: age 30.4 +/- 7.3 years and duration of IDDM 18.9 +/- 6.3 years (mean +/- SD). Retinopathy score correlated with glomerular basement membrane width (r = 0.39, P = 0.0002), mesangial volume fraction (VvMes/Glom) (r = 0.35, P = 0.0009), surface density of the peripheral capillary wall (SvPGBM/Glom) (r = 0.34, P = 0.0013), and index of arteriolar hyalinosis (r = 0.36, P = 0.0008). Abnormalities in VvMes/Glom and SvPGBM/Glom were more pronounced in patients with both retinopathy and hypertension. Four of the 15 patients (27%) with either normal urinary albumin excretion (UAE) or low-level microalbuminuria had advanced retinopathy but normal VvMes/Glom. In conclusion, the presence of advanced retinal disease with or without hypertension in patients with IDDM indicates a greater likelihood of advanced nephropathy as evidenced by increased VvMes/Glom and decreased SvPGBM/Glom. However, marked discordance between retinopathy and nephropathy occurs, as illustrated by patients with normal UAE or low-level microalbuminuria, normal glomerular structural measures, and advanced retinopathy.

Procoagulant effects of intraocular sodium hyaluronate (Healon) after phakic diabetic vitrectomy. A prospective, randomized study.

A procoagulant effect was reported previously after injection of 0.50 to 0.75 ml of sodium hyaluronate (Healon) into the vitreous cavity at the end of phakic diabetic vitrectomies. A multicenter, randomized, prospective trial was done to study this effect. In the treatment group the media was clear in 50% of eyes in the immediate postoperative period compared with only 8% in the control group. At 2 to 6 weeks, there was no statistically significant difference between the two groups. The authors conclude that such sodium hyaluronate injection provides clear media in a significant number of eyes in the immediate postoperative period, potentially allowing thorough postoperative evaluation and early retinal photocoagulation if needed.

A 10-year experience with 290 pancreas transplants at a single institution.

Since our report at the 1984 American Surgical Association meeting of 100 pancreas transplants from 1966 through 1983, another 190 have been performed. The current series, begun in 1978, now numbers 276 cases, and includes 133 nonuremic recipients of pancreas transplants alone (PTA), 46 simultaneous pancreas/kidney transplants (SPK), and 97 pancreas tranplants after a kidney transplant (PAK). Duct management techniques used were free intraperitoneal drainage in 44 cases, duct occlusion in 44, enteric drainage in 89, and bladder drainage in 128. The 1-year patient and graft survival rates in the entire cohort of 276 were 91% and 42%. One-year patient survival rates were 88% in the first 100, 91% in the second 100, and 92% in the last 76 cases; corresponding 1-year graft survival rates were 28%, 47%, and 56% (p less than 0.05). A prospective comparison of bladder drainage (n = 82) versus enteric drainage (n = 46) in PAK/PTA cases since November 1, 1984 favored bladder drainage (1-year graft survival rates of 52% vs. 41%) because of urinary amylase monitoring. The best results were in recipients of primary SPK bladder-drained transplants (n = 39), with a 1-year pancreas graft survival rate of 75%, kidney graft survival rate of 80%, and patient survival rate of 95%. Logistic regression analysis, with 1-year graft function as the independent variable, showed significant (p less than 0.05) predictors of success (odds ratio) to be technique: bladder drainage (5.8) versus enteric drainage (2.5) versus duct injection (1.0); category: SPK (6.0) versus PAK from same donor (3.2) versus PAK from different donor (1.2) versus PTA (1.0); and donor HLA DR mismatch: 0 (5.0) versus 1 (2.5) versus 2 (1.0) antigens. On April 1, 1989, 90 patients had functioning grafts (60 euglycemic and insulin-free for more than 1 year, 10 for 5 to 10 years); these, along with 24 others whose grafts functioned for 1 to 6 years before failing, are part of an expanding cohort in whom the influence of inducing a euglycemic state on pre-existing secondary complications of diabetes is being studied. Only preliminary data is available. In regard to neuropathy, at more than 1 year after transplant in patients with functioning grafts, conduction velocities in some nerves were increased over baseline. In regard to retinopathy, deterioration in grade occurred in approximately 30% of the recipients by 3 years, whether the graft functioned continuously or failed early, but thereafter retinopathy in the patients with functioning grafts remained stable.(ABSTRACT TRUNCATED AT 400 WORDS)

Treatment of cytomegalovirus retinitis with intravitreal ganciclovir. Long-term results.

