A case of retinal detachment in Kniest dysplasia treated with vitreous surgery

We report a case of retinal detachment with Kniest dysplasia for which vitreous surgery was effective. The patient was a 7-year-old female who had the typical ocular and physical findings of this disease. Visual acuity was light perception alone due to a hypermature cataract and bullous retinal detachment. We performed cataract surgery and pars plana vitrectomy, and used silicone oil tamponade. After seven months, the silicone oil was removed, and visual acuity improved to 0.09. We conclude that bullous retinal detachment with Kniest dysplasia can be treated by vitreous surgery in combination with the use of silicone oil tamponade.     

A quarter of a century of computer-assisted anticoagulant treatment]

PURPOSE: Presentation of two cases of crystalline lens posterior dislocation with concomitant, total, funnel-shaped retinal detachment. MATERIAL AND METHODS: The described patients were myopes and both had lost vision of the other eye earlier due to the same cause. The operation of dislocated lens removal through the limbal incision with the use of pars plana vitrectomy and simultaneous retinal detachment surgery were performed. RESULTS: In one patient almost full visual acuity was achieved, and in the second case visual acuity was improved to 3/50. CONCLUSION: The use of vitrectomy methods, including subretinal fluid drainage and intraocular silicone oil tamponade, enables efficient treatment of patients with dislocated lenses even in cases with total retinal detachment.     

Combined pars plana vitrectomy, lens removal and intraocular lens implantation for complications of diabetic retinopathy. Surgical results in 120 cases

We performed combined vitrectomy, lens removal and posterior chamber intraocular lens implantation for proliferative diabetic retinopathy in 120 eyes of 101 patients. Follow-up periods ranged from 3 to 63 months, with a mean of 17 months. Three lens removal methods were used: extracapsular cataract extraction (14 eyes), phacoemulsification and aspiration (49 eyes), and pars plana phacoemulsification (57 eyes). Preoperative rubeosis iridis or neovascular glaucoma was found in 21 eyes. Gas or temporary silicone oil tamponade was employed in 32 eyes. Surgical results were good, and the postoperative vision was finger counts or below only in 13 eyes. Thus the combined surgery proved to have no serious problems. Our results indicate two important points. (1) It is best to chose either of the following two methods for the lens surgery: phacoemulsification with continuous circular capsulorhexis, self sealing sclerocorneal incision, and in-the-bag fixation of the posterior chamber lens, or pars plana phacoemulsification leaving the anterior capsule, rub off and aspirating the lens epithelial cells, continuous circular capsulorhexis, and posterior chamber lens implantation in front of the anterior capsule from a self-sealing sclerocorneal wound. (2) It is mandatory to do complete vitrectomy and cut out the vitreous gels incarcerated in the sclerotomy site.     

Bone disease after liver transplantation should not be underestimated

PURPOSE: To report the management and outcome of cataract surgery and intraocular lens placement in a child with unilateral posterior lenticonus. METHODS: Case report. A 7-year-old boy with a best-corrected visual acuity of RE, 20/200, posterior lenticonus, and cataract underwent a pars plana lensectomy, vitrectomy, posterior chamber intraocular lens insertion into the ciliary sulcus, and central anterior capsulotomy. RESULT: At 2 years of follow-up, best-corrected visual acuity was RE, 20/40. CONCLUSION: This technique allowed complete removal of the opaque posterior lenticonus plaque while preserving the peripheral anterior capsule for sulcus fixation of the posterior chamber intraocular lens.     

Spontaneous dislocation into the vitreous of a poly(methyl methacrylate) disc lens 9 years after surgery

A 76-year-old woman had sudden visual loss 9 years after an extracapsular cataract extraction with implantation of a poly(methyl methacrylate) disc intraocular lens (IOL) in the capsular bag. Slitlamp examination showed the disc IOL had luxated into the vitreous through a linear inferior opening in the capsular bag; the IOL lay on the retinal surface. A pars plana vitrectomy was performed. The vitreous cavity was filled with perfluorocarbon liquid, floating the IOL to behind the iris. The IOL was removed through a limbal incision, then another type of IOL was implanted in the ciliary sulcus using transscleral fixation. Thirty days after surgery, best corrected visual acuity (BCVA) was 20/20. At 2 months, total retinal detachment appeared with a large superior retinal dialysis. Another pars plana vitrectomy was performed and the scleral-fixated IOL removed through a limbal incision. Internal gas tamponade was used. The eye was left aphakic. Final BCVA was 20/25.     

