Surgical management of macular holes: a report by the American Academy of Ophthalmology.

OBJECTIVE: The document describes macular hole surgery and examines the available evidence to address questions about the efficacy of the procedure for different stages of macular hole, complications during and after surgery, and modifications to the technique. METHODS: A literature search conducted for the years 1968 to 2000 retrieved over 400 citations that matched the search criteria. This information was reviewed by panel members and a methodologist, and it was evaluated for the quality of the evidence presented. RESULTS: There are three multicenter, controlled, randomized trials that constitute Level I evidence and compare the value of surgery versus observation for macular hole. There are three multicenter, controlled, randomized trials studying the use of adjuvant therapy in macular hole repair. Postoperative vision of 20/40 or better has been reported in 22% to 49% of patients in randomized trials. The risks of surgical complications include retinal detachment (3%), endophthalmitis (<1%), cataract (>75%), and late reopening the hole (2% to 10%). CONCLUSIONS: The evidence does not support surgery for patients with stage 1 holes. Level I evidence supports surgery for stage 2 holes to prevent progression to later stages of the disease and further visual loss. Level I evidence shows that surgery improves the vision in a majority of patients with stage 3 and stage 4 holes. There is no strong evidence that adjuvant therapy used at the time of surgery results in improved surgical outcomes. Patient inconvenience, patient preference, and quality of life issues have not been studied.

Safety of indocyanine green angiography during pregnancy: a survey of the retina, macula, and vitreous societies.

OBJECTIVES: To establish current practice patterns and assess the general knowledge among vitreoretinal-trained physicians regarding the use of indocyanine green (ICG) angiography during pregnancy, and to review the literature regarding the established safety of ICG angiography in pregnant women. METHODS: A survey was mailed to 1101 members of the Retina, Macula, and Vitreous Societies. RESULTS: Of the 520 respondents, 434 (83%) had seen at least 1 pregnant woman who required ICG angiography or fluorescein angiography. Of these, 385 (89%) withheld fluorescein angiography and 105 (24%) withheld ICG angiography, largely because of fear of teratogenicity or lawsuit. Diabetic retinopathy and choroidal neovascular membrane were the most common indications for fluorescein angiography, and choroidal neovascular membrane and choroidal tumor were the most common indications for ICG angiography. Only 24% thought that it was safe to use ICG angiography in a pregnant patient, and only 5% thought it was safer than fluorescein angiography. CONCLUSIONS: Despite the documented safety of ICG when used for retinal angiography and the extensive experience with the use of intravenous ICG to measure hepatic blood flow in pregnant women, the results of this survey suggest widespread hesitation to use ICG for retinal angiography in pregnant women. Current practice patterns regarding the use of ICG angiography in pregnant patients may be unnecessarily restrictive.

Patient-initiated second medical opinions: their necessity and economic cost.

PURPOSE: To assess the value of patient-initiated second medical opinions (SMO). METHODS: The authors prospectively collected demographic data from 100 consecutive patients. The authors recorded major changes in the patients' care, such as inappropriate surgery recommended, inadequate treatment performed, and appropriate treatment not recommended. The authors also recorded costs incurred or saved by the patients and the third-party payers. RESULTS: In nearly 15 of the cases, the authors had major disagreements with the initial diagnosis or management. Surgery had been recommended in 28 cases. They advised against it in nine. In 72 cases, no surgery had been recommended. They advised and performed it in five. The management of five other patients was not in accordance with that recommended by large clinical trials or was inadequately done. Including the consultation fees, surgery performed or advised against, retinal angiography, and ultrasonography, the 100 SMO cost third-party payers $12,426. If the authors subtract the cost of noncontroversial surgery they recommended and if the patients had paid the consultation fee and had brought along their fluorescein angiograms, third-party payers would have saved $4,079. CONCLUSION: The savings SMO generated by eliminating unnecessary surgery resulted in improved patient care at minimal cost to third-party payers.

Unusual immunogammopathy maculopathy.

