Opportunities for maloccurrence in delivery of specialized care in the managed care environment.

Two patients lost eyes because of complications of retinal detachment in managed care situations. In both cases the eyes might have been saved had the patients been treated earlier by highly qualified subspecialists.

Aspergillus endophthalmitis after sutureless cataract surgery.

PURPOSE: We studied a case of Aspergillus endophthalmitis after sutureless cataract surgery. METHODS: A patient underwent sutureless phacoemulsification complicated by a posterior capsular tear. She subsequently developed Aspergillus endophthalmitis. Amphotericin B was injected intravitreally at the time of repeat pars plana vitrectomy. RESULTS: The eye was enucleated because of pain and poor response to treatment. CONCLUSIONS: We recommend suturing the wound in any eye that has experienced a complication of surgery.

Phacoemulsification and implantation of posterior chamber intraocular lens in eyes with quiescent proliferative diabetic retinopathy.

A phacoemulsification procedure, combined with an "in-the-bag" lens implantation, was performed on ten eyes that once had proliferative diabetic retinopathy (PDR). The ten eyes were in eight patients who had a 20-plus year history of either type I or type II diabetes mellitus. All eyes had reached the "quiescent" state of diabetic retinopathy 2-13 years before the cataract surgery through either argon laser pan retinal photocoagulation and/or pars plana vitrectomy. Nine of ten eyes remained completely free of retinal neovascularization and rubeosis iridis, with follow-up periods between 1.5 and 5 years. One eye has been lost to recurrent vitreous hemorrhages and an inoperable retinal detachment.

Vitrectomy for chronic aphakic cystoid macular edema. Results of a national, collaborative, prospective, randomized investigation.

A five-year (1979-1984) prospective, randomized, controlled, collaborative study was performed by 27 experienced vitrectomy surgeons in 15 medical centers on 136 surgically aphakic eyes without lens implants but with vitreous adherent to the corneoscleral wound and with chronic aphakic cystoid macular edema (ACME). One hundred fifteen eyes completed the entire course of investigation. The purpose of the study was twofold: to determine the effectiveness of vitrectomy in eliminating established ACME and to determine the natural history of this condition. Following criteria contained within the study protocol, 68 eyes were randomized to surgery (RAN-S) or control (RAN-C), and 47 eyes were observed in the long-term observation group (LTO). Twenty-one eyes were eliminated from the investigation for reasons stated in the text. The RAN-S group proved to have a significantly better visual course than the RAN-C group (P = less than 0.01). An analysis of the LTO group revealed that if central vision did not decline to a level of 20/80 or worse, 27% of the eyes had a chance of spontaneously improving to a level of 20/50 or better. However, if central vision declines to or beyond this point, spontaneous visual improvement to 20/50 or better only occurred in 8% of eyes. Also reported are other important clinical findings such as the role of systemic diseases in ACME, the incidence of vitreous traction on the macula, prognostic value of pre-surgical medical therapy, a comparison of limbal versus pars plana surgical approach, the timing of surgery, and the effectiveness of fluorescein angiography as an objective monitor of visual function.

The incidence of retinal detachment following extracapsular cataract extraction. A ten-year study.

A long-term prospective study was conducted to evaluate the incidence of specific complications following extracapsular cataract extraction. Eight hundred forty-two consecutive extracapsular cataract extractions were performed over a ten-year period with a minimum follow-up time of one year. The mean follow up period for this series was 32.2 months. The incidence of retinal detachment in the entire population was 1.4%. In those eyes with a cataract as the only ocular abnormality and with no surgical complications, the frequency was 1.0%. The incidence in eyes following uncomplicated procedures, with no other ocular pathology and with an intact posterior capsule was 0.8%. The incidence of opacification of the posterior capsule requiring capsulotomy was 16.7%. The mean time interval for a secondary capsulotomy was 24.3 months. A positive correlation between this time interval and patient age was established.

The national, prospective, randomized vitrectomy study for chronic aphakic cystoid macular edema. Progress report and comparison between the control and nonrandomized groups.

