Management of submacular hemorrhage with intravitreous tissue plasminogen activator injection and pneumatic displacement.

OBJECTIVE: To investigate the efficacy and safety of treating thick submacular hemorrhages with intravitreous tissue plasminogen activator (tPA) and pneumatic displacement. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: From 5 participating centers, 15 eligible patients had acute (<3 weeks) thick subretinal hemorrhage involving the center of the macula in eyes with pre-existing good visual acuity. Hemorrhages were secondary to age-related macular degeneration in 13 eyes and macroaneurysm and trauma in 1 eye each. METHODS: The authors reviewed the medical records of 15 consecutive patients who received intravitreous injection of commercial tPA solution (25-100 microg in 0.1-0.2 ml) and expansile gas (0.3-0.4 ml of perfluoropropane or sulfur hexafluoride) for thrombolysis and displacement of submacular hemorrhage. After surgery, patients maintained prone positioning for 1 to 5 days (typically, 24 hours). MAIN OUTCOME MEASURES: Degree of blood displacement from under the fovea, best postoperative visual acuity, final postoperative visual acuity, and surgical complications. RESULTS: In 15 (100%) of 15 eyes, the procedure resulted in complete displacement of thick submacular hemorrhage out of the foveal area. Best postprocedure visual acuity improved by 2 lines or greater in 14 (93%) of 15 eyes. After a mean follow-up of 10.5 months (range, 4-19 months), final visual acuity improved by 2 lines or greater in 10 (67%) of 15 eyes and measured 20/80 or better in 6 (40%) of 15 eyes. Complications included breakthrough vitreous hemorrhage in three eyes and endophthalmitis in one eye. Four eyes developed recurrent hemorrhage 1 to 3 months after treatment, three of which were retreated with the same procedure. CONCLUSIONS: Intravitreous injection of tPA and gas followed by brief prone positioning is effective in displacing thick submacular blood and facilitating visual improvement in most patients. The rate of serious complications appears low. Final visual outcomes are limited by progression of the underlying macular disease in many patients.

Surgical management of posteriorly dislocated silicone plate intraocular lenses.

Silicone plate intraocular lenses do not adhere to the lens capsule and are placed under tension by postoperative contraction of the capsular bag. Recent reports suggest that a defect anywhere in the capsular bag can potentially lead to delayed posterior dislocation of silicone plate intraocular lenses. These implants are more difficult to grasp and manipulate inside the eye than traditional polymethylmethacrylate lenses and therefore, require special microsurgical techniques. Given sufficient anterior capsular support, posteriorly dislocated silicone plate implants can be repositioned in the ciliary sulcus and do not necessarily require intraocular lens exchange. With proper vitreoretinal surgical techniques, posteriorly dislocated silicone plate intraocular lenses can be repositioned or exchanged with excellent visual results and an acceptably low complication rate.

Surgical management of posteriorly dislocated silicone plate haptic intraocular lenses.

PURPOSE: To report a large series of delayed posterior dislocation of silicone plate haptic intraocular lenses after Nd:YAG laser capsulotomy and discuss the surgical management of this complication. METHODS: We reviewed the records of 11 consecutive patients (11 eyes) with delayed onset of posterior dislocation of a plate haptic silicone intraocular lens. The cause of the posterior capsular defect, time to dislocation, surgical management techniques, complications, and visual outcome were recorded. RESULTS: In eight of the 11 eyes, the silicone plate haptic intraocular lens dislocated an average of 1.8 months (range, 0 to 6.5 months) after Nd:YAG posterior capsulotomy. The other three eyes had surgical complications at the time of cataract extraction that compromised posterior capsular or zonular integrity and led to silicone plate haptic intraocular lens dislocation from 9 weeks to 6 months (mean, 3.6 months) postoperatively. Surgical management consisted of pars plana vitrectomy with intraocular lens repositioning (six eyes) or exchange (five eyes). The average follow-up period after intraocular lens repositioning or exchange was 6.5 months (range, 1 to 14 months). Best-corrected visual acuity at the last follow-up examination measured 20/40 or better in all but one eye that had preexisting macular disease. CONCLUSIONS: Cataract surgeons and patients should be aware of the potential for plate haptic silicone intraocular lenses to undergo delayed posterior dislocation through capsular defects. This complication can be managed effectively with vitrectomy and either repositioning or exchange of the implant. Postoperative visual acuity is generally excellent, and complications are minimal.

A new approach to the surgical management of idiopathic uveal effusion syndrome.

PURPOSE: To describe a new method for managing retinal detachment associated with idiopathic uveal effusion syndrome. METHODS: A 73-year-old man with idiopathic uveal effusion syndrome and total retinal detachment in the right eye underwent quadrantic partial-thickness sclerectomies in conjunction with pars plana vitrectomy, internal drainage of subretinal fluid, and fluid-gas exchange. RESULTS: In the right eye, the patient's retina remained attached for 1 year after the procedure, and visual acuity improved to 20/70 on final follow-up. CONCLUSION: Internal drainage of subretinal fluid performed in conjunction with quadrantic partial-thickness sclerectomies may be a preferred method of treating secondary retinal detachment in idiopathic uveal effusion syndrome. This procedure hastens reattachment of the neurosensory retina and may thereby improve the visual outcome.

