Visual field defects after macular hole surgery. A new finding

PURPOSE: The purpose of the study is to report the problem of a temporal visual field defect occurring after macular hole surgery. METHODS: The authors reviewed the records of 13 patients found to have visual field defects after vitrectomy for macular holes. Fluorescein angiograms (13 patients), optic nerve photographs (13 patients), focal electroretinograms (3 patients), and nerve fiber analyses (8 patients) were performed in patients with visual field defects. RESULTS: An absolute, temporal, usually inferior field defect was noted in 13 patients. In eight patients, the defect was detected because of specific reports or retrospective field examination results. Five patients examined in a prospective manner were found to have field defects. No history of abnormal intraocular pressure or direct trauma to the optic nerve or retinal vessels was identified. Four patients showed optic nerve pallor and three had an anomalous-appearing disc. Focal electroretinograms were of similar amplitude in the involved retina compared to corresponding areas in the healthy fellow eye. Nerve fiber analysis showed a reduction in nerve fiber layer thickness correlating to the visual field defect in those eight patients in which this test was used. CONCLUSION: A significant temporal field defect may occur in patients after otherwise uncomplicated surgery for macular holes. The cause is unclear; however, reductions in nerve fiber layer thickness from the superior and nasal peripapillary area suggest that acute surgical release of the posterior hyaloid and the use of long-acting intraocular gas may in certain patients result in visual field defects.     

Unilateral testing of utricular function

PURPOSE: To examine acquired pit of the optic nerve as a risk factor for progression of glaucoma. METHODS: In a retrospective longitudinal study, 25 open-angle glaucoma patients with acquired pit of the optic nerve were compared with a group of 24 open-angle glaucoma patients without acquired pit of the optic nerve. The patients were matched for age, mean intraocular pressure, baseline ratio of neuroretinal rim area to disk area, visual field damage, and duration of follow-up. Serial optic disk photographs and visual fields of both groups were evaluated by three independent observers for glaucomatous progression. RESULTS: Of 46 acquired pits of the optic nerve in 37 eyes of 25 patients, 36 pits were located inferiorly (76%) and 11 superiorly (24%; P < .001). Progression of optic disk damage occurred in 16 patients (64%) in the group with acquired pit and in three patients (12.5%) in the group without acquired pit (P < .001). Progression of visual field loss occurred in 14 patients (56%) in the group with acquired pit and in six (25%) in the group without pit (P=.04). Bilateral acquired pit of the optic nerve was present in 12 patients (48%). Disk hemorrhages were observed more frequently in the group with acquired pit (10 eyes, 40%) compared with the group without pit (two eyes, 8%; P=.02). CONCLUSION: Among patients with glaucoma, patients with acquired pit of the optic nerve represent a subgroup who are at increased risk for progressive optic disk damage and visual field loss.     

Efficacy of proton therapy in circumscribed choroidal hemangiomas associated with serious retinal detachment

OBJECTIVE: The purpose of the study is to evaluate the efficacy and safety of proton therapy in complicated circumscribed choroidal hemangiomas. DESIGN: The study design was a retrospective review. PARTICIPANTS: Studied were 13 patients (13 eyes) who had circumscribed choroidal hemangioma associated with serous retinal detachment. Of these, four eyes previously underwent laser unsuccessfully. INTERVENTION: Proton therapy including a total dose of 30 Cobalt-Gray-Equivalent was administered to each eye. MAIN OUTCOME MEASURES: Patients were controlled for initial and final best-corrected visual acuity, slit-lamp examination, intraocular pressure, fundus examination, fluorescein angiography, and tumor thickness on B-scan ultrasonography. RESULTS: The mean follow-up period was 26 months (range, 9-48 months). Retinal reattachment was obtained in all cases after a mean period of 52 days. The tumor height decreased in all cases. Visual acuity improved to two lines or more in eight eyes (62%) and reached 20/200 or more in nine eyes (69%). No radiation complication was detected during follow-up. CONCLUSIONS: Proton radiation seems to be effective and safe in the management of choroidal hemangioma associated with serous retinal detachment. It may be useful when photocoagulation can not be performed.     

