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Background: Prosthetic joint infection (PJI) is a well-described complication after total joint arthroplasty which imposes a substantial burden of morbidity and mortality on the individual, as well as cost to the health-care system. This study used a break-even analysis to investigate the cost-effectiveness of pulsed saline lavage (PSL) for PJI prophylaxis after a primary total knee arthroplasty (TKA) and total hip arthroplasty (THA)., Methods: An established model was used to calculate the minimum cost-effective absolute risk reduction of PSL for infection prophylaxis after a total joint arthroplasty. Baseline infection rates of TKA and THA and the cost of a revision surgery for PJI were derived from the literature while the cost of PSL implementation was obtained from institutional data., Results: PSL is cost-effective at an initial infection rate of 1.10%, revision costs of $32,132 for TKA PJI, and a protocol cost of $38.28 if it reduces infection rates by 0.12% or prevents infection in 1 out of 839 patients. PSL is cost-effective at an initial infection rate of 1.63% and a revision cost of $39,713 for THA PJI if it reduces infection rates by 0.10% or prevents infection in 1 out of 1037 patients. The absolute risk reduction needed for economic viability did not change with varying baseline infection rates and did not exceed 0.38% for infection treatment costs as low as $10,000 and remained less than 0.47% even if PSL cost was as high as $150., Conclusions: The use of PSL is a cost-effective protocol for PJI prophylaxis after TKAs and THAs., (© 2022 The Authors.)

Background: Primary lymphoma of bone (PLB) is a rare disease, comprising a malignant lymphoid infiltrate of bone. The goal of this study was to identify socioeconomic, demographic, and anatomic factors as prognostic indicators of survival for this disease using the Surveillance, Epidemiology, and End Results (SEER) database., Methods: The SEER database was used to identify a study population of 692 patients diagnosed with PLB in the United States from 1989 to 2003. Survival was analyzed using the Kaplan-Meier method, with effects of potential prognostic factors on survival analyzed using the log-rank test. Multivariable analysis was performed by Cox proportional hazards regression., Results: The overall 5-year survival rate was 49.6%, with a 10-year survival rate of 30.2%. Median overall survival was 4.9 years (95% CI: 3.9, 6.1). In multivariable analysis, age (p<0.0001), marital status (p=0.006), and appendicular vs. axial tumor location (p=0.004) were found to be independent predictors of survival., Conclusions: This population-based study of PLB identified age, marital status, and tumor location as independent indicators of prognosis. This finding supports the clinical suspicion that an appendicular tumor location confers a better prognosis than an axial tumor location.

Objectives: The goal of this study was to demonstrate superiority of sirolimus-eluting stents (SES) over bare-metal stents (BMS) and of abciximab over no abciximab in primary percutaneous coronary intervention (PCI)., Background: Drug-eluting stents (DES) are increasingly used in primary PCI, but the recommendations for use in primary PCI are based on a few randomized controlled trials with selected patients. The usefulness of abciximab in primary PCI is not established., Methods: Nine hundred seven patients referred to the Catharina Hospital were randomized to SES or BMS, and to abciximab or no abciximab in a prospective, randomized, open 2 × 2 factorial trial with blinded evaluation. Primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), defined as the composite of death, myocardial infarction (MI), stroke, repeat revascularization, and bleeding at 1 year (stent arm) and the composite of death, target vessel MI, target vessel revascularization (TVR), and bleeding at 30 days (abciximab arm)., Results: At 1 year, the rate of MACCE was lower in the SES arm (16.5% vs. 25.8%, p = 0.001), mainly driven by less repeat revascularization (9.8% vs. 16.8%; p = 0.003) and without influencing the cumulative incidence of death and MI (5.2% vs. 5.8%; p = 0.68). At 30 days, the rate of the composite of death, target vessel MI, TVR, and bleeding was lower in the abciximab arm (8.2% vs. 12.4%, p = 0.04), mainly driven by less TVR due to less stent thrombosis (1.2% vs.7.4%, p < 0.001). However, bleeding complications occurred more frequently in the abciximab group (5.7% vs. 2.8%, p = 0.03)., Conclusions: Primary PCI with SES reduces adverse events at 1 year, mainly by reduction of repeat revascularization, whereas abciximab reduces early stent thrombosis, at the expense of more bleeding complications. (Comparison of Drug Eluting and Bare Metal Stents With or Without Abciximab in ST Elevation Myocardial Infarction [DEBATER]; NCT00986050)., (Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The durability of restorations bonded with one-step self-etching (OSSE) adhesive systems is inferior compared with that of restorations bonded with conventional adhesives. The authors conducted an 18-month randomized clinical study to evaluate the clinical performance of two OSSE systems in noncarious cervical lesions applied as recommended or with an extra layer of hydrophobic adhesive layer after 18 months of clinical service., Methods: Thirty participants, each of whom had at least two pairs of similar-sized noncarious cervical lesions, took part in this study. The authors placed 120 restorations, 30 in each of four groups: Clearfil S3 Bond (Kuraray, Osaka, Japan) (CS) and iBond Gluma inside (Heraeus Kulzer, Hanau, Germany) (IB), and Clearfil S3 Bond (CSB) and iBond Gluma inside (IBB) with an extra layer of hydrophobic adhesive applied on top of them. They placed the restorations incrementally, using a resin-based composite. The authors evaluated the restorations at baseline and at 18 months following modified U.S. Public Health Service criteria., Results: At 18 months, the retention rate for the IB group was statistically lower than those for the CS, IBB and CSB groups. Marginal discoloration occurred in all groups and was statistically worse in the IB group., Conclusions: The conversion of the iBond Gluma inside and Clearfil S3 Bond adhesive systems into two-step systems by means of applying an extra hydrophobic adhesive layer improved the clinical performance of these materials after 18 months of clinical service., Clinical Implications: The application of an extra hydrophobic adhesive layer over OSSE adhesive systems, layers improved the OSSE systems clinical performance, mainly in terms of retention rate.

