James E. Puklin

Phacoemulsification for Cataract Following Pars Plana Vitrectomy

BACKGROUND AND OBJECTIVE To determine if the technical aspects of phacoemulsification for removal of cataract following pars plana vitrectomy differ from those of phacoemulsification for removal of cataract in nonvitrectomized eyes. PATIENTS AND METHODS Twenty-two eyes that had undergone prior vitrectomy were identified through a retrospective review of chart notes and operative records of 1039 consecutive cataract extractions performed by one surgeon. RESULTS Complications of proliferative diabetic retinopathy was the most common indication for prior vitrectomy. The predominant lens change was nuclear sclerosis. Deep anterior chambers with large anterior to posterior excursions of the iris lens diaphragm with simultaneous fluctuation in pupil size occurred during phacoemulsification. The posterior capsule was flaccid and mobile during lens cortex removal. No posterior capsules ruptured. Postoperative visual acuity improved in 91% of the patients. CONCLUSIONS Prior vitrectomy was associated with diabetes and nuclear sclerotic cataract. Phacoemulsification in this patient population was associated with inadequate pupillary mydriasis, superior conjunctival scarring, intraoperative anterior chamber depth, pupil size, and iris lens excursions that hindered phacoemulsification tip placement. Posterior capsules were excessively flaccid, prone to rapid anterior and posterior excursions, and may have plaques that are resistant to intraoperative removal.

Fungal Endophthalmitis Diagnosis by Detection of Candida albicans DNA in Intraocular Fluid by Use of a Species-Specific Polymerase Chain Reaction Assay

Candida endophthalmitis is a serious infection secondary to hematogenous dissemination or direct inoculation of the organisms following trauma or eye surgery. The diagnosis is based on the characteristic findings in the infected eye and on culture of vitreous samples. Unfortunately, the yield of vitreous cultures is limited. The use of a Candida albicans species-specific polymerase chain reaction (PCR) assay in the diagnosis of Candida endophthalmitis is reported herein. Four patients with suspected fungal endophthalmitis underwent vitrectomy for diagnostic and therapeutic purposes. In 2 of the 4, vitreous cultures were negative. However, characteristic PCR products were generated in all 4 patient specimens, enabling the rapid diagnosis of Candida endophthalmitis in all 4. Clinical response was observed in all cases. These results demonstrate the utility of PCR-mediated detection of C. albicans in vitreous samples.

Posterior Uveitis in Patients with Positive Serology for Syphilis

The clinical features and ophthalmologic findings of 20 patients with syphilitic posterior uveitis seen at the Detroit Medical Center from November 1993 through February 1996 were reviewed. The mean age was 58 years; 8 patients were male and 12 were female; and all patients were black. Three of 9 patients tested were HIV positive. Patients were divided into 2 groups: those with acute (8) and those with chronic (12) syphilitic posterior uveitis. Chorioretinitis was the predominant uveitic pattern (15/20). Eighteen patients presented with blurred vision. All patients had reactive serum fluorescent treponemal antibody, absorbed (FTA-ABS); 3 had nonreactive rapid plasma reagin (RPR). Mean RPR titer in the chronic uveitis group and in the acute uveitis group was 1:27.3 and 1:209.8, respectively. Seven patients had abnormal cerebrospinal fluid (CSF); CSF VDRL was reactive in 2 patients. All patients were treated with intravenous penicillin G. Eight of 14 patients seen at follow-up showed improvement of ophthalmologic findings. Syphilis should be considered in the differential diagnosis of posterior uveitis.

Syphilitic Posterior Uveitis: Correlative Findings and Significance

Twenty-one patients with syphilitic posterior uveitis were investigated retrospectively to study the disease spectrum, associations with neurosyphilis, and therapeutic implications. Ophthalmologic manifestations of syphilitic posterior uveitis are differentiated into acute and chronic uveitides. The several distinct acute uveitic syndromes are usually florid and are associated with early syphilis, with VDRL-positive syphilitic meningitis, and frequently with human immunodeficiency virus coinfection. The chronic posterior uveitides are often insidious, a manifestation of late syphilis, and associated commonly with subclinical neurosyphilis. All patients with acute cases and 54% of patients with chronic cases in our study received penicillin therapy appropriate for neurosyphilis. The frequent association of syphilitic posterior uveitis with neurosyphilis and the analogous spirochetal sequestration beyond the blood-brain and the blood-ocular barriers suggest that all patients with syphilitic posterior uveitis, irrespective of ocular disease intensity, should undergo evaluation of cerebrospinal fluid and be treated with penicillin regimens appropriate for neurosyphilis.

