Foveal neovascularization in diabetic retinopathy.

Retinal neovascularization in diabetes mellitus almost always occurs at the optic disc and/or near the major nasal and temporal vascular arcades, sparing the foveal area. We examined seven eyes of seven patients with long-standing insulin-dependent diabetes mellitus who had unilateral foveal retinal neovascularization. The neovascularization originated from the perifoveal capillaries and demonstrated typical leakage on fluorescein angiography.

A new culture method for infectious endophthalmitis.

We studied the use of blood culture bottles for culturing vitreous specimens obtained during vitrectomy for infectious endophthalmitis. In a retrospective review of 83 cases, blood culture bottles yielded a 91% incidence of positive cultures. A laboratory comparison of direct media inoculation, a membrane filter system, and three blood culture systems was undertaken using inocula of nine organisms in three different concentrations. The blood culture bottle systems became positive at the same time as, or within 24 hours of, the membrane filter system for nearly every organism tested. A prospective clinical comparison was also performed in 14 cases of endophthalmitis, confirming our laboratory findings. The direct inoculation of blood culture bottles may be an acceptable adjunct or alternative to more sophisticated laboratory techniques for vitreous cultures in infectious endophthalmitis.

Penetrating ocular injury from contaminated eating utensils.

Although the rate of infectious endophthalmitis following penetrating ocular injury is generally less than 10%, certain settings may carry a greater risk of infection. One such setting is penetrating injury resulting from eating utensils contaminated with oral flora. We reviewed six of these injuries. Culture-positive bacterial endophthalmitis developed in four of the six eyes; only one of the eyes retained reading visual acuity (greater than 20/50) and two eyes lost light perception. The potential for infection and limited visual outcome in this series warrants aggressive prophylaxis and treatment. The unexpected isolation of Haemophilus influenzae in two of the four infections suggests that broad-spectrum antibiotic treatment should be considered in all such injuries since less common organisms may be encountered.

Variation in visual field measurements with an automated perimeter.

Using the Octopus automated perimeter, we conducted visual measurements on four separate occasions during a four-week period in six subjects with normal eyes. In 11 of 12 eyes, we found at least one point at which the threshold for light detection determined for that point showed a variance of more than 4 dB between tests. Thus, automated visual fields must be interpreted cautiously because an apparent pathologic change may only represent normal variation.

Observations concerning patients with suspected impending macular holes.

Between September 1987 and April 1989, 18 patients (21 eyes) with suspected impending Stage 1 macular holes were referred to the Bascom Palmer Eye Institute. Only one patient had a Stage 1 hole. The others had an aborted stage of macular hole formation (eight eyes), Stage 2 holes (four eyes), a Stage 3 hole (one eye), or other lesions unrelated to hole formation. We believed that most of the apparently incorrect referring diagnoses were the product of incorrect interpretation of the biomicroscopic and fluorescein angiographic findings, and were not caused by changes occurring before our examination.

Management of subretinal foreign bodies with a cannulated extrusion needle.

We treated two patients who had nonmagnetic subretinal foreign bodies (metallic pellet and lens nucleus fragment) in the presence of a retinal detachment and a distant retinal break. After the pars plana vitrectomy, the soft, flexible tip of the cannulated extrusion needle was used to push the foreign object gently away from the posterior pole toward the retinal break where it was grasped and removed from the eye. This technique for subretinal foreign body removal is preferable to creating a large posterior retinotomy overlying the foreign body because of the potential risks of further macular trauma, hemorrhage, or proliferation of periretinal membranes from the retinotomy site.

Delayed-onset pseudophakic endophthalmitis.

We reviewed 19 cases of delayed-onset pseudophakic endophthalmitis in which diagnostic cultures were performed at one month or more after cataract extraction with posterior chamber intraocular lens implantation. We isolated four different organisms in these 19 cases: 12 Propionibacterium species (63%), three Candida parapsilosis (16%), three Staphylococcus epidermidis (16%), and one Corynebacterium species (5%). Because of the unusual delayed-onset features of these cases and the retrospective nature of this study, a variety of treatment regimens were used. Twelve patients had recurrence of marked inflammation despite an apparent initial cure, and ten of these patients had positive culture results on repeat examination of intraocular fluids. Nine patients continued to be treated with topical corticosteroids postoperatively to suppress low-grade inflammation. Of the 19 patients, 16 had final visual acuity of 20/400 or better. Delayed-onset pseudophakic endophthalmitis had a more favorable visual prognosis, compared to acute-onset endophthalmitis.

