Macular full-thickness and lamellar holes in association with type 2 idiopathic macular telangiectasia.

PURPOSE: To describe patients with full-thickness macular holes (FTMHs) and lamellar macular holes (LMHs) in association with type 2 idiopathic macular telangiectasia (type 2 IMT). METHODS: Six patients with either FTMH or LMH and type 2 IMT were evaluated by means of optical coherence tomography (OCT) imaging, funduscopy, and fluorescein angiography. RESULTS: The age of the examined patients ranged from 57 to 70 years (mean 62.5+/-5.2), and best-corrected visual acuity of the affected eyes ranged from 20/50 to 20/200 (mean 20/100). All eyes showed macular abnormalities typical for nonproliferative type 2 IMT except for one eye with a proliferative disease stage. Three patients had an FTMH, one presenting with bilateral FTMH, and three had an LMH on OCT. In all cases of FTMH, the macular holes did not have elevated margins. Surgery was performed in two patients with a FTHM without subsequent functional improvement. CONCLUSIONS: The altered foveal anatomy with progressive atrophic changes within the neurosensory retina in type 2 IMT may predispose to the development of FTMH and LMH. Type 2 IMT should be considered in the differential diagnosis in patients presenting with macular holes. The association between the two may reflect alternative pathogenetic mechanisms in the development of macular holes.

Clonidine as an adjuvant to local anaesthetic axillary brachial plexus block: a randomized, controlled study.

BACKGROUND: We compared the effects of clonidine added to levobupivacaine and bupivacaine on axillary brachial plexus block as well as the effectiveness of levobupivacaine alone compared with bupivacaine alone. METHODS: In this prospective, randomized, controlled, double-blind trial, four groups of 20 patients each were investigated, using (i) 40 ml of levobupivacaine 0.5% plus 0.150 mg of clonidine, (ii) 40 ml of levobupivacaine 0.5% plus 1 ml of NaCl 0.9%, (iii) 40 ml of bupivacaine 0.5% plus 0.150 mg of clonidine, and (iv) 40 ml of bupivacaine 0.5% plus 1 ml of NaCl 0.9%, respectively. The onset of motor and sensory block and duration of sensory block were recorded. RESULTS: There was no significant difference in duration between groups, but a significantly higher variance (P<0.001) was found in the two groups with clonidine than in the two groups without. CONCLUSIONS: These findings suggest responder and non-responder behaviour is a result of the addition of clonidine.

The fellow eye of patients with phakic rhegmatogenous retinal detachment from atrophic holes of lattice degeneration without posterior vitreous detachment.

BACKGROUND: Primary phakic rhegmatogenous retinal detachment (RRD) without posterior vitreous detachment (PVD) represents a unique clinical entity that behaves differently from RRD associated with PVD. While previous studies have reported the long term findings in the fellow eye of patients with RRD and PVD, the outcome of the fellow eye of patients with RRD without PVD is not known. METHODS: Consecutive patients with RRD not associated with PVD were studied retrospectively. The authors evaluated the fellow eye for retinal detachment or other vision threatening pathology. RESULTS: 27 patients (mean age 32 years) were studied with follow up of between 9 and 326 months (mean 111 months). 24 (89%) were myopic. Bilateral retinal detachment occurred in eight patients (30%). On initial examination, 17 patients (63%) had retinal findings (including lattice degeneration, atrophic holes, and/or cystic retinal tufts) in the fellow eye that might predispose them to retinal detachment. 14 vision threatening events or diagnoses occurred (nine of which were rhegmatogenous in nature) in the fellow eye including eight retinal detachments, one traumatic PVD without retinal tears, one retinal tear after PVD, one diagnosis of pigmentary glaucoma needing trabeculectomy, two visually significant cataracts, and one diagnosis of chorioretinitis. 23 patients (85%) maintained visual acuity better than 20/50, with most retaining 20/20 vision in the fellow eye. CONCLUSIONS: Patients who experience RRD without PVD are at risk of developing vision threatening events in the contralateral eye and, as such, the fellow eye should be followed carefully.

