Arnold J. Kroll

Endogenous bacterial and fungal endophthalmitis.

Endogenous endophthalmitis (EE) occurs as the result of hematogenous spread of organisms to the eye. Today, it remains a diagnostic and therapeutic dilemma because of relatively infrequent occurrence and the need for prompt identification and therapy to obtain a positive outcome. Standardized guidelines for diagnosis and treatment remain elusive because of insufficient incidence to allow establishment of conclusive clinical trials. This paper presents a review of bacterial and fungal EE with a view of determining where we currently stand in terms of diagnosis and management of this condition.

Endophthalmitis in the Era of Small Gauge Transconjunctival Sutureless Vitrectomy— Meta Analysis and Review of Literature

Purpose: The goal of this study was to review, evaluate, and perform a meta-analysis on the current literature that reports rates of postoperative endophthalmitis after small gauge transconjunctival sutureless vitrectomy (TSV) and compare it to 20-gauge pars plana vitrectomy (20G PPV). Methods: We performed an extensive review of the current literature. We included only large comparative institutional reviews. Meta-analysis of these reviews was performed. Results: We found six large retrospective comparative cases series on the 25-gauge (25G) TSV as compared to 20G PPV. The test for homogeneity for the meta-analysis indicates that the studies are not homogeneous and therefore the evidence is tentative. Conclusion: We cannot conclude that 25G TSV has a higher rate of postoperative endophthalmitis compared to the 20G PPV. Future retrospective or prospective trials need to take into consideration multiple factors.

The vitreo-retinal manifestations of persistent hyperplasic primary vitreous (PHPV) and their management.

Persistent hyperplastic primary vitreous (PHPV) has been called by various names, such as persistent tunica vasculosa lentis, persistent posterior fetal fibrovascular sheath of the lens, congenital retinal septum, and ablation falciformis congential. It was first reported by Jules Cloquet in 1818 in Mémoire sur la membrane pupillae, et sur la formation du petit cercle artériel de l’iris. In 1949, Reese defined this entity histopathologically. In 1955, Reese coined the term persistent hyperplastic primary vitreous (PHPV) a congenital anomaly in which the embryonic hyaloid vasculature fails to regress normally. In 1997, Goldberg renamed this entity as persistent fetal vasculature (PFV) as to encompass the complete spectrum of the disease. PHPV has been classified into 3 types:

Retinal Capillary Hemangiomas and von Hippel-Lindau Disease

von Hippel-Lindau disease is a multisystem familial cancer syndrome that commonly manifests in the eye as retinal capillary hemangiomas. As the earliest manifestation of the disease, these benign hamartomas can lead to secondary visual loss. Their typical clinical characteristics can lead to accurate diagnosis and appropriate treatment with either laser photocoagulation or cryotherapy enhancing ones probability of preserving vision before becoming symptomatic. Accurate diagnosis can also lead to surveillance of the various other organ systems involved in the disease such as the CNS, kidneys, adrenal glands and pancreas. This will also enable the clinician to provide genetic counseling for patients regarding the lifelong manifestations of this disease.

Surgical treatment of submacular hemorrhage in age-related macular degeneration.

Dense submacular hemorrhage in age-related macular degeneration (ARMD) portends a poor visual prognosis for central vision. There is evidence of direct toxicity from blood products to the photoreceptors. It obscures visualization of the presumed causative choroidal neovascular membrane (CNVM), and resolution of hemorrhage often results in disciform or atrophic scar. With recent advances in vitreoretinal surgical techniques, several approaches to remove subfoveal hemorrhage have been reported. While these methods are successful anatomically in clearing blood, the final visual acuities are not encouraging. This chapter reviews the literature for submacular hemorrhage in ARMD and its natural course and compares the treatment techniques, complications, and results.

A review of vitreoretinal interface pathology.

The vitreoretinal interface has been identified as the site of many different forms of retinal pathology. The dynamic interaction between the vitreous and the retina has implications for pathology both peripherally and in the posterior pole, in particular, the macula. Before the development of optical coherence tomography (OCT), clinicians relied on astute clinical observation and fundoscopy, fluorescein angiography (FA), and postmortem histology to make assumptions about the role the vitreoretinal interface plays in macular pathology. OCT has given us the ability to view the macula in cross section with resolutions of 1 to 15m and thus has improved our understanding of the following known clinical entities: posterior vitreous detachment (PVD), vitreomacular traction (VMT) syndromes, macular holes, and epiretinal membranes (ERMs). The diagnosis and treatment of these visually indistinct pathologic entities has continued to be a challenge and debated in the literature. A clear understanding of the histopathology of the vitreoretinal interface is useful when treating macular disease. This paper attempts to review the current literature focusing on the histology and ultrastructural pathology of the vitreoretinal interface.

Antibiotic therapy in post-operative endophthalmitis

Endophthalmitis following routine cataract surgery is a rare but potentially devastating complication resulting in severe vision loss. Various prophylaxis treatments have been tried. However, none have been demonstrated to completely eliminate the risk. The Endophthalmitis Vitrectomy Study (EVS) helped establish clinical guidelines in the treatment of postoperative endophthalmitis in a prospective, randomized, multicenter trial. The strength and limitation of the study will be discussed as well as the current knowledge of the pharmacokinetics of intravitreous injection of antibiotics. Additionally, the common pathologic organisms, the use of antibiotic therapy, steroids, and vitrectomy will be discussed.

Controversies regarding radial optic neurotomy for central retinal vein occlusion.

Central retinal vein occlusion (CRVO) can result in loss of vision from intraretinal hemorrhage, edema, or retinal ischemia. Recently, Opremcak has advocated the use of a radial optic neurotomy (RON) as a possible treatment of CRVO. Others have followed with similar case series. Opremcak concludes that radial optic neurotomy may improve visual acuity in eyes with CRVO, and it has initially proven to be safe, although further studies must be performed to address potential serous complications such as damage to the central retinal artery and vein. Hayreh believes that the procedure is useless and even possibly dangerous for several anatomic reasons. Additionally, the authors’ data (supporting Opremcak’s results regarding radial optic neurotomy and, in addition, intravitreal triamcinolone acetonide injection into the vitreous cavity at the end of the procedure) is presented. Central retinal vein occlusion is the number 2 cause of vision loss from retinal vascular disease. CRVO can result in loss of vision from intraretinal hemorrhage, edema, or retinal ischemia. Capillary nonperfusion and retinal ischemia occur in 25% to 33% of patients with CRVO. Forty-seven percent of patients have a final visual acuity of less than 20/200. Rubeosis iridis and neovascular glaucoma occur in 45% to 85% of eyes with ischemic CRVO. Bilaterality with CRVO occurs in 5% to 10% of cases. The site of obstruction is presumed to occur at or near the lamina cribosa. Here the artery and vein are in close proximity. The artery compresses the vein. Turbulence ensues in the vein. Endothelial damage occurs, and thrombus formation results. The findings of CRVO