Mithlesh C. Sharma

Intravitreal triamcinolone for treatment of complicated proliferative diabetic retinopathy and proliferative vitreoretinopathy

BACKGROUND We present a retrospective evaluation of the clinical outcome and complications associated with intravitreal injection of unaltered triamcinolone acetonide in conjunction with pars plana vitrectomy and silicone oil injection for the treatment of complicated proliferative diabetic retinopathy with tractional retinal detachment and severe proliferative vitreoretinopathy. METHODS Thirteen eyes of 12 consecutive patients were identified from a computerized patient database. All eyes were operated on by the same surgeon and received 4 mg of unaltered, commercially available triamcinolone acetonide intravitreally, before silicone oil injection. The patients were followed for a mean of 4.7 months (range 1-15 months), and demographic as well as pertinent preoperative and postoperative clinical information was gathered. RESULTS At the last follow-up visit, vision had improved in 4 eyes, remained stable in 5 eyes, and worsened in 4 eyes. The retina was attached at the end of follow-up in 10 of the 13 eyes. Eight of the 13 eyes did not show any clinical signs of re-roliferation or redetachment during the course of follow-up. The mean intra-ocular pressure did not increase (preoperative value was 10.8+/- 6.22 mm Hg with a range of 0-22 mm Hg; at last follow-up, mean pressure was 9.6 +/-3.86 mm Hg with a cumulative postoperative range of 0-26 mm Hg). Steroid crystals were visible at 1 month postoperatively in 3 eyes and did not hinder fundus examination significantly. INTERPRETATION The intravitreal injection of low-dose, unaltered triamcinolone acetonide in the setting of pars plana vitrectomy and silicone oil injection for the treatment of proliferative vitreoretinopathy and complicated proliferative diabetic retinopathy appears to be well tolerated. Further controlled study is needed to clearly define the potential beneficial effects of intravitreal steroids in these 2 disease processes.

Pseudohypopyon following intravitreal triamcinolone acetonide injection.

Objective: To report a case of a pseudohypopyon that developed after intravitreal injection of triamcinolone acetonide for choroidal neovascularization from age-related macular degeneration. Methods: Observational case report. Results: A 62-year-old woman received an intravitreal injection of triamcinolone acetonide for the treatment of a choroidal neovascular membrane that developed as a result of age-related macular degeneration. A layer of yellowish deposits was observed in the anterior chamber 1 day after the injection. The patient denied any pain or reduced vision, and there was no redness noted on examination. The deposits cleared spontaneously on the fourth postoperative day. Conclusions: Pseudohypopyon may develop after intravitreal injection of triamcinolone acetonide. Distinguishing this from a true hypopyon is important because the treatment and prognosis are very different for the two conditions.

Histologic findings after surgical excision of optic nerve head drusen

Purpose: To report the histopathologic findings of a case of bilateral massive optic nerve head (ONH) drusen. Methods: A 59-year-old man presented with bilateral massive ONH drusen and secondary compromise of the retinal vasculature leading to vision of counting fingers at 1 ft in the left eye and 20/30 in the right eye. The inferior one half of the left ONH druse was excised resulting in no light perception vision postoperatively. Results: Energy-dispersive spectroscopy suggested the composition of the ONH druse to be calcium phosphate (Ca3[PO4]2), which has implications on pathogenesis of neuronal cell death in ONH drusen. Scanning electron microscopy demonstrated embedded metal particles, likely to be remnants of the instruments used. Conclusion: Massive ONH drusen are actually one large druse that has multiple excrescences on its surface giving it the variegated appearance. Although surgical excision of ONH drusen may be technically possible, consideration should be given to improvements in instrumentation and patient selection criteria.

Pressure alopecia following vitreoretinal surgery

PURPOSE To describe a patient with pressure alopecia following vitreoretinal surgery. DESIGN Case report. METHODS An 11-year-old boy underwent vitreoretinal surgery for left retinal detachment. One week postoperatively, his parents noticed a patch of alopecia where his head may have been in contact with the wrist-rest assembly placed around the head during the surgical procedure. RESULTS Pressure alopecia on the parieto-occipital region of the scalp was observed. Hair regrowth occurred during the follow-up visits. CONCLUSION Pressure alopecia is a rare complication of lengthy surgery and is underrecognized in ophthalmic practice. Precautions should be taken to avoid this preventable complication.

Persistent Hyperplastic Primary Vitreous (PHPV)

Persistent fetal vasculature (PFV), also known as persistent hyperplastic primary vitreous (PHPV) is a constellation of ophthalmic findings typically consisting of microphthalmia, cataract (Figs. 8.1 and 8.2), centrally dragged ciliary processes, retrolental fibrous tissue, and a persistent hyaloid artery. It has long been recognized in the differential diagnosis of leukokoria or amaurotic pupillary reflex. The full spectrum of findings in PFV was not fully appreciated until 1949 when Reese described the syndrome in more detail, differentiating PFV from retrolental fibroplasia [1]. In the 1956 Jackson Memorial lecture, Reese further elucidated the findings of this disorder [2]. He termed the anterior findings anterior hyperplastic vitreous. Michaelson, and later Pruett and Schepens, termed the posterior component posterior hyperplastic primary vitreous and stressed the anterior and posterior findings could overlap [3]. Goldberg suggested replacing the term PHPV with the more comprehensive PFV, which emphasizes the etiology of the disorder [4].