The surgical management of giant retinal tears with the cannulated extrusion needle.

In 18 eyes of 17 patients, we treated retinal detachment caused by a giant retinal tear by unfolding and repositioning the retina with a cannulated extrusion needle. After pars plana vitrectomy, a fluid-gas exchange was performed with the patient in the supine position. Using the cannulated extrusion needle to drain subretinal fluid posterior to the giant retinal tear, the retinal flap was manipulated into the correct anatomic position. With this technique, 18 of 18 eyes with retinal detachment caused by a giant retinal tear were successfully reattached intraoperatively. Although eight of these eyes subsequently redetached and required additional surgical procedures, 16 of 18 eyes remain attached with a mean follow-up of 11 months.

Familial iris melanosis--a misnomer?

Iris melanosis is an unusual condition characterised by the presence of minute, discrete, pigmented elevations arising from the anterior surface of the iris. We encountered two unrelated Mexican families in which all children, but no parent, had varying degrees of the condition bilaterally. Some family members also gave findings suggestive of ocular hypertension. No family member had any other ocular or cutaneous pigmentary changes with the exception of a hairy naevus on the thigh of one member. To our knowledge these are the first families reported with more than one member having isolated iris melanosis. This is also the first report of a possible relationship with ocular hypertension. Finally we suggest that the term 'melanosis' may be a misnomer, since the condition is characterised not by abnormal iris hyperpigmentation but by discrete, round elevations on the anterior iris surface.

Blunt ocular trauma.

The emergency medicine physician is encouraged to perform a brief eye history and examination on patients presenting with not only ocular but also multisystem trauma. Obviously, life-threatening conditions take precedence, but it is important to give attention to the ocular area once the patient is stabilized. The minor injuries can be treated initially in the emergency room and referred to an ophthalmologist for follow-up care. If, however, the emergency medicine physician has any doubts as to the nature or severity of the injury, appropriate ophthalmologic consultation should be sought. It is hoped that by taking a rational approach to blunt ocular trauma, as outlined in this article, the emergency medicine physician can provide emergency eye care in a confident and thorough manner.

Posterior tractional retinal breaks complicating branch retinal vein occlusion.

A total of 358 patients with branch retinal vein occlusion (BRVO) were reviewed to examine the relationship between branch retinal vein occlusion with neovascularization elsewhere (NVE), vitreous hemorrhage, and posterior tractional retinal breaks. Twenty-eight of 358 (7.8%) BRVO patients had vitreous hemorrhage. In this group of 28 patients, 24 of the 28 (85.7%) had NVE. Of the 24 BRVO patients with vitreous hemorrhage and NVE, six (21.4%) were found to have posterior tractional retinal breaks adjacent to avulsed neovascular tissue. These data indicate a strong association between BRVO patients with vitreous hemorrhage and posterior tractional retinal breaks due to avulsion of neovascular tissue.

Clinical course of multifocal choroiditis: photographic and angiographic evidence of disease recurrence.

Multifocal choroiditis is a syndrome that simulates the presumed ocular histoplasmosis syndrome but, in addition, includes vitritis and anterior uveitis. Because of its relatively recent acceptance as a distinct clinical entity, there is little information available on the long-term natural history of this condition. We managed three cases of multifocal choroiditis with recurrent active inflammation. Two patients had new peripheral chorioretinal lesions in previously normal retina, and the other had both peripheral chorioretinal scars and new swelling of the disc.

Purulent anterior segment endophthalmitis following paracentesis.

A 67-year-old man developed a central retinal artery occlusion and was treated with an oral carbonic anhydrase inhibitor, oral glycerin, carbachol rebreathing, and anterior chamber paracentesis. He subsequently developed an anterior segment endophthalmitis. Vigorous medical and surgical management cured the endophthalmitis, but his visual acuity remained at light perception. To the best of our knowledge, this patient represents the first reported case of a culture-positive, anterior segment endophthalmitis following anterior chamber paracentesis.