Fluorescein labeling of tissue plasminogen activator for subretinal thrombolysis.

PURPOSE: To assess a technique that facilitated the use of tissue plasminogen activator in the dissolution and evacuation of subretinal blood. METHODS: Fluorescein dye was added to the tissue plasminogen activator solution before subretinal injection. RESULTS: Labeling tissue plasminogen activator solution with fluorescein made the solution easily visible, enhancing the ability of the surgeon to assess clot lavage, detect reflux into the vitreous cavity, and judge the extent of clot dissolution. CONCLUSIONS: Adding fluorescein dye to tissue plasminogen activator solution is simple and gives the surgeon added control of clot lysis.

An animal model of focal, subacute, viral retinitis.

To study local intravitreal therapies for retinitis due to herpes viruses, an animal model of focal, subacute, relatively nonlethal herpes family retinitis is needed. Herpes simplex virus type 1 (HSV-1) was injected into the subretinal space of 33 Dutch pigmented rabbit eyes. The animals were observed for up to 42 days after the inoculation. All inoculated eyes developed a focal, enlarging area of retinitis in a predictable manner, showing focal enlarging areas of retinal opacification and necrosis with variable retinal hemorrhage. In the inoculated eyes, retinal detachment developed in all animals within 21 days; 33% of the animals developed focal retinitis in the uninoculated eye. Histologic examination showed encephalitis to be present in 11 (73%) of the 15 animals studied after 1 week. This model may be used to evaluate the therapeutic efficacy of new antiviral agents and modalities in the treatment of herpes family viral retinitis. The model is most similar to herpes simplex or zoster retinitis in humans, but also shares some similarities (and differences) with cytomegalovirus (CMV) retinitis in humans.

Hemorrhagic choroidal detachment with anterior vitreoretinal adhesions.

We present three cases of large intraoperative or postoperative hemorrhagic choroidal detachment with subsequent adherence of the retina to anterior segment structures. Surgical management involved bimanual vitrectomy through anterior sclerotomy sites and dissection within the anterior segment. Successful retinal reattachment was achieved in two of these cases (18-months' follow up). In the third case, the retina remained attached for 4 months but then redetached.

Experimental endoretinal biopsy.

We performed transvitreal endoretinal biopsy in rabbit eyes to develop a reliable and safe technique to obtain retinal specimens from attached retina. Pars plana vitrectomy without lensectomy was followed by injection of Ringer's solution into the subretinal space to produce a focal retinal detachment. The apex of the focal detachment was excised by intraocular scissors and removed from the eye by pneumohydraulic expulsion. A fluid-air exchange reattached the retina. The biopsy sites were evaluated clinically and by light and electron microscopy at regular intervals up to 20 weeks postoperatively. The initial five procedures were performed without heparin in the infusion fluid, and they were complicated by severe fibrin reaction and early retinal detachment. Of the remaining 17 eyes, 15 were without intraoperative complication and maintained attached retinas. The biopsy site developed an early ring of hyperpigmentation along the border, and the biopsy bed became increasingly hyperpigmented because of cytoplasmic hyperplasia and hypertrophy of the pigment epithelium. Epiretinal membranes and subretinal neovascularization were observed histologically. Retinal biopsy specimens were reproducible and suitable for diagnostic studies.

The agar-albumin sandwich technique for processing retinal biopsy specimens.

Retinal biopsy may be useful procedure in the diagnosis of certain cases of infectious retinitis complicated by retinal detachment. The small, delicate pieces of retina obtained by retinal biopsy are difficult to handle and prepare for histologic processing. The tissue is friable, may curl upon itself, and is often lost during normal processing. Routine methods for handling small biopsy specimens of other tissues are inadequate for preparing retinal specimens. We developed an agar-albumin tissue mount for the sterile recovery and transport of small pieces of retina from the operative field to the laboratory. The agar-albumin sandwich mount facilitates tissue processing without interfering with histologic sectioning or interpretation. The ability to recover small, friable pieces of retina in a manner that allows good histologic examination is essential if retinal biopsy specimens are to be used in the diagnosis and management of patients with infectious retinitis where the causative agent is unclear.

Cell cycle responses of heterogeneous human colon adenocarcinoma subpopulations to X-irradiation.

The cell cycle responses of two exponentially growing subpopulations of cells (clones A and D), originally obtained from a human colon adenocarcinoma to X-irradiation, were studied using centrifugal elutriation. Cell suspensions were separated by changing counter-current flow rate while keeping the rotor speed constant (1600 rpm) and the composition of eluted fractions was determined using flow cytometry. The X-ray sensitivity of unseparated clone D cells was somewhat greater than that of clone A cells (e.g. 10% greater at the 10% level of survival). This difference appeared to be due to a greater value of the alpha parameter (one-hit cell killing), using the linear-quadratic equation in which the relative survival S/S0 = exp - (alpha D + beta D2) with dose (D) in Gy. This finding was confirmed in the cell cycle studies where the alpha parameter was always greater for the clone D cells than for the clone A cells. The beta parameter was essentially the same for both cell lines through the cell cycle.