Infection and associated risk factors in the immediate postoperative period of pediatric liver transplantation: a study of 176 transplants

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.     

Forum on ethics. Genetics: manipulating mother nature

BACKGROUND AND OBJECTIVE: To report the results of silicone oil removal from aphakic eyes using a self-sealing clear corneal incision under topical anesthesia. PATIENTS AND METHODS: Twenty-two eyes of 22 patients who had pars plana vitrectomy combined with silicone oil injection underwent silicone oil removal under topical anesthesia using a self-sealing clear corneal incision. Mean time between silicone oil injection and removal was 3.1+/-1.42 months. Fourteen eyes were filled with 1300 cs of silicone oil and 8 eyes were filled with 5700 cs of silicone oil. The removal was performed with passive washout in the eyes filled with 1300 cs of silicone oil and with active aspiration in the eyes filled with 5700 cs of silicone oil. RESULTS: All of the 22 silicone oil removal procedures performed under topical anesthesia had clear corneal incisions that did not require suturing at the end of surgery. Three cases that had 1300 cs of silicone oil required aspiration because of residual silicone oil bubbles. CONCLUSION: Silicone oil can be removed from the aphakic eye using a self-sealing corneal tunnel incision under topical anesthesia.     

Viral gastroenteritis among young children in northern Jordan

Perforating and penetrating globe injuries secondary to peribulbar and retrobulbar anaesthesia are often complicated by vitreous haemorrhage and retinal detachment. We describe the effectiveness of primary silicone oil tamponade in the repair of three perforated globes secondary to local anaesthesia for ophthalmic surgery. Three patients with axial myopia had peribulbar and retrobulbar anaesthesia for extracapsular cataract extraction (two patients) and cryotherapy (one patient). All eyes sustained a vitreous haemorrhage obscuring the view to the fundus. Retinal detachments were detected by B-scan ultrasound. In all eyes, scleral buckling, pars plana vitrectomy and silicone oil tamponade were performed as a primary surgical procedure. All the patients had complete anatomic reposition. In two patients, after two years follow-up, visual acuity was between 6/12 to 6/36 with the retina attached and no proliferative vitreoretinopathy (PVR). The third patient had blind painful eye and enucleation was performed. Primary use of silicone oil tamponade, in the management of perforated globe with retinal detachment due to local anaesthesia injection, is recommended.     

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.     

Combined endocapsular phacoemulsification, pars plana vitrectomy, and intraocular lens implantation

OBJECTIVE: To determine whether a combined vitrectomy and phacoemulsification is a safe and feasible approach in patients requiring a vitrectomy who have a concomitant significant lens opacity. SETTING: Royal Victoria Eye and Ear Hospital, Dublin, Ireland. METHODS: This retrospective study comprised five patients with significant lens opacities who had combined trans pars plana vitrectomy and phacoemulsification with intraocular lens implantation. Main outcome measures were visual acuity and intraoperative and postoperative complications. RESULTS: The combined surgical approach resulted in minimal complications, and postoperative visual acuity was satisfactory. CONCLUSION: In the hands of experienced phacoemulsification and vitrectomy surgeons, combined trans pars plana vitrectomy and phacoemulsification can be a safe approach in treating patients requiring a vitrectomy who have significant lens opacities precluding a view of the posterior segment.     

