P K Leaver

Primary vitrectomy for rhegmatogenous retinal detachment

One hundred and twenty-four eyes with a rhegmatogenous retinal detachment, considered to be at high risk of failure if treated conventionally, underwent vitrectomy and internal tamponade, with or without scleral buckling, as the primary procedure. The retina was reattached in 64.5% of eyes after one operation, 75.0% after two, and in 83% of eyes after more than two operations, with no difference in the success rate between those eyes which underwent vitrectomy alone, and those that received adjunctive scleral buckling; duration of surgery was significantly shorter, however, in the former group. Twenty percent of eyes redetached in association with proliferative vitreoretinopathy, and 20% of phakic eyes developed posterior subcapsular lens opacities after surgery. Vitrectomy is now an established method in the management of selected cases of rhegmatogenous retinal detachments.

Vitrectomy and fluid/silicone-oil exchange for giant retinal tears: results at six months.

The results of vitrectomy combined with fluid/silicone-oil exchange in 73 eyes with giant retinal tears are reported at six months after surgery. Initial anatomical success was achieved in 71 out of 73 eyes (97%) and, prior to removal of silicone-oil, in 66 out of 73 eyes (90%). In 63 eyes (86%) the retina remained attached six months after surgery. Of these visual acuity was 6/60 or better in 44 (70%). The high proportion of eyes with macular detachment before surgery and the frequency of macular abnormalities are thought to account for reduced vision in many of the anatomically successful cases.

Phacoemulsification and silicone oil removal through a single corneal incision

OBJECTIVE Cataracts are a frequent complication after silicone oil infusion for the repair of complicated retinal detachments, occurring in up to 100% of eyes retaining silicone oil for 6 months or more. The authors devised a combined procedure for cataract and silicone oil removal with intraocular lens (IOL) implantation through a single corneal incision and evaluated their results. DESIGN A prospective, noncomparative case series. PARTICIPANTS Thirty-four eyes of 34 consecutive patients with a history of retinal detachment repair requiring silicone oil placement in whom a clinically significant cataract subsequently developed were identified when removal of silicone oil was scheduled. INTERVENTION All 34 eyes were prospectively entered into a study to evaluate the efficacy and potential complications of a combined procedure for cataract and silicone oil removal with posterior chamber lens implantation. All patients underwent uncomplicated phacoemulsification removal of cataract followed by removal of silicone oil and placement of an IOL through a single corneal incision. MAIN OUTCOME MEASURE Recurrent retinal detachment and IOL-related complications were measured. RESULTS Ten eyes had recurrent retinal detachments develop. Final visual acuity ranged from 6/12 to hand movements with 25 eyes (74%) showing stabilized or improved vision. Pre-existing macular pathology and recurrent retinal detachment generally were responsible for poor visual outcome. CONCLUSIONS Combined phacoemulsification, IOL implant with silicone oil removal is a useful procedure in these complicated eyes. Visual outcome generally is good with improvement in visual acuity, even with recurrent retinal detachment or pre-existing macular pathology or both.

Pseudophakic retinal detachment.

The clinical findings, surgical techniques, anatomic results and visual recovery in 71 pseudophakic and 71 aphakic eyes with retinal detachment repaired concurrently were compared. Preoperative visibility of the peripheral retina was significantly reduced in the pseudophakic group. Intraoperative identification of retinal breaks was useful for the pseudophakic eyes. The surgical techniques used in the two groups were similar. Anatomic success was achieved in 65 pseudophakic eyes (92%) and 63 aphakic eyes (89%); however, the visual recovery after a mean follow-up period of 18 months was poorer in the pseudophakic group, only 35 (54%) of which, compared with 39 (62%) of the aphakic group, had a final best-corrected visual acuity of 6/15 or better.

Vitrectomy and fluid/silicone-oil exchange for giant retinal tears: results at 18 months.

Sixty-five eyes with giant retinal tears previously reviewed at 6 months after vitrectomy and fluid/silicone-oil exchange were again reviewed 18 months after surgery. The retina remained attached in 54 eyes (83%), and of these 32 (57%) had visual acuities of 6/60 or better. Poor acuities were attributed in most cases to cataract associated with silicone-oil contact or macular damage from preoperative macular detachment. Glaucoma occurred chiefly in those eyes which were aphakic prior to surgery, or were rendered aphakic at surgery, but did not influence the visual outcome at this stage. Encouraging results of surgery after 6 months were confirmed after 18 months, although the level of vision had fallen in some cases due to the development of lens opacities.

