Objective: To determine whether earlier treatment using ablation of the avascular retina in high-risk prethreshold retinopathy of prematurity (ROP) results in improved grating visual acuity and retinal structural outcomes compared with conventional treatment.Methods: Infants with bilateral high-risk prethreshold ROP (n=317) had one eye randomized to early treatment with the fellow eye managed conventionally (control eye). in asymmetric cases (n=84), the eye with high-risk prethreshold ROP was randomized to early treatment or conventional management. High risk was determined using a model based on the Multicenter Trial of Cryotherapy for Retinopathy of Prematurity natural history cohort. At a corrected age of 9 months, visual acuity was assessed by masked testers using the Teller acuity card procedure. At corrected ages of 6 and 9 months, eyes were examined for structural outcome. Outcomes for the 2 treatment groups of eyes were compared using chi(2) analysis, combining data for bilateral and asymmetric cases.Results: Grating acuity results showed a reduction in unfavorable visual acuity outcomes with earlier treatment, from 19.5% to 14.5% (P=.01). Unfavorable structural outcomes were reduced from 15.6% to 9.1% (P<.001) at 9 months. Further analysis supported retinal ablative therapy for eyes with type I ROP, defined as zone I, any stage ROP with plus disease (a degree of dilation and tortuosity of the posterior retinal blood vessels meeting or exceeding that of a standard photograph); zone I, stage 3 ROP without plus disease; or zone II, stage 2 or 3 ROP with plus disease. The analysis supported a wait-and-watch approach to type 2 ROP, defined as zone I, stage I or 2 ROP without plus disease or zone II, stage 3 ROP without plus disease. These eyes should be considered for treatment only if they progress to type I or threshold ROP.Conclusions: Early treatment of high-risk prethreshold ROP significantly reduced unfavorable outcomes to a clinically important degree. Additional analyses led to modified recommendations for the use of peripheral retinal ablation in. eyes with ROP. Long-term follow-up is being conducted to learn whether the benefits noted in the first year after birth will persist into childhood.

OBJECTIVE To evaluate outcomes at 10 years after randomization for eyes undergoing cryotherapy vs eyes serving as controls, for patients enrolled in the Multicenter Trial of Cryotherapy for Retinopathy of Prematurity (CRYO-ROP). METHODS The randomized cohort originally consisted of 291 preterm children with birth weights less than 1251 g who developed a defined threshold of ROP severity in one or both eyes. Patients with bilateral threshold ROP (n = 240) were randomly assigned to receive cryotherapy to one eye and no cryotherapy to the other eye. Those with ROP of less severity than threshold in the fellow eye ("asymmetric"; n = 51) were randomly assigned to cryotherapy or no cryotherapy in the eye with threshold ROP. Ten years later, a tester who was masked to treatment status of each eye measured distance and near visual acuity, with "unfavorable" outcome being 20/200 or worse. Patients also were evaluated by study-certified ophthalmologists who assessed ROP residua primarily in the posterior pole of the fundus, with unfavorable outcome being a posterior retinal fold or worse. RESULTS For the 247 children examined, both functional and structural primary outcomes showed fewer unfavorable outcomes in treated vs control eyes: 44.4% vs 62.1% (P<.001) for distance visual acuity and 27.2% vs 47.9% (P<.001) for fundus status. Near acuity results were similar to those for distance (42.5% vs 61.6%; P<.001). Total retinal detachments had continued to occur in control eyes, increasing from 38.6% at 5(1/2) years to 41.4% at 10 years, while treated eyes remained stable (at 22.0%). A previously disturbing subgroup trend that more control eyes than treated eyes had visual acuity of 20/40 or better (in the 5(1/2)-year report) was no longer present at 10 years; eyes that received cryotherapy were found at least as likely as control eyes to have 20/40 or better visual acuity. CONCLUSIONS At 10 years, eyes that had received cryotherapy were much less likely than control eyes to be blind. A previous trend for a higher proportion of sighted control eyes than sighted treated eyes to show acuity in the normal range was not confirmed. The results show long-term value from cryotherapy in preserving visual acuity in eyes with threshold ROP.

The Macular Photocoagulation Study criteria require that at least 1.5 clock hours of temporal peripapillary retina be spared when treating choroidal neovascular membrane in that location. The authors successfully treated peripapillary choroidal neovascular membrane involving temporal 180 degrees with the krypton laser without any loss of visual acuity and central field.

We studied the use of human retinal pigment epithelial cells cultured on a collagen support as a potential transplantation therapy to replace diseased or damaged retinal pigment epithelium. Using a transvitreal approach, we transplanted human retinal pigment epithelial cells attached to either a sheet of noncross-linked or cross-linked type I collagen into the subretinal space of New Zealand white rabbits, whose eyes lack pigment. Animals were killed after six weeks, and the eyes were fixed for light microscopy. The results demonstrated that, in eyes receiving the noncross-linked collagen support, a layer of pigmented donor retinal pigment epithelium was visible within the subretinal space, with a normal-appearing retina and no evidence of proliferative vitreoretinopathy or graft rejection. We believe this method may be applicable to replace dysfunctional retinal pigment epithelial cells in humans.