Molecular genetics of glucose-6-phosphate dehydrogenase deficiency in Mexico

PURPOSE: To report the results of a prospective study of the incidence of peripheral visual field loss after macular hole surgery. METHODS: Prospectively, 30 eyes of 30 consecutive patients with full-thickness macular holes operated on between December 1995 and April 1996 had preoperative and postoperative Goldmann visual field tests. The surgical procedure consisted of three-port pars plana vitrectomy, posterior hyaloid removal, nonexpansile fluid-hexafluoroethane (C2F6) exchange, and, in 19 of 30 patients, autologous platelet injection, followed by face-down positioning. RESULTS: Twenty-nine of these 30 cases were considered to be anatomic successes. Comparison of preoperative and postoperative visual fields disclosed that four patients (13%) had a peripheral scotoma, including one patient with stage 4 macular hole. Three other patients (10%) had a postoperative relative arcuate defect. Mean postoperative intraocular pressure was higher in the latter group. None of the patients complained of peripheral scotoma. CONCLUSIONS: Overall, seven of 30 patients (23%) had a postoperative visual field defect. Two categories of scotomas were observed: peripheral and relative arcuate. The cause of peripheral visual field loss is unclear. Increased intraocular pressure may be the cause of relative arcuate scotomas.     

Surgical treatment of serous detachments of the macular neuroepithelium in diabetics

PURPOSE: Maculopathy in diabetes mellitus represents one of the most serious complications of the diabetic retinopathy. Retinal photocoagulations are often impossible and even dangerous. We propose a new method of surgical treatment for this macular serous detachment. MATERIAL AND METHOD: Thirteen eyes from 11 patients were treated using the same surgical procedure: vitrectomy, aspiration of subretinal liquid through a temporal retinotomy, fragmentation and extraction of the sub and intra retinal exsudates through one or several retinotomies, macular massaging with fluorodecaline, endophotocoagulations (focal on vascular anomalies and macular grid) and fluid-gas exchange (C3F8). RESULTS: Macular serous detachment and subretinal exsudates disappeared in all the cases, the fluorescein leakage decreased. A functional improvement was obtained in 11 eyes, a stabilization in 2. DISCUSSION: The clinical results of this new surgical treatment appear to depend on the preoperative macular ischemia and on the age of the detachment. This surgical procedure is very beneficial but could perhaps be technically improved.     

Intraocular silicone oil tamponade. A clinico-pathologic study of 36 enucleated eyes

BACKGROUND: Previous histological studies have shown that intraocular silicone oil induces irreversible changes in ocular tissues, especially the retina. The purpose of this study was to analyze, in a larger group of enucleated eyes, changes in intraocular tissue after silicone oil injection, dependent on intraocular pressure, how long the oil was in the eye, and the viscosity of intraocular silicone oil. PATIENTS AND METHODS: We did histological examinations on 36 enucleated globes with intraocular silicone oil after vitreoretinal surgery and compared them with 68 enucleated globes treated with buckle and encircling band using immunohistochemistry (n = 5) and electron microscopy (n = 7). For statistical evaluation we used the chi(2) test and analysis of variance. RESULTS: After silicone oil injection we observed a more pronounced reduction in corneal endothelial cells (58%), more frequent closed chamber angle (86%), atrophy of the ciliary body (80%) (P < 0.05), proliferative vitreoretinopathy (89%), and glaucomatous atrophy of the optic nerve (56%) (P < 0.01). The retinae showed independent of the use of silicone oil a loss of inner and outer segments of photoreceptors and of ganglion cells and thinning and rareficaton of all other retinal layers. Globes with silicone oil revealed vacuoles both free and incorporated by macrophages in all layers of the retina. Similar vacuoles were seen in the optic nerve, choroid, retinal pigment epithelium, ciliary body, iris, chamber angle and the corneal endothelium. Silicone oil vacuoles were seen in the retina and optic nerve by 1 month after surgery in two eyes with high intraocular pressure (42 mmHg). Six of eight eyes with normal intraocular pressure levels showed retinal vacuoles, 3 of them after 2 months. Vacuoles in the optic nerve were found in eight of nine eyes with intraocular instillation of 1000 mPa silicone oil. There was no clinicohistopathological correlation between the presence of vacuoles in the retina or optic nerve and the duration and viscosity of intraocular silicone oil. CONCLUSIONS: This study suggests that vacuoles in eyes with silicone oil instillation can be found in the retina after 4 weeks. The period of intraocular silicone oil should be limited to 3-6 months.     