Reduced need for corneal epithelial debridement during vitreo-retinal surgery using two different viscous surface lubricants.

PURPOSE Corneal clarity is frequently reduced during vitrectomy and scleral buckling surgery secondary to epithelial edema, requiring epithelial debridement to improve visibility. The presence of toxic preservatives in the corneal lubricant solutions is hypothesized to be a contributing factor to epithelial edema during vitreo-retinal surgery. DESIGN Interventional study. METHODS We compared prospectively the corneal clarity and epithelial debridement frequency in 71 patients within a single institution in whom either Goniosol (2.5% methylcellulose, boric acid, edetate disodium, sodium borate, potassium chloride, water, and 0.01% benzalkonium chloride) or GenTeal gel (0.3% hydoxypropyl-methylcellulose, carbopol 980, phosphonic acid, sorbitol, water, and 0.028% sodium perborate) was used as a corneal lubricant during the course of vitrectomy surgery using sutured contact lenses. Corneal clarity was subjectively graded in a scale of I to IV during surgery. Statistical analysis was made between these two groups for parametric and categorical data. RESULTS All eyes started with a corneal clarity grade of I (best possible). Corneal clarity decreased significantly faster in eyes where Goniosol was used to a median grade of III at 1 hour of surgical time. In eyes where GenTeal gel was used, corneal clarity decreased much slower, to a median grade of I at 1 hour of surgical time. The difference in frequency of epithelial debridement was also statistically significant: 54% and 14% for Goniosol and GenTeal eyes, respectively. Other factors that may cause corneal epithelial edema and affect corneal clarity were not statistically different between the Goniosol and the GenTeal groups, including median operative time, estimated intraocular pressure, pre- and intraoperative topical solutions and medications, and number of prior ocular procedures. CONCLUSIONS The use of GenTeal gel as a corneal lubricant maintains corneal clarity longer than Goniosol during the course of vitrectomy surgery using a contact lens viewing system, limiting the need for epithelial debridement.

Scleral Flap Necrosis and Infectious Endophthalmitis after Cataract Surgery with a Scleral Tunnel Incision

BACKGROUND Long scleral tunnel dissection techniques have been developed for cataract surgery incisions. These incisions reduce postoperative astigmatism and keratorefractive instability. If fashioned correctly, the internal lip of the incision produces a tight seal to the anterior chamber, permissible of sutureless surgery. The behavior of such a wound during intraocular infection is unknown. METHODS The authors describe two elderly patients in whom postoperative bacterial endophthalmitis was accompanied by infectious scleritis, infectious sclerokeratitis or keratitis, and rapid scleral flap necrosis. One of the patients had a painless disease process. RESULTS Intraocular isolates of Staphylococcus aureus and Streptococcus equinus were recovered from the two patients, respectively. Management was complicated by loss of tectonic integrity that followed scleral flap necrosis, by impaired vitreoretinal visualization associated with rapidly progressive sclerokeratitis or keratitis, and by bacterial scleritis in the base of the scleral flap. No light perception was retained in either eye. CONCLUSION Scleral tunnel incisions create a potential abscess cavity. Although a rare occurrence, postoperative endophthalmitis in such an eye may present major surgical and therapeutic problems intrinsic to the wound design.

