Ophthalmologic Presentations of Incontinentia Pigmenti

Purpose: To characterize treatments and outcomes in incontinentia pigmenti. Methods: Cases of incontinentia pigmenti were consecutively identified from a retina practice. Inclusion criteria were patients with incontinentia pigmenti with at least 6 months of follow-up. All patients had a full ophthalmic examination, including imaging with widefield fundus photography and widefield fluorescein angiography. Eyes with areas of avascular retina were treated with laser photocoagulation (except for 1 eye with mild changes). Results: Thirty-six eyes of 18 patients with incontinentia pigmenti were included. The median age at presentation was 11 months. On presentation, 7 eyes had a visual acuity (VA) of 20/40 or better and 3 eyes had VA of 20/50 to 20/100. The remaining 26 eyes could fix and follow or had at least light perception (LP) VA given the patients' young age. Of the 36 eyes, 20 (56%) had retinal involvement. The mean follow-up for treated patients was 6.9 years. Seventy-four percent of treated eyes required 1 laser session only. No eye that received laser treatment subsequently developed a retinal detachment. Of the 26 eyes with initial fix-and-follow or LP VA, 12 had Snellen or Allen VA testing at follow-up. Nine of these eyes had a follow-up VA of 20/40 or better. Of 10 eyes with a Snellen or Allen VA recorded at the initial visit, 9 had a final VA that was the same or improved. Conclusions: Laser photocoagulation was effective in treating patients with retinal manifestations of incontinentia pigmenti. Except for 1 eye, VA remained stable at the final follow-up.

Survey of Retina Specialists' Attitudes and Practice Patterns of Screening and Management of Candida Endophthalmitis

PURPOSE

To understand retina specialists' attitudes and practice patterns for screening for and managing Candida endophthalmitis and any impact of the COVID-19 pandemic on these practice patterns.

METHODS

A survey was developed on Survey Monkey and distributed to ASRS regular members via email in April 2021.

RESULTS

The survey had 231 respondents, of whom 169 (73%) performed inpatient consultations. Ninety percent responded that they do not recommend routinely screening asymptomatic patients with candidemia. For unresponsive patients with candidemia that lack visible signs of endophthalmitis, 65% did not recommend routine screening.However, 85% reported their affiliated hospitals did not have a policy to defer such screening consultations; this proportion did not significantly change when asked if a policy was implemented in response to the COVID-19 pandemic.For patients with a dilated examination without signs of endophthalmitis, 89% surveyed recommended continuing systemic antifungals and reconsult PRN, while the remainder recommended repeat examinations until off antifungals. For initial management of Candida endophthalmitis, 55% indicated systemic antifungals only; 43% indicated systemic antifungals with tap & inject, and 2% indicated systemic antifungals with vitrectomy and intravitreal antifungals.

CONCLUSION

A discordance exists between the prevailing opinion among retina specialists against routine Candida endophthalmitis screening and hospital consultation policies, which were not significantly impacted by the COVID-19 pandemic. In cases of diagnosed endogenous endophthalmitis, slightly more than half of surveyed retina specialists would not initiate additional treatment beyond systemic antifungals while just under half surveyed recommended initial tap and inject in addition to systemic antifungals.

Opportunity Cost of Vitreoretinal Surgeries

Purpose: To compare physician reimbursements for vitreoretinal surgeries with office-based patient care. Methods: A theoretical model was performed comparing physician work reimbursements for the 10 most common vitreoretinal surgeries with office-based work relative value units (wRVUs) that could have been generated during the same global time period. The reference physician was modeled at 40 patients per 8-hour workday. A lower volume physician and higher volume physician were modeled at 30 patients/day and 50 patients/day, respectively. The reimbursement rates and allocated times for surgery were based on the 2021 values set by Medicare, and the average wRVU per office visit was based on 2021 real-world data from the Vestrum Retinal Healthcare Database. Results: In the reference case, performing any of the 10 most common vitreoretinal surgeries was associated with an opportunity cost with a weighted mean of 49% (range, 40%-68%) relative to lost office productivity. The Centers for Medicare & Medicaid Services (CMS) allocated a weighted mean intraservice time of 73 minutes; however, the reference physician would have to complete the surgery with a weighted average of 5 minutes (range, -31-12 minutes) for surgical wRVUs to equal office-based reimbursements. Performing these 10 surgeries was associated with a 25% opportunity cost even for the lower volume physician and 61% for the higher volume physician. Probability sensitivity analysis with a range of conditions identified opportunity costs from surgery in over 99% of simulated scenarios. Conclusions: Medicare reimbursements for the physician work component of vitreoretinal surgeries represented a significant opportunity cost for the physician relative to office-based patient care of equivalent time, especially for busier physicians. The model did not explore practice overhead and professional liability insurance, which are factored separately by CMS and may influence the opportunity cost depending on utilization. The average threshold surgery times for surgical reimbursements to equal office-based reimbursements may be difficult to achieve.

The Broader Economic Value of Treatment for Diabetic Macular Edema

OBJECTIVE

To simulate economic outcomes for individuals with diabetic macular edema (DME) and estimate the economic value of direct and indirect benefits associated with DME treatment.

RESEARCH DESIGN AND METHODS

Our study pairs individual and cohort analyses to demonstrate the value of treatment for DME. We used a microsimulation model to simulate self-reported vision (SRV) and economic outcomes for individuals with DME. Four scenarios derived from clinical trial data were simulated and compared for a lifetime horizon: untreated, anti-VEGF therapy, laser, and steroid. To quantify the relative magnitude of costs and benefits of DME treatment in the U.S., we used a cohort-level analysis based on real-world treatment parameters derived from published data.

RESULTS

In the model, excellent/good SRV roughly corresponded to 20/40 or better visual acuity. A representative 51-year-old treated for DME would spend 30-35% additional years with excellent/good SRV and 29-32% fewer years with fair/poor SRV relative to being untreated. A treated individual would experience 4-5% greater life expectancy and 9-13% more quality-adjusted life-years. Indirect benefits from treatment included 6-9% more years working, 12-19% greater lifetime earnings, and 8-16% fewer years with disability. For the U.S. DME cohort (1.1. million people), total direct benefit was $63.0 billion over 20 years, and total indirect benefit was $4.8 billion. Net value (benefit - cost) of treatment ranged from $28.1 billion to $52.8 billion.

CONCLUSIONS

Treatment for DME provides economic value to patients and society through improved vision, life expectancy, and quality of life and indirectly through improved employment and disability outcomes.

Amniotic Membrane Patching to Assist Closure of Recalcitrant Macular Holes

BACKGROUND AND OBJECTIVE

This study reports a case series of patients with persistent macular holes (MHs) who underwent human amniotic membrane subretinal placement to achieve successful anatomic MH closure.

PATIENTS AND METHODS

This was a retrospective case series of patients with persistently open full-thickness MHs who underwent human amniotic membrane placement. Patients were observed up to 6 months postoperatively.

