Internal limiting membrane peeling in macular hole surgery

PURPOSE

To evaluate prospectively the ability to peel epiretinal membranes and to correlate the degree of membrane peeling to anatomic success rates.

DESIGN

Consecutive, noncomparative, interventional case series.

PARTICIPANTS

One hundred ninety-three patients.

METHODS

The extent of membrane peeling and other intraoperative features were correlated to endpoints.

MAIN OUTCOME MEASURES

Anatomic success (inducing hole closure), visual acuity of 20/50 or better, and visual improvement of two or more Snellen lines.

RESULTS

One hundred ninety-three eyes were eligible for the study by virtue of having a minimum follow-up interval of 6 weeks. The overall anatomic success rate was 93% in these cases. There was a two-line or more improvement in 72%; 56% attained 20/50 or better visual acuity. The internal limiting membrane was peeled completely in 23%, partially in 43%, and not at all in 34%. The degree of internal limiting membrane peeling was not correlated with the duration of the hole or rate of two-line visual improvement, but was inversely correlated with the rate of anatomic success (P = 0.045). Final visual acuity was correlated with a better preoperative visual acuity, shorter preoperative duration of macular hole, and more complete internal limiting membrane peeling.

CONCLUSIONS

Peeling of the internal limiting membrane is not essential for anatomic or visual success in macular hole surgery, but it may be a means to standardize inducement of the proper degree of gliosis. Excessive, unsuccessful attempts at internal limiting membrane peeling may decrease visual success. Techniques delivering a more reproducible, complete, atraumatic peeling of the internal limiting membrane should be studied.

Acrylic intraocular lens placement in conjunction with pars plana vitrectomy

PURPOSE

To report the results of placing a foldable acrylic intraocular lens through a clear cornea incision in eyes undergoing pars plana vitrectomy.

METHODS

This interventional case series is a retrospective report of 15 eyes of 15 consecutive patients undergoing foldable (acrylic) intraocular lens insertion in conjunction with pars plana vitrectomy in a single academic institution. Outcome measures included visual acuity and complications.

RESULTS

The intraocular lens was successfully implanted and retained in position in all 15 cases. The intraocular lens did not pose difficulty in examining the fundus or cause any vitreoretinal complications. With mean follow-up of 4.5 months (range, 1--10 months), final median postoperative visual acuity range was 20/200 (range, 20/40--2/200) and consistent with the level of vitreoretinal disease.

CONCLUSION

Acrylic intraocular lenses may be safely implanted in conjunction with pars plana vitrectomy in selected cases.

Long-term follow-up of unoperated macular holes

OBJECTIVE

To investigate the anatomic and visual acuity outcomes among patients with unoperated macular holes and at least 5 years of follow-up.

DESIGN

Retrospective, noncomparative case series from an institutional practice setting.

PARTICIPANTS

All patients with unoperated full-thickness macular holes evaluated at Bascom Palmer Eye Institute between January 1, 1968 and December 31, 1993 and observed for at least 5 years.

METHODS

Demographic and clinical data were abstracted from patients' medical records and ophthalmologic photography records. For patients with bilateral macular holes, only one eye was included.

MAIN OUTCOME MEASURES

Visual acuity and clinical features on initial examination, at 5 years, and at final follow-up.

RESULTS

The study included 65 eyes of 65 patients with a median age of 65 years (range, 52-85 years) and a median follow-up of 9.3 years (range, 5-29 years). On initial examination at Bascom Palmer Eye Institute, the macular hole was stage 2 in 15 eyes (24%), stage 3 in 23 eyes (37%), and stage 4 in 25 eyes (40%). At final follow-up, the macular hole was stage 3 in 10 eyes (16%) and stage 4 in 53 eyes (84%). Visual acuity was 20/200 or worse in 35 eyes (54%) on initial examination, in 43 eyes (74%) at 5 years, and in 53 eyes (82%) at final follow-up. Poorer visual acuity on initial examination was a significant predictor of poorer final vision (P < 0.01). Other accompanying clinical features such as the presence of operculum, posterior vitreous detachment, and epiretinal membrane were not significantly associated with final vision. Throughout follow-up, there was a redistribution and reduced number of yellow nodular opacities at the level of the retinal pigment epithelium at the base of the macular holes and the development of retinal pigment epithelial atrophy around the macular holes.

CONCLUSIONS

Long-term follow-up of unoperated macular holes demonstrates progression in hole size and stage, vision loss which generally stabilizes at the 20/200 to 20/400 level, a redistribution and reduced number of yellow nodular opacities at the level of the retinal pigment epithelium, and the development of retinal pigment epithelial atrophy surrounding the macular hole, resulting in a "bull's-eye" macular appearance.

Surgery for idiopathic macular holes associated with extensive subretinal fluid

PURPOSE

To study the baseline characteristics and outcomes of surgery for idiopathic macular holes associated with localized macular detachment.

METHODS

In this case-control study, eight consecutive patients with idiopathic macular hole associated with localized macular detachment (cases) and 30 randomly selected patients with idiopathic macular hole not associated with macular detachment underwent macular hole surgery.

RESULTS

The mean age (62.1 versus 68.2 years; P = 0.086), mean refractive error (-0.13 versus +0.23 diopters; P = 0.68), average duration of symptoms (5.9 versus 4.6 months; P = 0.47), and macular hole stage (P = 0.43) were similar in the cases and controls. The baseline visual acuity ranged from 20/50-20/80 (1 [13%] versus 1 [3%]) to 20/100-20/200 (2 [25%] versus 24 [80.0%]) to < 20/200 (5 [63%] versus 5 [17%]) (P = 0.10). Single-operation anatomic success was achieved in 2 (25%) cases and 24 (80%) controls (P = 0.007). Visual acuity 3 months after the last macular hole surgery was worse in cases compared to controls: > or = 20/40 in 0 versus 6 (20%), 20/50-20/80 in 1 (13%) versus 13 (43%), 20/100-20/200 in 4 (50%) versus 10 (33%), and < 20/200 in 3 (38%) versus 1 (3%) (P = 0.003). The mean improvement in visual acuity was 0.2 logMAR units in cases versus 0.4 logMAR units in controls (P = 0.054).

CONCLUSIONS

Surgical outcomes for idiopathic macular hole associated with a localized macular detachment compare poorly with the outcomes for macular hole not associated with extensive surrounding subretinal fluid.

Outcomes of vitreoretinal surgery for complications of branch retinal vein occlusion

OBJECTIVE

To investigate outcomes of vitreoretinal surgery for complications of branch retinal vein occlusion (BRVO).

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

The medical records of all patients who underwent vitreoretinal surgery for complications of BRVO at Bascom Palmer Eye Institute between January 1, 1991 and December 31, 1998 were reviewed. Thirty-six eyes from 36 consecutive patients were identified.

MAIN OUTCOME MEASURES

Visual acuity outcomes include preservation of preoperative visual acuity and visual acuity greater than or equal to 20/40, 20/200 and 5/200. When preoperative retinal detachment was present, the anatomic outcome assessed was complete retinal attachment. Postoperative event rates of retinal detachment, vitreous hemorrhage, epiretinal membrane (ERM), and cataract were tabulated. All outcomes were assessed at 6 months.

RESULTS

Surgical indications included nonclearing vitreous hemorrhage (17 patients), traction retinal detachment involving the macula (15), and ERM (4). Mean follow-up was 19 months. Preoperatively, best-corrected vision was greater than or equal to 20/200 in 19/36 (53%) eyes. Six months postoperatively, best-corrected vision was greater than or equal to 20/40 in 12/36 (33%) eyes, greater than or equal to 20/200 in 27/36 (75%) eyes, and greater than or equal to 5/200 in 31/36 (86%) eyes. Postoperative complications included retinal detachment (2/36; 6% eyes), ERM (3; 8%), vitreous hemorrhage (2; 6%), suprachoroidal hemorrhage (1; 3%), central retinal vein occlusion (1; 3%), and central retinal artery occlusion (1; 3%). Clinical features associated with better visual outcome include better preoperative visual acuity (P: = 0.05), absence of preoperative afferent pupillary defect (P: = 0.01), and absence of preoperative macular edema (P: = 0.08).

