Silicone oil tamponade to seal macular holes without position restrictions.

OBJECTIVE: The authors performed a study to determine the effectiveness and safety of silicone oil as a substitute for gas to fill the vitreous cavity to treat macular holes. DESIGN: Multicenter, nonrandomized, interventional trial. PARTICIPANTS: Thirty-seven consecutive patients chose vitrectomy with silicone tamponade instead of gas to treat 40 eyes with stage-2 to stage-4 idiopathic age-related macular holes. Stage-2 holes constituted 40% of the holes, and stage-3 and stage-4 holes made up 60%. INTERVENTION: All eyes were treated with vitrectomy, manual detachment of the posterior vitreous face (not done for stage-4 holes), autologous serum instillation, and silicone fill of the vitreous cavity. After insertion of the oil, the patients resumed normal activity with no restriction of head or eye position except to avoid faceup position. The oil was removed after approximately 6 weeks. MAIN OUTCOME MEASURES: The authors considered the seal of the macular hole and the preoperative and postoperative logarithm of the minimum angle of resolution (logMAR) visions the most significant measures for comparison to other studies. RESULTS: Eighty percent of all holes and 86% of holes not treated previously were sealed with a single silicone tamponade of the vitreous cavity. The logMAR value of visual acuity improved an average of 0.26 (2.6 lines) to 0.61 (20/81) for all eyes and 0.34 (3.4 lines) to 0.52 (20/66) when the macular hole sealed. Completeness of fill of the vitreous cavity with silicone affected seal of the macular hole. Three of eight eyes in which open holes developed after oil removal had less than 90% fill of the vitreous cavity by silicone. Sixty-nine percent of lenses increased opacity one grade or were removed after silicone tamponade. There were no significant adverse effects arising from silicone tamponade. CONCLUSIONS: Silicone oil tamponade of macular holes is effective and safe. Silicone may be optimal for the treatment of macular holes in persons who must travel, who cannot maintain facedown positioning, or who have monocular vision. The most important factor in the successful closure of the macular hole was the completeness of fill of the vitreous cavity with silicone oil.

Treatment of carotid-cavernous sinus fistulas using a detachable balloon catheter through the superior ophthalmic vein.

Four consecutive patients with carotid-cavernous sinus fistulas that could not be treated by the standard techniques of endoarterial balloon occlusion or embolization were successfully treated by advancement of a detachable balloon catheter through the ipsilateral superior ophthalmic vein. Under angiographic monitoring, the balloon was passed into the cavernous sinus, inflated to close the fistula, and detached. Three of the patients had a spontaneous fistula, and one had a traumatic fistula that had previously been trapped unsuccessfully. All patients had complete resolution of symptoms and signs after occlusion of the fistula. There were no intraoperative or postoperative complications. The transvenous approach to the cavernous sinus through the superior ophthalmic vein is a safe, effective treatment of carotid-cavernous sinus fistulas, whether they are direct or dural in nature.

Vitrectomy and scleral buckling methods for proliferative vitreoretinopathy.

The authors operated on 95 eyes with retinal detachment (RD) complicated by proliferative vitreoretinopathy (PVR) using vitrectomy combined with scleral buckling. The retina was successfully reattached in 10 (91%) of 11 eyes with mild PVR (B, C1), 14 (93%) of 15 eyes with moderate PVR (C2-C3), and 52 (75%) of 69 eyes with severe PVR (D1-D3). Thirteen (88%) of 15 eyes in which silicone oil was injected were successfully reattached. Eighty-eight percent of the 76 successfully reattached cases had a postoperative visual acuity of 5/200 or better; the median postoperative visual acuity was 20/200. Severe PVR was the cause of failure in 17 (89%) of 19 eyes in which the retina was not reattached.

Choroidopathy in systemic lupus erythematosus.

Choroidopathy in association with systemic lupus erythematosus (SLE) is a clinically unusual manifestation, previously described in only six patients, to our knowledge. We have followed up six patients with SLE and choroidopathy manifested by multifocal, serous elevations of the retinal pigment epithelium and sensory retina. In four patients, macular involvement was present, and they suffered visual loss. Two eyes of two patients progressed to large, bullous, exudative retinal detachments. In the three patients in whom control of the systemic disease was achieved, the serous detachments resolved. The pathogenesis is most likely related to choroidal vascular disease with resultant pigment epithelial damage and serous fluid leakage beneath the retina.

Uremic optic neuropathy.

Vision loss progressing over several days, reduced pupil reactions to light, and swollen optic nerves were the clinical features in six patients with severe renal disease manifested by uremia, anemia, and (in four patients) moderately or severely elevated blood pressure. In two patients pale edema of the optic nerve head extended into the macula. One patient with renal transplant rejection was in the early phases of cryptococcal meningitis that went undiagnosed for two weeks. Medical management with hemodialysis was followed by improvement of vision in four patients. In one patient, resumption of oral corticosteroid therapy was followed by improvement in vision. The patient whose vision improved the most rapidly was managed by prompt use of both dialysis and oral corticosteroid therapy. The patient with cryptococcal meningitis did not recover vision.

Osmotic tolerance of rabbit and human corneal endothelium.

Rabbit and human corneas were mounted in a specular microscope and perfused with a balanced salt solution of varying osmolality (200 to 500 mOsm). Measurements of corneal thickness were made throughout the perfusion period, and at selected times the corneas were fixed and prepared for scanning and transmission electron microscopy. A hypo-osmotic perfusion medium caused an increase in corneal thickness; by comparison, a hyperosmotic perfusion medium decreased corneal thickness in both rabbit and human corneas. Despite the marked changes in corneal thickness and the water movement that occurred across the endothelium, the cellular ultrastructure remained intact. In reversal studies (return to 300-mOsm perfusion medium), corneal thickness returned to control values with no marked changes in endothelial cell structure. These data indicate that the corneal endotheium can tolerate a wide range of solution osmolalities (200 to 400 mOsm) without marked endotheial cell breakdown if the essential ions are present.