RESULTS

Ten patients were included. The mean preoperative best-corrected visual acuity was 1.6 logMAR (20/800). Postoperatively, mean best-corrected visual acuity improved to 1.3 logMAR (20/400) at 1 month and 1.1 logMAR (20/250) by the 3- and 6-month visits. In all cases, the MH appeared closed at the 1-week visit and remained closed at their last follow-up. Optical coherence tomography showed closure in all cases. No adverse events were reported.

CONCLUSIONS

Human amniotic membrane sub-retinal placement may serve as a useful surgical technique to assist in the closure of recalcitrant macular holes. [Ophthalmic Surg Lasers Imaging Retina 2023;54(x):X-X.].

Stickler and Wagner Syndrome in African Americans

BACKGROUND

Stickler (STL) and Wagner (WGN) syndromes are rare inherited vitreoretinopathies associated with retinal detachments (RD). There is a paucity of case reports describing these diseases in African American patients.

METHODS

An IRB-approved, retrospective chart review of African American patients with genetically proven ocular-only STL or WGN was performed, and 6 patients were identified.

RESULTS

Three patients had a COL2A1 mutation, two had a COL11A1 mutation, and one had a VCAN mutation. None had Pierre Robin facies. All were myopes with lattice degeneration and five had RD. Three underwent RD repair with vitrectomy (PPV), scleral buckle (SB), endolaser (EL), and silicone oil (SO). Two received laser retinopexy for localized RD and one received a prophylactic SB with 360° peripheral laser retinopexy.

CONCLUSION

STL and WGN should be considered in myopic African American patients with lattice degeneration, giant retinal tears, abnormal vitreous, or spontaneous RD. Prophylactic laser treatment and aggressive surgical treatment of RD should be considered. [Ophthalmic Surg Lasers Imaging Retina 2023;54:97-101.].

Topical Dexamethasone as an Adjuvant to Mineralocorticoid Receptor Antagonists for the Treatment of Recalcitrant Central Serous Chorioretinopathy

BACKGROUND AND OBJECTIVE

A previous report demonstrated efficacy of mineralocorticoid antagonist with adjuvant topical dexamethasone (MRA+DEX) in resolving subretinal fluid (SRF) in a chronic central serous chorioretinopathy (CSCR) patient. This pilot study investigates the use of MRA+DEX to treat recalcitrant, chronic CSCR patients.

STUDY DESIGN

Retrospective review of chronic, recalcitrant CSCR patients unresponsive to MRA alone who were treated with MRA+DEX and followed for up to 3 months. Apical SRF thickness and visual acuity were measured.

RESULTS

Ten eyes of eight chronic, recalcitrant patients were included with an average follow-up of 109 days. Mean percent reduction in apical fluid thickness at one month and at last follow-up after adding dexamethasone (DEX) was 33% and 52%, respectively. Five eyes (50%) achieved complete resolution of SRF. Three eyes (30%) showed partial response and two (20%) eyes had no response. There was no significant change in visual acuity.

CONCLUSIONS

MRA+DEX decreased SRF in some recalcitrant, chronic CSCR patients. Large prospective studies are needed to evaluate the utility of MRA+DEX in these chronic CSCR patients. [Ophthalmic Surg Lasers Imaging Retina 2022;53:659-665.].

Efficacy, durability, and safety of intravitreal faricimab up to every 16 weeks for neovascular age-related macular degeneration (TENAYA and LUCERNE): two randomised, double-masked, phase 3, non-inferiority trials

BACKGROUND

Faricimab is a bispecific antibody that acts through dual inhibition of both angiopoietin-2 and vascular endothelial growth factor A. We report primary results of two phase 3 trials evaluating intravitreal faricimab with extension up to every 16 weeks for neovascular age-related macular degeneration (nAMD).

METHODS

TENAYA and LUCERNE were randomised, double-masked, non-inferiority trials across 271 sites worldwide. Treatment-naive patients with nAMD aged 50 years or older were randomly assigned (1:1) to intravitreal faricimab 6·0 mg up to every 16 weeks, based on protocol-defined disease activity assessments at weeks 20 and 24, or aflibercept 2·0 mg every 8 weeks. Randomisation was performed through an interactive voice or web-based response system using a stratified permuted block randomisation method. Patients, investigators, those assessing outcomes, and the funder were masked to group assignments. The primary endpoint was mean change in best-corrected visual acuity (BCVA) from baseline averaged over weeks 40, 44, and 48 (prespecified non-inferiority margin of four letters), in the intention-to-treat population. Safety analyses included patients who received at least one dose of study treatment. These trials are registered with ClinicalTrials.gov (TENAYA NCT03823287 and LUCERNE NCT03823300).

FINDINGS

Across the two trials, 1329 patients were randomly assigned between Feb 19 and Nov 19, 2019 (TENAYA n=334 faricimab and n=337 aflibercept), and between March 11 and Nov 1, 2019 (LUCERNE n=331 faricimab and n=327 aflibercept). BCVA change from baseline with faricimab was non-inferior to aflibercept in both TENAYA (adjusted mean change 5·8 letters [95% CI 4·6 to 7·1] and 5·1 letters [3·9 to 6·4]; treatment difference 0·7 letters [-1·1 to 2·5]) and LUCERNE (6·6 letters [5·3 to 7·8] and 6·6 letters [5·3 to 7·8]; treatment difference 0·0 letters [-1·7 to 1·8]). Rates of ocular adverse events were comparable between faricimab and aflibercept (TENAYA n=121 [36·3%] vs n=128 [38·1%], and LUCERNE n=133 [40·2%] vs n=118 [36·2%]).

INTERPRETATION

Visual benefits with faricimab given at up to 16-week intervals demonstrates its potential to meaningfully extend the time between treatments with sustained efficacy, thereby reducing treatment burden in patients with nAMD.

FUNDING

F Hoffmann-La Roche.

Surgical Outcomes of Epiretinal Membrane Removal Due to Combined Hamartoma of the Retina and RPE

BACKGROUND AND OBJECTIVE

To evaluate the surgical outcomes of epiretinal membrane (ERM) associated with combined hamartoma of the retina and retinal pigment epithelium (CHRRPE) after vitrectomy and membrane peel.

PATIENTS AND METHODS

A retrospective review of 15 patients who underwent pars plana vitrectomy with membrane peeling. No plasmin enzyme was used.

RESULTS

The mean age at surgery was 10 years old, with an average follow-up of 5.7 years. The average preoperative visual acuity (VA) was 20/514. The average postoperative VA was 20/138 (P = .0251) at 1-year follow-up and 20/89 (P = .0025) on the latest exam on final follow-up. VA was improved in 14 patients (93%) and deteriorated in one patient (7%). All 15 patients (100%) had improvement of retinal/macular anatomy postoperatively.

CONCLUSION

In the treatment of patients with ERM due to CHRRPE, vitrectomy with membrane peeling without plasmin injection can result in improved VA and retinal structure. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:546-554.].

Efficacy of Every Four Monthly and Quarterly Dosing of Faricimab vs Ranibizumab in Neovascular Age-Related Macular Degeneration: The STAIRWAY Phase 2 Randomized Clinical Trial

Question

How does extended dosing with faricimab compare with monthly ranibizumab in treating patients with neovascular age-related macular degeneration?