Clear lensectomy and implantation of a low-power posterior chamber intraocular lens for correction of high myopia: a four-year follow-up

PURPOSE: To evaluate the 4-year postoperative outcomes of patients who are highly myopic who underwent clear lensectomy via phacoemulsification and low power posterior chamber intraocular lens implantation. METHODS: The authors performed surgery in 52 eyes of 30 patients in which prophylactic retinal treatment, clear lensectomy, and posterior chamber intraocular lens implantation were used to treat high myopia of 12 diopters (D) or greater. A total of 49 eyes of 28 patients were evaluated at the 4-year postoperative timeframe. Visual acuity, complications, and refractive stability were assessed. RESULTS: The incidence of retinal detachment through 4 years was 1.9%. No new macular complications were observed. Two patients had posterior vitreous detachment without clinical impact between 1 and 4 years after surgery. The incidence of neodymium:YAG (Nd:YAG) capsulotomy was 36.7%. The mean postoperative spherical equivalent was -0.92 D. Four patients had a myopic shift of 0.50 D to 1.00 D from the 1- to 4-year timeframe. Corrected visual acuity of 20/40 or better was achieved in 82% of eyes that had undergone Nd:YAG capsulotomy versus 56% of untreated eyes. Uncorrected visual acuity of 20/100 or better was achieved in 82% of eyes treated with the Nd:YAG laser versus 62% of untreated eyes. CONCLUSION: Visual acuity and refractive outcomes with clear lensectomy are favorable. Retinal detachment remains the major concern of this procedure. Continuous follow-up of these patients is necessary.     

Change in optic disk topography after trabeculectomy

PURPOSE: To investigate the relationship between optic disk topography and intraocular pressure before and after trabeculectomy with confocal scanning laser ophthalmoscopy. METHODS: The eyes of 49 consecutive patients undergoing trabeculectomy at a university-based glaucoma practice underwent preoperative and postoperative imaging using a confocal scanning laser ophthalmoscope (Heidelberg Retina Tomograph). Three images of one eye of each patient were obtained with a 15-degree field of view. Preoperative images were obtained approximately 2 months before surgery (mean +/- SD, 2.4 +/- 1.6 months). Postoperative images were obtained at least 3 months after surgery (mean, 4.5 +/- 2.6 months). RESULTS: Mean preoperative intraocular pressure, postoperative intraocular pressure, and percent change in intraocular pressure respectively were 23.1 +/- 6.8 mm Hg, 12.7 +/- 7.1 mm Hg, and 43.8% +/- 29.9%. A significant association (P < .01) was found between percent decrease in intraocular pressure and decreases in cup area, cup volume, and cup/disk area ratio as well as between percent decrease in intraocular pressure and increases in rim area, rim volume, mean height contour, retinal cross-section area, and height in contour. Between 11.7% and 31.2% of the variability (R2) in these parameters was explained by the percent change in intraocular pressure. Topography changes were more strongly associated with percent change than with mean change in intraocular pressure. We found no association between percent decrease in intraocular pressure and reference plane height or maximum cup depth. CONCLUSIONS: Changes in optic nerve topography were associated with reduction in intraocular pressure after trabeculectomy.     

Laser scanning tomography of the optic nerve head in ocular hypertension and glaucoma

BACKGROUND: This study evaluated the ability of laser scanning tomography to distinguish between normal and glaucomatous optic nerve heads, and between glaucomatous subjects with and without field loss. METHODS: 57 subjects were classified into three diagnostic groups: subjects with elevated intraocular pressure, normal optic nerve heads, and normal visual fields (n = 10); subjects with glaucomatous optic neuropathy and normal visual fields (n = 30); and subjects with glaucomatous optic neuropathy and repeatable visual field abnormality (n = 17). Three 10 degrees image series were acquired on each subject using the Heidelberg retina tomograph (HRT). From the 14 HRT stereometric variables, three were selected a priori for evaluation: (1) volume above reference (neuroretinal rim volume), (2) third moment in contour (cup shape), and (3) height variation contour (variation in relative nerve fibre layer height at the disc margin). Data were analysed using analysis of covariance, with age as the covariate. RESULTS: Volume above reference, third moment in contour, and mean height contour were significantly different between each of the three diagnostic groups (p < 0.001). Height variation contour showed no significant difference among the three diagnostic groups (p = 0.906). CONCLUSIONS: The HRT variables measuring rim volume, cup shape, and mean nerve fibre layer height distinguished between (1) subjects with elevated intraocular pressures and normal nerve heads, and glaucomatous optic nerve heads, and (2) glaucomatous optic nerve heads with and without repeatable visual field abnormality. This study did not directly assess the ability of the HRT to identify patients at risk of developing glaucoma. It is hypothesised that the greatest potential benefit of laser scanning tomography will be in the documentation of change within an individual over time.     

