Communication between the subretinal space and the vitreous cavity in the morning glory syndrome.

BACKGROUND: The aim was to describe a pathogenic mechanism for a rhegmatogenous retinal detachment in a 69-year-old man with the morning glory syndrome. METHODS: During vitreous surgery for a retinal detachment, a membrane was removed that covered the optic disc anomaly and produced traction on the peripapillary retina. A retinal hole was found in tissue lying within the optic cup, and the hole was sealed using a autologous plasma-thrombin mixture. Silicone oil was used for retinal tamponade. RESULTS: A retinal hole in tissue lying within the optic cup provided a fluid pathway between the vitreous cavity and the subretinal space. Following vitrectomy surgery, bubbles of silicone oil passed through the retinal hole into the subretinal space of the macula. CONCLUSION: This case demonstrates that a retinal hole in tissue lying within the optic disc anomaly of the morning glory syndrome provides a communication for fluid between the subretinal space and the vitreous cavity, resulting in a rhegmatogenous retinal detachment. Vitreous replacement with silicone oil resulted in the migration of silicone bubbles into the subretinal space.

Perfluorocarbon liquid in the management of retinal detachment with proliferative vitreoretinopathy.

PURPOSE: To describe the techniques and results of perfluoro-N-octane used during vitrectomy for managing retinal detachment with severe proliferative vitreoretinopathy (PVR). METHODS: The authors retrospectively studied 223 consecutive patients who underwent vitreoretinal surgery for severe PVR (93% D1-D3). Patients underwent an average of 1.72 prior vitreoretinal surgeries. Perfluoro-N-octane was used intraoperatively to flatten the retina, avoiding posterior drainage retinotomy, to identify areas of residual retinal traction and periretinal membranes, to stabilize the peripheral retina during dissection of anterior PVR, and to help determine the extent and location of relaxing retinotomies. Extended-term gas tamponade was used in 91% of eyes. All patients were followed for a minimum of 6 months. RESULTS: Seventy-eight percent of the retinas were reattached posterior to the scleral buckle after a single vitreoretinal surgery and 96% were reattached after multiple surgeries. An average of 1.24 vitrectomy surgeries were required. The final visual acuity was 20/400 or better in 74% of eyes and 20/80 or better in 30% (P = 0.004). Preoperative hypotony (intraocular pressure < or = 5 mmHg) and multiple prior vitreoretinal surgeries were associated with a poor final visual acuity (P = 0.01 and 0.02, respectively). Preoperative hypotony (intraocular pressure < or = 5 mmHg) was associated with a greater frequency of relaxing retinotomies (P = 0.02). Retained perfluoro-N-octane was observed postoperatively in the vitreous cavity in 1.3% and subretinal perfluoro-N-octane in 0.9%. CONCLUSION: Experience with perfluoro-N-octane has demonstrated its usefulness both diagnostically and therapeutically as an intraoperative tool and improved the anatomic and visual outcome for retinal detachment complicated by severe PVR.

Surgical techniques for repositioning a dislocated intraocular lens, repair of iridodialysis, and secondary intraocular lens implantation using innovative 25-gauge forceps.

PURPOSE: We developed surgical techniques for the sulcus fixation of a posteriorly dislocated or secondarily implanted posterior chamber intraocular lens, repair of an iridodialysis, and the management of a decentered intraocular lens during vitreous surgery using innovative 25-gauge forceps. METHODS: The 25-gauge forceps have a curved shaft, a tip with a distal platform for grasping a suture, and a proximal groove for gripping a haptic. The forceps are inserted through a grooved scleral incision into the plane of the ciliary sulcus, facilitating manipulations such as fastening a suture loop around a haptic, repositing an intraocular lens at the ciliary sulcus, and grasping sutures during repair of a iridodialysis or implantation of a secondary intraocular lens. Seven patients underwent vitreous surgery using the new forceps. RESULTS: In all seven patients the surgical objectives were accomplished with the 25-gauge forceps without postoperative complications such as hemorrhage, hypotony, or lens decentration. CONCLUSIONS: The 25-gauge forceps are innovative instrumentation designed specifically for anterior segment applications during vitreous surgery.

Effect of intravitreal tissue plasminogen activator on experimental subretinal hemorrhage.

PURPOSE: To study the effect of intravitreally injected tissue plasminogen activator (tPA) in an experimental model of subretinal hemorrhage. METHODS: Autologous blood was transsclerally injected into the subretinal space in 34 albino rabbits. One day later tPA was injected into the posterior vitreous in 24 eyes and saline was injected into 10 control eyes. Lysis of the subretinal blood was assessed ophthalmoscopically and retinal function was evaluated electroretinographically. RESULTS: In all eyes in which tPA was injected intravitreally 1 day after subretinal injection of blood, the formed subretinal clots was not visible within 24 hours of treatment. Liquefied subretinal blood that formed from clot lysis disappeared within 6 days. Conversely, in all saline-injected control animals, the subretinal clots were unchanged at 24 hours and were observed for at least 3 days after injection. As a result of the presence of subretinal blood, scotopic electroretinogram amplitudes were markedly reduced in the tPA and saline-injected groups. In many eyes, blood migrated from the subretinal space into the vitreous, but it was detected later, was less severe, and cleared more rapidly after tPA injection. CONCLUSION: Intravitreal injection of tPA 1 day after subretinal injection of blood in rabbits facilitated more rapid lysis of the clotted blood, however, retinal damage was not prevented.