Background: Photodynamic therapy (PDT) with verteporfin is now the standard of care worldwide for the treatment of choroidal neovascularization, but has been used only rarely in those with subretinal neovascular membranes (SRNVM) due to type 2A idiopathic juxtafoveolar retinal telangiectasis (IJT). We performed a retrospective study to examine the outcome of patients treated with PDT for SRNVM secondary to IJT., Methods: Retrospective interventional case series of 7 eyes of 6 IJT patients with SRNVMs treated with PDT. Ophthalmic examination and fluorescein angiography were performed before treatment, with retreatment every 3 months as needed. The main outcome was the proportion of patients avoiding vision loss (change of +/- 4 letters, or better)., Results: Baseline Snellen acuity ranged from 20/40 to 20/400 (median 20/80). Mean follow-up was 21 months. Patients received 2.4 treatments on average. Five of 7 patients avoided vision loss; acuity improved in 3 eyes (> or = 1 line improvement), stayed the same in 2 eyes (+/- 4 letters) and decreased in 2 eyes (> or = 1 line decrease) over time. Median final acuity was 20/80. Five of 7 eyes had final acuities of > or = 20/200. No leakage was observed in any eyes following cessation of treatment.

Background: Reduced growth in utero is associated with type 2 (non-insulin-dependent) diabetes and impaired glucose tolerance in adult life. There is no direct evidence in human beings that maternal nutrition during gestation affects insulin-glucose metabolism. We investigated glucose tolerance in people born around the time of famine in the Netherlands during 1944-45., Methods: We included 702 people born between Nov 1, 1943, and Feb 28, 1947, in Amsterdam, for whom we had detailed prenatal and birth records. We compared glucose and insulin responses to a standard oral glucose load in participants exposed to famine at any stage during gestation (exposed participants) with those who were born in the year before or conceived in the year after the famine (non-exposed participants)., Findings: Glucose concentrations were increased 2 h after a standard glucose load among exposed participants (p = 0.006), and were highest in men and women exposed during mid and late gestation. Mean 2 h glucose concentration among non-exposed participants was 5.8 mmol/L; concentrations were 0.5 mmol/L (95% CI 0.1-0.9) higher among participants exposed during late gestation, 0.4 mmol/L (0-0.8) higher among those exposed during mid gestation, and 0.1 mmol/L (-0.4 to 0.6) among those exposed during early gestation. Participants born as thin babies to mothers with low bodyweights had the highest concentrations and concentrations were especially high among people exposed to famine who became obese as adults. Prenatal exposure to famine was related to increased fasting proinsulin (p = 0.05) and 2 h insulin concentrations (p = 0.04), which suggests an association with insulin resistance., Interpretation: Prenatal exposure to famine, especially during late gestation, is linked to decreased glucose tolerance in adults. Poor nutrition in utero may lead to permanent changes in insulin-glucose metabolism, even if the effect on fetal growth is small. This effect of famine on glucose tolerance is especially important in people who become obese.

