Patrick E. Rubsamen

Vitrectomy for diabetic macular edema associated with a thickened and taut posterior hyaloid membrane

PURPOSE To evaluate the surgical results in a series of patients with diabetic macular edema associated with traction from a thickened and taut posterior hyaloid membrane and to identify features associated with better visual outcome. METHODS We reviewed the clinical records of ten consecutive patients who underwent pars plana vitrectomy in one eye for diabetic macular edema that was preoperatively attributed to thickening and traction of the posterior hyaloid membrane. RESULTS Best-corrected, preoperative visual acuity was 20/200 in seven eyes, 20/300 in one eye, and 20/400 in two eyes. Intraoperatively, seven patients were found to have an attached posterior hyaloid membrane which was thickened and taut. Among these seven patients, postoperative best-corrected visual acuity improved by six lines in two eyes, by five lines in one eye, by two lines in one eye, and remained within one line of preoperative visual acuity in three eyes. The other three patients had an epiretinal membrane simulating an attached and thickened posterior hyaloid membrane. CONCLUSIONS Vitrectomy effectively improved visual acuity in some eyes with diabetic macular edema associated with traction from a thickened and taut posterior hyaloid membrane. Despite careful preoperative examination with a fundus contact lens, however, in some patients it may be difficult to assess how the posterior hyaloid membrane contributes to the macular edema. In selected patients, early surgical intervention may be associated with better visual outcome.

Endophthalmitis after penetrating trauma : risk factors and visual acuity outcomes

PURPOSE To identify clinical characteristics that were associated with an increased incidence of endophthalmitis in eyes with penetrating ocular trauma. METHODS In part 1, a retrospective analysis was performed on 258 consecutive patients with penetrating ocular trauma presenting to the Bascom Palmer Eye Institute between October 1987 and January 1991. In part 2 of the study, 28 consecutive patients with culture-proven endophthalmitis were identified from the Clinical Microbiology Registry from April 1987 through September 1987 and February 1991 through August 1993. Clinical variables were evaluated in each part for association with an increased risk of endophthalmitis. RESULTS In part 1 of the study, endophthalmitis developed in 13 (5%) of the 258 patients. Endophthalmitis did not occur in eyes that had blunt injury. In those eyes with a lacerating injury, there was an increased relative risk of infection in eyes with disruption of the crystalline lens. This risk factor was found statistically significant by univariate and multivariate analysis. In part 2 of the study, lens disruption was present in 24 (86%) of 28 patients with culture-proven endophthalmitis. Of the 41 patients with infection from part I and part II, 22 (54%) achieved visual acuity of 20/ 400 or greater. Endophthalmitis caused by coagulase-negative staphylococci had the best visual outcome, with 7 (64%) of 11 patients obtaining visual acuity of 20/ 400 or greater. CONCLUSION Lens disruption in eyes with penetrating trauma is a significant risk factor for the development of endophthalmitis. The prognosis for useful vision in eyes with posttraumatic endophthalmitis is best when infection is caused by less virulent organisms.

Retained Lens Fragments after Phacoemulsification

PURPOSE The authors present the clinical features of patients with retained lens fragments after phacoemulsification and their outcome after pars plana vitrectomy. METHODS The authors performed a retrospective chart review of 62 patients who had surgical management of posteriorly dislocated lens fragments after phacoemulsification during the 3-year period from January 1990 to December 1992. RESULTS Eight of the 62 patients underwent vitrectomy on the same day as the cataract surgery. Of the remaining 54 patients examined in the outpatient clinic, initial clinical features included marked intraocular inflammation (87%), elevated intraocular pressure of 30 mmHg or higher (46%), and corneal edema (46%). Retinal detachment was present before vitrectomy in one patient and occurred after vitrectomy in two others. Initial visual acuity was 20/200 or worse in 68% of patients. After vitrectomy, final visual acuity was 20/40 or better in 68% of patients. Using the percentage of patients with 20/40 or better final visual acuity, there was no statistically significant difference in surgery performed within 7 days (70%), between 1 and 4 weeks (60%), and after 4 weeks (70%). Twenty (80%) of 25 patients with initial posterior chamber intraocular lenses (PC IOLs) and 16 (62%) of 26 patients with initial anterior chamber IOLs (AC IOLs) achieved 20/40 or better visual acuity. A visual acuity outcome of 20/200 or worse occurred in all three patients with retinal detachment. Six of the eight patients who underwent vitrectomy on the same day as the cataract surgery achieved 20/30 or better visual acuity. CONCLUSIONS The timing of vitrectomy did not influence visual acuity outcomes. Intraocular lenses inserted at the primary operation did not adversely affect the visual outcome. However, vitrectomy on the same day as cataract surgery generally yielded favorable visual acuity outcomes and eliminated the need for a second operation at a later date. In most patients with retained lens fragments, management with vitrectomy allowed good visual acuity outcomes.

