Age-related macular degeneration (AMD) remains the leading cause of visual loss in adults older than 65 years. Retinal angiomatous proliferation (RAP) is a newly recognized manifestation of exudative AMD that has a poor natural history and demonstrated resistance to treatment with conventional laser photocoagulation. A novel surgical technique has been developed in this pilot series that shows promise in the treatment of this subtype of neovascular lesions. Through specific surgical lysis of the feeding arteriole and draining venule of an RAP lesion, improvement in visual acuity has been noted. This has been correlated with resolution of intraretinal edema and flattening of associated pigment epithelial detachment, which was confirmed by fluorescein angiography, optical coherence tomography, and high-speed indocyanine green angiography.

PURPOSE: To report a case of malattia leventinese involving subretinal hemorrhage.METHODS: Case report.RESULTS: Two weeks after initial presentation, the visual acuity of this 34-year-old man decreased to LE: 20/100, Funduscopic evaluation revealed a subretinal hemorrhage involving the center of the foveal in the left eye that was interpreted as secondary to a neovascular membrane on fluorescein angiography. The patient did well after the removal of the submacular material by pars plana vitrectomy.CONCLUSION: Patients with malattia leventinese may occasionally present with submacular hemorrhage. Prompt diagnosis and intervention may enhance the patient's chance for visual improvement. (Am J Ophthalmol 2001;131:517-518, (C) 2001 by Elsevier Science Inc. All rights reserved).

PURPOSE: To evaluate the relationship between microbiologic factors, effect of treatment, and visual outcome in the Endophthalmitis Vitrectomy Study.METHODS: Four hundred twenty patients were enrolled in the Endophthalmitis Vitrectomy Study between February 1990 and January 1994. Of these, 394 completed 9 to 12 months of follow-up. Patients presented with features of bacterial endophthalmitis within 6 weeks of cataract extraction or secondary intraocular lens implantation. The relations between visual outcome and the identity of infecting species, gram stain results, antibiotic susceptibilities, and presence of vitrectomy cassette growth were examined.RESULTS: Rates of achieving final visual acuity of 20/100 or better for the more common isolates were as follows: gram-positive, coagulase-negative micrococci, 84%; Staphylococcus aureus, 50%; streptococci, 30%; enterococci, 14%; and gram-negative organisms, 56%. A positive gram stain or infection with species other than gram-positive, coagulase-negative micrococci were significantly associated with poorer visual outcome (P <.001 for species group comparisons). However, presenting visual acuity was more powerful than microbiologic factors in predicting visual outcome and favorable response to vitrectomy. Bacterial growth from the vitrectomy cassette specimen had prognostic significance equivalent to growth from other intraocular sources.CONCLUSIONS: Visual prognosis was strongly associated with the type of infecting organism and gram stain positivity. However, visual acuity at initial presentation appeared to be more useful than microbiologic factors in predicting visual outcome and judging the value of immediate vitrectomy in acute bacterial endophthalmitis after cataract surgery.

PURPOSE: To describe a patient whose initial sign of giant cell arteritis was a branch retinal artery occlusion.METHODS: We examined a 77-year-old woman who developed arteritic anterior ischemic optic neuropathy three weeks after an isolated nonem belie branch retinal artery occlusion occurred in the same eye.RESULTS: The diagnosis of giant cell arteritis was confirmed by temporal artery biopsy after the patient was treated with intravenous corticosteroids.CONCLUSIONS: Although a rare cause of branch retinal vascular occlusion, giant cell arteritis should be considered in the differential diagnosis of a nonembolic branch retinal artery occlusion in elderly patients.

Objective: To determine the roles of immediate pars plana vitrectomy (VIT) and systemic antibiotic treatment in the management of postoperative endophthalmitis.Design: Investigator-initiated, multicenter, randomized clinical trial.Setting: Private and university-based retina-vitreous practices.Patients: A total of 420 patients who had clinical evidence of endophthalmitis within 6 weeks after cataract surgery or secondary intraocular lens implantation.Interventions: Random assignment according to a 2 X 2 factorial design to treatment with VIT or vitreous tap or biopsy (TAP) and to treatment with or without systemic antibiotics (ceftazidime and amikacin).Main Outcome Measures: A 9-month evaluation of visual acuity assessed by an Early Treatment Diabetic Retinopathy Study acuity chart and media clarity assessed both clinically and photographically.Results: There was no difference in final visual acuity or media clarity with or without the use of systemic antibiotics. In patients whose initial visual acuity was hand motions or better, there was no difference in visual outcome whether or not an immediate VIT was performed. However, in the subgroup of patients with initial light perception-only vision, VIT produced a threefold increase in the frequency of achieving 20/40 or better acuity (33% vs 11%), approximately a twofold chance of achieving 20/100 or better acuity (56% vs 30%), and a 50% decrease in the frequency of severe visual loss (20% vs 47%) over TAP. In this group of patients, the difference between VIT and TAP was statistically significant (P < .001, log rank test for cumulative visual acuity scores) over the entire range of vision.Conclusions: Omission of systemic antibiotic treatment can reduce toxic effects, costs, and length of hospital stay. Routine immediate VIT is nor necessary in patients with better than light perception vision at presentation but is of substantial benefit for those who have light perception-only vision.