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.

Proliferative vitreoretinopathy: a natural history of the fellow eye.

OBJECTIVE: To determine how often the fellow eyes of patients with proliferative vitreoretinopathy (PVR) harbor a vision-threatening condition at presentation; to determine how often the fellow eyes of patients with PVR develop vision-threatening conditions; and to determine how often the fellow eyes of patients with PVR lose vision. DESIGN: A retrospective case review design was used. PARTICIPANTS: Two hundred and forty-nine patients with PVR were studied. INTERVENTION: The authors observed the fellow eye of eyes with PVR for vision-threatening pathology. MAIN OUTCOME MEASURES: The primary anatomic endpoint of this study was the detection of vision-threatening pathology in the fellow eye of patients with PVR. Secondary outcome measures included the development of visual loss in the fellow eye. RESULTS: A wide variety of vision-threatening conditions were diagnosed in the fellow eyes of patients with PVR. Of patients meeting entry criteria with reliable follow-up data, greater than 50% of fellow eyes demonstrated vision-threatening pathology at some point during follow-up. CONCLUSIONS: Patients who develop PVR in one eye are at considerable risk for developing vision-threatening pathology or vision-damaging conditions in the fellow eye. This information should be carefully considered when making surgical decisions in patients facing PVR surgery.

Bilateral endogenous Fusarium endophthalmitis associated with acquired immunodeficiency syndrome.

A 51-year-old man with acquired immunodeficiency syndrome and cytomegalovirus retinitis had bilateral endogenous fungal endophthalmitis. Cultures yielded Fusarium species. Histopathologic examination showed a severe necrotizing acute and granulomatous reaction, with numerous fungal elements in the retina and uveal tract. Fungal elements were seen in the lens, sclera, and emissarial vessels. Angiopathic infiltration by fungus and widespread thrombosis produced retinal and choroidal infarction. In some areas, fungal infection coexisted with cytomegalovirus retinitis. The bilateral distribution suggests hematogenous seeding of the eyes. The eye findings were the first clinically apparent manifestations of fungal disease in this patient.

Pars plana incisions of four patients: histopathology and electron microscopy.

The pathology of pars plana incisions of four patients is described: three with light microscopy and one with light and electron microscopy. Two eyes were removed because of choroidal melanoma, immediately and 8 days after vitrectomy and transvitreous retinal biopsy. Considerable disruption of tissues surrounding the pars plana incisions was observed. Vitreous was incarcerated in the wounds, which healed with granulation tissue. One eye was examined 4 months after vitrectomy for diabetic retinopathy and a failed pars plana filtering operation. It contained fibrovascular ingrowth from all the incisions, infiltrating the vitreous base with granulation tissue and causing vitreous haemorrhage and retinal detachment. One eye was removed 1 year after vitrectomy for anterior hyaloidal fibrovascular proliferation and early phthisis. The wound had fibrous ingrowth histologically and evidence of active fibroplasia.

Vitrectomy techniques in late-stage Coats'-like exudative retinal detachment.

Retinal telangiectasia is the hallmark of Coats' disease. In the late stages, leakage from these abnormal vessels can result in a total, bullous exudative retinal detachment with cholesterol-laden subretinal fluid. Secondary angle-closure glaucoma may result in a blind and painful eye which may require enucleation or evisceration. Surgical reattachment of the retina and destruction of the retinal telangiectasia may preserve these eyes. We have found that vitrectomy, internal drainage of subretinal fluid and cholesterol, direct treatment of the retinal telangiectasia with intraocular diathermy and intravitreal gas or silicone oil injection are effective surgical techniques for salvaging these severely damaged eyes.

The progressive outer retinal necrosis syndrome. A variant of necrotizing herpetic retinopathy in patients with AIDS.

