Mark K. Walsh

25-Gauge pars plana vitrectomy for retained lens fragments.

Purpose:The purpose of this study was to report the outcomes and complications of 25-gauge pars plana vitrectomy for the management of retained lens fragments after complicated cataract surgery. Methods:This is a retrospective consecutive case series of 17 patients who presented with retained lens fragments, ranging from mostly cortex to the entire lens, which were managed using only 25-gauge instrumentation. Results:Eight men and 9 women (mean age, 73.1 years) were followed for a mean of 4.5 months after 25-gauge vitrectomy for removal of retained lens fragments. Mean preoperative visual acuity was 20/427 and mean final postoperative visual acuity was 20/62. Mean surgical operating time was 48.5 minutes. Mean preoperative intraocular pressure was 24.5 mmHg and mean 1-day postoperative intraocular pressure was 17.9 mmHg. No cases required the use of a phacofragmatome, no sutures were required to close the sclerotomies, and there were no cases of postoperative hypotony. Cystoid macular edema and glaucoma developed postoperatively in 29.4% and 5.9% of eyes, respectively. There were no cases of postoperative retinal detachment or endophthalmitis. Conclusion:A 25-gauge vitrectomy technique, without the use of a phacofragmatome, may be a suitable alternative to 20-gauge vitreous surgery using a phacofragmatome in the management of retained lens fragments after complicated cataract surgery. Clinical outcomes and complication rates are comparable to those found in the literature for 20-gauge surgery.

Early vitrectomy effective for bilateral combined anterior and posterior persistent fetal vasculature syndrome.

Purpose: The purpose of this study was to review our surgical experience with patients with bilateral combined anterior and posterior persistent fetal vasculature syndrome (PFVS). Methods: We retrospectively reviewed the charts of all patients seen in our tertiary care pediatric retinal practice from 1988 to 2008 with a potential diagnosis of bilateral PFVS with posterior involvement. Clinical diagnosis required the presence of either bilateral persistent hyaloidal stalk tissue with retinal involvement or bilateral dense retrolental fibrovascular plaques (usually with no posterior view preoperatively) without a family history or genetic testing consistent with Norrie disease or familial exudative vitreoretinopathy. Results: Chart review showed 22 vitrectomized patients with clinical findings consistent with bilateral PFVS with posterior involvement who did not have a family history or genetic testing consistent with Norrie disease or familial exudative vitreoretinopathy. All 22 of these patients with posterior retinal involvement also had anterior findings and thus can be classified as combined anterior and posterior PFVS. Of the 13 patients with visual acuity follow-up data, 9 patients (69%) maintained at least light perception vision in at least 1 eye at last follow-up. Of the 28 operated eyes in 16 patients with follow-up data, 3 eyes (11%) were phthisical at last follow-up. Conclusion: Children with bilateral PFVS with posterior retinal involvement have a dismal visual prognosis if left unoperated. In this relatively large series of a rare condition, we find that vitrectomy with or without lensectomy is beneficial in bilateral combined anterior and posterior PFVS in two regards: maintenance or restoration of vision and avoidance of phthisis bulbi.

Early Vitrectomy Effective for Norrie Disease

OBJECTIVE To review our experience with Norrie disease to determine if early vitrectomy abrogates the natural history of this rare disease; namely, bilateral no light perception visual acuity and phthisis bulbi. METHODS We retrospectively reviewed the medical records of all patients seen in our tertiary care pediatric retinal clinical practice from 1988 through 2008 with a potential diagnosis of Norrie disease. Inclusion required not only clinical findings consistent with Norrie disease but also genetics and/or a family history consistent with Norrie disease. RESULTS Medical record review revealed 14 boys with clinically diagnosed Norrie disease and either Norrie disease gene (NDP) mutations noted on genetic testing (13 patients) and/or a clear family history consistent with Norrie disease (4 patients). All 14 boys with definite Norrie disease had vitrectomy with or without lensectomy in at least 1 eye prior to 12 months of age. Of the 14 boys with definite Norrie disease, 7 maintained at least light perception visual acuity in 1 eye and 3 had no light perception visual acuity bilaterally; visual acuity data were not available for 4 patients. Only 2 of 24 (8%) eyes became phthisical. CONCLUSIONS Historically, no treatment has been offered to mitigate the dismal natural history of Norrie disease. We recommend consideration of early vitrectomy in Norrie disease.

Hyphema after intravitreal injection of ranibizumab or bevacizumab.

BACKGROUND Exudative age-related macular degeneration is commonly treated with intravitreal injection of medications containing antibodies against vascular endothelial growth factors, including ranibizumab (Lucentis, Genentech, South San Francisco, CA) and bevacizumab (Avastin, Genentech). To the best of our knowledge, hyphema has not previously been reported as a complication of intravitreal injection of ranibizumab or bevacizumab. METHODS Retrospective case series. RESULTS Three patients developed hyphema after intravitreal injection of anti-vascular endothelial growth factor medications: one after ranibizumab and two after bevacizumab. Two patients were pseudophakic and taking warfarin in combination with low-dose aspirin, and one was phakic and not taking any coagulation-altering medications. A total of 26,184 intravitreal injections of ranibizumab or bevacizumab were given during the study period, for an estimated incidence of hyphema after intravitreal injection of approximately 1 in 10,000. CONCLUSION The authors describe hyphema, either gross or microscopic, as a complication of intravitreal injection of anti-vascular endothelial growth factor medications. In all three patients, best-corrected vision returned to baseline after resolution of the hyphema and subsequent injections occurred without complication.

Retinal detachments involving the posterior pole in hallermann-streiff syndrome.