CONCLUSIONS

Following surgery, retinal attachment and improved visual acuity were achieved in the majority of patients. Pre-existing pathology and postoperative complications may limit final vision in eyes with BRVO.

Outcomes of macular hole surgery in severely myopic eyes: a case-control study

PURPOSE

To evaluate the outcomes of macular hole surgery in highly myopic eyes and to compare these outcomes with a control group of eyes that were not severely myopic.

METHODS

The study design was a matched, case-control, retrospective chart review. The participants included 26 eyes of 24 patients who had vitreous surgery for macular holes. The eyes were divided into two groups: 13 consecutive eyes with severe myopia (defined as -6.00 diopters of refractive error or greater) and 13 control eyes without severe myopia that were operated on immediately before or after each study eye, with the most recently operated eye chosen. The main outcome parameters were preoperative and final follow-up visual acuity, macular hole closure rates, reoperation rates, duration of preoperative symptoms, and follow-up time.

RESULTS

Using the Snellen equivalent of logarithm of minimal angle of resolution (logMAR) units, visual acuity improved after macular hole surgery in severely myopic eyes from 20/152 to 20/89 (P =.041) and in control eyes from 20/152 to 20/47 (P <.001). At final follow-up, visual acuities were lower in severely myopic eyes compared with control eyes (P =.048). Macular hole closure rates, reoperation rates, duration of pre-operative symptoms, and follow-up intervals were not significantly different statistically between groups.

CONCLUSIONS

Macular hole surgery results in anatomical and visual improvements in severely myopic eyes but generally yields poorer visual acuity outcomes compared with eyes that are not severely myopic.

Outcomes and complications associated with perfluoro-n-octane and perfluoroperhydrophenanthrene in complex retinal detachment repair

OBJECTIVE

To compare rates of perfluorocarbon liquid (PFCL) intraocular retention, anatomic and visual acuity outcomes, and complications associated with intraoperative perfluoro-n-octane (Perfluoron) versus perfluoroperhydrophenanthrene (Vitreon) in retinal detachment repair.

DESIGN

Retrospective noncomparative consecutive case series.

PARTICIPANTS AND METHODS

Records of consecutive patients who underwent retinal detachment repair with intraoperative Perfluoron (n = 78) or Vitreon (n = 84) at the Bascom Palmer Eye Institute between November 1, 1991, and October 31, 1994, were retrospectively reviewed.

MAIN OUTCOME MEASURES

Comparison of PFCL intraocular retention rates, retinal reattachment rates, visual acuity outcomes, and postoperative complication rates between the Perfluoron and Vitreon groups at postoperative day 1, week 1, month 1, month 3, and month 6. To assess the study's generalizability, the Perfluoron data obtained in the current study were compared with results of the Perfluoron Multicenter Clinical Study.

RESULTS

Retained Perfluoron was noted less frequently (P < 0.03) than retained Vitreon at each postoperative visit assessed. At 6 months postoperatively, the cumulative rate of retained PFCL (noted at any of the study postoperative visits) was 7.8% of patients in the Perfluoron group and 38.3% in the Vitreon group (P < 0.001). No significant difference was found between the groups in retinal reattachment rates; at 6 months postoperatively, the retina was attached in 45 of 61 (74%) patients in the Perfluoron group and 36 of 57 (63%) patients in the Vitreon group (P = 0.2). There was a trend (P = 0.055) toward better 6-month visual acuity in the Perfluoron group compared with the Vitreon group. The incidence of corneal abnormality at any study visit was 46.7% in the Perfluoron group and 77.4% in the Vitreon group (P < 0.001). At 6 months postoperatively, the cumulative rate of elevated intraocular pressure (>25 mmHg) was 13 +/- 4% and 37 +/- 5%, respectively (P = 0.004). No significant difference was found between the groups in rates of postoperative hypotony. Results of this study are comparable with those observed in the Perfluoron Multicenter Clinical Study.

CONCLUSIONS

In this study, Perfluoron was retained intraocularly less frequently than Vitreon. Although no significant difference was found between groups in retinal reattachment rates, Perfluoron is associated with slightly better 6-month visual acuity and lower rates of corneal abnormality and elevated intraocular pressure compared with Vitreon.

Combined pars plana vitrectomy and glaucoma drainage implant placement for refractory glaucoma

PURPOSE

To report visual acuity and intraocular pressure outcomes among patients who have undergone combined pars plana vitrectomy and placement of a glaucoma drainage implant.

METHODS

The medical records of all patients who underwent combined pars plana vitrectomy and placement of a glaucoma drainage implant at the Bascom Palmer Eye Institute by one of the authors between January 1, 1990, and February 28, 1998, were reviewed. Forty patients (40 eyes) were identified, including 14 patients with neovascular glaucoma secondary to proliferative diabetic retinopathy or central retinal vein occlusion, 15 patients with other posterior segment disease, seven patients with secondary angle-closure glaucoma, and four patients with aphakia with ruptured anterior hyaloid face. Main outcome measures included visual acuity and intraocular pressure at 1 year postoperatively.

RESULTS

At 1 year postoperatively, 31 (77.5%) of 40 patients had stable or improved visual acuity; three eyes (7. 5%) had a final visual acuity of no light perception and three additional eyes (7.5%) were enucleated (because of chronic pain in two eyes and endophthalmitis in one eye). Mean preoperative intraocular pressure was 34 mm Hg and the median number of preoperative antiglaucoma medications was two. At 1 year postoperatively, mean intraocular pressure was 13 mm Hg and the median number of antiglaucoma medications was zero. Twenty-two patients (55.0%) achieved an intraocular pressure greater than 5 mm Hg and less than or equal to 21 mm Hg without antiglaucoma medication, and an additional seven patients (17.5%) achieved this level of intraocular pressure control with medication. Only one patient (2.5%) underwent further glaucoma surgery for uncontrolled intraocular pressure.

CONCLUSIONS

Although combined pars plana vitrectomy and placement of a glaucoma drainage implant is often a successful management option in selected patients with refractory glaucoma, visual outcome may be poor because of severe underlying ocular disease and postoperative complications.

Surgical management and outcomes of dislocated intraocular lenses

OBJECTIVE

To evaluate the surgical management and visual acuity outcomes in a large series of patients with dislocated intraocular lenses (IOLs).

DESIGN

Retrospective consecutive noncomparative case series.

PARTICIPANTS

All patients who underwent surgical management of dislocated IOLs by two vitreoretinal surgeons at one institution between January 1, 1991, and March 31, 1998.

METHODS

Demographic and clinical data were abstracted from patients' medical records.

MAIN OUTCOME MEASURES

Visual acuity at final follow-up and surgical complications.

RESULTS

The study population consisted of 110 patients, with a median follow-up interval of 50 weeks after dislocated IOL management. Surgical techniques included IOL repositioning in 93 (84.5%) eyes, IOL exchange in 16 (14.5%) eyes, and IOL removal in 1 (1 %) eye. Final visual acuity was > or =20/40 in 63 patients (57%) patients, 20/50-20/200 in 34 (31%) patients, and <20/200 in 13 (12%) patients. Ninety-nine (90%) patients had stable or improved final vision. Observed complications included postoperative retinal detachment in 7 (6.3%) eyes, chronic cystoid macular edema in 19 (17%) eyes, and suprachoroidal hemorrhage in 1 (1%) eye.

CONCLUSIONS

Surgical management of dislocated IOLs usually results in satisfactory visual outcomes. Pre-existing ocular pathology and postoperative complications may limit final vision.