Between September 1985 and September 1987, 101 eyes with rhegmatogenous retinal detachment and severe (with a classification of at least C-3) proliferative vitreoretinopathy but without prior vitrectomy were treated with vitrectomy and randomized to either a mixture of 20% sulfur hexafluoride gas and air or to 1 000 centistokes of silicone oil. Between 50% and 60% of eyes that received silicone oil had visual acuity better than or equal to 5/200 compared with 30% to 40% of the eyes that received sulfur hexafluoride gas (P<.05). Macula attachment was more frequent in eyes that received silicone oil than in those that received sulfur hexafluoride gas (80% vs 60%, P<.05). Hypotony was more prevalent in eyes with a detached macula (40% to 50% for sulfur hexafluoride gas vs 25% to 30% for silicone oil) when compared with those with attached maculas (<5% for either modality). Keratopathy was more prevalent in eyes with detached maculas (about 55% to 60% for either modality) compared with eyes with attached maculas (25% to 30% for sulfur hexafluoride gas vs 10% to 15% for silicone oil). In a companion article, we show that these differences between a gas tamponade and silicone oil are not found for perfluoropropane gas.

Between September 1987 and October 1990, 265 eyes with rhegmatogenous retinal detachment and severe (with a classification of at least C-3) proliferative vitreoretinopathy were treated with vitrectomy and randomized to treatment with perfluoropropane gas or silicone oil; 131 eyes had undergone no prior vitrectomy (group 1) while 134 eyes had undergone vitrectomy with intraocular gas tamponade (group 2). At the last examination, there were no differences between perfluoropropane gas and silicone oil in achieving visual acuity greater than or equal to 5/200 (43% vs 45% for group 1, 38% vs 33% for group 2) and complete posterior retinal reattachment (73% vs 64% for group 1, 73% vs 61% for group 2). For group 1 eyes followed up for at least 18 months, there was an advantage favoring perfluoropropane gas in achieving complete posterior retinal reattachment (83% vs 60% at 36 months, P=.045). The rates of reoperation and keratopathy were similar, while hypotony was more prevalent in eyes randomized to perfluoropropane gas (group 2). Regardless of tamponade, groups 1 and 2 had similar anatomic and visual success. However, hypotony was twice as prevalent in group 2 (perfluoropropane), and the prevalence of keratopathy increased with follow-up in group 2 (either tamponade). Either tamponade produced better results than those seen with sulfur hexafluoride gas (Silicone Study Report 1).

Twenty-two infants with "threshold" stage 3+ retinopathy of prematurity (ROP) were entered into a prospective, randomized clinical trial to compare the efficacy of transscleral cryotherapy versus laser photocoagulation delivered by the indirect ophthalmoscope. Eighteen infants have been followed for at least 3 months. Fifteen of 16 eyes randomized to laser and 9 of 12 eyes randomized to cryotherapy showed regression. The results suggest that laser therapy is as effective as cryotherapy in the treatment of ROP (P = 0.285).

The authors report on 11 patients with age-related macular degeneration associated with massive subretinal hemorrhage, who were treated with surgical removal of the hemorrhage and associated fibrosis. Preoperative visual acuity ranged from 20/400 to hand motions. Postoperative visual acuity ranged from 20/200 to light perception with a minimum of 3 months of follow-up. Complications included partial or total retinal detachment in four patients (36%) and cataract in four patients (36%). Four of 11 patients showed some improvement in vision (36%). All four of these patients had surgery within 1 week of the onset of severe visual loss. Although surgical removal of large subretinal hemorrhages is technically feasible, visual recovery is limited, even in uncomplicated cases, by macular degenerative changes.

Posterior 360° retinotomy in conjunction with extensive peripheral retinectomy was necessary for retinal reattachment in 18 eyes. A visual acuity of 20/400 or better was achieved in 22% of the patients; in patients with rubeosis, regression was found in 89%. Of the hypotonus eyes, preoperatively 78% were normotensive postoperatively after removal of anterior proliferative vitreoretinopathy (PVR) covering ciliary epithelium. The major intraoperative complication was hemorrhage, which could be readily controlled. Recurrent retinal detachment (RD) occurred in 39% and reproliferation in 50% of the patients.

