Don H. Nicholson

Retained Lens Fragments after Phacoemulsification

PURPOSE The authors present the clinical features of patients with retained lens fragments after phacoemulsification and their outcome after pars plana vitrectomy. METHODS The authors performed a retrospective chart review of 62 patients who had surgical management of posteriorly dislocated lens fragments after phacoemulsification during the 3-year period from January 1990 to December 1992. RESULTS Eight of the 62 patients underwent vitrectomy on the same day as the cataract surgery. Of the remaining 54 patients examined in the outpatient clinic, initial clinical features included marked intraocular inflammation (87%), elevated intraocular pressure of 30 mmHg or higher (46%), and corneal edema (46%). Retinal detachment was present before vitrectomy in one patient and occurred after vitrectomy in two others. Initial visual acuity was 20/200 or worse in 68% of patients. After vitrectomy, final visual acuity was 20/40 or better in 68% of patients. Using the percentage of patients with 20/40 or better final visual acuity, there was no statistically significant difference in surgery performed within 7 days (70%), between 1 and 4 weeks (60%), and after 4 weeks (70%). Twenty (80%) of 25 patients with initial posterior chamber intraocular lenses (PC IOLs) and 16 (62%) of 26 patients with initial anterior chamber IOLs (AC IOLs) achieved 20/40 or better visual acuity. A visual acuity outcome of 20/200 or worse occurred in all three patients with retinal detachment. Six of the eight patients who underwent vitrectomy on the same day as the cataract surgery achieved 20/30 or better visual acuity. CONCLUSIONS The timing of vitrectomy did not influence visual acuity outcomes. Intraocular lenses inserted at the primary operation did not adversely affect the visual outcome. However, vitrectomy on the same day as cataract surgery generally yielded favorable visual acuity outcomes and eliminated the need for a second operation at a later date. In most patients with retained lens fragments, management with vitrectomy allowed good visual acuity outcomes.

Light and Electron Microscopic Study of Early Lesions in Angiomatosis Retinae

Multiple early untreated lesions of angiomatosis retinae in the peripheral retina and optic disk were discovered after death in both eyes of a patient with von Hippel-Lindau disease. Each of the four peripheral angiomas was studied by a different technique: routine light microscopy of serial histologic sections, electron microscopy, flat mount and trypsin digestion, and frozen section with special stains for lipid. The large capillaries comprising the core of each angioma displayed normal endothelium, basement membrane, and pericytes. Thus, capillary hemangioma of the retina is a more correct histopathologic designation for the von Hippel angioma than terms such as hemangioblastoma or hemangioendothelioma. Interstitial cells separating the vascular channels of the angioma were identified as astrocytes that contain large lipid-filled cacuoles. Serial histologic sections demonstrated that both retinal and choroidal vessels communicate with vascular channels of the juxtapapillary capillary hemangiomas.

Results and Complications in Treated Retinal Breaks

One hundred sixty-four patients (171 eyes) were treated for retinal breaks and the treatment outcomes were studied. One hundred two eyes were acutely symptomatic, 22 eyes were chronically symptomatic, and 47 eyes were asymptomatic. The reasons for further treatment in 38 of the 171 eyes (22%) included the following: (1) inadequate closure of the original break without detachment in eight eyes (5%), (2) new breaks without detachment in 15 eyes (9%), (3) an operation for retinal detachment caused by the original break in seven eyes (4%), or (4) retinal detachment caused by a new break in eight eyes (5%). Failure rates of treatment among acutely symptomatic, chronically symptomatic, and asymptomatic subgroups were not statistically significant. The risk of treatment failure was higher for aphakic and pseudophakic eyes, and in eyes with peripheral retinal abnormalities in the fellow eye. Among 38 patients with failed treatments, 20 (52%) returned for further examination within one month of initial treatment, whereas eight of the 38 patients with failed treatments (21%) returned six months or more after initial treatment. Peripheral retinal abnormalities were recognized initially in 65 of the 171 fellow eyes (38%) and subsequently developed in nine of the fellow eyes (5%) during the follow-up interval. Further treatment is often necessary after initial treatment of peripheral retinal breaks, emphasizing the need for careful long-term follow-up care.

Echographic and histologic tumor height measurements in uveal melanoma.

We studied the relation between echographic tumor elevation (measured by standardized A-scan echography) and histologic tumor thickness (measured from histologic slides with an ocular micrometer) in a series of 53 choroidal and ciliary body melanomas enucleated within one month of the most recent echographic measurement. Histologic height was less than echographic height for all sizes and locations studied, with a correlation coefficient of r = .926. The following equations for straight lines described the relationship: Echographic height = 1.964 + (1.042 X histologic height). Histologic height = -0.660 + (0.823 X echographic height). Thus, current thickness criteria for small (less than 3 mm), medium (3 to 5 mm), and large (more than 5 mm) melanomas, based on histologic measurements, may be translated to the following echographic terms: small, less than 5.2 mm; medium, 5.2 to 7.2 mm; and large, more than 7.2 mm. The source of this difference is a variable degree of tumor shrinkage induced by fixation and histologic preparation.

