Sudden monocular visual loss in pseudotumor cerebri.

We describe a patient with papilledema due to benign intracranial hypertension who had sudden, painless monocular visual loss. Fear of further visual deterioration prompted vigorous therapeutic efforts to reduce intracranial pressure. Subsequent neuro-ophthalmologic evaluation disclosed that the visual loss was due to a subretinal neovascular membrane. Vision continued to improve after medical therapy was discontinued, and was accompanied by complete resolution of papilledema and headache. In any patient with minimal papilledema, sudden visual deterioration should initiate a search for other causes rather than zealous therapeutic efforts to reduce intracranial pressure.

Electrocoaptation conjunctival closure in retinal detachment surgery.

This report describes the method of electrocoaptation, a sutureless technique for closure of the conjunctiva, in 75 patients who underwent primary scleral buckling or vitrectomy procedures. The technique is safe, rapid, easily performed, and results in a secure wound that heals well.

Technique for removing a fishhook from the posterior segment of the eye.

A man was admitted to the hospital with a penetrating injury to the eye caused by a fishhook. One of the current techniques for removing cutaneously embedded hooks was used to remove it. This technique, in conjunction with detachment surgery, resulted in the successful restoration of vision in our patient. To our knowledge, this is the first report of the successful removal of a fishhook that penetrated the retina and lay within the vitreous of the eye.

Incidence of cystoid macular edema following scleral buckling procedure.

Sixty eyes of 58 patients who underwent scleral buckling procedures were prospectively evaluated with postoperative fluorescein angiograms. Forty-three percent of these eyes showed angiographic cystoid macular edema (CME). Aphakic patients showed a 64% incidence of cystect the final visual acuity of aphakic patients but significantly reduced the visual recovery in the phakic group. The incidence of CME was not related to preoperative foveal detachment, duration of aphakia, duration of detachment, surgical approach, or refraction.

Subretinal lesions following scleral buckling procedure.

In five patients, subretinal lesions developed several weeks after scleral buckling procedures for retinal detachment. The lesions appear to be subretinal, well circumscribed, dome shaped, yellow-orange unassociated with edema or disturbance of the overlying retina, and unaccompanied by overlying inflammatory cells in the vitreous. All were located temporal to the fovea in the posterior pole. The angiographic pattern was characteristic, showing obscuration of the usual appearance of the lamina choroidocapillaris. Throughout the angiogram, the lesion remained unchanged, showing no increasing hyperfluorescence or hypofluorescence. Final visual acuities were 20/40 or better in all five patients, with follow-up periods from three to seven months. There is some evidence to suggest that these lesions represent persistent, isolated pockets of subretinal fluid.

A flute syringe for vitreous surgery.

We have devised a method whereby an inexpensive, disposable tuberculin syringe may be used as a flute syringe with retrograde flushing capability. This syringe is particularly useful in vitreous surgery and alleviates problems that occur with commercially available instruments of this type.

Retinal complications of gas myelography.

Bilateral retinal and preretinal hemorrhages with an acute and permanent partial loss of visual acuity developed in a 60-year-old man after an oxygen myelogram. In order to increase the contrast of the myelogram, a greater volume of oxygen was injected in the subarachnoid space than the volume of CSF that was removed. It is believed that the hemorrhages and visual loss were secondary to the sudden increase in CSF pressure caused by the excess volume of oxygen injected.

Aphakic retinal detachment. Management of the fellow eye.

One hundred eighty-five patients with unilateral aphakic retinal detachment were studied to determine the frequency of retinal detachment in the fellow eyes undergoing cataract surgery. It was found to be four times higher than the frequency in those eyes that remained phakic (26% vs 7%). Despite the high incidence of detachment, 94% of the aphakic group had a final visual acuity of 20/60 or better in the second eye. At the time of surgery, the macula was still attached in only 17% of the 185 first eyes as compared to 57% of the 21 second eyes that developed an aphakic retinal detachment.

Ocular injuries from exploding beverage bottles.

Exploding glass bottles filled with carbonated beverages cause serious ocular injuries that have not received adequate attention in ophthalmic publications. All three patients described in this article had corneal lacerations and traumatic cataracts developed. One patient was left with an inoperable retinal detachment. Beverage bottles may explode with normal handling and without provocation. Manufacturing standards have just taken effect that may help to eliminate defective bottles. The addition of plastic sleeves to beverage bottles and the use of plastic shatterproof bottles also reduce the hazard of explosions and high velocity fragments. It is advisable to avoid subjecting beverage bottles to undue heat and agitation and to direct the cap away from the face when opening the bottle.

Surgical management of premacular fibroplasia.