PURPOSE: To describe an unusual maculopathy in patients with serum immunogammopathies. DESIGN: Retrospective observational small case series. PARTICIPANTS: Three patients derived from the clinical retina practices of the authors were noted to have unusual maculopathy. METHODS: Each patient underwent fluorescein angiography and serum laboratory evaluation. MAIN OUTCOME MEASURE: Findings on fluorescein angiography. RESULTS: An unusual and atypical macular detachment with or without subretinal precipitates or fundus signs of serum hyperviscosity, such as retinal hemorrhages and dilated retinal veins, may be observed in patients with immunogammopathies such as multiple myeloma, Waldenström's macroglobulinemia, and benign polyclonal gammopathy. Fluorescein angiography shows macular hypofluorescence with no evidence of retinal vascular or retinal pigment epithelial leakage within the macular elevation. CONCLUSIONS: Patients with atypical unilateral or bilateral macular detachment may be afflicted with a serum immunogammopathy such as multiple myeloma or Waldenström's macroglobulinemia. Diagnostic serum protein electrophoresis and hematology consultation should be considered.

Visual outcomes following the use of intravitreal steroids in the treatment of postoperative endophthalmitis.

OBJECTIVE: To compare visual outcomes between cases of acute postoperative endophthalmitis that did or did not receive intravitreal steroids. DESIGN: Retrospective nonrandomized comparative trial. PARTICIPANTS: Fifty-seven patients with postoperative endophthalmitis. INTERVENTION: Thirty-one patients with postoperative endophthalmitis resulting from cataract extraction received both intravitreal antibiotics and steroids, whereas the remaining 26 received only intravitreal antibiotics. MAIN OUTCOME MEASURES: Improvement in visual acuity. RESULTS: Multivariate logistic regression was used to analyze the variables that potentially influence a three-line visual acuity improvement. The mean baseline visual acuities of both groups were comparable. The use of intravitreal steroids reduced the probability of developing a three-line improvement in visual acuity (odds ratio [OR] = 0.287; 95% confidence interval [CI] [0.072-0.852]). On the basis of logistic regression analysis using our multivariate model, gender, baseline visual acuity, and pars plana vitrectomy were not significantly associated with visual outcome differences between the two groups. CONCLUSIONS: Patients who received intravitreal steroids had a significantly reduced likelihood of obtaining a three-line improvement in visual acuity. At a minimum our study provides no support for their use and, therefore, steroids may not be efficacious for acute endophthalmitis related to cataract extraction.

Results after lens extraction in patients with diabetic retinopathy: early treatment diabetic retinopathy study report number 25.

OBJECTIVE: To assess the visual results after surgical lens removal in patients with diabetic retinopathy. DESIGN: A multicenter randomized clinical trial designed to assess the effect of photocoagulation and aspirin in patients with mild to severe nonproliferative or early proliferative diabetic retinopathy and/or macular edema. PARTICIPANTS: Of the 3711 patients enrolled in the Early Treatment Diabetic Retinopathy Study, lens surgery was performed on 205 patients (270 eyes) during follow-up that ranged from 4 to 9 years. OUTCOME MEASUREMENTS: Visual acuity, macular edema status, and degree of diabetic retinopathy. In addition, risk factors associated with lens extraction and with poor postoperative visual acuity (worse than 20/100) were assessed. RESULTS: The risk of lens extraction increased with increasing age, female sex, and baseline proteinuria. Ocular variables associated with increased risk of lens surgery included poor baseline visual acuity and vitrectomy performed during the course of the study. At 1 year after lens surgery, visual acuity improvement of 2 or more lines from preoperative levels occurred in 64.3% of the operated-on eyes assigned to early photocoagulation and 59.3% of eyes assigned to deferral of photocoagulation. In eyes assigned to early photocoagulation, 46% of eyes achieved visual acuity better than 20/40; 73%, better than 20/100; and 8%, 5/200 or worse at 1 year after surgery. Visual acuity results for eyes assigned to deferral of laser photocoagulation at 1 year were not as favorable; 36% achieved visual acuity better than 20/40; 55%, better than 20/100; and 17%, 5/200 or worse at 1 year after surgery. Evaluation of 1-year postoperative visual acuities for all eyes with mild to moderate nonproliferative diabetic retinopathy at the annual visit before lens surgery showed that 53% were better than 20/40; 90%, better than 20/100; and 1%, 5/200 or worse. However, for eyes with severe nonproliferative or worse retinopathy at the annual visit before lens surgery, only 25% were better than 20/40; 42%, better than 20/100; and 22%, 5/200 or worse at 1 year after lens surgery. There was little change in visual acuity between 1 and 2 years postoperatively. Increased severity of retinopathy and poor visual acuity before surgery were associated with visual acuity of worse than 20/100 at 1 year after surgery. Lens surgery was associated with a borderline statistically significant increased risk of progression of diabetic retinopathy in the adjusted analyses (P = .03). No statistically significant long-term increased risk of macular edema was documented after lens surgery. CONCLUSIONS: Visual acuity results after lens surgery in patients in the Early Treatment Diabetic Retinopathy Study were better than published results for similar patients. This may be because of more intensive photocoagulation for lesions of diabetic retinopathy in the Early Treatment Diabetic Retinopathy Study than in previously reported studies. Although patients with severe nonproliferative retinopathy or worse before lens surgery had poorer visual results, visual improvement was seen in 55% of these patients at 1-year follow-up. The main causes of poor visual results in eyes after lens surgery were complications of proliferative retinopathy and/or macular edema.