The techniques introduced by Kimura and Ingram et al. were applied to assess the distribution of motor refractory periods (DMRPs) in peroneal nerve fibres of 28 diabetics with symptoms indicating polyneuropathy and in 28 controls. Results were compared with conventional motor nerve conduction velocity (MNCV) and compound muscle action potential (CMAP) measurements. MRP95 and MRP90 (the 5% and 10% slowest recovering fibres) obtained with Ingram's technique were prolonged in the diabetic patients. In the 26 patients with a value of MRP95 and MNCV, a prolonged MRP95 and a decreased MNCV were found in 12 patients. Thus conventional MNCV had a sensitivity of 46% to detect neuropathy; addition of MRP95 obtained with Ingram's technique raised the sensitivity to 73%. Specificity was 100% in both cases. With Kimura's technique or with the fast recovering fibres in Ingram's technique, it was not possible to discriminate the patients from the controls. This study indicates that measurement of the DMRP with the technique introduced by Ingram et al. improves the electrophysiological diagnosis of diabetic polyneuropathy.

Mutations in gene p53 are the most common defects in lung cancer and may be a pathway through which environmental carcinogens initiate cancer. We investigated p53 mutations in lung cancers from uranium miners with high radon exposure. 16 (31%) of 52 large-cell and squamous-cell cancers from miners contained the same AGG to ATG transversion at codon 249, including cancers from 3 or 5 miners who had never smoked. This specific mutation has been reported in only 1 of 241 published p53 mutations from lung cancers. The codon 249 mutation may be a marker for radon-induced lung cancer.

Afferent and efferent central pathways were tested by electrically elicited long-latency reflexes (LLRs), somatosensory evoked potentials (SEPs), and motor potentials (MEPs) evoked by transcranial magnetic stimulation (TMS) in 37 patients with multiple sclerosis. Of these 27 (72.9%) had abnormal results, with bilateral abnormalities in 17 (45.9%). MEPs were abnormal in 21 (56.8%), LLRs in 17 (45.9%) and SEPs in 16 (43.2%). Compared with TMS (MEPs) alone, additional testing of LLRs and SEPs revealed abnormalities in 6 additional patients (2 LLRs, 3 SEPs, 1 LLR and SEP). When the hands were analysed separately 32 (47.3%) showed abnormal results with TMS, 29 (39.2%) with LLRs and 22 (29.7%) with SEPs. All hands with absent or delayed N20 components of the SEP also had abnormal LLRs, supporting the hypothesis that LLRs and SEPs share the same afferent pathways. In contrast to this, 10 hands had normal LLRs but slightly delayed central motor conduction times. Calculating the sum of the latency of the N20 component of the SEP and the latency of the MEP, we found a mean cortical relay time for the LLR of 8.5 +/- 4.7 msec, which is compatible with a polysynaptic transcortical pathway. This is supported by our finding of a linear correlation between the LLR latency and the sum of N20 and MEP latencies.

Background: Retinal pigment epithelial (RPE) cells are a major component of contractile cellular membranes in proliferative vitreoretinopathy (PVR). Displacement of viable RPE cells into the vitreous cavity is necessary for membrane formation. This study examines the effect of cryotherapy during surgery for giant retinal tears on the dispersion of viable cells into the vitreous cavity., Methods: A total of seven eyes undergoing vitrectomy and retinal reattachment surgery were studied. Vitreous fluid from three eyes was aspirated immediately after cryotherapy; fluid from four eyes was aspirated after scleral indentation with the cryoprobe, but without cryotherapy. Colonies of pigmented cells routinely grew in flasks inoculated with fluid from eyes treated with cryotherapy. In contrast, flasks inoculated with fluid from eyes not treated with cryotherapy contained significantly fewer viable cells., Conclusion: Cryotherapy performed during retinal reattachment surgery in eyes with giant retinal tears is likely to enhance intravitreal dispersion of viable RPE cells. The findings in this study suggest that possible harmful effects of cryotherapy should be evaluated further and that alternative methods of creating a chorioretinal adhesion should be considered in cases with an especially high risk of PVR.

Background: Full-thickness macular holes generally cause a significant reduction in visual acuity, due in part to a rim of surrounding neurosensory retinal detachment and retinal thickening. Recent studies have suggested that flattening of this narrow rim of neurosensory detachment can result in improved visual acuity. However, the ability to flatten the neurosensory detachment is limited using current surgical techniques., Methods: Transforming growth factor-beta 2 (TGF-beta 2) is a recently discovered potent stimulator of wound healing. The authors, therefore, performed a prospective randomized study of 60 patients to determine if the local application of TGF-beta 2 to the edge of the macular hole can reproducibly induce flattening of the surrounding neurosensory detachment. The results of a study designed to determine the effect of a pars plana vitrectomy, fluid-gas exchange, and intravitreal instillation of TGF-beta 2 in eyes with a full-thickness macular hole and reduced visual acuity are reported., Results: After treatment, visual acuity improved 2 lines or more in 5 of 11 eyes treated with 70 ng, in 4 of 12 eyes treated with 330 ng, and in 10 of 11 eyes treated with 1330 ng of TGF-beta 2. In some eyes, hyaluronic acid was added. In these cases, visual acuity improved 2 lines or more in 0 of 9 eyes treated with 70 ng TGF-beta 2, in 2 of 8 eyes treated with 330 ng, and in 4 of 9 eyes treated with 1330 ng., Conclusion: Logistic regression analysis demonstrated a statistically significant beneficial effect of TGF-beta 2 on visual improvement (P = 0.003).

