Small incision cataract surgery and placement of posterior chamber intraocular lenses in patients with diabetic retinopathy.

BACKGROUND AND OBJECTIVE: Diabetic patients undergoing cataract surgery have been demonstrated to have a guarded prognosis. Small incision cataract surgery has been postulated to cause fewer complications than other techniques of cataract extraction. We looked at small incision cataract surgery to see how diabetics fared. PATIENTS AND METHODS: One hundred fifty-four eyes of diabetic patients were evaluated preoperatively through dilated fundus examination and Snellen visual acuity. The eyes then underwent small incision cataract surgery and were followed, undergoing periodic ophthalmoscopy, Snellen visual acuity measurement and additional postoperative therapeutic and surgical intervention. RESULTS: Final visual acuity improved by two Snellen lines or more in 61 out of 154 (40%) eyes. Final visual acuity worsened in 38 out of 154 (25%) eyes. CONCLUSIONS: Our results are similar to those reported for extracapsular surgery and phacoemulsification, suggesting that the prognosis is guarded for diabetics, even when undergoing small incision cataract surgery.

Ultrasound-guided cryotherapy for retinal tears in patients with vitreous hemorrhage.

BACKGROUND AND OBJECTIVE: The goal was to utilize ultrasound-guided cryotherapy as an immediate, low-risk, noninvasive, precise method of treating retinal tears obscured by vitreous hemorrhage. PATIENTS AND METHODS: Eleven patients with sudden onset of vitreous hemorrhage were referred for diagnosis and management. Ophthalmoscopy with scleral depression was unsuccessful at localizing peripheral retinal tears, and all of the patients were examined with ultrasound using the techniques of standardized echography. The cryoprobe was positioned for cryotherapy using both transverse and longitudinal B-scan approaches following the indentation of the globe as it appeared on the oscilloscope. RESULTS: On follow-up examination after the vitreous hemorrhage cleared, 10 of the 11 tears were examined by ophthalmoscopy and were thought to have been adequately treated. One patient had a retinal detachment after remaining stable for 3 months. Two patients were treated with laser to enhance the cryotherapy seal. One patient was observed by another physician and underwent vitrectomy due to vitreous hemorrhage that persisted 2 months following cryotherapy. After vitrectomy, the physician reported a successful cryotherapy reaction at the treated tear. One final patient in the series required vitrectomy and scleral buckle before the hemorrhage had cleared, and the treatment did not appear to be complete. CONCLUSION: Ultrasound-guided cryotherapy provides a noninvasive, inexpensive treatment alternative for retinal tears obscured by vitreous hemorrhage.

Blindness from retrobulbar injection into the optic nerve.

We report two patients with marked visual loss due to injection within the optic nerve sheath. Findings included severe visual loss, optic disc edema, retinal edema, and intraretinal, preretinal, and vitreous hemorrhage. A review of similar cases in the literature reveals a common but ill-advised use of sharp retrobulbar needles with the technique of retrobulbar injection described by Atkinson. A modified technique which limits the risk of optic nerve trauma is described.

Retinal pigment epithelial lipofuscin and melanin and choroidal melanin in human eyes.

Optical measurements of the pigments of the retinal pigment epithelium (RPE) and choroid were made on 38 human autopsy eyes of both blacks and whites, varying in age between 2 wk and 90 yr old. Lipofuscin in melanin-bleached RPE was measured as fluorescence at 470 mm following excitation at 365 nm and was found to be proportional to fluorescence measured at 560 nm in unbleached tissue. Transmission measurements of RPE and choroidal melanin were converted and expressed as optical density units. The choroidal melanin content increased from the periphery to the posterior pole. RPE melanin concentration decreased from the periphery to the posterior pole with an increase in the macula. Conversely, the amount of RPE lipofuscin increased from the periphery to the posterior pole with a consistent dip at the fovea. There was an inverse relationship between RPE lipofuscin concentration and RPE melanin concentration. The RPE melanin content was similar between whites and blacks. Lipofuscin concentration was significantly greater (P = 0.002) in the RPE of whites compared to blacks; whereas blacks had a significantly greater (P = 0.005) choroidal melanin content than whites. The amounts of both choroidal and RPE melanin showed a trend of decreasing content with aging, whereas the amount RPE lipofuscin tended to increase (whites greater than blacks). Per fundus area, the amount of choroidal melanin was always greater than that in the RPE. There was a statistically significant (P = 0.001) increase in RPE height with age, most marked in eyes of whites after age 50 and correlated with the increase in lipofuscin concentration.