Findings

In this phase 2 randomized clinical trial of faricimab in 76 patients, vision gains from baseline were +9.6, +10.1, and +11.4 letters for the monthly ranibizumab, faricimab every-12-weeks, and faricimab every-16-weeks arms, respectively, at week 52.

Meaning

Through simultaneous neutralization of angiopoietin-2 and vascular endothelial growth factor A, faricimab maintains initial vision and anatomic improvements comparable with ranibizumab in neovascular age-related macular degeneration; the findings support pursuing extended interval dosing with faricimab in phase 3 trials as a potential alternative to more frequently dosed anti–vascular endothelial growth factor therapy.

Importance

Faricimab neutralizes angiopoietin-2 and vascular endothelial growth factor A via both simultaneous and independent binding.

Objective

To evaluate extended dosing with faricimab, the first bispecific antibody designed for intraocular use, in patients with neovascular age-related macular degeneration.

Design, Setting, and Participants

This phase 2 randomized clinical trial was a 52-week multicenter, active comparator–controlled, parallel-group study. Study participants were enrolled in 25 sites in the US from January and March 2017 with treatment-naive choroidal neovascularization secondary to neovascular age-related macular degeneration and best-corrected visual acuity (BCVA) Early Treatment Diabetic Retinopathy Study letter score of 73 (approximate Snellen equivalent, 20/40) to 24 (approximate Snellen equivalent, 20/320). Analysis began January 2017 and ended March 2018.

Interventions

Participants were randomized 1:2:2 to receive intravitreal ranibizumab, 0.5 mg, every 4 weeks or faricimab, 6.0 mg, every 12 or 16 weeks. Participants in the faricimab arms initially received 4 monthly injections of faricimab. No rescue injections were allowed. Participants randomized to dosing every 16 weeks were assessed for disease activity at week 24 using prespecified criteria. Those with no active disease continued dosing every 16 weeks through trial end; participants with disease activity continued received dosing every 12 weeks.

Main Outcomes and Measures

Mean change in BCVA from baseline at week 40.

Results

Of 76 participants enrolled (mean [SD] age, 78.5 [8.5] years; age range, 56-94 years; 41 women [58%]; 69 white [97%]), 16 (21.0%) were randomized to ranibizumab every 4 weeks, 29 (38.2%) to faricimab every 12 weeks, and 31 (40.8%) to faricimab every 16 weeks. At week 24, 12 weeks after their last initiation injection, 65% (36 of 55) of all faricimab-treated participants had no disease activity. At week 40, adjusted mean BCVA gains from baseline (Early Treatment Diabetic Retinopathy Study letters) were +11.4 (80% CI, 7.8-15.0), +9.3 (80% CI, 6.4-12.3), and +12.5 (80% CI, 9.9-15.1) for the ranibizumab every 4 weeks, faricimab every 12 weeks, and faricimab every 16 weeks arms, respectively. Participants received a mean (SD) total of 12.9 (0.25), 6.7 (0.91), and 6.2 (093) injections, for the ranibizumab every 4 weeks, faricimab every 12 weeks, and faricimab every 16 weeks arms, respectively, through week 52. The secondary BCVA and anatomical imaging end points supported the primary end point and were comparable with ranibizumab every 4 weeks. No new or unexpected safety signals were identified.

Conclusions and Relevance

At week 52, faricimab dosing every 16 weeks and every 12 weeks resulted in maintenance of initial vision and anatomic improvements comparable with monthly ranibizumab. These results suggest a role for simultaneous neutralization of angiopoietin-2 and vascular endothelial growth factor A in providing sustained efficacy through extended durability, warranting further investigation.

Trial Registration

ClinicalTrials.gov Identifier: NCT03038880

Traumatic Retinal Detachment in Patients with Self-Injurious Behavior: An International Multicenter Study

PURPOSE

To describe the clinical characteristics, surgical outcomes, and management recommendations in patients with traumatic rhegmatogenous retinal detachment (RRD) resulting from self-injurious behavior (SIB).

DESIGN

International, multicenter, retrospective, interventional case series.

PARTICIPANTS

Patients with SIB from 23 centers with RRD in at least 1 eye.

METHODS

Clinical histories, preoperative assessment, surgical details, postoperative management, behavioral intervention, and follow-up examination findings were reviewed.

MAIN OUTCOME MEASURES

The rate of single-surgery anatomic success (SSAS) was the primary outcome. Other outcomes included new RRD in formerly attached eyes, final retinal reattachment, and final visual acuity.

RESULTS

One hundred seven eyes with RRDs were included from 78 patients. Fifty-four percent of patients had bilateral RRD or phthisis bulbi in the fellow eye at final follow-up. The most common systemic diagnoses were autism spectrum disorder (35.9%) and trisomy 21 (21.8%) and the most common behavior was face hitting (74.4%). The average follow-up time was 3.3 ± 2.8 years, and surgical outcomes for operable eyes were restricted to patients with at least 3 months of follow-up (81 eyes). Primary initial surgeries were vitrectomy alone (33.3%), primary scleral buckle (SB; 26.9%), and vitrectomy with SB (39.7%), and 5 prophylactic SBs were placed. Twenty-three eyes (21.5%) with RRDs were inoperable. The SSAS was 23.1% without tamponade (37.2% if including silicone oil), and final reattachment was attained in 80% (36.3% without silicone oil tamponade). Funnel-configured RRD (P = 0.006) and the presence of grade C proliferative vitreoretinopathy (P = 0.002) correlated with re-detachment. The use of an SB predicted the final attachment rate during the initial surgery (P = 0.005) or at any surgery (P = 0.008. These associations held if restricting to 64 patients with ≥12 months followup. Anatomic reattachment correlated with better visual acuity (P < 0.001).

CONCLUSIONS

RRD resulting from SIB poses therapeutic challenges because of limited patient cooperation, bilateral involvement, chronicity, and ongoing trauma in vulnerable and neglected patients. The surgical success rates were some of the lowest in the modern retinal detachment literature. The use of an SB may result in better outcomes, and visual function can be restored in some patients.

Long-Term Follow-Up of Retinal Detachment Repair in Patients With Stickler Syndrome

BACKGROUND AND OBJECTIVE

To report the long-term anatomic and visual outcomes of patients with Stickler syndrome undergoing retinal detachment (RD) surgery.

PATIENTS AND METHODS

Retrospective, interventional, consecutive case series of patients with Stickler syndrome undergoing RD repair from 1999 to 2017 at the Long Island Vitreoretinal Consultants, New York. Retinal attachment status and visual acuity (VA) at 1-year and last follow-up were assessed.

RESULTS

Successful reattachment was achieved in 28 of 29 eyes (97%) with an average of 2.3 surgeries (including silicone oil removal surgeries). Redetachment after the first surgery occurred in 13 eyes (45%). Mean Snellen VA at initial presentation, 1-year follow-up, and last follow-up were 20/289, 20/118 (P = .012), and 20/103 (P = .022), respectively.