Giant retinal tears complicated by proliferative vitreoretinopathy (PVR) pose one of the more complex problems in vitreoretinal surgery. The authors developed a technique using perfluoro-octane, a temporary vitreous substitute that is heavier than water, combined with vitrectomy, scleral buckling, fluid-gas exchange, and direct manipulation of the retina to treat these cases. Ten eyes with giant retinal tears and grade D-1 PVR or worse were treated. In all eyes, the retina was successfully reattached at the end of surgery. Nine of the ten retinas remained attached after 6 months of follow-up. Five eyes required a total of six reoperations for epiretinal membrane formation without retinal detachment. The one eye in which the retina did not remain reattached developed severe recurrent PVR and iris neovascularization. Visual acuity improved in 8 of 10 eyes. Final visual acuity was 20/400 or better in 8 of 10 eyes, and 20/80 or better in 4 eyes.

Percutaneous transluminal angioplasty of coronary stenoses distal to anastomosis of a venous graft was attempted through the graft 22 times in 19 patients. Ten patients had stable angina, seven unstable angina and two patients acute myocardial infarction. The mean interval between bypass surgery and angioplasty was 6.5 years (range 1-15). Fifteen lesions were dilated in the left anterior descending artery, five in the right coronary artery, and two in the circumflex artery. Three procedures were for double lesions. In two cases, a stenosed vein graft was also dilated. All grafts were cannulated with an El Gamal guiding catheter. The procedure failed in two cases. The remaining 20 lesions were successfully dilated. Early and late occlusion of the graft occurred in one patient, and coronary arterial stenosis recurred in two patients. All three patients underwent successful redilatation. The 17 patients undergoing successful dilatation were asymptomatic, with a normal exercise test and/or maintained angiographic result at follow-up of 14 months mean duration (range 2-48). Angioplasty of coronary stenosis through a vein graft is feasible, safe and effective. This therapeutic approach avoids the need for repeat bypass surgery and, as judged by long-term follow-up, has a favourable clinical outcome.

The survival rate after vitreous surgery for complications of diabetic retinopathy was studied in 552 consecutive patients who underwent operations between 1979 and 1984. The 5-year postoperative survival rate was 74.7%. Factors associated with a lower survival rate included older age, older age at diagnosis of diabetes, history of renal disease, and a longer duration of diabetes. Factors unrelated to survival rate included insulin treatment, sex, and anatomic and visual outcome. Improved management of systemic diabetic complications has improved survival rates, a finding reflected in the relatively high rate of long-term survival after diabetic vitrectomy.

To determine the current incidence and outcome of iatrogenic retinal breaks occurring during pars plana vitrectomy, the authors reviewed 404 consecutive operations done on eyes without preexisting retinal breaks. Thirteen eyes had 14 iatrogenic peripheral retinal breaks. Three other eyes had both peripheral breaks and posterior breaks. Twenty-five eyes had 43 posterior breaks. The incidence of peripheral breaks was 4% and of posterior breaks was 6%. Patients with proliferative diabetic retinopathy had a higher incidence of iatrogenic retinal breaks than those with other diagnoses. Peripheral breaks occurred most commonly just posterior to the site of insertion of the vitrectomy probe. Although six eyes required reoperation, 33 of 38 eyes had a successful anatomic outcome.

Pars plana vitrectomy has been used in cases of ocular toxocariasis to remove vitreous opacities due to chronic inflammation and to relieve vitreo-retinal traction causing macular distortion and retinal detachment. To date, the diagnosis of intraocular Toxocara infection in vitrectomy cases has been presumptive, based on characteristic clinical findings, the presence of eosinophils, and corroborative immunodiagnostic tests. The authors report a case in which a vitrectomy for vitreopapillary traction recovered an intact Toxocara canis organism.