Relationship of senile macular degeneration to ocular pigmentation.

We prospectively evaluated 650 consecutive white patients with senile macular degeneration and compared them to a control group of 363 patients. Ocular pigmentation (iris color and fundus pigmentation) was recorded for each patient, as was hair color (as a child and young adult) and age at evaluation. Patients were from the New England states and Florida. Our most significant finding was that 494 patients with senile macular degeneration (76%) had light-colored irides compared with 145 of the controls (40%). Fundus pigmentation closely corresponded to iris pigmentation (P less than 0.01). Hair color was blond or light brown in 370 of the patients with senile macular degeneration (57%) and in 105 of the controls (29%). Further, there was a tendency for individuals with lightly pigmented irides to have senile macular degeneration at an earlier age than those with dark irides (P less than .01). Thus, increased ocular pigmentation tends to decrease the risk of developing senile macular degeneration.

Visual acuity related to retinal distance from the fovea in macular disease.

The visual potential of patients with macular diseases involving the fovea has not been adequately documented. We evaluated 55 eyes of patients having discrete macular lesions and related best visual acuity to retinal distance from the fovea. Best visual acuity in the parafoveal area extending from the center of the fovea to a distance of 0.25 disk diameters (DD) away was 20/25 to 20/50; from 0.25 to 0.5 DD, 20/50 to 20/100; from 0.5 to 0.75 DD, 20/100 to 20/200; from 0.75 to 1.0 DD, 20/200 to 20/400; and greater than 1.0 DD, counting fingers. The clinical importance of the findings as they relate to the rationale of laser treatment of macular lesions and to the evaluation of the low-vision is discussed.

von Hippel-Lindau disease: angiomatosis of the retina and central nervous system.

von Hippel-Lindau disease is a phakomatosis that is characterized by multiple angiomatous hamartomas located in the retina, central nervous system (CNS),and visceral organs. Retinal angiomas causing blindness and CNS angiomas causing death are familiar consequences of this disease. In certain cases, early detection and treatment of these lesions may prevent their disastrous effects. Since this disease is considered to have an autosomal dominant inheritance pattern, the physician should initiate a systematic examination of all the patient's family members.

A fixation device for enucleated eyes.

We have constructed an ophthalmic fixation device that stabilizes an enucleated eye, and helps both in the pathologic examination of the eye and in ophthalmic practice surgery.

A makeshift retinoscopy rack.

A simple makeshift retinoscopy rack consists of various trial lenses placed into the slots of a nonfrosted, 35-mm slide viewing sheet. It is useful in determining the patient's refractive error at the bedside and in the operating room.

The topography and age relationship of lipofuscin concentration in the retinal pigment epithelium.

Lipofuscin pigment granules (LPG) have been implicated as a marker of cellular aging. We have quantitated the content of LPG in human retinal pigment epithelium (RPE) as a function of age. Furthermore, topographic distribution of LPG within individual eyes was measured. Microspectrofluorometric determination of the distribution of LPG in human RPE cells revealed a progressive accumulation of LPG with increasing age. LPG first appeared in the basilar portions of RPE cells of young eyes. In older eyes, LPG formed into clumps and were noted to fill the entire RPE cell. The RPE topographic distribution of LPG revealed an increased accumulation in the posterior pole, with a consistent dip at the fovea. The ratio of lipofusion accumulation at the posterior pole, to the total RPE, remained constant throughout life.