There are many alternatives available to the vitreoretinal surgeon in the management of posterior... more There are many alternatives available to the vitreoretinal surgeon in the management of posteriorly dislocated intraocular lenses (IOL). The lens may be repositioned in the ciliary sulcus if there is adequate capsular support, but if this support is absent, it must either be sutured in place (to the sclera or iris) or exchanged for an anterior chamber (AC) IOL. Scleral-sutured IOLs can be associated with hemorrhage, cystoid macular edema, retinal detachment, and endophthalmitis (through the suture tract), and use sutures that must last for the lifetime of the patient. Anterior chamber IOLs (ACIOLs) are easier to implant but require a limbal incision for insertion. The authors sought to determine the safety and efficacy of combining removal of posteriorly dislocated IOLs with ACIOL placement.A retrospective chart review, in which all cases of dislocated IOLs managed at the authors’ institution over the last 5 years were reviewed. Patient characteristics, pre-existing ocular conditions, preoperative visual acuity (VA), intraocular pressure (IOP), type of lens dislocated, operation performed, postoperative VA and IOP, and length of follow-up were recorded.A total of nine cases were identified. Seven of these underwent primary posterior chamber (PC) IOL removal with ACIOL implantation. One had an ACIOL placed after a sulcus-sutured PCIOL dislocated, and one had enough capsular support for placement of a PCIOL after removal of a plate haptic silicone lens. Of the seven primary ACIOL cases, the best-corrected VA improved in five cases, was unchanged in one (remained 20/20), and declined in another. The final postoperative VA (mean follow-up, 12 months) was 20/30 or better in five patients, and was limited by age-related macular degeneration and epiretinal membrane in the other two. A hyphema occurred in two patients and cleared in both without visual compromise. There was no evidence of corneal compromise or exacerbation of glaucoma in any of the patients.Given that the results and complication rates in this small series appear to be similar to those reported for sulcus-suture techniques, implantation of an ACIOL after removal of a posteriorly dislocated IOL appears to be a viable alternative to suture fixation in the absence of capsular support.
Golf-related ocular injuries have been reported since the early 1900s. Although this type of ocul... more Golf-related ocular injuries have been reported since the early 1900s. Although this type of ocular injury is fortunately a relatively rare occurrence, the effects are usually devastating. The purpose of this article is to review the mechanism of golf injuries, the prognosis for different types of golf-related injuries, and how such injuries might be prevented.
To evaluate the clinical outcomes after vitrectomy with inner retinal fenestration-making a parti... more To evaluate the clinical outcomes after vitrectomy with inner retinal fenestration-making a partial thickness retinal hole radial to the pit-for the treatment of optic disc pit maculopathy. Retrospective, interventional case series. Eighteen eyes with optic disc pit maculopathy. Pars plana vitrectomy with creation of an inner retinal fenestration was performed in all eyes. A bent 25-gauge needle was used to make a partial thickness inner retinotomy just temporal to the optic disc pit. Anatomic outcomes determined by optical coherence tomography and postoperative best-corrected visual acuity (BCVA). Before surgery, gross thickening of the inner and outer retinal layers with accumulation of fluid in the central macula was present in all eyes. Macular detachment was observed in 14 eyes, and outer layer hole was identified in 9 eyes. Patients were followed up for a mean of 34.6±26.6 months after surgery. After surgery, complete resolution of fluid in and under the fovea was achieved in ...
The authors studied the effect of a direct acting antithrombin agent, desulfatohirudin variant 1 ... more The authors studied the effect of a direct acting antithrombin agent, desulfatohirudin variant 1 (Revasc, Ciba-Geigy, Ltd., Basel, Switzerland), on postoperative fibrin formation after cataract surgery in rabbits. Phacoemulsification was performed in a masked fashion on 28 eyes of 28 New Zealand white rabbits. Ten control group eyes had lactated Ringer's solution in the infusion and an intracameral injection (approximately 1.5 ml) at the end of the case. Ten group 1 eyes received hirudin 100 micrograms/ml in the infusion and intracameral injection. Eight group 2 eyes had 100 micrograms/ml hirudin in the intracameral injection only. Using slit-lamp examination, all eyes were graded for the amount of fibrin and intraocular hemorrhage in a masked fashion on postoperative day 1. Comparison of the mean postoperative fibrin grade (0-4) in group 1 (mean = 0.3), group 2 (mean = 0.25) and the control group (mean = 3.4) revealed a statistically significant difference between hirudin-treat...