Proliferative vitreoretinopathy (PVR) is the leading cause of failure after retinal detachment surgery. Therefore, both the extracellular matrix and cellular components of preretinal membranes from 23 eyes with PVR were characterized immunohistochemically. The membrane stroma was composed primarily of types I, II, and III collagen. Laminin and both heparan sulfate proteoglycans and collagens types IV and V were co-distributed in discrete regions within the stroma. Glial and retinal pigment epithelial (RPE) cell populations were identified in these membranes using specific immunohistochemical markers as was a small but significant macrophage population. Double-labeling experiments indicated that RPE cells in these membranes expressed the class II histocompatibility antigen HLA-DR, although neither the RPE monolayer in situ nor cultured RPE cells was HLA-DR positive unless induced by gamma interferon. Only rare isolated vascular endothelial cells were detected in 5 of the 23 membranes.

The ability of intravitreal bovine thrombin to control intraoperative bleeding was investigated by a prospective double blind study of 28 consecutive patients with vascularized preretinal membranes undergoing vitrectomy for diabetic retinopathy. Addition of thrombin (100 units/ml) to the vitrectomy infusate was associated with a significantly reduced intraocular bleeding time after cutting vascularized membranes. The mean bleeding time without thrombin was 111.5 seconds, compared to 12.3 seconds with intravitreal thrombin (P less than 0.0001). Patients receiving thrombin had less overall bleeding during surgery and less vitreous hemorrhage on the second postoperative day. Intravitreal bovine thrombin was associated with increased postoperative intraocular inflammation in 20% of patients receiving thrombin. This inflammation could be controlled by use of frequent topical steroids.

A retrospective multivariate analysis of 264 consecutive cases of vitrectomy for removal of epiretinal membranes of the macula was performed. Two main preoperative prognostic factors were identified that were associated with the visual outcome of surgery: (1) the preoperative visual acuity, and (2) the duration of blurred vision before surgery. Discriminant functions constructed using these two factors allowed correct classification of eyes into an outcome group with good visual acuity with a 69% accuracy, and an 80% accuracy in classifying eyes into a group showing significant improvement in the level of visual acuity. Eyes that began with vision better than 20/100 tended to have slightly better postoperative visions than eyes with poorer preoperative visual acuity. However, eyes with worse preoperative vision tended to improve the greatest amount after surgery. Eyes with a longer history of blurred vision had poorer visual acuity after surgery and also less improvement in vision. Other statistically significant prognostic factors were identified; however, they did not appreciably improve the accuracy of the discriminant function in predicting visual outcome.

Closed vitrectomy techniques provide new capabilities to treat severe penetrating ocular injuries involving posterior segment structures. With these methods damaged iris tissue, lens, and vitreous can be removed and intraocular opacities can be cleared to identify and treat any retinal damage. Removal of damaged vitreous also prevents later cyclitic membrane formation and traction on the retina. The vitrectomy technique can be combined with additional methods to treat other conditions including nonmagnetic intraocular foreign bodies. We present the rationale and technique of vitrectomy together with the results of treatment in 51 consecutive cases of penetrating ocular trauma. Guidelines are offered for management of severe penetrating injuries.

Results of pars plana vitrectomy for complications of diabetic retinopathy were analyzed by logistic regression analysis in 1007 eyes to determine the preoperative and intraoperative factors associated with visual success or failure. Preoperative factors associated with a poorer visual outcome (final visual acuity less than 5/200) include preoperative iris neovascularization, cataract, visual acuity less than 5/200 and traction or rhegmatogenous retinal detachment. Intraoperative factors associated with a greater chance of a poor visual result include use of intravitreal gas or air and creation of an iatrogenic retinal break or detachment. The presence of any one of these factors resulted in a 1.5 to 3.9 times greater risk of a poor final visual result. The regression coefficients may be combined to predict the likelihood of obtaining final acuity greater than or equal to 5/200 in eyes with various preoperative characteristics.

Reported are 15 cases of age-related macular degeneration (AMD) complicated by massive subretinal and/or vitreous hemorrhage. Clinicopathologic correlation is presented in four of the seven cases studied histopathologically. Salient histologic findings include: subretinal and subretinal pigment epithelium (sub-RPE) fibrovascular scar in the posterior pole; discontinuities in Bruch's membrane with choroidal neovascularization; extensive hemorrhagic detachment of the RPE and sensory retina; and vitreous hemorrhage. In three cases, a choroidal artery, emerging from breaks in Bruch's membrane, had ruptured walls. The authors have reviewed the previously reported cases of AMD complicated by massive hemorrhage and found that 19% of the patients were taking Coumadin (warfarin) or aspirin treatment when the bleeding occurred. Forty percent had a positive history of systemic hypertension and cardiovascular diseases. Although the occurrence of hypertension is expected in the aged population with AMD, use of anticoagulants or antithrombotics by such patients may predispose them to serious ocular hemorrhagic complications.

