Incidence of retinal detachment and visual outcome in eyes presenting with posterior vitreous separation and dense fundus-obscuring vitreous hemorrhage.

PURPOSE: To determine visual outcomes and the incidence of retinal detachment in eyes presenting with posterior vitreous separation and dense fundus-obscuring vitreous hemorrhage. DESIGN: Retrospective consecutive noncomparative interventional case series. PARTICIPANTS: Thirty-six eyes (15 right eyes and 21 left eyes) of 34 patients (18 female and 16 male) ranging in age from 42 to 94 years. Mean follow-up was 14 months. METHODS: A comparison of the best-corrected initial visual acuities versus final visual acuities after spontaneous resolution of vitreous hemorrhage or surgical intervention. The number of eyes that were found to have retinal tears or that had a rhegmatogenous retinal detachment develop was documented. Logarithm of the minimum angle of resolution-converted visual acuities was used for comparison. Categorical data were analyzed by Fisher's exact test, and population means were compared by Student's t test. MAIN OUTCOME MEASURES: Final mean visual acuities, number of eyes with at least one retinal tear, location of retinal tears, number of eyes that had retinal detachment develop, and the number of eyes repaired with scleral buckling surgery and/or pars plana vitrectomy. RESULTS: Twenty-four of 36 eyes (67%) were found to have at least one retinal break (range, 0-4 breaks), with 88% of breaks located in the superior retina. Eleven eyes (31%) had more than one retinal break. Fourteen of 36 eyes (39%) had a rhegmatogenous retinal detachment develop that was repaired with pars plana vitrectomy and scleral buckling. An additional 14 eyes (39%) underwent vitrectomy for nonclearing vitreous hemorrhage. The incidence of retinal detachment in eyes with a history of retinal detachment in the contralateral eye was 75% (P = 0.04). Seven of 14 eyes (50%) with retinal detachment had coexisting proliferative vitreoretinopathy. Most retinal breaks and detachments occurred in emmetropic or myopic eyes. For all 36 eyes the mean preoperative visual acuity was 20/1233, and the mean final visual acuity was 20/62 (P < 0.0001). Eyes that had a macula-off retinal detachment develop had worse final visual outcomes (20/264; P = 0.01), as did eyes that had proliferative vitreoretinopathy develop (20/129; P = 0.04). CONCLUSIONS: Acute, spontaneous, nontraumatic posterior vitreous separation with dense fundus-obscuring vitreous hemorrhage is associated with a high incidence of retinal tears and detachment. Close follow-up with clinical examination and ultrasonography is necessary, because many of these eyes may eventually require surgical intervention. Aggressive management with early vitrectomy should be considered when there is a history of retinal detachment in the contralateral eye.

A comparison of visual results and complications in eyes with posterior chamber intraocular lens dislocation treated with pars plana vitrectomy and lens repositioning or lens exchange.

PURPOSE: To compare the visual results and the postoperative complications in eyes with posterior chamber intraocular lens (PCIOL) dislocation that underwent pars plana vitrectomy with lens repositioning with eyes that underwent pars plana vitrectomy with lens exchange. DESIGN: Nonrandomized consecutive comparative case series. PARTICIPANTS: Fifty-nine eyes (27 right eyes and 32 left eyes) of 56 subjects (28 women and 28 men) ranging in age from 59 to 90 years. Mean follow-up was 34 months. METHODS: A comparison of the best-corrected preoperative visual acuities, final visual acuities, and postoperative complications in subjects with dislocated PCIOLs that underwent pars plana vitrectomy. Logarithm of the minimum angle of resolution (LogMAR)-converted visual acuities were used for comparison. Categorical data were analyzed by Fisher's exact test, and population means were compared by a pooled Student's t test. MAIN OUTCOME MEASURES: Final mean visual acuities, change in mean visual acuities, and postoperative complications. RESULTS: For all 59 eyes the mean preoperative visual acuity was 20/152, and the mean final visual acuity was 20/48. Final visual results were similar between the eyes that underwent lens repositioning (20/55) and the eyes that underwent lens exchange (20/43; P = 0.19). Final visual results were also similar between the eyes that underwent lens exchange with sutured PCIOL placement (20/51) and the eyes that underwent lens exchange with anterior chamber intraocular lens (ACIOL) placement (20/38; P = 0.26). Final mean visual acuity in eyes that received an ACIOL (20/38) was better than in eyes that underwent repositioning of the dislocated lens into the ciliary sulcus (20/65; P = 0.01). The mean increase in visual acuities was greater for eyes with ACIOL placement compared with eyes with sutured PCIOL placement (P = 0.01). For all eyes, final visual results were unaffected by a concurrent diagnosis of age-related macular degeneration (20/52; P: = 0.71), glaucoma (20/48; P = 0.95), or postoperative cystoid macular edema (20/55; P = 0.45). Final visual acuities were significantly worse in eyes with a detectable preoperative afferent pupillary defect (20/200; P<0.0001). Postoperative retinal detachments developed in 4 of 29 eyes (14%) that underwent lens repositioning and in 2 of 30 eyes (7%) that had lens exchange (P = 0.42). Postoperative lens subluxations occurred in 6 of 29 eyes (21%) that underwent lens repositioning and in 1 of 30 eyes (3%) that underwent lens exchange (P = 0.05). CONCLUSIONS: The final visual results in eyes with dislocated PCIOLs that underwent pars plana vitrectomy with lens repositioning were similar to the visual results obtained in eyes that underwent pars plana vitrectomy with lens exchange. For eyes that underwent lens exchange, final visual results in eyes that received an ACIOL were similar to the visual results obtained in eyes that received a PCIOL; however, eyes with an ACIOL showed a greater increase in mean visual acuity. Eyes with a preoperative afferent pupillary defect had worse final visual results.

