Follow-up of functionally lost eyes after vitrectomy and silicone oil tamponade for tractional retinal detachment.

BACKGROUND: Is there any association between, on the one hand, retention or removal of silicone oil or any specific ocular finding in patients with functionally lost eyes after vitrectomy and silicone oil tamponade for tractional retinal detachment and, on the other, a greater chance of preservation of the eye? This information is important in deciding whether to remove silicone oil, as well as in counseling patients about their individual chances of preserving their eye. METHODS: Seventy-three consecutive patients with a functionally lost eye with a minimum follow-up of 3 years were retrospectively studied. The relation between the variables at study entry or the removal of silicone oil during the follow-up period and a subsequent intervention (enucleation, evisceration or conjunctival cover with a scleral shell) were tested for statistical significance with Cox proportional hazards analysis. RESULTS: The absence or removal of silicone oil was not associated with a greater chance of finally preserving the eye. Nor could we identify other factors which predicted better chances of preservation. CONCLUSION: The notion that functionally lost eyes after treatment with vitrectomy and silicone oil tamponade for complicated tractional retinal detachment have better chances of preservation of the eye without silicone oil is not supported by our study.

Occurrence of retained lens fragments after phacoemulsification in The Netherlands.

PURPOSE: To determine the incidence of retained lens fragments after phacoemulsification in The Netherlands and to evaluate the effect of vitrectomy on this complication. SETTING: Eleven vitreoretinal centers in The Netherlands. METHODS: We performed a retrospective analysis of all patients with retained lens fragments (N = 70) who were referred for vitreoretinal surgery to 11 specialized centers. Seven patients (10%) were treated with medication alone, and 63 (90%) had pars plana vitrectomy. Minimum follow-up after vitrectomy was 3 months. RESULTS: The incidence of retained lens fragments in The Netherlands was calculated at 0.9/1000 cataract operations. Retained lens fragments occurred during the learning curve and with experienced surgeons. After medical or surgical treatment, visual acuity was 20/40 or better in 43 of 70 patients (61%). Uveitis disappeared in all cases. Retinal detachment occurred in 10 patients (14%). Attached retinal breaks were treated in an additional 5 patients. Corneal grafting was performed in 2 patients. Patients who had immediate vitrectomy did not have better functional results than patients in whom vitrectomy was delayed. The iris-fixated claw lens was implanted successfully when capsular support was insufficient. CONCLUSIONS: The introduction of phacoemulsification in The Netherlands is associated with an increase of patients with retained lens fragments. Retained lens fragments are complicated by an increased risk for retinal detachment and corneal decompensation. Vitrectomy resulted in a marked improvement of visual acuity and clearing of uveitis.

Rubeosis of the iris in proliferative vitreoretinopathy.

PURPOSE: The authors report the findings and clinical course of rubeosis in patients with essentially reattached retinas after vitrectomy and silicone oil for proliferative vitreoretinopathy (PVR). METHODS: From 1989 on, the authors prospectively noted all patients with rubeosis and with attached retina posterior to the buckle after vitrectomy and silicone oil for PVR as a complication of rhegmatogenous retinal detachment. RESULTS: Thirty-eight patients (38 eyes) were studied. Mean follow-up after the appearance of rubeosis was 27 months (range, 6-66 months) in all patients, peripheral residual retinal detachment coexisted with rubeosis. Hypotony occurred in six patients. Cyclocryocoagulation for neovascular glaucoma had been performed in four patients. The peripheral detached retina was removed in 16 patients, resulting in total disappearance of rubeosis in 7 patients and regression in 4 more patients. In patients with visible, nonradially oriented iris vessels, the authors found vessels in the anterior chamber angle crossing the trabecular meshwork. The frequently present anterior synechiae in association with vessels never totalled more than three clock hours (except in the four patients who underwent cyclocryocoagulation). CONCLUSIONS: Detached retina peripheral to dense photocoagulation scars was present in all of these patients. Removal of this peripheral detached retina was statistically significantly associated with disappearance of rubeosis, which suggests that the peripheral detachment was a causative factor. Extensive anterior synechiae are not formed frequently in this condition. This may explain the infrequent (11%) occurrence of neovascular glaucoma. However, hypotony is more frequent.

Cytokines in vitreous humor: interleukin-6 is elevated in proliferative vitreoretinopathy.

