On the Ia immunogenicity of mouse corneal allografts infiltrated with Langerhans cells.

Langerhans cells were induced to infiltrate the corneal epithelium of mice by pretreating the surface of the cornea with dinitrofluorobenzene (DNFB). Treated corneas then were used in heterotopic grafting experiments to determine their Ia immunogenicity. It was found that Langerhans cell containing cornea grafts sensitized their recipients to the Ia alloantigens of the donors. Moreover, corneas infiltrated with Langerhans cells were rejected at heterotopic sites by recipients presensitized to the Ia alloantigens of the graft donor. These results demonstrate that corneas, which normally lack both Langerhans cells and Ia-antigen expressing cells, can have their Ia immunogenicity restored if Langerhans cells are induced to infiltrate the epithelium. The implications of these results for improving the success of clinical, orthotopic, corneal allografts are discussed.

Studies of tumor-infiltrating lymphocytes from a human choroidal melanoma.

Cell suspensions prepared enzymatically from an ocular choroidal melanoma were cultured in vitro in an effort to generate (1) melanoma tumor cell lines and (2) tumor-infiltrating lymphocytes cytotoxic for ocular melanoma cells. Even though histologic study of the tumor did not show "significant" infiltrating bone marrow-derived cells, lymphocytes were generated readily in cultures to which interleukin-2 was added. Phenotypic analysis of the cultured lymphocytes indicated that T-cells, natural killer (NK) cells, and lymphokine-activated killer (LAK) cells were present. Moreover, functional studies of the cultured lymphocytes revealed NK activity, LAK activity, and most importantly, tumor antigen-specific cytotoxic T-cell activity. It was concluded that it is possible to obtain tumor cell lines and tumor-infiltrating lymphocytes from ocular tumors, both of which would be required if cellular immunotherapy of ocular tumors is contemplated. In addition, these results indicate that ocular melanomas can express unique tumor-specific antigens and that the immune system of a patient with such an ocular tumor can perceive these tumor antigens because antigen-specific precursor cytotoxic T-cells were present in the tumor-containing eye at the time of enucleation. The theoretic and therapeutic implications of these findings are discussed.

Comparison of flow cytometry with the surgeon regarding ability to predict the ultimate success of surgery for proliferative vitreoretinopathy.

OBJECTIVE: To analyze vitreous specimens obtained from human eyes with proliferative vitreoretinopathy (PVR) by use of flow cytometery (FC) to compare the capacity of FC with that of the surgeon's in predicting the ultimate outcome after PVR surgery. METHODS: Thirty-one vitreous aspirates were obtained at vitrectomy or from postoperative fluid-gas exchanges for complicated retinal detachment due to PVR. Samples were analyzed by FC for the concentration of total and proliferating cells. These measurements were compared with the surgeon's preoperative prognosis (good, poor, or indeterminate) for the ultimate result. At 12 weeks, the eyes were evaluated for clinical outcome. An unsuccessful outcome was one in which the retina was attached with macular pucker or hypotony or was anatomically detached. Anatomic attachment of the retina anterior and posterior to the scleral buckle without these findings was considered a successful outcome. RESULTS: Flow cytometry was capable of quantifying the concentration of total and proliferating cells in eyes with PVR. Eyes destined for an ultimately successful outcome demonstrated fewer total and proliferating cells than did eyes destined for an unsuccessful outcome. No differences were observed between eyes destined for development of macular pucker and those destined for anatomic redetachment. The surgeon was able to accurately predict a good or a poor outcome in 64.5% of the cases, with a sensitivity of 92% and a specificity of 89%. Using the total number of recovered cells, FC was able to correctly predict a good or a bad outcome with a 77% accuracy, whereas the surgeon was able to do so with a 65% accuracy. Combining the surgeon's prediction with the result of FC increased the diagnostic power of the prediction to 87%. CONCLUSIONS: The diagnostic power of FC was similar to that of the surgeon's in predicting ultimate outcome, but the two techniques probably evaluate different features of the disease process. The combination of the two techniques was the most powerful approach to the prediction of ultimate outcome after PVR surgery.

