Endogenous Aspergillus endophthalmitis. Clinical features and treatment outcomes.

OBJECTIVE: This study evaluated the clinical features and treatment outcomes in patients with endogenous Aspergillus endophthalmitis. DESIGN: The study design was a multicenter retrospective chart review. PARTICIPANTS: Ten patients (12 eyes) with culture-proven endogenous Aspergillus endophthalmitis treated by 1 of the authors were studied. INTERVENTION: Intravitreous amphotericin B injection, pars plana vitrectomy, systemic amphotericin B therapy, and oral anti-fungal therapy were performed. MAIN OUTCOME MEASURES: Elimination of endogenous Aspergillus endophthalmitis and Snellen visual acuity, best corrected, were measured. RESULTS: All patients had a 1- to 3-day history of pain and marked loss of visual acuity in the involved eyes. Varying degrees of vitritis was present in all 12 eyes. In 8 of 12 eyes, a central macular chorioretinal inflammatory lesion was present. Four patients (six eyes) had associated pulmonary diseases and were receiving concurrent steroid therapy. One of these patients with chronic asthma also was abusing intravenous drugs. Overall, six patients (six eyes) had a history of intravenous drug abuse, whereas a seventh patient (one eye) was suspected of abusing intravenous drugs. Blood cultures and echocardiograms were negative for systemic aspergillosis. Management consisted of a pars plana vitrectomy in 10 of 12 eyes. Intravitreous amphotericin B was administered in 11 of 12 eyes. Systemic amphotericin B therapy was used in eight patients. One patient was treated with oral antifungal agents. In three eyes without central macular involvement, final visual acuities were 20/25 to 20/200. In eight eyes with initial central macular involvement, final visual acuities were 20/400 in three eyes and 5/200 or less in four eyes. Two painful eyes with marked inflammation, hypotony, and retinal detachment were enucleated. CONCLUSIONS: Endogenous Aspergillus endophthalmitis usually has an acute onset of intraocular inflammation and often has a characteristic chorioretinal lesion located in the macula. Although treatment with pars plana vitrectomy and intravitreous amphotericin B is capable of eliminating the ocular infection, the visual outcome generally is poor, especially when there is direct macular involvement.

The Endophthalmitis Vitrectomy Study. Relationship between clinical presentation and microbiologic spectrum.

PURPOSE: The authors determine if specific features of the clinical presentation of acute postoperative endophthalmitis correlated with the microbiologic culture results. METHODS: A total of 420 patients who had clinical evidence of endophthalmitis within 6 weeks after cataract surgery or secondary intraocular lens implantation were evaluated as part of a randomized clinical trial. Results of cultures performed on aqueous and vitreous specimens obtained at presentation were categorized as follows: gram-positive coagulase-negative micrococci, "other" gram-positive, gram-negative, and equivocal/no growth. RESULTS: Eleven features of the initial clinical presentation were associated with significant differences in the microbiologic spectrum (P < 0.05). Baseline factors correlating with higher rates of both gram-negative and other gram-positive isolates were: corneal infiltrate, cataract wound abnormalities, afferent pupillary defect, loss of red reflex, initial light perception-only vision, and symptom onset within 2 days of surgery. Gram-negative organisms did not grow in any eyes in which a retinal vessel could be visualized, and 61.9% of these eyes had equivocal or no growth. Diabetes mellitus was associated with a higher yield of gram-positive, coagulase-negative micrococci. Eye pain was not a discriminator for culture results. CONCLUSIONS: The presenting characteristics of acute endophthalmitis after cataract surgery may be helpful in predicting the most likely culture results. Such predictions do not appear sufficiently strong to guide the initial empiric choice of intravitreal antibiotics.

Visual acuity of eyes after vitrectomy for retinopathy of prematurity: follow-up at 5 1/2 years. The Cryotherapy for Retinopathy of Prematurity Cooperative Group.

PURPOSE: To provide long-term follow-up on the structural status and visual function at 5 1/2 years of age for 128 eyes of 98 infants who participated in the multicenter randomized clinical trial of cryotherapy for retinopathy of prematurity in whom total retinal detachment developed from retinopathy of prematurity (ROP) by the 3-month study examination. Fifty-four patients had lensectomy-vitrectomy procedures in one or both eyes before 1 year of age (n=72 eyes), and 44 patients did not (n=56 eyes). METHODS: When the children were 5 1/2 years of age, an eye examination was performed and residua of ROP was assessed. Recognition acuity (Early Treatment of Diabetic Retinopathy Study chart) and grating visual acuity (Teller acuity card procedure) assessments were undertaken by testers who were masked to the status of each of the child's eyes. RESULTS: At least partial retinal attachment was present at 5 1/2 years in 21% compared with 28% at 1 year of age (not significant). All except one of the eyes tested at 5 1/2 years had vision limited to light perception or no light perception, regardless of whether a vitrectomy had been performed. One eye that underwent vitrectomy had minimal pattern vision. The two eyes that were reported previously to have minimal pattern vision at 1 year of age were blind at the longer-term follow-up. CONCLUSIONS: The poor visual outcome after a lensectomy-vitrectomy procedure for retinal detachment due to ROP demands that emphasis be placed on prevention of retinal detachment in premature infants.