PURPOSE To report a case of Hallermann-Streiff syndrome and bilateral retinal detachments involving the posterior pole. METHODS Retrospective case report and literature review. RESULTS A 2-year-old girl with Hallermann-Streiff syndrome was evaluated. Fundus examination showed bilateral exudative retinal detachments involving a significant portion of the posterior pole. The left eye showed several large, cyst-like areas of retinal detachment. The child was observed without treatment, and the subretinal fluid remained stable during the follow-up of 10 months. CONCLUSION Bilateral retinal detachments can be seen in patients with Hallermann-Streiff syndrome. The etiology is likely to be multifactorial, and uveal effusion may contribute to the exudative fluid. Further evaluation is necessary to determine the visual prognosis and optimal management of patients with exudative retinal detachments associated with Hallermann-Streiff syndrome.

Subretinal abscess after strabismus surgery: case report and literature review.

PURPOSE The purpose of this study is to describe the first reported case of a subretinal abscess after strabismus surgery and the successful treatment with vitrectomy, intravitreal antibiotics, and cryotherapy. METHODS This is a retrospective case report and literature review. RESULTS A 4-year-old boy underwent uncomplicated bilateral medial rectus muscle recession. Within 9 days after surgery, he developed unilateral endophthalmitis with a subretinal abscess at the approximate location of the medial rectus muscle insertion. The rectus muscle-scleral suture was removed, and transscleral cryotherapy was applied to the abscess site. Vitrectomy with injection of intravitreal antibiotics was performed. A bacterial culture of the removed suture was positive for Staphylococcus aureus and sensitive to his antibiotics. By 1 month, the abscess and vitritis had resolved completely. CONCLUSION This is the first reported case of endophthalmitis with a subretinal abscess occurring after strabismus surgery. In general, endophthalmitis after strabismus surgery has a poor visual prognosis. Early diagnosis and intervention with intravitreal antibiotics and possible vitrectomy may be advantageous for patients with a subretinal abscess.

Serratia marcescens endophthalmitis after 20-gauge pars plana vitrectomy.

PURPOSE To describe the first reported case of endophthalmitis after 20-gauge vitrectomy caused by Serratia marcescens. METHODS Retrospective case report. RESULTS An 86-year-old woman underwent a standard 20-gauge vitrectomy for repair of a chronic rhegmatogenous retinal detachment. All sclerotomies were sutured at the completion of the case. Within 2 days after surgery, she developed severe endophthalmitis. A bacterial culture of her aqueous sample was positive for S. marcescens. Despite the culture-demonstrated sensitivity of this organism to the antibiotics given intravitreally, systemically, and topically to treat this infection, her condition deteriorated, and she developed panophthalmitis, orbital cellulitis, a corneal ulcer, and eventual no light perception vision. CONCLUSIONS This is the first reported case of S. marcescens endophthalmitis after vitrectomy surgery. Endophthalmitis caused by S. marcescens has a poor visual prognosis and may show an in vivo clinical resistance to antibiotic therapy regardless of in vitro culture sensitivities.

De novo emergence of a circumscribed choroidal hemangioma in a premature infant.

PURPOSE To present a case of a premature infant who was witnessed to have de novo development of a circumscribed choroidal hemangioma over the course of routine retinopathy of prematurity screening. METHODS Retrospective case report. RESULTS A former 29-week, 1446-g premature infant boy was examined multiple times by both a pediatric retinal specialist and pediatric ophthalmologist before a posterior pole circumscribed choroidal hemangioma was noted, initially at postmenstrual age 39 weeks. The tumor remained fairly stable until the most recent follow-up examination at 2 years of age when it was noted to be much less prominent. CONCLUSION Circumscribed choroidal hemangiomas previously have been thought to be congenital in nature. We present the earliest described case as well as the first de novo emergence of such a tumor.

Scleral-Fixated Intraocular Lenses: An Update on the Current Surgical Approaches

In the past, the available surgical options for patients with a lack of capsulozonular support or aphakia were limited to placing an intraocular lens (IOL) in the anterior chamber, suturing an IOL to the iris, or suturing it to the sclera. The first two options involve leaving the IOLs in close proximity to the iris and the cornea and are not ideal for patients with compromised corneas, peripheral anterior synechiae, shallow anterior chambers, or glaucoma. Scleral-sutured IOL fixation allows the IOL to sit away from the cornea and closer to the nodal point of the eye, but the suture-related complications and the technically challenging nature of the surgery are unappealing. In recent years, with the advent of novel sutureless scleral fixation techniques, an increasing number of surgeons are adopting the sutureless techniques, such as the fibrin glue and the intrascleral tunnel IOL fixation techniques. We discuss the pros and cons as well as the preliminary results of these techniques as reported in the recent literature.

Intravitreal bevacizumab and ranibizumab for choroidal neovascularization secondary to endogenous endophthalmitis.

PURPOSE To report two patients with endogenous endophthalmitis complicated by choroidal neovascularization managed with intravitreal bevacizumab (Avastin, Genentech, Inc., South San Francisco, CA) or ranibizumab (Lucentis, Genentech, Inc., South San Francisco, CA) and their respective outcomes. METHODS Retrospective chart review of 2 patients, one a 54-year-old diabetic woman on chemotherapy for pemphigus vulgaris and the other a 77-year-old diabetic male with cellulitis, who were treated for endogenous endophthalmitis complicated by choroidal neovascularization. RESULTS The patients were managed with off-label intravitreal anti-vascular endothelial growth factor injections. The first patient received one dose of intravitreal bevacizumab (Avastin) with improvement in vision and anatomy. The second patient received four doses of intravitreal ranibizumab (Lucentis) with improvement in vision and structural appearance. CONCLUSION Choroidal neovascularization secondary to endogenous endophthalmitis responds to anti-vascular endothelial growth factor therapy with bevacizumab or ranibizumab.