Metastatic choroidal abscess and choroidal neovascular membrane associated with Staphylococcus aureus endocarditis in a heroin user.

BACKGROUND: A 44-year-old man who was an intravenous heroin user developed multiple septic emboli, including a choroidal abscess in the macula and foot and skin infection after Staphylococcus aureus endocarditis. METHODS: Prompt administration of systemic oxacillin and gentamicin was prescribed for the endocarditis. RESULTS: One week after septic embolization to the choroid, a subfoveal, poorly-defined choroidal neovascular membrane with retinochoroidal anastomosis was noted at the site of active choroidal infection. CONCLUSION: Systemic antibiotic therapy successfully eradicated the choroidal infection, prevented progression to endophthalmitis, and improved visual acuity.

The edrophonium-Hess screen test in the diagnosis of ocular myasthenia gravis.

The interpretation of the edrophonium (Tensilon) test in the diagnosis of acquired strabismus caused by myasthenia gravis has been problematic because of poorly defined endpoints and unknown sensitivity and specificity. We evaluated the endpoint criteria, dynamics, sensitivity, and specificity of binocular alignment in response to edrophonium by using the Hess screen test in ten normal control subjects, 12 nonmyasthenic patients with acquired strabismus, and in ten patients with acquired strabismus caused by ocular myasthenia gravis. A positive response to the edrophonium-Hess screen test was defined as a 50% or greater reduction in the strabismic deviation at the fixation point associated with maximum deviation within one minute of edrophonium infusion. All myasthenic patients had a 50% or greater reduction in the initial deviation within one minute of edrophonium infusion. Myasthenic patients had a statistically significant reduction in the average deviation up to 150 seconds after edrophonium infusion (P < .05 for all time periods). In contrast, with or without edrophonium infusion, control subjects had a purely horizontal fluctuation in binocular alignment of less than or equal to 2 degrees for the entire four-minute period after edrophonium infusion. None of the 12 nonmyasthenic patients tested positive to the edrophonium-Hess screen test. According to the criterion of positive response as was defined in this study, the test had a high sensitivity and specificity in this sample. These results suggest that clearly defined endpoint criteria make the edrophonium-Hess screen test a sensitive and specific quantitative study for the diagnosis of acquired strabismus caused by myasthenia gravis.

Concomitant lymphangioma and arteriovenous malformation of the orbit.

An 8-year-old girl had an orbital-adnexal lymphangioma and ipsilateral orbital and middle cranial fossa arteriovenous malformations. High-resolution magnetic resonance image scanning, orbital ultrasonography, and digital subtraction angiography were used for diagnosis and preoperative assessment. Complications related to this vascular neoplasm included amblyopia, acute hemorrhage with proptosis, exposure keratitis, cosmetic deformity, and recurrent preseptal cellulitis. The girl was treated with both embolization and orbital surgery for recurrent hemorrhage and proptosis. We postulated that the coexistence of a lymphangioma and arteriovenous malformation represents an unusual and extensive maldevelopment of vascular embryogenesis.

Cinefluoroscopy of the aortic valve: an accurate noninvasive method for assessing critical aortic stenosis in the elderly.

The purpose of this study was to assess whether the degree of fluoroscopic aortic valve calcification could help identify the presence of aortic stenosis in the elderly. To evaluate the diagnostic utility of cardiac fluoroscopy for the detection of aortic stenosis (aortic valve area less than or equal to 1.0 cm 2) in patients 60 years or older, aortic valve area determined by cardiac catheterization was related to the pattern of calcification seen on cinefluoroscopy in 97 patients (mean age of 72 +/- 6 years) with suspected aortic stenosis. Dense circumferential (3+) calcification of the aortic valve was seen on cinefluoroscopy in 56 of 59 patients with an aortic valve area less than or equal to 1.0 cm 2 (sensitivity 95%), compared to 5 of 38 patients with aortic valve area greater than 1.0 cm2 (specificity 87%) (p less than .001). These findings suggest that in patients 60 years of age or older with suspected aortic stenosis, a dense circumferential (3+) aortic valve calcification on cinefluoroscopy is highly predictive of an aortic valve area less than or equal to 1.0 cm2 with a positive predictive accuracy of 91% and a negative predictive accuracy of 91%. Thus cinefluoroscopy may provide an accurate adjunct or alternative to Doppler echocardiography in the assessment of aortic stenosis in the elderly.