Extracapsular cataract extraction (ECCE) was done in 31 eyes of 27 patients after previous retinal reattachment surgery with scleral buckling. A posterior chamber intraocular lens (IOL) was implanted in 21 eyes. No significant modifications in the cataract surgical technique were necessary. Final visual acuity was 20/40 or better in 26 eyes (84%). The complication rate was low. One patient was found to have a retinal detachment (RD) after cataract extraction that probably predated the cataract surgery. No recurrent retinal tears or detachment developed in any patients during an average 24-month follow-up period.

The authors used vitreous surgery to treat 514 cases with retinal detachment. Three hundred sixty-five (71%) of the 514 eyes had retinal detachment associated with proliferative diabetic retinopathy. A successful anatomic result was achieved in 245 (67%) of these 365 cases and 227 (62%) obtained final vision of 5/200 or better. Five factors were associated with a successful visual result in diabetic eyes: (1) preoperative visual acuity of 5/200 or better, (2) retaining the crystalline lens, (3) an attached macula preoperatively, (4) preoperative retinal detachment limited to the posterior pole or less than one quarter the fundus area, and (5) absence of iatrogenic retinal breaks. Of those cases without diabetic retinopathy, a successful anatomic result was achieved in (1) 27 (84%) of 32 eyes with nondiabetic traction detachment, (2) 13 (65%) of 20 giant retinal tears, (3) 21 (50%) of 42 eyes with opaque media complicating retinal detachment, (4) 9 (90%) of 10 eyes with posterior retinal breaks, (5) 29 (42%) of 69 eyes with advanced proliferative vitreoretinopathy (PVR), and (6) 29 (64%) of 45 eyes with retinal detachment complicating prior ocular trauma.

The ability of various tonometers to measure intraocular pressure (IOP) accurately after pars plana vitrectomy was determined by using Schiøtz, Goldmann, and Digilab pneumatic tonometers before and after the procedure in 47 eyes. Seventeen of these eyes underwent intraoperative fluid-gas exchange and had an intravitreal gas bubble on the first postoperative day. The Schiøtz tonometer underestimated the Goldmann IOP by more than 10 mmHg in 6 (35%) of 17 eyes after vitrectomy with intravitreal gas and 4 (13%) of 30 eyes without intravitreal gas. The Digilab tonometer did not underestimate the Goldmann IOP by more than 10 mmHg in any eye postoperatively. However, the Digilab tonometer underestimated the Goldmann IOP by more than 5 mmHg in 3 (18%) of 17 eyes after vitrectomy with intravitreal gas and two (7%) of 30 eyes without intravitreal gas.

A case of primary amyloidosis with vitreous involvement was diagnosed by study of a specimen obtained by pars plana vitrectomy. Vitreous opacities had been interpreted clinically as a vitreous hemorrhage. Medical evaluation after study of the vitreous specimen failed to demonstrate evidence of amyloidosis, although postmortem examination 19 months later established the systemic diagnosis of nonfamilial systemic primary amyloidosis. Both eyes were obtained postmortem. Amyloid involvement of the vitreous, retina, and choroid was found. There was also amyloid deposition in the trabecular meshwork, although the intraocular pressure was normal. Amyloid was deposited along the anterior, pupillary, and posterior surfaces of the iris. The histochemistry, ultrastructure, and treatment of this condition are discussed.

Endolaser photocoagulation of the ciliary body was used to treat 42 eyes with severe glaucoma that could not be managed successfully by medical therapy and conventional glaucoma surgery. Follow-up ranged from 6 to 36 months (mean, 13 months). The preoperative intraocular pressure (IOP) ranged from 13 to 76 mmHg (mean, 37 mmHg). The postoperative IOP ranged from 1 to 44 mmHg (mean, 17 mmHg), representing an absolute decrease of 20 mmHg, and a mean decrease of 48%. After one or two (7 eyes) treatment sessions, 11 eyes (26%) had an IOP less than 21 mmHg without medications; 21 eyes (50%) had an IOP less than 21 mmHg with medications; 5 eyes (12%) had an IOP of 21 to 25 mmHg with or without medications; and 5 eyes (12%) had an IOP greater than 25 mmHg. Postoperatively, the number of antiglaucoma medications required was reduced from a mean of 2.8 +/- 0.13 to a mean of 1.4 +/- 0.19. Twenty-three (72%) of 32 patients were able to discontinue carbonic anhydrase inhibitors.