Variation in biochemical screening for Down''s syndrome in the United Kingdom

OBJECTIVE: To document the spontaneous resolution of retinal detachment developing after macular hole surgery. METHODS: We identified all patients who developed a postoperative retinal detachment after undergoing macular hole surgery at Washington University School of Medicine, St Louis, Mo; the surgery was performed by one of us (L.V.D.P. or H.J.K.) between 1991 and 1996. RESULTS: Six of 73 eyes developed a postoperative retinal detachment; the retinal detachment was inferior in all cases. Two eyes that had inferior retinal breaks underwent further surgery to repair the retinal detachment. Retinal breaks could not be identified in the other 4 eyes; the retinal detachment resolved without further surgery in all 4 of these eyes. CONCLUSION: The recognition that retinal detachment occurring after macular hole surgery can resolve without additional surgery may result in the avoidance of further surgical intervention in some eyes.     

Complications of posterior capsulotomy with the Nd:YAG laser. Study of 226 cases

BACKGROUND: Severe complications are classically described after capsulotomy: ocular hypertension, cystoid macular edema and secondary retinal detachment. PATIENTS AND METHODS: A series of 226 patients having sustained Nd:YAG laser (PC). Posterior capsulotomy has been studied retrospectively in order to determine the rate of early complications (24 hours after PC) and late complications (up to 6 months after the PC). RESULTS: Fifteen patients (6.6%) presented acute temporary intraocular hypertension, 2 patients (0.9%) a retinal detachment, 2 patients (0.9%) a cystoid macular edema (CME). A total number of complications of 8.4% was observed, 1.8% were heavy. CONCLUSIONS: Transient rise of intraocular pressure is seen. Prophylactic treatment with acetazolamide 500 mg (Diamox) and timolol (Timoptic) is necessary.     

Surface ultrastructure of human dermis and wounds

BACKGROUND: Intermediate uveitis is characterized by vitreal inflammation with associated inflammation of the vitreous base and peripheral anterior retina and choroid. It may be found as an isolated and idiopathic condition or in association with systemic disorders such as multiple sclerosis and sarcoidosis. OBJECTIVE: To identify the clinical features of intermediate uveitis and assess its association with systemic diseases. METHODS: Retrospective study of 83 patients presenting with intermediate uveitis between 1970 and 1991. RESULTS: Evidence of systemic disorders was found in 26 of 83 patients (31.3%). Of these 26 patients, 10 had presumed sarcoidosis, 6 had multiple sclerosis, 2 had isolated optic neuritis, 2 had inflammatory bowel disease, 4 had isolated thyroid abnormalities, and 2 had histories suggestive of Epstein-Barr virus infection. Associated ocular findings included cystoid macular edema, peripheral retinal perivascular sheathing, cataracts, posterior vitreous detachment, fine keratic precipitates, preretinal macular fibrosis, retinal tears, retinal detachment, and optic disc edema. CONCLUSIONS: Patients with intermediate uveitis may have associated systemic diseases and should have careful follow-up with regular systemic evaluation.     

The surgical treatment of normotensive glaucoma

The efficacy of surgical treatment of low (normal)-pressure glaucoma is validated on the basis of analysis of the disease progress risk factors. The risk factors are inadequate intraocular pressure (IOP) and insufficient blood supply to the optic nerve and retina. For stabilizing the glaucomatous process, IOP is to be reduced below 14 mm Hg. After antiglaucoma surgery, IOP decreases by 35% on average (to 13.9 mm Hg), and visual field is retained in remote period in 81.2% patients. Antiglaucoma operation with simultaneous decompression of the optic nerve results in a greater increase of visual field due to improvement of blood supply to the optic nerve and retina; visual functions are stabilized for a long time in 77.8% cases at a higher IOP (16.14 mm Hg) in patients with worse initial status. Functional results of surgery for normotensive glaucoma depend on ophthalmic tone and optic nerve and retinal hemodynamics.     