To determine the efficacy of a specific antithrombin agent (recombinant desulphatohirudin variant... more To determine the efficacy of a specific antithrombin agent (recombinant desulphatohirudin variant 1 [Revasc, Ciba-Geigy, Ltd., Basel, Switzerland]) administered in the infusion fluid to prevent early postoperative fibrin formation in a rabbit lensectomy and vitrectomy model. Standard fragmatome lensectomies and core vitrectomies were performed prospectively in a masked fashion on ten control eyes with lactated Ringer's infusion and on ten eyes treated with 10 microgram of recombinant hirudin/ml in the infusate. The amounts of fibrin and hemorrhage were graded in a masked fashion by using slit-lamp examination and indirect ophthalmoscopy on postoperative days 1 through 5 and on day 7. The difference in the mean grade of fibrin formed on the first postoperative day in the eyes treated with recombinant hirudin (mean, 0.9) in relation to the mean grade of fibrin in the control eyes (mean, 3.5) was statistically significant (P = .004). This difference was also significant on the seco...
Ophthalmic Surgery, Lasers and Imaging Retina, 2013
Retinal artery occlusion from carotid dissection is rare and classically considered a post-trauma... more Retinal artery occlusion from carotid dissection is rare and classically considered a post-traumatic phenomenon occurring in young patients and associated with additional symptoms of dissection such as neck pain, headache, or focal neurological deficits. The authors report three cases of retinal artery occlusion due to carotid artery dissection and briefly review the literature. Antecedent trauma or neck injury was reported in only 42% (five of 12) of previously reported cases and in none of the three cases presented here. All three patients in this series initially denied symptoms such as headache or neck pain; however, one patient's wife later recalled her husband experiencing minor neck soreness several days prior to visual loss. In 17% (two of 12) of previously reported cases, no additional symptoms of carotid dissection were reported. These cases highlight the importance of considering carotid dissection in young patients with retinal artery occlusion, even in the absence of a report of recent trauma or associated symptoms such as pain.
To compare baseline characteristics, treatment frequency, visual acuity (VA), and morphologic out... more To compare baseline characteristics, treatment frequency, visual acuity (VA), and morphologic outcomes of eyes with >50% of the lesion composed of blood (B50 group) versus all other eyes (Other group) enrolled in the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT). Prospective cohort study within a multicenter randomized clinical trial. CATT patients with neovascular age-related macular degeneration (AMD). Treatment for the study eye was assigned randomly to either ranibizumab or bevacizumab and to 3 different dosing regimens over a 2-year period. Reading center graders evaluated baseline and follow-up morphology in color fundus photographs, fluorescein angiography (FA), and optical coherence tomography (OCT). Masked examiners tested VA. Morphologic features and VA at 1 and 2 years. The B50 group consisted of 84 of 1185 (7.1%) patients enrolled in CATT. Baseline lesion characteristics differed between groups. In the B50 group, choroidal neovascularization ...
