CONTRALATERAL ANESTHESIA IN TWO PATIENTS AFTER RETROBULBAR BLOCK.

PURPOSE: To report a case series of two patients with contralateral anesthesia after retrobulbar block. METHODS: Retrospective review of two cases and review of the literature. RESULTS: Two patients of one practitioner received contralateral anesthesia after retrobulbar block for posterior segment surgery. Patient 1 suffered from transient contralateral akinesia, whereas Patient 2 experienced transient contralateral amaurosis. CONCLUSION: Posterior spread of anesthetics is a rare but potentially serious complication of retrobulbar anesthesia caused by spread of anesthetics along the optic nerve sheath. Modification of injection technique can decrease the risk of this complication.

PROPHYLACTIC PREOPERATIVE LASER RETINOPEXY DOES NOT REDUCE THE OCCURRENCE OF RHEGMATOGENOUS RETINAL COMPLICATIONS IN MACULAR SURGERY.

PURPOSE: Knowledge on the utility of prophylactic 360° laser retinopexy before pars plana vitrectomy in the absence of peripheral retinal pathology is limited. This study compares the occurrence of rhegmatogenous events in the setting of small-gauge pars plana vitrectomy with and without prophylactic preoperative laser. METHODS: Our multicenter, retrospective case-control analysis reviewed patients who underwent epiretinal membrane removal or macular hole repair through 23- or 25-gauge pars plana vitrectomy: 205 controls who did not receive prophylactic laser and 176 cases who received preoperative prophylactic laser retinopexy anterior to the equator. Main outcome measures were the rate and characteristics of postoperative retinal tears and detachments. Patients with previous pars plana vitrectomy or significant retinal disease were excluded. RESULTS: Of those patients with prophylactic laser and those without, there was no significant difference in the number of retinal breaks (1.7% vs. 0.49%, respectively; P = 0.339) or retinal detachments (0% vs. 0.49%, respectively; P = 1.00). Of the lasered group, there was one sclerotomy-related retinal break and two non-sclerotomy-related retinal breaks. Of the nonlasered group, there was one non-sclerotomy-related retinal break and one sclerotomy-related retinal detachment. CONCLUSION: Preoperative prophylactic peripheral laser retinopexy does not seem to offer an added benefit in the prevention of intraoperative and postoperative rhegmatogenous events.

Optic disk pit morphology and retinal detachment: optical coherence tomography with intraoperative correlation.

BACKGROUND: The pathogenesis of optic nerve head pits and associated retinal detachment, and the most effective surgical intervention when visual loss develops, remains unclear. METHODS: The morphology of the optic disk in patients with pits was investigated with optical coherence tomography. For those who underwent surgical treatment for pit-associated retinal detachment, the efficacy of treatment by vitrectomy and separation of the posterior hyaloid, with and without additional peeling of peripapillary tissue, was assessed. RESULTS: On optical coherence tomography imaging, 14 of 18 pits (78%) demonstrated a localized pit-like invagination, whereas 3 (17%) had disks with a generally excavated structure. For 16 of 18 pits (89%), there was evidence of condensed vitreous or glial tissue seen extending from the pit or inside the optic disk. Nine eyes with retinal detachment underwent vitrectomy, posterior hyaloid separation, and endolaser. The retinal detachment completely resolved in 6 of 6 cases where the surgeon additionally peeled the fibrous tissue from the pit and 2 of 3 cases where this was not performed. CONCLUSION: Spectral domain optical coherence tomography demonstrates the varying morphology of optic pit anatomy. Condensed vitreous strands or glial tissue in the optic nerve pit may also contribute to retinal detachment development.

Sequential bilateral central retinal vein occlusions in a cystic fibrosis patient with hyperhomocysteinemia and hypergamma-globulinemia.

PURPOSE: To report a case of sequential bilateral central retinal vein occlusions in a cystic fibrosis patient with hyperhomocysteinemia and hypergamma-globulinemia over 6 years of follow up. METHODS: Observational case report of one patient. RESULTS: A 31 year-old male with a history of cystic fibrosis presented with a central retinal vein occlusion (CRVO) in his left eye, followed by a CRVO in his right eye 4 years later. His medical workup was significant for elevated levels of homocysteine and gamma-globulins, which coincided with initiation of intravenous immunoglobulin (IVIG) proceeding his second CRVO. CONCLUSIONS: We describe a case of sequential bilateral central retinal vein occlusions in a cystic fibrosis patient with hyperhomocysteinemia and hypergamma-globulinemia over 6 years of follow up and discuss the important role of these risk factors in retinal venous occlusive disease.

