Serous retinal detachment and cystoid macular edema in hypotony maculopathy.

PURPOSE: To report the foveal structural findings of hypotony maculopathy imaged with optical coherence tomography. METHODS: Case report of a 39-year-old white woman with a 20 year history of uveitis, who underwent pars plana vitrectomy and pars plana Baerveldt implant for intractable glaucoma. Four months postoperatively, decreased vision and hypotony maculopathy ensued. Optical coherence tomographic (OCT) images were taken horizontally through the macula. RESULTS: OCT demonstrated large intraretinal cysts, serous macular detachment, and choroidal folds, which resolved upon resolution of hypotony. CONCLUSION: Cystic macular changes and serous macular detachment can be prominent features of hypotony maculopathy.

Modified technique of haptic externalization for scleral fixation of dislocated posterior chamber lens implants.

PURPOSE: To describe a modified technique of haptic externalization during repositioning of dislocated posterior chamber lens implants, which facilitates placement of scleral fixation sutures around the haptic for implant stabilization. METHODS: We describe a technique of repositioning a dislocated posterior chamber implant with scleral fixation sutures, which uses a small, clear corneal incision for externalization of the haptic. After a loop of 10-0 Prolene suture (Ethicon, Inc., Somerville, New Jersey) is placed around the externalized haptic, the sutures are retrieved through a sclerotomy 1.0 mm posterior to the limbus. The haptic is reimplanted into the ciliary sulcus. A separate scleral fixation bite closes the sclerotomy, and it is tied to the 10-0 Prolene sutures looped around the haptic. RESULTS: The dislocated implant was stable and fixated in good position 5 months after surgery using this technique. CONCLUSION: This externalization technique minimizes the extensive intraocular manipulations necessary to create a suture loop around a haptic of a dislocated implant. The clear corneal incision allows for clear visualization during externalization of the haptic.

Vitreous hemorrhage after intravitreal tissue plasminogen activator (t-PA) and pneumatic displacement of submacular hemorrhage.

PURPOSE: To report the immediate complication of dense vitreous hemorrhage after intravitreal injection of tissue plasminogen activator and gas for treatment of two cases of sudden submacular hemorrhage associated with retinal arterial macroaneurysm. METHODS: Case reports. RESULTS: Two patients, a 67-year-old woman and a 92-year-old man, presented with sudden vision loss related to submacular hemorrhage from a retinal macroaneurysm. Tissue plasminogen activator at a dose of 50 microg to 75 microg and a sulfur hexafluoride (SF(6)) gas bubble were injected intravitreally under local anesthesia. Dense vitreous hemorrhage was noted on the first postoperative day in both cases, which subsequently required pars plana vitrectomy removal. CONCLUSION: Sudden severe vitreous hemorrhage may be an immediate complication after intravitreal injection of tissue plasminogen activator and gas for treatment of submacular hemorrhage associated with retinal arterial macroaneurysm.

Multiple evanescent white dot syndrome in older patients.

PURPOSE: To report two patients in their seventh decade who exhibited findings consistent with multiple evanescent white dot syndrome. METHODS: Case reports of two patients referred for evaluation of decreased vision, visual field loss, and retinal white spots. RESULTS: A 60-year-old man and a 67-year-old woman had photopsia, visual field loss, and decreased central visual acuity. Examination disclosed numerous white retinal spots, ranging from 50 to 400 microm, with eventual foveal granularity. Visual field testing showed an enlarged blind spot and peripheral field defects. Fluorescein angiography, electroretinography, and electrooculography results were consistent with multiple evanescent white dot syndrome. Eventually, the retinal lesions resolved in both patients and baseline visual acuity was recovered. CONCLUSION: A diagnosis of multiple evanescent white dot syndrome should be considered in patients with retinal findings typical of multiple evanescent white dot syndrome, regardless of age.

Paraproteinemias associated with serous detachments of the retinal pigment epithelium and neurosensory retina.

BACKGROUND: Serous retinal and retinal pigment epithelial detachments resembling central serous chorioretinopathy developed in three patients who had paraproteinemias. METHODS: The patients in this study were examined at two institutions, and their charts, photographs, and fluorescein angiograms were reviewed by the authors. Two patients had cryoglobulinemia and one had lgA, lgM benign gammopathy. RESULTS: These patients had decreased central visual acuity and metamorphopsia at the initial examination. All three patients were women. Two patients were taking systemic corticosteroids in tapering doses at the time of the initial examination. The multiple serous retinal pigment epithelial and retinal detachments were unilateral in one patient and bilateral in two patients. Two patients were treated with laser photocoagulation because of chronic visual loss and foveal detachments. At the most recent examination, each patient had visual acuity of 20/30 or better in both eyes and complete resolution of subretinal fluid. CONCLUSIONS: Patients with paraproteinemia may develop multiple serous detachments of the retinal pigment epithelium and of the neurosensory retina. The chorioretinopathy in these patients may have been related to their paraproteinemia, type A personality, corticosteroid use, or a combination of these factors. The final visual acuity in these three patients was good.

Visual acuity as a prognostic indicator in stage I macular holes. The Vitrectomy for Prevention of Macular Hole Study Group.