To determine the effect of endophthalmitis on diabetic retinopathy. Noncomparative case series. T... more To determine the effect of endophthalmitis on diabetic retinopathy. Noncomparative case series. The records of all consecutive patients with endophthalmitis treated between 1992 and 1997 at the Medical College of Wisconsin were retrospectively reviewed. Those patients with diabetes mellitus were analyzed. From 77 reviewed records, 11 patients (12 eyes; 14%) were identified as diabetics with endophthalmitis and were studied. Stage of diabetic retinopathy, time to retinopathy progression, and visual acuity. Mean patient age was 68 years, and mean duration of diabetes was 11.7 years. Mean patient follow-up was 17 months. Of the six cases without evidence of retinopathy before the endophthalmitis, none went on to develop retinopathy. Of six eyes with pre-existing nonproliferative retinopathy, four showed evidence of progression within 6 months of the infection. Three developed severe proliferative disease and macular edema, and one developed severe nonproliferative disease. More patients without pre-existing retinopathy achieved a final visual acuity of 20/40 or greater. Patients with pre-existing diabetic retinopathy may be at increased risk for rapid retinopathy progression and a poorer visual outcome after endophthalmitis. These results support the concept that inflammation may exacerbate diabetic retinopathy.
To examine the 7-month results for patients treated with combined photodynamic therapy (PDT) with... more To examine the 7-month results for patients treated with combined photodynamic therapy (PDT) with verteporfin and intravitreal bevacizumab for choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). This is a retrospective series of 24 eyes with juxtafoveal or subfoveal CNV secondary to AMD. Patients were treated with PDT with verteporfin and 1.25 mg of intravitreal bevacizumab. All patients were naive to treatment and had either treatment within a 14-day interval. Main outcome measures were visual acuity stabilization (defined as no change or a gain in visual acuity) and retreatment rate. At the 7-month follow-up, 20 (83%) of 24 patients had stabilization of visual acuity. Sixteen eyes (67%) had improvement in visual acuity. Mean improvement in visual acuity (n = 24) was 2.04 Snellen lines. Fifteen eyes (63%) required only a single combined treatment for CNV resolution. There were no complications, including endophthalmitis, uveitis, and ocular hypertension. The results of this study suggest that combined treatment of PDT with verteporfin and intravitreal bevacizumab may be useful in treating neovascular AMD by reducing retreatment rates and improving visual acuity. Further investigation with large, controlled trials is warranted to outline the appropriate treatment paradigm for combination therapy.
Several authors have reported significant exposure rates using the hydroxyapatite orbital implant... more Several authors have reported significant exposure rates using the hydroxyapatite orbital implant in the treatment of the anophthalmic socket. Histologic studies by ourselves and others have suggested that lack of fibrovascular ingrowth into the implants may contribute to conjunctival breakdown and exposure. Recently, much attention has been given to angiogenic factors, such as rTGF-beta 2 and those found in plasma, in accelerating wound healing and fibrovascular ingrowth. This pilot study compares the rate of vascularization of hydroxyapatite orbital implants pretreated with plasma, rTGF-beta 2, and a saline/gentamicin solution with that in untreated controls ina population of New Zealand albino rabbits. Hydroxyapatite orbital spheres were implanted subcutaneously and in enucleated orbits. Untreated implants were used as a control. Implants pretreated with plasma, rTGF-beta 2, and a saline/gentamicin solution were removed and examined histologically at weekly intervals for the first 3 weeks after implantation. Histologic studies demonstrated that the rate of vascularization significantly increased between 2 and 3 weeks postoperatively in all study groups. Pretreating the implants with rTGF-beta 2 in phosphate buffered solution (PBS) or autogenous plasma did not significantly increase the rate of vascularization in comparison with controls at weeks 1 and 2. However, pretreating the implants with a saline/gentamicin solution or PBS alone was associated with an increased rate of vascularization at weeks 2 and 3. No statistically significant difference in vascularization was noted between the subcutaneous and orbital implants at any week. Hydroxyapatite implants pretreated with saline/gentamicin or phosphate buffered solutions underwent more rapid vascularization at weeks 2 and 3 in comparison with controls. Additionally, all groups were noted to have a more rapid rate of ingrowth between weeks 2 and 3 than between weeks 1 and 2. Plasma and rTGF-beta 2 (at the dose used) did not significantly alter the rate of vascularization of hydroxyapatite implants during the first 2 to 3 weeks. The significance of these findings is discussed.