The authors reviewed 3065 consecutive cases of extracapsular cataract extraction with posterior chamber lens implant (ECCE-PC IOL) and found the incidence of retinal detachment to be 1.4% overall (44/3065) and 1.7% in a group of eyes followed for at least 1 year (40/2330). Retrospective analysis of the retinal detachment (RD) group (n = 44) showed the patients to be significantly younger than the overall group (n = 3065) (P less than 0.0001). Comparison with an age-matched group of 302 eyes without RD showed higher rates of RD in males (P = 0.0013) and in eyes with axial eye length (AEL) greater than 25 mm (P less than 0.0001). No significant correlation was found between RD and PC IOL manufacturer, phacoemulsification (PKE), or primary discission. Sixty-four percent of RDs occurred within 1 year of cataract operation. Only 10% occurred more than 2 years later. Visual results in eyes with ultimate anatomic success of RD repair (43 of 44 eyes, averaging 15 months follow-up) are substantially better than previously reported in series with other types of IOLs (96% greater than or equal to 20/40 if the macula was not involved, 75% greater than or equal to 20/40 if the macula was involved).

Cataract extractions were performed in 25 patients who had previously undergone pars plana vitrectomy. Posterior chamber IOLs were implanted in 20 of 26 eyes. Modification of the usual surgical technique was often necessary because the zonules and/or posterior capsule were unusually mobile. Lens opacities were nuclear sclerotic in 17 eyes (65%) and posterior subcapsular in nine eyes (35%). Visual acuity improved an average of five lines, and final visual acuity was 20/50 or better in 13 eyes (50%). Visual acuity after cataract extraction closely paralleled the best visual acuity after vitreous surgery in all patients. Complications were tears in the posterior capsule in two eyes and postoperative vitreous hemorrhage in one eye. These complications did not limit final vision.

The visual outcome, as well as the preoperative sensory and anatomic status, of 49 eyes undergoing vitrectomy within 72 hours after a penetrating injury, was compared to 54 eyes with penetrating injury operated on by vitrectomy at longer intervals. The eyes operated on within 72 hours of the injury had a better visual outcome than those operated on later, but this difference was not statistically significant. However, there were important differences between the two patient groups. Eyes undergoing vitrectomy within 72 hours had a better initial visual acuity after injury, a greater percentage of anteriorly located lacerations, fewer cases of severe vitreous hemorrhage, and a higher proportion of cases with an intraocular foreign body. Each of these factors had been shown previously to be associated with a comparatively favorable visual prognosis in eyes treated by conventional means of wound repair without vitrectomy. Therefore, the visual acuity differences among the two main groups in this study are probably due to differences in the types of cases selected for early versus later vitrectomy, rather than to the difference in the timing of surgery.

Human, bovine, and rabbit retinal extracts are shown to be capable of stimulating (1) proliferation and thymidine uptake of bovine vascular endothelial cells in cultures and (2) neovascularization of the chick chorioallantoic membrane (CAM). Extracts of skeletal muscle, heart, and liver lack similar stimulatory activity. Vitreous aspirates from patients with proliferative diabetic retinopathy, in a preliminary study, were able to stimulate vascular endothelial cell thymidine uptake. Most vitreous samples from patients without intraocular neovascularization lacked similar stimulatory activity. Indirect evidence suggests the liberation of an angiogenic factor from the retina in several ocular disorders. The data contained in this report represent the first direct evidence of angiogenic activity from mammalian retina.

Vitreous surgery techniques are useful in the management of selected retinal detachments with an otherwise poor prognosis. Vitrectomy methods can be used to remove intraocular opacities; cut vitreous sheets causing vitreo-retinal traction and separate epiretinal membranes covering or distorting the retina; provide a fluid space to aid in creation of a scleral buckle or use of an intravitreal gas bubble; perform other intraocular procedures, including transvitreal treatment of retinal breaks, transvitreal removal of subretinal fluid, and intraocular fluid-gas exchange. These surgical capabilities can be combined with conventional retinal reattachment methods to treat selected types of retinal detachment. The surgical techniques, indications for surgery, and role of vitrectomy methods in the current management of retinal detachment are reviewed.

A prominent posterior retinal "starfold" was seen in an eye with an extensive rhegmatogenous retinal detachment. The retina was reattached with a scleral buckling operation. The epiretinal membrane causing the starfold was later removed by vitreous surgery and was studied by electron microscopy, permitting the first such clinicopathologic correlation in a human eye. The membrane was composed of vitreous collagen, newly formed collagen, and cells. The cell types included retinal pigment epithelial (RPE) cells, fibrous astrocytes, and macrophages. The fibrous astrocytes and some of the RPE cells contained intracytoplasmic microfilaments of the type thought to be myofibrils. These may account for contraction of the membrane, causing the starfold configuration of the underlying and adjacent retina.

