PURPOSE:Retinal neovascularization is one of the leading causes of blindness. A crucial event in this process is the remodeling and penetration of the capillary basement membrane by migrating endothelial cells. This process requires proteolysis of basement membrane components by a variety of proteinases. The objective of the present study was to determine the expression of proteinases in human retinal tissues showing active neovascularization.METHODS:Epiretinal neovascular membranes surgically removed from patients with proliferative diabetic retinopathy were analyzed by zymography, and the types and amounts of proteinases present in the tissues were determined. Retinas from nondiabetic donor eyes served as control specimens.RESULTS:Both the high- (54 kDa) and low- (33 kDa) molecular-weight forms of urokinase were present at significantly higher levels in neovascular membranes than in normal retinas. The pro forms of the matrix metalloproteinases (MMP) MMP-2 and MMP-9 were significantly elevated in the neovascular membranes in comparison with levels in normal retinas. In addition, the active forms of these enzymes were present in the membranes, whereas there was no detectable level of the active forms in normal retinas.CONCLUSIONS:Human diabetic neovascular membranes contain high levels of urokinase and MMP. The increased activity of proteinases in the final common pathway of retinal neovascularization indicates that inhibition of these enzymes may be a useful therapeutic target as an alternative approach in the management of proliferative retinopathies.

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.

*From the Department of Ophthalmology, University of Arizona, Tucson, Arizona, and †Retina Consultants of Nevada, Las Vegas, Nevada. Presented in part at the annual meeting of the Western Association for Vitreoretinal Education. Maui, Hawaii, July 25-29, 1994; the annual meeting of the Retina Society. Williamsburg, Virginia, September 28-October 1, 1994; and the annual meeting of the Macula Society. Tucson, Arizona, February 21-24, 1996. Reprints requests: Richard R. Ober, MD, Department of Ophthalmology, University of Arizona, 1801 N. Campbell Avenue. Tucson, Arizona 85719.

PURPOSE: To determine the efficacy and safety of subconjunctival 5-fluorouracil injections after trabeculectomy in patients with poor prognoses, to determine risk factors for surgical failure, and to examine the relationship of intraocular pressure and visual function.METHODS: In this multicenter clinical trial, 213 patients with previous cataract surgery or previous failed filtering surgery were randomly assigned to receive either trabeculectomy alone or trabeculectomy with postoperative subconjunctival 5-fluorouracil injections. Measurements of intraocular pressure, visual acuity, and visual fields were performed throughout the five years, with the clinician masked to the treatment group,Failure was defined as a reoperation to control intraocular pressure or an intraocular pressure greater than 21 mm Hg at or after the first year examination.RESULTS: Fifty-four (51%) of the 105 eyes in the 5-fluorouracil group and 80 (74%) of the 108 eyes in the standard filtering surgery group were classified as failures (P < .001, Mantel-Cox survival analysis), Risk factors for failure include high intraocular pressure, a short time interval after the last procedure involving a conjunctival incision, the number of procedures with conjunctival incisions, and Hispanic ethnicity. Patients in both treatment groups with controlled intraocular pressures were more likely to maintain visual acuity., Patients in the 5-fluorouracil group had a higher risk of late-onset bleb leaks (9%, nine of 105) than those in the standard filtering surgery group (2%, two of 108) (P = .032, Fisher's exact test).CONCLUSIONS: We recommend the use of subconjunctival 5 fluorouracil after trabeculectomy in eyes after previous cataract surgery or unsuccessful filtering surgery, but caution against its routine use in patients with good prognoses.

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.

Purpose: Effective eye care, both preventive and problem-directed, requires that patients actually see trained eye care providers. The authors examined the impact of a multimedia campaign on patient behavior in using eye care.Methods: The authors surveyed 2000 individuals 1 year after they mailed in a contrast sensitivity screening card during a focused multimedia educational campaign. The response rate was 39%, allowing precision of estimates to +/-4%.Findings: Those who failed the screening test were much more likely to have had an eye examination in the year after the campaign and were much more likely to have seen an ophthalmologist for their care. Other important factors significantly related to using eye care services were: having had prior examinations, having a non-ophthalmologist physician, and having a history of cancer or macular degeneration. Importantly, 22% of those who failed the screening test thought they had had normal results when asked 1 year later.Conclusions: A focused multimedia campaign combined with interactive patient involvement can directly increase the use of eye care services. In addition, such care is much more likely to be delivered by ophthalmologists as opposed to other providers.

PURPOSE:Acute retinal toxicity secondary to inadvertent intracameral injection of massive doses of gentamicin is a devastating complication of cataract surgery, for which no treatment, to date, either surgical or medical, has been shown to be effective. A rabbit experimental model was used to examine the effect of immediate pars plana vitrectomy in the management of inadvertent intracameral injection of gentamicin.METHODS:Twenty-seven rabbit eyes were subjected to lensectomy with or without preservation of the lens capsule. Aphakic rabbit eyes and rabbit eyes with an intact lens capsule were then subjected to injections of massive doses (4 mg and 20 mg) of gentamicin into the anterior chamber. Experimental eyes underwent an immediate pars plana vitrectomy and posterior segment lavage. The rabbits were killed after 7 days. Light microscopic examination was then performed to ascertain the degree of retinal damage caused by the injection.RESULTS:Rabbit eyes receiving immediate pars plana vitrectomy exhibited far less structural damage to the retina, as seen by light microscopy, than did corresponding control eyes. Furthermore, there appeared to be a protective effect of an intact lens capsule with regard to retinal damage.CONCLUSIONS:Immediate pars plana vitrectomy and posterior segment lavage may alleviate the effects of intracameral injection of gentamicin. This preliminary study demonstrates the need to perform further studies with a vascularized primate retina to evaluate immediate pars plana vitrectomy in the management of inadvertent intracameral injection of gentamicin.

Abstact: Extracorporeal membrane oxygenation (ECMO) is a modified, prolonged cardiopulmonary bypass procedure used to treat newborns who have reversible cardiac or respiratory failure. The venoarterial bypass technique requires cannulation of both the right carotid artery and the internal jugular vein, and after decannulation these vessels are permanently ligated. Left-sided retinal vascular changes after ECMO have been reported, and were attributed to ligation of these vessels. A retrospective review of the results of ocular examinations of 86 infants who had undergone ECMO therapy at Childrens Hospital in Los Angeles between March, 1987 and May, 1991 was conducted. Normal findings were noted in 73 infants. One infant had bilateral retinal vascular tortuosity, and 12 infants had incidental ocular findings, but there was no evidence of letf-sided retinal hemorrhage, venous congestion, or tortuosity. Our results suggest that left-sided retinal vascular changes after ECMO do not occur, occur only rarely, or clear rapidly and result in no permanent retinal damage. To unequivocally rule out the possibility that ECMO can cause transitory retinal vascular changes, we recommend further prospective studies, with ocular examinations performed before, during, and after ECMO.

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.