Macular pucker after successful surgery for proliferative vitreoretinopathy. Silicone Study Report 8.

BACKGROUND: The prevalence of postoperative macular pucker and the factors associated with its development after successful surgery for proliferative vitreoretinopathy (PVR) using silicone oil or gas tamponade are unknown. METHODS: The postoperative status of the macula was determined by reviewing the photographs of 336 eyes taken 6 months after randomization. Two hundred eleven eyes with attached maculas were identified and analyzed to determine the prevalence of macular pucker after silicone oil and gas tamponades in eyes without (group 1) and with (group 2) previous vitrectomy surgery. Data obtained at baseline, from the primary study surgery, and from subsequent examinations and repeat surgeries during a follow-up period of 6 months were analyzed for factors associated with postoperative macular pucker. RESULTS: The 6-month-point prevalence rate of postoperative macular pucker was 15% (32 of 211 eyes). Ten of the 32 eyes were new cases of macular pucker. The authors were unable to document a difference in the 6-month-point prevalence of postoperative macular pucker between group 1 and group 2 eyes (13% versus 18%) or between eyes randomized to gas versus silicone oil (19% versus 12%). Postoperative pucker was three times as likely to develop in aphakic/pseudophakic eyes compared with phakic eyes (P = 0.02). Focal contraction posteriorly causing starfolds, and intravitreal contraction involving the vitreous base or vitreous cavity, were significantly less prevalent in eyes with postoperative macular pucker (P < 0.05). Large (> or = 2 disc diameters) retinal breaks (P = 0.04) were associated significantly with postoperative macular pucker (P = 0.04). The authors were unable to document an association between postoperative macular pucker and the type of adhesive modality used or the extent of its application. Postoperative visual acuity was significantly better if the macula was not puckered (P < 0.01). CONCLUSIONS: The occurrence of macular pucker after successful surgery for retinal detachments complicated by severe PVR is not influenced by the choice of intraocular tamponade. Certain preoperative factors may be associated with postoperative macular pucker.

The incidence of corneal abnormalities in the Silicone Study. Silicone Study Report 7.

OBJECTIVE: To determine factors that were prognostic of corneal abnormalities in eyes following surgery for severe proliferative vitreoretinopathy. DESIGN: Subgroup analysis of the Silicone Study. SETTINGS: Community and university-based ophthalmology clinics. MATERIALS: Eyes with attached maculae at the 24-month follow-up examination that did not have a pre-existing corneal abnormality. INTERVENTIONS: Vitrectomy surgery with long-acting gas or silicone oil. OUTCOME MEASURES: Epithelial and/or stromal edema, corneal opacity and/or previous corneal transplant. RESULTS: The incidence of corneal abnormalities at 24 months was 27% and did not differ significantly between treatment groups. Prognostic factors were preoperative aphakia or pseudophakia (P = .003), preoperative iris neovascularization (P = .006), reoperation (P = .001), the absence of a fluid/gas exchange (P = .03), corneal touch by silicone oil (P = .02), and the presence of aqueous cells (P = .009) or aqueous flare (P = .08). In a multivariate analysis, independent prognostic factors were iris neovascularization (relative risk [RR] = 13.1), aphakia or pseudophakia (RR = 3.0), postoperative aqueous flare (RR = 5.4), and reoperations (RR = 3.4). Corneal abnormalities were correlated with poor visual acuity and hypotony (P < .001). CONCLUSIONS: To our knowledge, this is the first study to document that the incidence rates of corneal abnormalities are equivalent between oil and gas. The incidence of corneal abnormalities in gas-filled eyes was higher than expected, and remained high in oil-filled eyes, despite the use of an inferior iridectomy. Successful surgical repair of the retinal detachment with a single operation, and prevention and early management of corneal touch by silicone oil should help to prevent corneal abnormalities. If rubeosis iridis or severe aqueous flare is present, preoperative treatment with intense topical and possibly periocular steroids might reduce inflammation, which might mediate corneal damage.

Adenocarcinoma of retinal pigment epithelium arising from a juxtapapillary histoplasmosis scar.