Current popularity of pneumatic retinopexy.

PURPOSE: To compare the popularity of pneumatic retinopexy (PR) in 1997 with its popularity in 1990 among retinal specialists. METHODS: In 1997, a survey was mailed to the 1994-1995 members of the Retina or Vitreous Societies who lived in the United States or Canada, asking how they would manage a hypothetical retinal detachment. The choices were limited to PR, segmental scleral buckling, scleral bucking with encircling, primary vitrectomy, and Lincoff balloon. The results of the survey were compared with those previously reported by a similar survey in 1990. RESULTS: The majority (55%) of respondents selected PR, which is a twofold increase over those who preferred it in 1990 (odds ratio 2.08; 95% confidence interval 1.53, 2.85). The popularity of PR was inversely proportional to the length of time the respondents had been in practice. If the eye with the hypothetical detachment had pseudophakia, only 30% of respondents selected PR. If the eye had additional tears, vitreous hemorrhage, or lattice degeneration, only about one-sixth preferred PR. CONCLUSION: Pneumatic retinopexy was much more popular in 1997 than it was in 1990. Its popularity continues to be influenced by the age of the surgeon and by the complexity of the detachment.

Ultrasound biomicroscopy as a tool for detecting and localizing occult foreign bodies after ocular trauma.

OBJECTIVE: To show the utility of ultrasound biomicroscopy (UBM) in imaging small ocular foreign bodies of the anterior segment. DESIGN: Retrospective case series. PARTICIPANTS: Twelve eyes of 12 consecutive patients evaluated in the emergency department or referred to specialty services at 1 institution between August 1994 and November 1997 were examined. INTERVENTION: Ocular ultrasound biomicroscopy was performed. MAIN OUTCOME MEASURES: Detection and localization of an ocular foreign body were measured. RESULTS: An intraocular or superficial foreign body was detected by UBM in 9 (75%) of 12 eyes. The foreign body was classified as corneal in two eyes, subconjunctival in two, intrascleral in three, and intraocular in two eyes. The foreign body was not visible by ophthalmic physical examination in seven of the nine eyes with a confirmed ocular foreign body. In the remaining two eyes, UBM was used to determine the depth of a visible foreign body. In three of the eyes with a confirmed foreign body, computed tomography and/or contact B-scan ultrasonography was obtained and failed to show a foreign body. Six of the foreign bodies were nonmetallic. CONCLUSIONS: Clinical detection of ocular foreign bodies after trauma can be hindered by small size, haziness of the optical media, poor patient cooperation, or hidden location. Ultrasound biomicroscopy is a valuable adjunct in the evaluation of suspected ocular foreign bodies, especially in cases involving small, nonmetallic objects.

Activated protein C resistance, factor V Leiden, and central retinal vein occlusion in young adults.

OBJECTIVE: To confirm the relationship between resistance to activated protein C (APC), factor V Leiden, and central retinal vein occlusion in young adults as reported in a recent study of patients younger than 50 years. PATIENTS AND METHODS: Patients younger than 50 years with central retinal vein occlusion were identified from the medical records of the Wills Eye Hospital Retina and Retina Vascular Services. Blood samples were taken from each patient and analyzed for resistance to APC and identification of factor V Leiden. RESULTS: Only 1 (4.7%) of 21 patients evidenced resistance to APC and the presence of factor V Leiden. This patient was also the only one to report a family history of thrombotic disease. CONCLUSIONS: We were unable to confirm the high percentage of resistance to ACP among young adult patients with central retinal vein occlusion. The finding of resistance to APC in only 1 (4.7%) of 21 patients is similar to that found in the general population.

