Herbert L. Cantrill

Ocular Complications Associated with Retrobulbar Injections

The authors describe six complications, of retrobulbar injections documented by fundus photography and fluorescein angiography. These include (1) injection of corticosteroid into the posterior ciliary arterial circulation resulting in emboli in the vasculature of the choroid and the optic nerve head; (2) injection of corticosteroid into the ophthalmic artery resulting in emboli in both the choroidal and retinal circulations; (3) presumed injection of lidocaine and air into the optic nerve sheath adjacent to the globe with extension anteriorly into the subretinal space and the space between the posterior vitreous and the internal limiting membrane; (4) occlusion of the central retinal artery without an associated retrobulbar hemorrhage; (5) trauma to and partial injection of lidocaine in the central retinal artery with embolization into the retinal circulation; and (6) presumed injection of lidocaine into the optic nerve sheath producing a combined central retinal vein and artery occlusion. Alternative techniques that might decrease the incidence of complications associated with retrobulbar injections are discussed.

Treatment of Cytomegalovirus Retinitis with Intravitreal Ganciclovir: Long-term Results

Long-term management of cytomegalovirus (CMV) retinitis by intravitreal injection of ganciclovir was evaluated in ten patients with acquired immune deficiency syndrome (AIDS). Patients were unable to tolerate systemic ganciclovir because of severe neutropenia (8 cases), catheter-induced sepsis (1 case), or the need to continue therapy for human immunodeficiency virus (HIV) with zidovudine (ZDV) (1 case). All patients had a favorable response to initial treatment. Cytomegalovirus retinitis progressed in four fellow eyes in which treatment was deferred. Vision improved or remained stable in all but one eye. Patients were followed for a mean of 4 months and received an average of 16.6 intravitreal injections in each eye. Relapse occurred late in the course while on maintenance treatment in five eyes (33%). There was no evidence of toxicity from repeated intravitreal injections. Treatment was very well tolerated. The only severe complication in a total of 249 injections was a single case of Staphylococcus epidermidis endophthalmitis which responded to intravitreal antibiotic treatment. Intravitreal ganciclovir is an effective alternative to systemic ganciclovir in those patients with severe neutropenia and in those patients who desire to remain on systemic ZDV.

Diabetic macular edema associated with glitazone use.

Purpose: To describe diabetic macular edema (DME) in patients who developed fluid retention as a consequence of glitazone use. Methods: A chart review identified 30 patients who used pioglitazone or rosiglitazone and had both lower extremity edema and macular edema. Clinical reports, photographs, and fluorescein angiograms were reviewed. Patients followed for >3 months were analyzed separately. Results: Seventeen patients took oral pioglitazone, 11 took rosiglitazone, and 2 took both drugs at different times. Eleven patients were observed for >3 months after cessation of glitazones. Mean weight gain during drug administration in this group was 30 lb, and mean weight loss after drug discontinuation was 19 lb. Rapid reduction in macular edema off drug occurred in only 4 of 11 patients, but 8 of 11 had reduced edema over 2 years. Mean visual acuity in this group at the initial visit was 20/60, and at the final visit, it was 20/85. Four eyes of three patients had resolution of diffuse macular edema with improved vision after cessation of glitazones without laser treatment. Conclusions: Fluid retention occurs in 5% to 15% of patients taking glitazones. In some of these patients, glitazone use appears to be a cause of macular edema, and drug cessation appears to result in rapid resolution of both peripheral and macular edema. Fluid retention associated with glitazone use should be considered when assessing treatment options for patients with DME, especially those with concomitant peripheral edema.

Surgical management of posteriorly dislocated silicone plate haptic intraocular lenses

PURPOSE To report a large series of delayed posterior dislocation of silicone plate haptic intraocular lenses after Nd:YAG laser capsulotomy and discuss the surgical management of this complication. METHODS We reviewed the records of 11 consecutive patients (11 eyes) with delayed onset of posterior dislocation of a plate haptic silicone intraocular lens. The cause of the posterior capsular defect, time to dislocation, surgical management techniques, complications, and visual outcome were recorded. RESULTS In eight of the 11 eyes, the silicone plate haptic intraocular lens dislocated an average of 1.8 months (range, 0 to 6.5 months) after Nd:YAG posterior capsulotomy. The other three eyes had surgical complications at the time of cataract extraction that compromised posterior capsular or zonular integrity and led to silicone plate haptic intraocular lens dislocation from 9 weeks to 6 months (mean, 3.6 months) postoperatively. Surgical management consisted of pars plana vitrectomy with intraocular lens repositioning (six eyes) or exchange (five eyes). The average follow-up period after intraocular lens repositioning or exchange was 6.5 months (range, 1 to 14 months). Best-corrected visual acuity at the last follow-up examination measured 20/40 or better in all but one eye that had preexisting macular disease. CONCLUSIONS Cataract surgeons and patients should be aware of the potential for plate haptic silicone intraocular lenses to undergo delayed posterior dislocation through capsular defects. This complication can be managed effectively with vitrectomy and either repositioning or exchange of the implant. Postoperative visual acuity is generally excellent, and complications are minimal.