CONCLUSIONS

Anatomic success can be achieved in most eyes. However, redetachments are common, and multiple surgeries are often required. Reasonable visual recovery is possible in many eyes. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:612-616.].

A Multicenter Study of Pediatric Macular Holes: Surgical Outcomes With Microincisional Vitrectomy Surgery

Purpose:

Pediatric macular holes occur often related to trauma and rarely require surgical intervention. The purpose of the present study was to evaluate outcomes of microincisional vitrectomy surgery.

Methods:

A multicenter retrospective consecutive case series was conducted of pediatric patients undergoing surgery for macular hole repair.

Results:

A total of 31 eyes from 8 centers were included in this study. The mechanism of macular hole development was blunt trauma in 30 eyes (97%) and industrial laser in 1 eye (3%). The rate of anatomic closure after primary vitrectomy was 81% (25 eyes); the final anatomic closure rate after a secondary vitrectomy was 94% (29 eyes). There was a statistically significant improvement in visual acuity from initial presentation (20/164) to final follow-up (20/100) ( P = .009).

Conclusions:

Microincisional vitrectomy surgery for pediatric macular holes results in substantial anatomic success and modest improvement in visual acuity.

Comparison of the tissue penetration and glide force of 22-gauge thin-wall needles for intravitreal implant administration

BACKGROUND AND OBJECTIVE

To identify a needle to improve intravitreal dexamethasone implant administration by evaluating ease of ocular tissue penetration and glide force, key characteristics of needle performance.

MATERIALS AND METHODS

Two custom-applicator needles coated with distinct lubricants (needles A and B) and the original dexamethasone implant needle were evaluated by five retina specialists. Ex vivo porcine eyes were injected, and a visual analog scale was used in ratings.

RESULTS

Ease of ocular tissue penetration and glide force of needle B were rated significantly higher than that of the original applicator needle (P < .001), but there were no significant differences for needle A. Lot to lot, needle B was not significantly different in penetration and glide, whereas a significant difference was observed for penetration of needle A (P = .043).

CONCLUSION

Needle design and lubricant appear to facilitate penetration and reduce glide force when administering dexamethasone intravitreal implants. Minimal lot-to-lot variation should be considered in needle choice.

Early initial clinical experience with intravitreal aflibercept for wet age-related macular degeneration

Background

Age-related macular degeneration (AMD) is a degenerative process that leads to severe vision loss. Wet AMD is defined by choroidal neovascularisation, leading to the accumulation of subretinal fluid (SRF), macular oedema (ME), and pigment epithelium detachments (PED). Purpose To evaluate the initial clinical experience of conversion from bevacizumab or ranibizumab to aflibercept in wet AMD patients.

Methods

Records of 250 consecutive wet AMD patients were retrospectively reviewed. Of 250 patients, 29 were naive (with no previous treatment), and 221 were previously treated with bevacizumab (1/3) or ranibizumab (2/3). On average, converted patients received 14 injections every 6 weeks on a treat-and-extend regimen with Avastin or Lucentis before being converted to aflibercept every 7 weeks on average (no loading dose) for three doses. For the purposes of this study, we concentrated on the patients converted to aflibercept since the number of naive patients was too small to draw any conclusion from. Snellen (as logMar) visual acuities, and optical coherence tomography (OCT) were compared predrug and postdrug conversion.

Results

Converted patients did not show a significant difference in visual acuity or average OCT thickness from preconversion values; however, small improvements in ME (p=0.0001), SRF (p=0.0001), and PED (p=0.008) grading were noted on average after conversion to aflibercept.

Conclusions

No significant difference in visual outcome or average OCT thickness was observed when switched from bevacizumab or ranibizumab q6 week to aflibercept 7-week dosing, on average. Mild anatomic improvements did occur in converted patients with regard to ME, SRF and PED improvement, on average, after conversion to aflibercept, and aflibercept was injected less frequently. No serious adverse reactions, including ocular infections or inflammation, as well as ocular and systemic effects were noted.

Subretinal hemorrhage masquerading as a hemorrhagic choroidal detachment in a case of nonaccidental trauma

Retinal hemorrhages are the most commonly reported ocular findings in nonaccidental trauma in children. Other reported ocular findings include perimacular folds, traumatic retinoschisis, choroidal hemorrhages, and retinal detachments. We report the clinical and pathologic findings in a case of a 10-month-old boy who sustained nonaccidental trauma and whose clinical presentation was characteristic of a hemorrhagic choroidal detachment. Postmortem examination revealed a large subretinal hemorrhage, with no evidence of choroidal hemorrhage.

Ranibizumab combined with verteporfin photodynamic therapy in neovascular age-related macular degeneration: year 1 results of the FOCUS Study

OBJECTIVE

To investigate the safety and efficacy of intravitreal ranibizumab treatment combined with verteporfin photodynamic therapy (PDT) in patients with predominantly classic choroidal neovascularization secondary to age-related macular degeneration.

METHODS

In this 2-year, phase I/II, multicenter, randomized, single-masked, controlled study, patients received monthly ranibizumab (0.5 mg) (n = 106) or sham (n = 56) injections. The PDT was performed 7 days before initial ranibizumab or sham treatment and then quarterly as needed.

MAIN OUTCOMES MEASURES

Proportion of patients losing fewer than 15 letters from baseline visual acuity at 12 months (primary efficacy outcome) and the incidence and severity of adverse events.

RESULTS

At 12 months, 90.5% of the ranibizumab-treated patients and 67.9% of the control patients had lost fewer than 15 letters (P<.001). The most frequent ranibizumab-associated serious ocular adverse events were intraocular inflammation (11.4%) and endophthalmitis (1.9%; 4.8% if including presumed cases). On average, patients with serious inflammation had better visual acuity outcomes at 12 months than did controls. Key serious nonocular adverse events included myocardial infarctions in the PDT-alone group (3.6%) and cerebrovascular accidents in the ranibizumab-treated group (3.8%). CONCLUSION/APPLICATION TO CLINICAL PRACTICE: Ranibizumab + PDT was more efficacious than PDT alone for treating neovascular age-related macular degeneration. Although ranibizumab treatment increased the risk of serious intraocular inflammation, affected patients, on average, still experienced visual acuity benefit.

RETINAL TEARS AND RETINAL DETACHMENT AS FACTORS AFFECTING VISUAL OUTCOME AFTER CATARACT EXTRACTION COMPLICATED BY POSTERIORLY DISLOCATED LENS MATERIAL

PURPOSE

To evaluate the incidence and effect on visual acuity of complicating factors such as retinal tears (RTs) and rhegmatogenous retinal detachment (RRD) in eyes with posteriorly dislocated lens fragments after cataract extraction.

METHODS

Retrospective consecutive series of patients presenting at a referral vitreoretinal practice with posteriorly dislocated lens material after cataract extraction over a period of 8 years. The presence of RT, RRD, endophthalmitis, and choroidal hemorrhage was noted, and their effect on visual outcome was studied.

