Retinal fibrovascular proliferation associated with Nocardia subretinal abscess.

PURPOSE: To report the development of extensive fibrovascular proliferation in association with Nocardia subretinal abscess. METHOD: Case report. RESULTS: Extensive retinal neovascularization with tractional retinal detachment developed soon after ocular involvement in a 61-year-old patient with systemic nocardiosis. Fundus fluorescein angiography showed extensive area of capillary nonperfusion and severe leakage from the neovascular complex. The Nocardia subretinal abscess responded to systemic antibiotics, and the retinal neovascularization and tractional retinal detachment stabilized after 3 months. CONCLUSIONS: Retinal ischemia and severe retinal neovascularization may complicate intraocular nocardiosis. The authors propose secondary retinal vasculitis as a contributing factor towards the development of retinal ischemia in this setting.

The relationship between nuclear colour and opalescence on the LOCSIII scale and physical characteristics of cataract nuclei.

PURPOSE: To evaluate the compression characteristics of the human lens nucleocortex in relation to its LOCSIII clinical grading. METHODS: Sixteen subjects undergoing planned extracapsular cataract surgery had pre-operative slit-lamp examination and assessment of cataract LOCSIII grade followed by postoperative in vitro evaluation of the nucleus with measurement of 'linear compressibility' by a purpose-designed caliper incorporating a strain gauge, enabling the derivation of a graph of nuclear compression (D (mm) against applied force (F (N)). RESULTS: Nuclear colour correlates with the force required to compress a lens to 75% of its original depth (F75) (R = 0.625, P = 0.017). Nuclear opalescence correlates with the force required to compress a lens to 75% of its original depth (R = 0.651, P = 0.012) and inversely with linear compressibility (DeltaD/DeltaF, the slope of the graph of nuclear compression against applied force) (R = -0.610, P = 0.014). F75 is a direct and linear compressibility is an inverse related parameter of lens nucleus 'hardness'. CONCLUSION: A new instrument is described which allows measurement of 'hardness'-related compression characteristics of the human cataract in vitro. There is a relationship between the LOCSIII clinical classification of nuclear cataracts and mechanical compression characteristics of the cataractous lens. LOCSIII classification may aid the preoperative planning of an appropriate surgical approach to an individual cataract.

Giant cell arteritis: diagnosis and management.

Visual loss caused by giant cell arteritis is a medical emergency that requires prompt recognition and treatment with systemic corticosteroids. A delay in diagnosis can lead to devastating ophthalmic and systemic complications. Recent advances in genetic and immunocytochemical research techniques have led to greater understanding of the underlying pathomechanisms of giant cell arteritis. Giant cell arteritis is a systemic condition with a strong predilection for the ocular vasculature. Visual symptoms are often the presenting manifestation of the disease, placing the ophthalmologist in a critical position for early diagnosis and treatment. Maintenance of a high clinical suspicion in the appropriate clinical setting is important in establishing an early diagnosis. Because of the complex nature of the disease process, many cases may be a therapeutic challenge requiring prolonged immunosuppression.

Superficial temporal artery biopsy diagnostic for lung carcinoma.

PURPOSE: To report a unique finding of metastatic tumor cells in the lumen of a superficial temporal artery biopsy specimen in a patient with severe visual loss and optic neuropathy. METHODS: Case report. RESULTS: A 69-year-old man presented with anorexia, pancranial headaches, and acute unilateral visual loss. Ophthalmic examination showed a visual acuity of no light perception and an amaurotic pupil in the left eye. Fundus examination was normal. A superficial temporal artery biopsy, performed for presumed arteritic posterior ischemic optic neuropathy, demonstrated intraluminal cells with irregular nuclei and prominent nucleoli suggestive of metastatic malignancy. Further systemic evaluation uncovered a poorly differentiated adenocarcinoma of the lung with intravascular infiltration and multiple distant metastases. CONCLUSION: Extensive systemic intravascular tumor embolization may be associated with optic neuropathy.

Late endophthalmitis associated with glaucoma drainage implants.