Surgical outcomes after massive subretinal hemorrhage secondary to age-related macular degeneration.

PURPOSE: Massive subretinal hemorrhage (SRH), defined as a thick submacular bleed that extends past the equator in at least two quadrants, is a rare sequela of age-related macular degeneration. This report describes outcomes after surgical intervention for massive SRH. METHODS: The study design is a retrospective interventional case series. Records of consecutive patients who underwent surgical intervention for massive SRH were reviewed. Outcomes included change from baseline in postoperative acuity at Months 1, 3, 6, 9, and 12 and postoperative complications. RESULTS: Fifteen consecutive eyes of 13 patients who underwent surgery for massive SRH were included. Procedures performed on initial surgery included subretinal instillation of 25 µg/0.1 mL tissue plasminogen activator (15 of 15), gas tamponade (12 of 15), oil tamponade (3 of 15), 180° or greater retinotomy (4 of 15), and/or cataract extraction (2 of 15). Patients were followed for a median of 20 months (range, 3-66 months). The median visual acuity at baseline and postoperative Month 1 was hand motions but improved to counting fingers at postoperative Months 3 (P = 0.04), 6 (P = 0.04), 9 (P = 0.04), and 12 (P = 0.10). Of the 15 eyes, 9 required at least 1 additional procedure for an indication of hyphema and/or vitreous hemorrhage (n = 6), retinal detachment (n = 2), glaucoma (n = 1), cataract (n = 1), and aphakia (n = 1). At the time of the onset of SRH, 5 of 13 patients were anticoagulated with warfarin (4 patients) or clopidogrel (1 patient), and 1 was diagnosed with a coagulopathy, factor XI deficiency. CONCLUSION: Massive SRH related to age-related macular degeneration has a grave prognosis. Risk factors may include anticoagulation and coagulopathy. Limitations of the study include its retrospective nature, small sample size, imprecision in acuity measurements below 20/400, and lack of a control group. In this series, surgical intervention was associated with a modest improvement in median visual acuity up to 1 year postoperatively.

Simultaneous appearance of multiple evanescent white dot syndrome and multifocal choroiditis indicate a common causal relationship.

PURPOSE: To report simultaneous occurrence of multiple evanescent white dot syndrome (MEWDS) and multifocal choroiditis (MFC) in the same eye of a 33-year-old Caucasian woman. METHODS: Review of clinical and fluorescein angiographic features of a patient who presented with decreased visual acuity and was followed for 3 months. RESULTS: Patient presented with concurrent lesions of MEWDS and MFC occurring in the same eye. During the follow-up period MEWDS lesions resolved and MFC lesions evolved into chorioretinal scars. CONCLUSIONS: Simultaneous development of MEWDS and MFC may indicate a possible common causal entity.

Influence of postoperative lens status on intraocular pressure in proliferative vitreoretinopathy.

PURPOSE: To determine the influence of lens status on postoperative intraocular pressure (IOP) in eyes undergoing vitrectomy for repair of recurrent retinal detachment (RD) resulting from proliferative vitreoretinopathy (PVR). DESIGN: Retrospective, consecutive, nonrandomized, single-center series. METHODS: One hundred and forty-five eyes with recurrent RD resulting from PVR were reviewed retrospectively. In all, 99 eyes underwent relaxing retinotomy at the time of surgery (68.4%). Perfluorocarbon gas (n = 60) or silicone oil (n = 85) were used as postoperative tamponades. For analysis, eyes were subdivided first based on tamponade and retinotomy status. The resultant groups then were divided further by lens status into 2 groups: aphakic eyes (aphakic group) and phakic and pseudophakic eyes (nonaphakic group). RESULTS: Surgical reattachment was achieved in all eyes except one. Eyes receiving both silicone oil and relaxing retinotomy had the worst baseline characteristics compared with those receiving other interventions. In this subset of eyes, a significantly lower proportion of hypotony was found in those eyes that were aphakic after surgery when compared with those eyes that were nonaphakic (P = .037). CONCLUSIONS: Surgical management of PVR often results in ultimate retinal reattachment. In eyes receiving both relaxing retinotomy and silicone oil, higher IOPs and a lower proportion of hypotony are found where a native lens or intraocular implant is absent. Removal of the lens or intraocular implant may be considered for those eyes at greatest risk of hypotony.