The results of pars plana vitrectomy and membrane peeling for premacular fibroplasia (PMF) were reviewed retrospectively for 88 eyes of 86 patients. Premacular fibroplasia was idiopathic in 61 eyes (69%) and postdetachment in 27 eyes (31%). All patients had a minimum follow-up of 12 months. Visual symptoms of blurring and metamorphopsia were reduced in 75 (85%) study eyes at the end of the follow-up period. Poor visual outcome was significantly related to preoperative cystoid macular edema and prolonged duration of visual blurring. Posterior retinal breaks occurred in three eyes (5%) with idiopathic PMF and five eyes (19%) with postdetachment PMF. Cataract progression was demonstrated in 35 eyes (48%) at 12 months of follow-up and 49 eyes (68%) at 24 months of follow-up, reflecting an incidence of cataract formation that has not been previously reported (to our knowledge) after limited vitrectomy and membrane peeling for PMF.

Endogenous Pseudallescheria boydii endophthalmitis. Clinicopathologic findings in two cases.

Two cases of endogenous Pseudallescheria boydii endophthalmitis are presented. One patient had severe pulmonary fibrosis but no history of ocular trauma and no clinical or laboratory evidence of immunocompromise. Despite therapy with repeated intravitreal miconazole nitrate injections and systemic fluconazole, enucleation of the globe was required, and the patient eventually died with disseminated pseudallescheriasis. The other patient was an immunosuppressed cardiac transplant recipient who also received systemic fluconazole therapy. The infected eye eventually required evisceration, but there was no evidence of disseminated pseudallescheriasis before his death of unrelated causes.

Surgical management of submacular hemorrhage. A series of 47 consecutive cases.

BACKGROUND: The development of a thick submacular hemorrhage usually carries a poor visual prognosis. The surgical removal of submacular blood may improve the otherwise poor outlook in these cases. SUBJECTS AND METHODS: Forty-seven consecutive patients underwent vitrectomy with surgical removal of submacular hemorrhage. The patient population consisted of two consecutive groups. Group 1 (1989 to 1991) included 23 patients (20 with age-related macular degeneration [ARMD], one with idiopathic submacular hemorrhage, one with presumed ocular histoplasmosis syndrome [POHS], and one with angioid streaks) who underwent mechanical clot extraction. Group 2 (1991 to 1993) included 24 patients (19 with ARMD, two with POHS, two with arterial macroaneurysm, and one with angioid streaks) who underwent tissue plasminogen activator-assisted drainage of thick submacular hemorrhage. The dose of tissue plasminogen activator ranged from 10 to 40 micrograms. All patients had surgery within 72 hours of diagnosis. RESULTS: In group 1, the mean size of the submacular hemorrhage was 11 disc areas (range, 1 to 16 disc areas). Mean follow-up was 40 weeks. Mean postoperative visual acuity for eyes with ARMD was 20/200. (Visual acuity improved in six eyes, was stable in seven eyes, and deteriorated in seven eyes.) All three of the eyes without ARMD had visual improvement with a mean postoperative visual acuity of 20/70. Overall, visual acuity stabilized or improved in 13 (57%) of 23 patients and decreased in 10 (43%) patients. In group 2, the mean size of the submacular hemorrhage was 11 disc areas (range, 3 to 16 disc areas). Mean follow-up was 24 weeks. Mean postoperative visual acuity for eyes with ARMD was 20/480 (visual acuity was stable in 15 eyes, improved in two eyes, and deteriorated in two eyes). Four of five eyes without ARMD had visual improvement and one was stable, with a mean postoperative visual acuity of 20/60. Visual acuity stabilized or improved in 22 (92%) of 24 patients and decreased in two (8%). The degree of clot lysis was variable. CONCLUSIONS: Submacular hemorrhage secondary to ARMD has a poor visual prognosis, with or without surgical drainage. The addition of tissue plasminogen activator-assisted clot lysis does not appear to significantly improve the visual outcome following surgery. The determination of whether surgical intervention is appropriate in these cases requires a prospective, randomized clinical trial.

Pars plana vitrectomy for treatment of stage 2 macular holes.

OBJECTIVE: To assess the anatomic outcome and visual acuities at follow-up after pars plana vitrectomy in the management of stage 2 macular holes. DESIGN: Retrospective. SETTING: Retina Consultants, Ltd, St Louis, Mo. PATIENTS: Thirty-three patients, aged 43 to 75 years, with stage 2 macular holes. INTERVENTION: Total pars plana vitrectomy with separation of the posterior hyaloid membrane and injection of intraocular gas followed by postoperative face-down positioning. MAIN OUTCOME MEASURES: Visual acuity and anatomic appearance of the macular hole. RESULTS: Postoperatively, 20 (61%) of 33 eyes attained a visual acuity of 20/50 or greater. Twenty (61%) of 33 eyes showed an improvement in visual acuity, while nine (27%) of 33 were stable. Four (12%) of 33 eyes showed a decline in postoperative visual acuity with progression to a stage 3 macular hole. Twenty-five (76%) of 33 eyes showed stabilization or improvement in the appearance of the macular hole. CONCLUSIONS: Pars plana vitrectomy in conjunction with postoperative intraocular gas tamponade may result in visual and anatomic stabilization or improvement in eyes with stage 2 macular holes. However, because of limited natural history data, it is unknown whether these results are any better than those that might occur without surgery.

