Postoperative endophthalmitis: optimal management and the role and timing of vitrectomy surgery.

PURPOSE: To review the evolving role of pars plana vitrectomy, as well as other therapeutic modalities, in the treatment and prevention of postoperative endophthalmitis and its sequelae. METHODS: Medline database searches and review of recent relevant literature on the prevention and treatment of postoperative endophthalmitis. RESULTS: Despite significant technologic advances in ophthalmic surgery and the ready availability of improved pharmacologic agents, the rates of postoperative endophthalmitis have dramatically increased over the last decade. New surgical procedures, interventions, and techniques have increased patient exposures to this serious surgical complication. Cause, presentation, and outcome vary significantly requiring a tailored approach to each case. Appropriate prophylaxis and good surgical technique remain the mainstays of prevention. Intravitreal antibiotics and pars plana vitrectomy remain the primary treatment options. CONCLUSIONS: Postoperative endophthalmitis is a complex and multifaceted entity with potentially grave visual consequences. It requires a multifaceted approach, including appropriate prevention and prophylaxis, rapid recognition, and aggressive management. Since publication of the Endophthalmitis Vitrectomy Study, improvements in pharmacologic agents and vitrectomy techniques have refocused debate on the role of early surgical intervention in this condition.

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.

Treatment strategies for postoperative Propionibacterium acnes endophthalmitis.

PURPOSE: Propionibacterium acnes endophthalmitis after cataract extraction and posterior chamber intraocular lens (IOL) implantation is characterized by a chronic indolent course, frequently associated with recurrence after standard endophthalmitis treatment. This study was designed to evaluate the efficacy of various therapeutic methods in the treatment of primary and recurrent episodes of postoperative P. acnes endophthalmitis. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Twenty-five patients treated at Wills Eye Hospital for P. acnes endophthalmitis. METHODS: The authors retrospectively reviewed the clinical charts and microbiology files of all patients treated at Wills Eye Hospital between January 1991 and April 1998 with culture-proven P. acnes endophthalmitis after cataract extraction and posterior chamber IOL implantation. MAIN OUTCOME MEASURES: Results of cultures and microbiologic examinations, efficacy of various treatment methods in the prevention of recurrent inflammatory episodes, and final visual outcome. RESULTS: Twenty-five patients who met inclusion criteria were identified; initial therapy consisted of 1 of the following: intraocular antibiotic (IOAB) injections alone (2 patients); IOAB combined with pars plana vitrectomy (PPV) (10 patients); IOAB and PPV combined with partial capsulectomy (9 patients); and IOAB, PPV, total capsulectomy, and IOL exchange (4 patients). Nearly half of the patients (10 of 21, or 48%) initially treated with IOAB alone (1 of 2), IOAB and PPV (5 of 10), and IOAB combined with PPV and partial capsulectomy (4 of 9) required further therapeutic interventions for recurrent disease. Retreatment with IOAB alone or combined with PPV and partial capsulectomy in these patients failed to eradicate the infection in three (75%) of four patients. None of the patients (0 of 4) treated initially with total capsulectomy and IOL exchange required additional surgical intervention. Furthermore, none of the patients (0 of 13) who underwent total capsulectomy with IOL removal or exchange or IOL exchange alone as an initial, secondary, or tertiary treatment required further intervention. CONCLUSION: In the authors' series, approximately half of the patients with P. acnes endophthalmitis were treated successfully initially with nonsurgical or limited surgical intervention. All patients treated with total capsulectomy and IOL exchange or removal, either as an initial treatment or for recurrent disease, were cured. Removal of the entire capsular bag and the IOL may be performed as a definitive initial therapy and should be performed for recurrent inflammation.

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.

Stop codon in the procollagen II gene (COL2A1) in a family with the Stickler syndrome (arthro-ophthalmopathy).

