M. Madison Slusher

Intraocular foreign bodies: management, prognostic factors, and visual outcomes.

OBJECTIVE To determine prognostic factors and visual outcomes in patients with intraocular foreign bodies (IOFBs). DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS Fifty-nine consecutive patients undergoing removal of an IOFB with a minimum of 6 months of follow-up. INTERVENTION Surgical removal of the IOFB and repair of associated ocular trauma. MAIN OUTCOME MEASURES Final best corrected visual acuity was the main outcome measured. Ocular findings at presentation were compared with final visual acuity to determine prognostic factors for visual outcome. RESULTS Final best corrected visual acuity of 20/40 or more was obtained in 42 patients (71%) and ambulatory vision (>5/200) was achieved in 50 patients (85%). Presenting visual acuity was predictive of final visual outcome (P < 0.01). Prognostic factors for a better visual outcome (P < 0.05) included better presenting visual acuity and hammering metal on metal as the mechanism of injury. Prognostic factors for a poor outcome (P < 0.05) included poor presenting visual acuity, the presence of an afferent pupillary defect, and vitreous hemorrhage. CONCLUSIONS Final visual outcomes were excellent in 71% of patients. Presenting visual acuity was the strongest predictor of final visual outcome in this series. Additional predictive factors included the mechanism of injury, the presence of an afferent pupillary defect, and vitreous hemorrhage.

Retinal Arterial Occlusions in Young Adults

PURPOSE To determine the cause, associated factors, visual results, and systemic morbidity in patients less than 40 years old with retinal arterial occlusions. METHODS We studied 27 eyes with nontraumatic retinal arterial occlusions in 21 patients less than 40 years old (range, 22 to 38 years; mean, 28 years). RESULTS Of the 21 patients, branch retinal artery (arteriolar) occlusion occurred in 15 (71%), central retinal artery occlusion occurred in five (24%), and cilioretinal artery occlusion occurred in one (5%). Retinal artery occlusions were bilateral in six patients (29%) and occurred in 14 women (67%). Emboli were identifiable in seven patients (33%). Cardiac valvular disease was the most commonly recognized etiologic agent and was present in four patients (19%). Various associated factors leading to a hypercoagulable state or embolic condition were identified in 19 patients (91%). CONCLUSION Retinal arterial occlusions in young adults occur via multiple mechanisms. Systemic evaluation allows detection of a risk factor for retinal arterial occlusive disease in most patients.

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.

Epiretinal Membrane Release and Posterior Vitreous Detachment

The spontaneous release of epiretinal membranes is a rare clinical phenomenon, the mechanism of which is poorly understood. The authors present three patients with epiretinal macular membranes associated with peripheral retinal lesions, in whom spontaneous release of the membrane occurred in conjunction with detachment of the posterior vitreous. In each patient, the membrane remained attached to the posterior vitreous face, and in each eye there was a decrease in retinal striae and an improvement in vision. The authors postulate that posterior vitreous separation was the mechanism by which these membranes detached from the macula.

Protein S deficiency and bilateral branch retinal artery occlusion

A macular branch retinal artery occlusion developed in the right eye of a 25-year-old woman when she was 38 weeks pregnant. She subsequently presented 5 days postpartum with a branch retinal artery occlusion in her left eye. Although her initial work-up did not reveal a source for her occlusions, subsequent studies have documented a deficiency of protein S.

The spectrum of cavitary optic disc anomalies in a family.

The current classification of cavitary optic disc anomalies including the morphologically related entities--optic nerve pit, morning glory disc anomaly, coloboma of the optic nerve, and retinochoroidal coloboma involving the optic nerve--is inexact and confusing. Traditionally, these disc abnormalities have been regarded as distinct morphologic anomalies. Thirty-five members of a five-generation kindred with autosomal dominantly inherited optic disc anomalies were examined. Observed abnormalities in this pedigree comprised a spectrum of morphologic variants ranging from large anomalous discs to typical pits and colobomas. The findings in this family suggest a variable expression of a single autosomal dominant defect rather than the chance occurrence of three separate, distinct, but morphologically similar entities occurring in a single pedigree.

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.

Anatomic and visual results in asymptomatic clinical rhegmatogenous retinal detachment repaired by scleral buckling

PURPOSE To report presenting characteristics as well as anatomic and visual results in asymptomatic clinical rhegmatogenous retinal detachment repaired by scleral buckling. METHODS Review of 28 eyes of 27 patients with an asymptomatic clinical retinal detachment-defined as a rhegmatogenous retinal detachment with subretinal fluid extending more than 2 disk diameters posterior to the equator-which were repaired by scleral buckling from January 1989 through December 1996 with follow-up of 6 months or longer. RESULTS With a single scleral buckling procedure, anatomic reattachment of the retina occurred in all eyes; one eye redetached 14 months after the initial surgery secondary to a new retinal break and was successfully reattached. All eyes had best-corrected presenting and final visual acuity of 20/50 or better. Final best-corrected Snellen visual acuity was within 1 line of best-corrected presenting visual acuity in 82% of eyes; three eyes improved more than 1 line of Snellen visual acuity and two eyes lost more than 1 line. CONCLUSION Anatomic and visual results in asymptomatic clinical rhegmatogenous retinal detachment after scleral buckling surgery are excellent. Strong consideration should be given to repair of these detachments.

Visual results, prognostic indicators, and posterior segment findings following surgery for cataract/lens subluxation-dislocation secondary to ocular contusion injuries.

Objective To determine visual outcomes, incidence of posterior segment abnormalities, and prognostic factors in eyes undergoing lens removal for cataract or lens subluxation-dislocation secondary to ocular contusion injuries. Design Retrospective, noncomparative, interventional case series. Participants Forty eyes in forty consecutive patients undergoing lens extraction for ocular contusion-related cataract or lens subluxation, all with a minimum of 6 months’ follow-up. Intervention Lens extraction in the traumatized eye. Main Outcome Measure Final best-corrected visual acuity. Results Final best-corrected visual acuity was 20/40 or better in 55% of eyes, and ambulatory vision (>5/200) was achieved in 88%. Preoperative factors associated with poorer visual outcome (<20/40) were the presence of an afferent pupillary defect or an iridodialysis (P < 0.05). Seventy percent of eyes were determined to have significant posterior segment injuries. The cause of final visual acuity less than 20/40 included macular scarring (23%), retinal detachment (15%), and optic atrophy (5%). Conclusion Cataract or lens subluxation secondary to ocular contusion injuries is often associated with severe posterior segment sequelae and poor visual outcomes.

Progressive outer retinal necrosis secondary to varicella zoster virus in acquired immune deficiency syndrome.

Background A syndrome consisting of rapidly progressive outer retinitis in patients with suppressed immune systems has been described. The etiologic agent appears to be a member of the herpes virus family. Methods A 41-year-old man with acquired immune deficiency syndrome (AIDS) developed bilateral outer retinitis and choroiditis, which progressed despite antiviral treatment. A transscleral eye wall biopsy specimen and whole globe were submitted for microbiologic and histologic study. Results Polymerase chain reaction of a transscleral eye wall biopsy specimen and of the enucleated specimen determined the etiologic agent to be varicella zoster virus (VZV). Histologic studies demonstrated intranuclear inclusions consistent with viral particles in choroidal cells. Conclusion Our study revealed intranuclear inclusions in choroidal cells, a previously undocumented finding in progressive outer retinal necrosis. Polymerase chain reaction was very useful in identifying the causative agent.