Primary cataract extraction and intraocular lens implantation in penetrating ocular trauma.

PURPOSE: To analyze the postoperative outcome and complication rate after cataract extraction or lensectomy with primary intraocular lens (IOL) implantation for penetrating traumatic cataract. DESIGN: Retrospective, nonconsecutive, noncomparative case series. METHODS: We retrospectively reviewed the files of 21 patients who were admitted to our departments because of traumatic cataract with corneal or scleral laceration caused by penetrating trauma with or without intraocular foreign body (IOFB) from 1992 through 1997. Lens aspiration or manual extracapsular cataract extraction with primary IOL implantation was performed in all patients. Removal of an IOFB was performed in eight patients. MAIN OUTCOME MEASURES: Final visual acuity and deviation of actual refraction from emmetropia and from expected postoperative refraction. RESULTS: The mean follow-up was 20.4 months. Fourteen eyes (67%) achieved final visual acuity of 20/40 or better, 95% obtained 20/60 or better final visual acuity, and all eyes achieved 20/100 or better final visual acuity. Major causes of limited visual acuity were central corneal scar and central retinal injury. Eleven eyes (57%) experienced secondary cataract and underwent neodymium:yytrium-aluminum-garnet capsulotomy. CONCLUSIONS: Primary implantation of posterior chamber lenses after penetrating ocular trauma is associated with favorable visual outcome and a low rate of postoperative complications.

Management of persistent loculated subretinal fluid after pneumatic retinopexy.

AIM: To report on the incidence and management of a unique and troublesome complication of pneumatic retinopexy-localised, delayed subretinal fluid absorption (DSRFA). METHODS: A retrospective chart review was done for all patients who underwent pneumatic retinopexy for retinal detachment over a 5 year period to identify the patients with DSRFA. RESULTS: Seven phakic patients (five females, two males, age range 26-87 years) were identified with the phenomenon of delayed resolution of subretinal fluid after pneumatic retinopexy and cryotherapy. In four patients the subretinal fluid involved the macula. Time taken to complete absorption of the subretinal fluid ranged from 10 to 26 months. In one patient there was still residual fluid inferiorly at 18 months of follow up. During the follow up period additional procedures were performed--scleral buckling (five eyes), pars plana vitrectomy (one eye), and mild laser scatter to extramacular areas of shallow subretinal fluid (four eyes). None of these procedures appeared to influence the rate of fluid absorption. CONCLUSIONS: Loculated subretinal fluid following pneumatic retinopexy may persist for very long periods, extending up to more than 2 years. Additional surgical procedures or laser photocoagulation do not affect the rate of subretinal fluid absorption. Spontaneous reattachment eventually occurs in most eyes, and conservative management is indicated.

Thrombophilia as a cause for central and branch retinal artery occlusion in patients without an apparent embolic source.

PURPOSE: To assess the prevalence of vascular risk factors and thrombophilias in central and branch retinal artery occlusion in patients in whom an embolic source is not apparent. METHODS: The study group consisted of 21 consecutive patients with retinal artery occlusion (RAO) in whom Doppler ultrasonography of the carotid arteries and transthoracic or transoesophageal echocardiography were normal. Laboratory methods included polymerase chain reaction for detection of factor V G1691A, factor II G20210A and methylentetrahydrofolate reductase C677T mutations, assays of plasma levels of protein C, free protein S, antithrombin, fibrinogen and homocysteine; and tests for the presence of lupus anticoagulant and anticardiolipin antibodies. Controls for the laboratory tests were 243 healthy subjects. RESULTS: Nine of the 21 (43%) patients had at least one thrombophilic marker: 4 were homozygous for MTHFR C677T, 1 was heterozygous for factor V G1691A, 1 had a high titre of IgM anticardiolipin, 2 were heterozygous for factor V G1691A and homozygous for MTHFR C677T, and 1 had lupus anticoagulant, a high titre of IgM anticardiolipin, homozygosity for MTHFR C677T and hyperhomocysteinaemia. An interaction between vascular risk factors and thrombophilias seemed important since out of 14 patients with hypertension, diabetes and/or hypercholesterolaemia 7 (50%) had a thrombophilia. Homozygous MTHFR C677T was a significant risk factor with odds ratio of 3.18 (95% CI 1.20-8.47). The prevalence of factor V G1691A was also higher in the RAO patients versus controls with an odds ratio of 2.36 (95% CI 0.63-8.88), but this value did not reach significance, probably due to the small sample size. CONCLUSION: A search for thrombophilia in RAO is advisable in patients without evident source of emboli even when vascular risk factors are identified.