Choroidal neovascularization following macular hole surgery

BACKGROUND

Retinal pigment epitheliopathy, a recognized finding in eyes that have undergone macular hole surgery, may limit visual outcome and predispose to the development of choroidal neovascularization (CNV). This study reports on the features and outcomes of CNV following otherwise successful surgery for idiopathic macular holes.

METHODS

Case series including three eyes of two patients who developed CNV following macular hole surgery.

RESULTS

Choroidal neovascularization developed 3 to 30 months after macular hole surgery. The CNV was crescent-shaped, surrounding a central area of retinal pigment epithelial mottling that corresponded to the site of the macular hole in all three cases. All neovascular membranes were adjacent to the fovea and were associated with substantial leakage of fluorescein. The macular hole remained closed in all cases.

CONCLUSION

Choroidal neovascularization is a rare complication following macular hole surgery. Retinal pigment epitheliopathy and defects in the Bruch's membrane, pre-existing or secondary to surgery, may be predisposing factors.

Retinal detachment associated with macular hole surgery: characteristics, mechanism, and outcomes

OBJECTIVE

To study the frequency, features, and outcomes of retinal detachment (RD) occurring after macular hole surgery.

METHODS

Retrospective review of all cases of macular hole surgery. Cases with postoperative RD were identified for study. Outcome measures included baseline demographic and ocular characteristics, RD features, surgical procedure, macular hole status, and final visual and anatomic outcomes.

RESULTS

Retinal detachment occurred in 8 (1.8%) of 438 eyes undergoing macular hole surgery. The rate of RD was 3.5% early in the course of the surgeon's experience (first 200 cases) and 0.4% later in the surgeon's experience (after 200 cases) (P = 0.026). Two of the eight eyes with RD had undergone previous macular hole surgery. All six primary cases occurred after repair of stage 3 macular holes, which had involved peeling of the posterior cortical face. The RD involved the inferior quadrants in seven eyes and the macula in two eyes. The pathogenic retinal break was in the equatorial region in four eyes, was anterior to the equator in two eyes, and remained undetermined in two eyes. The retina was attached and the macular hole was closed in all cases at the final follow-up examination (mean 30 months). The macular hole reopened 2 years following successful reattachment of the RD in one eye. Final visual acuity was > or =20/60 in four eyes and <20/200 in one eye.

CONCLUSION

Retinal detachment after macular hole surgery is uncommon, and may be related to posterior cortical vitreous stripping. Early detection of RD minimizes adverse visual and anatomic outcomes.

Quality of life of low-vision patients and the impact of low-vision services

PURPOSE

To investigate the functional status and quality of life of patients at a low-vision clinic and to evaluate the impact of low-vision services.

METHODS

Interviews, including the Medical Outcomes Study 36-Item Short Form (SF-36), the Visual Function-14 (VF-14), and the 51-item Field Test Version of the National Eye Institute Visual Functioning Questionnaire (NEI-VFQ), were administered to 156 consecutive patients 1 week before and 3 months after their low-vision clinic visit.

RESULTS

Low-vision patients scored lower (P < .001) in physical functioning and role limitations caused by physical and emotional health problems than published SF-36 scores of the age-appropriate United States normal population, patients with congestive heart failure, and clinically depressed patients. Low-vision services were associated with improvement in the subjective functional status of 150 patients (98.7%) and were rated "very useful" by 82 (53.9%) patients. The SF-36 scores did not change significantly after low-vision services. The VF-14 mean score improved from 35.8 to 41.2 (P < .001). Four NEI-VFQ subscale scores improved significantly (P < .001): general vision, near activities, distance activities, and peripheral vision.

CONCLUSIONS

The SF-36, VF-14, and NEI-VFQ demonstrate that low-vision clinic patients perceive marked impairment of functional status and quality of life. Low-vision services are associated with high patient satisfaction. Vision-targeted questionnaires are more sensitive than general health-related quality of life questionnaires to changes in functional status and quality of life after low-vision services, and they may help elucidate the outcomes of low-vision services.

Vitrectomy in the management of diabetic retinopathy

According to the Early Treatment Diabetic Retinopathy Study, at least 5% of eyes receiving optimal medical treatment will still have progressive retinopathy that requires laser treatment and pars plana vitrectomy. During the past decade, improvements in instrumentation and surgical techniques have allowed more difficult cases of diabetic retinopathy to be candidates for vitrectomy. However, although the thresholds for performing surgery within established indicated situations have been lowered, only a few additional indications have been established. Although vitrectomy improves the prognosis for a favorable visual outcome, preventive measures, such as improved control of glucose levels and timely application of panretinal photocoagulation, produce better results. The authors review the indications, techniques, and results of vitrectomy in the management of diabetic retinopathy.

Combined lensectomy, vitrectomy and scleral fixation of intraocular lens implant after closed-globe injury

PURPOSE

To describe our experience in the surgical management of cataracts in patients with complications of closed-globe injury using pars plana lensectomy (PPL), pars plana vitrectomy (PPV), and scleral fixation of posterior chamber intraocular lens (PCIOL).

METHODS

We retrospectively reviewed charts of all patients with closed-globe injury who underwent PPL, PPV and scleral fixation of PCIOL at our institution between January 1991 and July 1997. We identified 28 eyes; because of less than 2 weeks follow-up, 4 eyes were excluded from the current study. All eyes had lens subluxation/dislocation and visually significant cataract. Additional indications for surgery included secondary glaucoma (10 eyes), vitreous hemorrhage (3 eyes) and retinal detachment (1 eye).

RESULTS

The postoperative follow-up interval ranged from 6 to 61 months (mean 18.5 months). Preoperative visual acuity (VA) ranged from 20/60 to hand motion and was 20/100 or better in 6 eyes (25%). Postoperatively, 19 eyes (79%) improved to 20/100 or better. Five eyes had subsequent surgery for the following indications: retinal detachment (2 eyes), poorly controlled glaucoma (2 eyes), and epiretinal membrane formation (1 eye).

CONCLUSIONS

In patients undergoing PPL, PPV and scleral fixation of PCIOL for cataract after a closed-globe injury, a substantial visual improvement occurred in a majority of the involved eyes.

Reopening of macular holes after initially successful repair

OBJECTIVE

To evaluate the frequency and prognosis of reopening of a macular hole after initially successful repair in a defined patient cohort.

DESIGN

Retrospective consecutive noncomparative case series.

PARTICIPANTS

Seventeen cases of reopened macular holes among 390 cases of idiopathic macular holes that previously had undergone macular hole surgery were studied.

MAIN OUTCOME MEASURES

Assessment of demographics, visual acuity, preoperatively, postoperatively, after reopening of macular hole and after reoperation, if applicable, and precipitating factors.

RESULTS

There were 17 (4.8%) of 353 cases in which the macular hole reopened after initial successful surgical closure. The mean visual acuity before reopening was 20/48 and was 20/133 after reopening. Twelve eyes underwent reoperation with improvement to a mean visual acuity of 20/54. The five eyes that were not reoperated on maintained a mean visual acuity of 20/200. Ten of the eyes had undergone cataract surgery between macular hole surgeries, but in only one did the reopening appear to occur in association with this procedure.

CONCLUSIONS

Reopening of a previously successfully operated macular hole is uncommon and seems to be a spontaneous event. Reoperation generally yields results similar to those present before the reopening. Reopening of a macular hole associated with cataract surgery is rare.

Treatment outcomes of endogenous fungal endophthalmitis

Endogenous fungal endophthalmitis may present in a debilitated or otherwise healthy host, may be increasing in prevalence, and is most commonly caused by Candida albicans. Recognizing the potential for complications with systemic amphotericin B use, recent investigators have developed several newer principles governing the treatment of such cases. For cases of simple choroiditis or very minimal endophthalmitis (i.e., vitritis), systemic treatment with oral fluconazole may be effective; however, if vitritis symptoms persist or progress, vitrectomy allows for better clearing of the organism. Intravitreal amphotericin B in conjunction with vitrectomy has been advocated by many. The most recent series have shown that an extended course of oral fluconazole following vitrectomy without intravitreal amphotericin B affects resolution of infection in the vast majority of patients. Final visual acuity outcomes depend most on the site of initial choroiditis. If the macula is spared and preretinal membranes can be effectively removed, visual acuity results can be exceedingly good.

