Site of potential operating microscope light-induced phototoxicity on the human retina during temporal approach eye surgery.

OBJECTIVE: To determine the site of focal illumination on the retina of phakic human cadaver eyes from an operating microscope positioned for temporal approach eye surgery. DESIGN: Experimental study. METHODS: A Zeiss OPMI-6SFR operating microscope (Zeiss Humphrey Systems, Dublin, CA) was positioned over two phakic human cadaver eyes to measure the site of the focal illumination on the retina by directly observing the illumination on the posterior scleral surface of the globe. External localization of the foveola was made by direct observation using scleral indentation and indirect ophthalmoscopy. Various combinations of microscope angulation and field of view were analyzed. MAIN OUTCOME MEASURES: Distance of focal illumination from the operating room microscope relative to the foveola was measured. RESULTS: The diameter of the "hot spot" of focal illumination on the retina was 4.0 mm. With the eye positioned straight ahead and the level operating room microscope positioned for temporal approach eye surgery, the center of retinal illumination was 0.9 and 1.4 mm nasal relative to the foveola when the microscope field of view was centered over the cornea and temporal limbus, respectively. With the microscope angled 5, 10, 15, and 20 degrees temporally (oculars tilted toward surgeon), the center of the illumination was displaced nasal to the foveola by 1.1, 1.5, 3.8, and 5.1 mm, respectively, when the field of view was centered over the cornea and 1.5, 2.6, 4.7, and 6.0 mm, respectively, nasal to the foveola when centered over the temporal limbus. CONCLUSIONS: Retinal illumination from an operating microscope positioned for temporal approach eye surgery has the potential for light-induced injury to the fovea. Angulation of the operating microscope by up to 10 degrees temporally when the microscope field of view was centered over the cornea and up to 5 degrees temporally when centered over the temporal limbus was not adequate to displace the focal illumination off the foveola when the eye was in the straight-ahead position. Tilting the operating microscope 15 degrees or more temporally when centered on the pupil and 10 degrees or more when centered over the temporal limbus should safely displace the retinal light exposure away from the fovea during temporal approach surgery. Suggestions for reducing the risk of iatrogenic phototoxicity are reviewed.

Gentamicin and other antibiotic toxicitiy.

Antibiotics have the potential to cause significant ocular toxicity when they gain access to the inside of the eye. The aminoglycosides, in particular gentamicin, are the most toxic of the antibiotics commonly used in ophthalmology. Extreme caution should be used when administering a periocular injection of aminoglycoside for treatment or prophylaxis of infection. Intraocular injection of aminoglycoside for gram-negative coverage in endophthalmitis management has been replaced in most cases by ceftazidime. Ceftazidime provides excellent coverage against gram-negative bacteria with less potential for retinal toxicity at therapeutic dosages. Experimental and clinical studies have shown that intraocular vancomycin is safe and effective treatment against gram-positive organisms causing endophthalmitis. A combination of ceftazidime and vancomycin provides broad-spectrum coverage for virtually all bacteria causing endophthalmitis and is the current intraocular treatment of choice.

Nonsurgical management of macular hemorrhage secondary to retinal artery macroaneurysms.

OBJECTIVE: To report visual acuity outcomes of nonsurgical management of macular hemorrhage secondary to retinal artery macroaneurysms. METHODS: Forty-one patients at multiple centers with macular hemorrhage secondary to retinal artery macroaneurysms managed with observation alone were reviewed. Time to clearance of macular hemorrhage, visual acuity at final follow-up, and presence or absence of macular pigmentary changes after absorption of the hemorrhage were recorded for each patient. RESULTS: On initial examination, visual acuity was 20/200 or worse in all except 4 patients (3 with 20/70, 1 with 20/80). At an average follow-up of 15. 7 months, a final visual acuity of 20/40 or better was achieved in 15 eyes (37%), between 20/50 and 20/100 in 12 (29%), and 20/200 or worse in 14 (34%). Macular pigmentary abnormalities were noted after clearance of the hemorrhage in 23 (56%) of 41 cases, and these eyes generally had worse visual acuity outcomes. CONCLUSIONS: In eyes with macular hemorrhage secondary to retinal artery macroaneurysms managed with observation alone, good visual acuity outcomes can often be achieved. Poorer visual acuity outcomes are associated with macular pigmentary changes after resorption of blood. Arch Ophthalmol. 2000;118:780-785

Treatment outcomes in a 10-year study of endogenous fungal endophthalmitis.