Primary Intraocular Lens Implantation in the Setting of Penetrating Ocular Trauma

PURPOSE To evaluate the clinical outcome of patients who underwent lensectomy and intraocular lens (IOL) implantation at the time of primary repair of a penetrating ocular injury. METHODS A review of 14 patients who sustained cataracts and lens rupture in the setting of a corneal laceration to determine anatomic and visual outcome, in addition to complications related to the primary IOL. RESULTS The IOL remained anatomically stable in all 14 patients with no complications encountered at implantation or after surgery. Final visual acuity in 9 of the 14 patients was 20/40 or better. Six patients underwent pars plana vitrectomy for removal of an intraocular foreign body. CONCLUSION Intraocular lens implantation at the time of lensectomy and primary repair of a corneal laceration allows good visual rehabilitation with restoration of binocular function and serves as an alternative to contact lens correction in select patients.

Pars Plana Vitrectomy for Chronic Pseudophakic Cystoid Macular Edema

PURPOSE We determined the efficacy of pars plana vitrectomy in a series of patients with chronic pseudophakic cystoid macular edema. METHODS Clinical records were reviewed on 24 consecutive patients who underwent pars plana vitrectomy in one eye for chronic pseudophakic cystoid macular edema. All 24 patients had failed to improve on medical therapy and had preoperative evidence of either vitreous adhesions to anterior segment structures (23 eyes) or iris capture of the intraocular lens (one eye). RESULTS The mean, best-corrected Snellen visual acuity was 20/190 preoperatively (median, 20/200; range, 20/50 to 3/200) and 20/52 postoperatively (median, 20/40; range, 20/20 to 20/400 [P < .0001]). Visual acuity improved postoperatively in all 24 eyes, with a mean improvement of 4.7 Snellen lines (range, one to eight lines). There was no highly significant difference in preoperative visual acuity (P = .41) or postoperative visual improvement (P = .17) between patients with anterior as opposed to posterior chamber intraocular lenses. Longer time interval from cataract surgery to vitrectomy did not correlate with less postoperative visual improvement. CONCLUSIONS In pseudophakic eyes with chronic cystoid macular edema, vitreous adhesions to anterior segment structures, and visual loss that is unresponsive to medical therapy, pars plana vitrectomy with removal of these vitreous adhesions may lead to improved visual acuity.

Removal of Retained Lens Fragments after Phacoemulsification Reverses Secondary Glaucoma and Restores Visual Acuity

PURPOSE The purpose of the study is to evaluate the effect of vitrectomy on secondary glaucoma and visual acuity outcomes in patients with retained lens fragments after phacoemulsification. METHODS A retrospective analysis of 126 patients who had vitrectomy for retained lens fragments after phacoemulsification during the 3-year period between January 1, 1993, and December 31, 1995. RESULTS Glaucoma, defined as an intraocular pressure of greater than or equal to 30 mmHg, occurred in 42 (36.8%) of 114 patients before vitrectomy and in 4 patients (3.2%) of 126 after vitrectomy. There were no differences in the rates of persistent glaucoma regardless of the intervals between cataract surgery and the vitrectomy: less than or equal to 1 week, 2 patients (4.1%); greater than 1 week to less than or equal to 4 weeks, 1 patient (2.5%) and greater than 4 weeks, 1 patient (2.6%). The visual acuity was 20/40 or better in 13 patients (11.4%) before vitrectomy and in 75 patients (59.5%) after vitrectomy. The rates of visual acuity 20/40 or better also were similar for all intervals: less than or equal to 1 week, 29 patients (59.2%); greater than 1 week to less than or equal to 4 weeks, 22 patients (56.4%) and greater than 4 weeks, 24 patients (63.1%). CONCLUSIONS Vitrectomy for removal of retained lens fragments reduces secondary glaucoma and yields favorable visual acuity outcomes. In eyes with elevated intraocular pressure, early vitrectomy generally is recommended, but delayed vitrectomy also has favorable outcomes.