OBJECTIVE: To report the clinical course of a series of patients who had late endophthalmitis develop after glaucoma drainage implant (GDI) surgery. DESIGN: Noncomparative, interventional, consecutive case series. PARTICIPANTS: Four patients were identified with late endophthalmitis associated with Baerveldt glaucoma implants. METHODS: The medical records of all patients with endophthalmitis associated with a GDI treated at the Bascom Palmer Eye Institute or University of Florida between January 1, 1987 and December 31, 1999 were retrospectively reviewed. Patients with culture-positive endophthalmitis diagnosed more than 1 month after GDI surgery were included in this series. MAIN OUTCOME MEASURES: Visual acuity and intraocular pressure (IOP). RESULTS: Late endophthalmitis associated with Baerveldt glaucoma implants developed 7 weeks to 2 years postoperatively. Exposure of the GDI tube was present in all cases. The implant was removed in three of four patients. Visual acuity worsened from preinfection level in two of four cases. IOP was controlled at last follow-up in all patients, although replacement of the explanted GDI was required in one patient. CONCLUSIONS: Late endophthalmitis may occur after GDI surgery. Exposure of the GDI tube seems to represent a major risk factor for these infections. To prevent this potentially devastating complication, we recommend prophylactic surgical revision with a patch graft in all cases in which there is an exposed GDI tube.

Suprachoroidal hemorrhage during pars plana vitrectomy.

Suprachoroidal hemorrhage is an uncommon but serious complication of pars plana vitrectomy that can be associated with a guarded visual prognosis. Risk factors for development of suprachoroidal hemorrhage during pars plana vitrectomy include high myopia, history of previous retinal detachment surgery, rhegmatogenous retinal detachment, use of cryotherapy, scleral buckling at the time of pars plana vitrectomy, external drainage of the subretinal fluid, intraoperative systemic hypertension, and bucking during general anesthesia. In eyes with suprachoroidal hemorrhage during pars plana vitrectomy, the final visual and anatomic outcomes may be compromised by persistent retinal detachment, secondary glaucoma, and ocular hypotony. In most cases, intraoperative drainage of suprachoroidal hemorrhage is not associated with a better outcome. The prognosis is more favorable if the suprachoroidal hemorrhage is localized and does not extend in to the posterior pole.

Surgery for idiopathic macular holes associated with extensive subretinal fluid.

PURPOSE: To study the baseline characteristics and outcomes of surgery for idiopathic macular holes associated with localized macular detachment. METHODS: In this case-control study, eight consecutive patients with idiopathic macular hole associated with localized macular detachment (cases) and 30 randomly selected patients with idiopathic macular hole not associated with macular detachment underwent macular hole surgery. RESULTS: The mean age (62.1 versus 68.2 years; P = 0.086), mean refractive error (-0.13 versus +0.23 diopters; P = 0.68), average duration of symptoms (5.9 versus 4.6 months; P = 0.47), and macular hole stage (P = 0.43) were similar in the cases and controls. The baseline visual acuity ranged from 20/50-20/80 (1 [13%] versus 1 [3%]) to 20/100-20/200 (2 [25%] versus 24 [80.0%]) to < 20/200 (5 [63%] versus 5 [17%]) (P = 0.10). Single-operation anatomic success was achieved in 2 (25%) cases and 24 (80%) controls (P = 0.007). Visual acuity 3 months after the last macular hole surgery was worse in cases compared to controls: > or = 20/40 in 0 versus 6 (20%), 20/50-20/80 in 1 (13%) versus 13 (43%), 20/100-20/200 in 4 (50%) versus 10 (33%), and < 20/200 in 3 (38%) versus 1 (3%) (P = 0.003). The mean improvement in visual acuity was 0.2 logMAR units in cases versus 0.4 logMAR units in controls (P = 0.054). CONCLUSIONS: Surgical outcomes for idiopathic macular hole associated with a localized macular detachment compare poorly with the outcomes for macular hole not associated with extensive surrounding subretinal fluid.

Subretinal "napkin-ring" membrane in proliferative vitreoretinopathy.

A "napkin-ring" subretinal membrane is an unusual expression of subretinal proliferation associated with retinal detachment. An 80-year-old man with a total funnel-shaped retinal detachment underwent pars plana vitrectomy, 360 degrees relaxing retinotomy, excision of a subretinal napkin-ring membrane, and silicone oil injection. Histopathologic examination of the removed napkin-ring subretinal membrane revealed the presence of retinal pigment epithelium (RPE) as the major source of cells within the membrane. Myofibroblasts were the most common cellular constituents; the total number of these cells may have correlated with the degree of clinical contraction, causing a funnel-shaped retinal detachment. Arch Ophthalmol. 2000;118:1287-1289

Hardness and ultrasonic characteristics of the human crystalline lens.