There are many alternatives available to the vitreoretinal surgeon in the management of posterior... more There are many alternatives available to the vitreoretinal surgeon in the management of posteriorly dislocated intraocular lenses (IOL). The lens may be repositioned in the ciliary sulcus if there is adequate capsular support, but if this support is absent, it must either be sutured in place (to the sclera or iris) or exchanged for an anterior chamber (AC) IOL. Scleral-sutured IOLs can be associated with hemorrhage, cystoid macular edema, retinal detachment, and endophthalmitis (through the suture tract), and use sutures that must last for the lifetime of the patient. Anterior chamber IOLs (ACIOLs) are easier to implant but require a limbal incision for insertion. The authors sought to determine the safety and efficacy of combining removal of posteriorly dislocated IOLs with ACIOL placement.A retrospective chart review, in which all cases of dislocated IOLs managed at the authors’ institution over the last 5 years were reviewed. Patient characteristics, pre-existing ocular conditions, preoperative visual acuity (VA), intraocular pressure (IOP), type of lens dislocated, operation performed, postoperative VA and IOP, and length of follow-up were recorded.A total of nine cases were identified. Seven of these underwent primary posterior chamber (PC) IOL removal with ACIOL implantation. One had an ACIOL placed after a sulcus-sutured PCIOL dislocated, and one had enough capsular support for placement of a PCIOL after removal of a plate haptic silicone lens. Of the seven primary ACIOL cases, the best-corrected VA improved in five cases, was unchanged in one (remained 20/20), and declined in another. The final postoperative VA (mean follow-up, 12 months) was 20/30 or better in five patients, and was limited by age-related macular degeneration and epiretinal membrane in the other two. A hyphema occurred in two patients and cleared in both without visual compromise. There was no evidence of corneal compromise or exacerbation of glaucoma in any of the patients.Given that the results and complication rates in this small series appear to be similar to those reported for sulcus-suture techniques, implantation of an ACIOL after removal of a posteriorly dislocated IOL appears to be a viable alternative to suture fixation in the absence of capsular support.
Golf-related ocular injuries have been reported since the early 1900s. Although this type of ocul... more Golf-related ocular injuries have been reported since the early 1900s. Although this type of ocular injury is fortunately a relatively rare occurrence, the effects are usually devastating. The purpose of this article is to review the mechanism of golf injuries, the prognosis for different types of golf-related injuries, and how such injuries might be prevented.
To evaluate the clinical outcomes after vitrectomy with inner retinal fenestration-making a parti... more To evaluate the clinical outcomes after vitrectomy with inner retinal fenestration-making a partial thickness retinal hole radial to the pit-for the treatment of optic disc pit maculopathy. Retrospective, interventional case series. Eighteen eyes with optic disc pit maculopathy. Pars plana vitrectomy with creation of an inner retinal fenestration was performed in all eyes. A bent 25-gauge needle was used to make a partial thickness inner retinotomy just temporal to the optic disc pit. Anatomic outcomes determined by optical coherence tomography and postoperative best-corrected visual acuity (BCVA). Before surgery, gross thickening of the inner and outer retinal layers with accumulation of fluid in the central macula was present in all eyes. Macular detachment was observed in 14 eyes, and outer layer hole was identified in 9 eyes. Patients were followed up for a mean of 34.6±26.6 months after surgery. After surgery, complete resolution of fluid in and under the fovea was achieved in ...
The authors studied the effect of a direct acting antithrombin agent, desulfatohirudin variant 1 ... more The authors studied the effect of a direct acting antithrombin agent, desulfatohirudin variant 1 (Revasc, Ciba-Geigy, Ltd., Basel, Switzerland), on postoperative fibrin formation after cataract surgery in rabbits. Phacoemulsification was performed in a masked fashion on 28 eyes of 28 New Zealand white rabbits. Ten control group eyes had lactated Ringer's solution in the infusion and an intracameral injection (approximately 1.5 ml) at the end of the case. Ten group 1 eyes received hirudin 100 micrograms/ml in the infusion and intracameral injection. Eight group 2 eyes had 100 micrograms/ml hirudin in the intracameral injection only. Using slit-lamp examination, all eyes were graded for the amount of fibrin and intraocular hemorrhage in a masked fashion on postoperative day 1. Comparison of the mean postoperative fibrin grade (0-4) in group 1 (mean = 0.3), group 2 (mean = 0.25) and the control group (mean = 3.4) revealed a statistically significant difference between hirudin-treat...
