Christina J Flaxel

The use of corticosteroids for choroidal neovascularisation in young patients.

Purpose To investigate the role of systemic corticosteroids in the treatment of sight-threatening choroidal neovascularisation (CNV) in patients with punctate inner choroidopathy (PIC) and multifocal inner choroiditis (MIC).Methods Twelve eyes of 10 patients with evidence of PIC or MIC with recent visual symptoms were identified. All eyes had CNV within the foveal avascular zone on fundus fluorescein angiography (FFA). Systemic oral prednisolone at an initial dose of 1 mg/kg (60-80 mg) was given for 3-5 days and the dose was subsequently tapered. Changes in best corrected visual acuity and leakage on FFA were recorded during follow-up. Systemic side-effects of the corticosteroids were monitored.Results In 10 of 12 eyes vision improved or stabilised. Leakage on FFA resolved in 9 eyes and was reduced in 3. Four patients required more than one course of oral corticosteroids. One patient was maintained on low-dose oral corticosteroids for recurrent CNV activity. No systemic complications from the treatment were observed.Conclusion A course of oral corticosteroids in healthy young patients with subfoveal CNV in PIC or MIC may reduce subretinal vascular leakage and stabilise vision when no other proven treatment option is available.

Phacoemulsification and silicone oil removal through a single corneal incision

OBJECTIVEnCataracts are a frequent complication after silicone oil infusion for the repair of complicated retinal detachments, occurring in up to 100% of eyes retaining silicone oil for 6 months or more. The authors devised a combined procedure for cataract and silicone oil removal with intraocular lens (IOL) implantation through a single corneal incision and evaluated their results.nnnDESIGNnA prospective, noncomparative case series.nnnPARTICIPANTSnThirty-four eyes of 34 consecutive patients with a history of retinal detachment repair requiring silicone oil placement in whom a clinically significant cataract subsequently developed were identified when removal of silicone oil was scheduled.nnnINTERVENTIONnAll 34 eyes were prospectively entered into a study to evaluate the efficacy and potential complications of a combined procedure for cataract and silicone oil removal with posterior chamber lens implantation. All patients underwent uncomplicated phacoemulsification removal of cataract followed by removal of silicone oil and placement of an IOL through a single corneal incision.nnnMAIN OUTCOME MEASUREnRecurrent retinal detachment and IOL-related complications were measured.nnnRESULTSnTen eyes had recurrent retinal detachments develop. Final visual acuity ranged from 6/12 to hand movements with 25 eyes (74%) showing stabilized or improved vision. Pre-existing macular pathology and recurrent retinal detachment generally were responsible for poor visual outcome.nnnCONCLUSIONSnCombined phacoemulsification, IOL implant with silicone oil removal is a useful procedure in these complicated eyes. Visual outcome generally is good with improvement in visual acuity, even with recurrent retinal detachment or pre-existing macular pathology or both.

Vitreoretinal surgery after inadvertent globe penetration during local ocular anesthesia

OBJECTIVEnThis study aimed to review visual morbidity resulting from inadvertent globe penetration during administration of local anesthetic and to identify the most appropriate management.nnnDESIGNnThe records of 20 consecutive patients referred to a specialist vitreoretinal unit over a 2-year period were reviewed.nnnPARTICIPANTSnTwenty eyes of 20 consecutive patients were included.nnnINTERVENTIONnObservations included type of local anesthetic administered (e.g., retrobulbar or peribulbar), level of training of person administering the block, type of needle used for the block, and findings at presentation to the vitreoretinal unit. The authors also observed results of B-scan ultrasound evaluation of the retina, interval between the recognition of the complication and referral, as well as nature and timing of subsequent surgical intervention.nnnMAIN OUTCOME MEASURESnFinal visual acuity and retinal status (attached versus detached) were measured.nnnRESULTSnThe most common presentation was vitreous hemorrhage observed from the first postoperative day. Ten eyes were found to have an associated retinal detachment on initial assessment in the vitreoretinal unit. These eyes generally had a poor visual outcome despite vitrectomy with long-acting gas or silicone oil tamponade. Seven (70%) of the remaining eyes with attached retina at the time of presentation achieved good visual recovery after vitrectomy.nnnCONCLUSIONSnThe authors recommend prompt referral for consideration of early vitrectomy in eyes with dense vitreous hemorrhage after inadvertent globe penetration. This management may improve the overall visual prognosis by preventing subsequent retinal detachment.

Aspirin is a hazard for vitreoretinal surgery

EDITOR,-Aspirin is known to have a significant effect on platelet function. Seven days are required to reverse its effects completely. Whereas it is easy to discontinue aspirin in advance of elective surgery, this is not possible for emergency procedures.2 There have been no reports of increased morbidity relating to the use of aspirin in vitreoretinal surgery.3 We observed significant intraoperative haemorrhages in three patients undergoing emergency vitreoretinal surgery while on aspirin. One required subsequent vitrectomy, one cleared without further intervention, and one developed severe proliferative vitreoretinopathy.