Long-term management of cytomegalovirus (CMV) retinitis by intravitreal injection of ganciclovir was evaluated in ten patients with acquired immune deficiency syndrome (AIDS). Patients were unable to tolerate systemic ganciclovir because of severe neutropenia (8 cases), catheter-induced sepsis (1 case), or the need to continue therapy for human immunodeficiency virus (HIV) with zidovudine (ZDV) (1 case). All patients had a favorable response to initial treatment. Cytomegalovirus retinitis progressed in four fellow eyes in which treatment was deferred. Vision improved or remained stable in all but one eye. Patients were followed for a mean of 4 months and received an average of 16.6 intravitreal injections in each eye. Relapse occurred late in the course while on maintenance treatment in five eyes (33%). There was no evidence of toxicity from repeated intravitreal injections. Treatment was very well tolerated. The only severe complication in a total of 249 injections was a single case of Staphylococcus epidermidis endophthalmitis which responded to intravitreal antibiotic treatment. Intravitreal ganciclovir is an effective alternative to systemic ganciclovir in those patients with severe neutropenia and in those patients who desire to remain on systemic ZDV.

Long-term survival following kidney transplantation in 100 type I diabetic patients.

Between December 1966 and April 1978, 265 uremic patients with type I diabetes received primary renal allografts at the University of Minnesota. One hundred of the diabetic patients were alive with a functioning graft 10 years after transplantation. The actual 10-year patient and primary graft functional survival rates overall were 40% and 32%, respectively. For recipients of HLA-identical sibling (n = 45), mismatched living-related (n = 121), and cadaver donor grafts (n = 99), the actual 10-year patient survival rates were 64%, 33%, and 36%, respectively, and the actual 10-year graft functional survival rates were 62%, 28%, and 22%, respectively. The differences in patient and graft survival rates between HLA-identical graft recipients and recipients of mismatched related and cadaver grafts were significant (P less than 0.001). Of the 100 patients who survived into a second decade, at 15 years posttransplant 51% were alive, and 41% had functioning grafts. For recipients of HLA-identical sibling, mismatched living-related donor grafts, and cadaver donor grafts who survived 10 years, 47%, 57%, and 43%, respectively, were alive at 15 years, and 31%, 45%, and 43%, respectively, had functioning grafts. For recipients who made it to the second decade, patient and primary graft survival rates thereafter were not statistically different by donor source. Twenty-three patients died in the second decade after transplantation, 10 of cardiovascular disease. Twenty-five patients lost graft function in the second decade, 19 from death with a functioning graft. In regard to diabetic complications, recurrence of diabetic nephropathy was common, but only two patients lost graft function solely for this reason. In 21 patients (42 eyes) followed prospectively for 10 years, visual acuity deteriorated in 26%, was stable in 64%, and improved in 10% of eyes. Neurophysiological test results indicated that correction of uremia does not stop the progression of diabetic neuropathy in recipients of kidney transplants alone. Even without cyclosporine, nearly two-thirds of recipients of HLA-identical kidney grafts, more than one-quarter of recipients of mismatched living-related donor grafts, and more than one-fifth receiving cadaver grafts enjoyed an extension of life for more than 10 years.

Pancreas transplantation in nonuremic, type I diabetic recipients.

