Brian C. Joondeph

Delayed-Onset Pseudophakic Endophthalmitis

We reviewed 19 cases of delayed-onset pseudophakic endophthalmitis in which diagnostic cultures were performed at one month or more after cataract extraction with posterior chamber intraocular lens implantation. We isolated four different organisms in these 19 cases: 12 Propionibacterium species (63%), three Candida parapsilosis (16%), three Staphylococcus epidermidis (16%), and one Corynebacterium species (5%). Because of the unusual delayed-onset features of these cases and the retrospective nature of this study, a variety of treatment regimens were used. Twelve patients had recurrence of marked inflammation despite an apparent initial cure, and ten of these patients had positive culture results on repeat examination of intraocular fluids. Nine patients continued to be treated with topical corticosteroids postoperatively to suppress low-grade inflammation. Of the 19 patients, 16 had final visual acuity of 20/400 or better. Delayed-onset pseudophakic endophthalmitis had a more favorable visual prognosis, compared to acute-onset endophthalmitis.

Observations Concerning Patients With Suspected Impending Macular Holes

Between September 1987 and April 1989, 18 patients (21 eyes) with suspected impending Stage 1 macular holes were referred to the Bascom Palmer Eye Institute. Only one patient had a Stage 1 hole. The others had an aborted stage of macular hole formation (eight eyes), Stage 2 holes (four eyes), a Stage 3 hole (one eye), or other lesions unrelated to hole formation. We believed that most of the apparently incorrect referring diagnoses were the product of incorrect interpretation of the biomicroscopic and fluorescein angiographic findings, and were not caused by changes occurring before our examination.

Choroidal granulomas in systemic sarcoidosis.

Purpose To evaluate the clinical course, including response to therapy, of patients with macular and peripapillary choroidal granulomas secondary to systemic sarcoidosis. Methods This is a retrospective case study and literature review. Nine patients with choroidal granulomas were identified. Eight patients had a tissue biopsy confirming sarcoidosis; one was diagnosed from clinical history and typical gallium scan. Ocular examinations included fundus examination, fluorescein angiography, and visual field examination. Eight patients had magnetic resonance imaging (MRI) scans looking for intracranial granulomas. Treatment consisted of oral prednisone in eight patients (one with concomitant subconjunctival triamcinolone); one patient received no treatment because of good vision and granuloma in the nasal retina. Variables studied included visual acuity (VA), response of granulomas to treatment, time to recurrence, and associated anterior segment findings. Results Eight of nine patients had a solitary lesion whereas one had multifocal involvement. The granulomas ranged in size from one half to four disk diameters. Eight patients had blurry vision; one was asymptomatic. All nine patients had hilar adenopathy and/or pulmonary parenchymal disease. No patient had nonocular neurologic symptoms and in eight patients who underwent MRI examination no intracranial granulomas were detected. Of the eyes that were treated (n = 8) all had decrease in the size of the choroidal mass at an average of 4 months of treatment. Two had complete resolution. Mean follow-up was 29.2 months. At the time of initial diagnosis only one patient had an active anterior uveitis. Five of nine patients had at least one recurrence. Mean time to recurrence was 7.6 months after discontinuing oral prednisone. The VA at presentation ranged from 20/30 to 20/300. Final VA was 20/30 or better in all patients. Conclusions Choroidal granulomas related to systemic sarcoidosis respond well to oral corticosteroids. They may recur but good vision can be maintained. They are not typically associated with concomitant iritis and also do not appear to be associated with intracranial granulomas.

Liposome-Encapsulated 5-Fluorouracil in the Treatment of Proliferative Vitreoretinopathy

Liposomes, small bilayer vesicles composed of phospholipids, can entrap and thus slow the release of drugs. We investigated the use of liposome-encapsulated 5-fluorouracil (5-FU), an antiproliferative agent, in the treatment of proliferative vitreoretinopathy (PVR) in an animal model. Doses of up to 1.6 mg administered intravitreally in rabbits demonstrated no retinal toxicity by histologic or electroretinographic criteria. In an experimental animal model of PVR, intravitreal injection of homologous rabbit corneal fibroblasts caused tractional retinal detachments in 90% of eyes after 4 weeks. The addition of 1.6 mg of liposome-encapsulated 5-FU decreased the rate of detachment to 32%, compared with 55% for 1 mg of free 5-FU. Thus, liposomal encapsulation of an anti-proliferative agent such as 5-FU may be a valuable adjunct to conventional vitreous surgery in managing PVR.