Vitreoretinal surgery outcomes: results of a patient satisfaction/functional status survey

OBJECTIVE

This study aimed to assess patient satisfaction and change in functional status after surgery for epiretinal membrane (ERM), rhegmatogenous retinal detachment (RRD), and complex retinal detachment (CRD). This study also aimed to determine whether objective measures of vision are predictive of subjective improvement after surgery.

DESIGN

The study design included patient interviews and retrospective chart review.

PARTICIPANTS

Participants were those patients who underwent surgery for ERM, RRD, or CRD by one surgeon at the Bascom Palmer Eye Institute between January 1, 1993, and December 31, 1994.

INTERVENTION

Patient satisfaction and patients' perceptions of the impact of surgery on their functional status were assessed by telephone interviews conducted by one interviewer at least 6 months after surgery.

MAIN OUTCOME MEASURES

Responses to patient satisfaction survey and subjective change in patients' functional status were measured.

RESULTS

Of 187 eligible patients, 146 (78.1%) could be contacted and all agreed to participate. Ninety patients (61.6%) reported improved functioning after surgery in 2 or more of the 5 activities investigated. Twenty-one patients (14.4%) reported worse postoperative vision than expected, but only 5 patients (3.4%) thought surgery had not been worthwhile. One hundred forty-three patients (97.9%) reported adequate explanation of surgery and its expected results. Patients with preoperative study eye visual acuity between 20/40 and 20/200 were most likely to improve in two or more activities. Lower preoperative worse eye vision and better final study eye vision were associated with a greater likelihood of satisfaction after surgery. Diagnostic category was not predictive of change in functional status or patient satisfaction.

CONCLUSIONS

There is a high rate of patient satisfaction and improved functional status after surgery for ERM, RRD, and CRD, even among patients with good fellow eye vision.

Quantification of holmium: YAG and thulium: YAG laser-induced scleral shrinkage for buckling procedures

BACKGROUND AND OBJECTIVE

To quantify and compare holmium:YAG (2.1 microns) and thulium:YAG (2.0 microns) laser-induced scleral shrinkage for retinal buckling procedures.

MATERIALS AND METHODS

Two overlapping spots of either laser radiation were applied at the equatorial sclera of 50 human cadaver eyes. Scleral shrinkage was expressed as a relative change of length between two reference points on the scleral surface, and quantified as a function of energy per pulse, total energy, scleral thickness, and intraocular pressure (IOP). Tissue effects were studied histopathologically.

RESULTS

Shrinkage was most dependent on total fluence and attained a maximum of 27% to 30% with an IOP of 4 mm Hg, regardless of scleral thickness or laser parameters, but decreased with increasing IOP. The thulium:YAG laser produced more efficient scleral shrinkage and less collagen damage than the holmium:YAG laser.

CONCLUSION

The recommended parameters for laser-induced scleral shrinkage are the thulium:YAG laser, with 2.4 J/cm2 per pulse and 12.0 to 14.4 J/cm2 total fluence (5 to 6 pulses). IOP control (< or = 4 mm Hg) is crucial during laser scleral buckling.

Comparison of recombinant transforming growth factor-beta-2 and placebo as an adjunctive agent for macular hole surgery

OBJECTIVE

This study aimed to compare the visual and anatomic results of macular hole surgery in eyes treated with recombinant transforming growth factor-beta-2 (TGF-beta2) or placebo.

DESIGN

The design was a prospective, multicenter, randomized, double-masked, placebo-controlled clinical study.

PARTICIPANTS

One hundred thirty eyes with idiopathic macular holes of 1 year or less and a refracted Early Treatment Diabetic Retinopathy Study visual acuity of 20/80 or worse were treated with 1.1 microg recombinant TGF-beta2 or placebo to the macular hole after fluid-gas exchange.

INTERVENTION

The effect of recombinant TGF-beta2 as an adjunctive agent for macular hole surgery was evaluated.

MAIN OUTCOME MEASURES

Closure of the macular hole and change in visual acuity at 3 months were measured.

RESULTS

The 3-month visits were completed for 120 eyes. The macular hole was closed at 3 months in 35 (61.4%) of 57 eyes treated with placebo and 49 (77.8%) of 63 eyes treated with recombinant TGF-beta2 (P = 0.08). The mean visual acuity gain was +6.4 letters in eyes receiving placebo and +8.9 letters in eyes treated with recombinant TGF-beta2 (P = 0.27). Visual acuity improved 2 or more lines in 23 (40.4%) of 57 eyes treated with placebo and 30 (47.6%) of 63 eyes treated with recombinant TGF-beta2 (P = 0.42). Intraocular pressure elevation greater than 30 mmHg was more common 2 weeks after surgery in eyes treated with recombinant TGF-beta2 (P < 0.001).

CONCLUSIONS

Recombinant TGF-beta2 resulted in a similar proportion of successful closure of macular holes as placebo. There was no statistically significant visual acuity benefit with the use of recombinant TGF-beta2 for the treatment of macular holes.

Outcomes of vitreoretinal surgery in patients with X-linked retinoschisis

BACKGROUND AND OBJECTIVE

To assess the outcomes of vitreoretinal surgery in the treatment of vision-threatening posterior segment complications of X-linked retinoschisis.

PATIENTS AND METHODS

The authors performed a retrospective analysis of 16 eyes from 11 patients who underwent vitreoretinal surgery. All the patients had a documented positive family history of X-linked retinoschisis, and all patients had bilateral macular disease.

RESULTS

The ages of the patients ranged from 14 months to 37 years (mean age 15.1 years; median age 11.5 years), and postoperative follow-up ranged from 3 months to 10 years (mean 2.8 years; median 1 year). The indications for surgical intervention included rhegmatogenous retinal detachment (12 eyes), vitreous hemorrhage (2 eyes), progression of the schisis cavity through the fovea (2 eyes), cataract associated with a persistent hyperplastic primary vitreous-like condition (2 eyes), and exudative maculopathy (1 eye). The primary surgical intervention included pars plana vitrectomy alone (7 eyes), pars plana vitrectomy and pars plana lensectomy (4 eyes), and a scleral buckle procedure alone (5 eyes). Surgical success (defined as reattachment of the retina, removal of media opacities, or arrest of schisis progression) was achieved in 14 of 16 eyes, after an average of 1.2 procedures per eye. The major reason for reoperations was recurrent retinal detachment due to proliferative vitreoretinopathy. Two eyes were eventually enucleated due to pain associated with neovascular glaucoma resulting from recurrent retinal detachment. Of the remaining 14 eyes, visual acuity improved in 8 eyes and remained unchanged in 6 eyes.

CONCLUSION

Vitreoretinal surgery is often helpful in stabilizing or improving visual function in patients with posterior segment complications from X-linked retinoschisis.

Vitreous surgery for chronic macular holes

OBJECTIVE

The purpose of the study is to compare the results of vitreous surgery for a group of patients with chronic macular holes with a group of patients with acute-onset macular holes undergoing identical surgery.

DESIGN

A case-control study design was used.

PARTICIPANTS

The duration of symptoms of visual loss due to macular holes was greater than 1 year's duration in 11 eyes in each group consecutively operated on within a few days.

INTERVENTION

All patients underwent macular hole surgery.

MAIN OUTCOME MEASURES

Ophthalmoscopic resolution of the macular hole, improvement of 2 lines of visual acuity or greater, improvement in mean and median visual acuity, and rate of 20/40 or greater final visual acuity.