Prophylactic 360° cryotherapy in fellow eyes of patients with spontaneous giant retinal tears

Abstract Purpose To assess the effect of prophylactic 360° peripheral retinal cryotherapy in fellow eyes of patients with spontaneous giant retinal tears (GRTs) on the incidence of retinal detachment. Design Retrospective, noncomparative case series. Participants Forty-eight consecutive patients (31 male, 17 female) with spontaneous GRTs were included. The average age was 41 ± 2 years. The average refraction of the fellow eye was −4.0 ± 0.8 diopters (D). Intervention Patients underwent vitrectomy and silicone oil tamponade in the affected eye and 360° peripheral cryotherapy in the unaffected fellow eye during the same anesthetic. Main outcome measure Attachment of the retina in the fellow eye was determined clinically by indirect ophthalmoscopy. Results During a mean follow-up of 84 ± 10 months after cryotherapy, one patient (2%) experienced a retinal tear without retinal detachment, and three patients (6%) experienced a retinal detachment in the fellow eye. These occurred 18 ± 9 months after prophylactic treatment and were the result of a small retinal break in two cases and a GRT posterior to the treated area in one case. Conclusions Prophylaxis of fellow eyes with 360° cryotherapy appears to be associated with a lower incidence of retinal detachment than that reported in natural history studies. A prospective, randomized clinical trial of such prophylaxis is desirable but would require a sample size of at least 645 patients in each arm of the study, as well as long-term follow-up of at least 5 years to show an unequivocal difference in outcome.

Behaviour of Intraocular Gases

The changes in volume of intraocular bubbles of air, sulphur hexafluoride, perfluoropropane and mixtures of these gases, were studied in human eyes, following vitrectomy for treatment of retinal detachment. The implications of these findings, for the provision of optimal internal tamponade in the treatment of retinal detachment, are discussed.

Closed microsurgery for diabetic traction macular detachment.

Ischaemic diabetic retinopathy maybecomplicated bymultiple outgrowths offibrovascular tissue onto theretinal surface within themostcortical part ofthe vitreous gel,typically alongthemajorvascular arcades andnasal totheoptic disc. Tangential traction, exerted bycontraction ofthecoalescent epiretinal membranes, results indistortion, folding, and detachment oftheunderlying retina. Thisprocess is frequently exacerbated by traction alongthe detached posterior hyaloid interface between the vitreous baseanteriorly and theepiretinal membranes intowhichthegelisincarcerated posteriorly (anteroposterior traction) orbetween individual sitesof fibrovascular proliferation (bridging traction). A retinal break, usually sited immediately peripheral totheavulsed edgeofa posterior fibrovascular membrane,may also contribute toretinal separation byallowing exchange offluid between theretrohyaloid andsubretinal spaces. Thefovea, which isusually free ofoverlying vasoproliferation, mayeventually become detached, with consequent serious impairment ofvision. Closed microsurgical techniques canbeusedtoeliminate eachoftheelements ofvitreoretinal traction described aboveandtosealretinal breaks, thus allowing themacular retina toreattach withsome restoration ofcentral visual function. Wepresent the results ofclosed microsurgery performed fordiabetic traction macular detachment intheSurgical Vitreoretinal UnitatMoorfields EyeHospital. Thesurgical prognosis iscorrelated withtheextent ofpreoperative epiretinal fibrovascular proliferation.

Peripheral transscleral retinal diode laser for rubeosis iridis.

Purpose: To evaluate the results of peripheral transscleral retinal diode photocoagulation with or without transscleral cyclodiode therapy in patients with rubeosis iridis with or without elevated intraocular pressure and no fundal view. Methods: Peripheral transscleral retinal diode photocoagulation was performed in 15 eyes of 13 patients in an attempt to promote regression of rubeosis. The fundus could not be seen in any of the 15 eyes, so conventional panretinal photocoagulation was not possible. Nine eyes had associated elevated intraocular pressure and were treated with concurrent transscleral diode cyclophotocoagulation. Results: All eyes showed regression of rubeosis. Of the nine eyes treated with combination therapy, six had stabilized intraocular pressure, and three developed hypotony. None of the eyes developed a peripheral retinal detachment, and one eye lost the ability to perceive light. Conclusions: This method is effective in treating patients with rubeosis iridis when the view of the fundus is inadequate for conventional panretinal photocoagulation and more extensive intraocular surgery is precluded. It may be combined with transscleral cyclophotocoagulation therapy to manage concurrent high intraocular pressure in rubeotic glaucoma, but this involves a risk of postoperative hypotony. RETINA 17:421‐429, 1997

Basilar aneurysm An unusual cause of pain in a blind eye

A patient who suffered traumatic hematomas of both occipitotemporal regions, but who had normal visual acuity, language, and cognitive functions, could not recognize faces of family members, celebrities , or recent acquaintances (prosopagnosia). He could distinguish same from different faces when they were presented simultaneously, but could not recognize faces that had been presented to him 90 seconds earlier. He could read and name objects correctly, but could not recognize any previously viewed object if it was reexamined later with other objects of the same semantic class. He had no difficulty copying complex figures, but synthesized incomplete visual information poorly and pursued an abnormal visual search strategy. We suggest that prosopagnosia is part of a more general inability to distinguish among objects within a visual semantic class. It results from impaired visual memory and perception caused by visual association cortex damage and interruption of the inferior longitudinal fasciculus connecting visual association cortex and temporal lobe.