Hemostatic Effects of Air Versus Fluid in Diabetic Vitrectomy

The potential hemostatic effect of an intravitreal air bubble after diabetic vitrectomy was studied in an animal model and in a randomized clinical trial. One day after vitrectomy with induced intraoperative hemorrhage, vitreous cavity hemorrhage was present in 60% of air-filled rabbit eyes compared with 27% of fluid-filled eyes. The prevalence and extent of hemorrhage was equal in the two groups on postoperative days 3 and 7. In a clinical trial of 51 eyes undergoing diabetic vitrectomy, 70% of eyes randomized to air-filled vitreous cavity after vitrectomy had vitreous cavity hemorrhage on postoperative day 1 compared with 50% of fluid-filled eyes. At 1 week, the incidence of hemorrhage was 78% for air and 61% for fluid. The 6-month visual and anatomic results were similar in both groups. These findings suggest that an intravitreal air bubble neither improves hemostasis nor reduces the visual outcome after diabetic vitrectomy.

Endophthalmitis after pars plana vitrectomy: a New Zealand experience.

Purpose: To describe the clinical course and estimate the incidence of endophthalmitis after pars plana vitrectomy in New Zealand. Methods: A retrospective analysis was performed on all cases of culture-positive endophthalmitis after vitreoretinal surgery over a 10-year period. Results: Five cases of culture-positive endophthalmitis were identified between 1993 and 2002. During this interval, 10,397 vitrectomies were performed, equating to an overall incidence of 0.048%. All patients presented within 7 days of surgery. Conclusions: Endophthalmitis after pars plana vitrectomy is uncommon but is associated with a poor functional outcome.

Posterior tractional retinal breaks complicating branch retinal vein occlusion.

A total of 358 patients with branch retinal vein occlusion (BRVO) were reviewed to examine the relationship between branch retinal vein occlusion with neovascularization elsewhere (NVE), vitreous hemorrhage, and posterior tractional retinal breaks. Twenty-eight of 358 (7.8%) BRVO patients had vitreous hemorrhage. In this group of 28 patients, 24 of the 28 (85.7%) had NVE. Of the 24 BRVO patients with vitreous hemorrhage and NVE, six (21.4%) were found to have posterior tractional retinal breaks adjacent to avulsed neovascular tissue. These data indicate a strong association between BRVO patients with vitreous hemorrhage and posterior tractional retinal breaks due to avulsion of neovascular tissue.

Purulent Anterior Segment Endophthalmitis Following Paracentesis

A 67-year-old man developed a central retinal artery occlusion and was treated with an oral carbonic anhydrase inhibitor, oral glycerin, carbachol rebreathing, and anterior chamber paracentesis. He subsequently developed an anterior segment endophthalmitis. Vigorous medical and surgical management cured the endophthalmitis, but his visual acuity remained at light perception. To the best of our knowledge, this patient represents the first reported case of a culture-positive, anterior segment endophthalmitis following anterior chamber paracentesis.

COMPARISON OF THREE PERMANENT INTRAOCULAR MAGNETS

A comparison was performed of three small-gauge, permanent, rare-earth, intraocular magnets to assist the posterior segment surgeon with the decision as to which magnet to purchase or to use in different clinical situations. The magnetic force was measured at varying distances from the instrument tip using a 1/8-inch steel ball as the test object. There were small differences in magnetic strength between the three instruments that may have clinical significance in certain situations. Two of the instruments had a retractable magnet within an outer sleeve, allowing for controlled attraction and release of a magnetic foreign body by the surgeon.

Management of subretinal foreign bodies with a cannulated extrusion needle

We treated two patients who had nonmagnetic subretinal foreign bodies (metallic pellet and lens nucleus fragment) in the presence of a retinal detachment and a distant retinal break. After the pars plana vitrectomy, the soft, flexible tip of the cannulated extrusion needle was used to push the foreign object gently away from the posterior pole toward the retinal break where it was grasped and removed from the eye. This technique for subretinal foreign body removal is preferable to creating a large posterior retinotomy overlying the foreign body because of the potential risks of further macular trauma, hemorrhage, or proliferation of periretinal membranes from the retinotomy site.