Merkel Cell Carcinoma of the Eyelid and Periocular Tissues

Five patients had eyelid and periocular Merkel cell carcinoma. The tumor was located on the left lower eyelid in two patients, the left upper eyelid in one patient, the right upper eyelid in one patient, and was metastatic to the right outer canthus in one patient. The mean duration of symptoms was approximately four months. The diagnosis of Merkel cell carcinoma was not suspected clinically in any of the four primary eyelid cases, but was only established on histopathologic examination of biopsy specimens. Light microscopy disclosed carcinoma with small primitive cells in all five tumor biopsy specimens. Immunohistochemical studies showed neuron-specific enolase and keratin and transmission electron microscopy demonstrated neurosecretory granules typical for Merkel cell carcinoma. All five patients in this study were treated with wide surgical excision of the eyelid tumors with intraoperative frozen-section monitoring of the margins of resection. The left lower eyelid Merkel cell carcinoma spread to the preauricular lymph node in one patient. This patient subsequently died of metastatic Merkel cell carcinoma. One patient with metastatic right outer canthus Merkel cell carcinoma received radiotherapy (6,550 cGy). Eyelid Merkel cell carcinoma has the potential for recurrence and metastatic spread. We recommend lifetime follow-up for patients treated for eyelid Merkel cell carcinoma.

Retained lens fragments after phacoemulsification manifesting as marked intraocular inflammation with hypopyon

We reviewed the medical records of four patients with marked intraocular inflammation and hypopyon as the initial manifestation of retained lens fragments after phacoemulsification. The severe inflammatory reaction occurred between one month and one year after the cataract extraction. All four patients underwent pars plana vitrectomy to remove the lens fragments. The vitreous specimens were cultured to rule out infectious endophthalmitis. In all patients, no organisms were isolated from the vitrectomy specimens placed on both aerobic and anaerobic media. All patients had improved vision and resolution of the marked intraocular inflammation after vitrectomy. Echography was useful in establishing the diagnosis in these uncommon cases.

Giant Retinal Tear as a Complication of Attempted Removal of Intravitreal Lens Fragments During Cataract Surgery

PURPOSE To report giant retinal tear and retinal detachment as a complication of attempted removal of intravitreal lens fragments at the time of cataract surgery and to evaluate the anatomic and visual acuity outcomes of pars plana vitrectomy and retinal reattachment surgery. METHODS Retrospectively, 10 patients with giant retinal tear, retinal detachment, and intravitreal lens fragments in 10 eyes were reviewed. RESULTS In 10 eyes, retrieval of intravitreal lens fragments using the limbal approach by deep vitrectomy, copious vitreous cavity irrigation, or deep vitreous cavity phacoemulsification had been attempted by the anterior segment surgeon at the time of cataract surgery in each patient. The average interval from cataract surgery to the initial vitreoretinal consultation was 8 days. Each of the 10 eyes had a giant retinal tear involving the inferior retina: in four eyes, of between 90 degrees and 180 degrees; in four, equal to 180 degrees; and in two, of greater than 180 degrees. After pars plana vitrectomy and retinal detachment repair, nine (90%) of 10 eyes had retinal reattachment, but seven patients required more than one operation. One eye had persistent retinal detachment, and one eye had corneal graft failure. Seven (70%) of the 10 eyes had best-corrected final visual acuity of 20/200 or better; three eyes had light-perception, hand-motion, and counting-fingers vision. CONCLUSIONS Aggressive attempts at intravitreal lens fragment retrieval from a limbal-based approach should be avoided because these procedures may result in serious retinal complications, such as formation of a giant retinal tear.

Useful Visual Outcomes after Treatment of Bacillus cereus Endophthalmitis

PURPOSE Bacillus cereus endophthalmitis occurring after penetrating ocular trauma has been almost always associated with a poor visual outcome. The purpose of our study was to review and report patients who had useful visual acuity outcomes. METHODS The study group consisted of five patients from a single medical center with penetrating ocular trauma and endophthalmitis caused by B. cereus. The study population was derived from a review of the microbiology records, clinical records, and operative reports of patients with culture-proven, post-traumatic endophthalmitis over a 15-year period. Patients were only included if the final visual acuity outcomes were 20/200 or better. RESULTS All five patients had penetrating ocular injuries, and four patients had a retained intraocular foreign body. Endophthalmitis was diagnosed preoperatively in three patients and intraoperatively in two patients. All patients underwent pars plana vitrectomy and injection of intravitreal and periocular antibiotics. Postoperatively, a rhegmatogenous retinal detachment developed in three patients between 4 weeks and 12 months after the injury (average, 19 weeks); all retinal detachments were reattached with additional vitreoretinal surgery. Final postoperative visual acuities were 20/200 (two patients), 20/30 (one patient), and 20/25 (two patients). The postoperative follow-up time interval ranged from 12 months to 30 months (average, 19.2 months). CONCLUSION The current series adds further support to the observation that certain eyes with post-traumatic B. cereus endophthalmitis may be associated with preservation of anatomic integrity and restoration of useful visual acuity.