Jay L. Federman

Complications Associated with the Use of Silicone Oil in 150 Eyes after Retina-vitreous Surgery

Complicated retinal detachments (RDs) were successfully managed in 150 eyes of 170 consecutive patients by one surgeon (JLF) using silicone oil in conjunction with modern pars plana vitrectomy. Long-term postoperative complications were observed between 6 months and 5 years of follow-up. Cataracts developed in all phakic eyes and all corneas with oil-endothelial touch showed band keratopathy within 6 months. Recurrent detachments were noted in 22% of eyes during silicone oil tamponade and occurred in 13% of eyes after the oil had been removed. Other complications associated with the use of oil for vitreous surgery included pupillary block glaucoma (3%), closure of the inferior iridectomy (14%), fibrous epiretinal and subretinal proliferations (15%), pain (5%), and subconjunctival deposits of oil (3%). Without exception, within a period of 1 year the intraocular silicone oil showed some degree of emulsification, suggesting that the physicochemical characteristics of the oil injected may be an important variable in long-term complications.

Surgical Removal of Massive Subretinal Hemorrhage Associated with age-related Macular Degeneration

The authors report on 11 patients with age-related macular degeneration associated with massive subretinal hemorrhage, who were treated with surgical removal of the hemorrhage and associated fibrosis. Preoperative visual acuity ranged from 20/400 to hand motions. Postoperative visual acuity ranged from 20/200 to light perception with a minimum of 3 months of follow-up. Complications included partial or total retinal detachment in four patients (36%) and cataract in four patients (36%). Four of 11 patients showed some improvement in vision (36%). All four of these patients had surgery within 1 week of the onset of severe visual loss. Although surgical removal of large subretinal hemorrhages is technically feasible, visual recovery is limited, even in uncomplicated cases, by macular degenerative changes.

Arterial Obstruction and Ocular Neovascularization

A series of 12 patients (13 eyes) with neovascular glaucoma in association with arterial obstructive disease is presented. Appropriately characterized as having an ocular ischemic syndrome, the anterior segment findings in each included aqueous flare and rubeosis iridis. Posterior segment manifestations included midperipheral intraretinal hemorrhages (venous stasis retinopathy), narrowed retinal arteries, often a cherry red spot, and neovascularization of the disc and/or retina. Most eyes with the ocular ischemic syndrome have either ipsilateral common carotid artery obstruction or severe bilateral obstruction of the internal carotid arteries.

Arteriovenous adventitial sheathotomy for the treatment of macular edema associated with branch retinal vein occlusion

PURPOSE To report arteriovenous adventitial sheathotomy for treatment of macular edema associated with branch retinal vein occlusion. METHODS Case reports with review. Five eyes of five patients with best-corrected visual acuity of less than 20/200 secondary to branch retinal vein occlusion had pars plana vitrectomy and arteriovenous adventitial sheathotomy and were followed postoperatively for a mean of 6.5 years (range, 5 to 7 years). RESULTS In four of five eyes, the best-corrected visual acuity improved to 20/30 to 20/70. In the remaining eye, visual acuity remained at finger counting secondary to macular ischemia. CONCLUSION Arteriovenous adventitial sheathotomy may be beneficial for select patients with poor vision secondary to branch retinal vein occlusion.

The Management of Giant Retinal Tears Using Perfluoroperhydrophenanthrene: A Multicenter Case Series

OBJECTIVE The purpose of the study was to determine the predictors of success and evaluate the use of perfluoroperhydrophenanthrene as an intraoperative and postoperative tool in the management of giant retinal tears in a multicentered collaborative study. DESIGN Multicentered prospective case series. PARTICIPANTS Twenty-three centers consecutively enrolled 162 eyes of 161 patients with retinal tears 90 degrees or greater in circumferential extent. INTERVENTION Perfluoroperhydrophenanthrene was used as an intraoperative surgical adjunct in all cases and left after surgery in 16 eyes (9.9%). MAIN OUTCOME MEASURES Retinal reattachment and visual acuity. RESULTS Intraoperative reattachment was achieved in 158 eyes (97.5%); 147 eyes (90.7%) remained attached at their most recent follow-up. Seventy-nine eyes (48.8%) experienced an improvement in their visual acuity, 26 eyes (16.0%) remained unchanged, and 57 (35.2%) worsened. Recurrent retinal detachment occurred in 80 patients (49.4%). Other significant postoperative complications included cataract formation in 20 (39.2%) of 51 eyes, macular pucker in 12 (7.4%), corneal decompensation in 10 (6.2%), and hypotony (intraocular pressure equal to or less than 5 mmHg) in 9 (5.6%). A chi-square analysis of preoperative characteristics showed that hypotony (P = 0.007), macular detachment (P = 0.020), a history of cataract extraction (P = 0.003), poor visual acuity (P = 0.000), giant tear extent greater than 180 degrees (P = 0.004), and higher grade proliferative vitreoretinopathy (P = 0.000) all predicted a poor visual outcome. Vitreon (Vitrophage, Inc., Lyons, IL) was left in 16 eyes (9.9%) for an extended postoperative retinal tamponade for between 3 and 1034 days (mean, 87.2 days). The Vitreon was well tolerated, and these eyes experienced a similar outcome and rate of retinal reattachment to the rest of the group. CONCLUSIONS Vitreon is a safe and useful adjunct to pars plana vitrectomy in the management of giant retinal tears and may, additionally, be the perfluorocarbon liquid that can be used most safely as a temporary postoperative tool for extended retinal tamponade, reinforcing its role as a useful adjunct in the management of these complex retinal detachments.