RESULTS

A total of 307 eyes with posteriorly dislocated lens material after cataract extraction were identified. Fifty-eight eyes (19%) were managed medically (Group I), whereas the other 249 eyes (81%) underwent pars plana vitrectomy for removal of the lens material (Group II). Indications for surgical management included uncontrolled inflammation, elevated intraocular pressure, and large lens fragments. No eyes in Group I developed RT or RRD. Of the 249 Group II eyes, 13 (5%) were found to have RT, and 25 (10%) developed RRD. In Group II, choroidal hemorrhage and endophthalmitis were noted in 12 (5%) and 4 (2%) eyes, respectively. Fifty-one (88%) of 58 eyes in Group I and 138 (55%) of 249 eyes in Group II achieved a final visual acuity of 20/40 or better. Seven (54%) of the 13 eyes with RT and 9 (36%) of the 25 eyes with RRD achieved a final visual acuity of 20/40 or better. In the RRD group, 9 (56%) of the 16 macula-on eyes achieved a final visual acuity of 20/40 or better, whereas none of the 9 macula-off eyes had a final visual acuity of 20/40 or better. None of the 4 eyes with endophthalmitis and only 1 (8%) of the 12 eyes with choroidal hemorrhage had a final visual acuity of 20/40 or better. Five (62%) of eight eyes with retinal detachment treated with pneumatic retinopexy needed further treatment with scleral buckle to achieve anatomical reattachment.

CONCLUSION

A good visual outcome (20/40 or better) is possible in eyes with posteriorly dislocated lens fragments after cataract extraction, even when retinal tears or macula-on retinal detachment is present. The presence of a macula-off retinal detachment, however, has a significant adverse effect on the visual outcome. Pneumatic retinopexy is not associated with retinal reattachment in many cases and is not preferred.

Near confluent laser photocoagulation for the treatment of threshold retinopathy of prematurity

OBJECTIVE

To evaluate the effect of a near confluent pattern of indirect laser photocoagulation in reducing the rate of progression and re-treatment of threshold retinopathy of prematurity.

METHODS

This study examined a noncomparative interventional case series. We performed a retrospective review of the medical records of patients who underwent peripheral laser ablation by 1 surgeon for threshold retinopathy of prematurity from 1997 to 2002. A total of 58 eyes from 31 patients were treated, and 44 eyes of 23 patients were included in the study. Ten eyes of 5 infants had zone 1 disease, and 34 eyes of 18 infants had zone 2 disease. Laser spots were placed in a near confluent pattern in the peripheral avascular retina between the ridge of extraretinal proliferation and the ora serrata. The mean +/- SD number of laser spots was 2534 +/- 455 for zone 1 (range, 2100-3378) and 1850 +/- 487 for zone 2 (range, 1030-2689).

RESULTS

In 7 eyes of 4 infants with zone 1 disease, the retinopathy regressed and did not require any further treatment. Three eyes of 2 infants, however, progressed after laser treatment and required vitrectomy surgery. Progression was defined as the development of stage 4 or 5 disease. None of the patients with zone 2 disease had progression of retinopathy, and none of them needed more than 1 treatment. Patients tolerated the procedure well, and there were no complications at the time of the procedure or at follow-up visits.

CONCLUSIONS

A near confluent pattern of laser photocoagulation may reduce the rate of progression of threshold retinopathy of prematurity in zone 2 (0%). The near confluent pattern of treatment may also reduce the re-treatment rate of the disease (0%). Larger studies are needed to confirm our findings.

Indocyanine green angiography findings in sympathetic ophthalmia

A 78-year-old woman with a recurrent retinal detachment in the right eye presented 2 years after her last surgery with clinical and fluorescein angiographic evidence of sympathetic ophthalmia in the left eye. Fluorescein angiography showed discrete multifocal areas of central hypofluorescence with a hyperfluorescent ring. After immunosuppressive therapy, fluorescein angiography displayed multiple hypofluorescent spots without the hyperfluorescent collar. Prior to systemic and periocular corticosteroid therapy, indocyanine green angiography (ICGA) revealed multifocal hypo-fluorescent spots that became more prominent as the study progressed. The early stages of the posttreatment ICGA appeared normal, but the hypofluorescent spots reappeared in the late stage of ICGA. ICGA is a useful diagnostic adjunct to fluorescein angiography and clinical examination in helping to secure the diagnosis and monitor the treatment progress of sympathetic ophthalmia.

Lens-Sparing Vitrectomy for Progressive Tractional Retinal DetachmentsAssociated With Stage 4A Retinopathy of Prematurity

OBJECTIVE

To describe the results of lens-sparing vitrectomy in infants with progressive, fovea-threatening, tractional retinal detachments associated with stage 4A retinopathy of prematurity.

METHODS

In a retrospective, interventional, consecutive clinical case series, the records of patients with stage 4A retinopathy of prematurity who underwent lens-sparing vitrectomy for progressive retinal detachments were reviewed. Retinal attachment status, reversed or arrested retinal dragging, and visual acuity were assessed after the procedure.

RESULTS

Thirty-two eyes of 29 patients underwent lens-sparing vitrectomy at a mean postconceptional age of 43 weeks. Thirty (94%) of 32 eyes had complete retinal reattachment and arrest or reversal of retinal dragging after 1 lens-sparing vitrectomy. Visual acuity of at least central, steady, and unmaintained was observed in 17 (81%) of the 21 eyes in which it was tested and at least central, steady, and maintained vision was measured in 13 (62%) of 21 eyes, with 1 eye achieving 20/40 visual acuity.

CONCLUSIONS

Lens-sparing vitrectomy is a safe and effective procedure for the treatment of fovea-threatening retinal detachments in patients with stage 4A retinopathy of prematurity.

The effects of scleral buckling on young rabbit eyes

OBJECTIVE

To evaluate the effects of scleral buckling surgery on the developing eye in an animal model.

METHODS

Eleven young rabbits underwent scleral buckling surgery in one eye. In 6 rabbits, a 2.5 x 0.6-mm solid silicone encircling band (240 style) with a Watzke sleeve was used, and in 5 rabbits, a 2.0-mm silicone encircling sponge (502 style) with its ends abutting, but not connected, was used. After 3 months, both eyes of each animal were enucleated. Six eyes of an additional 3 rabbits served as baseline controls for determining initial globe volumes.

RESULTS

Of the eyes buckled with a 240 band, 4 of 6 developed glaucoma compared with 0 of 5 eyes buckled with a 502 sponge (P =.06). Migration of the element occurred in all eyes with a 240 band (3 anterior, 3 posterior), while none of the 502 sponges migrated. There was no significant difference in the mean final corneal diameter between eyes with a 240 band (P =.94) and untreated fellow eyes or between eyes with a 502 sponge and untreated fellow eyes (P =.25). The mean axial length of eyes with a 240 band and untreated fellow eyes was 19.57 mm and 16.83 mm, respectively (P =.009). The mean axial length of eyes with a 502 sponge and untreated fellow eyes was 16.67 mm and 16.50 mm, respectively (P =.67). When comparing eyes with a 240 band with eyes with a 502 sponge, a significant difference was observed in the mean axial length (P =.006) and mean volume (P =.006) between the 2 scleral buckle groups.

