Steven R. Bennett

Factors Prognostic of Visual Outcome in Patients With Subretinal Hemorrhage

We reviewed the charts of 29 patients with large subretinal hemorrhages involving the center of the fovea to evaluate factors that might be prognostic of visual outcome. The average final visual acuity was 20/480 with a mean follow-up of three years. Patients with thick hemorrhages (causing an obvious elevation of the fovea) had worse final visual acuity than patients with thin hemorrhages (P = .02). The diameter of the hemorrhage was not a significant predictor of outcome. Patients with aging macular degeneration had poorer final visual acuity (mean, 20/1,700, P = .002), and patients with choroidal ruptures had better final visual acuity, (mean 20/35, P less than .001) than the remainder of the patients. We found that the presence of aging macular degeneration was a more important predictor of the outcome of legal blindness than the thickness of the hemorrhage (P = .03). Although the prognosis in patients with subfoveal blood is generally poor, some patients have excellent return of vision.

Surgical management of posteriorly dislocated silicone plate haptic intraocular lenses

PURPOSE To report a large series of delayed posterior dislocation of silicone plate haptic intraocular lenses after Nd:YAG laser capsulotomy and discuss the surgical management of this complication. METHODS We reviewed the records of 11 consecutive patients (11 eyes) with delayed onset of posterior dislocation of a plate haptic silicone intraocular lens. The cause of the posterior capsular defect, time to dislocation, surgical management techniques, complications, and visual outcome were recorded. RESULTS In eight of the 11 eyes, the silicone plate haptic intraocular lens dislocated an average of 1.8 months (range, 0 to 6.5 months) after Nd:YAG posterior capsulotomy. The other three eyes had surgical complications at the time of cataract extraction that compromised posterior capsular or zonular integrity and led to silicone plate haptic intraocular lens dislocation from 9 weeks to 6 months (mean, 3.6 months) postoperatively. Surgical management consisted of pars plana vitrectomy with intraocular lens repositioning (six eyes) or exchange (five eyes). The average follow-up period after intraocular lens repositioning or exchange was 6.5 months (range, 1 to 14 months). Best-corrected visual acuity at the last follow-up examination measured 20/40 or better in all but one eye that had preexisting macular disease. CONCLUSIONS Cataract surgeons and patients should be aware of the potential for plate haptic silicone intraocular lenses to undergo delayed posterior dislocation through capsular defects. This complication can be managed effectively with vitrectomy and either repositioning or exchange of the implant. Postoperative visual acuity is generally excellent, and complications are minimal.

An Autosomal Dominant Form of Low-Tension Glaucoma

A condition causing glaucomatous optic atrophy and visual field loss at normal or borderline intraocular pressure affected eight members of a family of consecutive generations. The disease was detectable in early adulthood and progressed slowly throughout life. The pattern of inheritance is autosomal dominant. One affected individual died of a myocardial infarction, and his eyes were obtained post mortem. Light and electron microscopic examination demonstrated glaucomatous optic atrophy with loss of ganglion cells. The trabecular meshwork, choroidal and optic nerve vasculature, retinal pigment epithelium, and photoreceptors were normal in appearance. We believe this family has an autosomal dominant genetic condition that is a distinct type of low-tension glaucoma.

Arteriovenous Crossing Dissection Without Separation Of The Retina Vessels For Treatment Of Branch Retinal Vein Occlusion

Purpose To evaluate visual outcome after arteriovenous (AV) crossing dissection for the treatment of branch retinal vein occlusion (BRVO) and secondary macular dysfunction in which difficulty separating the retinal vessels was experienced. Methods A pars plana vitrectomy and dissection of the involved AV crossing site were performed consecutively in 20 eyes of 20 patients with BRVO and vision loss. The overlying retinal artery was dissected free from the retinal surface, and separation of the artery and vein at the crossing site was attempted. Results In 19 of 20 eyes, the retinal artery was dissected around the crossing site, but a marked adhesion between the artery and vein precluded separation. After a mean follow-up of 10.5 months, VA improved by at least two lines in 16 eyes (80%), remained unchanged in three eyes (10%), and worsened by at least two lines in three eyes (10%). Mean change (± SE) in logMAR acuity was −0.28 ± 0.11 (two or three lines of improvement, P = 0.016) at 1 to 2 months’ follow-up and −0.44 ± 0.14 (three or four lines of improvement, P = 0.008) at the final follow-up. Cataract formation or progression occurred in 88%. Conclusions A surgically important adhesion between the retinal artery and vein at proximal AV crossings was encountered in all eyes undergoing AV crossing dissection, correlating with previous histologic and cadaver eye studies. Cataract formation or worsening was a frequent complication. Visual improvement may occur after vitrectomy and AV crossing dissection without separation of the retinal vessels.

