Neodymium:YLF picosecond laser segmentation for retinal traction associated with proliferative diabetic retinopathy.

PURPOSE: To determine the applicability of laser segmentation for severing fibrovascular tissue and hyaloid interfaces in the treatment of tractional complications of proliferative diabetic retinopathy. METHODS: A prototype neodymium:yttrium-lithium-fluoride (Nd:YLF) picosecond pulse photodisruptive laser was used in eight eyes (seven patients) with proliferative diabetic retinopathy as part of a Food and Drug Administration-approved phase 1 protocol. There were three indications for treatment: type I: distortion and shallow elevation of the macular caused by taut, adherent, posterior hyaloid interface (two eyes); type II: traction retinal detachment involving the fovea (two eyes); and type III: fovea-threatened, traction retinal detachment (four eyes). Traction release was accomplished by laser segmentation of the detached hyaloid interfaces and fibrotic, contracted proliferative tissue. The Nd:YLF uses low pulse energy (0.10 mJ, 1,000 pulses per second for 10 consecutive seconds) that allows tissue cutting near the retinal surface. RESULTS: Both type I eyes had relief of traction forces; visual acuity improved from 20/400 to 20/50 in one eye; the other remained stable. Of the two type II eyes, one had anatomic reattachment of the fovea with improvement in visual acuity (hand movements to 20/50); the second required vitrectomy. Of the four type III eyes, all had anatomic improvement; three maintained pretreatment acuity; the fourth eye developed vitreous hemorrhage at 6 months and underwent vitrectomy. Three treatments (two eyes) caused vitreous hemorrhage that resulted in a transient drop in acuity (1 to 2 lines). No patient developed a retinal break or choroidal hemorrhage. CONCLUSION: In a small pilot study, the Nd:YLF laser segmented proliferative tissue near the retinal surface and elevated hyaloid interfaces. In selected cases, this may enable flattening of traction retinal detachment or release of retinal distortion.

Protracted posttraumatic optic disc swelling.

BACKGROUND: Optic disc swelling is a rare sequela of blunt ocular trauma. METHODS: The authors examined three young patients who had an unusual post-traumatic optic neuropathy in which protracted swelling of the optic nerve head was the salient clinical feature. RESULTS: Associated choroidal ruptures in two patients suggested a contrecoup mechanism of injury to the optic nerve at its junction with the globe. All patients had partial recovery of vision over months, concurrent with resolution of the nerve head swelling and development of optic disc pallor. CONCLUSION: Despite its protracted course, posttraumatic optic disc swelling appears to be associated with a favorable prognosis for visual recovery.

Hemodilution therapy in central retinal vein occlusion. One-year results of a prospective randomized study.

Systemic hemorheologic abnormalities may play a part in the pathogenesis of central retinal vein occlusions. A statistically significant elevation of plasma viscosity was found in patients with acute central retinal vein occlusion compared with control patients. Local retinal blood flow parameters including arteriovenous passage time and mean arterial dye bolus velocity were significantly altered in the central retinal vein occlusion patients compared with age-matched controls at baseline examination. We performed a randomized, prospective, single-blind clinical investigation to determine the effect of hemorheological manipulation on the clinical course and retinal blood flow of eyes with central vein occlusion. Hemodilution included plasma expansion with hydroxyethyl-starch, withdrawal of whole blood if the hematocrit was above 42%, and rheologic manipulation with parenteral pentoxifylline. We found a statistically significant improvement in visual acuity at 1 year post-treatment for the treated group compared with the control group (increase of visual acuity of 1.5 lines vs decrease of 1.5 lines). The retinal blood flow parameters were markedly improved soon after the institution of therapy, and this may have contributed to the improvement in visual acuity in the treated group. There was no statistically significant difference between the two groups in the progression to ischemic central vein occlusion.

Retinal detachments in incontinentia pigmenti.

We report on retinal detachments in six eyes of four patients with incontinentia pigmenti. These nonrhegmatogenous traction retinal detachments are characterized by extensive preretinal and vitreous fibrous organization that pull the retina anteriorly behind the lens. The clinical course and fundus appearance of the retinal detachments, beginning with the avascular peripheral retina and leading to traction retinal detachment, are similar to those of cicatricial retinopathy of prematurity. Vitreous surgery was performed on three eyes (two patients), with partial reattachment of a total retinal detachment in one eye and complete reattachment of a partial retinal detachment in a second eye. These cases represent the first successful surgical interventions reported for retinal detachment in incontinentia pigmenti.

Modified technique of blunt cannula retrobulbar anesthesia for vitreoretinal surgery.

We prospectively evaluated a modified version of a previously reported technique of retrobulbar anesthesia for vitreoretinal surgery involving the use of a blunt 19-gauge cannula to directly infuse anesthetic into the retrobulbar space. Using this method, 60 consecutive patients undergoing scleral buckling surgery had effective anesthesia and akinesia, with no complications.

Posterior scleritis in children.

Posterior scleritis was diagnosed in four adolescent boys. These patients represented a distinct subgroup of patients with posterior scleritis that differed from the adult variant by gender, lack of systemic disease, and absence of the associated ocular findings often seen in the adult variant of the disorder. The four patients had diminished visual acuity, ocular pain, and exudative retinal detachments at initial examination. Fluorescein angiography demonstrated multiple pinpoint leaks at the level of the retinal pigment epithelium in three patients with late-phase patchy staining of a mass-like lesion in one patient. B-scan ultrasonography demonstrated choroidal and scleral thickening with increased acoustic density of the choroid in all patients. Systemic evaluation of these patients disclosed no underlying disease. Clinical signs and symptoms resolved in three of the patients after treatment with low-dose, orally administered corticosteroid or noncorticosteroid anti-inflammatory medication. High systemic doses of corticosteroid in combination with noncorticosteroid anti-inflammatory medication and local corticosteroid therapy was required to induce remission in one patient. All patients recovered good visual acuity.

Choroidal effusions in two patients with glomerulonephritis.

Two patients with renal disease and choroidal effusions are presented. The renal disease was mediated by humoral immunologic mechanisms as demonstrated by immunofluorescent studies of renal biopsies. Experimental and clinical studies provided evidence of simultaneous immune-complex deposition in both the renal glomerulus and the uvea of the eye. Immune-mediated vascular damage may result in glomerulonephritis and choroidal effusions.