Vogt-Koyanagi-Harada syndrome. Clinical course, therapy, and long-term visual outcome.

We reviewed data from 26 patients with Vogt-Koyanagi-Harada syndrome who presented at the Bascom Palmer Eye Institute between March 1969 and February 1990. Visual outcomes were good, with final visual acuity of better than 20/30 in 29 (66%) of 44 eyes and of worse than 20/400 in only three (7%) of 44 eyes. A poor prognosis was associated with the development of choroidal neovascular membranes or chronic uveitis. All patients were treated with systemic corticosteroids. Corticosteroid therapy averaged 6 months, but was prolonged (48 months) in patients who developed chronic uveitis. Disease recurred in nine (43%) of 21 patients in the first 3 months, usually in association with a rapid tapering of steroid dosage. We recommend the early, aggressive use of systemic corticosteroids in patients with Vogt-Koyanagi-Harada syndrome and a gradual tapering of drug dosage for 6 months after presentation.

Pars plana vitrectomy in the management of phakic and pseudophakic malignant glaucoma.

OBJECTIVE: To determine the indications for and outcome of pars plana vitrectomy in the management of phakic and pseudophakic malignant glaucoma. DESIGN: Retrospective review. SETTING: Tertiary referral ophthalmic hospital. PATIENTS: Twenty-two patients (24 eyes) who underwent pars plana vitrectomy in the management of malignant glaucoma. RESULTS: Fourteen eyes were phakic and 10 were pseudophakic at the initial vitrectomy. The primary indication for vitrectomy was failure of other therapies. In phakic eyes, the initial vitrectomy was successful in terminating malignant glaucoma without further surgery in 7 (100%) of 7 eyes that underwent lensectomy and in 5 (71%) of 7 eyes that not did not undergo lensectomy. The primary indication for lensectomy was corneal edema caused by lens-corneal touch. In pseudophakic eyes, the initial vitrectomy was successful in 9 (90%) of 10 eyes. Removal of the intraocular lens was performed in 1 eye. Perioperative complications included transient serous choroidal detachment in 2 eyes, transient exudative retinal detachment in 1 eye, and suprachoroidal hemorrhage in 1 eye. CONCLUSIONS: Pars plana vitrectomy is effective in treating phakic and pseudophakic malignant glaucoma. Success is contingent on establishing a pathway for aqueous flow into the anterior chamber, which usually is accompanied by intraoperative deepening of the anterior chamber. In phakic eyes, lensectomy may be considered for marked corneal edema, for dense cataract, or when the anterior chamber will not deepen during vitrectomy.

Prevention of experimental proliferative vitreoretinopathy with a biodegradable intravitreal implant for the sustained release of fluorouracil.

OBJECTIVE: To test the efficacy of a biodegradable device for the intravitreal sustained release of fluorouracil in the treatment of tractional retinal detachment due to proliferative vitreoretinopathy. METHODS: A 6 x 0.9-mm (20-gauge) cylindrical solid implant molded from copolymers of lactide and glycolide admixed with 1 mg of fluorouracil was placed in the vitreous cavity of rabbits in which retinal detachment with proliferative vitreoretinopathy had been initiated. Comparisons of the control (drug-free polymer) and experimental (fluorouracil polymer) groups were made with weekly indirect ophthalmoscopic examinations. In another experiment, the intravitreal concentration of fluorouracil was tested at each time point. RESULTS: Retinas of eight (89%) of nine rabbits that received the polymer with fluorouracil remained attached compared with only one animal (11%) that received the control polymer without the drug. The therapeutic effect of the drug-containing implant was associated with sustained intravitreal concentrations of fluorouracil between 1 and 13 mg/L for at least 14 days, and fluorouracil concentrations remained above 0.3 microgram/mL for almost 21 days. No evidence of the toxic effects of the drug or polymer implant was observed with electroretinographic and histopathologic study. CONCLUSION: Intravitreal implantation of biodegradable polymers containing fluorouracil can prevent proliferation of epiretinal membranes resulting in complicated retinal detachment in an animal model of proliferative vitreoretinopathy and indicate their possible usefulness for intravitreal delivery of therapeutic agents.

