Richard R. Ober

Punctate inner choroidopathy

Ten moderately myopic women had blurred vision, light flashes, or paracentral scotomas associated with small yellow-white lesions of the inner choroid and pigment epithelium. Most lesions had an overlying serous detachment, were hyperfluorescent, and leaked fluorescein during the acute phase. The lesions healed into atrophic scars and became progressively more pigmented with time. Subretinal neovascular membranes later developed from scars in six patients. Vision was usually only minimally affected unless the lesions were subfoveal or unless choroidal neovascular membranes subsequently occurred. Extensive laboratory studies were noncontributory.

Rhegmatogenous Retinal Detachment After Neodymium-YAG Laser Capsulotomy in Phakic and Pseudophakic Eyes

A retrospective study of 18 eyes in 17 patients with rhegmatogenous retinal detachments after neodymium-YAG laser posterior capsulotomy was performed to determine operative settings and to describe anatomic changes after the procedure in an effort to assess their relationship to subsequent retinal detachment. The laser energy required to create a capsulotomy did not appear to be excessive and the capsulotomy openings were not unusually large. The time between YAG capsulotomy and diagnosis of retinal detachment ranged from four to 82 weeks (mean, 28 weeks). The characteristics of the retinal detachments were similar to those after routine cataract extraction. Retinal reattachment surgery was ultimately successful in all 18 eyes. Both YAG laser and knife-needle posterior capsulotomies may increase the risk of subsequent rhegmatogenous retinal detachment as a result of opening the capsule.

Experimental retinal tolerance to liquid silicone.

The effect of intraocular liquid silicone on the electroretinogram (ERG) and on retinal morphology was studied in rabbits. After vitrectomy, liquid silicone (1000 centistokes) or balanced salt solution (BSS) was injected Into the eyes. The intraocular silicone was well tolerated clinically in all eyes that were followed over a period of 3 days to 6 months. ERG responses were equivalent in operated control and siliconeinjected eyes. Light and electron microscopy showed slight but comparable changes in both operated control and silicone-injected eyes that were consistent with either fixation artifact and/or surgical trauma. The results suggest that exposure to silicone for up to 6 months does not have a toxic effect on the rabbit retina.

Ocular Perforation From a Retrobulbar Injection

Proliferative vitreoretinopathy occurred in three of seven cases of ocular perforation from retrobulbar injection, resulting in a visual acuity of 20/200 or worse. Direct macular injury and macular pucker occurred in two cases each. Needle injury exit sites were in the posterior pole in all cases. Predisposing factors were not experimentally verified, but associated conditions included axial myopia, multiple injections, traditional superonasal gaze position, previous retinal buckling procedure, and enophthalmos.

Article for CME creditMassive mycobacterial choroiditis during highly active antiretroviral therapy: Another immune-recovery uveitis?☆

PURPOSE To describe the ocular presentation of disseminated mycobacterial disease occurring during immune-recovery in a patient with acquired immune deficiency syndrome (AIDS). STUDY DESIGN Case report and literature review. PARTICIPANTS A 41-year-old AIDS patient with a prior diagnosis of cytomegalovirus retinitis. METHODS The patient developed progressive, bilateral multifocal choroiditis with panuveitis 2 months after beginning and responding to highly active antiretroviral therapy. His left eye became blind and painful and was enucleated. Pathologic examination revealed massive choroiditis with well-formed, discrete granulomas and multiple intracellular and extracellular acid-fast organisms within the choroidal granulomas. Culture and polymerase chain reaction of vitreous specimens revealed Mycobacterium avium complex (MAC). RESULTS Empiric, and later sensitivity-guided, local and systemic antibiotic therapy was used to treat the remaining right eye, but it continued to deteriorate. Despite medical therapy, three vitrectomies and repeated intravitreal injections of amikacin, a total retinal detachment ensued. One week after the third vitrectomy, the patient died from mesenteric artery thrombosis in the setting of disseminated mycobacterial disease. CONCLUSIONS This is the first report of ocular inflammation as the presenting finding in the recently recognized syndrome of immune-recovery MAC disease. Pathogenesis of this entity is related to an enhanced immune response to a prior, subclinical, disseminated infection. The formation of discrete granulomas, normally absent in MAC infections in AIDS, reflects this mechanism.

Central Retinal Vein Occlusion Associated with Retinal Arteriovenous Malformation

PURPOSE/BACKGROUND Retinal arteriovenous malformations can be seen in a variety of ways and have multiple, associated, ocular changes that can affect vision. The authors report two cases of retinal arteriovenous malformation. In each case, a central retinal vein occlusion developed. METHODS Each patient underwent clinical examination and fluorescein angiography. One patient was followed over a long period of time. CONCLUSION The authors propose that a turbulent flow, high intravascular volume, and arteriolar pressure in the venous side of the retinal arteriovenous malformation may lead to vessel wall damage, thrombosis, and occlusion. They also suggest that compression of the central retinal vein by the mass effect of the arteriovenous malformation on the optic nerve further leads to turbulence and thrombosis.

Vitreoretinal dissection instruments.

We developed and evaluated clinically a series of three vitreoretinal dissection instruments with a constant-diameter shaft and various tip designs including a 90-degree hooked tip, a 130-degree hooked tip, and a blunt-tip right-angle spatula. The instruments, manufactured from a titanium alloy, are lightweight and glare resistant. We have used these instruments interchangeably with other vitreous surgery instruments introduced through a 20-gauge sclerotomy. They facilitate delicate manipulations associated with separation of epiretinal membranes from the inner retinal surface.

Subretinal neovascularization in the Vogt-Koyanagi-Harada syndrome

Two Hispanic patients with Vogt-Koyanagi-Harada (VKH) syndrome each developed a disciform lesion involving the macula of one eye several months after the onset of symptoms. Each had extraocular manifestations which included pleocytosis of the cerebrospinal fluid. The disciform lesions were associated with retinochoroidal anastomoses, a finding not previously reported in VKH syndrome. Each patient had a separate extramacular disciform lesion in the same eye. Two other Hispanic patients with diffuse bilateral intraocular inflammation had ocular findings consistent with VKH syndrome. One of these patients developed bilateral peripapillary disciform lesions and the other developed a disciform macular scar in one eye. Fluorescein angiography in each patient showed early irregular hyperfluorescence with late intense staining. The disciform detachments occurred in areas of reactive proliferation of the retinal pigment epithelium, and we postulate that growth of subretinal new vessels occurred through areas of Bruchs membrane that were damaged by the inflammation.

A combined anterior and posterior approach to cataract surgery in patients with chronic uveitis

Although several recent papers have focused on the results of cataract surgery in patients with uveitis, little has been published on specific surgical techniques that are most appropriate to such cases. We have found that a combined anterior and posterior approach using extracapsular techniques (usually phacoemulsification) and pars plana vitrectomy, with or without intraocular lens placement, is best suited for selected uveitis patients who have cataract, vitreous opacities, and cystoid macula edema. This paper discusses the surgical techniques that we have found to be best for the management of these cases.

Panuveitis and multifocal retinitis in a patient with leucocytoclastic vasculitis.

To our knowledge, bilateral panuveitis and multifocal retinitis/vasculitis have not been described previously in association with leucocytoclastic vasculitis. We describe a patient with bilateral panuveitis associated with multifocal retinitis/vasculitis who also had multiple purpuric, palpable skin lesions. Biopsies of the skin lesions were diagnostic of leucocytoclastic vasculitis. An extensive examination for systemic disease was otherwise negative. Prompt treatment with systemic corticosteroids resulted in dramatic improvement ofboth the ocular and the skin lesions.