RESULTS

The hole resolved in 9 of 11 eyes in the chronic group and 10 of 11 eyes in the acute group. The mean (median) preoperative visual acuity was 20/151 (20/200) in the chronic group and 20/139 (20/200) in the acute group. The 3-month mean (median) postoperative visual acuity was 20/85 (20/80) in the chronic group and 20/62 (20/63) in the acute group. The final mean (median) postoperative visual acuity was 20/96 (20/ 100) in the chronic group and 20/48 (20/50) in the acute group (P = 0.022). The mean interval to final follow-up examination was 70 weeks for the chronic group and 44 weeks for the acute group. Five (45%) of 11 eyes with chronic holes and 8 (73%) of 11 eyes in the acute group had a final visual acuity of 2 lines or better than the preoperative visual acuity. Cataract extraction had been performed by the final follow-up examination in 7 chronic eyes (64%) and 2 acute eyes (18%).

CONCLUSIONS

Chronic macular holes have a similar anatomic success rate, but a poorer visual prognosis than acute holes after macular hole surgery. Vitreous surgery benefits some patients with idiopathic macular holes of greater than 1 year's duration.

Visual acuity outcomes among patients with appositional suprachoroidal hemorrhage

OBJECTIVE

The purpose of the study is to investigate visual acuity outcomes among patients with appositional suprachoroidal hemorrhage and to identify clinical features associated with visual prognosis.

DESIGN

The study design was a retrospective chart review.

PARTICIPANTS

All patients whose ocular echographic examination results showed appositional suprachoroidal hemorrhage at the Bascom Palmer Eye Institute between January 1, 1987, and December 31, 1996 were included. Fifty-one patients were identified.

INTERVENTION

Demographic and clinical data were abstracted from patients' medical records.

MAIN OUTCOME MEASURES

Visual acuity at 3, 6, and 12 months posthemorrhage and clinical features associated with visual prognosis were defined.

RESULTS

At final follow-up fifteen (29.4%) patients achieved either their prehemorrhage visual acuity (n = 7) or a visual acuity of 20/200 or better (n = 8), but 14 (27.5%) patients had no light perception. Predictors of a poor visual outcome include vitreous incarceration in the wound/bleb (P = 0.014), concurrent or delayed retinal detachment (P = 0.003), and afferent pupillary defect on presentation (P = 0.002). Poorer visual acuity on presentation (r = 0.37, P = 0.008) and longer duration of central retinal apposition (r = 0.51, P < 0.001) also were significantly associated with poor final visual acuity. Patients in whom the suprachoroidal hemorrhage maintained an appositional configuration for more than 14 days were more likely to have worse final visual acuities than were patients with appositional choroidals for fewer than 14 days (P = 0.006). The association between duration of apposition and final visual acuity was significant, both among patients whose suprachoroidal hemorrhages were observed (n = 26, r = 0.60, P = 0.001) and among patients who underwent secondary surgical intervention (n = 23, r = 0.66, P = 0.001). Patients with postoperative suprachoroidal hemorrhages achieved better final visual acuities than did patients in whom suprachoroidal hemorrhages developed intraoperatively or after trauma (P = 0.038).

CONCLUSIONS

Appositional suprachoroidal hemorrhage is a serious ocular complication with a guarded visual prognosis. A variety of clinical features, including vitreous incarceration in the wound/bleb, concurrent or delayed retinal detachment, afferent pupillary defect, presenting visual acuity, and duration of central retinal apposition, may help predict visual outcome.

Visual acuity outcomes among patients with appositional suprachoroidal hemorrhage

OBJECTIVE

The purpose of the study is to investigate visual acuity outcomes among patients with appositional suprachoroidal hemorrhage and to identify clinical features associated with visual prognosis.

DESIGN

The study design was a retrospective chart review.

PARTICIPANTS

All patients whose ocular echographic examination results showed appositional suprachoroidal hemorrhage at the Bascom Palmer Eye Institute between January 1, 1987, and December 31, 1996 were included. Fifty-one patients were identified.

INTERVENTION

Demographic and clinical data were abstracted from patients' medical records.

MAIN OUTCOME MEASURES

Visual acuity at 3, 6, and 12 months posthemorrhage and clinical features associated with visual prognosis were defined.

RESULTS

At final follow-up fifteen (29.4%) patients achieved either their prehemorrhage visual acuity (n = 7) or a visual acuity of 20/200 or better (n = 8), but 14 (27.5%) patients had no light perception. Predictors of a poor visual outcome include vitreous incarceration in the wound/bleb (P = 0.014), concurrent or delayed retinal detachment (P = 0.003), and afferent pupillary defect on presentation (P = 0.002). Poorer visual acuity on presentation (r = 0.37, P = 0.008) and longer duration of central retinal apposition (r = 0.51, P < 0.001) also were significantly associated with poor final visual acuity. Patients in whom the suprachoroidal hemorrhage maintained an appositional configuration for more than 14 days were more likely to have worse final visual acuities than were patients with appositional choroidals for fewer than 14 days (P = 0.006). The association between duration of apposition and final visual acuity was significant, both among patients whose suprachoroidal hemorrhages were observed (n = 26, r = 0.60, P = 0.001) and among patients who underwent secondary surgical intervention (n = 23, r = 0.66, P = 0.001). Patients with postoperative suprachoroidal hemorrhages achieved better final visual acuities than did patients in whom suprachoroidal hemorrhages developed intraoperatively or after trauma (P = 0.038).

CONCLUSIONS

Appositional suprachoroidal hemorrhage is a serious ocular complication with a guarded visual prognosis. A variety of clinical features, including vitreous incarceration in the wound/bleb, concurrent or delayed retinal detachment, afferent pupillary defect, presenting visual acuity, and duration of central retinal apposition, may help predict visual outcome.

Long-term visual outcomes in patients with successful macular hole surgery

OBJECTIVE

The purpose of the study is to determine the long-term visual outcomes in patients undergoing successful macular hole surgery.

DESIGN

A consecutive series of eyes with an anatomically successful macular hole surgical result and at least 1 year postoperative follow-up information was identified and studied. Preoperative and postoperative visual acuities were measured in accordance with the Early Treatment Diabetic Retinopathy Study protocol.

MAIN OUTCOME MEASURES

Visual acuity, improvement of visual acuity, and rate of final visual greater than or equal to 20/40 were measured.

RESULTS

The median visual acuity increased from 20/125 before surgery to 20/50 1 year after surgery (93 eyes) and to 20/30 at 36 months after surgery (68 eyes). The trend for improvement in visual acuity after 1 year after surgery was statistically significant. The postoperative visual acuity was greater than or equal to 20/40 in 15 (17%) eyes at 3 months and 53 (78%) at 36 months. Before surgery, 12 (13%) eyes were pseudophakic, and 77 (83%) were pseudophakic at 36 months. Median visual acuity in the fellow eye was 20/32 at baseline and 20/32 at 36 months. The visual acuity in the study eye was better than in the fellow eye in 36 (39%) patients at 36 months after surgery.

CONCLUSIONS

Visual acuity in patients after anatomically successful macular hole surgery continues to improve even beyond 1 year after surgery. Although substantial improvement occurs soon after cataract extraction, further improvement in visual acuity continues for 2 years thereafter.

Macular hole surgery without using adjunctive additives

BACKGROUND AND OBJECTIVE

To evaluate the efficacy of performing surgical techniques for macular holes without using adjunctive additives.

PATIENTS AND METHODS

A prospective study was completed of consecutive eyes treated for macular holes of 1 year or less duration that had not had previous vitreous surgery. The best-corrected visual acuity and hole flattening were determined.

RESULTS

Postoperative flattening of the hole was achieved in 39 (91%) of 43 eyes, with at least a 50% reduction of the minimum resolvable visual angle (3-line visual increase) in 65% of the eyes and a final vision of 20/40 or better in 40% of the eyes during the follow-up interval (mean 10.6 months).

