Lov K. Sarin

Outcomes of Vitrectomy for Retained Lens Fragments

PURPOSE Retained lens fragments after cataract surgery is an infrequent, but potentially serious surgical complication. The aim of this study is to evaluate outcomes after vitrectomy has been performed for removal of retained lens material. METHODS A retrospective review was conducted to evaluate all cases of pars plana vitrectomy for removal of retained lens fragments performed at Wills Eye Hospital from April 1991 through August 1994. RESULTS A total of 121 eyes of 121 patients underwent pars plana vitrectomy with removal of retained lens material over the 3 1/2-year period. Visual acuity on presentation was 20/200 or worse in 95 eyes (79 percent). Visual acuity after vitrectomy was 20/40 or better in 82 eyes (68 percent). The postoperative visual acuity was 20/50 to 20/400 in 21 eyes (17 percent), and counting fingers or worse in 18 eyes (15 percent). Nineteen eyes (16 percent) had retinal detachment (RD), 8 were noted at the time of vitrectomy and 11 occurred after vitrectomy. Of the 19 eyes with RD, visual acuity was 20/200 or worse in 12 (63 percent) and counting fingers or worse in 6 (32 percent) at the time of last follow-up. The use of posterior segment phacofragmentation was associated with higher rate of RD, but the difference did not reach statistical significance. Major causes of poor final visual outcome included RD (6 eyes), cystoid macular edema (4 eyes), and glaucoma (2 eyes). CONCLUSION The timing of vitrectomy did not have a statistically significant impact on visual outcome. Neither the type of intraocular lens nor the timing of lens implantation significantly altered the final visual acuity. Most eyes with retained lens fragments do well after vitrectomy, with the majority recovering good vision. However, the risk of RD is increased, and visual outcome may be adversely affected if RD occurs.

PSEUDOPHAKIC RETINAL DETACHMENTS. ANATOMIC AND VISUAL RESULTS

Retinal reattachment rates and visual results were analyzed in 227 consecutive primary pseudophakic rhegmatogenous retinal detachments. The overall anatomic reattachment rate was 90%, with no significant difference between the anterior chamber (AC) and posterior chamber intraocular lens groups. Visual results were significantly worse in the AC lens group (P less than 0.05). Negative prognostic indicators for reattachment included age greater than 65 years, poorer preoperative vision, larger extent of the retinal detachment, inability to identify a retinal break, longer duration of symptoms before presentation, and grades C or D proliferative vitreoretinopathy (P less than 0.05). In addition to the above factors, eyes with AC reaction, AC lenses, and macular detachment had a poorer visual prognosis.

Classification of Proliferative Vitreoretinopathy Used in the Silicone Study

The Silicone Study is a multicenter randomized clinical trial that compares a long-acting gas with silicone oil for the surgical treatment of proliferative vitreoretinopathy (PVR). As part of the study, a topographic classification of PVR has been developed that is based on the characteristic patterns of retinal distortion produced by the contraction of proliferative membranes on the retina or within the vitreous base. This classification is used to document the extent and anatomic distribution of PVR present preoperatively and to help standardize the surgical treatment. Experience has shown that this classification facilitates the identification of these membranes and their systematic dissection, and the authors therefore suggest that it be used to augment the Retina Society classification of PVR.

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.

Managment of Intraretinal Foreign Bodies

Closed posterior intraocular microsurgery with vitreous instruments and bimanual surgical techniques have markedly altered the management of intraocular foreign bodies (IOFB). This paper presents an approach to 14 metallic intraretinal foreign bodies (IRFB) that could not be removed by conventional methods. In all cases, posterior vitrectomy was required to visualize the foreign body or to facilitate its removal through a pars plana incision with intraocular forceps under microscopic visualization. Although successful removal of the intraretinal foreign body was possible in all 14 patients, central visual acuity of 20/400 or better was obtainable in only 40% of this series. An important observation in these patients was a tendency to macular pucker from subsequent epiretinal membrane formation and retinal detachment with massive periretinal proliferation (MPP), which occurred in 90% of these eyes. Despite an obviously enhanced ability to remove foreign bodies from the retina, made possible by vitreous instruments and surgical techniques, the magnitude of the secondary complications in this variety of ocular trauma suggests a poor visual prognosis for such injuries.

Lipemic Diabetic Retinopathy

A study group of eight patients with diabetic retinopathy and marked accumulation of hard exudates in the fundi is described. There was a significant increase in serum triglyceride levels (P less than 0.05) in the study group as compared to a control group of 23 consecutive patients with diabetic retinopathy. This exudative disorder is visually disabling and is associated with legal blindness in 50% of eyes. The authors believe that the term most appropriate to describe such a severe type of exudative response is lipemic diabetic retinopathy.

Malattia leventinese presenting with subretinal neovascular membrane and hemorrhage.

PURPOSE To report a case of malattia leventinese involving subretinal hemorrhage. METHODS Case report. RESULTS Two weeks after initial presentation, the visual acuity of this 34-year-old man decreased to LE: 20/100. Funduscopic evaluation revealed a subretinal hemorrhage involving the center of the foveal in the left eye that was interpreted as secondary to a neovascular membrane on fluorescein angiography. The patient did well after the removal of the submacular material by pars plana vitrectomy. CONCLUSION Patients with malattia leventinese may occasionally present with submacular hemorrhage. Prompt diagnosis and intervention may enhance the patients chance for visual improvement.

Intraocular microsurgery: I. New instrumentation (SITE).

The SITE instrument appears to combine advantages of other instruments previously described. It meets the proposed objectives of an efficient cutter where tissue is removed at the front end of the tip. It allows the surgeon complete control of the suction and reflux systems. The instrument is of a simple modular dsign. A fiber optic attachment is available. It is dependable and safe.