Pascal dynamic contour tonometry versus goldmann applanation tonometry in gas and air-filled eyes after vitrectomy surgery.

PURPOSE: To compare Pascal Dynamic Contour Tonometry with Goldmann Applanation Tonometry in eyes after vitrectomy surgery with intraocular tamponade of air, silicone oil or perfluorocarbon gas. METHODS: Prospective clinical comparative study. Eighty-two consecutive patients undergoing vitrectomy surgery with postoperative air, gas or oil tamponade were recruited. Intraocular pressure was measured with both devices. RESULTS: Mean Goldmann intraocular pressure was 16.6 mmHg (range, 1.0-46.0; SD = 8.80) and the mean Pascal intraocular pressure was 21.70 (range, 4.7-58.5; SD = 9.8) The mean difference between the Pascal and Goldmann readings was 5.09 mmHg (range, -14.7 to +12.9; 95% CI = 4.2-6.0; SD, 4.0; P < 0.001). Mean differences for the different tamponades were 5.09 mmHg for silicone oil, 4.02 mmHg for air, and 5.38 mmHg for perfluorocarbon gas. CONCLUSION: Pascal dynamic contour tonometry gives readings that are highly correlated with Goldmann applanation tonometry, but on average 5 mmHg higher in eyes after vitrectomy surgery with air, gas or silicone oil tamponades. The difference between Goldmann and Pascal readings does not appear to be altered by the presence of a scleral buckle, or the size of the intraocular gas bubble.

Nanophthalmos and acquired retinoschisis.

PURPOSE: To report three cases of nanophthalmos associated with acquired (senile) retinoschisis. DESIGN: Observational case series. METHODS: Complete ophthalmologic evaluation (including funduscopy with scleral indentation, total axial length measurement with A-scan, optical coherence tomography [Stratus 3 OCT; Carl Zeiss Meditec Inc, Dublin, California, USA], and fundus photography) of three consecutive patients presenting with nanophthalmos and acquired retinoschisis. RESULTS: Three patients with nanophthalmos presented with bilateral acquired retinoschisis. One patient underwent a course of systemic steroids to treat concurrent and bilateral uveal effusion with macular edema. In this patient, one eye responded to this course of therapy without recurrence, while the fellow eye required vortex vein decompression with scleral windows, with subsequent, successful resolution. The average follow-up period was 40 months (range, eight to 95 months). Retinoschisis cavities remained stationary in each case. CONCLUSIONS: Bilateral acquired retinoschisis may occur in patients with nanophthalmos, suggesting that there may be correlation in the mechanisms underlying these ocular disorders.

Diabetic vitrectomy: the influence of lens status upon surgical outcomes.

PURPOSE OF REVIEW: Management of the lens in diabetic eyes undergoing vitrectomy has long been a source of controversy. Initially, the lens was removed during diabetic vitrectomy because of intraoperative changes. It was noted, however, that anterior segment neovascular complications were greater in aphakic eyes after diabetic vitrectomy, and subsequently the vitreoretinal surgeon attempted to spare the lens. Lens management in this regard continues to attract discussion. This report reviews recent trends in the management of the native lens in the diabetic eye undergoing vitrectomy. RECENT FINDINGS: The rate of cataract formation after diabetic vitrectomy is high in eyes left phakic. The rates of anterior segment neovascularization and retinal detachment after diabetic vitrectomy are similar in phakic and nonphakic eyes. The rate of subsequent reoperation after diabetic vitrectomy may be greater in eyes left phakic. SUMMARY: Although the management of the lens in an eye undergoing diabetic vitrectomy should be individualized, cataract extraction performed either before or in combination with vitrectomy may reduce the rate of subsequent reoperation. The vitreoretinal surgeon may consider rendering an eye nonphakic before or during diabetic vitrectomy to optimize outcomes.