CONCLUSIONS

The success rate of current macular hole surgical techniques suggests that adjunctive additives may not be necessary for most cases. Thus, new treatment modalities need to be evaluated with carefully controlled studies.

Giant retinal tear as a complication of attempted removal of intravitreal lens fragments during cataract surgery

PURPOSE

To report giant retinal tear and retinal detachment as a complication of attempted removal of intravitreal lens fragments at the time of cataract surgery and to evaluate the anatomic and visual acuity outcomes of pars plana vitrectomy and retinal reattachment surgery.

METHODS

Retrospectively, 10 patients with giant retinal tear, retinal detachment, and intravitreal lens fragments in 10 eyes were reviewed.

RESULTS

In 10 eyes, retrieval of intravitreal lens fragments using the limbal approach by deep vitrectomy, copious vitreous cavity irrigation, or deep vitreous cavity phacoemulsification had been attempted by the anterior segment surgeon at the time of cataract surgery in each patient. The average interval from cataract surgery to the initial vitreoretinal consultation was 8 days. Each of the 10 eyes had a giant retinal tear involving the inferior retina: in four eyes, of between 90 degrees and 180 degrees; in four, equal to 180 degrees; and in two, of greater than 180 degrees. After pars plana vitrectomy and retinal detachment repair, nine (90%) of 10 eyes had retinal reattachment, but seven patients required more than one operation. One eye had persistent retinal detachment, and one eye had corneal graft failure. Seven (70%) of the 10 eyes had best-corrected final visual acuity of 20/200 or better; three eyes had light-perception, hand-motion, and counting-fingers vision.

CONCLUSIONS

Aggressive attempts at intravitreal lens fragment retrieval from a limbal-based approach should be avoided because these procedures may result in serious retinal complications, such as formation of a giant retinal tear.

Idiopathic macular hole following vitrectomy: implications for pathogenesis

BACKGROUND AND OBJECTIVE

Attention to the pathogenesis and clinical features of macular hole formation has increased with the advent of therapy. The purpose of this study is to present three cases that occurred in atypical settings that may have important pathogenic implications.

PATIENTS AND METHODS

The authors conducted a retrospective study of three patients who presented with macular holes that developed 10 months to 5.5 years after previous vitrectomy. In each case, the cortical vitreous layer was absent in the region of the macula at the time of operation for the macular hole.

RESULTS

The macular hole was successfully sealed and the visual acuity improved in all patients. All three cases in this report lacked an operculum, occurred long after vitreous removal, and had no evidence of any residual cortical vitreous.

CONCLUSIONS

Macular hole formation in the absence of cortical vitreous suggests the possibility that the etiology of macular holes may involve a spontaneous umbo dehiscence rather than vitreous-induced surface traction. A mechanism involving a cystic degenerative process is proposed as the cause of atypical and typical macular hole formation.

Vitreoretinal surgery outcomes. Impact on bilateral visual function

PURPOSE

The authors evaluated the impact of vitreoretinal surgery for epiretinal membrane (ERM), rhegmatogenous retinal detachment (RRD), and complex retinal detachment (CRD) on bilateral visual function.

METHODS

Anatomic and visual acuity outcomes were reviewed by the authors for all patients who underwent surgery for ERM, RRD, or CRD during a 2-year period. Several outcome measures of bilateral visual function were applied to quantitate the impact of surgery on bilateral visual function. Data were also analyzed by subdividing patients into two cohorts based on whether vision in the fellow eye was normal (visual acuity > or = 20/40) or abnormal (visual acuity < or = 20/50) at baseline.

RESULTS

Anatomic and visual acuity outcomes of 187 study eyes were similar to previous studies. Postoperatively, the study eye was the eye with better vision in 30.9%, 26.8%, and 16.7% of patients with ERM, RRD, and CRD, respectively. The mean bilateral visual impairment according to American Medical Association Guidelines for Disability decreased postoperatively by 8.7% points, 6.8% points, and 3.6% points, respectively, and decreased most when vision in the fellow eye was abnormal. A higher bilateral visual system functional level resulted postoperatively in 10.7% of all patients, including 28.6% of patients with abnormal vision in the fellow eye (by definition, the visual system functional level of patients with normal vision in the fellow eye could not be improved).

CONCLUSIONS

Surgery was associated with a reduction in bilateral visual disability among patients with ERM, RRD, and CRD, and 28.6% of patients with abnormal vision in the fellow eye achieved a higher bilateral visual functional level.

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.

Removal of retained lens fragments after phacoemulsification reverses secondary glaucoma and restores visual acuity

PURPOSE

The purpose of the study is to evaluate the effect of vitrectomy on secondary glaucoma and visual acuity outcomes in patients with retained lens fragments after phacoemulsification.

METHODS

A retrospective analysis of 126 patients who had vitrectomy for retained lens fragments after phacoemulsification during the 3-year period between January 1, 1993, and December 31, 1995.

RESULTS

Glaucoma, defined as an intraocular pressure of greater than or equal to 30 mmHg, occurred in 42 (36.8%) of 114 patients before vitrectomy and in 4 patients (3.2%) of 126 after vitrectomy. There were no differences in the rates of persistent glaucoma regardless of the intervals between cataract surgery and the vitrectomy: less than or equal to 1 week, 2 patients (4.1%); greater than 1 week to less than or equal to 4 weeks, 1 patient (2.5%) and greater than 4 weeks, 1 patient (2.6%). The visual acuity was 20/40 or better in 13 patients (11.4%) before vitrectomy and in 75 patients (59.5%) after vitrectomy. The rates of visual acuity 20/40 or better also were similar for all intervals: less than or equal to 1 week, 29 patients (59.2%); greater than 1 week to less than or equal to 4 weeks, 22 patients (56.4%) and greater than 4 weeks, 24 patients (63.1%).

CONCLUSIONS

Vitrectomy for removal of retained lens fragments reduces secondary glaucoma and yields favorable visual acuity outcomes. In eyes with elevated intraocular pressure, early vitrectomy generally is recommended, but delayed vitrectomy also has favorable outcomes.

Treatment outcomes in a 10-year study of endogenous fungal endophthalmitis

BACKGROUND AND OBJECTIVE

To review prevalence of organisms, associated factors, and treatment outcomes from one medical center's 10-year experience managing culture-proven endogenous fungal endophthalmitis (EFE).

PATIENTS AND METHODS

The authors retrospectively reviewed the microbiology and corresponding clinical records of patients diagnosed as having culture-proven EFE at the Bascom Palmer Eye Institute during a 10-year period.

RESULTS

Culture-proven EFE occurred in 20 eyes of 18 patients. Candida species occurred in 17 of 20 eyes (85%), and Aspergillus species occurred in 3 of 20 eyes (15%). The most common association was long-term intravenous line placement, which was present in 12 patients (67%). Whereas 12 patients (67%) had a history of recent hospitalization, only 2 (11%) had a documented history of systemic fungal infection. After initial examination, only 2 patients had a systemic culture positive for a fungal organism (none had a positive blood culture). Treatment after initial examination included pars plana vitrectomy in 17 of the 20 eyes (85%), intravitreal amphotericin B in 19 eyes (95%), and systemic antifungal medication in 16 eyes of 15 patients. Thirteen of the 17 eyes (76%) with Candida endophthalmitis and 0 of 3 eyes with Aspergillus endophthalmitis achieved visual acuity of 20/400 or better.

CONCLUSION

The most common cause of culture-proven EFE at the authors' institution is Candida species. The overall visual outcomes were more favorable for Candida cases than they were for Aspergillus cases. In the treatment of patients with marked vitreous infiltrates from EFE, pars plana vitrectomy, intravitreal amphotericin B injection, and administration of appropriate systemic antifungal medication (fluconazole for Candida) are generally recommended.

Visual acuity and macular hole size after unsuccessful macular hole closure

PURPOSE

To evaluate the visual acuity, change in macular hole size, and change in subretinal fluid cuff size after unsuccessful macular hole closure.