PURPOSE/METHODS: To evaluate the role of initial visual acuity as a factor for progressive loss of vision or progression to a full-thickness macular hole in eyes with stage I macular holes (tractional foveal detachment without dehiscence). The study population included 35 patients with stage I macular holes with best-corrected visual acuity of 20/25 to 20/80 in one eye, and a full-thickness macular hole in the fellow eye. RESULTS/CONCLUSIONS: Eyes with stage I macular holes with best corrected visual acuity between 20/50 and 20/80 had a 66% (ten of 15 eyes) rate of progression to full-thickness macular hole, whereas eyes with best-corrected visual acuity of between 20/25 and 20/40 had a 30% (six of 20 eyes) risk of progression to full-thickness macular hole. The risk of progression to macular hole is significantly higher in eyes with stage I macular holes with best-corrected visual acuity of 20/50 or worse (P = .03).

Clinical correlation of ultrasonographic findings in macular holes.

PURPOSE: Theoretically, idiopathic macular holes develop because of tangential vitreous traction on the fovea. The purpose of this study was to demonstrate ultrasonographically the vitreomacular relationships in a series of 44 consecutive patients with macular holes and to correlate the ultrasonographic findings with the clinical and intraoperative findings of these patients. METHODS: I examined 47 eyes with a macular holes by using contact lens biomicroscopy and clinically staged the macular hole and the status of the vitreous. A kinetic B-scan ultrasonographic examination of the vitreomacular relationships was performed in each study eye and in the fellow eye by using a contact method, with topical anesthesia. RESULTS: The clinical stage of macular hole in 47 eyes of 44 patients included eight holes in stage 1, five in stage 2, 22 in stage 3, and 12 in stage 4. The vitreous was attached to the macular region by ultrasound interpretation in seven of eight stage 1 holes, two of five stage 2 holes, 21 of 22 stage 3 holes, and zero of 12 stage 4 holes. The correlation between the clinical status of the vitreous and the ultrasonographic findings was high (94%). The status of the vitreous by ultrasound was confirmed intraoperatively in all 14 patients undergoing subsequent surgery. CONCLUSIONS: Ultrasonographic examination of the vitreomacular relationships provides an accurate assessment of vitreomacular attachment or detachment. The ultrasonographic findings in these 47 eyes with macular holes support the vitreomacular traction theory of macular holes.

Early stage of macular hole in a severely myopic eye.

PURPOSE/METHODS: A progressive early stage of macular hole developed in a severely myopic eye of a 37-year-old woman. RESULTS/CONCLUSIONS: The patient improved after pars plana vitrectomy, peeling of the posterior hyaloid, and gas-fluid exchange. Biomicroscopic, ultrasonographic, and intraoperative findings support the theory of cortical vitreous traction as the cause of macular hole in severely myopic eyes.

Intraocular gas and low-altitude air flight.

BACKGROUND: Air travel has been contraindicated for patients with intraocular gas on the basis of experimental studies, because of the risk of elevated intraocular pressure during atmospheric depressurization. METHODS: A clinical study of gas bubble volume and intraocular pressure rise during a low-altitude air flight was performed on a patient with a gas bubble volume of 65% after retinal detachment surgery. RESULTS: The flight was well tolerated, and the patient did not experience pain or decreased vision. The maximum altitude of the flight was 3,000. Maximum intraocular pressure was 49 mmHg, with a baseline of 16 mmHg. Increases in intraocular pressure and bubble volume were instantaneous with changes in altitude. Implications for pressurized flight situations are discussed. CONCLUSION: Low-altitude air flight can be well tolerated by patients with intraocular gas, even with a relatively large vitreous cavity gas fill. Decisions about when to let patients with intraocular gas fly should be made on an case-to-case basis, depending on ocular factors and the planned flight characteristics.

Posterior chamber intraocular lens insertion during pars plana lensectomy and vitrectomy for complications of proliferative diabetic retinopathy.

We inserted posterior chamber lenses into 21 eyes with complications of diabetic retinopathy upon completion of pars plana lensectomy and vitrectomy in a single session. After the original surgery, two eyes developed retinal detachments and underwent vitrectomy revisions with scleral buckling, one eye had a fluid-gas exchange for residual vitreous cavity blood, one eye had supplemental laser treatment, and one eye had intraocular antibiotics for endophthalmitis. Six months later, postoperative vision was better in 16 of the 21 eyes (76%), the same in four eyes (19%), and worse in one eye (5%). In 16 eyes visual acuity was 20/200 or better, and in six eyes it was 20/40 or better postoperatively. Decreased vision was caused by preexisting macular disease; two eyes had corneal edema with iris neovascularization associated with residual retinal detachment. The procedure and lenses were well tolerated and provided good pseudophakic vision.

Herpes simplex virus type 1. A cause of the acute retinal necrosis syndrome.

The authors have isolated herpes simplex virus type 1 (HSV-1) from the vitreous of two patients with acute retinal necrosis. Clinical and laboratory data suggest that one case represented a primary HSV-1 infection, whereas the other case appeared to be a recurrent HSV-1 infection. In the primary case, changes on magnetic resonance imaging (MRI) suggest spread of the virus posteriorly to both optic tracts and the lateral geniculate ganglia. This case shares many features with the "von Szily" experimental model for HSV retinitis in the mouse.