Dwain G. Fuller

Factors Influencing Final Visual Results in Severely Injured Eyes

We reviewed 194 consecutive eyes treated by pars plana vitrectomy for severe injury with posterior segment involvement. By using multivariate analysis, we determined which of a large number of clinical, ultrasonographic, and electrophysiologic factors influenced or predicted postoperative visual acuity. Additionally, the effects of the timing of vitrectomy on final vision and the usefulness of prophylactic scleral buckling were analyzed. We found that although clinical data have predictive value, it is electrophysiological information, specifically the visual-evoked potential, which most accurately predicts the postoperative vision of an injured eye. We could not demonstrate a significant effect of the timing of surgery on the final visual result but could determine that prophylactic scleral buckling clearly reduces the rate of delayed retinal detachments.

Retained Intravitreal Lens Fragments after Cataract Surgery

PURPOSE The purpose of this study is to review the possible benefits and complications of vitrectomy for retained lens fragments after cataract surgery. METHODS The authors reviewed the charts of 65 patients referred over a 12-year period for retained lens fragments after cataract surgery. Of these, 56 underwent vitrectomy and 9 were followed. Of these 56 eyes, 29 (52%) had received an intraocular lens (IOL) at the time of cataract surgery. RESULTS Resulting complications from retained lens material included glaucoma (52%), corneal edema (46%), uveitis (56%), and decreased vision (100%). These sequelae responded equally to vitrectomy in eyes with or without an IOL and irrespective of type of cataract surgery (phacoemulsification or extracapsular cataract extraction). The timing of surgery did not statistically influence the final vision or the incidence of glaucoma. CONCLUSION Removal of retained lens fragments allows rapid visual restoration, enhances resolution of uveitis, and improves control of glaucoma. Insertion of an IOL at the time of cataract surgery in the face of dislocated lens fragments is not contraindicated provided that it could be performed safely.

Visual field defects after macular hole surgery. A new finding.

PURPOSE The purpose of the study is to report the problem of a temporal visual field defect occurring after macular hole surgery. METHODS The authors reviewed the records of 13 patients found to have visual field defects after vitrectomy for macular holes. Fluorescein angiograms (13 patients), optic nerve photographs (13 patients), focal electroretinograms (3 patients), and nerve fiber analyses (8 patients) were performed in patients with visual field defects. RESULTS An absolute, temporal, usually inferior field defect was noted in 13 patients. In eight patients, the defect was detected because of specific reports or retrospective field examination results. Five patients examined in a prospective manner were found to have field defects. No history of abnormal intraocular pressure or direct trauma to the optic nerve or retinal vessels was identified. Four patients showed optic nerve pallor and three had an anomalous-appearing disc. Focal electroretinograms were of similar amplitude in the involved retina compared to corresponding areas in the healthy fellow eye. Nerve fiber analysis showed a reduction in nerve fiber layer thickness correlating to the visual field defect in those eight patients in which this test was used. CONCLUSION A significant temporal field defect may occur in patients after otherwise uncomplicated surgery for macular holes. The cause is unclear; however, reductions in nerve fiber layer thickness from the superior and nasal peripapillary area suggest that acute surgical release of the posterior hyaloid and the use of long-acting intraocular gas may in certain patients result in visual field defects.

Cataract Extraction in the Diabetic Eye after Vitrectomy

We examined 289 phakic, diabetic eyes for evidence of cataract formation after a successful vitrectomy. Of 289 eyes, 107 (37%) developed or had significant progression of a cataract over a follow-up period of 16 to 108 months. Postvitrectomy hemorrhage and vitreous lavage were associated with an increased rate of cataract formation. Of the 107 eyes, 33 (31%) subsequently had cataract extraction, with 24 eyes (73%) treated by extracapsular cataract extraction and nine eyes (27%) with intracapsular surgery. A posterior chamber lens was used in 11 of the 24 eyes that underwent extracapsular surgery. Of the 33 eyes, 31 (94%) had improved visual acuity after cataract extraction. Intraoperative and postoperative complications were minimal and did not result in permanent reduction of vision. Intraocular lenses were well tolerated in the 11 patients in whom they were used.

A Comparison of Visual Function Tests in Eyes with Maculopathy

Several recently developed tests of visual function, including the Potential Acuity Meter (PAM), laser interferometer (LI), white-light interferometer (WLI), blue field entoptic phenomenon, and focal electroretinogram (ERG) were compared in 81 eyes with clear media and known macular disease. The results indicate that the PAM, the LI, and the WLI overread relative to Snellen acuity. Laser interferometric acuity values differed from Snellen acuity by at least 1.5 octaves in approximately 40% of all eyes, regardless of stimulus size (2, 5, or 8 degrees). Similar results were obtained with the WLI. Agreement with Snellen acuity was better for the PAM, with 91% of eyes falling within 1.5 octaves of Snellen acuity. Blue field and focal ERG results were categorized as normal or abnormal. While not producing Snellen equivalents, abnormal results from the blue field and focal ERG corresponded with poor Snellen acuity (less than 20/40) in 65% and 91% of eyes, respectively. Assuming that media opacities do not prevent adequate retinal stimulation, the present results suggest that the PAM and focal ERG are the most reliable for evaluating macular function when maculopathy is present.