Between July 1978 and January 1988, 111 of 210 pancreas transplants were in nonuremic, nonkidney (NUNK) recipients in whom complications of diabetes were judged more serious than the potential side effects of antirejection therapy. In all NUNK cases, the 1-year patient survival rate (PSR) and graft survival rate (GSR) were 90% and 39%. Since November 1984, 1-year PSR and GSR for 62 NUNK recipients of pancreas transplants alone (PTA) were 93% and 48%, compared to 89% and 37% for 28 pancreas transplants after (PAK) and 89% and 73% for 20 simultaneous (SPK) with a kidney transplant. The 1-year GSR for 1984-88 technically successful (TS) PTA cases (n = 47) was 63%, versus 75% for PAK (n = 13) and 86% for SPK (n = 17) cases. The 1-year GSRs, by technique and source for 1984-88 PTA cases, were 58% for bladder-drained cadaver (n = 30), 51% for enteric-drained related (n = 32), and 29% for enteric-drained cadaver (n = 17) donor transplants, and 75% (n = 24), 77% (n = 16), and 38% (n = 13) for the corresponding TS cases. Of NUNK recipients, 35 have had grafts function for more than 1 year and all but 3 were treated with cyclosporine (CsA). In the CsA-treated recipients, serum creatinine increased and creatinine clearances decreased by a magnitude of 40% during the first 6 months but thereafter remained stable in all but 2 patients. In the patients with functioning grafts studied at 1 year, retinopathy remained stable in 59% and progressed in 41% of the eyes (n = 39). Motor nerve conduction velocities were significantly increased and muscle action potentials remained stable in 24 patients with functioning grafts studied at 1 year, while in 14 patients in whom transplants failed there was a significant decrease in evoked muscle action potentials. A sustained euglycemic, insulin-independent state can be established in nonuremic, nonkidney diabetic recipients of pancreas transplants alone, with a beneficial effect on neuropathy, lack of an immediate benefit on advanced retinopathy, and an effect on nephropathy compounded by the influence of CsA on renal function.

Progression of diabetic retinopathy after pancreas transplantation for insulin-dependent diabetes mellitus.

We studied the effect of successful pancreas transplantation and consequent normoglycemia (mean total hemoglobin A1, 7.0 percent; range, 5.8 to 8.3) on visual function and diabetic retinopathy in 22 patients with Type I diabetes mellitus (study group). Sixteen similar patients in whom pancreas transplantation had been unsuccessful (mean total hemoglobin A1, 12.0 percent; range, 8.0 to 18.0) served as a control group. The majority of patients in both groups had advanced proliferative retinopathy. At a mean follow-up of 24 months we found no significant difference between the groups in the rate of progression of retinopathy, expressed as a score. Success of the transplantation did not prevent progression of retinopathy across the range of retinopathy studied. Progressive retinopathy was observed more commonly in patients with low retinopathy scores (nonproliferative or mild proliferative retinopathy) at base line in both the study group (13 of 17 eyes, or 76 percent) and the control group (7 of 12 eyes, or 58 percent). Further analysis suggested the possibility that after three years of euglycemia, the study group had less deterioration than the control group, particularly in eyes with advanced retinopathy. We observed no difference in the rate of loss of vision between the two groups. This study provides evidence that pancreas transplantation and subsequent normoglycemia neither reverse nor prevent the progression of diabetic retinopathy.

Vitrectomy and endolaser for complications of proliferative diabetic retinopathy.

Argon laser endophotocoagulation capability during vitrectomy surgery represents a significant technological advance. This report details the initial experience with this technique at the University of Minnesota in 18 patients with particularly high-risk complications of proliferative diabetic retinopathy. Overall, 13 of the 18 eyes (72%) were stabilized anatomically. In comparison with preoperative levels, visual acuity improved in 11 eyes, remained unchanged in 1 eye and deteriorated in 6 eyes. The technique is used intraoperatively to treat existing, iatrogenic or purposeful retinal breaks and to do panretinal scatter therapy to reduce the incidence of postoperative neovascular complications affecting either the anterior or posterior segment of the globe.

Timing of vitrectomy for active proliferative diabetic retinopathy.

