Subretinal neovascularization in children and adolescents.

Subretinal neovascular membranes (SRNVM) in the pediatric population are rare. The clinical presentation, etiology, course, and management of SRNVM in 25 children (27 eyes) were studied retrospectively. Inflammatory or infectious conditions predominated (10 of 25). Eleven of 19 untreated SRNVM (58%) spontaneously involuted, with 9 of these 11 achieving a final visual acuity of 20/50 or better. A hyperpigmented ring on fluorescein angiography was associated with 9 of the 11 involuted SRNVM. The presence of this pigmented ring may help to identify those cases with a better visual prognosis.

Retinal hemangioblastoma. A histologic, immunohistochemical, and ultrastructural evaluation.

The authors evaluated the histologic, immunohistochemical, and ultrastructural characteristics of two eyes with retinal hemangioblastoma from patients with von Hippel-Lindau and von Hippel disease. Results of histologic evaluation showed the eyes to have degenerative changes and residual retinal hemangioblastoma. Immunohistochemical stains performed for MAC-387, factor XIIIa, lysozyme, alpha 1 anti-chymotrypsin (histiocyte markers), factor VIII-associated antigen, ulex europeaus (endothelial markers), neuron-specific enolase, chromogranin, neurofilament (neuroectodermal/neural/neuroendocrine markers) and glial fibrillary acid protein (glial marker) showed normal retinal vascular endothelium, neurons, and glial cells to stain where expected. Vascular endothelium in the retinal hemangioblastomas stained for factor VIII and ulex europeaus. Interstitial cells in the stroma of the tumors failed to stain for the histiocyte markers, chromogranin, and neurofilament. The stromal cells stained for glial fibrillary acid protein and neuron specific enolase. Ultrastructural findings in both eyes included endothelial/pericyte-lined vascular channels, elongated stromal cells, and plump, vacuolated stromal cells with ultrastructural features consistent with glial cells. This study supports the concept that retinal hemangioblastoma is composed of a proliferation of capillaries and glial cells.

Retinal detachment: is reparative surgery always mandatory?

The author reports 16 cases of rhegmatogenous retinal detachment in which, for a variety of reasons, immediate reparative surgery was not carried out. To date, one-half of these cases have not been operated, and four have been followed for 6 years or longer. No case suffered visual loss because of the delay in surgery, nor has chronic inflammation, glaucoma, or rubeosis been a problem. The clinical characteristics of this group of cases is defined.

Massive hemorrhage complicating age-related macular degeneration. Clinicopathologic correlation and role of anticoagulants.

Reported are 15 cases of age-related macular degeneration (AMD) complicated by massive subretinal and/or vitreous hemorrhage. Clinicopathologic correlation is presented in four of the seven cases studied histopathologically. Salient histologic findings include: subretinal and subretinal pigment epithelium (sub-RPE) fibrovascular scar in the posterior pole; discontinuities in Bruch's membrane with choroidal neovascularization; extensive hemorrhagic detachment of the RPE and sensory retina; and vitreous hemorrhage. In three cases, a choroidal artery, emerging from breaks in Bruch's membrane, had ruptured walls. The authors have reviewed the previously reported cases of AMD complicated by massive hemorrhage and found that 19% of the patients were taking Coumadin (warfarin) or aspirin treatment when the bleeding occurred. Forty percent had a positive history of systemic hypertension and cardiovascular diseases. Although the occurrence of hypertension is expected in the aged population with AMD, use of anticoagulants or antithrombotics by such patients may predispose them to serious ocular hemorrhagic complications.

Ocular and testicular abnormalities in alopecia areata.

Ocular abnormalities similar to those usually found in patients with vitiligo occurred in nine patients with alopecia areata and one patient with poliosis. Exophthalmos, iris color change, discrete depigmentation, and, frequently, associated pigment hyperplasia of the choroid and retinal epithelium were found in the ten patients. Four patients had had a bilateral iris color change from dark brown to blue-green. Hypogonadism, thyroid disease, and poliosis may frequently be associated with pigmentary disturbances of the eye, as well as hair loss. Testicular dysfunction with oligospermatism to aspermatism, hypoandrogyny, hyperretractable testes, and epididymal cyst is reported. Two patients had unilateral and one patient had bilateral testicular atrophy.

Results of surgery for ocular Toxocara canis.

It has been shown that the diagnosis of ocular Toxocara canis is highly accurate when the typical clinical findings are associated with a positive ELISA titer in the serum of 1:8 or greater. The inflammatory reaction in this disorder can be devastating and not infrequently leads to a tractional detachment of the posterior pole or a rhegmatogenous detachment and/or a progressive cyclitic membrane leading to phthisis bulbi. We have recently performed vitreoretinal surgery on 17 patients with complications secondary to ocular T canis. Fifteen patients had stability or improvement in visual acuity, and one patient had a decrease in visual acuity. There were no surgical complications present. The clinical features, operative techniques used, and postoperative course are summarized, and the indications for the used of various surgical procedures are presented.

Rhematogenous retinal detachment complicated by severe intraocular inflammation, hypotony, and choroidal detachment.