Glaucoma after macular hole surgery

OBJECTIVE: The study aimed to report incidence and to assess risk factors of postoperative glaucoma in patients with stage 3 idiopathic macular hole treated with pars plana vitrectomy, removal of posterior hyaloid membrane, and perfluoropropane gas tamponade. DESIGN: The author performed a retrospective chart review and statistical analysis of risk factors of postoperative glaucoma by using chi-square statistics, Fisher's exact test, and logistic regression. PARTICIPANTS: Forty consecutive patients with stage 3 idiopathic macular hole who were operated on between January 1994 and December 1995 were studied. INTERVENTION: A pars plana vitrectomy, removal of posterior hyaloid membrane, and 14% perfluoropropane gas tamponade were done to all patients. MAIN OUTCOME MEASURES: Preoperative and postoperative intraocular pressure measurements were performed. RESULTS: Twenty-one (52%) of 40 patients experienced transient intraocular pressure elevation to more than 30 mmHg. Nine (22%) had pressure elevation within 2 to 4 hours, 6 (15%) in 24 hours, and 6 (15%) in 1 week after surgery. Three patients, including one with a history of preoperative ocular hypertension, required extended topical antiglaucoma medication. Factors of age, race, gender, lens status, preoperative intraocular pressure (all preoperative intraocular pressure were 25 mmHg or less), and success in closure of macular hole were not to any statistically significant degree associated with postoperative pressure elevation. CONCLUSION: Glaucoma is a significant complication after stage 3 macular hole surgery even without adjunctive therapy. Usually happening within the first postoperative week, elevation of intraocular pressure in most cases is transient and can be controlled by medication. However, extended medication might become necessary in some cases.     

Normalization of low vitamin B12 serum levels in older people by oral treatment

PURPOSE: To report the potential for retinal ischemia caused by high intraocular pressure and to suggest a simple test for this condition. METHODS: We measured the intraocular pressure and directly examined the optic nerve head in four eyes of four patients at the conclusion of cataract surgery. RESULTS: With intraocular pressure above 40 mm Hg, elderly patients may abruptly lose the ability to perceive microscope illumination. The central retinal artery pulsated at these pressures. Light perception returned immediately upon reduction of intraocular pressure. CONCLUSION: Testing for light perception at the conclusion of surgery can indicate retinal ischemia with loss of light perception, which may occur during sealing of the cataract surgical wound.     

Secondary implantation of scleral-fixated intraocular lenses

PURPOSE: To evaluate the results of a large series of secondary implantations using scleral-fixated posterior chamber intraocular lenses (IOLs). SETTING: Bellevue Eye Hospital, Kiel, Germany. METHODS: This retrospective review comprised 624 consecutive patients who had secondary implantation of a posterior chamber IOL with scleral fixation between 1988 and 1995. All patients had been aphakic for at least 1 year. An ab interno or ab externo suture technique through the ciliary sulcus was used. Visual outcome and complications 1 year after surgery were determined. RESULTS: Best corrected visual acuity improved or remained unchanged in 92.0% of eyes; 8.0% lost one or two lines. Intraocular lens decentration of more than 1.5 mm occurred in 1.9% of eyes. Suture erosion was observed in 17.9%, cystoid macular edema in 5.8%, retinal detachment in 1.4%, and vitreous hemorrhage in 1.0%. Severe uveitis occurred in 0.5%. CONCLUSION: Secondary IOL implantation with scleral fixation was a safe procedure. Although there was a small risk of significant complications, more than 90% of patients regained or improved their preoperative visual acuity.     

