Increased incidence of sterile endophthalmitis following intravitreal preserved triamcinolone acetonide.

AIM: To report an increased incidence of sterile endophthalmitis following intravitreal injection of preserved triamcinolone acetonide (IVTA) from 1 May to 31 July 2006. METHODS: Charts were reviewed for all patients who underwent IVTA injections between 1 January 2005 and 31 July 2006 at the offices of a referral vitreo-retinal practice. Patients were included if they presented post-IVTA with a clinical picture consistent with endophthalmitis. RESULTS: Between 1 January 2005 and 31 July 2006, 554 eyes underwent IVTA. Eleven eyes (1.9%) developed an endophthalmitis. All eleven eyes underwent vitreous tap and intravitreal injection of antibiotics. All cultures and gram stains were negative for bacterial or fungal organisms. From 1 May to 31 July 2006, 97 eyes underwent IVTA. Nine eyes (9.3%) developed sterile endophthalmitis. This represented a statistically significant (p<0.0001) clustering of cases. Triamcinolone acetonide phials from affected lot numbers were analysed and were all found to be negative for bacterial endotoxin (<0.05 EU/ml). CONCLUSION: Over the 19-month period analysed, 11 cases of sterile endophthalmitis occurred following IVTA, and nine of these cases were clustered over a 3-month period. No endotoxin was detected in the phials tested. The aetiology of this increased incidence of sterile endophthalmitis is still unclear.

Bilateral secondary angle-closure glaucoma as a complication of anticoagulation in a nanophthalmic patient.

PURPOSE: To describe bilateral hemorrhage of the posterior segment and secondary angle-closure glaucoma as sequelae of anticoagulation therapy in a nanophthalmic patient. METHODS: An 80-year-old man who was nanophthalmic and was undergoing anticoagulation therapy presented with declining visual acuity in left eye. Six months later, he experienced declining visual acuity in his right eye. RESULTS: In the LE and six months later in the RE, ocular examination disclosed angle-closure glaucoma and a hemorrhagic retinal detachment. Peripheral iridoplasty successfully treated the initial attack. The subretinal hemorrhage was successfully drained by pars plana vitrectomy, retinotomy, and air-fluid exchange in the left eye. Anatomic success and intraocular pressure control were obtained, but visual recovery was limited. CONCLUSION: Intraocular hemorrhage and angle-closure glaucoma are potential complications of anticoagulation therapy in a patient with nanophthalmos.

Management of dislocated nuclear fragments after phacoemulsification.

We examined 13 patients referred for management of dislocated lens fragments after phacoemulsification. Ocular findings included corneal decompensation, glaucoma, inflammation, and retinal tears and detachments. Eleven of the 13 patients underwent vitrectomy with removal of lens fragments. Surgical indications included the presence of large lens fragments, uncontrolled glaucoma, persistent and severe inflammation, and retinal detachment. Better visual acuity was observed in patients who had smaller lens fragments or when vitrectomy was delayed to allow medical treatment of intraocular inflammation and glaucoma. The results indicate that nucleus dislocation during phacoemulsification is an important visual complication, with seven of the 13 patients having a final visual acuity of 20/80 or less.

Vitrectomy retinotomy aspiration biopsy of choroidal tumors.

We used an investigational technique for the biopsy of intraocular tumors to aid in the diagnosis of three choroidal tumors. A three-port trans-pars plana vitrectomy was performed in conjunction with retinotomy, tumor biopsy, endophotocoagulation, and air-fluid exchange. Vitrectomy was used to decrease the amount of traction secondary to retained vitreous after intraocular surgery. Retinotomy sites were chosen under microscopic control to avoid large caliber retinal vessels. Then a modified tumor-aspiration technique, together with endophotocoagulation and aspiration of intraoperative vitreous hemorrhages, provided an opportunity to sample tumor tissue continually at varied depths. We have added standard vitreous surgery concepts, techniques, and instrumentation to produce vitrectomy retinotomy aspiration biopsy of choroidal tumors.

Intraocular radiation blocking.

Iodine-based liquid radiographic contrast agents were placed in normal and tumor-bearing (Greene strain) rabbit eyes to evaluate their ability to block iodine-125 radiation. This experiment required the procedures of tumor implantation, vitrectomy, air-fluid exchange, and 125I plaque and thermoluminescent dosimetry (TLD) chip implantation. The authors quantified the amount of radiation attenuation provided by intraocularly placed contrast agents with in vivo dosimetry. After intraocular insertion of a blocking agent or sham blocker (saline) insertion, episcleral 125I plaques were placed across the eye from episcleral TLD dosimeters. This showed that radiation attenuation occurred after blocker insertion compared with the saline controls. Then computed tomographic imaging techniques were used to describe the relatively rapid transit time of the aqueous-based iohexol compared with the slow transit time of the oil-like iophendylate. Lastly, seven nontumor-bearing eyes were primarily examined for blocking agent-related ocular toxicity. Although it was noted that iophendylate induced intraocular inflammation and retinal degeneration, all iohexol-treated eyes were similar to the control eyes at 7 and 31 days of follow-up. Although our study suggests that intraocular radiopaque materials can be used to shield normal ocular structures during 125I plaque irradiation, a mechanism to keep these materials from exiting the eye must be devised before clinical application.

Management of macular puckers associated with retinal angiomas.

Monocular visual loss in four patients was caused by epiretinal macular membranes associated with peripheral retinal capillary angiomas or angioma-like lesions. Three patients had solitary vascular lesions and one had two discrete vascular lesions. All patients were in good health, with no evidence of the von Hippel-Lindau syndrome. In three patients, spontaneous peeling of the macular membranes and visual improvement occurred 2 to 6 months after obliteration of the angioma-like lesions with cryotherapy (two patients), or cryotherapy combined with argon laser (one patient). The fourth patient underwent a vitrectomy 8 months after the macular pucker had failed to respond to treatment of the vascular lesion.