Laser treatment in fellow eyes with large drusen: Updated findings from a pilot randomized clinical trial

PURPOSE To update the findings from the Choroidal Neovascularization Prevention Trial (CNVPT) with respect to resolution of drusen, incidence of choroidal neovascularization, and visual function. DESIGN A multicenter, randomized, controlled, pilot clinical trial. PARTICIPANTS The 120 patients enrolled in the CNVPT. Patients had signs of choroidal neovascularization or retinal pigment epithelial detachment in 1 eye and had >/=10 large (>63- micro m) drusen in the contralateral, or fellow, eye. INTERVENTION The fellow eye of 59 patients was assigned randomly to argon green laser treatment consisting of multiple 100- micro m spots at least 750 micro m from the center of the fovea. The fellow eye of the remaining 61 patients was assigned randomly to observation. MAIN OUTCOME MEASURES Change in visual acuity was the primary outcome measure. Incidence of choroidal neovascularization, resolution of drusen, change in contrast threshold, change in critical print size for reading, and incidence of geographic atrophy were secondary outcome measures. RESULTS Throughout 4 years of follow-up, there were no statistically significant differences in change in visual acuity, contrast threshold, critical print size, or incidence of geographic atrophy. With additional follow-up, the large increase in the incidence of choroidal neovascularization observed within 18 months of treatment was maintained; however, by 30 months, the incidence in the two treatment groups was the same. Most drusen resolution in treated eyes occurred within 24 months of the initial treatment. Treated eyes that received higher-intensity laser burns had an increased risk of choroidal neovascularization. Among eyes developing choroidal neovascularization in each treatment group, most lesions (two thirds or more) were composed of occult neovascularization only. CONCLUSIONS Laser treatment as applied in the CNVPT caused an excess risk of choroidal neovascularization in the first year or so after treatment. The increased early incidence of choroidal neovascularization was not associated with either a harmful or beneficial effect in this pilot study.

prediction Of Postoperative Vision In Eyes With Severe Trauma

&NA; The single most important factor determining the potential for return of useful vision in severely injured eyes is the magnitude of damage incurred by the macula or optic nerve at the time of injury. Most gravely injured eyes have media opacities that prevent funduscopic examination. In such eyes, the flash visually evoked potential is the single best predictor of postoperative vision. The second most reliable predictor is the bright‐flash electroretinogram. Ultrasonography is an important part of the preoperative assessment of injured eyes with opaque media, but is of less value than electrophysiological testing in predicting postoperative vision in eyes with major trauma.

Retinal Detachment and Pseudophakia

A consecutive series of pseudophakic retinal detachments was statistically compared with a matched group of aphakic retinal detachments. Distribution of breaks, anatomic results, and final visual acuities were tabulated. Success in reattachment was equal in the two groups, but final visual acuities were better in the aphakic group. Emphasis was placed on the intraoperative ophthalmoscopic examination of pseudophakic eyes with compromised peripheral fundus visibility.

A Technique for Accurate Placement of Episcleral Iodine-125 Plaques

Confirmation of iodine-125 plaque position was determined with a modified fiberoptic light pipe that directed light at right angles to the long axis of the fiberoptic pipe. While the examiner observed the interior of the eye with indirect ophthalmoscopy, the point source of light from the fiberoptic light pipe was moved along the margins of the episcleral plaque. The position of the plaque relative to the location of the underlying melanoma could then be verified by transillumination.

Temporary Keratoprosthesis for Combined Penetrating Keratoplasty, Pars Plana Vitrectomy, and Repair of Retinal Detachment

The Landers-Foulks temporary keratoprosthesis was used to combine penetrating keratoplasty, pars plana vitrectomy, and scleral buckling in the management of 13 eyes with opaque cornea and posterior segment abnormalities. In seven cases, trauma precipitated the ocular disease. Complications of cataract surgery resulted in anterior and posterior segment pathology in six cases. The corneal graft was initially clear in all cases. However, corneal edema complicated phthisis bulbi in four cases and followed homograft reaction in two cases. Eight eyes with retinal detachment (RD) preoperatively were successfully reattached. In five eyes, the retina redetached as these eyes became phthisical. Visual function improved in six cases. In general, eyes with a history of trauma had a much poorer outcome than did eyes with anterior and posterior segment problems related to previous cataract surgery.