Intraocular penetration of tamoxifen.

OBJECTIVEnTo document ocular penetration of oral tamoxifen in patients being administered systemic therapy by measuring intraocular and serum levels of the drug in a series of patients undergoing elective ocular surgery.nnnDESIGNnNonrandomized, prospective, comparative trial.nnnPARTICIPANTSnTwenty-one eyes of 21 patients undergoing elective ocular surgery (cataract extraction or vitrectomy). Twenty patients were using the antiestrogen, tamoxifen, and one participant was not. Nine patients were excluded in the final analysis because of inadequate sample size.nnnINTERVENTIONnPreoperative serum samples and perioperative aqueous samples, vitreous samples, or both were obtained for each patient, and these were analyzed for tamoxifen and its metabolites. Dilated fundus examination was performed before surgery on all patients.nnnMAIN OUTCOME MEASURESnEvidence of tamoxifen, its metabolites, or both in the samples.nnnRESULTSnTamoxifen was detected in all analyzed serum samples (range, 82.4-290.0 ng/ml.) from patients taking the medication and was found to have penetrated into both vitreous (range, 0.5-7.8 ng/ml) and aqueous (range, 0.5-3.9 ng/ml) cavities. No relationship was found between serum and intraocular levels.nnnCONCLUSIONSnThis study shows that tamoxifen penetrates intraocular fluids to varying degrees. The drug levels in aqueous and vitreous do not appear to correlate with serum levels. Evidence of tamoxifen retinopathy or keratopathy was not seen.

Peripheral transscleral retinal diode laser for rubeosis iridis.

Purpose: To evaluate the results of peripheral transscleral retinal diode photocoagulation with or without transscleral cyclodiode therapy in patients with rubeosis iridis with or without elevated intraocular pressure and no fundal view. Methods: Peripheral transscleral retinal diode photocoagulation was performed in 15 eyes of 13 patients in an attempt to promote regression of rubeosis. The fundus could not be seen in any of the 15 eyes, so conventional panretinal photocoagulation was not possible. Nine eyes had associated elevated intraocular pressure and were treated with concurrent transscleral diode cyclophotocoagulation. Results: All eyes showed regression of rubeosis. Of the nine eyes treated with combination therapy, six had stabilized intraocular pressure, and three developed hypotony. None of the eyes developed a peripheral retinal detachment, and one eye lost the ability to perceive light. Conclusions: This method is effective in treating patients with rubeosis iridis when the view of the fundus is inadequate for conventional panretinal photocoagulation and more extensive intraocular surgery is precluded. It may be combined with transscleral cyclophotocoagulation therapy to manage concurrent high intraocular pressure in rubeotic glaucoma, but this involves a risk of postoperative hypotony. RETINA 17:421‐429, 1997

Intraocular penetration of tamoxifen1

OBJECTIVEnTo document ocular penetration of oral tamoxifen in patients being administered systemic therapy by measuring intraocular and serum levels of the drug in a series of patients undergoing elective ocular surgery.nnnDESIGNnNonrandomized, prospective, comparative trial.nnnPARTICIPANTSnTwenty-one eyes of 21 patients undergoing elective ocular surgery (cataract extraction or vitrectomy). Twenty patients were using the antiestrogen, tamoxifen, and one participant was not. Nine patients were excluded in the final analysis because of inadequate sample size.nnnINTERVENTIONnPreoperative serum samples and perioperative aqueous samples, vitreous samples, or both were obtained for each patient, and these were analyzed for tamoxifen and its metabolites. Dilated fundus examination was performed before surgery on all patients.nnnMAIN OUTCOME MEASURESnEvidence of tamoxifen, its metabolites, or both in the samples.nnnRESULTSnTamoxifen was detected in all analyzed serum samples (range, 82.4-290.0 ng/ml.) from patients taking the medication and was found to have penetrated into both vitreous (range, 0.5-7.8 ng/ml) and aqueous (range, 0.5-3.9 ng/ml) cavities. No relationship was found between serum and intraocular levels.nnnCONCLUSIONSnThis study shows that tamoxifen penetrates intraocular fluids to varying degrees. The drug levels in aqueous and vitreous do not appear to correlate with serum levels. Evidence of tamoxifen retinopathy or keratopathy was not seen.

Scleral rupture during retinal detachment surgery: risk factors, management options, and outcomes