BACKGROUND: The progressive outer retinal necrosis syndrome is a recently recognized variant of necrotizing herpetic retinopathy. This report characterizes more fully its clinical features and course. METHODS: Using standardized clinical criteria, patients with progressive outer retinal necrosis syndrome from four institutions were identified. Patient records were reviewed retrospectively for the following data: medical and demographic characteristics, presenting symptoms, physical findings, course, responses to treatment, and outcomes. RESULTS: Thirty-eight patients (65 involved eyes) were studied. All had acquired immune deficiency syndrome. A known history of cutaneous zoster was documented in 22 (67%) of 33 patients. Median CD4 lymphocyte count was 21/mm3 (range, 0-130/mm3). Median follow-up was 12 weeks. The most common presenting symptom was unilateral decreased vision (35 of 65 eyes, 54%); median visual acuity at presentation was 20/30 (range, 20/20 to no light perception [NLP]). Anterior chamber and vitreous inflammatory reactions were absent or minimal in all patients. Typical retinal lesions were multifocal, deep opacities scattered throughout the periphery, although macular lesions also were present in 21 eyes (32%) at diagnosis. Lesions progressed rapidly to confluence. Initial intravenous antiviral therapy appeared to reduce disease activity in 17 (53%) of 32 eyes, but treatment did not alter final visual outcome. Visual acuity was NLP in 42 (67%) of 63 eyes within 4 weeks after diagnosis. Retinal detachment occurred in 43 (70%) of 61 eyes, including 13 (93%) of 14 eyes that received prophylactic laser retinopexy. CONCLUSION: The progressive outer retinal necrosis syndrome is characterized by features that distinguish it from cytomegalovirus retinopathy, acute retinal necrosis syndrome, and other necrotizing herpetic retinopathies. Visual prognosis is poor with current therapies.

A light and electron microscopic study of the healing of pars plana incisions in the rhesus monkey.

Pars plana incisions were made in 11 rhesus monkey eyes. Six animals had injections of 0.1 ml of blood into the vitreous cavity with a 25-gauge needle and five animals had vitrectomy through a 4-mm incision with a multifunction vitrectomy probe. Six to 13 years later the scars in the pars plana were found to consist of fibrous tissue and blood vessels which extended from the episclera into the vitreous. The intravitreous scar was shaped by the incarceration of vitreous strands in the internal aspect of the wounds. There were quantitative, but no qualitative differences between the two types of incision. The ultrastructural features were those of mature scar tissue: fibroblasts, adult collagen, uveal melanocytes, macrophages, myelinated and non-myelinated nerves, and capillaries with non-fenestrated endothelium. There were associated proliferative ciliary epithelial changes, but no evidence of ciliary epithelial metaplasia.

Wound complications in pars plana vitrectomy.

Eighteen eyes with examples of clinically important wound-related complications are reported. These include hemorrhage, fibrous ingrowth, and tractional or mechanical problems. Wound hemorrhages may occur early or late and can be the cause of substantial morbidity. Furthermore, intraocular blood is undesirable because it may provoke cataract formation, contribute to the postvitrectomy fibrin syndrome, induce fibrovascular proliferation, and lead to further surgery to remove the blood. Fibroplasia at the wound sites may in some patients contribute to the development of anterior hyaloid fibrovascular proliferation. Fibrous ingrowth may occur early or late and may be self-limited, with few side effects, or florid, with progression to retinal detachment or phthisis bulbi. Dilation of subconjunctival blood vessels entering the incision site suggests the presence of fibrous ingrowth or fibrovascular proliferation occurring in the vitreous base. Tractional or mechanical problems include retinal breaks, which may or may not lead to retinal detachment, and scarring within the vitreous base, which may contribute to the formation of anterior vitreoretinal traction or anterior proliferative vitreoretinopathy.

Management of giant retinal tears without scleral buckling. Use of radical dissection of the vitreous base and perfluoro-octane and intraocular tamponade.