Merkel cell carcinoma of the eyelid and periocular tissues.

Five patients had eyelid and periocular Merkel cell carcinoma. The tumor was located on the left lower eyelid in two patients, the left upper eyelid in one patient, the right upper eyelid in one patient, and was metastatic to the right outer canthus in one patient. The mean duration of symptoms was approximately four months. The diagnosis of Merkel cell carcinoma was not suspected clinically in any of the four primary eyelid cases, but was only established on histopathologic examination of biopsy specimens. Light microscopy disclosed carcinoma with small primitive cells in all five tumor biopsy specimens. Immunohistochemical studies showed neuron-specific enolase and keratin and transmission electron microscopy demonstrated neurosecretory granules typical for Merkel cell carcinoma. All five patients in this study were treated with wide surgical excision of the eyelid tumors with intraoperative frozen-section monitoring of the margins of resection. The left lower eyelid Merkel cell carcinoma spread to the preauricular lymph node in one patient. This patient subsequently died of metastatic Merkel cell carcinoma. One patient with metastatic right outer canthus Merkel cell carcinoma received radiotherapy (6,550 cGy). Eyelid Merkel cell carcinoma has the potential for recurrence and metastatic spread. We recommend lifetime follow-up for patients treated for eyelid Merkel cell carcinoma.

Vitrectomy for diabetic macular edema associated with a thickened and taut posterior hyaloid membrane.

PURPOSE: To evaluate the surgical results in a series of patients with diabetic macular edema associated with traction from a thickened and taut posterior hyaloid membrane and to identify features associated with better visual outcome. METHODS: We reviewed the clinical records of ten consecutive patients who underwent pars plana vitrectomy in one eye for diabetic macular edema that was preoperatively attributed to thickening and traction of the posterior hyaloid membrane. RESULTS: Best-corrected, preoperative visual acuity was 20/200 in seven eyes, 20/300 in one eye, and 20/400 in two eyes. Intraoperatively, seven patients were found to have an attached posterior hyaloid membrane which was thickened and taut. Among these seven patients, postoperative best-corrected visual acuity improved by six lines in two eyes, by five lines in one eye, by two lines in one eye, and remained within one line of preoperative visual acuity in three eyes. The other three patients had an epiretinal membrane simulating an attached and thickened posterior hyaloid membrane. CONCLUSIONS: Vitrectomy effectively improved visual acuity in some eyes with diabetic macular edema associated with traction from a thickened and taut posterior hyaloid membrane. Despite careful preoperative examination with a fundus contact lens, however, in some patients it may be difficult to assess how the posterior hyaloid membrane contributes to the macular edema. In selected patients, early surgical intervention may be associated with better visual outcome.

Retained lens fragments after phacoemulsification manifesting as marked intraocular inflammation with hypopyon.

We reviewed the medical records of four patients with marked intraocular inflammation and hypopyon as the initial manifestation of retained lens fragments after phacoemulsification. The severe inflammatory reaction occurred between one month and one year after the cataract extraction. All four patients underwent pars plana vitrectomy to remove the lens fragments. The vitreous specimens were cultured to rule out infectious endophthalmitis. In all patients, no organisms were isolated from the vitrectomy specimens placed on both aerobic and anaerobic media. All patients had improved vision and resolution of the marked intraocular inflammation after vitrectomy. Echography was useful in establishing the diagnosis in these uncommon cases.

Treatment of massive subretinal hemorrhage from complications of scleral buckling procedures.