Safety and efficacy assessment of chimeric ribozyme to proliferating cell nuclear antigen to prevent recurrence of proliferative vitreoretinopathy.

OBJECTIVE: To determine the safety and efficacy of VIT100 (Immusol, Inc, San Diego, California), a ribozyme to proliferating cell nuclear antigen, in preventing recurrent proliferative vitreoretinopathy (PVR) in patients with established PVR who undergo vitrectomy for retinal reattachment repair. METHODS: A multicenter, double-masked, placebo-controlled, randomized clinical trial. One hundred seventy-five eyes from 175 patients with grade C or worse PVR were randomly assigned to receive high-dose VIT100, low-dose VIT100, or placebo by intravitreal injection at the conclusion of retinal reattachment surgery. MAIN OUTCOME MEASURES: The primary efficacy end point was recurrent retinal detachment secondary to PVR. The secondary end point was recurrent retinal detachment due to any cause. RESULTS: One hundred fifty-four patients completed the study. Forty-one patients (27%) developed recurrent retinal detachment due to PVR by 24 weeks, including 18 patients (33%) in the group receiving 0.75 mg, 13 patients (24%) in the group receiving 0.15 mg, and 10 patients (22%) in the placebo group. There was no statistically significant difference in patients reaching this end point by 24 weeks (P = .37). Ancillary statistical analyses are reported. CONCLUSIONS: VIT100 was not effective in preventing PVR recurrence in patients with established grade C or worse PVR. APPLICATION TO CLINICAL PRACTICE: To our knowledge, this is the most recent, meticulously designed clinical trial in PVR.

Optic pit maculopathy after laser-assisted in situ keratomileusis.

CASE REPORT: Optic disc pit is an embryological malformation of the optic nerve that occurs in less than one in 10,000 people. It is 10%-15% bilateral, and 25% to 70% of patients develop a neurosensory macular detachment within the 2nd to 4th decade. COMMENTS: We report a case of unilateral optic disc pit maculopathy 2 months after laser-assisted in situ keratomileusis (LASIK) revision.

Ocular hypotony: a review.

The etiology, diagnosis, sequelae, and management of ocular hypotony are discussed in this review. Hypotony from decreased production of aqueous is often due to inflammation, medications, or proliferative vitreoretinopathy. Hypotony from aqueous loss may be external, such as following surgery or trauma, or internal, as in cyclodialysis cleft or retinal detachment. Treatment of hypotony is most effective if the underlying cause can be addressed, either surgically or medically. Marked improvement in vision may be achieved if hypotony is reversed.

Diabetic vitrectomy: influence of lens status upon anatomic and visual outcomes.

OBJECTIVE: To determine the effect of lens status upon the anatomic and visual results in primary diabetic vitrectomy. DESIGN: Retrospective, comparative, consecutive case series. PARTICIPANTS: One hundred two eyes of 85 patients with proliferative diabetic retinopathy and its complications that underwent primary vitrectomy. METHODS: The eyes that remained phakic after vitrectomy were compared with the eyes that were either aphakic or pseudophakic (nonphakic) postoperatively. MAIN OUTCOME MEASURES: Intraoperative and postoperative complications, vitreoretinal reoperation rate, and ultimate anatomic and visual success with at least 6 months' follow-up. RESULTS: Preoperatively, 72 eyes were phakic, and 30 were aphakic (n = 1) or pseudophakic (n = 29). During vitrectomy, 1 eye underwent lensectomy and 12 eyes underwent phacoemulsification with lens implantation. Postoperatively, 59 eyes were phakic and 43 eyes were nonphakic. The vitreoretinal reoperation rate was significantly higher (P = 0.04) for the phakic group (28.8%) than for the nonphakic group (11.6%). Rubeosis iridis developed in 3 phakic eyes and no nonphakic eyes (P = 0.26). Intraoperative complications were similar in the phakic and nonphakic groups (P = 0.40). Postoperative complications such as rhegmatogenous retinal detachment (P = 0.39), nonclearing vitreous hemorrhage (P = 0.07), and anterior chamber complications (P = 0.60) were also similar. Visual acuity improved by at least 0.2 logarithm of the minimum angle of resolution units in 76.2% of the phakic eyes and 86.0% of the nonphakic eyes (P = 0.22). CONCLUSIONS: Eyes that were phakic after primary diabetic vitrectomy had a significantly higher subsequent vitreoretinal reoperation rate when compared with nonphakic eyes, suggesting that diabetic eyes are less likely to require additional vitreoretinal surgery if they are rendered nonphakic before or during vitrectomy.

