Marvin F. Kraushar

The Relationship Between Retina Surgery and Preretinal Macular Fibrosis

A prospective study of 440 eyes of 220 patients following successful operations for primary rhegmatogenous retinal detachment (132 eyes) and prophylactic operations for retinal breaks (103 eyes) revealed an incidence of preretinal macular fibrosis (PRMF) of 47% after scleral buckling surgery and 42% after prophylactic laser or cryopexy. The incidence of PRMF was significantly greater in aphakic vs phakic detachments, in detachments with operculated vs horseshoe breaks, in detachments with horseshoe breaks vs lattice degeneration, in detachments involving the macula, after scleral buckling with cryotherapy vs diathermy, and after prophylactic treatment of retinal breaks of fellow eyes with retinal detachment or retinal breaks that had developed postoperative PRMF. Analysis of the data suggests that PRMF is most likely a result of the retinal break, detachment, and subsequent treatment.

Miotics and retinal detachment: Upgrading the community standard

The majority of ophthalmologists who responded to a questionnaire regarding the relationship between miotics and retinal detachment felt that such a relationship does exist, and that myopia and aphakia/pseudophakia predispose to the formation of new retinal breaks or to retinal detachment from pre-existing breaks with miotics. Horseshoe breaks and dialyses are pre-existing lesions that should be treated prophylactically prior to miotic therapy. Patients with no predisposing pathology or whose eyes have lattice degeneration or operculated breaks should be warned of possible retinal detachment prior to starting miotics. Not performing a peripheral retina examination prior to prescribing a miotic is acceptable, but not optimal, medical practice. Examining the peripheral retina or obtaining a retina consultation prior to prescribing a miotic may be beneficial to the patient and could be invaluable in the defense of litigation.

Pseudohypopyon in Best's Vitelliform Macular Dystrophy

We examined ten eyes with pseudohypopyon in seven patients with Bests vitelliform macular dystrophy. Fluorescein angiography showed hyperfluorescent defects in the retinal pigment of the superior half of the lesion in all ten eyes. The electro-oculographic findings were abnormal in all four patients who underwent this test. The fluid shifted slightly in two of six patients whose heads were turned to the side for an hour or longer, indicating that the material was probably located between the retinal pigment epithelium and the sensory retina. The volume of the hypopyon increased in one eye.

Prevention of accidental intraocular injection following inadvertent needle perforation of the eyeball

To prevent accidental intraocular injection after inadvertent single needle perforation of the eyeball, the authors recommend moving the needle and watching for corresponding movement of the globe following peribulbar or retrobulbar placement of the needle and prior to injecting. The authors have found this technique to be safe and reliable, with negligible morbidity.

Learning Scleral Depression With Binocular Indirect Ophthalmoscopy

Scleral depression with binocular indirect ophthalmoscopy will be easier to learn if the examiner observes the patients pupillary reflex through the ophthalmoscope without looking through the hand-held condensing lens. When the tip of the scleral depressor is properly positioned the pupillary reflex will darken slightly. If the condensing lens is then moved into position the actual scleral depression will be visible.

Revelation of Adverse Events and the Conundrum of an Apology

Disclosure of error and apology in the practice of medicine is an evolving concept and procedure. Currently, a few institutions have policies for disclosure of error that often include an apology. Approximately 30 states have passed legislation making physician’s apologies, including admission of fault, subsequently inadmissible in malpractice litigation. Not all these statutes are equally protective of physicians. Other states have laws allowing expression of regret, caring, and consolation without admitting fault. Recently, prompt disclosure of medical error to the patient in a timely manner has been endorsed as ethically proper by the American Medical Association (AMA). Furthermore, honest dialogue is regarded as a means of strengthening the relationship between a physician and a patient, thereby enhancing the prevention of litigation. No action should be taken by a physician or a member of his or her office staff before a thorough investigation of the case, circumstances, results, and possible attendant damages have been discussed with the insurance company and the appropriate lawyers. However, some states require that the patient or the patient’s family be advised of the adverse event during the episode of care or, if discovered afterward, in a timely fashion. Therefore, prompt investigation and evaluation on the physician’s part is recommended.