Three years ago, a prospective, randomized, collaborative study investigating the effectiveness of vitrectomy for chronic aphakic cystoid macular edema in eyes with vitreous adherent to the cataract wound but without an intraocular lens was started. To date, the study consists of 130 eyes which have been assigned to three different groups. Without disturbing the data related to the question of the effectiveness of surgery, an analysis of patient histories and eye findings reveal interesting facts. The time between cataract surgery and onset of visual decrease was three months. Most of the eyes have a detached posterior vitreous face, and only 4% had evidence of vitreous traction on the macula. All eyes demonstrated some degree of flare and cells in the aqueous or vitreous, and the presence of systemic vascular disease in the patient does not seem to determine the eye's long term visual performance.

Surgical therapy for chronic aphakic cystoid macular edema.

Aphakic cystoid macular edema (ACME) is a common condition seen after intracapsular cataract extractions. In an overwhelming majority of these cases, the condition improves spontaneously. Those cases that persist for months or years, however, are often associated with vitreous strands adherent to the surgical wound and distortion of the pupil. This article reviews the surgical and photocoagulation therapies for this condition that have been reported over the past two decades. All studies report encouraging results, but all have been nonrandomized, uncontrolled trials. This paper describes two randomized, controlled clinical studies that are attempting to evaluate objectively the role of vitrectomy for chronic cases of aphakic cystoid macular edema.

Incidence of retinal detachments following extracapsular cataract extractions. A prospective study.

This is a preliminary report on a prospective study designed to determine the incidence of retinal detachment following planned extracapsular cataract extractions. The population consists of 454 eyes with a mean follow-up period of 23 months. The incidence of detachment is much lower than that reported for intracapsular extractions. The most significant finding to date is the importance of maintaining the posterior capsule and the vitreous face intact. The incidence of detachment when this is accomplished in normal eyes is 0.9%. The overall incidence of this complication in the entire series is 1.50%. The reported disadvantage of maintaining the posterior capsule is the 40% to 50% incidence of a secondary cataract. In this series, the incidence is 11%. The factors responsible for this low figure are enumerated.

A new 20-gauge intravitreal cryoprobe.

A new intraocular 20-gauge (0.89-mm) cryoprobe is compatible with the Ocutome-Fragmatome system. The iceball forms only at the tip and there is a rapid freeze and defrost cycle. Actual clinical testing during vitreous surgery showed the probe to be reliable and easy to use. It is useful for the treatment of posterior tears, the removal of dislocated lenses, and softening the lens nucleus before phacofragmentation.

Anterior vitrectomy for chronic aphakic cystoid macular edema.

This report describes a series of 13 patients who underwent anterior vitrectomies for chronic aphakic cystoid macular edema (CME). All eyes had formed vitreous adherent to the intracapsular wound, vision of 20/50 or worse, and fluorescein angiographically documented CME for six months or more. Following the presentation of the results (success rate of 69%) and a discussion of this form of treatment, the beginning of a national, randomized, prospective study designed to evaluate the effectiveness of this treatment is described.

The role of vitrectomy instrumentation in the treatment of severe traumatic hyphema.

Eight patients with severe traumatic hyphemas underwent clot evacuation with vitrectomy instrumentation. The patients were followed up for periods of one to four years. No significant intraoperative complications were noted, but one eye developed a postoperative flat anterior chamber and another developed multiple staphylomas with uncontrolled glaucoma, leading to the eventual enucleation. Seven of the eight operated eyes achieved intraocular pressure control in the early postoperative period, and this control was sustained throughout the course of follow-up without antiglaucomatous medication. These same seven eyes had final visual acuities of 6/12 (20/40) or better.

The effect of calcium dobesilate on nonproliferative diabetic retinopathy: a controlled study.

Two independent, double-masked, controlled studies were made to evaluate the efficacy of calcium dobesilate for the treatment of nonproliferative diabetic retinopathy. Forty-two patients underwent a six-month crossover evaluation while receiving calcium dobesilate (750 mg per day) and placebo in random order. Thirty-six patients received calcium dobesilate (1,000 mg per day) or placebo for one year. Evaluation by clinical examination, fluorescein angiography, angiography, and fundus photography failed to demonstrate any beneficial effect of calcium dobesilate.

Phacoemulsification.

Ten years have passed since the phacoemulsification procedure was introduced to ophthalmology. Enough experience has now been gained to evaluate its effectiveness. This report sets forth a list of case-selection criteria designed to avoid the most common complications associated with the operation. Average visual acuity results have been tabulated for the purpose of assisting those who are deciding whether or not ot adopt the procedure.