Reduced rate of retinal detachment following silicone oil removal.

PURPOSE: To investigate the rate of retinal redetachment and other complications after silicone oil removal over a 4-year period. METHODS: Retrospective analysis of charts of patients who underwent vitrectomy and silicone oil injection between January 1994 and June 1998 followed by oil removal. RESULTS: Sixty-eight eyes of 67 patients were included. The average follow-up time after oil removal was 15 months. Significant retinal redetachment developed in 6 eyes (8.8%). The redetachment rate was slightly higher in the 32 eyes with proliferative vitreoretinopathy (9.3%) than in the 36 eyes with other pathologies (8.3%). The average time to redetachment was 4.2 months. These eyes were reoperated and reattached, and at the end of the follow-up, three retained silicone oil. Two other eyes without redetachment were hypotonus after oil removal. Cataract extraction and intraocular lens implantation were performed at the time of oil removal in 18 eyes; 2 (11%) developed redetachment. Visual acuity improved significantly after oil removal (P < 0.001). CONCLUSION: The rate of retinal redetachment after removal of silicone oil in recent years is low compared with previous series. The authors attribute this reduction to the improved surgical management of complicated retinal detachments; particularly, the introduction of perfluorocarbon liquids and wide-field viewing systems and the widespread use of endolaser.

The role of angiotensin converting enzyme and angiotensin II type 1 receptor gene polymorphisms in patients with nonarteritic anterior ischemic optic neuropathy.

OBJECTIVE: To determine the role of angiotensin converting enzyme (ACE) and angiotensin II type 1 receptor (AT1R) polymorphisms in the pathogenesis of nonartertic anterior ischemic optic neuropathy (NAION). DESIGN: Retrospective, case-control study. PARTICIPANTS: Seventy-four patients with NAION diagnosed from 1984 through 1999. Seventy-one patients who visited the Eye Institute comprised the control group. TESTING INTERVENTION: DNA was extracted from whole blood obtained from all patients and control participants. Polymerase chain reaction (PCR) was used for analysis of ACE and AT1R polymorphisms. RESULTS: The frequency of the polymorphism for ACE among the NAION patients (39.2% deletion allele [DD], 54.0% deletion/insertion [D/I] locus, 6.8% insertion allele [II]) was similar to that of the control group (50.7% DD, 39.4% D/I, 9.9% II), with P = 0.21. The frequency of the polymorphism of AT1R in the NAION patients was 5.4% CC, 44.6% CA, 50% AA, and in the control group it was 4.2% CC, 33.8% CA, 62.0% AA, with P = 0.35. Participants less than 55 years of age and those more than 55 had quite similar distributions. CONCLUSIONS: Angiotensin converting enzyme and AT1R polymorphisms have no part in the mechanism of NAION. Thus drugs such as ACE inhibitors or AT1R antagonists are not specifically indicated for treatment of these patients.

ICGA-guided laser photocoagulation of feeder vessels of choroidal neovascular membranes in age-related macular degeneration. Indocyanine green angiography.

PURPOSE: To report the ability of indocyanine green angiography (ICGA) with a confocal scanning laser ophthalmoscope (SLO) to identify feeder vessels of choroidal neovascular membranes (CNVM) secondary to age-related macular degeneration (ARMD) and to show the feasibility of inducing complete closure of the CNVM by photocoagulation targeted exclusively to the feeder vessels. METHODS: Five consecutive patients with exudative ARMD in whom ICGA with the confocal SLO showed extrafoveal feeder vessels supplying choroidal neovascular nets had laser photocoagulation done only to the feeder vessels. In two patients, two separate membranes were seen. RESULTS: Laser photocoagulation resulted in closure of the feeder vessels and the CNVM in four patients. Complete closure was achieved with one treatment in one patient and with two treatments in three patients. In one patient, two treatments failed to close the feeder vessel and the CNVM, but a third, more intense laser treatment resulted in temporary closure of the feeder vessel and CNVM, which recanalized 2 to 4 weeks later with development of a large rip in the retinal pigment epithelium. In one patient, two separate CNVMs grew from the edge of the laser scars, but they were not directly related to the original CNVM and its feeder vessel, and were treated successfully. The same eye later developed subfoveal occult CNVM with gradual deterioration of visual acuity. In the other four patients, visual acuity improved in two and was unchanged in two. CONCLUSIONS: Indocyanine green angiography with the confocal SLO can identify choroidal feeder vessels supplying CNVM secondary to ARMD. Laser treatment to such extrafoveal feeder vessels, particularly in membranes that are large or subfoveal, may be effective in closing the feeder vessel and CNVM with preservation of the fovea and central vision. More than one treatment may be required, however, and failures and complications may be expected with this treatment modality.