The introduction of intraoperative perfluorocarbon liquids in the management of giant retinal tears has allowed exact anatomic reapposition of the retina and the giant retinal tear. Therefore, the authors managed 11 eyes with giant retinal tears and no proliferative vitreoretinopathy without scleral buckling. Maximum removal of the basal vitreous gel was performed in all cases, and perfluoro-octane was used intraoperatively to unfold the inverted posterior flap and reattach the retina completely. Endophotocoagulation was applied to the edges of the tear and perfluoropropane or silicone oil was used as an intraocular tamponade. Although 1 eye required reoperation for a redetachment from posterior proliferative vitreoretinopathy, all retinas were reattached with final visual acuity of 5/200 or better in 9 eyes. Eight additional major procedures were necessary in seven eyes: removal of silicone oil in four (with removal of perisilicone proliferation in three), repeat vitrectomy and membrane removal with photocoagulation twice in one eye, cataract extraction in one eye, and removal of a macular pucker in one eye. Four eyes required postoperative fluid-gas exchange and three eyes had tissue plasminogen activator injections into the anterior chamber for postoperative fibrin reactions.

Herpesvirus antibody levels in the etiologic diagnosis of the acute retinal necrosis syndrome.

Quantitative antibody levels to three herpesviruses in acute and chronic sera from six patients with clinical signs of the acute retinal necrosis syndrome were consistent with a specific etiologic diagnosis only in the two cases associated with cutaneous herpes zoster. Available data on acute and convalescent antibody titers to herpes group viruses from these six patients in addition to data from 27 acute retinal necrosis cases from the literature disclosed that only 13 of the 33 patients (39%) had a diagnostic increase or decrease in herpes group viral antibody levels on serial sampling. Three patients had nondiagnostic changes in viral antibody levels despite positive vitreous cultures for herpesviruses. In contrast, a review of 25 cases from the literature with paired antiviral serum and intraocular fluid antibody levels suggested a more promising approach to the etiologic diagnosis of the acute retinal necrosis syndrome. By calculating the ratio of antiviral antibodies in intraocular fluid and serum, an etiologic diagnosis could be made in 12 of 14 (86%) of subacute and convalescent samples. The sensitivity of this method decreased to 72% (13 of 18) when fluids were obtained earlier in the course of the disease.

Topical indomethacin in the treatment of chronic cystoid macular edema.

Eighty percent of 30 eyes with chronic cystoid macular edema (CME) after cataract extraction achieved improved visual acuity of three or more lines when treated with 1% indomethacin eye drops. Of these patients 53% demonstrated an "on/off" phenomenon induced by the initiation and cessation of treatment documented by visual acuity measurements and fluorescein angiography. This "on/off" phenomenon suggests that there is a direct relationship between the use of 1% indomethacin eye drops and the resolution of chronic CME after cataract extraction. Previous studies on the treatment of CME with indomethacin have not addressed the use of indomethacin eye drops for chronic CME.

Intravitreous granulation tissue and retinal detachment following pars plana injection for cytomegalovirus retinopathy.

Recently, the pars plana route of injection has been used to administer drugs for the treatment of severe intraocular infections. We observed a complication of this method in a patient with AIDS and cytomegalovirus (CMV) retinopathy.

Surgical management of retinal detachment associated with the acute retinal necrosis syndrome.

We operated on nine eyes in eight patients with retinal detachment associated with acute retinal necrosis (ARN) syndrome. The patients were treated with scleral buckling, vitreoretinal surgery, or a combination of these treatments. Vitrectomised eyes underwent combinations of lensectomy, membrane dissection, scleral buckling, air-fluid exchange, endolaser photocoagulation, cryotherapy, and retinal tamponade with C3F8 gas or SF6 gas. Macular attachment was achieved in eight (89%) eyes. Vision improved in seven (78%) eyes, of which five (56%) achieved 20/200 or better vision. Three eyes that had received laser treatment posterior to areas of retinitis suffered retinal detachment despite this prophylactic treatment. Poor visual outcome resulted from viral infection of the optic nerve or macular involvement, macular hole formation, macular pucker, or hypotony.