Visual and surgical outcomes of retinal detachment following macular hole repair.

OBJECTIVE: To characterize 20 cases of retinal detachment (RD) following surgical repair of macular holes. METHODS: Retrospective review of 20 eyes in 16 patients (4 patients [25%] had bilateral macular hole repairs with subsequent RD) who developed RD in the same eye in which surgical repair of a macular hole had been performed. RESULTS: Twenty detachments in 16 patients were reviewed. The average duration between macular hole repair and presentation of RD was 5.5 weeks. The inferior retina was involved more frequently than the superior retina. A total of 76% of all breaks were located inferiorly. Ten of the 20 eyes were asymptomatic at the time the detachment was diagnosed. Of the 20 eyes, 19 underwent surgical repair, all with anatomic reattachment. At final follow-up, the macular hole was closed in all 20 eyes, and 60% of the patients had final visual acuity improved by 2 lines or more over that before their macular hole repair. CONCLUSION: Retinal detachment is a complication of macular hole surgery. These detachments tend to occur within the first 2 months of follow-up, and have a high success rate of anatomic reattachment with surgery. The occurrence of RD does not preclude improved final visual acuity.

The progressive outer retinal necrosis syndrome: successful treatment with combination antiviral therapy.

BACKGROUND AND OBJECTIVE: To assess a two-drug combination of antiviral therapy for the progressive outer retinal necrosis syndrome (PORN), given the current poor outcome with acyclovir alone. PATIENTS AND METHODS: A retrospective review was performed on six consecutive patients who were diagnosed with PORN and were treated with various combinations of intravenous or oral plus intravenous antiviral therapy. The relative efficacies of these modalities were compared. RESULTS: Six eyes of six patients showed active retinitis at the time of presentation. Three patients had unilateral retinitis, and the remaining patients had necrotic, end-stage disease in their fellow eye. All the patients were treated with combination therapy, consisting of either ganciclovir and acyclovir (three patients), foscarnet and ganciclovir (two patients), or foscarnet and acyclovir (one patient). Standard induction doses were employed. During the combination therapy, all six eyes showed resolution of the retinitis, manifested by complete fading of the original retinal lesions and an absence of new lesion formation. At the final follow-up, the areas of prior active retinitis had resolved and remained quiescent. A mild recurrence developed in one eye when ganciclovir and foscarnet were both tapered to a single daily dose. This recurrence promptly resolved with reinduction (twice daily) dosing. Two patients maintained a visual acuity of 20/50 or better in their involved eye for the duration of follow-up (38 and 27 weeks, respectively). One patient maintained a visual acuity of 20/40 for 14 weeks. The remaining three patients had macula-off retinal detachments despite resolution of active retinitis. In addition, for the duration of follow-up, one of the three patients with unilateral disease had retinitis in the uninvolved eye; all three uninvolved fellow eyes maintained a visual acuity of 20/20. One patient had progressive optic atrophy. CONCLUSIONS: Prolonged combination antiviral therapy for PORN may successfully arrest the progression of retinitis, maintain remission, and prevent involvement of the fellow eye. Furthermore, if aggressive therapy is begun early, good vision may be preserved.

Treatment of relapsed cytomegalovirus retinitis with the sustained-release ganciclovir implant.

PURPOSE: Sustained-release ganciclovir implants are effective in delaying progression of newly diagnosed cytomegalovirus (CMV) retinitis. An uncontrolled case series was assembled to evaluate the efficacy of the intravitreal ganciclovir implant for patients with sight-threatening CMV retinitis who had previously failed to respond to intravenous ganciclovir and/or foscarnet. METHODS: Between August 1993 and March 1995, 72 eyes of 55 patients received intravitreal ganciclovir implants. Patients were examined monthly after implant surgery. RESULTS: A total of 56 eyes (77.8%) were available for evaluation after implant surgery. At the 1-month postoperative visit, 48 eyes (85.7%) of 38 patients had no progression. Implants failed to control progression at the 1-month visit in eight eyes (14.3%) of six patients receiving primary implants. A total of 32 eyes (57.1%) of 29 patients did not experience three-line loss of visual acuity through the follow-up period. The median time to three-line loss was 190 days from implantation. Four eyes (7.1%) developed visual acuity of 20/200 or worse by the 1-month follow up. The median time from implantation to development of visual acuity of 20/200 or less was 224 days. The median survival time was 376 days from study entry. The most common postoperative complication was retinal detachment, which was observed in 12 eyes receiving implants. Additional self-limiting complications included significant vitreous hemorrhage (three eyes) and hypotony maculopathy (two eyes). CONCLUSION: Ganciclovir implants were effective in delaying visual loss in a significant proportion of patients who failed ganciclovir or foscarnet therapy. A number of these patients, however, experienced visual loss. Although the implants can be effective as therapy for relapsed CMV retinitis, the efficacy does not appear to match that noted in initial CMV retinitis therapy.