Linkage analysis with restriction fragment length polymorphisms for the gene for type II procollagen (COL2A1) was carried out in a family with the Stickler syndrome, or arthro-ophthalmopathy, an autosomal dominant disorder that affects the eyes, ears, joints, and skeleton. The analysis demonstrated linkage of the disease and COL2A1 with a logarithm-of-odds score of 1.51 at zero recombination. A newly developed procedure for preparing cosmid clones was employed to isolate the allele for type II procollagen that was linked to the disease. Analysis of over 7000 nucleotides of the gene revealed a single base mutation that altered a CG dinucleotide and converted the codon CGA for arginine at amino acid position alpha 1-732 to TGA, a stop codon. From previous work on procollagen biosynthesis, it is apparent that the truncated polypeptide synthesized from an allele with a stop codon at alpha 1-732 cannot participate in the assembly of type II procollagen, and therefore that the mutation would decrease synthesis of type II procollagen. It was not apparent, however, why the mutation produced marked changes in the eye, which contains only small amounts of type II collagen, but relatively mild effects on the many cartilaginous structures of the body that are rich in the same protein.

Histopathology of incipient fundus flavimaculatus.

A 9-year-old boy was diagnosed with fundus flavimaculatus in his left eye. The boy's fellow eye was enucleated at 16 months of age for retinoblastoma. The authors reviewed the material submitted for histopathologic examination and found that the retinal pigment epithelial cells demonstrated increased autofluorescence and increased reactivity to periodic acid-Schiff staining. Many cells had their melanin granules displaced toward the cell apex. The retinal pigment epithelial changes are consistent with previous histopathologic findings in fundus flavimaculatus and imply that the structural changes are seen in early life.

Computerised visual field deficits in tears of the retinal pigment epithelium.

Retinal Pigment epithelial tears have been well documented as a complication of pigment epithelial detachment in patients with age related macular degeneration. Spontaneous and iatrogenic separation of detached retinal pigment epithelium, with subsequent retraction and exposure of the underlying choriocapillaris and Bruch's membrane, usually results in poor visual function in the affected areas. However, exact characterisation of the resultant scotomas has not been previously described. We present two patients with spontaneous pigment epithelial tears who underwent Octopus computerised visual field analysis. The density and characteristics of their associated field loss is compared with their clinical and fluorescein angiographic appearance.

Treatment of foveal pigment epithelial detachments with contiguous extrafoveal choroidal neovascular membranes.

Fourteen eyes of 14 patients who had subfoveal retinal pigment epithelial detachments and extrafoveal contiguous choroidal neovascular membranes associated with age-related macular degeneration underwent laser photo-coagulation treatment directed solely to their choroidal neovascular membrane. In eight of 14 eyes (57%), photocoagulation treatment resulted in closure of the choroidal neovascular membrane with subsequent collapse of the pigment epithelial detachment. Six of the eight eyes also had visual improvement. In six of 14 eyes (43%), the neovascular membrane eventually progressed into the fovea with resultant visual loss. The results of our study suggest that photocoagulation of extrafoveal choroidal neovascular membranes associated with foveal detachments of the retinal pigment epithelium may preserve and even improve visual function in affected patients.

Flurbiprofen sodium to prevent intraoperative miosis during vitreoretinal surgery.

To assess the efficacy of flurbiprofen sodium 0.03% at maintaining pupillary dilation during vitreoretinal surgery, we performed a randomized, double-masked, controlled trial of 139 consecutive patients. The mean decrease in pupil size during surgery in patients who received flurbiprofen was 0.9 mm; for patients who did not receive the drug it was 0.8 mm. The type of surgery performed (vitrectomy or scleral buckle), gender, age, lens status, and a history of diabetes or previous intraocular surgery were assessed and the addition of flurbiprofen to routine preoperative dilation did not significantly affect the mean change in pupil size for any of these subgroups. Of the nine patients who developed at least 3 mm of miosis, five received flurbiprofen and four did not. Use of flurbiprofen did not appear to reduce intraoperative miosis during vitreoretinal surgery in a clinically meaningful manner.

Retinal injury and detachment in boxers.

From March 1983 to October 1985, the members of the Retina Service of the Wills Eye Hospital treated nine boxers with traumatic retinal injuries. Eight of these had retinal detachments requiring scleral buckling procedures. The ninth had a large tear without subretinal fluid that was treated with cryotherapy alone. In this article the authors describe the type and location of retinal injury, initial and follow-up treatment, and associated ocular findings and the mechanism of injury.