Autosomal Dominant Neovascular Inflammatory Vitreoretinopathy

Twenty-eight of 61 members of a six-generation family are affected by an autosomal dominant eye disease which has not been described previously. Affected patients are asymptomatic in early adulthood, but have vitreous cells and the selective loss of the b-wave on the electroretinogram. Later, peripheral retinal scarring and pigmentation, peripheral arteriolar closure, and neovascularization of the peripheral retina at the ora serrata or occasionally neovascularization of the optic disc develop. Cystoid macular edema, vitreous hemorrhage, tractional retinal detachment, and neovascular glaucoma can cause profound visual loss. Vitrectomy reduces traction on the retina and allows for retinal reattachment. The role of argon laser photocoagulation or cryopexy in reducing the neovascular complications remains uncertain.

Localized retinal detachment with combined central retinal artery and vein occlusion after retrobulbar anesthesia

The authors report a patient who was observed to have a localized retinal detachment with combined central retinal artery and vein occlusion after cataract surgery performed with retrobulbar anesthesia. The authors propose that this condition resulted from injection of the anesthetic mixture into the optic nerve. No acute neurologic symptoms occurred, but visual loss was severe and permanent. This case adds to the previously reported spectrum of complications from retrobulbar anesthesia.

Prophylactic treatment to the fellow eye of patients with phakic lattice retinal detachment: analysis of failures and risks of treatment.

The authors performed a retrospective analysis on 296 phakic patients who had bilateral lattice degeneration and a retinal detachment in one eye. The analysis was done to determine the complications of full prophylactic treatment to lattice and breaks in the fellow eye and to explain the reasons that this treatment sometimes did not prevent new retinal breaks or detachments. The patients were followed for a mean ± SD of 7.415 ± 5.422 years after their first detachment. Twenty-four new tears occurred in the fellow eyes during this time, seven (29.2%) of which were away from areas of visible lattice. Prophylactic treatment did not appear to cause new tears or increase the risk of detachment if a new tear occurred. It also did not compromise the surgical repair in those patients who had eyes in which new breaks or detachments developed. The risk of visual loss was similar in those patients receiving prophylactic treatment compared with those not receiving treatment.

The Risk of Cytomegalovirus Transmission by Penetrating Keratoplasty

To investigate the risk of cytomegalovirus transmission by corneal transplantation, we quantitated anticytomegalovirus IgG levels of donor, preoperative, and postoperative serum samples. Of 118 patients, 79 (67%) were seropositive preoperatively. Twenty-five patients who were seronegative preoperatively received a graft from a positive donor and two (8%) seroconverted. Eleven patients who were seronegative preoperatively received a graft from a negative donor and one (9%) seroconverted. None of the patients who seroconverted had a febrile illness and all three grafts were clear.

Reversible loss of light perception after vitreoretinal surgery.

PURPOSE We studied reversible loss of light perception after vitreoretinal surgery to show that functional vision can return in some patients. METHODS We reviewed the medical records of seven patients who had postoperative reversible loss of light perception in the eye that underwent vitreoretinal surgery. Differences in the postoperative courses and interventions were studied. RESULTS Five of the seven patients had diabetes mellitus but none had hypertension. The indications for vitreoretinal surgery were severe proliferative diabetic retinopathy in five patients and retinal detachment with advanced proliferative vitreoretinopathy in two patients. Seven patients had reversible loss of light perception within the first three postoperative days. Six of the seven patients had an intraocular pressure greater than 26 mm Hg at the time the eye had no light perception. Decreasing the intraocular pressure was associated with return of light perception in five of seven patients. Return of useful vision was gradual. Four of seven patients had a visual acuity of 20/400 or better one month after surgery, and all seven had a visual acuity of 20/400 or better three months after surgery. Visual acuity in four eyes improved further to 20/70 or better at six months or more after surgery. CONCLUSION Reversible loss of light perception after vitreoretinal surgery does occur in some patients. Monitoring vision and intraocular pressure is important because prompt treatment may assist in the recovery of functional vision.

Perfluoropropane 12% versus 20%. Effect on intraocular pressure and gas tamponade after pars plana vitrectomy.

A randomized prospective study was performed on 30 nonglaucomatous eyes undergoing pars plana vitrectomy and intraoperative fluid-gas exchange, comparing the effect of two perfluoropropane gas concentrations (12% and 20%) on postoperative intraocular pressure, early postoperative bubble size, and intravitreal longevity. No significant differences in mean intraocular bubble size at 36 to 48 hours and mean peak and final follow-up intraocular pressure were found between the 12% group (n = 15) and the 20% group (n = 15, unpaired T-test). Intravitreal longevity was significantly greater for the 20% concentration (mean +/- standard deviation = 8.4 +/- 1.8 weeks) compared with the 12% concentration (mean +/- standard deviation = 6.7 +/- 1.6 weeks). In nonglaucomatous eyes under careful observation and appropriate antiglaucoma therapy, the choice between a 12% or 20% concentration of perfluoropropane gas determined primarily longevity of gas tamponade rather than postoperative pressure or early bubble size.