Echographic features of medulloepithelioma

PURPOSE To evaluate the echographic features of medulloepithelioma that may assist in establishing the diagnosis. METHODS Retrospective review identified four eyes with medulloepithelioma studied with echography. Clinical records, echographic findings, histopathologic tumor features, and the clinical course were reviewed. RESULTS The initial preoperative diagnosis of medulloepithelioma was uncertain, based on clinical findings alone in three cases but was accurate when echographic findings were combined with clinical findings in all four cases. Cysts posterior to the iris were detected on clinical examination in only two cases, but were revealed on echography in all four cases. Additional echographic findings included irregular high internal reflectivity (n = 4), irregular tumor surface (n = 3), molding around intraocular structures (n = 3), and internal vascularity (n = 2). CONCLUSIONS The diagnosis of medulloepithelioma is not always apparent on clinical examination alone. Echographic findings of a highly reflective, irregularly structured tumor with associated cystic changes involving the ciliary body region may help establish a presumed diagnosis of medulloepithelioma.

A clinical and histopathological study of François-Neetens speckled corneal dystrophy.

A 57-year-old black man had François-Neetens speckled dystrophy of the cornea and orbital phycomycosis. Examination of family members confirmed an auto-somal-dominant pattern of inheritance. Light and electron microscopic study of the cornea of a blind eye disclosed that the corneal opacities were represented by swollen, vacuolated keratocytes filled with histochemically demonstrable acid mucopolysaccharide and complex lipids. Thus, this dystrophy may represent a dominantly inherited metabolic disorder confined to the cornea.

Congenital Cysts of the Iris Stroma

We managed three cases of congenital iris stromal cysts and compared them with 22 cases in the published reports to delineate the clinical features of this condition and determine the best treatment. Our first patient, a 5-month-old girl, had injection of a cyst with trichloroacetic acid, but developed a cataract and endothelial damage to the cornea and the eye was eventually enucleated. Our second patient, a 9-week-old girl, was treated with repeated xenon photocoagulation, drainage of the cyst, and cryotherapy, but required enucleation of the eye. Our third patient, a 5-month-old girl, had excision of the cyst by sector iridectomy with preservation of vision and no recurrence two years later. Our results suggest that complete surgical excision is a superior method of treatment for congenital cysts of the iris stroma.

Rhegmatogenous Retinal Detachment in Angiomatosis Retinae

Three patients with von Hippel tumors of the retina developed rhegmatogenous retinal detachments caused by surface traction on the angioma. The break in each case was located at the posterior base of the angioma, between the afferent and efferent vessels. Conventional scleral buckling surgery with cryotherapy and a silicone episcleral sponge successfully reattached the retina in all three cases.

Pars plana vitrectomy during cataract surgery for prevention of aqueous misdirection in high-risk fellow eyes

PURPOSE To report the use of pars plana vitrectomy as a prophylactic measure during cataract surgery for prevention of aqueous misdirection in high-risk fellow eyes. METHODS Chart review of two patients with severe aqueous misdirection in their first eye at the time of cataract surgery that only responded to pars plana vitrectomy. RESULTS In both patients, cataract extraction with posterior chamber intraocular lens implantation was initially performed after pars plana vitrectomy, with the creation of hyaloido-capsulo-iridotomy to establish a communication between the vitreous cavity and the anterior chamber. CONCLUSION Pars plana vitrectomy as a prophylactic measure during cataract surgery may have a beneficial role in fellow eyes at high risk for developing aqueous misdirection.

Treatment of Massive Subretinal Hemorrhage From Complications of Scleral Buckling Procedures

Vitrectomy techniques permit removal of subretinal hemorrhage, but the prognosis varies and depends principally on the cause of the hemorrhage. Nine consecutive patients undergoing pars plana vitrectomy with internal drainage of massive subretinal hemorrhage from complications of scleral buckling procedures were studied, to evaluate the long-term results. In all eyes, the final visual acuity was improved, compared with preoperative visual acuity, and was 20/80 or better in seven of nine cases. Recurrent retinal detachment secondary to proliferative vitreoretinopathy developed in two patients, but complete retinal reattachment was achieved after further procedures were performed. Patients with massive subretinal hemorrhage from complications of scleral buckling procedures comprise a subgroup of patients with subretinal hemorrhage in which internal drainage via pars plana vitrectomy is an acceptable alternative to observation only and may result in improved visual acuity outcomes.