PURPOSE: To evaluate the relationship between hardness of the human crystalline lens and its acoustic characteristics. SETTING: St. George's Hospital Medical School, University of London, London, United Kingdom. METHODS: Cataractous lenses from patients who had extracapsular cataract surgery were studied for hardness and ultrasonic characteristics. Lens hardness was assessed with an automated guillotine. Ultrasound velocity and attenuation were measured with a scanning acoustic macroscope using the pulse transmission reflection method. RESULTS: Thirty-seven lenses from 37 patients (mean age 75.5 years) were evaluated. Lens hardness was associated with ultrasound attenuation (r = 0.65, P <.0001) and attenuation frequency gradient (r = 0.67, P <.0001). The correlation of hardness with mean ultrasound velocity was not significant (r = 0.22, P =.2). CONCLUSIONS: The attenuation of ultrasound waves by the human crystalline lens correlated with its hardness. Ultrasonography can be used to evaluate lens hardness.

Intraocular hemorrhages associated with endoscopic spinal surgery.

PURPOSE: To report the occurrence of intraocular hemorrhages in association with endoscopic spinal surgery. METHODS: Case report. RESULTS: A 40-year-old patient noted severe visual loss in both eyes after epidural endoscopy, epidurography, and endoscopic adhesiolysis. Ophthalmic examination showed a best-corrected visual acuity of RE: 20/800, and LE: counting fingers, and extensive subhyaloid, retinal, and subretinal hemorrhages in both eyes. The hemorrhages resolved over a period of 8 weeks and the best-corrected visual acuity improved to 20/40 in both eyes after 4 months. CONCLUSION: A syndrome of visual loss and intraocular hemorrhages after an endoscopic spinal procedure is studied.

Scleral rupture during retinal detachment surgery: risk factors, management options, and outcomes.

OBJECTIVE: To evaluate the potential risk factors, management strategies, and outcomes of scleral rupture during retinal detachment (RD) surgery. DESIGN: Case-control study. PARTICIPANTS AND CONTROLS: Fourteen consecutive patients with scleral rupture during RD surgery (cases) and 65 consecutive patients who underwent RD surgery without scleral rupture (controls). INTERVENTION: Demographic and clinical data were abstracted from patients' medical records. OUTCOME MEASURES: Visual acuity and retinal attachment status at the last examination. RESULTS: Significant risk factors for scleral rupture during RD surgery were reoperation after failed RD surgery (71 % vs. 32%), and pre-existing scleral pathologic condition (29% vs. none). The site of rupture was in the bed of a previously placed scleral buckle in all patients with a previous buckling surgery. Repair of the rupture included scleral sutures in eight (57%), scleral patch graft in four (29%), and placement of a scleral buckle over the site in two (14%) eyes. Eleven (79%) underwent vitrectomy with retinal tamponade by gas (n = 4) or silicone oil (n = 7). Complications observed postoperatively included vitreoretinal incarceration (n = 3), vitreous hemorrhage (n = 2), suprachoroidal hemorrhage (n = 2) and subretinal hemorrhage (n = 3). In the 14 eyes with scleral rupture, the final visual acuity was > or =20/40 in 1 (7%), 20/50 to 20/200 in 5 (36%), and <20/200 in 8 (57%). Ten (71 %) had proliferative vitreoretinopathy develop. The retina was attached in 7 (50%), 6 (43%) had localized peripheral detachment, and 1 had a total retinal detachment. The vision improved in 4 (29%), was unchanged in 5 (36%), and was worse than before surgery in 5 (36%). In the 65 controls, the visual acuity at the time of the last examination was > or =20/40 in 26 (40%), 20/50 to 20/200 in 21 (32%), and <20/200 in 18 (28%). Sixty three (97%) patients had complete retinal reattachment, 1 (2%) had a localized peripheral RD, and 1 (2%) had an RD involving the posterior pole. After surgery, the vision improved in 45 (69%), was unchanged in 15 (23%), and was worse in 5 (8%) of the control eyes. The visual and anatomic outcomes of the eyes with scleral rupture were significantly worse than in the control group (P = 0.002 and P < 0.001, respectively). CONCLUSIONS: Risk factors associated with intraoperative scleral rupture include reoperation for failed RD surgery and pre-existing scleral pathology. Although this complication may be compatible with a good visual outcome in some patients, a high incidence of persistent or recurrent RD with proliferative vitreoretinopathy worsens the visual outcome for most patients with this complication.