METHODS

Forty-two consecutive eyes with macular hole and unsuccessful surgery for macular hole were studied. Preoperative and postoperative best-corrected visual acuities were tested according to the Early Treatment Diabetic Retinopathy Study (ETDRS) protocol, and changes were compared. Preoperative and postoperative fundus photographs were analyzed on a photograph documenter for changes in diameter of the macular hole and surrounding subretinal fluid cuff.

RESULTS

Mean visual acuity decreased from 20/133 preoperatively to 20/154 postoperatively (mean loss, 0.79 ETDRS line). Mean diameter of the macular hole enlarged 22%; mean diameter of the visible surrounding subretinal fluid cuff enlarged 36%. A decrease in best-corrected visual acuity postoperatively was correlated with better preoperative visual acuity, earlier macular hole stage, and shorter duration. Enlargement in the diameter of the macular hole and fluid cuff did not correlate with better preoperative best-corrected visual acuity, earlier macular hole stage, or shorter duration. In 23 eyes that had failed previous surgery, macular hole surgery was anatomically successful in 17 (65%) (mean improvement, 3.7 ETDRS lines; mean best-corrected final visual acuity, 20/74).

CONCLUSION

After macular hole surgery, anatomically unsuccessful closure of the hole correlates with small enlargements in the diameter of the macular hole and its surrounding subretinal fluid cuff, and with a slight decrease in visual acuity. Macular hole closure after repeat surgery improves visual acuity outcome in the majority of retreated eyes.

Vitrectomy and systemic fluconazole for treatment of endogenous fungal endophthalmitis

BACKGROUND AND OBJECTIVE

To investigate the efficacy of pars plana vitrectomy and oral fluconazole without injection of intravitreal antimycotic agents in the treatment of vitritis resulting from Candida endophthalmitis.

PATIENTS AND METHODS

Six eyes of five patients with suspected Candida endophthalmitis were treated with pars plana vitrectomy and systemic fluconazole for at least 3 weeks. Patients were observed postoperatively for at least 4 months.

RESULTS

Clinical signs of infection cleared and visual acuity improved postoperatively in all six cases. One recurrent case was attributed to a retained indwelling venous catheter.

CONCLUSIONS

Treatment of advanced endogenous Candida endophthalmitis with vitrectomy and systemic fluconazole offers an effective alternative to management with intravitreal amphotericin B in selected cases.

Irreversible silicone oil adhesion to silicone intraocular lenses. A clinicopathologic analysis

PURPOSE

To report a newly defined complication of foldable intraocular lenses (IOLs), namely silicone oil-silicone IOL interaction. This is a complication not generally seen by the implanting cataract surgeon but, rather, at a later stage in a patient's postoperative course, by a vitreoretinal surgeon.

METHODS

Three clinical case histories, including two explanted silicone IOLs, were submitted for analysis. The submitted silicone lenses were photographed under water, and the nature of the silicone oil coating was documented.

RESULTS

In each instance, the silicone coating was manifest as a thick coating with droplet formation on the lens surface that was tenaciously adherent and could not be dislodged by instruments or injection of viscoelastics.

CONCLUSION

The use of silicone IOLs in patients with current vitreoretinal disease or those who are at high risk for future vitreoretinal disease that may require silicone oil as part of the therapy should be reconsidered. The authors recommend that information regarding the existence and significance of this complication be printed on all silicone oil and silicone IOL packages and inserts (if not as a warning, at least as an informative comment regarding the existence of this condition). This is a rare but clinically significant complication that will affect the occasional patient treated with both of these modalities.

Retinal detachment in patients with retained lens fragments or dislocated posterior chamber intraocular lenses

BACKGROUND AND OBJECTIVE

Retinal detachment is a complication of dislocated crystalline and intraocular lenses. The purpose of this study was to compare the frequency and management of coexisting or subsequent retinal detachment in patients with retained lens fragments or dislocated posterior chamber intraocular lenses (PC IOLs).

PATIENTS AND METHODS

A retrospective, consecutive series of patients undergoing vitrectomy for dislocated PC IOLs (99 eyes) or removal of retained lens material (80 eyes) were studied.

RESULTS

Eyes with retinal detachment and retained lens fragments (2 cases) or dislocated PC IOLs (2 cases), or retinal detachment following vitrectomy for removal of retained lens fragments (2 cases) or repair of dislocated IOL (1 cases) were identified. The prevalence of coexisting or postoperative retinal detachment and retained lens fragments (5% total) was slightly higher than the prevalence of coexisting or postoperative retinal detachment and dislocated PC IOLs (3% total). The retina was reattached in all cases using the standard scleral buckling and vitrectomy techniques.

CONCLUSION

The rate of retinal detachment associated with retained lens material is decreased compared with previous reports. This may possibly be a results of increasing attention to minimizing surgical trauma by the cataract surgeon at the time of lens fragment loss and by the vitrectomy surgeon during primary repair.

Outcome of functioning filtering blebs after pars plana vitrectomy

BACKGROUND AND OBJECTIVE

To determine the status of filtering bleb function following pars plana vitrectomy.

PATIENTS AND METHODS

The authors retrospectively reviewed patients with functioning filtering blebs undergoing pars plana vitrectomy.

RESULTS

Twenty-three eyes with functioning filtering blebs underwent pars plana vitrectomy. Postoperatively, 7/23 (30 percent) of the eyes had moderate (5 to 20 mm Hg) intraocular pressure (IOP), 8/23 of the eyes had IOP persistently greater than 20 mm Hg, and 7/23 of the eyes had IOP of less than 5 mm Hg. One of 7 eyes that underwent vitrectomy within 6 weeks after trabeculectomy maintained bleb function, whereas 6 of 16 eyes that underwent trabeculectomy 6 weeks or later maintained bleb function. Loss of bleb function occurred in the early postoperative period in the majority of the patients. Prior antimetabolite therapy was not associated with preservation of bleb function.

CONCLUSION

There is a substantial risk of bleb failure following vitrectomy, which is in part related to the often severe nature of the diseases requiring vitreoretinal surgery.

Vitrectomy for diabetic macular edema associated with a thickened and taut posterior hyaloid membrane

PURPOSE

To evaluate the surgical results in a series of patients with diabetic macular edema associated with traction from a thickened and taut posterior hyaloid membrane and to identify features associated with better visual outcome.

METHODS

We reviewed the clinical records of ten consecutive patients who underwent pars plana vitrectomy in one eye for diabetic macular edema that was preoperatively attributed to thickening and traction of the posterior hyaloid membrane.

RESULTS

Best-corrected, preoperative visual acuity was 20/200 in seven eyes, 20/300 in one eye, and 20/400 in two eyes. Intraoperatively, seven patients were found to have an attached posterior hyaloid membrane which was thickened and taut. Among these seven patients, postoperative best-corrected visual acuity improved by six lines in two eyes, by five lines in one eye, by two lines in one eye, and remained within one line of preoperative visual acuity in three eyes. The other three patients had an epiretinal membrane simulating an attached and thickened posterior hyaloid membrane.

CONCLUSIONS

Vitrectomy effectively improved visual acuity in some eyes with diabetic macular edema associated with traction from a thickened and taut posterior hyaloid membrane. Despite careful preoperative examination with a fundus contact lens, however, in some patients it may be difficult to assess how the posterior hyaloid membrane contributes to the macular edema. In selected patients, early surgical intervention may be associated with better visual outcome.

Endophthalmitis in patients with retained lens fragments after phacoemulsification

PURPOSE

To review the treatment and outcomes of patients presenting with concurrent endophthalmitis and retained lens fragments after phacoemulsification.

METHODS

A retrospective chart review was conducted on patients presenting with culture-proven endophthalmitis and retained lens fragments after phacoemulsification between 1990 and 1994.

