Transscleral diode laser retinopexy in retinal detachment surgery: results of a multicenter trial.

PURPOSE: To evaluate the safety and efficacy of transscleral diode laser for retinopexy in rhegmatogenous retinal detachment surgery in a multicenter trial. METHODS: Seventy-two patients with primary rhegmatogenous retinal detachments were enrolled. No patient with chronic detachment, a retinal break greater than 90 degrees, history of uveitis or infectious retinopathy, or proliferative vitreoretinopathy was enrolled. RESULTS: Information from follow-up of 6 months or longer was available on 65 eyes. Retinas were attached at 6 months with a single operation in 58 (89%) of these eyes. Complications included apparent pinpoint breaks in Bruch's membrane in 15 eyes, scleral-thermal effect in 14 eyes, and limited hemorrhage, which was intraretinal in 10 eyes and extended into the vitreous in 3 eyes. In one case, hemorrhage was judged perhaps to have contributed to initial surgical failure. The other complications had no known adverse effects. Complications were significantly associated with the physician's experience in using transscleral laser retinopexy. CONCLUSIONS: In this multicenter study, transscleral diode laser retinopexy served as a safe and effective means of creating chorioretinal adhesion during retinal reattachment surgery. Minor complications were minimized by increasing experience with the technique.

The effect of propranolol versus placebo on resident surgical performance.

PURPOSE: To determine whether propranolol can decrease surgical tremor and anxiety in residents performing ocular microsurgery without impairing patient or physician safety. METHODS: In this randomized, double-masked, crossover study, 5 third-year ophthalmology residents ingested a capsule containing either propranolol, 40 mg, or placebo 1 hour prior to performing ophthalmic microsurgery. All residents were healthy men under age 30 years. Prior to commencement of the study, all participants had successfully been administered a test dose of propranolol without side effects. The study took place over a 10-week period. At the conclusion of each case, both the resident and attending surgeon observer independently completed a form grading, on a sliding scale: (1) amount of overall tremor; (2) amount of tremor during placement of the first 3 sutures after lens or nucleus extraction; (3) anticipated difficulty of the case; (4) actual difficulty with the case; and (5) anxiety (surgeon only). In addition, the type of procedure performed, complications encountered, and surgeon side effects were recorded. The data were analyzed with a 2-way analysis of variance for unbalanced data. RESULTS: A total of 73 surgical cases were performed; the surgeons were administered propranolol for 40 cases and placebo for 33. As judged by the resident surgeon, there was a highly significant effect of propranolol in decreasing anxiety (P = .0058), reducing surgical tremor overall (P < .0001), and reducing tremor while placing the first 3 sutures following lens extraction (P < .0001). There was no treatment-by-surgeon interaction for any of the measures. Complications and difficulty of the case, as judged by both the resident and attending surgeons, were not significantly different in the propranolol versus placebo groups (P > .05). There were no side effects reported or observed in any of the surgeons. CONCLUSIONS: Propranolol, 40 mg, administered 1 hour prior to surgery, significantly decreases tremor and anxiety in the surgeon without untoward effects to the surgeon and the patient. However, it is unknown whether decreased tremor and anxiety improved surgical outcome.

An investigation of the hospital charges related to the treatment of endophthalmitis in the Endophthalmitis Vitrectomy Study.

PURPOSE: The purpose of the study is to assess the hospital charges associated with the treatment of endophthalmitis using a sample of patients from the Endophthalmitis Vitrectomy Study (EVS). METHODS: The Endophthalmitis Vitrectomy Study was a multicenter, randomized clinical trial with a two-by-two factorial design to compare immediate pars plana vitrectomy to tap-biopsy and to compare the use of systemic antibiotics (intravenous) to no intravenous antibiotics in the management of postoperative endophthalmitis. Hospital charge data were collected retrospectively from 129 patients from the 4 clinical centers participating in this ancillary study. This represents 31% of the total Endophthalmitis Vitrectomy Study population. An analysis of variance was used to compare hospital charges across center and treatment. A charge-effectiveness analysis compared measures the effectiveness across treatment groups. The annual savings of hospital charges in the United States was estimated for a range of annual incidence rates of endophthalmitis. RESULTS: The use of intravenous antibiotics significantly increased hospital charges. Patients undergoing vitrectomy had significantly higher hospital charges than did patients undergoing tap-biopsy. The most charge-effective treatment for patients presenting with light perception only vision was immediate vitrectomy, whereas the most charge-effective treatment for patients presenting with better vision was tap-biopsy. Factors other than treatment independently associated with hospital charges were female sex, history of diabetes, symptom of red eye, and baseline vision of light perception only. CONCLUSIONS: Assuming the results of the Endophthalmitis Vitrectomy Study were used as a guide for the treatment of endophthalmitis, the estimated annual nationwide reduction of hospital charges would be between $7.6 million and $40.0 million.

Multicenter trial of transscleral diode laser retinopexy in retinal detachment surgery.