Intraoperative echographic localization of iodine-125 episcleral plaque for brachytherapy of choroidal melanoma.

PURPOSE: To report intraoperative echographic localization of iodine-125 episcleral plaque for brachytherapy of choroidal melanoma. METHODS: In a retrospective study, 117 eyes with medium-sized choroidal melanoma in 117 patients not participating in the Collaborative Ocular Melanoma Study underwent iodine-125 episcleral plaque radiotherapy with intraoperative echographic verification of plaque placement between January 1992 and December 1998 at the Bascom Palmer Eye Institute. RESULTS: After initial plaque placement using standard localization techniques, intraoperative echography demonstrated satisfactory tumor-plaque apposition in 76% of eyes (89 of 117). In the 28 eyes (28 of 117, 24%) that required repositioning of the plaque, the extent of misplacement was less than 1 mm in 10 eyes, 1.1 to 3.0 mm in six eyes, and greater than 3 mm in eight eyes. Two eyes had tilting of the plaque, and in two additional eyes, although the plaque covered all tumor margins, the centration was considered suboptimal. Repositioning was necessary in 1 eye with an anteriorly located tumor (1 of 13, 7.7%) and in 20 eyes with peripapillary or posterior pole tumors (20 of 67, 26.3%). Anteriorly located tumors required plaque repositioning significantly less frequently than did posteriorly located tumors (P = .041). Misalignment involved one tumor margin in 23 eyes and two margins in five eyes. The most commonly misaligned margins were the lateral (35%) and posterior margins (26%). In no case was an anterior marginal misalignment documented. At a mean follow-up of 37 months, no tumor-related death or metastatic disease was noted. Two of the 117 patients (1.7%) had local tumor recurrence and underwent enucleation. CONCLUSIONS: Intraoperative echography is an effective adjunct for localization and confirmation of tumor-plaque relationship. This technique facilitates the identification and correction of suboptimal plaque placement at the time of surgery, potentially minimizing treatment failures.

Choroidal neovascularization following macular hole surgery.

BACKGROUND: Retinal pigment epitheliopathy, a recognized finding in eyes that have undergone macular hole surgery, may limit visual outcome and predispose to the development of choroidal neovascularization (CNV). This study reports on the features and outcomes of CNV following otherwise successful surgery for idiopathic macular holes. METHODS: Case series including three eyes of two patients who developed CNV following macular hole surgery. RESULTS: Choroidal neovascularization developed 3 to 30 months after macular hole surgery. The CNV was crescent-shaped, surrounding a central area of retinal pigment epithelial mottling that corresponded to the site of the macular hole in all three cases. All neovascular membranes were adjacent to the fovea and were associated with substantial leakage of fluorescein. The macular hole remained closed in all cases. CONCLUSION: Choroidal neovascularization is a rare complication following macular hole surgery. Retinal pigment epitheliopathy and defects in the Bruch's membrane, pre-existing or secondary to surgery, may be predisposing factors.

Emerging ciprofloxacin-resistant Pseudomonas aeruginosa.

PURPOSE: To report a clinical series of ciprofloxacin-resistant ocular isolates of Pseudomonas aeruginosa from a tertiary care ophthalmic center. METHODS: Review of in vitro sensitivities of all ocular isolates of P. aeruginosa be tween July 1991 and September 1998. In vitro resistance was defined as a minimum inhibitory concentration of 4 or more microg per ml. RESULTS: Nine of 423 ocular isolates of P. aeruginosa showed in vitro resistance to ciprofloxacin. From 1991 to 1994, 0.44% (1/227) of ocular isolates were resistant to ciprofloxacin, whereas from 1995 to 1998, 4.1% (8/ 196) of ocular isolates showed in vitro resistance (P = .014). CONCLUSIONS: Ciprofloxacin-resistant P. aeruginosa has been identified in recent clinical ocular specimens. Ciprofloxacin resistance among ocular isolates of P. aeruginosa is a local and worldwide concern.