Spontaneous separation of an idiopathic macular pucker in a young girl.

PURPOSE: To report a young girl with spontaneous separation of an idiopathic epiretinal membrane and notable visual recovery. METHOD: Case report. RESULT: A 12-year-old girl had spontaneous improvement in visual acuity of the left eye from 20/100 to 20/40 attributable to spontaneous peeling of an idiopathic epiretinal membrane more than 2 years after it was diagnosed. CONCLUSION: Conservative treatment can be considered in young patients with epiretinal membrane because spontaneous separation may occur and result in good vision.

Analysis of prothrombotic and vascular risk factors in patients with nonarteritic anterior ischemic optic neuropathy.

OBJECTIVE: To determine whether genetic or acquired thrombophilias and other risk factors are associated with nonarteritic anterior ischemic optic neuropathy (NAION). DESIGN: Retrospective case-control study. PARTICIPANTS: Sixty-one patients with NAION diagnosed between 1984 and 1997. Ninety consecutive patients who visited the Eye Institute made up the control group. INTERVENTION: Protein C, protein S, antithrombin III, lupus anticoagulant, and three recently described prothrombotic polymorphisms (i.e., factor V G1691A, factor II G20210A, and methylenetetrahydrofolate reductase [MTHFR] C677T) were analyzed. In addition, risk factors for arteriosclerotic vascular disease were assessed. MAIN OUTCOME MEASURES: Parameters of thrombophilia. RESULTS: None of the thrombophilic markers (genetic and acquired) constituted a significant risk factor for NAION. Ischemic heart disease, hypercholesterolemia, and diabetes mellitus were discerned as risk factors for NAION with odds ratios of 2.9 (95% confidence interval [CI], 1.3-6.4), 2.6 (95% CI, 1.2-5.5), and 2.3 (95% CI, 1.1-4.8), respectively. Multiple logistic regression analysis indicated that ischemic heart disease and hypercholesterolemia exerted an additive risk for NAION with a combined odds ratio of 4.5 (95% CI, 1.4-14.5). However, none of these risk factors statistically predicted second eye involvement. CONCLUSION: NAION was not found to be associated with thrombophilic risk factors, yet it was related to ischemic heart disease, hypercholesterolemia, and diabetes mellitus.

Analysis of genetic polymorphisms related to thrombosis and other risk factors in patients with retinal vein occlusion.

The purpose of this study was to investigate the role of genetic polymorphisms associated with venous and arterial thrombosis in patients with retinal vein occlusion (RVO). One-hundred and two consecutive patients with RVO were examined for factor V G1691A and factor II G20210A, methylenetetrahydrofolate reductase (MTHFR) C677T and apolipoprotein E4 by amplification of specific DNA fragments and restriction analysis. The risks exerted by these polymorphisms and by the conventional risk factors of RVO were evaluated by comparing their frequencies among patients and controls and by estimating the respective odds ratios. We found that the prevalences of the factor V G1691A, factor II G20210A, and apolipoprotein E4 polymorphisms were similar in the study and control groups. Logistic regression analysis involving the parameters for which significant differences were detected disclosed an odds ratio of 1.9 for MTHFR C677T homozygosity (95% confidence interval 0.95-3.81), an odds ratio of 2.12 for hypertension (95% confidence interval 1.16-3.73) and an odds ratio of 3.25 for a family history of stroke (95% confidence interval 1.07-9.51). Our data suggests that homozygosity for the MTHFR C677T polymorphism is a risk factor of RVO in addition to arterial hypertension and a family history of stroke.

Pneumatic retinopexy as supplemental therapy for persistent retinal detachment after scleral buckling operation.