A 66-year-old woman underwent a transocular fine-needle aspiration biopsy for an enlarging mass arising from a juxtapapillary histoplasmosis scar in the left eye. The cytologic study revealed pigmented malignant cells, suggesting that the lesion was either a malignant choroidal melanoma or an adenocarcinoma of the retinal pigment epithelium. The eye was enucleated and histopathologic studies revealed findings suggestive of an adenocarcinoma of the retinal pigment epithelium. Immunohistochemical stains were positive for cytokeratin and were negative for melanoma-specific antigen, supporting an epithelial origin of the neoplasm. It is possible that the tumor developed as a neoplastic transformation of a reactive proliferation of the retinal pigment epithelium in a histoplasmosis scar. The possible association between a chorioretinal scar and the development of a tumor of the pigment epithelium is discussed herein.

Blood levels in macular cystoid spaces and their relationship to retinal vein obstruction.

BACKGROUND: Blood levels in macular cystoid spaces are commonly seen in patients with branch or central retinal vein obstruction, but have not been previously reported. METHODS: To determine blood levels in cystoid spaces, a retrospective study was conducted of 102 eyes with branch retinal vein obstruction, 54 eyes with central retinal vein obstruction, 207 eyes with clinically significant diabetic macular edema, and 109 eyes with aphakic or pseudophakic cystoid macular edema seen over a 5-year period. RESULTS: Definite blood levels in cystoid spaces were found in 26 eyes (25%) with branch vein obstruction and in 4 eyes (8%) with central vein obstruction. In contrast, this clinical change was detected in only 1 of 207 eyes (1%) with diabetic cystoid macular edema, and in only 2 of 109 eyes (2%) with aphakic or pseudophakic cystoid macular edema (P < 0.001). When blood levels in cystoid spaces were detected in patients with branch vein obstruction, the site of obstruction tended to be superotemporal (P < 0.05). CONCLUSION: Blood levels in cystoid spaces are an important sign of retinal vein obstruction, and may help establish the diagnosis in certain cases.

Postoperative intraocular pressure abnormalities in the Silicone Study. Silicone Study Report 4.

BACKGROUND: Chronically abnormal intraocular pressure (IOP) may follow surgery for proliferative vitreoretinopathy (PVR), using either long-acting gas or silicone oil tamponade. Its prevalence and clinical significance are unclear. METHODS: In the Silicone Study, 241 eyes with severe (> or = C-3) PVR were treated with vitrectomy, randomized to perfluoropropane gas (C3F8) or silicone oil, and followed for 6 months or longer. Chronic IOP abnormalities, based on findings at two consecutive or any three postoperative visits, were defined as (1) low IOP (hypotony), 5 mmHg or less, or (2) elevated IOP, more than 25 mmHg. RESULTS: Eleven (5%) eyes had chronically elevated IOP and 58 (24%) had chronic hypotony. Chronically elevated IOP was more prevalent in eyes randomized to silicone oil than in those randomized to C3F8 gas (8% versus 2%; P < 0.05). Chronic hypotony was (1) more prevalent in eyes randomized to C3F8 gas than in those randomized to silicone oil (31% versus 18%; P < 0.05); (2) more prevalent in eyes with anatomic failure (48% versus 16%; P < 0.01); and (3) correlated with poor postoperative vision (P < 0.0001), corneal opacity (P < 0.001), and retinal detachment (P < 0.001). Factors prognostic of chronic hyotony included preoperative hypotony (P < 0.01), diffuse contraction of the retina anterior to the equator (P < 0.01), rubeosis (P = 0.02), and large retinal breaks (P = 0.02). In a multivariate analysis, diffuse contraction of the retina anterior to the equator remained an independent factor prognostic of chronic hypotony (odds ratio = 4.2), regardless of whether the retina was attached postoperatively. CONCLUSION: Intraocular pressure abnormalities are a common postoperative complication in eyes with PVR, and may occur with either C3F8 gas or with silicone oil. The presence of diffuse contraction of the retina anterior to the equator should alert the vitrectomy surgeon that the eye is likely to be hypotonus postoperatively.

Visual loss complicating OKT3 monoclonal antibody therapy.

OKT3 is a murine monoclonal antibody used for immunosuppression of solid-organ transplant rejection. We studied severe visual loss after administration of OKT3 in two patients who received renal transplants (one 25-year-old woman with interstitial nephritis and severe hypertension and one 27-year-old woman with diabetic nephropathy). Both patients lost visual acuity to the level of light perception after a second or third dose of OKT3. Ophthalmoscopy disclosed arteriolar constriction, but there was no evidence of optic atrophy. The electroretinogram was extinguished in one patient, indicating an effect on the outer retina or retinal pigment epithelium. Ophthalmologists should be aware that OKT3 may cause profound visual loss in patients who receive organ transplants.

Ophthalmic aspects of orbital injury. A comprehensive diagnostic and management approach.