BACKGROUND AND OBJECTIVE: To review prevalence of organisms, associated factors, and treatment outcomes from one medical center's 10-year experience managing culture-proven endogenous fungal endophthalmitis (EFE). PATIENTS AND METHODS: The authors retrospectively reviewed the microbiology and corresponding clinical records of patients diagnosed as having culture-proven EFE at the Bascom Palmer Eye Institute during a 10-year period. RESULTS: Culture-proven EFE occurred in 20 eyes of 18 patients. Candida species occurred in 17 of 20 eyes (85%), and Aspergillus species occurred in 3 of 20 eyes (15%). The most common association was long-term intravenous line placement, which was present in 12 patients (67%). Whereas 12 patients (67%) had a history of recent hospitalization, only 2 (11%) had a documented history of systemic fungal infection. After initial examination, only 2 patients had a systemic culture positive for a fungal organism (none had a positive blood culture). Treatment after initial examination included pars plana vitrectomy in 17 of the 20 eyes (85%), intravitreal amphotericin B in 19 eyes (95%), and systemic antifungal medication in 16 eyes of 15 patients. Thirteen of the 17 eyes (76%) with Candida endophthalmitis and 0 of 3 eyes with Aspergillus endophthalmitis achieved visual acuity of 20/400 or better. CONCLUSION: The most common cause of culture-proven EFE at the authors' institution is Candida species. The overall visual outcomes were more favorable for Candida cases than they were for Aspergillus cases. In the treatment of patients with marked vitreous infiltrates from EFE, pars plana vitrectomy, intravitreal amphotericin B injection, and administration of appropriate systemic antifungal medication (fluconazole for Candida) are generally recommended.

Asymptomatic rhegmatogenous retinal detachment.

The vast majority of patients with rhegmatogenous retinal detachments present with either acute or chronic symptoms. In these cases repair of the retinal detachment is almost always recommended to either improve vision or prevent further visual loss. In a small subgroup, rhegmatogenous retinal detachments were detected as incidental findings in asymptomatic patients. Such asymptomatic detachments are often caused by atrophic holes in lattice degeneration and are more commonly located in the inferior quadrants. Demarcation lines are often present. Asymptomatic retinal detachments also occur in a younger age group of patients when compared with symptomatic rhegmatogenous retinal detachments. The management of eyes with an asymptomatic retinal detachment is controversial. The risk of complications during surgical repair must be weighed against the chance that the retinal detachment will progress. Recently published clinical data suggest that the risk of progression of asymptomatic rhegmatogenous retinal detachments is small. Consequently, observation can be considered as a reasonable management option in reliable patients until progression is documented or symptoms occur. Patient education geared toward instruction on self-monitoring of the visual field and a review of the risks and benefits of retinal detachment repair versus observation are important in patients with asymptomatic retinal detachment.

Central serous chorioretinopathy in women.

BACKGROUND: Central serous chorioretinopathy is a disorder that typically affects young and middle-aged men. Although extensive information is available pertaining to the clinical features of central serous chorioretinopathy in men, little is known about this condition in women. MATERIALS AND METHODS: The authors reviewed the medical records and photographic files of women who received a diagnosis of central serous chorioretinopathy. The women were divided into three groups for data analysis: idiopathic, exogenous corticosteroid use, and pregnancy. RESULTS: Fifty-one women with active central serous chorioretinopathy were evaluated. These findings in women with idiopathic serous chorioretinopathy were similar to those described in men, with the exception that women tend to be older at the time of onset. Central serous chorioretinopathy in women taking exogenous corticosteroids more likely was characterized by bilateral involvement and subretinal fibrin. Central serous chorioretinopathy in pregnant women typically developed in the third trimester and resolved spontaneously within 1-2 months after delivery. CONCLUSION: Idiopathic central serous chorioretinopathy is similar in women and men, with the exception that women tend to be more older at the time of onset. The finding of exogenous corticosteroid use in a significant number of women in our study provides further support that cortisol may play a role in the development of central serous chorioretinopathy. The mechanism by which cortisol influences the development of central serous chorioretinopathy is unclear.

Asymptomatic rhegmatogenous retinal detachments.

OBJECTIVE: To describe the clinical characteristics and risk of progression of asymptomatic rhegmatogenous retinal detachments. METHODS: We retrospectively reviewed the clinical records of 28 patients (31 eyes) with asymptomatic rhegmatogenous retinal detachments followed up without surgery for 0.5 to 12.1 years (mean, 3.4 years). Tractional tears were present in six eyes and atrophic holes in 25 eyes. In five patients, the asymptomatic retinal detachment was noted when the patient presented with a symptomatic retinal detachment in the fellow eye. RESULTS: Twenty-nine of the 31 eyes remained asymptomatic without progression of the retinal detachment. Two eyes progressed to a symptomatic retinal detachment 2.25 and 3.3 years after the initial examination, underwent a successful scleral buckling procedure, and maintained 20/20 visual acuity. CONCLUSIONS: Observation can be considered a reasonable option in the treatment of patients with asymptomatic retinal detachments. Chart documentation of the risks and benefits of observation and instruction of the patient on self-monitoring of the peripheral visual field are necessary in such patients.

Choroidal nonperfusion in giant cell arteritis.