Measurement of the actual dose of triamcinolone acetonide delivered by common techniques of intravitreal injection.

PURPOSE: To measure the actual dose of triamcinolone acetonide (TA) delivered during intravitreal injection performed by several common techniques. DESIGN: Experimental study. METHODS: A 0.1-ml, 40-mg vial of TA (Kenalog-40; Bristol-Myers-Squibb, Peapack, New Jersey, USA) was prepared according to one of four protocols and the mass determined after drying overnight on waxed paper. In group 1, a 0.1-ml aliquot of TA was dispensed with a 30-gauge needle after shaking the vial 10 or 30 times. Group 2 used a 27-gauge needle. In group 3, the supernatant was removed from the crystals. Group 4 passed the suspension through a 0.2-microm micropore filter and rinsed the crystals with saline. RESULTS: There was no statistically significant difference between 30- or 27-gauge needles (P = 0.83, t test) or between shaking the vial 10 or 30 times before withdrawing the drug (P = 0.99). A statistically significant difference (t test, P = 0.001) was found between TA delivered from the initial 60% of each syringe (mean +/- SD, 2.7 +/- 1.0 mg) to that drawn from the last 40% of each syringe (7.8 +/- 3.6 mg). Group 3 had a mean weight of 32.1 +/- 7.0 mg and group 4, 10.6 +/- 2.1 mg. CONCLUSIONS: Efforts to achieve a 4.0-mg dose of TA, regardless of method used, are variable and inconsistent. Injecting through a small-gauge needle appears to concentrate the remaining suspension. Techniques to concentrate TA or remove aqueous preservatives by filtering effectively increase the concentration, but these results are variable.

Optical coherence tomography in asteroid hyalosis.

PURPOSE: To demonstrate the clinical utility of optical coherence tomography (OCT) in diagnosing macular structural abnormalities in patients with asteroid hyalosis. METHODS: Case series. RESULTS: Seven eyes of seven patients underwent OCT due to inadequate funduscopic visualization secondary to asteroid hyalosis. Fluorescein angiography and B-scan ultrasonography were conducted for two patients but failed to provide diagnostic clarity. OCT provided definitive anatomical diagnoses that included macular epiretinal membrane, macular hole, traction retinal detachment, cystoid macular edema, and drusen. On the basis of OCT-assisted diagnoses, three patients elected to undergo surgical intervention. CONCLUSION: OCT can be critical to diagnose macular conditions when retinal visualization is limited by asteroid hyalosis.

Accuracy and reliability of remote retinopathy of prematurity diagnosis.

OBJECTIVE: To determine the accuracy and reliability of retinopathy of prematurity (ROP) diagnosis using remote review of digital images by 3 masked ophthalmologist readers. METHODS: An atlas was compiled of 410 retinal photographs from 163 eyes of 64 low-birth-weight infants taken using a wide-angle digital fundus camera. All the images were independently reviewed by 3 readers, and the diagnosis in each eye was classified into 1 of 4 ordinal categories: no ROP, mild ROP, type 2 prethreshold ROP, or ROP requiring treatment. Findings were compared with a reference standard of dilated indirect ophthalmoscopy with scleral depression performed by an experienced pediatric ophthalmologist. RESULTS: Sensitivities/specificities of the diagnosis of any ROP were 0.845/0.910 for the first reader, 0.816/0.955 for the second reader, and 0.864/0.493 for the third reader. Sensitivities/specificities of the diagnosis of ROP requiring treatment were 0.850/0.960 for the first reader, 0.850/0.973 for the second reader, and 0.900/0.953 for the third reader. When ROP was classified into ordinal categories, the overall weighted kappa for interreader reliability was 0.743. Intrareader reliability for detection of low-risk prethreshold ROP or worse was 100% for all readers. CONCLUSION: The accuracy, interreader reliability, and intrareader reliability of remote diagnosis of clinically relevant ROP based on digital imaging are substantial.