CONCLUSIONS

The use of a noninterrupted solid silicone encircling band appeared to have significant effects on the growth of young rabbit eyes. The use of an interrupted silicone sponge produced a buckling effect similar to the solid silicone band and did not migrate, adversely affect eye growth, or result in glaucoma.

CLINICAL RELEVANCE

Noncontinuous encircling elements may prove to be as beneficial as continuous encircling elements in the treatment of tractional and rhegmatogenous retinal detachment in infant eyes without the potentially deleterious effects associated with a nondivided encircling band or the need for a second surgery to divide the encircling element.

Management of macular holes that develop after retinal detachment repair

PURPOSE

To study the characteristics and management of macular holes that develop after prior rhegmatogenous retinal detachment (RD) repair.

DESIGN

Retrospective, interventional, consecutive case series.

METHODS

The setting was a clinical practice. The case records of all of our patients (n = 12) who developed a new full-thickness macular hole after prior RD repair over an 8-year period were examined. Patients who developed a macular hole after prior RD repair were offered either surgical repair of the macular hole or continued observation. For eyes that underwent macular hole repair, main outcome measures included macular attachment status and postoperative visual acuity.

RESULTS

Twelve full-thickness macular holes were detected in a series of 2,380 eyes (0.5% prevalence), which had undergone surgery for prior primary RD. Ten macular holes developed after scleral buckling surgery, two after pneumatic retinopexy, and none were seen after primary vitrectomy. The fovea had been detached in 11 of the 12 eyes at the time of RD. The median time to macular hole diagnosis after RD repair was 3.4 months (range, 0.3-161 months). Eight of the eight eyes (100%) undergoing surgical repair achieved macular reattachment with a median of 3.5 lines of visual improvement at a median of 14.8 months of follow-up. Seven of these eight eyes had an improvement in visual acuity of at least 3 Snellen lines, and four of the eight had at least 20/40 visual acuity postoperatively. Four eyes with macular holes were observed.

CONCLUSIONS

Macular holes developed in less than 1% of eyes that had previously undergone repair of rhegmatogenous RD. In our series, these atypical holes were seen predominantly after macula-off detachments, most commonly occurring after scleral buckling procedures. They were effectively repaired using conventional pars plana vitrectomy with long-acting gas tamponade and a variety of adjuvant therapies. A good visual outcome is possible with this approach.

Bilateral cataracts, retinal detachment and vitreous hemorrhage in a newborn with congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is associated with a wide range of other malformations. We describe a patient with CDH who also had significant eye findings noted at birth.

Sensitivity of spiral computed tomography scanning for detecting intraocular foreign bodies

OBJECTIVE

The purpose of this study is to determine whether 3-mm computed tomography (CT) cuts are equivalent to 1-mm CT cuts for detecting small intraocular foreign bodies (IOFBs).

DESIGN

Experimental instrument validation study.

PARTICIPANTS

Seventy-two porcine eyes were divided into three groups. Each group had 0.5 ml of human blood injected into the vitreous cavity and were surgically implanted with IOFBs.

INTERVENTION

Each eye was surgically implanted with 0.5-mm metallic, 0.5-mm glass, or 0.5-mm stone IOFBs. Two additional eyes were left without IOFBs to serve as negative controls.

MAIN OUTCOME MEASURES

Axial CT images of both 3-mm and 1-mm thickness were obtained and analyzed in masked fashion by two separate neuroradiologists.

RESULTS

The sensitivity for detecting 0.5-mm metallic, 0.5-mm glass, and 0.5-mm stone IOFBs with 3-mm CT images was 100%. The sensitivity for detecting 0.5-mm metallic, 0.5-mm glass, and 0.5-mm stone IOFBs with 1-mm CT images was also 100% (confidence interval, 95%; range, 0.88-1.00). Two negative control eyes without IOFBs were also correctly evaluated by the neuroradiologists.

CONCLUSIONS

With modern spiral CT scanning, 3-mm cuts are as sensitive as 1-mm cuts for detecting small metallic, glass, and stone IOFBs.

Vitrectomy for diffuse diabetic macular edema associated with a taut premacular posterior hyaloid

PURPOSE

To evaluate the role of vitrectomy in eyes with diffuse diabetic macular edema associated with a taut posterior hyaloid.

METHODS

Records of 55 eyes of 50 patients with diabetic retinopathy and diffuse clinically significant diabetic macular edema who underwent vitrectomy with stripping of the premacular posterior hyaloid were reviewed. In all 55 eyes, diffuse diabetic macular edema was present on contact lens examination and confirmed with fluorescein angiography. On fundus examination, the premacular posterior hyaloid was attached and appeared taut.

RESULTS

The mean preoperative best-corrected visual acuity was 20/160, and the mean final best-corrected visual acuity was 20/80 (P <.0001, Wilcoxon signed rank test), with 27 (49.1%) of the 55 eyes demonstrating improvement in best-corrected visual acuity of 2 or more lines. Fifty-two (94.5%) of the 55 vitrectomized eyes showed improvement in clinically significant macular edema and in 45 eyes (81.8%) the macular edema resolved completely during a mean period of 4.5 months (range, 1 to 13 months). Eyes with macular ischemia and preoperative best-corrected visual acuity of 20/200 or less tended to respond less favorably to vitrectomy than eyes lacking these characteristics. All eyes had at least 6 months of follow-up after surgery, with a mean follow-up of 23.2 months.

CONCLUSION

In eyes with persistent diffuse diabetic macular edema with a taut premacular posterior hyaloid face unresponsive to laser therapy, vitrectomy with removal of the posterior hyaloid appears to be beneficial in some cases. Careful selection of eyes with favorable preoperative clinical characteristics may improve surgical outcomes.

Diode laser ablation for threshold retinopathy of prematurity: short-term structural outcome

OBJECTIVE

To describe short-term structural outcomes and associated ocular complications in premature infants treated with diode laser ablation for retinopathy of prematurity.

METHODS

The records of all infants who were diagnosed as having threshold retinopathy of prematurity and treated with diode laser therapy at our hospital from January 1, 1992, through December 31, 1996, were retrospectively reviewed. Sixty-four eyes reached threshold during this period. Three eyes received cryotherapy in addition to laser treatment and were excluded, leaving 61 eyes eligible for review.

RESULTS

Of the 61 eyes with threshold disease treated exclusively with diode laser, 4 (7%) had zone I disease and 57 (93%) had zone II disease at the time of initial laser treatment. Three (5%) of the 61 eyes progressed to stage 4 disease (2 eyes, stage 4A; 1 eye, stage 4B). There were no cataracts or other ocular complications noted secondary to laser treatment based on short-term follow-up (mean follow-up, 120 days).

CONCLUSION

In this population of infants, diode laser ablation appears to be a safe and effective treatment for threshold retinopathy of prematurity.