PURPOSE: To measure the levels of interleukins (IL) 1 beta, 6, and 8, and tumor necrosis factor-alpha (TNF alpha) in the vitreous of patients with proliferative vitreoretinopathy (PVR), proliferative diabetic retinopathy (PDR), vitreous hemorrhage, and macular pucker. METHODS: Vitreous samples were collected, undiluted, from patients with PVR, PDR of varying severity, and miscellaneous lesions (vitreous hemorrhage from trauma, macular degeneration, vein occlusion, and non-PVR patients with giant tear, retinal detachment, and macular pucker). Immunoreactive levels of the cytokines, IL-1 beta, IL-6, IL-8, and TNF alpha were determined by enzyme-linked immunoadsorbent assays, and samples were analyzed for protein and hyaluronic acid content using standard assays. RESULTS: The levels of TNF alpha were below detection limits of the assay (< 3 pg/ml). In 45 of the 47 samples tested, IL-1 beta levels also were below detection limits of the assay (< 3 pg/ml). IL-6 levels ranged from < 30 to 5487 pg/ml, with the highest values observed in the PVR patients. IL-8 levels ranged from < 20 to 1900 pg/ml, and were consistently high in the miscellaneous group. Some of the PVR patients with C2 and C3 level severity also exhibited IL-8 levels exceeding 100 pg/ml. In a second study, IL-6 content of vitreous from miscellaneous and PVR patients was compared. In this study, significantly elevated levels of IL-6 were observed in the PVR patients (91.5 +/- 18 pg/ml) compared to the miscellaneous group (10.3 +/- 3.7 pg/ml) CONCLUSIONS: Elevated levels of IL-6 in the vitreous occur in PVR, implicating a role for this cytokine in the pathogenesis of this ocular disorder.

Five-year results of vitrectomy and silicone oil in patients with proliferative vitreoretinopathy.

The purpose for this study was to evaluate the results of silicone oil use in patients who have undergone vitrectomy for proliferative vitreoretinopathy (PVR). The authors reviewed the 5-year results of 50 consecutive patients (52 eyes) with grade C1/D3 PVR operated on in 1987. Silicone oil has been removed in 42 eyes. The retina remained attached in 38 eyes. Visual acuities were finger counting in 12 eyes and 0.1 or greater in 19 eyes. Glaucoma was thought to be the major cause of loss of visual acuity after an initial improvement (9 eyes), as well as the most frequent complication of surgery (13 eyes). Silicone oil was deemed nonremovable in 10 operated eyes. A questionnaire was developed to determine the patients' perceptions of the use of silicone oil, and 46 patients responded to the questionnaire. Four patients indicated that they would not have elected to have surgery again. Six patients thought that surgery was not worthwhile, but would permit treatment again. Most patients thought that a modest amount of improvement had taken place and that vision was stable. Subjectively, most patients believed that surgery was worthwhile.

Endophthalmitis: incidence, therapy and visual outcome in the period 1983-1992 in the Rotterdam Eye Hospital.

From 1983 to 1992, 134 patients were treated for clinically suspected endophthalmitis. 61% of this endophthalmitis population consisted of cases that were referred to our clinic. In this nine year period antibiotic treatment was carried out according to three consecutively used guidelines. These three treatment schemes differed in antibiotic spectrum and mode of antibiotic delivery. In 68 patients we performed vitrectomy on account of clinical deterioration under antibiotic treatment. We did not find significant differences in visual outcome between the three treatment groups. The incidence of endophthalmitis following cataract or vitreous surgery did not change throughout the study period. There was however a dramatic decrease in incidence of post-traumatic endophthalmitis following the introduction of a prophylactic antibiotic treatment scheme consisting of fortified gentamicin and cefazolin eyedrops, and intravenously and subconjunctivally administered gentamicin, cefazolin, and clindamycin. In 55 of 68 cases in which vitrectomy was performed in conjunction with intravitreal antibiotics, a vitreous or anterior chamber specimen was cultured. 36 patients had a positive culture result. In the group with positive culture result 42% had better visual acuity in the post-treatment period than before treatment. In the group with a sterile culture result 79% had better vision after treatment.

Analysis of local antibody production in the vitreous humor of patients with severe uveitis.