PURPOSE: To evaluate the safety and efficacy of transscleral diode laser for retinopexy in rhegmatogenous retinal detachment surgery in a multicenter trial. DESIGN: 67 patients with primary rhegmatogenous retinal detachment underwent scleral buckling surgery, using transscleral diode laser for retinopexy, at five study centers. STUDY PARTICIPANTS: 72 patients with primary rhegmatogenous retinal detachments were enrolled. No patient with chronic detachment, a retinal break greater than 90 degrees, history of uveitis or infectious retinopathy, or proliferative vitreoretinopathy was enrolled. Five eyes were excluded because they required additional nonprotocol treatment at the time of surgery (vitrectomy or supplementary cryotherapy due to probe malfunction). MAIN OUTCOME MEASURES: Retinal reattachment at six months after one operation. Secondary measures: visual acuity and complications, including choroidal, retinal, and vitreous hemorrhage, inflammation, and scleral damage. RESULTS: Six months or greater follow-up information was available on 65 eyes. Retinas were attached at 6 months with a single operation in 58 (89%) of these eyes. Complications included apparent pinpoint breaks in Bruch is membrane in 15 eyes, scleral thermal effect in 14 eyes, and limited hemorrhage, which was intraretinal in 10 eyes, and extended into the vitreous in 3 eyes. In one case, hemorrhage was judged to have contributed possibly to initial surgical failure. The other complications had no known adverse effects. Complications were significantly associated with the physicians experience with transscleral laser retinopexy. CONCLUSION: In this multicenter series, transscleral diode laser retinopexy served as a safe and effective means of creating chorioretinal adhesion during retinal reattachment surgery. Minor complications were minimized by increasing experience with the technique.

Management of giant retinal tears in dogs.

Sixteen dogs with giant retinal tears resulting in total retinal detachment (360 degrees) underwent unilateral retinal reattachment surgery. In all dogs, complete vitrectomy was performed, and in most, perfluorooctane liquid was used to unroll and flatten the detached retina. Stainless steel tacks were used to anchor the retina to the choroid and sclera. Silicone oil was injected into the vitreous cavity to provide for permanent retinal tamponade. Endophotocoagulation or cryosurgery was used in several dogs to induce formation of permanent chorioretinal adhesions. Retinal attachment was successful in 14 of 16 dogs, and 13 of 14 dogs in which reattachment was successful retained some degree of vision. Complications included formation of cataracts and corneal erosions, development of glaucoma, and dislodgement of tacks.

Endogenous Candida endophthalmitis after intravenous anesthesia with propofol.

Propofol is an intravenous anesthetic agent that was approved by the US Food and Drug Administration in October 1989. It has gained rapid acceptance and is in widespread use. In June 1990, the Centers for Disease Control reported four clusters of postsurgical infections associated with the use of propofol. We describe one of those clusters, consisting of four cases of endogenous Candida albicans endophthalmitis. These infections occurred in nonimmunocompromised patients after they had undergone nonophthalmologic surgery in which propofol had been used as anesthesia. An investigation by the Centers for Disease Control concluded that the infections in these patients were due to extrinsic contamination of propofol during preparation for use at the hospital. Ophthalmologists should be aware of this new potential source of endogenous endophthalmitis.

Iatrogenic choroidal neovascularization after krypton red laser photocoagulation.

A major cause for failure of krypton red laser photocoagulation in patients with exudative age-related macular degeneration has been the development of recurrent choroidal neovascularization adjacent to the previously treated areas. After reviewing the possible causes of recurrences, it is apparent that a certain number are iatrogenic, ie, induced by krypton red laser causing disruption and damage to the pigment epithelium-Bruch's membrane-choroidal complex. We describe three separate episodes in two patients of iatrogenic recurrent choroidal neovascularization after krypton red laser photocoagulation.

Macular serpiginous choroiditis.

The authors describe in seven eyes of four patients a form of serpiginous choroiditis beginning in the macula without initial peripapillary activity. Eyes with macular serpiginous choroiditis often had a poor visual prognosis and sometimes developed subretinal neovascularization. Fluorescein angiography of the acute lesions showed hypofluorescence; some cases were thus initially diagnosed as having choroidal ischemia. Fluorescein angiography in one eye, however, suggested that at least some of the hypofluorescence seen acutely in eyes with serpiginous choroiditis is secondary to blocked fluorescence from "opaque" retinal pigment epithelium.

Intrusion of retinal tacks.

We examined nine patients in whom retinal tacks intruded into the eye and lodged in the subretinal space, preretinal space, vitreous cavity, or anterior chamber. Complications included retinal pigment epithelium atrophy; retinal phlebitis; vitreous hemorrhage; focal corneal, iris, and retinal injury; and corneal edema. The intrusion of the retinal tacks did not apparently cause, but was associated with retinal redetachment in five patients. Factors associated with intrusion of the retinal tacks included absence of a barb at the end of the tack to anchor it to the sclera, absence of a groove in the tack, a short shaft, incomplete penetration of the retina, choroid, and sclera by the tack, self-inflicted trauma to the eye, placing a scleral buckle after inserting the tacks, and reproliferation of periretinal membranes. In four patients the intruded tacks did not cause any complications. In four patients the intruded tacks were removed without complications and in the remaining five patients, they were left in the eye.

Acute retinal necrosis.

Five patients with the acute stages of acute retinal necrosis underwent vitrectomy, with acyclovir in the infusion fluid, and the placement of a 360 degrees scleral buckle after intravenous therapy with acyclovir. Anatomic reattachment was achieved in all patients, and improvement over preoperative visual acuity was obtained in four. Recommendations for the treatment of acute retinal necrosis include a high index of suspicion in healthy patients with retinitis, early diagnosis, early intravenous therapy with acyclovir, early pars plana vitrectomy with the use of intravitreal acyclovir in the infusion fluid, and a 360 degrees scleral buckling procedure.