A 68-year-old man had visual loss secondary to isolated choroidal nonperfusion as a clinical manifestation of giant cell arteritis. Ophthalmoscopy disclosed scattered yellow-white lesions at the level of the retinal pigment epithelium in the posterior pole of the right eye. Intravenous fluorescein angiography demonstrated marked delay in choroidal filling of the macula in the right eye. There was no ophthalmoscopic or angiographic evidence of anterior ischemic optic neuropathy or central retinal artery occlusion. After approximately 72 hours of intravenous corticosteroid therapy, the patient's visual acuity improved and repeat intravenous fluorescein angiography showed normal choroidal circulation. Isolated choroidal ischemia is a potential cause of reversible visual loss in patients with giant cell arteritis.

Presumed exudative retinal detachment after cryotherapy in retinopathy of prematurity.

Cryotherapy of the peripheral avascular retina in selected cases of retinopathy of prematurity has been shown to reduce the incidence of posterior retinal detachment, retinal fold involving the macula, and retrolental tissue. Although exudative retinal detachments have been described after cryotherapy during scleral buckling procedures, to our knowledge, this observation has not been reported after cryotherapy in retinopathy of prematurity. We describe such a case.

Unusual retinal and renal vascular lesions in the Klippel-Trenaunay-Weber syndrome.

Ocular fundus abnormalities associated with the Klippel-Trenaunay-Weber syndrome are uncommon and include retinal vascular tortuosity and diffuse choroidal hemangioma. A case involving a young girl with Klippel-Trenaunay-Weber syndrome who had unusual bilateral, exudative, outer retinal vascular masses involving the peripheral fundus in one eye and the foveal area in the other eye is reported. Kidney biopsy for renal insufficiency disclosed abnormal excess mesangial tissue. The fundus lesions appear to represent vascular tumors of the retina that differ clinically from previously reported retinal vascular tumors and Coats disease. The simultaneous retinal and renal involvement suggest that Klippel-Trenaunay-Weber syndrome may be associated with more widespread vascular malformations than previously realized.

Management of endophthalmitis while preserving the uninvolved crystalline lens.

Twelve phakic eyes (11 patients) with culture-positive endophthalmitis were treated without removal of the uninvolved crystalline lens. Eight eyes were treated by pars plana vitrectomy and intraocular injection of antibiotics. Four eyes were treated with intraocular antibiotic injection alone. The clinical infection was successfully eradicated in all patients, including one patient treated with reinjection of antibiotics. During follow-up after successful treatment, eight eyes had progression of a preexisting lens opacification, two eyes had stable lens opacification, and two eyes maintained clear lenses. Six of 12 eyes achieved 20/80 or better visual acuity with an average follow-up time of 13 months. Six of eight eyes treated with pars plana vitrectomy and intraocular antibiotic injection achieved this level of visual acuity in contrast to none of four eyes treated with only intraocular antibiotic injection. These results indicated that endophthalmitis in phakic eyes can be successfully treated while preserving a clear, uninvolved crystalline lens by the use of pars plana vitrectomy and intraocular administration of appropriate antibiotics.

Chickenpox-associated acute retinal necrosis syndrome.

Acute retinal necrosis (ARN) syndrome usually occurs as the result of secondary reactivation of latent, previously acquired, varicella-zoster or herpes simplex virus. The authors report four patients who developed a mild form of ARN within 1 month (5 to 28 days) after the onset of chickenpox. In contrast to typical cases of ARN, these cases were less severe, with retinitis limited to two quadrants or less (three patients), no retinal detachment (four patients), minimal vitreitis (four patients), and no loss of visual acuity (four patients). Thus, ARN may occur during the course of primary varicella-zoster infection.

Correlation between vitreous pigment granules and retinal breaks in eyes with acute posterior vitreous detachment.

The authors prospectively studied 106 consecutive phakic eyes with acute posterior vitreous detachment to determine the correlation between anterior vitreous pigment granules and retinal breaks. Pigment granules were identified in 15 eyes (14.1%), all of which had either a flap or an operculated retinal break. A retinal tear was found in only one eye without pigment granules (P = 0.000). Other factors demonstrating a statistically significant association with retinal breaks included grossly visible preretinal or vitreous blood (P = 0.039) and male gender (P = 0.000). In the absence of other ocular pathology, the presence of vitreous pigment granules identifies a very high-risk group of acute posterior vitreous detachment patients.

Effect of contact lens biomicroscopy on the clarity of fluorescein angiography.

To study the effect of contact lens fundus biomicroscopy on the clarity of subsequent fluorescein angiography, the authors compared the fluorescein angiogram from 20 eyes recently examined using a fundus contact lens with fellow control eyes. Saline solution was used to couple the lens to the cornea. In 15 (75%) of the 20 pairs of eyes studied, there was no difference in the fluorescein angiogram clarity between examined and control eyes. In five (25%) patients, there was a slight asymmetry in clarity between the examined and control eyes, but this did not affect the ability to interpret the angiogram. The results were verified by comparing the overall quality of the transit phase of the angiograms. The application of a fundus contact lens to the cornea using saline solution as a coupling agent does not adversely affect the clarity of subsequent fluorescein angiography.