To determine the efficacy of a specific antithrombin agent (recombinant desulphatohirudin variant... more To determine the efficacy of a specific antithrombin agent (recombinant desulphatohirudin variant 1 [Revasc, Ciba-Geigy, Ltd., Basel, Switzerland]) administered in the infusion fluid to prevent early postoperative fibrin formation in a rabbit lensectomy and vitrectomy model. Standard fragmatome lensectomies and core vitrectomies were performed prospectively in a masked fashion on ten control eyes with lactated Ringer's infusion and on ten eyes treated with 10 microgram of recombinant hirudin/ml in the infusate. The amounts of fibrin and hemorrhage were graded in a masked fashion by using slit-lamp examination and indirect ophthalmoscopy on postoperative days 1 through 5 and on day 7. The difference in the mean grade of fibrin formed on the first postoperative day in the eyes treated with recombinant hirudin (mean, 0.9) in relation to the mean grade of fibrin in the control eyes (mean, 3.5) was statistically significant (P = .004). This difference was also significant on the seco...
Ophthalmic Surgery, Lasers and Imaging Retina, 2013
Retinal artery occlusion from carotid dissection is rare and classically considered a post-trauma... more Retinal artery occlusion from carotid dissection is rare and classically considered a post-traumatic phenomenon occurring in young patients and associated with additional symptoms of dissection such as neck pain, headache, or focal neurological deficits. The authors report three cases of retinal artery occlusion due to carotid artery dissection and briefly review the literature. Antecedent trauma or neck injury was reported in only 42% (five of 12) of previously reported cases and in none of the three cases presented here. All three patients in this series initially denied symptoms such as headache or neck pain; however, one patient's wife later recalled her husband experiencing minor neck soreness several days prior to visual loss. In 17% (two of 12) of previously reported cases, no additional symptoms of carotid dissection were reported. These cases highlight the importance of considering carotid dissection in young patients with retinal artery occlusion, even in the absence of a report of recent trauma or associated symptoms such as pain.
To compare baseline characteristics, treatment frequency, visual acuity (VA), and morphologic out... more To compare baseline characteristics, treatment frequency, visual acuity (VA), and morphologic outcomes of eyes with >50% of the lesion composed of blood (B50 group) versus all other eyes (Other group) enrolled in the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT). Prospective cohort study within a multicenter randomized clinical trial. CATT patients with neovascular age-related macular degeneration (AMD). Treatment for the study eye was assigned randomly to either ranibizumab or bevacizumab and to 3 different dosing regimens over a 2-year period. Reading center graders evaluated baseline and follow-up morphology in color fundus photographs, fluorescein angiography (FA), and optical coherence tomography (OCT). Masked examiners tested VA. Morphologic features and VA at 1 and 2 years. The B50 group consisted of 84 of 1185 (7.1%) patients enrolled in CATT. Baseline lesion characteristics differed between groups. In the B50 group, choroidal neovascularization ...