Eyes with active proliferative diabetic retinopathy with dense sub-hyaloid hemorrhage and significant visual loss represent an appropriate indication for prompt vitrectomy. Twenty-six such eyes in 22 patients were operated. The results are compared to 49 diabetic eyes undergoing vitrectomy for other complications of diabetic retinopathy. The results demonstrated both an improved anatomic success rate (85% compared to 73%) and a higher rate of reading visual function (54% compared to 18%) in the early vitrectomy group, substantiating the study hypothesis.

Vitrectomy for double penetrating ocular injuries.

During the five-year period from 1977 to 1982, 15 consecutive patients with double penetrating ocular injuries were treated at the University of Minnesota. The 13 males and two females ranged in age from 5 to 38 years. Four patients had bilateral involvement. Vitrectomy techniques were used to stabilize the eyes and prevent or treat retinal detachment in 18 eyes. One eye was enucleated. Anatomic success was achieved in 11 eyes and visual success (visual acuity of 5/200 or better) in ten eyes. Surgical success was related to initial visual acuity, extent of vitreous hemorrhage, and the ability of the surgeon to excise completely the vitreous from the circumference of the exit wound.

Retinal vascular changes in malignant melanoma of the choroid.

A review of fluorescein angiograms from 41 patients with malignant melanoma of the choroid showed that 11 patients (27%) had evidence of retinal vascular abnormalities. Abnormal retinal capillaries were found in eight cases, areas of capillary nonperfusion in seven cases, and microaneurysms in four cases. Lipid exudation, retinal neovascularization, and arteriovenous communication were noted in one case each. Histopathologic studies in eight cases showed extensive degeneration of the overlaying retina in all eight cases and extension through Bruch's membrane by the tumor in four cases. Abnormal capillary architecture was demonstrated by trypsin digest preparations from four cases.

Pseudophakic retinal detachment.

The clinical findings, surgical techniques, anatomic results and visual recovery in 71 pseudophakic and 71 aphakic eyes with retinal detachment repaired concurrently were compared. Preoperative visibility of the peripheral retina was significantly reduced in the pseudophakic group. Intraoperative identification of retinal breaks was useful for the pseudophakic eyes. The surgical techniques used in the two groups were similar. Anatomic success was achieved in 65 pseudophakic eyes (92%) and 63 aphakic eyes (89%); however, the visual recovery after a mean follow-up period of 18 months was poorer in the pseudophakic group, only 35 (54%) of which, compared with 39 (62%) of the aphakic group, had a final best-corrected visual acuity of 6/15 or better.

Rips in the pigment epithelium.

Rips of the retinal pigment epithelium (RPE) are an uncommon complication of RPE detachment. We suspect that RPE rips are the result of tractional forces acting along the margin of the detached RPE, and that the risk of tearing is greatly enhanced by laser photocoagulation. Rips of the RPE have a characteristic clinical and angiographic appearance. There is a slight tendency for rips to occur bilaterally. Rips may be difficult to recognize because of healing of the RPE defect. This unusual clinical entity may, in fact, be more common than was previously appreciated.

Cryoretinopexy for proliferative diabetic retinopathy.

Cryoretinopexy can be used in the management of proliferative diabetic retinopathy. Indications include retinal neovascularization following photocoagulation or with opaque media, and anterior segment neovascularization. Of the six eyes in five patients treated with transconjunctival cryoretinopexy only one demonstrated regression of neovascularization; in this group, vision improved in two eyes, remained the same in three eyes and decreased in one eye. Of the 14 eyes in 14 patients treated with anterior transscleral cryoablation 5 demonstrated regression of posterior segment neovascularization and 2 demonstrated regression of anterior segment neovascularization; in this group, vision improved in 3 eyes, remained the same in 2 eyes and decreased in 9 eyes. No complications were associated with transconjunctival therapy, whereas uveitis (in 14 eyes), vitreous hemorrhage (in 2 eyes) and traction retinal detachment (in 5 eyes) were noted following transscleral therapy. Further studies are required to determine the risk/benefit ratio of cryoablation for proliferative diabetic retinopathy.