Replacing ganciclovir implants.

PURPOSE: The authors report their surgical experience replacing empty ganciclovir implants in patients with acquired immune deficiency syndrome (AIDS)-related cytomegalovirus (CMV) retinitis. METHODS: A chart review of all patients receiving two or more ganciclovir implants was performed. RESULTS: Nine eyes in eight patients received two or more implants. The average time before a second implant was needed was 6 months. Cytomegalovirus retinitis was controlled in all patients except one. Three patients required intermittent intravenous exogenous anti-CMV therapy, one for persistent CMV retinitis and two for systemic CMV. Visual acuity of 20/40 or better was maintained in five of eight patients, despite a longstanding history of CMV retinitis. CONCLUSION: In this small series, most patients retained good vision after ganciclovir implant replacement.

The appearance of stippled retinal pigment epithelial detachments. A sign of occult choroidal neovascularization in age-related macular degeneration.

The clinical source of 62 eyes that had been coded for macular degeneration and fibrovascular retinal pigment epithelial (RPE) detachment on fluorescein angiography was reviewed; 17 eyes had signs of a choroidal neovascular membrane (CNVM) at initial examination, and 30 eyes developed a definite CNVM during follow-up examination. Thus, 47 of the 62 eyes (76%) developed a CNVM in association with fibrovascular RPE detachments. Features of fibrovascular RPE detachments include: 1) focal, tiny hyperfluorescent spots at the level of the RPE arising in the mid and late frames of the angiogram, which do not correspond to drusen or foci of depigmentation (stippled hyperfluorescence); 2) intensification of these spots in the later stages of the angiogram; 3) slight enlargement of the spots in the late frames of the angiogram; 4) occasional presence of scant overlying subretinal fluid; and 5) minimal elevation of the RPE. Fibrovascular RPE detachments appear to be a distinct form of an RPE detachment. It is concluded that this sign is associated with a high risk of developing a frank CNVM and is thus a reliable indicator of occult neovascularization.

Dietary modulation of alpha-cell volume and function in strain 129/J mice.

Weanling female 129/J mice were maintained for 1, 2, 3, or 6 mo on either a control diet containing 60% sucrose and 23% protein or an isocaloric, high-protein, no-carbohydrate diet containing 83% protein and 0% sucrose. Mice were killed after each interval to assess the effect of diet on histological and physiological changes in the endocrine pancreas. Image analysis of islets stained immunocytochemically for alpha-cells, beta-cells, delta-cells, and PP cells was performed to quantify changes in islet structure. It was found that islet composition was strongly affected by diet. The volume density of the alpha-cells was significantly elevated in mice fed the high-protein diet (e.g., 35% vs. 16% in controls at 6 mo), whereas the volume density of beta-cells concomitantly decreased from 65 to 39%. Radioimmunoassay of the insulin and glucagon content of the pancreas and the plasma corroborated the morphometric findings. Pancreatic and plasma glucagon concentration in mice on the high-protein diet was elevated by an average of 2.5-fold above controls, whereas pancreatic insulin concentration was diminished by nearly half. The increase in alpha-cell volume density and pancreatic glucagon concentration appeared initially due to alpha-cell hypertrophy, although by 6 mo of high-protein feeding both hypertrophy and hyperplasia of the alpha-cells were evident. Presumably, these changes were compensatory responses to the increased functional demand on alpha-cells (i.e., glucagon biosynthesis and secretion) imposed by chronic high-protein feeding.