Outcomes of vitrectomy for retained lens fragments

PURPOSE: Retained lens fragments after cataract surgery is an infrequent, but potentially serious surgical complication. The aim of this study is to evaluate outcomes after vitrectomy has been performed for removal of retained lens material. METHODS: A retrospective review was conducted to evaluate all cases of pars plana vitrectomy for removal of retained lens fragments performed at Wills Eye Hospital from April 1991 through August 1994. RESULTS: A total of 121 eyes of 121 patients underwent pars plana vitrectomy with removal of retained lens material over the 3 1/2-year period. Visual acuity on presentation was 20/200 or worse in 95 eyes (79 percent). Visual acuity after vitrectomy was 20/40 or better in 82 eyes (68 percent). The postoperative visual acuity was 20/50 to 20/400 in 21 eyes (17 percent), and counting fingers or worse in 18 eyes (15 percent). Nineteen eyes (16 percent) had retinal detachment (RD), 8 were noted at the time of vitrectomy and 11 occurred after vitrectomy. Of the 19 eyes with RD, visual acuity was 20/200 or worse in 12 (63 percent) and counting fingers or worse in 6 (32 percent) at the time of last follow-up. The use of posterior segment phacofragmentation was associated with higher rate of RD, but the difference did not reach statistical significance. Major causes of poor final visual outcome included RD (6 eyes), cystoid macular edema (4 eyes), and glaucoma (2 eyes). CONCLUSION: The timing of vitrectomy did not have a statistically significant impact on visual outcome. Neither the type of intraocular lens nor the timing of lens implantation significantly altered the final visual acuity. Most eyes with retained lens fragments do well after vitrectomy, with the majority recovering good vision. However, the risk of RD is increased, and visual outcome may be adversely affected if RD occurs.     

Transscleral ciliary sulcus fixation of a posterior chamber lens in an eye with congenital aniridia

A 30-year-old man with bilateral congenital aniridia presented with a subluxated cataract in the right eye. He wore a soft contact lens for aphakic correction in the fellow eye after lensectomy for a subluxated cataract. We performed pars plana lensectomy and vitrectomy with implantation of a transscleral ciliary sulcus fixated posterior chamber intraocular lens in the right eye. Good postoperative visual acuity was obtained.     

Glaucoma after vitreo-retinal surgery with silicone oil injection: epidemiologic aspects

PURPOSE: To evaluate the prevalence of glaucoma after pars plana vitrectomy with silicone oil injection and to determine the different clinical forms. METHODS: Authors have carried out a retrospective longitudinal study on patients who underwent pars plana vitrectomy with silicone oil injection from 1981 to 1995. The examined population consists of 301 patients (301 eyes), with an age ranging from 8 to 85 years, affected by retinal detachment and proliferative vitreoretinopathy. RESULTS: The prevalence of the secondary glaucoma has been 18.5%. In all cases glaucoma was caused by trabecular meshwork obstruction due to silicone oil emulsification. The glaucoma has been more frequent after surgery for recurrent rhegmatogenous retinal detachment with fibrous PVR (52.86%) and for particular forms of rhegmatogenous retinal detachment (giant tears, multiple breaks, pseudophakia) with incipient PVR (30%). CONCLUSION: Glaucoma after intravitreal silicone oil injection for complicated retinal detachments is a relatively frequent complication mostly when surgery needs endophotocoagulation, endodiatermy and lensectomy.     

Immunosuppressive acidic protein in intraocular fluids

The levels of immunosuppressive acidic protein (IAP) in the vitreous fluid or the aqueous humor were measured in patients with ocular diseases. Undiluted samples of vitreous humor were obtained during pars plana vitrectomy in patients with uveitis, proliferative diabetic retinopathy, and premacular fibrosis. In patients with intraocular tumors, vitreous samples were aspirated after enucleation. Aqueous humor was aspirated during cataract surgery, and levels of IAP were measured in patients with secondary cataract due to uveitis and senile cataract. Single radial immunodiffusion assay was used to quantify IAP levels. To determine the intraocular synthesis of IAP, we calculated the percentage of IAP in patients with uveitis. Patients with uveitis, tumors, and diabetic retinopathy had significantly higher levels of vitreous IAP than patients with premacular fibrosis. The percentage of vitreous IAP was higher in patients with uveitis than in those with tumors and diabetic retinopathy. Patients with uveitis also had markedly higher aqueous IAP levels than patients with senile cataract. In one patient with Beh?et's disease, the IAP level was higher in the active stage than in the inactive stage. Our results suggest that immunosuppressive acidic protein could be produced in the eye and that it might modulate intraocular inflammatory processes.     

