Bruce M. Buerk

Intravitreal triamcinolone for treatment of complicated proliferative diabetic retinopathy and proliferative vitreoretinopathy

BACKGROUND We present a retrospective evaluation of the clinical outcome and complications associated with intravitreal injection of unaltered triamcinolone acetonide in conjunction with pars plana vitrectomy and silicone oil injection for the treatment of complicated proliferative diabetic retinopathy with tractional retinal detachment and severe proliferative vitreoretinopathy. METHODS Thirteen eyes of 12 consecutive patients were identified from a computerized patient database. All eyes were operated on by the same surgeon and received 4 mg of unaltered, commercially available triamcinolone acetonide intravitreally, before silicone oil injection. The patients were followed for a mean of 4.7 months (range 1-15 months), and demographic as well as pertinent preoperative and postoperative clinical information was gathered. RESULTS At the last follow-up visit, vision had improved in 4 eyes, remained stable in 5 eyes, and worsened in 4 eyes. The retina was attached at the end of follow-up in 10 of the 13 eyes. Eight of the 13 eyes did not show any clinical signs of re-roliferation or redetachment during the course of follow-up. The mean intra-ocular pressure did not increase (preoperative value was 10.8+/- 6.22 mm Hg with a range of 0-22 mm Hg; at last follow-up, mean pressure was 9.6 +/-3.86 mm Hg with a cumulative postoperative range of 0-26 mm Hg). Steroid crystals were visible at 1 month postoperatively in 3 eyes and did not hinder fundus examination significantly. INTERPRETATION The intravitreal injection of low-dose, unaltered triamcinolone acetonide in the setting of pars plana vitrectomy and silicone oil injection for the treatment of proliferative vitreoretinopathy and complicated proliferative diabetic retinopathy appears to be well tolerated. Further controlled study is needed to clearly define the potential beneficial effects of intravitreal steroids in these 2 disease processes.

Histologic findings after surgical excision of optic nerve head drusen

Purpose: To report the histopathologic findings of a case of bilateral massive optic nerve head (ONH) drusen. Methods: A 59-year-old man presented with bilateral massive ONH drusen and secondary compromise of the retinal vasculature leading to vision of counting fingers at 1 ft in the left eye and 20/30 in the right eye. The inferior one half of the left ONH druse was excised resulting in no light perception vision postoperatively. Results: Energy-dispersive spectroscopy suggested the composition of the ONH druse to be calcium phosphate (Ca3[PO4]2), which has implications on pathogenesis of neuronal cell death in ONH drusen. Scanning electron microscopy demonstrated embedded metal particles, likely to be remnants of the instruments used. Conclusion: Massive ONH drusen are actually one large druse that has multiple excrescences on its surface giving it the variegated appearance. Although surgical excision of ONH drusen may be technically possible, consideration should be given to improvements in instrumentation and patient selection criteria.

Peripapillary subretinal fibrosis: A characteristic finding of multifocal choroiditis and panuveitis

A 15-year-old girl developed blurred vision in the right eye. The patient was seen elsewhere with subfoveal choroidal neovascularization and treated with photodynamic therapy with visudyne (Novartis Ophthalmics, Duluth, Georgia). She was then referred for evaluation. Visual acuity was 20/400 in the right eye and 20/20 in the left eye. Results of the anterior segment examination were normal. There were 1 vitreous cells in both eyes. Fundus examination of the right eye demonstrated active choroiditis surrounding the optic nerve head with peripapillary swelling (Fig. 1A). The macula was thickened with the presence of subretinal hemorrhage. Fluorescein angiography demonstrated persistent leakage in the macula from choroidal neovascularization (Fig. 1B). Multiple punched-out scars and Schlaegel lines were seen in the periphery of both eyes. Examination of the left eye showed an inactive napkin ring of subretinal fibrosis surrounding the left optic nerve head. The patient was treated with a short course of oral corticosteroids. The macular thickening slowly resolved, and napkin ring peripapillary scarring developed in the right eye (Fig. 1, C and D).

Persistent Hyperplastic Primary Vitreous (PHPV)

Persistent fetal vasculature (PFV), also known as persistent hyperplastic primary vitreous (PHPV) is a constellation of ophthalmic findings typically consisting of microphthalmia, cataract (Figs. 8.1 and 8.2), centrally dragged ciliary processes, retrolental fibrous tissue, and a persistent hyaloid artery. It has long been recognized in the differential diagnosis of leukokoria or amaurotic pupillary reflex. The full spectrum of findings in PFV was not fully appreciated until 1949 when Reese described the syndrome in more detail, differentiating PFV from retrolental fibroplasia [1]. In the 1956 Jackson Memorial lecture, Reese further elucidated the findings of this disorder [2]. He termed the anterior findings anterior hyperplastic vitreous. Michaelson, and later Pruett and Schepens, termed the posterior component posterior hyperplastic primary vitreous and stressed the anterior and posterior findings could overlap [3]. Goldberg suggested replacing the term PHPV with the more comprehensive PFV, which emphasizes the etiology of the disorder [4].

Minimally Invasive Method for Repair of Rhegmatogenous Retinal Detachment Following Treatment for Retinoblastoma

A minimally invasive method for repair of rhegmatogenous retinal detachment following treatment of retinoblastoma is described. Two children with retinoblastoma developed rhegmatogenous retinal detachments following treatment with a combination of chemotherapy and cryotherapy. Each eye underwent a non-drainage scleral buckling procedure without retinopexy of the retinal break. Postoperatively, the retinas reattached and retinopexy with indirect laser photocoagulation was performed during subsequent examinations under anesthesia. The retinas have remained attached with 2 to 5 years of follow-up. The tumor recurred in case 2, was treated with additional chemotherapy, and has undergone type 1 regression. Non-drainage scleral buckling without retinopexy is a useful technique for repairing rhegmatogenous retinal detachment in eyes with retinoblastoma. The retinal break can be treated postoperatively with indirect laser photocoagulation to minimize the chance of viable tumor cell dissemination.