Twenty-five consecutive cases of culture-proven postsurgical endophthalmitis were evaluated. Patients underwent wound revision and pars plana vitrectomy with intravitreal antibiotic and steroid infusion (gentamicin 8 micrograms/cc, clindamycin 9 micrograms/cc, dexamethasone 8 micrograms/cc) and injection (gentamicin 100 micrograms plus clindamycin 200 micrograms [and amphotericin 5 micrograms in one case] and dexamethasone 800 to 1000 micrograms). Twenty cases demonstrated wound defects (eg, wound gape/malapposition, abscess/tissue necrosis, suture dehiscence, leak, vitreous wick). Culture-proven isolates included both gram negative and positive bacteria and fungi. Visual acuity improved in 18 of the 20 (90%) gram positive cases. Ten of the 17 (59%) patients in the Staphylococcus epidermidis subgroup achieved a visual acuity of 20/50 or better. Surgical wound defects are frequently associated with culture-proven endophthalmitis. When vitrectomy is included as part of the treatment regimen, we recommend meticulous inspection and closure of any defective surgical wounds associated with endophalmitis.

The authors reviewed the outcome of treatment of 100 consecutive patients with the diagnosis of infectious endophthalmitis. The parameters evaluated included age; sex; therapy; preoperative, postoperative, and six-month visual acuitites; year of treatment; organisms isolated; inciting insult; and the presence of wound defects. Overall, 63% were postsurgical, 24% were posttrauma, and 8% were endogenous infections; 5% were complications of corneal ulcers. The organisms isolated were as follows: gram-positive organisms, 42%; gram-negative organisms, 9%; fungal organisms, 6%; and mixed infections, 3%. A culture-negative rate of 37% was reported. For all treatment groups, the mean properative visual acuity was 0.0396 (approximately 20/500), and the mean six-month visual acuity was 0.173 (approximately 20/100). The data showed the potential for better visual outcome in the postsurgical group compared with those with trauma, endogenous infections, or complications of corneal ulcers (nonsurgical groups). Six treatment regimens were evaluated; three had improved visual acuitites.

Within the last 6 months, three cases of infectious endophthalmitis following sutureless cataract surgery have been referred to us. Two of these cases followed uncomplicated sutureless phacoemulsification with intraocular lens implantation. One case was complicated by a postoperative hyphema with additional surgery for clot removal 2 days following the initial procedure.

Three articles on the management of ocular penetration from local anesthesia have recently been published, two in this journal)•2 and a third in another journal.3 The most recent article noted that "Penetration of the globe may be difficult to notice at the time of surgery.,,3In that series, the proper diagnosis was made at the time of injection in only 5 of 12 cases.This is consistent with one of your articles reporting that the diagnosis was immediately recognized in only 12 of 23 cases. 2 For many years, I have used a quick and simple examination to avoid missing this complication.After every retrobulbar or peribulbar injection, I check the fundus with an indirect ophthalmoscope to be sure that the sclera has not been perforated and that the retinal vessels are patent.In cases where the fundus is known to be abnormal (e.g., diabetic retinopathy or retinal detachment), it would be useful to check the fundus both before and after the local anesthetic injection.

We studied zinc uptake by nonhuman primate retinal pigment epithelium (RPE) and choroid, using 65Zn as a probe. With intravenously administered 65ZnCl2, virtually all detectable tracer was lost from the plasma after 20 hours but the pigment epithelium-choroid showed prominent uptake and retention. Plasma concentrations of oral 65ZnO remained high 20 hours after feeding. Uptake and retention of orally administered 65Zn as 65ZnO from the bloodstream by the RPE/choroid was avid in both young and old animals. Excretion in urine and feces was minimal. All pigmented ocular tissues took up and retained 65Zn. A survey of total zinc content of human and nonhuman primate ocular tissues showed that the pigmented tissues had consistently higher concentrations of zinc. Our results demonstrate for the first time direct uptake and retention of zinc from the blood by primate RPE and other ocular tissues.

The histologic and clinical effect of intravitreal dexamethasone was studied in a rabbit model of experimentally induced gentamicin sensitive Staphylococcal epidermidis endophthalmitis. The study compared four treatment groups: vitrectomy alone (group I), vitrectomy plus intravitreal gentamicin (group II), vitrectomy plus intravitreal gentamicin and dexamethasone (group III), and intravitreal gentamicin and dexamethasone without vitrectomy (group IV). All eyes treated with dexamethasone, with or without vitrectomy, exhibited less clinical and histologic manifestations of inflammation. This study suggests that suppression of inflammation through the use of intravitreal dexamethasone leads to preservation of ocular architecture with potentially improved retinal function and visual benefit.

Sutureless cataract surgery has recently emerged as a new method of performing cataract surgery. The proposed benefits include decreased postoperative astigmatism and faster visual recovery. Several ophthalmologists have advertised this surgery as being of the art. One must remember that state of the art is not necessarily synonymous with standard of care or standard practice. See also p 1562. Our experience with the postoperative complications of this technique leads us to have serious reservations regarding its safety (risk-benefit ratio). Report of a Case. —A 53-year-old man was referred for evaluation of possible endophthalmitis. Approximately 2 weeks earlier he had undergone sutureless cataract surgery with implantation of a posterior chamber intraocular lens. Five days before being examined by us, he underwent an intraocular lens exchange because the original lens had the incorrect power. This surgery was performed through the original incision and was also closed without a suture. Our examination

The use of intraocular thrombin to control intraoperative hemorrhage is presented in two cases, one involving severe ocular trauma, the other severe proliferative diabetic retinopathy. The technique of intermittent boluses of 100 units/ml of thrombin in BSS Plus solution has certain advantages over the constant infusion mode of delivery. The ability to quickly manipulate the flow offers a distinct advantage in controlling the intraocular pressure and total amount of thrombin delivered. This is achieved by a simple and uncomplicated modification of the standard gravity infusion controlled by the surgical assistant.