Surgical repair of full-thickness idiopathic macular holes associated with significant macular drusen.

OBJECTIVE: To evaluate the visual and anatomic results of surgically repaired macular holes in eyes with intermediate or large-sized macular drusen. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Thirty-four eyes of 32 patients undergoing macular hole surgery with preoperative intermediate or large-sized macular drusen as defined by the Age-Related Eye Disease Study (AREDS). INTERVENTION: Pars plana vitrectomy for standard macular hole repair performed by multiple surgeons. MAIN OUTCOME MEASURES: Visual acuity, anatomic hole closure. RESULTS: Initial hole closure failed in 8 eyes (24%) overall, 5 of 28 eyes (18%) with AREDS category 2 drusen and 3 of 6 eyes (50%) with category 3 drusen (P = 0.1263). Final macular hole closure was seen in 93% of category 2 and 67% of category 3 eyes (P = 0.1347). Mean final visual acuity was 20/60 overall, 20/60 for category 2, and 20/50 for category 3 eyes. CONCLUSIONS: A trend of reduced initial macular hole closure was seen in eyes with significant macular drusen. Reoperation improved closure rates. If closure was accomplished, visual outcomes were excellent.

Pneumatic retinopexy: a survey of current practice patterns among the vitreous society members.

It was our purpose to assess the current practice patterns of vitreoretinal surgeons in the continental United States regarding the use of pneumatic retinopexy for the repair of rhegmatogenous retinal detachments. Preferences of vitreoretinal surgeons regarding the repair of rhegmatogenous retinal detachments were obtained via mail survey of all active members of the Vitreous Society residing in the continental United States as of December 1995. Forty-eight percent of those surveyed responded to the questionnaire. Scleral buckle was preferred over pneumatic retinopexy by more than 2 to 1 for repair of multiple superior tears within 3 clock hours, moderate myopia, small vitreous hemorrhage, detached macula, age greater than 65 years old, visually significant cataract, mild proliferative vitreoretinopathy, pseudophakia, and patient membership in an HMO. Pneumatic retinopexy was preferred in patients who were uninsured and in cases in which an operating room was not immediately available. Although the initial success rate of pneumatic retinopexy was felt to be lower than scleral buckling, the majority felt that there was no difference in the ultimate visual outcome. Among responding members of the Vitreous Society, scleral buckling continues to be the procedure of choice for the repair of the majority of primary retinal detachments.

Successful closure of traumatic macular holes.

PURPOSE: To establish the efficacy of vitreoretinal surgery without the use of transforming growth factor-beta or autologous platelet concentrate in the repair of traumatic macular holes. METHODS: This retrospective review consisted of 16 eyes from 16 consecutive patients treated by five vitreoretinal surgeons at a single institution between 1993 and 1997. Intervention included pars plana vitrectomy with creation of posterior vitreous detachment, placement of 14% to 16% C3F8 gas, and postoperative face-down positioning. Ten eyes received intraoperative autologous plasmin to facilitate formation of posterior vitreous detachment. Main outcome measures were anatomic closure rate and visual outcome. RESULTS: Anatomic closure of the macular holes was achieved in 15 (94%) of 16 eyes, with an average follow-up of 7 months. Six (38%) eyes achieved visual acuity of 20/40 or better. Visual acuity improved by 2 or more lines in 11 (69%) of 16 eyes. The average preoperative logMAR-converted visual acuity of 20/175 improved to 20/60 postoperatively. CONCLUSION: Traumatic macular holes can be closed successfully with substantial visual recovery without the use of transforming growth factor-beta or platelet concentrate.