Vitrectomy techniques permit removal of subretinal hemorrhage, but the prognosis varies and depends principally on the cause of the hemorrhage. Nine consecutive patients undergoing pars plana vitrectomy with internal drainage of massive subretinal hemorrhage from complications of scleral buckling procedures were studied, to evaluate the long-term results. In all eyes, the final visual acuity was improved, compared with preoperative visual acuity, and was 20/80 or better in seven of nine cases. Recurrent retinal detachment secondary to proliferative vitreoretinopathy developed in two patients, but complete retinal reattachment was achieved after further procedures were performed. Patients with massive subretinal hemorrhage from complications of scleral buckling procedures comprise a subgroup of patients with subretinal hemorrhage in which internal drainage via pars plana vitrectomy is an acceptable alternative to observation only and may result in improved visual acuity outcomes.

Pars plana vitrectomy for chronic pseudophakic cystoid macular edema.

PURPOSE: We determined the efficacy of pars plana vitrectomy in a series of patients with chronic pseudophakic cystoid macular edema. METHODS: Clinical records were reviewed on 24 consecutive patients who underwent pars plana vitrectomy in one eye for chronic pseudophakic cystoid macular edema. All 24 patients had failed to improve on medical therapy and had preoperative evidence of either vitreous adhesions to anterior segment structures (23 eyes) or iris capture of the intraocular lens (one eye). RESULTS: The mean, best-corrected Snellen visual acuity was 20/190 preoperatively (median, 20/200; range, 20/50 to 3/200) and 20/52 postoperatively (median, 20/40; range, 20/20 to 20/400 [P < .0001]). Visual acuity improved postoperatively in all 24 eyes, with a mean improvement of 4.7 Snellen lines (range, one to eight lines). There was no highly significant difference in preoperative visual acuity (P = .41) or postoperative visual improvement (P = .17) between patients with anterior as opposed to posterior chamber intraocular lenses. Longer time interval from cataract surgery to vitrectomy did not correlate with less postoperative visual improvement. CONCLUSIONS: In pseudophakic eyes with chronic cystoid macular edema, vitreous adhesions to anterior segment structures, and visual loss that is unresponsive to medical therapy, pars plana vitrectomy with removal of these vitreous adhesions may lead to improved visual acuity.

Giant retinal tear as a complication of attempted removal of intravitreal lens fragments during cataract surgery.

PURPOSE: To report giant retinal tear and retinal detachment as a complication of attempted removal of intravitreal lens fragments at the time of cataract surgery and to evaluate the anatomic and visual acuity outcomes of pars plana vitrectomy and retinal reattachment surgery. METHODS: Retrospectively, 10 patients with giant retinal tear, retinal detachment, and intravitreal lens fragments in 10 eyes were reviewed. RESULTS: In 10 eyes, retrieval of intravitreal lens fragments using the limbal approach by deep vitrectomy, copious vitreous cavity irrigation, or deep vitreous cavity phacoemulsification had been attempted by the anterior segment surgeon at the time of cataract surgery in each patient. The average interval from cataract surgery to the initial vitreoretinal consultation was 8 days. Each of the 10 eyes had a giant retinal tear involving the inferior retina: in four eyes, of between 90 degrees and 180 degrees; in four, equal to 180 degrees; and in two, of greater than 180 degrees. After pars plana vitrectomy and retinal detachment repair, nine (90%) of 10 eyes had retinal reattachment, but seven patients required more than one operation. One eye had persistent retinal detachment, and one eye had corneal graft failure. Seven (70%) of the 10 eyes had best-corrected final visual acuity of 20/200 or better; three eyes had light-perception, hand-motion, and counting-fingers vision. CONCLUSIONS: Aggressive attempts at intravitreal lens fragment retrieval from a limbal-based approach should be avoided because these procedures may result in serious retinal complications, such as formation of a giant retinal tear.

Reversible loss of light perception after vitreoretinal surgery.