Upregulation of RAGE and its ligands in proliferative retinal disease.

We sought to study the presence of the receptor for advanced glycation endproducts (RAGE) and its ligands, advanced glycation endproducts (AGEs), S100/calgranulins and amphoterin (high mobility group box 1 protein; HMGB1), in the vitreous cavity and epiretinal membranes (ERMs) of eyes of patients with proliferative diabetic retinopathy (PDR) and proliferative vitreoretinopathy (PVR). Undiluted vitreous specimens were collected from 30 eyes of 30 patients undergoing pars plana vitrectomy for repair of retinal detachment (RD) secondary to PDR (n = 15) or PVR (n = 15). The vitreous samples obtained from 10 eyes undergoing macular hole repair were used as controls. Epiretinal membranes were obtained from eight eyes with PDR and from 10 eyes with PVR. The levels of AGEs in the vitreous were measured using ELISA. The vitreous levels of soluble RAGE (sRAGE), S100/calgranulins and amphoterin were measured using Western blot analyses. The localization of RAGE and its ligands in ERMs was determined with immunohistochemistry. The vitreous levels of sRAGE were significantly increased in both PDR and PVR (p < or = 0.05) compared to control vitreous. In both PDR and PVR, the vitreous levels of AGEs (p < or = 0.01), S100/calgranulins (p < or = 0.05), and amphoterin (p < or = 0.01) were also elevated compared to control eyes. Expression of RAGE was detected in six of eight ERMs from eyes with PDR and eight of 10 ERMs from eyes with PVR. Many cells expressing RAGE also expressed vimentin, suggesting a glial cell origin. Ligands for RAGE were also detected in ERMs, with AGEs detected in five eyes with PDR and eight eyes with PVR. Similarly, S100 and amphoterin ERM expression was observed in six eyes with PDR; these ligands were also expressed in ERMs from eyes with PVR (8 and 7 cases, respectively). We conclude that RAGE and its ligands are increased in the vitreous cavity of eyes with PDR and PVR and are present in ERMs of eyes with these proliferative retinal disorders. These findings suggest a role for the proinflammatory RAGE axis in the pathogenesis of proliferative retinal diseases.

Intravitreal triamcinolone injection for treatment of macular edema secondary to branch retinal vein occlusion.

PURPOSE: To evaluate the efficacy of intravitreal triamcinolone injection in eyes with macular edema due to branch retinal vein occlusion (BRVO) over a 2-year period. METHODS: The authors performed a retrospective chart review of 13 eyes of 13 patients (mean age 68 years) who underwent intravitreal injections with 4 mg triamcinolone acetonide for macular edema due to BRVO. Six eyes received a single injection. Repeated injections were performed in one eye twice, four eyes three times, and two eyes four times. Mean follow-up was 13 months (range, 4 to 24). The time between the onset of symptoms and the injection averaged 7.4 months (range, 2 to 24). RESULTS: Mean postinjection central foveal thickness decreased to 56% of preinjection values (529 mum versus 295 mum, P < 0 .001). Final visual acuity improved in seven eyes (range 2 to 6 Snellen lines), remained the same in four eyes (range 0 to 1 Snellen lines), and worsened in two eyes (range -1 to -4 Snellen lines) compared to baseline. The retinal thickness decreased in all cases; vision improved in most cases. As the number of injections increased cataractous changes increased. Visual acuity improvement was significantly correlated with patient age (P = 0.026). Eight patients developed steroid induced ocular hypertension controlled by topical medication. Cataract extraction was judged to aggravate macular edema in three of the five eyes undergoing surgery, based upon optical coherence tomography or fluorescein angiography. Median best postinjection visual acuity (20/50) was significantly better than that of baseline (20/100) (P = 0.028) as well as last follow-up (20/70) (P = 0.003). CONCLUSIONS: Intravitreal triamcinolone should be further evaluated as a treatment option for macular edema associated with BRVO.