To determine the effect of endophthalmitis on diabetic retinopathy. Noncomparative case series. T... more To determine the effect of endophthalmitis on diabetic retinopathy. Noncomparative case series. The records of all consecutive patients with endophthalmitis treated between 1992 and 1997 at the Medical College of Wisconsin were retrospectively reviewed. Those patients with diabetes mellitus were analyzed. From 77 reviewed records, 11 patients (12 eyes; 14%) were identified as diabetics with endophthalmitis and were studied. Stage of diabetic retinopathy, time to retinopathy progression, and visual acuity. Mean patient age was 68 years, and mean duration of diabetes was 11.7 years. Mean patient follow-up was 17 months. Of the six cases without evidence of retinopathy before the endophthalmitis, none went on to develop retinopathy. Of six eyes with pre-existing nonproliferative retinopathy, four showed evidence of progression within 6 months of the infection. Three developed severe proliferative disease and macular edema, and one developed severe nonproliferative disease. More patients without pre-existing retinopathy achieved a final visual acuity of 20/40 or greater. Patients with pre-existing diabetic retinopathy may be at increased risk for rapid retinopathy progression and a poorer visual outcome after endophthalmitis. These results support the concept that inflammation may exacerbate diabetic retinopathy.
To examine the 7-month results for patients treated with combined photodynamic therapy (PDT) with... more To examine the 7-month results for patients treated with combined photodynamic therapy (PDT) with verteporfin and intravitreal bevacizumab for choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). This is a retrospective series of 24 eyes with juxtafoveal or subfoveal CNV secondary to AMD. Patients were treated with PDT with verteporfin and 1.25 mg of intravitreal bevacizumab. All patients were naive to treatment and had either treatment within a 14-day interval. Main outcome measures were visual acuity stabilization (defined as no change or a gain in visual acuity) and retreatment rate. At the 7-month follow-up, 20 (83%) of 24 patients had stabilization of visual acuity. Sixteen eyes (67%) had improvement in visual acuity. Mean improvement in visual acuity (n = 24) was 2.04 Snellen lines. Fifteen eyes (63%) required only a single combined treatment for CNV resolution. There were no complications, including endophthalmitis, uveitis, and ocular hypertension. The results of this study suggest that combined treatment of PDT with verteporfin and intravitreal bevacizumab may be useful in treating neovascular AMD by reducing retreatment rates and improving visual acuity. Further investigation with large, controlled trials is warranted to outline the appropriate treatment paradigm for combination therapy.
Several authors have reported significant exposure rates using the hydroxyapatite orbital implant... more Several authors have reported significant exposure rates using the hydroxyapatite orbital implant in the treatment of the anophthalmic socket. Histologic studies by ourselves and others have suggested that lack of fibrovascular ingrowth into the implants may contribute to conjunctival breakdown and exposure. Recently, much attention has been given to angiogenic factors, such as rTGF-beta 2 and those found in plasma, in accelerating wound healing and fibrovascular ingrowth. This pilot study compares the rate of vascularization of hydroxyapatite orbital implants pretreated with plasma, rTGF-beta 2, and a saline/gentamicin solution with that in untreated controls ina population of New Zealand albino rabbits. Hydroxyapatite orbital spheres were implanted subcutaneously and in enucleated orbits. Untreated implants were used as a control. Implants pretreated with plasma, rTGF-beta 2, and a saline/gentamicin solution were removed and examined histologically at weekly intervals for the first 3 weeks after implantation. Histologic studies demonstrated that the rate of vascularization significantly increased between 2 and 3 weeks postoperatively in all study groups. Pretreating the implants with rTGF-beta 2 in phosphate buffered solution (PBS) or autogenous plasma did not significantly increase the rate of vascularization in comparison with controls at weeks 1 and 2. However, pretreating the implants with a saline/gentamicin solution or PBS alone was associated with an increased rate of vascularization at weeks 2 and 3. No statistically significant difference in vascularization was noted between the subcutaneous and orbital implants at any week. Hydroxyapatite implants pretreated with saline/gentamicin or phosphate buffered solutions underwent more rapid vascularization at weeks 2 and 3 in comparison with controls. Additionally, all groups were noted to have a more rapid rate of ingrowth between weeks 2 and 3 than between weeks 1 and 2. Plasma and rTGF-beta 2 (at the dose used) did not significantly alter the rate of vascularization of hydroxyapatite implants during the first 2 to 3 weeks. The significance of these findings is discussed.
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