PURPOSE: We studied reversible loss of light perception after vitreoretinal surgery to show that functional vision can return in some patients. METHODS: We reviewed the medical records of seven patients who had postoperative reversible loss of light perception in the eye that underwent vitreoretinal surgery. Differences in the postoperative courses and interventions were studied. RESULTS: Five of the seven patients had diabetes mellitus but none had hypertension. The indications for vitreoretinal surgery were severe proliferative diabetic retinopathy in five patients and retinal detachment with advanced proliferative vitreoretinopathy in two patients. Seven patients had reversible loss of light perception within the first three postoperative days. Six of the seven patients had an intraocular pressure greater than 26 mm Hg at the time the eye had no light perception. Decreasing the intraocular pressure was associated with return of light perception in five of seven patients. Return of useful vision was gradual. Four of seven patients had a visual acuity of 20/400 or better one month after surgery, and all seven had a visual acuity of 20/400 or better three months after surgery. Visual acuity in four eyes improved further to 20/70 or better at six months or more after surgery. CONCLUSION: Reversible loss of light perception after vitreoretinal surgery does occur in some patients. Monitoring vision and intraocular pressure is important because prompt treatment may assist in the recovery of functional vision.

Keratoconus with acute hydrops and perforation. Brief case report.

Keratoconus is a corneal thinning disorder usually localized to the paracentral cornea. Though acute hydrops has been well described, perforation in keratoconus is an extremely rare event. We report a case of keratoconus with acute hydrops and perforation.

Impact of cultures on management decisions following surgical repair of penetrating ocular trauma.

BACKGROUND AND OBJECTIVE: The purpose of this study was to evaluate the utility of routine bacterial and fungal cultures in the diagnosis of endophthalmitis and in the subsequent management of patients following penetrating ocular trauma. PATIENTS AND METHODS: The medical records of 70 consecutive patients with penetrating ocular trauma for whom intraoperative bacterial and fungal cultures had been obtained from the wound, aqueous, vitreous, and/or intraocular foreign body (IOFB) were retrospectively reviewed. The incidences of infection among eyes with and without a clinical diagnosis of infection were compared. A determination as to change in clinical management (change of antibiotic, length of treatment) was made. RESULTS: Twenty of 70 patients (29%) had positive cultures of the wound, aqueous, vitreous, and/or IOFB. Nine (13%) of the 70 patients were diagnosed as having endophthalmitis, based on clinical findings at presentation and during the subsequent clinical course. Seven (78%) of these 9 patients with a clinical diagnosis of endophthalmitis had positive cultures. The remaining 61 eyes showed no evidence of clinically apparent infections, despite positive cultures from 13 eyes (21%). Microbiologic data derived from the culture results influenced the clinical management of all 7 patients with endophthalmitis. Culture results (positive or negative) did not alter clinical decisions in eyes without clinical evidence of infection. CONCLUSION: Bacterial or fungal cultures obtained from the eye in the setting of penetrating trauma often had growth of organisms without clinical signs of infection. Positive culture results directly influenced management decisions in cases with clinically evident endophthalmitis. However, routine intra-operative bacterial cultures did not help to identify patients in whom endophthalmitis would develop, nor did they assist in directing management decisions in eyes without clinical suspicion of infection.

Outcome of functioning filtering blebs after pars plana vitrectomy.

BACKGROUND AND OBJECTIVE: To determine the status of filtering bleb function following pars plana vitrectomy. PATIENTS AND METHODS: The authors retrospectively reviewed patients with functioning filtering blebs undergoing pars plana vitrectomy. RESULTS: Twenty-three eyes with functioning filtering blebs underwent pars plana vitrectomy. Postoperatively, 7/23 (30 percent) of the eyes had moderate (5 to 20 mm Hg) intraocular pressure (IOP), 8/23 of the eyes had IOP persistently greater than 20 mm Hg, and 7/23 of the eyes had IOP of less than 5 mm Hg. One of 7 eyes that underwent vitrectomy within 6 weeks after trabeculectomy maintained bleb function, whereas 6 of 16 eyes that underwent trabeculectomy 6 weeks or later maintained bleb function. Loss of bleb function occurred in the early postoperative period in the majority of the patients. Prior antimetabolite therapy was not associated with preservation of bleb function. CONCLUSION: There is a substantial risk of bleb failure following vitrectomy, which is in part related to the often severe nature of the diseases requiring vitreoretinal surgery.