RESULTS

Five patients were identified with culture-proven endophthalmitis and retained lens fragments after phacoemulsification. In all patients, coagulase-negative staphylococci were cultured from the vitreous fluid. One patient also had positive cultures for Proteus mirabilis and Escherichia coli. The interval between cataract surgery and treatment ranged from 5 days to 6 months. Echography was beneficial in showing retained lens fragments in five of five patients when media opacities obscured the view of the fundus. Four patients had vitrectomy and removal of retained lens fragments during their initial treatment. The fifth patient was treated with intravitreal antibiotics alone and continued to have marked inflammation, eventually requiring vitrectomy for removal of the retained lens fragments. A final visual acuity of 20/400 or better was achieved in four of the five patients.

CONCLUSIONS

Patients may present with endophthalmitis in the setting of retained lens fragments after phacoemulsification. In such cases, the preferred initial management may be pars plana vitrectomy, removal of retained lens fragments, and injection of intraocular antibiotics. In eyes with endophthalmitis and opaque media, echography is a useful screening modality.

Bilaterality of idiopathic macular holes

BACKGROUND

There has been wide variation in estimates of the incidence of bilateral idiopathic macular holes in the literature. This report of a large series of patients with macular holes provides further information regarding incidence of bilaterality, interval between onset in the first and the second eye, and visual outcome.

METHODS

A retrospective chart review was done of 550 patients with idiopathic macular holes examined at the Bascom Palmer Eye Institute between 1968 and 1994. The incidence of bilaterality was estimated from 365 patients in whom the fellow eye was normal at the initial examination. The rate of onset in the fellow eye was evaluated by survival analysis. Mean follow-up was 31 months (median 17 months).

RESULTS

Patients with incomplete macular holes (stage 1, aborted stage 1, lamellar) or full-thickness holes had a 19% incidence of bilaterality at 48 months follow-up. In the subset of 32 patients with full-thickness macular holes in the first eye, 13% developed full-thickness holes in the fellow eye within 48 months. The median interval between the onset in the first and in the second eye was 17.5 months. Visual acuity was excellent and stable in eyes with aborted stage 1 and lamellar holes. The visual acuity in the first eye with full-thickness macular hole decreased to 20/200 or worse in 79% of cases within 36 months' follow-up.

CONCLUSION

The incidence of bilaterality and poor visual function in the majority of full-thickness idiopathic macular holes by 3 years' duration should be considered when advising patients and planning management.

Bilateral visual function after macular hole surgery

PURPOSE

In this study, the authors apply objective measures of bilateral visual function to investigate the benefits of macular hole surgery to overall visual function.

METHODS

Anatomic and visual acuity outcomes were reviewed for patients undergoing primary macular hole surgery at one institution during a 3-year period. Several measures of bilateral visual function were defined to determine the impact of surgery on bilateral visual function. Patient data were analyzed in two separate cohorts based on whether the fellow eye was normal (visual acuity > or = 20/40, fellow eye normal group) or abnormal (visual acuity <20/40, fellow eye abnormal group) at baseline to determine the effect on visual function improvement.

RESULTS

The rim of subretinal fluid resolved after surgery in 85% of patients and 82% gained two or more Early Treatment Diabetic Retinopathy Study lines of visual acuity. After surgery, visual acuity in the surgical eye was better than or equal to the fellow eye in 35%, and average visual impairment according to the American Medical Association Guidelines for Disability decreased from 29% to 17%. Among the FEA group, vision in the surgical eye was better than or equal to that of the fellow eye in 70%, and visual impairment was reduced from 52% to 35%.

CONCLUSION

Bilateral visual function was improved after macular hole surgery. The improvement rate was markedly better in patients with subnormal vision in the fellow eye.

Intraocular tamponade duration and success of macular hole surgery

PURPOSE

The authors compare the success of macular hole surgery with a short duration tamponade using 5% perfluoropropane (C3F8), intermediate duration tamponade using 10% C3F8, or a long duration tamponade using 16% C3F8 in a prospective consecutive clinical trial at two institutions.

METHODS

Vitrectomy and fluid-gas exchange was performed in 29 eyes treated with 5% C3F8 and 1 week of prone positioning, 30 eyes treated with 10% C3F8 and 2 weeks of prone positioning, and 90 eyes treated with 16% C3F8 and 2 weeks of prone positioning 90% of time, followed by 2 weeks of prone positioning 50% of time.

RESULTS

The macular hole was closed successfully in 19 of 29 eyes (65.6%) treated with 5% C3F8, 19 of 30 eyes (63.3%) treated with 10% C3F8, and 85 of 90 eyes (94.4%) treated with 16% C3F8 at 3 months (P = 0.00017 for 5% vs. 16% C3F8, P = 0.00006 for 10% vs. 16% C3F8). The visual acuity improvements measured by refraction using the Early Treatment Diabetic Retinopathy Study (ETDRS) acuity charts paralleled the success of macular hole closure. The acuity improved a mean improvement of + 9.6 ETDRS letters for eyes treated with 5% C3F8, + 6.4 ETDRS letters for eyes treated with 10% C3F8, and + 13.1 ETDRS letters in eyes treated in 16% C3F8.

CONCLUSIONS

A long duration intraocular gas tamponade with 16% C3F8 gives a substantially higher success rate for macular hole surgery than a short (5% C3F8) or intermediate duration (10% C3F8) intraocular gas tamponade.

Reoperation after failed macular hole surgery

PURPOSE

The authors determined the anatomic and visual success rates of vitrectomy in patients who have failed previous macular hole surgery.

METHODS

Standardized Early Treatment Diabetic Retinopathy Study (ETDRS)-style best-corrected visual acuity was measured in each patient pre- and postoperatively. Surgery was performed at two centers using a standardized protocol, as previously reported, using 1330 ng bovine-derived transforming growth factor-beta 2 (TGF-beta 2) and 16% perfluoropropane internal gas tamponade. Endpoint analyses were conducted for anatomic closure of the hole, visual improvement of three or more ETDRS lines, and final visual acuity of > or = 20/63 and > or = 20/40.

RESULTS

Forty-eight failing macular hole surgery were reoperated. The anatomic results showed closure of the hole in 40 (83%) cases at the end of the mean follow-up interval of 7.4 months. The visual acuity improved in greater than or equal to three lines in 52%, was > or = 20/63 in 54%, and was > or = 20/40 in 25% of reoperated eyes. The only factor associated with a better final visual acuity was preoperative visual acuity better than 20/80. Nuclear sclerosis leading to cataract extraction was observed in 13 (30%) of 43 initially phakic eyes.

CONCLUSIONS

Macular hole closure was induced in this subset of reoperated patients. Visual improvement occurred often, although in a lower percentage than has been reported for primary surgical eyes. Repeat vitrectomy should be considered in patients with persistent macular hole after failure of primary surgery.

Vitrectomy for complications of proliferative diabetic retinopathy. Functional outcomes

PURPOSE

To quantitate the effect of diabetic vitrectomy on each patient's visual system and function.

METHODS

The anatomic and visual acuity outcomes of diabetic vitrectomy among three surgeons at one institution over a 4-year time interval were studied. Outcome parameters describing the visual system function were defined and applied to quantitate the effect on visual system disability.

RESULTS

The anatomic and visual success rates and prognostic factors in the cohort of 213 patients by standard statistical analysis were similar to previous studies. The study eye was the eye with better vision in 68 (32%) patients at the conclusion of the study, and vision was equal to the fellow eye in 35 (16%) patients. The mean impairment of the visual system by the American Medical Association Guidelines for Disability was reduced from 61% preoperatively to 50% postoperatively. The factor associated with greatest degree of reduction of impairment of the visual system was a previtrectomy diagnosis of vitreous hemorrhage. There was at least a one-step improvement of visual system function in 65 (31%) patients.

CONCLUSIONS

Vitrectomy for complications of severe proliferative diabetic retinopathy is especially valuable in improving the patient's overall visual function.