Intraoperative acetazolamide in the prevention of intraocular pressure rise after pars plana vitrectomy with fluid-gas exchange.

PURPOSE: To assess the effect of intraoperative acetazolamide (Diamox) on postoperative intraocular pressure (IOP) in gas-filled, vitrectomized eyes. METHODS: We conducted a prospective randomized clinical trial of 63 consecutive patients undergoing pars plana vitrectomy with total fluid-gas exchange and long-acting intraocular gas tamponade. Patients were randomized by a blind draw to receive either intravenous 500 mg acetazolamide (Diamox) (Group 1) or no treatment (Group 2) at the conclusion of the operative procedure. Intraocular pressures at the conclusion of surgery (IOP-1), 4-8 hours following surgery (IOP-2), and on the first postoperative day (IOP-3) were measured using an Oculab Tono-Pen. RESULTS: Patients in Groups 1 and 2 showed similar mean IOP on postoperative day 1 (20.48+/-7.84 mmHg versus 19.89+/-7.89 mmHg). A similar incidence of IOP-2 greater than 30 mmHg (1 versus 3 patients with high IOP) and IOP-3 greater than 30 mmHg (4 versus 3 patients with high IOP) was seen. Patients in Group 1 had a lower mean IOP at 4-8 hours postoperatively (16.25+/-6.47 mmHg) than those in Group 2 (20.13+/-6.33 mmHg). No correlation could be demonstrated between IOP-1 and subsequent IOP. However, IOP on the first postoperative day (IOP-3) was strongly correlated with IOP 4-8 hours after surgery (IOP-2) (P = 0.0001). No protective effect of Diamox could be demonstrated on either IOP-2 or IOP-3. CONCLUSIONS: No protective effect against pressure rise could be demonstrated for intraoperative acetazolamide (Diamox) in the prophylaxis of IOP rise following pars plana vitrectomy and total fluid-gas exchange with long-acting intraocular gas.

Anti-tumour and antioxidant activity of natural curcuminoids.

Matural curcuminoids, curcumin, I, II and III isolated from turmeric (Curcuma longa) were compared for their cytotoxic, tumour reducing and antioxidant activities. Curcumin III was found to be more active than the other two as a cytotoxic agent and in the inhibition of Ehrlich ascites tumour in mice (ILS 74.1%). These compounds were also checked for their antioxidant activity which possibly indicates their potential use as anti-promoters. The amount of curcuminoids (I, II and III) needed for 50% inhibition of lipid peroxidation was 20, 14 and 11 g/m. Concentrations needed for 50% inhibition of superoxides were 6.25, 4.25 and 1.9 micrograms/ml and those for hydroxyl radical were 2.3, 1.8 and 1.8 micrograms/ml, respectively. The ability of these compounds to suppress the superoxide production by macrophages activated with phorbol-12-myristate-13-acetate (PMA) indicated that all the three curcuminoids inhibited superoxide production and curcumin III produced maximum effect. These results indicate that curcumin III is the most active of the curcuminoids present in turmeric. Synthetic curcumin I and III had similar activity to natural curcumins.

Surgical management of submacular hemorrhage. A series of 47 consecutive cases.

BACKGROUND: The development of a thick submacular hemorrhage usually carries a poor visual prognosis. The surgical removal of submacular blood may improve the otherwise poor outlook in these cases. SUBJECTS AND METHODS: Forty-seven consecutive patients underwent vitrectomy with surgical removal of submacular hemorrhage. The patient population consisted of two consecutive groups. Group 1 (1989 to 1991) included 23 patients (20 with age-related macular degeneration [ARMD], one with idiopathic submacular hemorrhage, one with presumed ocular histoplasmosis syndrome [POHS], and one with angioid streaks) who underwent mechanical clot extraction. Group 2 (1991 to 1993) included 24 patients (19 with ARMD, two with POHS, two with arterial macroaneurysm, and one with angioid streaks) who underwent tissue plasminogen activator-assisted drainage of thick submacular hemorrhage. The dose of tissue plasminogen activator ranged from 10 to 40 micrograms. All patients had surgery within 72 hours of diagnosis. RESULTS: In group 1, the mean size of the submacular hemorrhage was 11 disc areas (range, 1 to 16 disc areas). Mean follow-up was 40 weeks. Mean postoperative visual acuity for eyes with ARMD was 20/200. (Visual acuity improved in six eyes, was stable in seven eyes, and deteriorated in seven eyes.) All three of the eyes without ARMD had visual improvement with a mean postoperative visual acuity of 20/70. Overall, visual acuity stabilized or improved in 13 (57%) of 23 patients and decreased in 10 (43%) patients. In group 2, the mean size of the submacular hemorrhage was 11 disc areas (range, 3 to 16 disc areas). Mean follow-up was 24 weeks. Mean postoperative visual acuity for eyes with ARMD was 20/480 (visual acuity was stable in 15 eyes, improved in two eyes, and deteriorated in two eyes). Four of five eyes without ARMD had visual improvement and one was stable, with a mean postoperative visual acuity of 20/60. Visual acuity stabilized or improved in 22 (92%) of 24 patients and decreased in two (8%). The degree of clot lysis was variable. CONCLUSIONS: Submacular hemorrhage secondary to ARMD has a poor visual prognosis, with or without surgical drainage. The addition of tissue plasminogen activator-assisted clot lysis does not appear to significantly improve the visual outcome following surgery. The determination of whether surgical intervention is appropriate in these cases requires a prospective, randomized clinical trial.