Recovery of human immunodeficiency virus from ocular tissues in patients with acquired immune deficiency syndrome.

Human immunodeficiency virus (HIV) was recovered from multiple ocular tissues in three patients with acquired immune deficiency syndrome (AIDS). Consistently found in the retina, HIV was also detected in the conjunctiva, cornea, and iris. In two cases, HIV was detectable despite treatment with oral zidovudine. All three patients had bilateral cytomegalovirus (CMV) retinitis managed by intravitreal injection of ganciclovir. Culture of the retina for CMV was negative in all three cases. The finding of HIV in multiple ocular tissues is consistent with the neurotropic nature of the virus, and may explain some of the common ocular manifestations of AIDS such as AIDS retinopathy. Infection with HIV may predispose the retina to other opportunistic infections and may explain the high incidence of CMV retinitis in AIDS patients. This is the first report of HIV isolation from tissue within the eye.

Multifocal choroiditis associated with progressive subretinal fibrosis.

Five patients (all female, 14 to 34 years old) had an unusual form of multifocal choroiditis resulting in progressive subretinal fibrosis. This condition differed from other multifocal choroidal diseases such as acute multifocal placoid pigment epitheliopathy, birdshot retinochoroidopathy, and punctate inner choroiditis. Instead of forming atrophic or pigmented chorioretinal scars, the acute lesion healed with the formation of discrete, sharply angulated subretinal scars. In the macula the lesions coalesced, forming broad zones of subretinal fibrosis. Serous and hemorrhagic macular detachment may occur during the course of the disease with fluorescein angiographic features suggesting subretinal neovascularization. Subretinal neovascularization could not, however, explain the widespread scarring. Although progressive subretinal fibrosis may be considered an unusual outcome for a variety of other diseases, we believe that it is a distinct clinical entity distinguishable from other multifocal choroidal diseases. Retinal pigment epithelial hyperplasia may cause the condition.

Timing of vitrectomy for active proliferative diabetic retinopathy.

Eyes with active proliferative diabetic retinopathy with dense sub-hyaloid hemorrhage and significant visual loss represent an appropriate indication for prompt vitrectomy. Twenty-six such eyes in 22 patients were operated. The results are compared to 49 diabetic eyes undergoing vitrectomy for other complications of diabetic retinopathy. The results demonstrated both an improved anatomic success rate (85% compared to 73%) and a higher rate of reading visual function (54% compared to 18%) in the early vitrectomy group, substantiating the study hypothesis.

Histocompatibility Antigen Frequencies in Diabetic Retinopathy

We studied the histocompatibility antigens A and B in 300 insulin-dependent diabetics: 200 had proliferative retinopathy and 100 did not. The two groups were matched for known duration of diabetes and other clinical features. In both groups the frequencies of HLA-B8, HLA-B18, and HLA-B8/HLA-B15 were significantly higher, and those of HLA-B7 and HLA-B12 were significantly lower than in healthy controls. The patients with proliferative retinopathy were significantly less often positive for HLA-B7 (X2 = 10.0; Pc < .03) than patients with nonproliferative retinopathy. When both groups were stratified for age at diagnosis, there were additional differences. HLA-B15 was significantly more frequent in the proliferative retinopathy group with age at diagnosis between 15 and 40 years (nonproliferative retinopathy = 16.4%; proliferative retinopathy = 39.4%; X2 = 7.89, Pc < .03; relative risk = 3.32) and HLA-B7 significantly less frequent (nonproliferative retinopathy = 23.6%; proliferative retinopathy = 5.6%; X2 = 8.0, Pc < .03; relative risk = 0.19). These differences in histocompatibility frequencies between patients with and without proliferative retinopathy indicate a genetic contribution to diabetic retinopathy.

Vitrectomy for Double Penetrating Ocular Injuries

During the five-year period from 1977 to 1982, 15 consecutive patients with double penetrating ocular injuries were treated at the University of Minnesota. The 13 males and two females ranged in age from 5 to 38 years. Four patients had bilateral involvement. Vitrectomy techniques were used to stabilize the eyes and prevent or treat retinal detachment in 18 eyes. One eye was enucleated. Anatomic success was achieved in 11 eyes and visual success (visual acuity of 5/200 or better) in ten eyes. Surgical success was related to initial visual acuity, extent of vitreous hemorrhage, and the ability of the surgeon to excise completely the vitreous from the circumference of the exit wound.

Retinal Vascular Changes in Malignant Melanoma of the Choroid

A review of fluorescein angiograms from 41 patients with malignant melanoma of the choroid showed that 11 patients (27%) had evidence of retinal vascular abnormalities. Abnormal retinal capillaries were found in eight cases, areas of capillary nonperfusion in seven cases, and microaneurysms in four cases. Lipid exudation, retinal neovascularization, and arteriovenous communication were noted in one case each. Histopathologic studies in eight cases showed extensive degeneration of the overlaying retina in all eight cases and extension through Bruchs membrane by the tumor in four cases. Abnormal capillary architecture was demonstrated by trypsin digest preparations from four cases.