Autologous platelet concentrate as an adjunct in macular hole healing: a pilot study

PURPOSE: A pilot study was undertaken to assess the efficacy of autologous platelets in macular hole healing. PATIENTS AND METHODS: Eight eyes of eight patients with stage 3 or 4 macular holes, two of which had failed to heal after previous vitrectomy and gas tamponade, were included. The procedure consisted of pars plana vitrectomy with removal of posterior cortical vitreous, stripping of associated epimacular membranes, 15% perfluoroethane-air tamponade, and instillation of autologous platelet concentrate onto the posterior pole. Strict postoperative facedown positioning was observed for 12 days. Postoperative evaluation included visual acuity measurement, biomicroscopic macular appearance and scanning laser ophthalmoscope examination. The follow-up period ranged from 3 to 13 months (mean, 7 months). RESULTS: Of eight eyes, flattening of the surrounding retina and closure of the hole were achieved in seven (87.5%). Visual acuity improved two lines or more in four eyes (50%) Four eyes (50%) reached a postoperative visual acuity of 20/50 or more. Increased nuclear sclerosis was observed in six eyes (75%), and retinal detachment occurred in two eyes (25%). CONCLUSIONS: Autologous platelet concentrate administered peroperatively in full-thickness macular holes seems to be a safe and effective adjunct to vitrectomy with removal of posterior hyaloid and gas tamponade. A larger multicenter randomized prospective study is underway to verify these encouraging results before advocating the use of autologous platelets in macular hole surgery.     

Deglutition in patients treated with reconstructive laryngectomy]

BACKGROUND: Chronic papilledema may lead to irreversible damage of optic nerve fibers. To preserve visual functions, a decompression of the optic nerve is recommended by means of a fenestration of the optic nerve sheath. In this study long-term results after optic nerve sheath fenestration in patients with idiopathic pseudotumor cerebri are reported. PATIENTS AND METHODS: 14 patients were re-examined 15 to 145 months (mean 62 months) after a fenestration of the retrobulbar optic nerve sheath on 23 eyes by a transconjunctival approach. Surgery was done to treat progressive visual loss or in severe obscurations. The patient's symptoms, visual acuity, visual fields, and ophthalmoscopic findings of the optic nerve head and the central fundus were compared to the preoperative status. RESULTS: Re-examination revealed improvement or stabilisation of objective and subjective findings in 17 eyes, one of them was operated on the more involved contralateral side only. Six eyes showed a recurrence of the papilledema without a functional change for the worse after an interval of 7 to 121 months. Three eyes of two patients ended up with optic atrophy and extensive visual loss. Preoperatively, these eyes had shown cotton wool spots in the optic nerve head and a rapid deterioration of vision. CONCLUSIONS: Fenestration of the retrobulbar optic nerve sheath can prevent further visual loss in most patients with pseudotumor cerebri, unless the eye has already become nearly blind. Postoperatively, ophthalmological controls are necessary at regular intervals because relapses after successful surgery can occur after months or years.     

Long-term evaluation of primary anterior chamber intraocular lens implantation in complicated cataract surgery

The long-term visual outcome and complications related to the use of a semiflexible open-loop all-PMMA anterior chamber intraocular lens were evaluated in 40 eyes in which the capsular support was lost. The mean follow up time was 2.3 years (range 6 months to 6.7 years). 55% of the eyes had exfoliation syndrome. 68% (27 of 40 eyes) obtained a visual acuity of 0.5 or better, and only in one of the remaining eyes decreased visual acuity was related to cataract surgery (cystoid macular oedema). No cases of corneal decompensation, uveitis-glaucoma-hyphaema syndrome or retinal detachment have developed, and no IOLs have been explanted. Based on these results, the use of a modern anterior chamber intraocular lens can be suggested at least in old persons, if the capsular support is lost.     

Fluorescein angiography in chronic simple and low-tension glaucoma

Fluorescein angiograms were performed on a group of low-tension glaucoma and chronic simple glaucoma patients with similar extent of visual field loss, under standardised conditions, to see whether differences attributable to chronic intraocular pressure elevation could be detected. There was no evidence for difference in circulation times between these two groups. There was no evidence that hypoperfusion of the peripapillary choroid contributed to optic nerve hypoperfusion. Low-tension glaucoma patients demonstrated focal sector hypoperfusion of the optic nerve in every case, while the chronic simple glaucoma patients demonstrated a wide range of optic nerve fluorescence, suggesting both focal and diffuse optic nerve head hypoperfusion. It was concluded that, while focal hypoperfusion of the optic nerve may reflect susceptible vasculature at the nerve head with or without intraocular pressure elevation, diffuse hypoperfusion suggested that prolonged intraocular pressure elevation may simultaneously affect the whole of the optic nerve head. This could be a direct effect on blood vessels or a mechanical effect with secondary vascular changes.