Electrophysiologic changes in chronic pars planitis.

We studied 13 patients, six males and seven females, ranging in age from 14 to 53 years, with chronic pars planitis and a form of secondary retinal degeneration. All had experienced visual blurring but none had significant pain. Nine of the 13 had some disturbance in night vision. Visual acuity had decreased in three patients (in one because of cataract, in one because of cystoid macular degeneration, and for unknown reasons in the third), increased in two patients (because of improvement in cystoid macular edema), and remained stable in eight. There were electrophysiologic abnormalities, consisting of delayed B-wave implicit time, abnormal response to 30-Hz flicker, and reduced B-wave oscillations, in almost every patient. Our finding suggested that pars planitis is a vitreoretinal disorder rather than an inflammatory disease of the uveal tract.

Histocompatibility antigen frequencies in diabetic retinopathy.

We studied the histocompatibility antigens A and B in 300 insulin-dependent diabetics: 200 had proliferative retinopathy and 100 did not. The two groups were matched for known duration of diabetes and other clinical features. In both groups the frequencies of HLA-B8, HLA-B18, and HLA-B8/HLA-B15 were significantly higher, and those of HLA-B7 and HLA-B12 were significantly lower than in healthy controls. The patients with proliferative retinopathy were significantly less often positive for HLA-B7 (X2 = 10.0; Pc < .03) than patients with nonproliferative retinopathy. When both groups were stratified for age at diagnosis, there were additional differences. HLA-B15 was significantly more frequent in the proliferative retinopathy group with age at diagnosis between 15 and 40 years (nonproliferative retinopathy = 16.4%; proliferative retinopathy = 39.4%; X2 = 7.89, Pc < .03; relative risk = 3.32) and HLA-B7 significantly less frequent (nonproliferative retinopathy = 23.6%; proliferative retinopathy = 5.6%; X2 = 8.0, Pc < .03; relative risk = 0.19). These differences in histocompatibility frequencies between patients with and without proliferative retinopathy indicate a genetic contribution to diabetic retinopathy.

Postpartum Candida endophthalmitis.

Two patients experienced endogenous Candida endophthalmitis after childbirth. One case was successfully treated with vitrectomy and intravitreal injection of amphotericin B. Although rare, Candida endophthalmitis must be included in the differential diagnosis in the postpartum patient with visual symptoms.

Ten year experience with renal transplantation in juvenile onset diabetics.

Between 1968 and 1978, 305 juvenile onset diabetic patients with uremia and 462 nondiabetic uremic patients of similar age received primary renal allografts at the University of Minnesota. Two hundred eight of the diabetic patients are alive and 190 have functioning renal grafts three months to ten years after transplantation. Cumulative patient survival rates at two years for diabetic recipients of kidneys from HLA identical siblings, other related and cadaver donors are 90, 73 and 68%, respectively, the corresponding graft functional survival rates are 90, 67 and 55%. For nondiabetic patients receiving kidneys from the same donor categories the corresponding patient survival rates are 97, 86 and 75%, while the graft functional survival rates are 94, 77 and 64%. The differences in patient and graft survival between diabetic and nondiabetic recipients are statistically significant only for the patients receiving grafts from HLA-nonidentical related donors. For all recipients under the age of 30, there are no statistically significant differences in patient and graft survival. Regardless of the age of the patient or the source of the kidney, the survival of diabetic patients treated with transplantation at our institution is better than the use of chronic hemodialysis, alone. Technical complications do not occur more frequently in diabetic transplant recipients. Cardiovascular disease is responsible for most of the late deaths in these diabetic patients. Amputations of digits or extremities have been required in 15% of the diabetic patients. On the positive side, the vision of 88% of these recipients remained stable or had improved visual acuity, and 82% of the diabetic patients were actively rehabilitated after transplantation. Kidney transplantation is the treatment of choice for end-stage renal failure in diabetic patients, just as it is for most uremic patients.