A comparison of dense versus less dense diode laser photocoagulation patterns for threshold retinopathy of prematurity

OBJECTIVE

To determine if the density of diode laser photocoagulation for the treatment of zone 1 or zone 2 threshold retinopathy of prematurity (ROP) affects the rate of progression of the disease.

DESIGN

Retrospective, nonrandomized, comparative trial (n = 12) and prospective, randomized, clinical trial (n = 46).

PARTICIPANTS

Two surgeons treated a total of 107 eyes from 58 patients with zone 1 or zone 2 threshold ROP within 72 hours of diagnosis. The two consecutive groups of patients were treated with two different diode laser photocoagulation patterns between May 1995 and October 1997 and were observed for at least 3 months.

INTERVENTION

All patients underwent diode laser photocoagulation of the peripheral avascular retina extending from the ridge of extraretinal proliferation to the ora serrata. One cohort received a near confluent laser pattern, whereas the second cohort received a pattern of laser spots placed 1 to 1.5 burn widths apart.

MAIN OUTCOME MEASURES

Anatomic outcome, rate of progression to stage 4 or 5 retinopathy of prematurity, postoperative complications, and timing and frequency of retreatment.

RESULTS

For analysis, the retrospective and randomized outcome data were grouped. The rate of progression in the near confluent laser treatment group was 3.6% overall, 0% of zone 1 eyes, and 3.8% of zone 2 eyes. The rate of progression in the less dense treatment group was 29% overall, 44% of zone 1 eyes, and 21 % of zone 2 eyes. Mean time to retreatment was 16 days in cohort 1 and 24 days in cohort 2.

CONCLUSIONS

A dense pattern of diode laser treatment for threshold ROP and prompt retreatment for residual plus disease significantly reduce the rate of progression in eyes with zone 2 disease (P = 0.02) and may be beneficial in eyes with zone 1 disease.

Telemedical evaluation and management of retinopathy of prematurity using a fiberoptic digital fundus camera

OBJECTIVE

We sought to determine whether retinopathy of prematurity (ROP) can be evaluated and managed telemedically.

DESIGN

Multicenter noncomparative case series.

PARTICIPANTS

Ten patients (19 eyes) with ROP were evaluated and treated per standard of care and imaged with the RetCam 120 digital fundus camera (Massie Research Laboratories, Inc., Dublin, CA).

INTERVENTION

Images were transmitted to a remote site for evaluation and management recommendations.

MAIN OUTCOME MEASURES

Telemedical evaluations and management recommendations were compared with traditional on-site standard of care evaluations and treatments.

RESULTS

The identification of Plus disease at the remote site was accurately identified in 95% of eyes. Prethreshold, threshold, and stage 4 or 5 ROP were correctly detected in 17 of 19 (89%) eyes.

CONCLUSIONS

Results indicate ROP can be evaluated and treatment recommendations made at remote sites with telemedicine strategies.

Successful closure of traumatic macular holes

PURPOSE

To establish the efficacy of vitreoretinal surgery without the use of transforming growth factor-beta or autologous platelet concentrate in the repair of traumatic macular holes.

METHODS

This retrospective review consisted of 16 eyes from 16 consecutive patients treated by five vitreoretinal surgeons at a single institution between 1993 and 1997. Intervention included pars plana vitrectomy with creation of posterior vitreous detachment, placement of 14% to 16% C3F8 gas, and postoperative face-down positioning. Ten eyes received intraoperative autologous plasmin to facilitate formation of posterior vitreous detachment. Main outcome measures were anatomic closure rate and visual outcome.

RESULTS

Anatomic closure of the macular holes was achieved in 15 (94%) of 16 eyes, with an average follow-up of 7 months. Six (38%) eyes achieved visual acuity of 20/40 or better. Visual acuity improved by 2 or more lines in 11 (69%) of 16 eyes. The average preoperative logMAR-converted visual acuity of 20/175 improved to 20/60 postoperatively.

CONCLUSION

Traumatic macular holes can be closed successfully with substantial visual recovery without the use of transforming growth factor-beta or platelet concentrate.

Management of complications in eyes containing two intraocular lenses

OBJECTIVE

To describe the management of complications in eyes containing two intraocular lenses (IOLs).

DESIGN

A retrospective noncomparative case series.

PARTICIPANTS

Eight patients having a dislocated posterior chamber intraocular lens (PC IOL) and a secondary anterior chamber intraocular lens (AC IOL) participated.

INTERVENTION

Surgical treatment of complications, including mobile dislocated PC IOLs in five eyes and retinal detachment in three eyes, was performed.

MAIN OUTCOME MEASURES

Visual acuity and anatomic status were evaluated.

RESULTS

Dislocated PC IOLs were removed through a pars plana incision in five eyes and a limbal incision in three eyes. Retinal detachments were repaired in three eyes. With follow-up from 7 months to 6.5 years, visual acuities ranged from 20/25 to 20/40 in five eyes and 20/60 to 20/400 in the three eyes undergoing retinal detachment repair.

CONCLUSION

Eyes in which dislocation of a PC IOL occurs during or after cataract surgery may have significant complications develop. Successful surgical repair is more complex in the presence of a secondary AC IOL.

Refractive changes associated with scleral buckling and division in retinopathy of prematurity

OBJECTIVE

To examine the refractive changes that occur in infant eyes with retinopathy of prematurity (ROP) retinal detachments that are subjected to scleral buckling and subsequent division of the scleral buckle.

METHODS

A retrospective medical record review of infants with ROP who were managed with an encircling scleral buckle that was subsequently divided and who underwent refraction evaluation during and after division of the scleral buckle.

RESULTS

Seven eyes from 6 patients had scleral exo-plants placed for stage 4 ROP retinal detachments at a mean postconceptional age of 48 weeks. The mean refractive error in eyes with the scleral buckle was -11 diopters (D) (range, -5 to -25 D) with an induced mean anisometropia of -9.5 D. After division of the scleral buckle at a mean of 36 weeks postoperatively, the average post-scleral buckle refractive error was -5.68 D, resulting in a mean myopic reduction of 5.5 D.

CONCLUSIONS

Scleral buckling in infants with ROP results in large myopic shifts, which are significantly reduced after division of the scleral buckle. This highlights the importance of repeated refraction testing in infants after placement and division of the scleral buckle to avoid refractive amblyopia.

Good visual acuity in an adult population with marked posterior segment changes secondary to retinopathy of prematurity

PURPOSE

To show that good visual acuity can be compatible with marked posterior segment changes secondary to retinopathy of prematurity (ROP) in the adult population.

METHODS

A retrospective chart review of adult patients with regressed ROP. We found 14 eyes in 12 patients who were older than 21 years with a visual acuity of 20/60 or better associated with marked posterior segment changes secondary to ROP.

RESULTS

Of the 14 eyes, 11 were myopic, with six eyes having the spherical equivalent of > or = -6.00. Best-corrected visual acuities ranged from 20/15-20/60. One eye had a macular fold. Thirteen eyes had macular ectopia.