OBJECTIVEnTo evaluate the potential risk factors, management strategies, and outcomes of scleral rupture during retinal detachment (RD) surgery.nnnDESIGNnCase-control study.nnnPARTICIPANTS AND CONTROLSnFourteen consecutive patients with scleral rupture during RD surgery (cases) and 65 consecutive patients who underwent RD surgery without scleral rupture (controls).nnnINTERVENTIONnDemographic and clinical data were abstracted from patients medical records.nnnOUTCOME MEASURESnVisual acuity and retinal attachment status at the last examination.nnnRESULTSnSignificant risk factors for scleral rupture during RD surgery were reoperation after failed RD surgery (71 % vs. 32%), and pre-existing scleral pathologic condition (29% vs. none). The site of rupture was in the bed of a previously placed scleral buckle in all patients with a previous buckling surgery. Repair of the rupture included scleral sutures in eight (57%), scleral patch graft in four (29%), and placement of a scleral buckle over the site in two (14%) eyes. Eleven (79%) underwent vitrectomy with retinal tamponade by gas (n = 4) or silicone oil (n = 7). Complications observed postoperatively included vitreoretinal incarceration (n = 3), vitreous hemorrhage (n = 2), suprachoroidal hemorrhage (n = 2) and subretinal hemorrhage (n = 3). In the 14 eyes with scleral rupture, the final visual acuity was > or =20/40 in 1 (7%), 20/50 to 20/200 in 5 (36%), and <20/200 in 8 (57%). Ten (71 %) had proliferative vitreoretinopathy develop. The retina was attached in 7 (50%), 6 (43%) had localized peripheral detachment, and 1 had a total retinal detachment. The vision improved in 4 (29%), was unchanged in 5 (36%), and was worse than before surgery in 5 (36%). In the 65 controls, the visual acuity at the time of the last examination was > or =20/40 in 26 (40%), 20/50 to 20/200 in 21 (32%), and <20/200 in 18 (28%). Sixty three (97%) patients had complete retinal reattachment, 1 (2%) had a localized peripheral RD, and 1 (2%) had an RD involving the posterior pole. After surgery, the vision improved in 45 (69%), was unchanged in 15 (23%), and was worse in 5 (8%) of the control eyes. The visual and anatomic outcomes of the eyes with scleral rupture were significantly worse than in the control group (P = 0.002 and P < 0.001, respectively).nnnCONCLUSIONSnRisk factors associated with intraoperative scleral rupture include reoperation for failed RD surgery and pre-existing scleral pathology. Although this complication may be compatible with a good visual outcome in some patients, a high incidence of persistent or recurrent RD with proliferative vitreoretinopathy worsens the visual outcome for most patients with this complication.

Partial Laser Ablation of Massive Peripapillary Subretinal Neovascularization

BACKGROUNDnAlthough peripapillary subretinal neovascular membranes (PSRNs) are less common and often larger than neovascular complexes arising near the fovea, they may lead to severe visual loss. Very large (massive) PSRNs (MPSRNs) are 3.5 disc areas or greater in overall size, are even less common, and may contain a significant occult component, leading to slow and unpredictable growth. Such massive lesions may begin at the nasal margin of the disc and do not become symptomatic until they have extended around the disc toward the macula, threatening central vision. Although complete laser ablation has been used for symptomatic PSRNs with variable success, the optimal treatment of MPSRNs remains controversial.nnnMETHODSnThe authors reviewed the clinical course of 12 eyes of seven patients with MPSRNs. Ten eyes received laser treatment, which was limited to the temporal portion of the subretinal neovascular complexes only and two received no treatment.nnnRESULTSnOf the ten eyes receiving laser treatment, six showed stabilization of visual acuity, whereas in four the neovascular membrane progressed beneath the fovea with severe visual loss. In the two untreated eyes, the subretinal neovascular membrane progressed beneath the macula with the loss of central vision.nnnCONCLUSIONSnIn contrast to the small symptomatic PSRNs, which are usually treated by complete laser ablation, MPSRNs may stabilize with only partial laser treatment. However, both types of lesions may remain stable for long periods of time without any treatment and require treatment only if progression toward the fovea occurs.

Intraocular penetration of tamoxifen13None of the authors have a proprietary interest in the medication or other therapy discussed in this manuscript.

OBJECTIVEnTo document ocular penetration of oral tamoxifen in patients being administered systemic therapy by measuring intraocular and serum levels of the drug in a series of patients undergoing elective ocular surgery.nnnDESIGNnNonrandomized, prospective, comparative trial.nnnPARTICIPANTSnTwenty-one eyes of 21 patients undergoing elective ocular surgery (cataract extraction or vitrectomy). Twenty patients were using the antiestrogen, tamoxifen, and one participant was not. Nine patients were excluded in the final analysis because of inadequate sample size.nnnINTERVENTIONnPreoperative serum samples and perioperative aqueous samples, vitreous samples, or both were obtained for each patient, and these were analyzed for tamoxifen and its metabolites. Dilated fundus examination was performed before surgery on all patients.nnnMAIN OUTCOME MEASURESnEvidence of tamoxifen, its metabolites, or both in the samples.nnnRESULTSnTamoxifen was detected in all analyzed serum samples (range, 82.4-290.0 ng/ml.) from patients taking the medication and was found to have penetrated into both vitreous (range, 0.5-7.8 ng/ml) and aqueous (range, 0.5-3.9 ng/ml) cavities. No relationship was found between serum and intraocular levels.nnnCONCLUSIONSnThis study shows that tamoxifen penetrates intraocular fluids to varying degrees. The drug levels in aqueous and vitreous do not appear to correlate with serum levels. Evidence of tamoxifen retinopathy or keratopathy was not seen.