The role of ultrasound biomicroscopy in ocular trauma.

PURPOSE: To demonstrate the usefulness of ultrasound biomicroscopy (UBM) in detecting and localizing small ocular foreign bodies. METHODS: This is a retrospective study of the records of 555 consecutive patients evaluated by UBM by the Visual Physiology Unit of the Wills Eye Hospital from August 1994 to November 1997. RESULTS: In 9 patients, a foreign body was identified. In 6 patients, the history suggested the presence of a foreign body, but one could not be detected by clinical examination. In 2 patients, the referring physicians requested UBM to determine whether or how deep a known foreign body had penetrated the globe. In 1 patient, the foreign body was not suspected clinically. In regard to other diagnostic techniques, CT failed to identify the foreign body in 1 patient. In another, contact B-scan ultrasonography failed. In a third, both CT and contact B-scan ultrasonography failed. The foreign body was intracorneal in 2 eyes, subconjunctival in 2, intrascleral in 3, and intraocular in 2. Six were nonmetallic. Two were metallic. In one case, the foreign body was lost and its composition is unknown. In 5 cases, the UBM findings altered the patient's management. CONCLUSIONS: UBM is a valuable adjunct in the evaluation of small, anteriorly located foreign body that may not be detectable by other methods. UBM may be especially useful for finding nonmetallic foreign bodies.

Ocular manifestations of diabetes.

Diabetes mellitus is a significant cause of visual morbidity worldwide. Progress continues in the identification of cellular elements involved in the pathogenesis of diabetic eye disease. Most notable is a greater elucidation of the role of vascular endothelial growth factor. Studies on the epidemiology and clinical course of diabetic eye disease provide a basis for examination, prognosis, and treatment of affected patients.

Vitrectomy for ciliary block (malignant) glaucoma.

BACKGROUND: Ciliary block (malignant) glaucoma is a rare surgical complication occurring in patients with pre-existing glaucoma. Misdirected aqueous fluid causes forward movement of the lens/iris diaphragm, shallowing the central and peripheral anterior chamber. Although most patients with ciliary block respond to medical or laser therapy, those with refractory glaucoma often require pars plana vitrectomy to normalize aqueous flow. METHODS: The medical records of 21 consecutive patients with refractory ciliary block glaucoma treated by pars plana vitrectomy were reviewed retrospectively to determine the efficacy of this procedure in alleviating ciliary block. Data were collected regarding anatomic characteristics of the eye, history of glaucoma, prior ocular surgery, and outcome after vitrectomy. RESULTS: Pre-existing glaucoma and recent intraocular surgery were noted in all patients with ciliary block glaucoma. Of 21 eyes, 8 (38%) had undergone multiple prior intraocular surgeries. The initial pars plana vitrectomy was successful in alleviating ciliary block in 14 (70%) of 20 eyes. Of those six eyes that failed to improve after initial vitrectomy, five (83%) were phakic. Additional vitrectomy surgery to relieve ciliary block was required in three (60%) of five phakic patients who failed initial vitrectomy. Complications during the treatment of ciliary block included cataract formation, retinal detachment, bleb failure, and serous choroidal detachment. CONCLUSIONS: Pars plana vitrectomy is a useful adjunct to therapy for ciliary block glaucoma when medical and laser treatment fail to alleviate the process. Surgically removing the anterior hyaloid to re-establish normal aqueous flow constitutes the primary goal of surgery. In some cases, surgery is compromised by poor visualization of the anterior hyaloid, avoiding glaucoma filtration sites, and guarding against damage to the crystalline lens.

Diabetic papillopathy. Patient characteristics and fundus findings.

OBJECTIVE: To better define the spectrum of patient characteristics and fundus findings in patients with a presumably unique clinical entity referred to as diabetic papillopathy. DESIGN: Retrospective series. SETTING: A university-based referral practice. METHODS: We retrospectively reviewed the medical records of all diabetic patients with benign, transient disc swelling who were evaluated at our institution from 1986 to 1992. Data pertaining to patient demographics, visual acuity and symptoms, disc and retinal findings, ancillary test results, and clinical course were collected. RESULTS: Twenty-seven eyes of 19 patients met the study definition of diabetic papillopathy. Patients were generally older (mean age, 50 years) and of a broader age range (19 to 79 years) compared with those in prior reports. Two thirds of patients had type II diabetes. Disc swelling was consistently hyperemic and, on average, resolved within 3.7 months. Macular edema was a frequent associated finding (70% of eyes) as was significant capillary nonperfusion (52% of tested eyes). Only four eyes (15%) had final visual acuities of less than 20/50 and each had prominent macular edema. Cup-disc ratio analysis of uninvolved eyes revealed a significantly small physiologic cup. CONCLUSIONS: The clinical profile of diabetic papillopathy can be expanded to include people who are older or have type II diabetes and that affected eyes commonly have macular edema or retinal vascular changes that can adversely affect the visual outcome. Last, a small physiologic cup may represent an anatomic predisposition to the condition.