Vitrectomy for retained lens fragments after phacoemulsification

PURPOSE: Posterior lens fragments after phacoemulsification can be a serious complication of cataract surgery. This study is designed to evaluate the clinical features of eyes after pars plana vitrectomy has been performed to remove posteriorly dislocated lens fragments after phacoemulsification. METHODS: The authors performed a retrospective chart review of 126 consecutive eyes of 126 patients with dislocated lens fragments after phacoemulsification, managed with pars plana vitrectomy at Associated Retinal Consultants of Michigan. These eyes were operated on from January 1986 through January 1996. RESULTS: The relation of the intervals between cataract surgery and vitrectomy to various postoperative clinical parameters was studied. Clinical features at presentation included elevated intraocular pressure (IOP over 25 mmHg) in 52.4% of the eyes, uveitis in 69.6%, and corneal edema in 50.8%. Initial visual acuity was 20/400 or worse in 73.8% of the eyes. The mean preoperative visual acuity was 20/278 (median, 20/400), whereas the mean final visual acuity was 20/40 (median, 20/50) after a mean follow-up of 18.9 months. Retinal detachments were found in 20 eyes: 7 before vitrectomy and 13 during or after it. After surgery, 44% of eyes achieved a final visual acuity of 20/40 or better and 90% were 20/400 or better. The distribution of best-corrected final visual acuities among the eyes showed statistically significant differences based on the type of intraocular lens (IOL) used, with posterior chamber IOL greater than anterior chamber IOL, and anterior chamber IOL greater than aphakia. Reasons for a poor visual outcome included persistent corneal edema (four eyes), retinal detachment (two eyes), central retinal vein occlusion (two eyes), age-related macular degeneration (two eyes) glaucoma (one year), and endophthalmitis (one eye). CONCLUSIONS: There were no statistically significant differences between early (< 7 days) and delayed (8 days or more) vitrectomy when increased IOP, corneal edema, choroidal effusions, cystoid macular edema, and visual acuity were analyzed. The use of vitrectomy to remove posteriorly dislocated lens fragments has been shown to be an effective treatment method that significantly reduces the inflammatory response and hastens visual recovery.     

Posterior pars plana high frequency capsulotomy

In special forms of complicated secondary cataract, especially after a cataract operation in eyes with proliferative disease and after a cataract operation associated with pars plana vitrectomy and silicone oil instillation, surgical capsulotomy must be performed. METHODS: We developed a new surgical technique for posterior capsulorhexis via pars plana by using the high-frequency capsulotomy method developed by Kl?ti. We analyzed 14 consecutive patients undergoing late pars plana capsulotomy using a specially designed instrument for radiofrequency capsulorhexis. The indication for surgical capsulotomy was extreme secondary cataract; in 6 eyes fibrosis was associated with vascularizations. RESULTS: The high-frequency technique for posterior capsulotomy allowed reliable and precise tissue cutting. The cutting required minimal application of pressure to the capsule, and therefore damage to zonula fibers is minimized. Furthermore, use of the radiofrequency technique permitted hemostatic incision in vascularized membranes by inducing a fine coagulation margin. CONCLUSIONS: Posterior capsulorhexis using radiofrequency offers precise and effective tissue cutting if surgical capsulotomy is necessary.     