CONCLUSIONS

Good vision can be compatible with marked posterior segment changes secondary to ROP in an adult population. This emphasizes the need to follow these patients closely during childhood and treat them promptly for any amblyogenic condition that could prevent them from reaching their full visual potential.

Plasmin enzyme-assisted vitrectomy in traumatic pediatric macular holes

OBJECTIVE

This study aimed to evaluate the benefit of plasmin enzyme-assisted macular hole surgery on a consecutive series of pediatric patients with traumatic macular holes.

DESIGN

Prospective noncomparative case series operated on at William Beaumont Hospital between July 13, 1996, and November 16, 1996, and observed for at least 6 months.

PARTICIPANTS

During this interval, the authors operated on four eyes from four consecutive patients who were 14 years of age or younger with traumatic macular holes.

INTERVENTION

The patients underwent plasmin enzyme-assisted pars plana vitrectomy with membrane peeling, fluid-gas exchange, and postoperative positioning. The enzyme used was 0.4 international unit (IU) of autologous plasmin enzyme.

MAIN OUTCOME MEASURES

Snellen lines of improvement in visual acuity and rate of final visual acuity of 20/40 or greater, and incidence of complications and reoperations were measured.

RESULTS

All four macular holes were closed successfully. Follow-up was from 6 to 12 months. There were no reoperations. Visual acuity improved from four to eight lines in all eyes. Three eyes (75%) achieved a postoperative visual acuity of 20/40 or better. Three eyes (75%) had transient, posterior, subcapsular cataracts develop: two of the eyes after surgery and one as a result of the initial injury.

CONCLUSION

The treatment of pediatric traumatic macular holes with plasmin enzyme-assisted vitrectomy, membrane peeling, and gas-fluid exchange resulted in closure of the macular holes with significant visual improvement.

Vitreoretinal surgery for complications of congenital retinoschisis

PURPOSE

To report the results of vitreoretinal surgery for the management of complications associated with congenital retinoschisis in children.

METHODS

We conducted a review of consecutive children with complications of congenital retinoschisis treated with advanced vitreoretinal techniques. Nine eyes of seven patients with congenital retinoschisis had vitreoretinal surgery for one of the following complications of congenital retinoschisis: hemorrhage within a large schisis cavity with a dense vitreous hemorrhage; rapid progression of schisis threatening the macula; obscuration of the macula by the overhanging inner wall of a schisis cavity; a combined schisistraction retinal detachment; or a combined schisis-rhegmatogenous retinal detachment. Vitreoretinal surgery consisted of vitrectomy, inner schisis wall retinectomy, fluid-gas exchange, endolaser treatment, and perfluoropropane gas injection. After vitreoretinal surgery, patients were followed up for a mean of 26 months (range, 9 to 67 months). Retinal reattachment, visual acuity, and visual fields were used as outcome measures.

RESULTS

Eight of nine eyes had successful retinal reattachment. Six eyes postoperatively had improved visual acuity or visual field, or both. One eye had stabilization of visual acuity, and two eyes had a decrease in visual acuity.

CONCLUSION

In children with complications of congenital retinoschisis, vitreoretinal surgery with excision of the inner wall of the peripheral schisis cavity may be effective in achieving retinal reattachment, thereby improving visual acuity or visual field size.

Lens clarity after lens-sparing vitrectomy in a pediatric population

PURPOSE

The purpose of the study is to assess lens clarity after pediatric lens-sparing vitrectomy.

METHODS

The study offers a retrospective analysis of 85 eyes of 77 pediatric patients who underwent lens-sparing vitrectomy for tractional retinal detachment or opaque media, and who were observed for 10 to 55 months.

RESULTS

A total of 57 eyes maintained clear lenses at last follow-up examination. Cataract was found in 13 (15%) of the 85 eyes. Fifteen eyes (18%) had undergone lens removal as part of reoperation for progressive ocular disease.

CONCLUSION

Sixty-seven percent of pediatric lenses remained clear after lens-sparing vitrectomy.

Choroidal hemorrhage associated with systemic tissue plasminogen activator

PURPOSE

To determine the cause of spontaneous choroidal hemorrhage in a 67-year-old man after a myocardial infarction and administration of tissue plasminogen activator.

METHODS

The patient underwent ocular examination.

RESULTS

The patient retained excellent visual acuity and the choroidal hemorrhage resolved completely within two months.

CONCLUSION

The administration of tissue plasminogen activator was responsible for the large extent of hemorrhage and should be considered in the differential diagnosis of hemorrhagic choroidal detachment.

Tissue plasminogen activator for preserving inferior peripheral iridectomy patency in eyes with silicone oil

PURPOSE

An inferior peripheral iridectomy (IPI) was used to prevent forward migration of silicone oil in vitrectomized eyes; however, in approximately one third of eyes, the IPI closed spontaneously. Occlusion of the IPI by fibrin is believed to be an early event in permanent IPI closure by scar tissue. The authors determined whether intraocular tissue plasminogen activator (tPA) would restore and maintain IPI patency in eyes that had early occlusion of the IPI by fibrin.

METHODS

Between November 1993 and January 1995, 12 patients who underwent vitrectomy with silicone tamponade and IPI for complicated retinal detachment received an anterior chamber injection of tPA (6.25 or 12.5 microgram) for occlusion of the IPI by fibrin.

RESULTS

All 12 patients had lysis of fibrin and maintained a patent IPI at the last follow-up (124+/-95 days). One patient required multiple tPA injections for recurrent fibrin formation. In another patient, a small hyphema developed after the tPA injection, which did not occlude the IPI. When compared with the natural course in a very similar group of patients previously reported, tPA had a statistically significant beneficial effect in the maintenance of IPI patency (P = 0.040).

CONCLUSIONS

Intraocular tPA can be safely used to lyse postoperative fibrin occluding the IPI in eyes with silicone oil tamponade. Early lysis of this fibrin maintains IPI patency.

The role of inner wall retinectomy in the management of juvenile retinoschisis

PURPOSE

The purpose of this paper is to describe the technique and application of relief of vitreous traction and inner wall retinectomy in the management of juvenile retinoschisis (JRS). In addition, during the course of this study a previously undescribed form of tractional retinal detachment associated with retinal schisis was observed.

METHODS

Six eyes of four children with visual field and/or central vision loss underwent vitrectomy (in five of the six eyes the lenses were preserved), inner wall retinectomy and photocoagulation for rhegmatogenous/schisis retinal detachment, tractional retinal detachment and reduced central vision secondary to intraschisis hemorrhage overhanging the macula.

RESULTS

The children were followed up for 1 to 4 years. All eyes showed anatomic reattachment. Three of the four eyes that could be tested for vision showed improved visual function postoperatively. One eye showed marked enlargement of visual field and central visual acuity improvement from 20/200 preoperatively to 20/50 postoperatively.

CONCLUSION

Inner wall retinectomy can be a useful ajunct in the management of the retinal complication of JRS. Appropriate case selection of eyes with associated central traction retinal detachment can result in improved visual field and central visual acuity. The success of this technique suggests that the mechanical and/or pharmacological relief of vitreous traction may be able to alter the clinical course of JRS.