Prospective incidence of photic maculopathy after cataract surgery.

PURPOSE/METHODS: To determine the incidence of photic retinal injury during cataract surgery, we studied 37 consecutive patients with intravenous fluorescein angiography within ten days after cataract surgery. The microscope irradiance was standardized for all cases. RESULTS/CONCLUSIONS: Fluorescein evidence of photic retinal injury did not develop in any of the 37 cataract patients. Incidence rates for photic retinal injury induced by the surgical microscope vary considerably among ophthalmologists and most likely reflect differences in microscope brightness, surgical duration, and surgical technique.

Familial exudative vitreoretinopathy.

PURPOSE: To evaluate the natural history of Familial Exudative Vitreoretinopathy (FEVR) with emphasis on the effect of the age of onset on its severity and on the development of late complications such as cataract and retinal detachment. Also, to evaluate affected patients for DNA abnormalities. METHODS: The records of thirty-nine patients with FEVR were studied. All were asked to come in for a final follow-up examination. The referring physician was asked to provide the latest findings for those who could not. On 10 patients, karyotypes were prepared. RESULTS: Only 2 of 28 patients whose onset of symptoms was prior to their third birthday had a final visual acuity of 20/200 or better. Older patients had a better prognosis, because they were more likely to have asymmetrical retinal deterioration with only one eye deteriorating. Preservation of good visual acuity into the teens and later was no guarantee that deterioration would not occur. In 3 eyes of 4 patients who were asymptomatic until 15 years of age, the final visual acuity was counting fingers or worse. In 5 patients, retinal detachment developed 6 to 17 years after apparent stabilization. The karyotype of 10 patients showed no evidence for rearrangement, altered size, translocations or deletions of chromosome 11 or any other chromosome. Of the 31 eyes in patients older than 15 years, 10 (32%) had a significant cataract. Three eyes underwent cataract surgery. CONCLUSIONS: The prognosis for infants with FEVR is extremely poor and the long-term prognosis for patients with a later onset of the condition is guarded. Retinal detachment, macular dragging, and cataract are common late complications which can develop even in patients whose eye findings appear to be stable. Karyotype studies ruled out involvement of chromosome 11 or others at a gross level, but did not exclude them at the location for some genetic defect related to FEVR because single base changes and small deletions or insertions may be undetectable by the methods utilized.

Accommodative amplitudes in the Early Treatment Diabetic Retinopathy Study.

PURPOSE: Accommodative amplitude in persons with diabetes was investigated using data collected as part of the Early Treatment Diabetic Retinopathy Study. METHODS: Accommodative amplitude was measured at the baseline visit in 1,058 patients who had good visual acuity and who were less than 46 years old. Risk factors for low accommodative amplitude at baseline were evaluated using multivariable linear regression. Change in accommodative amplitude after photocoagulation was evaluated using paired t tests and repeated measures analysis of variance for the 578 patients who underwent follow-up measurements at the 4-month visit. RESULTS: Accommodative amplitudes in Early Treatment Diabetic Retinopathy Study patients were lower than normal accommodative amplitudes. Older age (P < 0.001) and increased duration of diabetes (P < 0.01) were risk factors associated with low amplitudes of accommodation in the Early Treatment Diabetic Retinopathy Study. Full scatter photocoagulation was associated with an apparently transient additional reduction in accommodative amplitude; a one third diopter loss in accommodative amplitude was demonstrated only at the 4-month visit (P < 0.001). CONCLUSION: This study demonstrates that diabetes and duration of diabetes, along with age, are important risk factors for reduced accommodative amplitude. These factors along with an apparently transient decrease in accommodative amplitude following scatter photocoagulation should be considered when assessing the accommodative needs of patients with diabetes and when discussing side effects of full scatter photocoagulation.