Peripheral retinal neovascularization in birdshot retinochoroidopathy.

A 69-year-old black woman had ocular findings consistent with birdshot retinochoroidopathy; these included cream-colored depigmented spots at the level of the retinal pigment epithelium and vitreitis. She also had peripheral retinal neovascularization with localized vitreous hemorrhage. There were no laboratory or systemic findings consistent with other disease entities.

Bacillus Calmette-Guerin (BCG) endophthalmitis.

A patient who had been treated for metastatic bladder carcinoma with bacillus Calmette-Guerin (BCG) vaccine subsequently developed bilateral visual loss secondary to an infiltrative retinitis and vitreitis. Although assumed to have candida endophthalmitis, vitrectomy demonstrated mycobacterium bovis. The patient was placed on systemic anti-tuberculous therapy, and there was noted to be a reduction in retinal lesions prior to his death. This is the first report in the literature documenting endogenous endophthalmitis after BCG usage.

Macular pucker and retinal angioma.

A 44-year-old white female had a macular pucker associated with a peripheral retinal capillary angioma. Following successful destruction of the angioma with cryotherapy, the macular pucker regressed and visual acuity returned to normal. This is the first report documenting the regression of a macular pucker following successful treatment of a peripheral retinal angioma.

Scleral ruptures during retinal detachment surgery.

Two cases of retinal detachment are presented in which significant scleral ruptures occurred at the time of scleral buckling surgery. Retinal reattachment was achieved and scleral ruptures successfully closed utilizing standard scleral buckling elements. Long-term follow-up of both cases failed to disclose any significant ocular complications occurring at the rupture site. Intraoperative management and techniques recommended for the avoidance of this complication are discussed.

Retinal detachment following neodymium-YAG laser capsulotomy.

Five patients developed retinal detachments within one month of undergoing neodymium-YAG laser posterior capsulotomy. In four patients rhegmatogenous retinal detachments developed in association with typical aphakic breaks; in the fifth patient a previously stable extramacular traction detachment extended into the fovea. In all five patients scleral buckling or vitrectomy successfully reattached the retina and visual acuity improved. None of the findings associated with the detachments could be definitely attributed to the YAG laser. These included the lack of structural or positional changes in the vitreous as well as the absence of retinal damage. We were unable to learn the specific settings used for each laser but were told that the minimum energy levels needed to produce a capsulotomy were used.

Central serous choroidopathy in pregnancy.

Central serous choroidopathy is an infrequent complication of pregnancy. A serous detachment of the macula was seen in three women during the course of their normal pregnancy. All patients showed resolution of the macular serous detachment in the third trimester, with resultant retinal pigment epithelial mottling; symptoms resolved in all patients post partum. Laboratory testing was not beneficial in establishing the cause of this disorder.

Intraocular injection of silicone oil for experimental proliferative vitreoretinopathy.

We evaluated the effect of intraocular silicone oil as an internal tamponade on an animal model of proliferative vitreoretinopathy. Lensectomy and vitrectomy were performed on two groups of pigmented rabbits. Twenty-five rabbit eyes then had 1,000 centistokes' viscosity silicone oil injected into the vitreous cavity; 20 control eyes received balanced salt solution. Fourteen days later, each eye was injected with homologous fibroblasts (ten eyes with 100,000 cells, 25 eyes with 250,000 cells, and ten eyes with 750,000 cells). All membranes that developed after the cell injections in both experimental and control eyes produced traction retinal detachment. The character of the membranes formed and the timing of the traction retinal detachment were the same for both groups. In an active phase of experimental proliferation, the internal tamponade of silicone oil is insufficient to keep the retina in place.

The role of cellular proliferation in an experimental model of massive periretinal proliferation.

Transplantation of from 10,000 to 750,000 autologous and homologous dermal fibroblasts into the vitreous cavity of rabbit eyes resulted in identical clinical findings leading to massive periretinal proliferation. A dose-response relationship between the number of cells injected and the extent of retinal traction that developed was established. The second phase of the experiment evaluated the effects of formalin and cobalt irradiation on the fibroblasts' ability to cause traction retinal detachment. Cell proliferation or the attainment of a critical mass of living cells was necessary for the development of traction retinal detachment.

A comparison of different cellular inocula in an experimental model of massive periretinal proliferation.

We modified a preexisting experimental model of massive periretinal proliferation by injecting cells of differing origins into the rabbit vitreous cavity. These cells included autologous and homologous fibroblasts, homologous chondrocytes, homologous retinal pigment epithelial cells, heterologous bovine endothelial cells, and heterologous murine embryonal cells. All cell injections caused vitreous and retinal membrane formation that resulted in a process similar to massive periretinal proliferation. Clinically the character of the membranes formed and the time course in the development of traction retinal detachments was similar for all the different cell types. The initial cell dosage injected was the critical factor in determining the severity of the traction retinal detachments leading to massive periretinal proliferation.

Choroidal vascular changes in toxemia of pregnancy.

Twenty-seven patients with toxemia of pregnancy were examined during a postpartum period of two days to eight months. Five of these manifested abnormal photographic and angiographic findings including disk and retinal edema, retinal striae, deep retinal yellow-white focal lesions, choroidal nonfilling, leakage of dye from the optic disk and deep retinal lesions, and retinal pigment epithelial window defects. The location and configuration of the leakage correlated with the defects seen on color photography. The normal retinal, and predominantly abnormal choroidal vascular patterns provide evidence implicating choroidal vascular insufficiency as the primary basis for secondary retinal detachments seen in toxemia of pregnancy.