Cyclodestructive modalities in humans have been shown to be effective when applied 3.5 mm or more posterior to the limbus. Therefore, CW Nd:YAG contact transscleral laser and cryopexy were applied 6 mm posterior to the limbus of pigmented rabbits. The intraocular pressure (IOP), flare, iritis, cells and conjunctival hyperemia were monitored clinically up to 3 weeks. The pressure lowering effect was -7.5 +/- 7.7 mm Hg for laser retinopexy and -14.2 +/- 6.0 mm Hg for retinocryopexy at 3 weeks and was comparable to application of the same modalities directly over the ciliary body. Similarly, induction of intraocular inflammation by injecting 10 micrograms of endotoxin intravitreally lowered IOP significantly. These findings suggest that hypotension may not be directly due to cyclodestruction but may be related to the ocular irritative response and extent of neuroepithelial defect, irrespective of its distance from the limbus.

We report the use of a continuous wave Nd:YAG (CW-YAG) laser focused through a sapphire crystal to create a filtering bleb by ab-interno sclerostomy. A 2-mm clear corneal incision was made in each eye of five anesthetized Dutch Belted rabbits, and the 30-mm-long sapphire crystal with a 0.2-mm focal tip was passed across the anterior chamber until it came in contact with the opposite angle. Between two and three pulses of 0.8 J were required to produce a filtering bleb in each of the 10 eyes. The overlying conjunctiva was not damaged; the procedure time was under five minutes. Histological examination revealed a surrounding area of scleral melting that extended an average of 0.06 mm from the sclerostomy. These data suggest that the CW-YAG laser may be useful in performing glaucoma filtering surgery with minimal damage to surrounding ocular tissues.

We successfully used a semiconductor diode laser to deliver endophotocoagulation burns to the retina of a rabbit. The diode laser employed emits light at a wavelength of 817 nm (near infrared). It has a power output of up to 1.0 W in the continuous-wave mode, equivalent to the capability of current argon laser endophotocoagulators. A standard, commercially available fiberoptic endophotocoagulation probe was used to deliver the laser burns. We used power settings ranging from 300 mW to 400 mW and exposure times of 0.1 to 0.2 seconds to produce chorioretinal burns that appeared clinically and histopathologically indistinguishable from those induced with conventional wavelengths. This new laser system has the decided advantages over traditional endophotocoagulators of being much smaller, less costly, and requiring no water cooling, without sacrificing power output or ease of delivery.

Adequate pupillary dilation is essential to dissect and excise peripheral tractional proliferative tissue during vitreous surgery. Most surgical dilating procedures involve an incision or excision of iris tissue, that is either inadequate or irreversible. We describe a modification of a previously devised technique for stretching the pupil that ensures an excellent view of the peripheral retina. The technique has been used in aphakic and pseudophakic eyes in over 50 cases with no postoperative morbidity or problems with glare or poor cosmesis.

The cyclodestructive and inflammatory effects of CW Nd:YAG contact laser were compared to those of conventional cryopexy. CW Nd:YAG light transmitted by fiber optic cable and sapphire crystal was applied transsclerally to the ciliary body of pigmented and albino rabbits. Cyclocryopexy was given to a comparable second group. The intraocular pressure (IOP), flare, iritis, cells and conjunctival hyperemia were monitored clinically up to 3 weeks. The breakdown of the blood-aqueous barrier and time course of ocular inflammation was similar for both modalities and IOP was -12.2 +/- 4.2 mm Hg for laser cyclopexy and -15.1 +/- 5.4 mm Hg for cyclocryopexy at 3 weeks. Ciliary body lesions were noted in both groups. Overall, albino rabbits showed less histological damage and faster recovery of IOP. Contact cyclophotocoagulation and cyclocryopexy can be considered models of ocular injury. The similarities in ocular irritative response suggest a similar pathophysiologic mechanism underlying the pressure behavior in both thermal mode injuries.

Complicated retinal detachments (RDs) were successfully managed in 150 eyes of 170 consecutive patients by one surgeon (JLF) using silicone oil in conjunction with modern pars plana vitrectomy. Long-term postoperative complications were observed between 6 months and 5 years of follow-up. Cataracts developed in all phakic eyes and all corneas with oil-endothelial touch showed band keratopathy within 6 months. Recurrent detachments were noted in 22% of eyes during silicone oil tamponade and occurred in 13% of eyes after the oil had been removed. Other complications associated with the use of oil for vitreous surgery included pupillary block glaucoma (3%), closure of the inferior iridectomy (14%), fibrous epiretinal and subretinal proliferations (15%), pain (5%), and subconjunctival deposits of oil (3%). Without exception, within a period of 1 year the intraocular silicone oil showed some degree of emulsification, suggesting that the physicochemical characteristics of the oil injected may be an important variable in long-term complications.

An experimental technique utilizing a sapphire contact laser probe for thermal sclerostomy ab interna is described. The contact laser probe with a tip diameter of 0.2 mm is brought in contact with the trabecular meshwork. Using 3.50 watts of cw Nd:YAG at 0.1 second duration, three to five exposures established communication between anterior chamber and subconjunctival space in pigmented rabbits.