A novel ALL-L3 cell line, BALM-16, lacking expression of immunoglobulin chains derived from a patient with hypercalcemia

OBJECTIVE: The purpose of the study is to evaluate whether a posterior capsulectomy combined with anterior vitrectomy is a necessity in pediatric cataract. DESIGN: The incidence of posterior capsule opacification, the need for additional surgical interventions, and the influence of a primary posterior capsulectomy after cataract surgery in children were evaluated. The analysis was carried out by studying patients' records retrospectively or after prospective follow-up. PARTICIPANTS: In 94 eyes (69 aphakic and 25 pseudophakic), the medical records were studied retrospectively. Twenty-eight eyes (18 aphakic and 10 pseudophakic) were observed prospectively during 1 year after surgery. In 20 eyes (6 aphakic and 14 pseudophakic) of 10 patients with bilateral cataract, a prospective comparison between the 2 eyes of the same patient also was carried out. INTERVENTION: Cataract surgery through the limbus with or without a primary posterior capsulectomy was performed in 114 eyes (43 of these received a posterior chamber intraocular lens [IOL] and 71 remained aphakic). In 28 eyes, the surgery was carried out by way of the pars plana (6 eyes received an anterior chamber IOL and 22 remained aphakic). MAIN OUTCOME MEASURES: Incidence of posterior capsule opacification, the need for secondary surgical intervention, and visual acuity were measured. RESULTS: Opacification of the posterior capsule is observed in all children's eyes when a primary posterior capsulectomy (combined with an anterior vitrectomy) was not carried out. Earlier secondary cataract formation is associated with a younger age and with implantation of an IOL. Eyes undergoing a primary opening of the posterior capsule during the initial surgery of children with bilateral cataract achieved, in most cases, a better visual acuity than did their fellow eyes. CONCLUSION: Although possibly a choice in older children, a primary posterior capsulectomy combined with anterior vitrectomy is a must in younger children and particularly when implantation of an IOL is planned.     

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.     

Management of postoperative Acremonium endophthalmitis

PURPOSE: Four patients presented after cataract surgery with delayed-onset endophthalmitis caused by Acremonium kiliense with in vitro sensitivity to amphotericin B. In all patients, ocular infection was recalcitrant to single-dose intravitreous amphotericin B injection. The authors reviewed the management of endophthalmitis caused by A. kiliense and presented treatment recommendations. METHODS: The authors retrospectively evaluated a cluster of four patients with delayed-onset postoperative endophthalmitis after phacoemulsification with posterior chamber intraocular lens implantation. All patients underwent vitreous sampling, intravitreous injection of amphotericin B, and systemic administration of fluconazole. Pars plana vitrectomy was performed in all patients for management of either primary (1 eye) or persistent infection (3 eyes). Two patients with persistent infection also underwent surgical explanation of their posterior chamber intraocular lens. RESULTS: Worsening infection developed in three of three eyes that underwent vitreous aspiration with intravitreous injection 5 micrograms amphotericin B. These patients subsequently responded to vitrectomy followed by additional intravitreous amphotericin B injection. One eye underwent primary vitrectomy and intravitreous injection of 7.5 micrograms amphotericin B. Although treatment of the initial infection was successful, fungal keratitis developed in this patient 3 months after presentation. Visual outcome was variable, ranging from visual acuity of 20/25 to no light perception with follow-up of 2 years. Epidemiologic investigation suggested a common environmental source for the A. kiliense organisms. CONCLUSIONS: Single-dose administration of intravitreous amphotericin B was inadequate treatment for fungal endophthalmitis caused by A. kiliense. Vitrectomy with repeated intravitreous administration of amphotericin B may be necessary to eradicate intraocular function caused by this organism.     

Case study of a solitary vitreous body cyst

Vitreous cysts are rare and their origin unclear. We present a case of a 47-year-old woman who, after undergoing retinal detachment surgery on several occasions, developed disturbing vitreous opacities with which she presented for possible vitrectomy. Besides the typical postoperative vitreous condensations and opacifications, a solitary spherical cystic structure was present in the anterior vitreous cavity. The cystic structure was attached at its posterior aspect onto a vitreous membrane and was otherwise floating within a vitreous body lacuna. The vitreous opacities and the cyst were removed by performing a pars plana vitrectomy. The patient's visual acuity improved from 0.5 to 0.7. We presume that the cyst was acquired in association with the retinal detachment or the operations.