Improved prognosis for eye injuries sustained during facial trauma depends on early assessment and accurate diagnosis. The surgeon responsible for management of the orbital fracture(s) must perform an ocular assessment at the time of initial examination. Abnormalities found on the five-point assessment outlined herein should lead to urgent ophthalmic consultation. Fracture repair should not be undertaken until the results of consultation have been discussed with the ophthalmologist. Vision should be carefully monitored in the preoperative period because delayed optic neuropathy may occur. Similarly, vision should be followed regularly in the postoperative period after reduction of fractures of the orbital bones. Decreased postoperative vision should lead to immediate ocular assessment and early ophthalmologic consultation.

Evaluation of the tourniquet test as a predictor of diabetic retinopathy.

Medical practitioners often have difficulty in assessing the presence or severity of diabetic retinopathy. The tourniquet test is a method of assessing diabetic capillary fragility that has been felt to reliably correlate with background and proliferative diabetic retinopathy. We studied 100 consecutive diabetic patients and 50 age-matched controls in a masked fashion, using fundus photographs and fluorescein angiography to correlate the amount of capillary fragility with the presence and severity of background and proliferative diabetic retinopathy. Although the severity of diabetic capillary fragility did correlate with the presence and severity of diabetic retinopathy (p less than 0.001), this test was not as good an indicator of diabetic retinopathy as were other risk factors such as duration of diabetes (p much less than 0.001). The tourniquet test is unreliable in predicting the presence or severity of diabetic retinopathy because of its high false negative response rate.

Visual acuity in infants after vitrectomy for severe retinopathy of prematurity.

During the course of the Multicenter Trial of Cryotherapy for Retinopathy of Prematurity (CRYO-ROP), 98 infants (129 eyes) from the randomized segment of the trial developed total retinal detachment from retinopathy of prematurity (ROP) before the 1-year examination. The authors report as a case series the results of acuity card assessment of monocular grating acuity at 1 year in 53 infants (71 eyes) postvitrectomy and in 45 infants (58 eyes) who had retinal detachments but who did not undergo retinal reattachment surgery. The decision to undertake and the surgical technique used for a retinal reattachment procedure was not part of the randomized CRYO-ROP trial. Two eyes of one infant had pattern vision at the lowest measurable threshold after vitrectomy. None of the remaining eyes that had undergone vitrectomy and none of the eyes that did not undergo vitrectomy showed evidence of pattern vision. The relatively poor visual outcomes in this case series suggest that efforts are well-spent in attempting to prevent retinal detachment in ROP.

Outpatient and abbreviated hospitalization for vitreoretinal surgery.

We retrospectively reviewed 255 consecutive scleral buckling and vitrectomy operations dividing the patients into two groups. One group was managed traditionally with general anesthesia and postoperative hospitalization. The second group was managed with local anesthesia and with no hospitalization or abbreviated hospitalization whenever possible. There was no difference in the technical or functional success rates achieved in the two groups. We conclude that vitreoretinal surgery may be performed safely and effectively on an outpatient basis in selected cases.

The histopathology of successful retinal reattachment.

Fifteen eyes with rhegmatogenous retinal detachment that were successfully reattached with scleral buckling were studied histopathologically after enucleation or autopsy. Postoperative visual acuities ranged from 20/25 to 5/200. Epiretinal membranes were present in 9 of 15 eyes (60%) and cystoid macular edema was present in 4 of 15 (26%). Although the reattached retina was of normal morphology by light microscopy in 9 of 15 eyes, significant atrophy of outer retinal layers was noted in 4 of 15 eyes (26%). In 5 of 13 patients, reduced postoperative vision could be histopathologically correlated with macular edema or lack of retinal regeneration, but there was no compelling histopathologic explanation for reduced vision noted in 5 other cases.

Penetrating pellet fragmentation. A complication of ocular shotgun injury.

In three patients who had double-perforating ocular shotgun injuries, a single lead shotgun pellet apparently fragmented after striking the eye, resulting in two separate intraocular impact sites. The importance of detecting double-perforating eye injury and becoming aware of this potential complication with ocular shotgun injuries is emphasized.

Photocoagulation to prevent retinal detachment in acute retinal necrosis.

Retinal detachment (RD) occurs in more than 50% of eyes with acute retinal necrosis (ARN) and is the leading cause of visual loss in this syndrome. In order to decrease the incidence of RD in ARN, the authors treated 12 eyes of 10 patients with prophylactic laser photocoagulation. Retinal detachment occurred in two eyes (17%). Over the same time period, seven eyes with ARN did not receive prophylactic laser treatment, most often because of dense vitreous debris, with a 67% rate of RD. Prophylactic photocoagulation treatment should be considered in the management of patients with ARN.