Pars plana vitrectomy for treatment of stage 2 macular holes.

OBJECTIVE: To assess the anatomic outcome and visual acuities at follow-up after pars plana vitrectomy in the management of stage 2 macular holes. DESIGN: Retrospective. SETTING: Retina Consultants, Ltd, St Louis, Mo. PATIENTS: Thirty-three patients, aged 43 to 75 years, with stage 2 macular holes. INTERVENTION: Total pars plana vitrectomy with separation of the posterior hyaloid membrane and injection of intraocular gas followed by postoperative face-down positioning. MAIN OUTCOME MEASURES: Visual acuity and anatomic appearance of the macular hole. RESULTS: Postoperatively, 20 (61%) of 33 eyes attained a visual acuity of 20/50 or greater. Twenty (61%) of 33 eyes showed an improvement in visual acuity, while nine (27%) of 33 were stable. Four (12%) of 33 eyes showed a decline in postoperative visual acuity with progression to a stage 3 macular hole. Twenty-five (76%) of 33 eyes showed stabilization or improvement in the appearance of the macular hole. CONCLUSIONS: Pars plana vitrectomy in conjunction with postoperative intraocular gas tamponade may result in visual and anatomic stabilization or improvement in eyes with stage 2 macular holes. However, because of limited natural history data, it is unknown whether these results are any better than those that might occur without surgery.

Choroidal neovascularization associated with choroidal hemangiomas.

Two patients with choroidal hemangiomas developed choroidal neovascularization. One patient with Sturge-Weber syndrome, a unilateral diffuse choroidal hemangioma, and a serous detachment of the macula was treated with yellow dye laser photocoagulation in a grid pattern to the tumor before glaucoma filtration surgery. Four years after successful laser treatment, the patient developed subfoveal choroidal neovascularization in an area of treatment. A second patient with a circumscribed choroidal hemangioma developed spontaneous subfoveal choroidal neovascularization 12 years after initial diagnosis of the hemangioma. The development of choroidal neovascularization associated with choroidal hemangiomas represents a potential cause of poor visual outcome in these patients.

Surface reaction on silicone tubes used in the treatment of nasolacrimal drainage system obstruction.

Silicone tubes removed from patients who underwent intubation of the nasolacrimal system for acquired or congenital obstruction were studied to determine the cellular reaction on the tubes and to assess the relationship between the length of intubation and the cellular response. Twenty-one tubes were available for analysis. Length of intubation varied from 39 to 415 days; patient ages varied from 10 months to 75 years. All patients had undergone dacryocystorhinostomy or closed intubation of the nasolacrimal system. No patient had clinical signs of infection at the time of tube removal. All tubes were mounted on glass slides and stained with hematoxylin and eosin. The reactions seen, together with the location and type of cells present, were graded by a masked observer. There were varying numbers of inflammatory cells, predominantly polymorphonuclear leukocytes. As the length of intubation increased, the number of inflammatory cells also increased. The proximal portion of the tubing showed the least amount of cellular reaction at all lengths of intubation.

Crohn's disease and retinal vascular disease.

Patients with Crohn's disease may manifest extraintestinal findings including ocular involvement. We treated two patients with Crohn's disease who manifested retinal vascular disease that may have been related to the immune nature of the underlying disease or possibly to changes in the vasculature or coagulation system. One patient had a central retinal vein occlusion and the other had retinal vasculitis involving retinal arteries and veins with an apparent branch retinal artery occlusion. Both patients were in excellent health except for Crohn's disease, which was confirmed by a biopsy specimen. In one patient, the diagnosis of retinal vasculitis preceded the clinical diagnosis of Crohn's disease, whereas for the second patient the symptomatology of the intestinal disease preceded the ocular manifestations. We suggest that inflammatory bowel disease should be considered in the differential diagnosis of retinal vascular occlusive disease, especially in a young patient.