Mechanisms of Retinal Arterial Occlusive Disease in African American and Caucasian Patients

BACKGROUND AND PURPOSE The aim of our study was to evaluate the causes of retinal arterial occlusive disease in African American patients and to compare these etiologies with those observed in Caucasian patients with retinal ischemic symptoms. METHODS We performed a retrospective analysis of a series of consecutive patients evaluated by both the ophthalmology department and the neurology/stroke clinic. Patients had a diagnosis of amaurosis fugax, branch retinal artery occlusion, central retinal artery occlusion, or intra-arterial retinal plaques. RESULTS Twenty-nine African American patients and 17 Caucasian patients were evaluated. African American patients had a mean age of 61 years (range, 30 to 77 years) and Caucasian patients a mean age of 73 years (range, 56 to 94 years) (P=0.003). There was no statistically significant difference between the 2 groups with respect to visible emboli on funduscopy (P=0.462). After adjusting for age, there was also no difference between the 2 groups with regards to risk factors for arterial occlusive disease such as hypertension, coronary artery disease, hypercholesterolemia, tobacco use, and history of stroke or transient ischemic attacks. Caucasian patients had a 41% incidence (7/17) of high-grade ipsilateral internal carotid artery stenosis, measured by carotid duplex, compared with 3.4% incidence (1/29) in African American patients (P=0.002). CONCLUSIONS There are racial differences in the causes of retinal arterial occlusion. African American patients have a low prevalence of moderate to severe extracranial carotid stenosis, and a high proportion of African American patients have cryptogenic retinal ischemia. In Caucasian patients there is a stronger association between extracranial carotid artery disease and retinal arterial occlusion.

Corneal topography in Ehlers-Danlos syndrome

Purpose: To assess the use of corneal topography in conjunction with slitlamp biomicroscopy and retinoscopy to diagnose keratoconus in a large group of patients with Ehlers‐Danlos syndrome (EDS). Setting: Kresge Eye Institute, Wayne State University, Detroit, Michigan, USA. Methods: Thirty‐six patients (72 eyes) with genetically typed EDS had slitlamp biomicroscopy, retinoscopy, and videokeratography with the EyeSys instrument. The presence or absence of slitlamp keratoconus findings was correlated to a presumptive diagnosis based on corneal topography using derived topographic indexes associated with keratoconus. These topographic indexes included central corneal power, (CCP), difference in CCP, inferosuperior asymmetry (I‐S) value, and asphericity (Q). Axial and profile difference maps were generated and analyzed for findings suggestive of keratoconus. Results: In 72 eyes, no keratoconus was found using slitlamp biomicroscopy. No eye had an I‐S value greater than 1.60 diopters (D), 2 eyes had a CCP greater than 46.50 D, and 2 eyes had a Q value less than ‐1.00. Eight of 36 pairs of eyes had an intereye CCP greater than 0.92 D. In both eyes of the patient with Q values less than ‐1.00, the profile difference maps were mildly abnormal. Conclusions: Slitlamp biomicroscopy of the cornea was unremarkable in all patients. Only 1 patient had Q values and profile difference maps that were mildly suggestive of keratoconus. Even after adding topography to the examination, it appears that keratoconus in a known population of patients with EDS remains rare.

Chronic Propionibacterium acnes endophthalmitis as a cause of intermediate uveitis

Although the pathogenesis in most cases of intermediate uveitis is unknown, a small minority of cases is associated with a variety of specific inflammatory etiologies: sarcoidosis; multiple sclerosis; Lyme disease; syphilis; ocular lymphoma; and as a rare manifestation of Behçets disease and AIDS. A 61-year-old woman developed pars planitis after cataract surgery. A vitrectomy was performed after ten months when a white capsular plaque and an hypopyon developed. Propionibacterium acnes was isolated. The intermediate uveitis was not controlled until later removal of the intraocular lens and capsular remnants. Chronic propionibacterial endophthalmitis may be a cause of intermediate uveitis.

Pars plana cicatrization of sewn-in posterior chamber intraocular lens haptics

The authors describe the unexpected finding of cicatrization of posterior chamber lens haptics to the pars plana. This was found during removal of a secondary, transscleral sewn-in pseudophakos during a retinal reattachment procedure. Ophthalmic history and intraoperative photography revealed pars plana cicatrization of haptics. Despite removal of trans-scleral prolene fixation sutures and application of gentle traction, the posterior chamber lens haptics remained firmly adherent to pars plana retina. The haptics were amputated to prevent significant chorioretinal damage. The conventional belief that all sewn-in posterior chamber intraocular lenses cause little or no scarring response around the haptics may be unfounded.