An unusual type of rhegmatogenous retinal detachment is described and compared with a control group of patients with detached retina. Features of the condition, in addition to retinal detachment, include severe anterior and posterior uveitis, choroidal detachment, hypotony, deepened anterior chamber, posterior synechiae, iridophakodonesis, and a poor surgical and visual prognosis due to massive periretinal proliferation. The disease occurs in a disproportionately high ratio in blacks. These cases may be mistaken for uveitis, Harada's syndrome, the uveal effusion syndrome, dislocated lens, or malignant melanoma. It is postulated that the detached retina initiates a series of exaggerated pathophysiological changes in the eye, with the severe inflammation leading to choroidal detachment and hypotony. Such eyes are inoperable until the inflammation, hypotony, and choroidal detachment are reversed with corticosteroid treatment. The surgical and visual prognosis is very poor.

Applanation-Schiøtz disparity after retinal detachment surgery utilizing cryopexy.

Previous reports of applanation-Schiøtz disparity following retinal detachment surgery involved patients whose detachments were treated with diathermy and scleral buckling. In 73 patients with retinal detachments treated by cryopexy and scleral buckling, applanation and Schiøtz pressures were measured before and after surgery. In the postoperative period, applanation tension values were significantly higher than Schiøtz values in the operated eyes only; the mean disparity was 6 mm Hg, with a range of 0 to 14 mm Hg. Sex, age, surgical aphakia, and length of time after surgery did not influence the data. Placement of the buckle, rather than extent of cryopexy, appeared to be the main factor in producing this disparity. Ophthalmologists who utilize the Schiøtz tonometer should be aware of the various conditions, including retinal detachment surgery, which produce low ocular rigidity.

ELISA for diagnosis of ocular toxocariasis.

The enzyme-linked immunosorbed assay test was positive in 37 of 41 patients (90%) suspected of having clinical Toxocara infections. The antigen used in this test is prepared from the Toxocara egg and is felt to be extremely specific in making the diagnosis. The prevalence of Toxocara infection is much greater than previously believed. It is hoped that this test will help the surgeon fell more secure in not enucleating eyes containing masses suggestive of Toxocara infection.

The use of the 32P test in the management of malignant melanoma of the choroid: a five-year follow-up study.

We have presented mortality, clinical, and histopathologic data on a consecutive group of patients with malignant choroidal melanoma studied by a radioactive phosphorus uptake test. The mortality of 14% is the lowest reported in the literature (Table 11) and suggests that early diagnosis followed by prompt enucleation affords the patient a favorable prognosis. There is no evidence to suggest that the surgical manipulations involved expose the patient to added risks. Factors of importance regarding prognosis of malignant melanoma include tumor size, cell type, and presence or absence of extrascleral extension. Of these, we believe that cell type is the most important factor. Our data to date do not permit us to predict from the 32P tests the prognosis for patient survival.

Clinical experience with presumed hemangioma of the choroid: radioactive phosphorus uptake studies as an aid in differential diagnosis.

A total of 27 cases of choroidal hemangioma was evaluated with radioactive phosphorus uptake studies. In each case the diagnosis of malignant melanoma was initially entertained, but the 32P test was unequivocally negative in every instance. Follow-up studies in every case have supported the clinical diagnosis. In 22 patients, the lesion was treated with photocoagulation, and in every treated case the serous macular detachment disappeared. The importance of early and correct clinical diagnosis is stressed, since these are salvageable and potentially useful seeing eyes.

Infections after retinal detachment surgery.

The signs and symptoms of infection after retinal detachment surgery may be subtle and frequently are overlooked during early stages. A retrospective analysis of 3,334 consecutive procedures for retinal detachment revealed 37 cases (1.1%) with postoperative infection. In 13 of these a scleral abscess and a form of endophthalmitis developed, whereas 24 had no evidence of vitreous involvement and were classified as the granuloma type. Only 43% of infected patients had positive cultures. Analysis of changes in infection rate involved comparison with changes over the years in suture material, implant material, performance of scleral undermining, drainage of subretinal fluid, number of previous surgical procedures, age of patient, use of diathermy or cryotherapy, and type of prophylactic antibiotic therapy. During the 13 years studied the rate of infection decreased from 2.2% to 0.7%. Treatment requires surgical removal of all foreign material before the inflammatory signs can be cleared. Concurrent appropriate antibiotic therapy also is recommended. With this form of treatment, all but one patient showed a satisfactory response, although 4 patients still have mild conjunctival congestion.

The significance of the 32-P uptake test in the diagnosis of posterior uveal melanomas.

One hundred consecutive histologically confirmed malignant melanomas of the posterior uvea; on which the 32-P test was performed prior to enucleation, were classified according to cell type. The 32-P uptake results of the pure spindle cell melanomas were compared with the results in the mixed and epithelioid cell tumors. There appears to be no relationship between 32-P uptake and cell type using the Callender classification. The 32-P uptake results in the 100 melanomas were then compared with the results in teh 30 benign lesions which are known to simulate melanoma occasionally. There was a significant difference in 32-P uptake between the benign and malignant lesions, and no false-positive results were encountered. The importance of the 32-P test as a diagnostic adjunct for malignant intraocular tumors is emphasized.