Purtscher-like retinopathy associated with pancreatic adenocarcinoma.

PURPOSE: To investigate a case of Purtscher-like retinopathy that occurred in association with pancreatic adenocarcinoma. METHOD: Case report. RESULTS: A 63-year-old woman presented with multiple gray patches in the central vision of both eyes. Visual acuity was 20/20 in both eyes. Funduscopy showed large peripapillary yellow-white patches within the superficial retina and small superficial retinal hemorrhages in both eyes. The patient subsequently had abdominal pain. Computed tomography of the abdomen demonstrated a large pancreatic mass with extension into the liver. Histologic examination of a percutaneous needle biopsy specimen showed mucinous pancreatic adenocarcinoma. CONCLUSION: Pancreatic adenocarcinoma should be added to the list of systemic diseases that can be associated with Purtscher-like retinopathy.

Visual acuity outcomes of patients 50 years of age and older with high myopia and untreated choroidal neovascularization.

OBJECTIVE: To evaluate visual outcomes of untreated submacular choroidal neovascularization (CNV) in patients 50 years of age and older with high myopia. DESIGN: Retrospective observational case series. PARTICIPANTS: Twenty-two eyes in 22 patients were studied. All were 50 years of age and older with myopia of 6.0 diopters (D) or greater or an axial length of 25.5 mm or greater. Patients had untreated CNV documented by clinical examination and fluorescein angiography at two medical centers between 1986 and 1997. INTERVENTION: Demographic and clinical data were abstracted from patients' medical records. MAIN OUTCOME MEASURE: Visual acuity at 1 year after CNV diagnosis. RESULTS: The study included 22 eyes of 22 patients (mean age, 63.1 years; mean refraction, -11.0 D). Baseline visual acuity (VA) in the study eye was 20/40 or greater in 2 (9%) patients, 20/50 to 20/150 in 9 (41%) patients, and 20/200 or less in 11 (50%) patients. Drusen were present in seven (32%) eyes, and lacquer cracks were noted in ten (45%) eyes. Mean refractive error was -7.0 D for patients with drusen and -12.5 D for patients without drusen. Choroidal neovascularization was less than 0.25 disc diameters (DD) in 11 (50%) eyes, 0.25 to 0.5 DD in 5 (23%) eyes, and greater than 0.5 DD in 6 (27%) eyes. Visual acuity in the study eye 1 year after CNV diagnosis was 20/40 or greater in 3 (14%) patients, 20/50 to 20/150 in 3 (14%) patients, and 20/200 or less in 16 (73%) eyes. The presence of drusen was significantly associated with older age and a lower degree of myopia but was not associated with size of the CNV or visual acuity outcome. CONCLUSION: When compared to patients younger than 50 years of age with high myopia and CNV reported in previous publications, the patients in the current series generally have poorer visual outcomes.

Retinal detachment associated with macular hole surgery: characteristics, mechanism, and outcomes.

OBJECTIVE: To study the frequency, features, and outcomes of retinal detachment (RD) occurring after macular hole surgery. METHODS: Retrospective review of all cases of macular hole surgery. Cases with postoperative RD were identified for study. Outcome measures included baseline demographic and ocular characteristics, RD features, surgical procedure, macular hole status, and final visual and anatomic outcomes. RESULTS: Retinal detachment occurred in 8 (1.8%) of 438 eyes undergoing macular hole surgery. The rate of RD was 3.5% early in the course of the surgeon's experience (first 200 cases) and 0.4% later in the surgeon's experience (after 200 cases) (P = 0.026). Two of the eight eyes with RD had undergone previous macular hole surgery. All six primary cases occurred after repair of stage 3 macular holes, which had involved peeling of the posterior cortical face. The RD involved the inferior quadrants in seven eyes and the macula in two eyes. The pathogenic retinal break was in the equatorial region in four eyes, was anterior to the equator in two eyes, and remained undetermined in two eyes. The retina was attached and the macular hole was closed in all cases at the final follow-up examination (mean 30 months). The macular hole reopened 2 years following successful reattachment of the RD in one eye. Final visual acuity was > or =20/60 in four eyes and <20/200 in one eye. CONCLUSION: Retinal detachment after macular hole surgery is uncommon, and may be related to posterior cortical vitreous stripping. Early detection of RD minimizes adverse visual and anatomic outcomes.