Supplemental photocoagulation on the buckle for prevention of surgical revision after scleral buckling procedures.

Supplemental photocoagulation on the buckle appears to be a useful therapeutic modality in selected cases of persistent retinal detachment. In a retrospective review, 71 (63%) of 113 eyes were successfully treated with photocoagulation, thus avoiding the need for surgical revision. Median response time between treatment and postoperative subretinal fluid absorption in the successfully treated eyes was two days, with the majority responding within one day. The one favorable prognostic factor was the use of a soft silicone segmental sponge. Unfavorable prognostic factors included the following: contour of subretinal fluid (combined, ie, both anterior and posterior to the buckle); excessive amount of subretinal fluid; inadequate support of break(s); multiple drainages at first operation; rolled edge in association with a giant break; and residual vitreous traction on the break. Postoperative photocoagulation alone on the buckle did not appear to influence the rate of development of premacular fibroplasia or proliferative vitreoretinopathy.

Vitrectomy without scleral buckling for primary rhegmatogenous retinal detachment.

Trans pars plana vitrectomy with air-fluid exchange was performed on 29 selected cases of primary rhegmatogenous retinal detachment in which scleral buckling would be the usual surgical approach. The group contained 20 phakic eyes, two aphakic eyes, and seven pseudophakic eyes; the macula was detached preoperatively in 17 eyes (66%). The reattachment rate after one operation was 79% (23 of 29 eyes); after two operations this increased to 93% (27 of 29 eyes). Visual acuities of 20/50 or better were achieved in 22 of 27 successfully treated cases (81%). Vitrectomy without scleral buckling may allow retinal reattachment with excellent visual results in selected cases of primary rhegmatogenous retinal detachment.

The Lincoff temporary balloon buckle.

The Lincoff temporary balloon buckle is an equally effective alternative to more conventional techniques in the management of selected retinal detachments. We used this technique in the management of 45 selected primary retinal detachments operated on since Nov. 22, 1980. Initial complete retinal flattening was achieved in 42 eyes (93%). Two of the three eyes that initially did not show complete flattening ultimately went on to do well without further surgery. Redetachment occurred in three of the five aphakic eyes (60%) and in four of the 36 phakic eyes (11%). None of the retinas in the four eyes with intraocular lenses redetached. Conventional scleral buckling techniques were used in the one case of initial failure and in the seven cases of redetachment for a final success rate of 98% after an average follow-up of 13 months.

Massive suprachoroidal hemorrhage during pars plana vitrectomy associated with Valsalva maneuver.

PURPOSE: To report the intraoperative occurrence of massive intraocular suprachoroidal hemorrhage associated with Valsalva maneuver. METHODS: Retrospective, multicenter study of patients who developed massive choroidal hemorrhage associated with Valsalva maneuver during vitrectomy. RESULTS: Massive intraoperative suprachoroidal hemorrhage in seven patients (seven eyes) involved three men and four women with a median age of 52 years (range, 26 to 82 years). General anesthesia was used in six of seven cases. Coughing or "bucking" on the endotracheal tube during general anesthesia or severe coughing during the one vitrectomy performed under local anesthesia was associated with massive suprachoroidal hemorrhage. In five of seven eyes, this occurred near the end of surgery, after air-fluid exchange but before sclerotomy closure. Scleral plugs were immediately placed, and sclerotomy closure was performed exigently. Immediate posterior sclerotomy was performed on five of seven eyes; an additional patient underwent posterior sclerotomy postoperatively. After median follow-up of 18 months (range, 3 to 36 months), final visual acuity was no light perception in four eyes, light perception in one eye, 20/250 in one eye, and 20/20 in one eye. Four eyes became phthisical. CONCLUSIONS: Valsalva maneuver during pars plana vitrectomy may result in massive suprachoroidal hemorrhage with disastrous visual consequences. Precautionary measures to prevent coughing or "bucking" on the endotracheal tube during general anesthesia, or a prolonged episode of coughing during local anesthesia, may prevent this potentially devastating complication.

Xenon arc photocoagulation of proliferative diabetic retinopathy (a review of 2688 consecutive eyes in the format of the diabetic retinopathy study--DRS).

Over 2500 xenon arc-treated eyes which would have qualified for inclusion in the DRS were reviewed in the format of the DRS. When comparable risk groups were compared, the results of treatment were even more favorable than reported in the DRS without the severe complications attributed to xenon treatment in the DRS. A critical analysis of the DRS gives clues for the greater amount of visual loss found with xenon than argon in the DRS. Since these complications may be avoidable in some cases and since xenon has been shown to be at least as effective as argon, it should continue to be used in the treatment of PDR.