PURPOSE: Persistent retinal detachment following scleral buckling may be caused by persistent open retinal tears with a large amount of subretinal fluid, despite proper positioning of the buckle. In this study we evaluated the effectiveness of supplemental pneumatic retinopexy in flattening of the detached retina. METHODS: During 1990-1994 twelve cases of persistent retinal detachment following scleral buckling operation with appropriate position of the buckle, underwent supplemental gas injection. RESULTS: Reattachment of the retina with complete absorption of the subretinal fluid was observed within 24-48 hours from the gas injection in all eyes. Three eyes redetached and required additional operations. At the end of the follow-up (mean 16 months) the retina was attached in all eyes, and the visual acuity was 20/120 or better in 11 eyes, and 20/30 or better in 7 eyes. No complications were observed. CONCLUSION: Pneumatic retinopexy for persistent retinal detachment, following scleral buckling, is effective in obtaining fast flattening of the retina and achieving good visual results.

Vitrectomy and silicone oil injection in pediatric patients.

OBJECTIVE: To determine the functional and anatomic results of vitrectomy with silicone oil injection in complicated retinal detachments in children. DESIGN: A retrospective review of all records of children aged 15 years or younger who underwent vitrectomy with silicone oil injection between 1985 and 1994 in the Goldschleger eye institute. RESULTS: Twenty-eight eyes of 27 patients were included in the series, with a mean follow-up time of 24 months. The underlying pathologies included penetrating injury (11 eyes), high myopia (8 eyes), choroidal coloboma (2 eyes), retinopathy of prematurity (2 eyes), and various other pathologies (5 eyes). At the end of the follow-up, complete or partial anatomic success was obtained in 9 eyes (32%) and 3 eyes (10%), respectively. The final visual acuity was 20/400 or better in 5 eyes (18%) and hand motions or less in 19 eyes (68%). The visual acuity could not be determined in 3 eyes due to the age of the patients, and in 1 eye due to mental retardation. The worst results occurred in the perforating injury group. The usual complications associated with silicone oil occurred frequently. CONCLUSIONS: Satisfactory anatomic and functional results were obtained in a minority of the eyes included in our series. The grave prognosis was determined by the devastating nature of the external injury in the trauma cases and the severe vitreoretinal pathology in the other eyes.

Glaucoma and visual outcome in central retinal vein occlusion.

Glaucoma is a recognized risk factor for central retinal vein occlusion. The authors retrospectively reviewed charts of fifty patients with central vein occlusion examined over a 5-year period. The visual outcome and clinical characteristics of eyes with and without glaucoma were compared. There were 32 eyes without glaucoma and 18 eyes with glaucoma. Final visual acuity of 20/100 or better was obtained in 22% of eyes with glaucoma, compared with 34% of eyes without glaucoma, and final visual acuity of finger counting and less was found in 56% and 22%, respectively (p = 0.02). The rate of ischemic occlusion was higher in the glaucoma group, 44% and 28% respectively, but the difference did not reach statistical significance. There was no difference in the rate of neovascular complications and macular edema between the two groups. The results suggest that glaucoma has an adverse effect on the visual outcome of eyes with central vein occlusion.

Predicted and actual refraction after intraocular lens implantation in eyes with silicone oil.

OBJECTIVE: To determine the difference between the predicted and postoperative refraction in eyes with silicone oil that had extracapsular cataract extraction (ECCE), and intraocular lens (IOL) implantation. SETTING: Ophthalmology department providing primary, secondary, and tertiary care in central Israel. METHODS: Eight patients with silicone-oil-filled eyes following vitreoretinal procedures had ECCE and IOL implantation. The IOL power calculation was performed with the modified SRK II, the SRK/T, and the Holladay emmetropia/ametropia formulas, using the axial length of the eye, measured prior to the silicone oil injection, and the keratometric readings. The predicted and postoperative refractions were compared. RESULTS: The postoperative refraction was more hyperopic than predicted by an average of 4.08 diopters (D) for the SRK II formula, 3.91 D for the SRK/T formula, and 4.01 D for the Holladay emmetropia/ametropia formula. Removing the silicone oil from two eyes several months after cataract extraction reduced the deviation from the predicted refraction to 0.25 and 0.80 D. CONCLUSION: The presence of silicone oil in the vitreous space induces a hyperopic shift in eyes having ECCE and IOL implantation. This hyperopic shift should be considered when calculating the IOL power if a long-term tamponade with the oil is planned. If the silicone oil is to be removed shortly after the cataract extraction, the IOL power should be calculated solely from the formula.

The impact of the macular photocoagulation study results on the treatment of exudative age-related macular degeneration.

