Joel A. Schulman

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.

Intravitreal injection of liposome-encapsulated ganciclovir in a rabbit model.

The authors determined the intravitreal clearance of liposome-encapsulated ganciclovir. Liposome-encapsu-lated ganciclovir (84.1 μg/0.1 ml) was injected into the vitreous cavity of New Zealand rabbits, which were killed at 24 hours and 7, 14, and 28 days after injection. Total ganciclovir concentrations in the vitreous, up to 28 days, were higher than ID50 (50% inhibitory dose) for different clinical and laboratory strains of viruses belonging to the herpes simplex family. RETINA 7:227–229, 1987

Intravitreal corticosteroids as an adjunct in the treatment of bacterial and fungal endophthalmitis. A review.

The use of intravitreal corticosteroids in the management of endophthalmitis remains controversial. Several clinical and experimental reports are reviewed that suggest that intravitreal corticosteroid therapy, when used in conjunction with antibiotics with and without vitrectomy, reduces the intraocular inflammatory process and secondary complications associated with microbial endophthalmitis.

Proliferative vitreoretinopathy and chemotherapeutic agents.

Proliferative vitreoretinopathy (PVR) is a disease process that occurs in eyes with rhegmatogenous retinal detachments and accounts for the majority of failures following retinal detachment surgery. PVR involves the uncontrolled proliferation of non-neoplastic cells capable of forming membranes, which may occur on either surface of the retina or along the detached surface of the vitreous gel. Contraction of these membranes creates tractional forces that can distort or detach the retina. Various surgical procedures have been used to repair retinal detachments associated with PVR. The results have not been encouraging in many instances. Recent efforts have been directed toward the chemical inhibition of cellular proliferation in PVR. The majority of drugs used in these studies have been antineoplastic agents that affect various phases in the cycle of cell growth.

Toxicity and clearance of a combination of liposome-encapsulated ganciclovir and trifluridine.

New Zealand albino rabbits were given intravitreal injections of liposome-encapsulated ganciclovir and trifluridine. Preoperatively and postoperatively, the eyes were evaluated by indirect ophthalmoscopy at different time intervals up to 14 days after injection. At intervals up to 14 days postinjection, the animals were sacrificed, the eyes enucleated, vitreous antiviral levels determined in one group of eyes, and histopathological examination conducted in the other group. The results of this study demonstrated prolonged intravitreal drug levels above the mean inhibitory dose for many strains of virus belonging to the herpes simplex virus family. No evidence of gross retinal toxicity was found by clinical or light microscopic examination of the treated eyes.

Large capillary aneurysms secondary to retinal venous obstruction.

Three patients had unusually large capillary aneurysms. Two of the patients had had previous branch vein occlusions, while a third had had a central retinal vein occlusion. The large capillary aneurysms were located in areas of ischaemic retina that were drained by the previously obstructed veins. Retinal ischaemia and, possibly, increased hydrostatic pressure following vein occlusion were postulated to result in the development of these atypical capillary aneurysms. They are similar in size to arterial macroaneurysms, but originate from the venous side of the capillary bed. Like typical capillary microaneurysms and arterial macroaneurysms, these large capillary aneurysms may result in visual loss from macular oedema, serous elevation of the macula, and circinate lipid exudation. Argon laser obliteration of the aneurysms appears to be effective therapy.

Fatal disseminated cryptococcosis following intraocular involvement.

A 33-year-old man was treated with systemic steroids for a retinal inflammatory lesion before the diagnosis of cryptococcal retinitis and meningitis was suspected. He died from central nervous system disease despite treatment with parenteral antifungals. Histopathological studies demonstrated ocular and disseminated systemic infection with Cryptococcus neoformans. Direct cryptococcal involvement of the eye is rare and is usually associated with disseminated disease. Systemic steroids must be used with caution, and patients who take these drugs require frequent monitoring.

The Use of Magnetic Resonance Imaging in the Evaluation of Retinoblastoma

We examined a 4-year-old boy who had a painful blind eye, rubeosis iridis, and leukokoria. Ultrasonography and computed tomography (CT) detected intraocular calcification and other features suggestive of retinoblastoma. The CT scan showed extraocular extension along the optic nerve. Intracranial extension of the tumor could not be definitely excluded by CT scan with intrathecal metrizamide infusion. Magnetic resonance imaging (MRI) and CT performed after radiation and chemotherapy were useful in excluding intracranial spread of malignant cells, thereby aiding the selection of a surgical approach to ensure complete removal of the involved portion of the optic nerve.

Management of Viral Retinitis

Cytomegalovirus, herpes simplex, and herpes zoster are responsible for the majority of cases of viral retinitis. Herpes zoster also has been strongly incriminated as a causal agent in acute retinal necrosis. Effective chemotherapy exists for retinitis caused by herpes simplex and herpes zoster, along with acute retinal necrosis. Conventional antiviral therapy and immunomodulators are ineffective in the treatment of cytomegalovirus retinitis in patients with acquired immune deficiency disorder. Ganciclovir, a new antiviral agent, has significantly reduced visual morbidity in these patients. Recurrence of the infection is not uncommon while patients are on the drug or when the agent is discontinued, because ganciclovir is virostatic and does not stop viral replication in the retina. The inability to control this viral retinitis using presently available chemotherapy indicates a need to examine other therapeutic modalities.