Irreversible Silicone Oil Adhesion to Silicone Intraocular Lenses

PURPOSE To report a newly defined complication of foldable intraocular lenses (IOLs), namely silicone oil-silicone IOL interaction. This is a complication not generally seen by the implanting cataract surgeon but, rather, at a later stage in a patients postoperative course, by a vitreoretinal surgeon. METHODS Three clinical case histories, including two explanted silicone IOLs, were submitted for analysis. The submitted silicone lenses were photographed under water, and the nature of the silicone oil coating was documented. RESULTS In each instance, the silicone coating was manifest as a thick coating with droplet formation on the lens surface that was tenaciously adherent and could not be dislodged by instruments or injection of viscoelastics. CONCLUSION The use of silicone IOLs in patients with current vitreoretinal disease or those who are at high risk for future vitreoretinal disease that may require silicone oil as part of the therapy should be reconsidered. The authors recommend that information regarding the existence and significance of this complication be printed on all silicone oil and silicone IOL packages and inserts (if not as a warning, at least as an informative comment regarding the existence of this condition). This is a rare but clinically significant complication that will affect the occasional patient treated with both of these modalities.

Vitrectomy and cystoid macular edema.

Twenty-two patients who underwent vitrectomy surgery for chronic cystoid macular edema (CME) were evaluated. These patients all had uneventful intracapsular cataract extraction, but CME with vitreous adhesions to the cataract incision later developed. Vitrectomy was performed to remove the vitreous from the anterior segment structures in each case. Nineteen of the 22 patients showed improved visual acuities within six months, and all but two had complete resolutions of the CME by one year. These two patients did show marked improvements of visual acuity. The majority of patients younger than 65 years of age had final visual acuities of 20/50 or better, whereas the majority of those older than 65 years had less than 20/50. The results were not influenced by the duration or the pattern of the CME prior to vitrectomy. A prospective study to determine the value of vitrectomy in this type of patient is suggested.

Experimental Ocular Angiogenesis

In 29 experiments, vascular autologous retina from the contralateral rabbit eye was implanted into corneal pockets in New Zealand white rabbits. The implants induced a neovascular growth of limbal vessels that anastomosed with the vessels of the implant in 15 of the cases. Implantation of vascular autologous iris, choroid, optic nerve extraocular muscle, and conjunctiva also induced neovascularization. Avascular peripheral retina, cornea, and scleral implants did not cause a neovascular response, nor did boiled vascular retina, boiled iris, and boiled choroid. Neovascularization from the retinal and iris intracorneal implants was induced by V2 carcinoma.

Branch Retinal Artery Occlusion as the Initial Sign of Giant Cell Arteritis

PURPOSE To describe a patient whose initial sign of giant cell arteritis was a branch retinal artery occlusion. METHODS We examined a 77-year-old woman who developed arteritic anterior ischemic optic neuropathy three weeks after an isolated non-embolic branch retinal artery occlusion occurred in the same eye. RESULTS The diagnosis of giant cell arteritis was confirmed by temporal artery biopsy after the patient was treated with intravenous corticosteroids. CONCLUSIONS Although a rare cause of branch retinal vascular occlusion, giant cell arteritis should be considered in the differential diagnosis of a non-embolic branch retinal artery occlusion in elderly patients.

The Surgical and Nonsurgical Management of Persistent Hyperplastic Prima Vitreous

Fifteen patients (16 eyes) with persistent hyperplastic primary vitreous (PHPV) were followed from one to four years. All but one of the nine eyes in the nonsurgical group showed progressive deterioration. A closed intraocular microsurgical (CIOM) approach posterior to the limbus was used in seven eyes. Three intraoperative complications involving the retina occurred because the retina in these cases inserted directly into the pars plicata and due to the presence of a thick, well-formed vitreous gel. Anterior placement of incisions is recommended to avoid intraoperative complications in small eyes. Early CIOM management is suggested in selected cases of PHPV to prevent progressive deterioration leading to phthisis and to afford reasonable cosmetic improvements.