OBJECTIVE: To determine the percent of cases with all primary forms of exudative age-related macular degeneration that are eligible for treatment by the Macular Photocoagulation Study (MPS) guidelines in a retina clinic serving both as a primary care center and as a referral center. DESIGN: Fluorescein angiograms of patients with age-related macular degeneration examined at the Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, during a 5-year period (1985 to 1990) were randomly selected and reviewed. Angiograms showing all forms of exudative age-related macular degeneration were eligible. The first 100 eligible angiograms identified constituted the study series and were classified into four groups: active choroidal neovascularization (CNV), pigment epithelium detachment, hemorrhage, and disciform scars. The active CNVs were further divided into three subgroups: classic (well defined), occult (poorly defined), and combined. Eligibility for laser treatment was determined exclusively with use of the published MPS recommendations for treatment of extrafoveal, juxtafoveal, and subfoveal membranes. RESULTS: There were 10 cases in the pigment epithelium detachment group, 11 cases in the hemorrhagic group, and 16 cases with disciform scars. All of these 37 cases were ineligible for treatment by MPS guidelines. Sixty-three eyes had active membranes; 37 were classic CNVs (eight extrafoveal, seven juxtafoveal, and 22 subfoveal). All extrafoveal and juxtafoveal CNVs were found to be eligible for laser treatment. Eleven membranes of the subfoveal group were larger than 2 disc areas, a size for which the MPS did not demonstrate benefit from laser treatment. There were 19 membranes in the strictly occult CNV subgroup, all of them untreatable by MPS criteria. Seven cases had both occult and classic CNV, and all were larger than 3.5 disc areas and therefore ineligible for treatment. Overall, 26 cases were eligible for treatment by strict MPS criteria; these constitute 26% of the whole series and 41% of the active CNV cases in the series. CONCLUSIONS: Our results indicate that the MPS guidelines for laser treatment are applicable only to a minority of the cases with exudative age-related macular degeneration presenting to our clinic. Further studies should be conducted to identify additional treatment modalities for this common eye disease.

Orbital pseudotumor presenting as acute glaucoma with choroidal and retinal detachment.

A 68-year-old woman presented with acute visual loss, elevated intraocular pressure (IOP), and a flat anterior chamber combined with retinal and choroidal detachment. The diagnosis of orbital pseudotumor was based on the patient's poor response to conventional therapy and on computerized tomography and ultrasound findings. After treatment with oral corticosteroids, the inflammatory process, elevated IOP, and choroidal and retinal detachment resolved.

Removal of silicone oil in the management of glaucoma in eyes with emulsified silicone.

Glaucoma and emulsification are two complications of silicone oil injection that are often coexisting. This study was undertaken to determine whether removal of emulsified oil has any effect on the management of the glaucoma. A comparison of eyes with and without glaucoma with emulsified oil also was undertaken. Eighteen eyes that underwent removal of emulsified silicone oil more than 6 months after the injection of the oil were reviewed. All eyes were observed for at least 6 months after removal with attached retinas. Eleven eyes had glaucoma at the time of removal. The diagnosis of glaucoma preceded the identification of emulsification in 8 of 11 eyes (73%). Removal of the emulsified oil did not affect the intraocular pressure (IOP) in 10 of the 11 (91%) glaucomatous eyes. The IOP was reduced in one patient. In the glaucoma patients, the final visual acuity was significantly reduced compared with the best corrected visual acuity obtained during the follow-up period (P = 0.016). In the nonglaucoma eyes with emulsified oil, the visual acuity did not significantly deteriorate during follow-up. At the end of the follow-up period, optic atrophy was observed in 9 of 11 (82%) of the eyes with glaucoma compared with two of seven (28%) of eyes without glaucoma. The results suggest that removal of emulsified silicone oil failed to control the glaucoma, and could not change the aggressive nature of the glaucoma in these eyes.

Cataract extraction in eyes filled with silicone oil.

A surgical technique for cataract extraction in eyes filled with silicone oil was developed that has two major objectives: removal of the entire cataractous lens and complete preservation of the silicone oil volume. A regular extracapsular cataract extraction or phacoemulsification is performed, and the incision is closed with the final sutures. All steps are performed under continuous positive pressure achieved with an anterior chamber maintainer connected to a bottle of balanced saline solution. An inferior basal iridectomy is created with a vitrectomy probe, and the posterior capsule is then slowly pulled out through the limbal incision with intraocular forceps, again under positive pressure, in an eye that is actually a closed system, without any loss of silicone. This step results in transformation of the extracapsular cataract extraction condition into an intracapsular cataract extraction condition. The described technique was successfully performed in nine eyes. In the younger patients, the whole procedure was completed through two very small limbal openings.