Treatment outcomes in a 10-year study of endogenous fungal endophthalmitis.

BACKGROUND AND OBJECTIVE: To review prevalence of organisms, associated factors, and treatment outcomes from one medical center's 10-year experience managing culture-proven endogenous fungal endophthalmitis (EFE). PATIENTS AND METHODS: The authors retrospectively reviewed the microbiology and corresponding clinical records of patients diagnosed as having culture-proven EFE at the Bascom Palmer Eye Institute during a 10-year period. RESULTS: Culture-proven EFE occurred in 20 eyes of 18 patients. Candida species occurred in 17 of 20 eyes (85%), and Aspergillus species occurred in 3 of 20 eyes (15%). The most common association was long-term intravenous line placement, which was present in 12 patients (67%). Whereas 12 patients (67%) had a history of recent hospitalization, only 2 (11%) had a documented history of systemic fungal infection. After initial examination, only 2 patients had a systemic culture positive for a fungal organism (none had a positive blood culture). Treatment after initial examination included pars plana vitrectomy in 17 of the 20 eyes (85%), intravitreal amphotericin B in 19 eyes (95%), and systemic antifungal medication in 16 eyes of 15 patients. Thirteen of the 17 eyes (76%) with Candida endophthalmitis and 0 of 3 eyes with Aspergillus endophthalmitis achieved visual acuity of 20/400 or better. CONCLUSION: The most common cause of culture-proven EFE at the authors' institution is Candida species. The overall visual outcomes were more favorable for Candida cases than they were for Aspergillus cases. In the treatment of patients with marked vitreous infiltrates from EFE, pars plana vitrectomy, intravitreal amphotericin B injection, and administration of appropriate systemic antifungal medication (fluconazole for Candida) are generally recommended.

Outcomes of vitreoretinal surgery in patients with X-linked retinoschisis.

BACKGROUND AND OBJECTIVE: To assess the outcomes of vitreoretinal surgery in the treatment of vision-threatening posterior segment complications of X-linked retinoschisis. PATIENTS AND METHODS: The authors performed a retrospective analysis of 16 eyes from 11 patients who underwent vitreoretinal surgery. All the patients had a documented positive family history of X-linked retinoschisis, and all patients had bilateral macular disease. RESULTS: The ages of the patients ranged from 14 months to 37 years (mean age 15.1 years; median age 11.5 years), and postoperative follow-up ranged from 3 months to 10 years (mean 2.8 years; median 1 year). The indications for surgical intervention included rhegmatogenous retinal detachment (12 eyes), vitreous hemorrhage (2 eyes), progression of the schisis cavity through the fovea (2 eyes), cataract associated with a persistent hyperplastic primary vitreous-like condition (2 eyes), and exudative maculopathy (1 eye). The primary surgical intervention included pars plana vitrectomy alone (7 eyes), pars plana vitrectomy and pars plana lensectomy (4 eyes), and a scleral buckle procedure alone (5 eyes). Surgical success (defined as reattachment of the retina, removal of media opacities, or arrest of schisis progression) was achieved in 14 of 16 eyes, after an average of 1.2 procedures per eye. The major reason for reoperations was recurrent retinal detachment due to proliferative vitreoretinopathy. Two eyes were eventually enucleated due to pain associated with neovascular glaucoma resulting from recurrent retinal detachment. Of the remaining 14 eyes, visual acuity improved in 8 eyes and remained unchanged in 6 eyes. CONCLUSION: Vitreoretinal surgery is often helpful in stabilizing or improving visual function in patients with posterior segment complications from X-linked retinoschisis.