Late onset endophthalmitis associated with filtering blebs.

A consecutive series of 71 cases of late onset endophthalmitis (defined as onset of symptoms at least 2 weeks after surgery) were reviewed to determine the association of this entity with glaucoma surgery filtering blebs and to identify any predisposing factors. Sixteen cases were associated with filtering blebs and two with inadvertent blebs following cataract surgery. Onset of endophthalmitis ranged from 24 days to 20 years after surgery (mean, 6.9 years). Possible contributing factors included trauma, vitreous wicks, and bleb leak. Twelve cases were culture-positive, with 5 cases of Staphylococcus epidermidis; 2, Staphylococcus aureus; 4, Streptococcus; and 1, Pseudomonas. There were no cases of Hemophilus. The more virulent organisms were generally associated with a poor visual outcome. The organisms recovered in this series were similar to those found in postoperative endophthalmitis not associated with filtering blebs.

Indocyanine green angiography and occult choroidal neovascularization.

PURPOSE: To evaluate the use of digital indocyanine green (ICG) angiography as an adjunct to fluorescein angiography in the diagnosis and treatment of ill-defined choroidal neovascularization (CNV) associated with age-related macular degeneration (AMD). METHODS: The authors retrospectively reviewed all ICG angiograms performed at Wills Eye Hospital from March to July 1992. Included in this study were all cases with exudative manifestations of AMD in which fluorescein angiography showed ill-defined CNV. The initial ICG findings and the clinical outcome of both treated and untreated cases were evaluated through 6 months of follow-up. RESULTS: Of the 101 eligible cases, ICG angiography at presentation demonstrated well-defined hyperfluorescence in 40 cases (group 1), ill-defined hyperfluorescence in 43 cases (group 2), mixed pattern of well- and ill-defined hyperfluorescence in 14 cases (group 3), and no abnormalities in 4 cases (group 4). Approximately one half of the cases with well-defined ICG hyperfluorescence (21% of the total) had only extrafoveal changes. Laser photocoagulation treatment based solely on ICG angiogram findings was performed in 19 group 1 cases (extrafoveal hyperfluorescent foci only) and in 8 group 3 cases, with treatment in both groups being directed only to areas of well-defined hyperfluorescence. Successful treatment was achieved in 12 (63%) of 19 cases and in 2 (25%) of 8 cases, respectively. There was a strong correlation between post-treatment persistence or recurrence of ICG hyperfluorescence and treatment failure. CONCLUSIONS: Indocyanine green angiography is a valuable diagnostic adjunct to fluorescein angiography in evaluating occult CNV in AMD. In this series, well-defined, extrafoveal ICG hyperfluorescence was identified in 21% of the cases, and preliminary, short-term results suggest that ICG-guided laser treatment is promising in this subgroup.

Extracapsular cataract extraction with placement of a posterior chamber lens in patients with diabetic retinopathy.

PURPOSE: The authors evaluated factors that might influence the outcome of extracapsular cataract extraction with placement of a posterior chamber lens in patients with diabetic retinopathy. The factors included patient age and sex, severity of the retinopathy, preoperative laser photocoagulation, vitrectomy, and posterior capsulotomy. METHODS: The records of 109 patients who had been examined by the authors before cataract surgery were retrospectively reviewed. RESULTS: The final visual acuity in only 48% of the eyes was 20/40 or better, and 28% had 20/200 or worse visual acuity. Only 65% had an improvement in visual acuity of two or more Snellen lines. Eyes with preoperative macular edema had a poorer visual outcome than eyes without. Macular edema and ischemia accounted for 70% of the eyes with a final visual acuity of 20/50 or worse. The authors found that age was a strong predictor of final visual acuity and chances of improvement. In patients 63 years of age and younger, 58% had 20/40 or better and 81% had improved visual acuity. In patients 64 years of age and older, only 38% had 20/40 or better and only 54% were improved. Supplementary panretinal photocoagulation was required in 37% of patients who had received it preoperatively. Neovascularization of the iris developed in 6% of patients. Posterior capsulotomy did not cause an increased incidence of neovascularization of the iris or in the development or progression of proliferative retinopathy or macular edema. CONCLUSION: The prognosis of patients with diabetic retinopathy about to undergo cataract surgery, even extracapsular cataract extraction with placement of a posterior chamber lens, is guarded.