We analyzed the local antibody production in vitreous humor samples collected during vitrectomy in patients with severe vision-threatening uveitis. In 24 patients, paired serum and undiluted vitreous humor samples were collected and tested for antibodies against Toxoplasma gondii, herpes simplex virus, varicella-zoster virus, cytomegalovirus, Epstein-Barr virus, and Toxocara canis. Total IgG and the Goldmann-Witmer coefficient were determined. The initial diagnosis of ocular toxoplasmosis could be confirmed in six of the seven patients. The seventh patient showed a local antibody production against herpes simplex virus. One of the three patients with chronic panuveitis at initial diagnosis showed a local antibody production against T. gondii. These last two findings resulted in a change in medical treatment. Analysis of local antibody production in vitreous humor samples is a valuable diagnostic tool.

Retinal folds through the macula.

In a series of 137 consecutive conventional primary retinal detachment repairs we postoperatively found retinal folds through the macula in four cases (2.8%). All four patients had presented with an acute, bullous, superior detachment, and had been treated with an encircling band, drainage of subretinal fluid, injection of an air/gas mixture, cryocoagulation, and a radial buckle to close the largest retinal tear. Redundant retina (created by the encircling band and possibly by stretching in the bullous detachment) became folded either by compression by the gas-bubble in the recumbent patient, or by a steam roller action of the bubble when the patient sat up. In acute bullous detachments, we try to avoid this complication by using an air/gas bubble which is not greater than necessary to tampon the retinal break, and by positioning the patient in such a way that residual subretinal fluid is pressed away from the posterior pole.

Basal iridectomy at 6 o'clock in the aphakic eye treated with silicone oil: prevention of keratopathy and secondary glaucoma.

In the aphakic eye, with intact iris diaphragm, silicone oil has frequently caused a pupillary block. In this situation aqueous humour accumulates behind the iris and forces silicone oil through the pupil into the anterior chamber. An iridectomy at the 6 o'clock position can effectively prevent this pupillary block. The iridectomy allows free passage of aqueous to the anterior chamber which remains free of silicone oil. No permanent contact with silicone oil and the cornea is established, and development of keratopathy is prevented. The effect of this iridectomy in 62 eyes with intact iris diaphragm in patients in Rotterdam (35 cases) and Nagoya (27 cases) is demonstrated. Only in 6.5% of the cases was silicone oil present in the anterior chamber at the end of the follow-up period of 7 months.

[Liquid silicone in amotio surgery (II). Report on 280 cases - further development of the technic]. / Das flüssige Silikon in der Amotiochirurgie (II). Bericht über 280 Fälle - weitere Entwicklung der Technik.

Indications, results, modified techniques and complications in 280 cases treated with fluid silicon are reported. In about 80% of the cases intravitreal silicon injection under binoscopic control was performed according to the principles described by J. Scott. In the most difficult cases a vitrectomy was carried out and silicon was used only as an internal tamponade. In certain situations the retina itself was treated. The new techniques developed for that purpose are discussed. The follow-up period was between six months and four years. An anatomic success was achieved in more than 70% of the cases. Causes of late complications with the first 100 patients who underwent surgery are discussed. Removal of silicon after a certain period appears a real possibility in spite of initial complications.

[Fluid silicon in detachment for surgery (author's transl)]. / Das flüssige Silikon in der Amotiochirurgie. Bericht über 90 Fälle.

Indications, results and complications in 90 consecutive cases of intravitreal silicon injection are reported. Intravitreal silicon injection was performed according to the principles described by J. Scott. The patients, mostly cases which were inoperable with standard techniques, underwent surgery in the period between the beginning of 1978 and the end of 1979. The follow-up period was between five months and two years. An anatomic success was achieved in about 70% of the cases. The intraoperative complications were mostly hemorrhages and new retinal tears. Most of the late complications, such as cataract and glaucoma, could be surgically treated. The advantages and disadvantages of this procedure are discussed.

Retinal detachment and pseudophakos.

With the increasing number of intraocular lensimplants the retina surgeon is more often confronted with retinal detachment after lensimplantation. The treatment of pseudophakic retinal detachment is mostly a problem of examination. The Panfunduskop of Schlegel is a vary valuable aid and permits detection of most breaks situated anterior or on the equator. The article presents the results of 37 operated eyes.