We reviewed the records of 596 consecutive cases of vitrectomy performed for complications of diabetic retinopathy at the Wilmer Eye Institute. Accidental lens damage occurred during surgery in three eyes. Fourteen (8%) of 180 phakic eyes underwent later cataract removal. Follow-up of at least six months and detailed description of the lens at final examination were available in 151 eyes. Of these, visually significant opacities occurred in 32 eyes (21%), and the lens opacities accounted for substantial loss of final vision in 6 (19%) of these 32 eyes. Moderate or severe lens opacities that developed postoperatively were as follows: anterior subcapsular or cortical changes in 2 eyes (1%), nuclear sclerosis in 11 eyes (7%), posterior subcapsular changes in 25 eyes (17%). One hundred twenty-five preoperative, operative and postoperative factors were analyzed for each patient to detect correlations with postoperative lens changes. Nuclear sclerotic changes correlated with older patient age. Posterior subcapsular changes correlated with three intraoperative factors: longer duration of the operation, use of intravitreal gas, and use of a gas bubble filling more than 50% of the vitreous cavity. Posterior subcapsular changes were progressive with longer follow-up.

The authors studied the hospital records of 453 patients who underwent primary surgical repair of penetrating ocular injuries at the Wilmer Institute from January 1970 through December 1981. The injury was due to blunt force in 22%, a sharp laceration in 37%, and a missile in 41%. The following factors correlated with the final visual outcome: (1) initial visual acuity after the injury, (2) presence of an afferent pupillary defect, (3) type of injury, (4) location and extent of the penetrating wound, (5) type of lens damage, (6) presence and severity of vitreous hemorrhage, and (7) type of intraocular foreign body. This study emphasizes that the prognosis after a penetrating injury is strongly influenced by the nature of the injury and the extent of initial damage.

The authors treated 1007 eyes with vitrectomy for complications of proliferative diabetic retinopathy. Indications for surgery were: vitreous hemorrhage, 353 eyes (35%); traction retinal detachment, 360 eyes (36%); combined traction-rhegmatogenous retinal detachment, 172 eyes (17%); and other progressive fibrovascular proliferation 122 eyes (12%). During the study period, the frequency of vitreous hemorrhage as an indication for surgery decreased from 42 to 25%, and other progressive fibrovascular proliferation increased from 5 to 22%. The frequency of traction and traction/rhegmatogenous retinal detachments did not change. The results of surgery varied according to the indication. Seventy-nine percent of eyes with vitreous hemorrhage obtained final vision of 5/200 or better. Similar results were obtained in 64% of eyes with traction detachment, 56% of eyes with rhegmatogenous detachment, and 81% of eyes with progressive fibrovascular proliferation. The percentage of eyes achieving final vision of 20/100 or better are as follows: vitreous hemorrhage, 48%; traction detachment, 27%; rhegmatogenous detachment, 24%; and progressive fibrovascular proliferation, 46%. The success rate improved in each anatomic category during the last 3 years of the study.

Several recent studies have demonstrated that vascular endothelial cell migration is an essential element of new blood vessel formation. We have recently developed an in vitro assay to study the effect of various substances on vascular endothelial cell migration. We now report the use of this assay to study the effect of human intraocular fluid on endothelial cell migration. We have found a good correlation between the presence of progressive retinal neovascularization in an eye and the ability of vitreous cavity fluid from that eye (obtained at the time of vitrectomy) to stimulate vascular endothelial cell migration in vitro.

We used vitrectomy and transvitreal endophotocoagulation of the ciliary processes to treat 18 eyes with severe glaucoma that could not be managed successfully by medical therapy and conventional glaucoma surgery. Lensectomy was performed in the two phakic eyes in the series because of cataractous lens changes. A pars plana vitrectomy was done in each eye and a fiberoptic probe used to apply transvitreal blue-green argon laser photocoagulation directly to the ciliary processes. Treatment of more than 180 degrees was necessary for sufficient lowering of the intraocular pressure. Postoperative intraocular pressure was equal to or less than 20 mmHg in 14 of 18 eyes, although nine of the 14 successful cases required postoperative medical therapy. Complications included transient vitreous hemorrhage (2 eyes), transient choroidal detachment (2 eyes), and hypotony (1 eye).

Vitreous surgery was used to treat 130 consecutive cases with epiretinal membranes causing macular pucker. The membrane: (1) occurred after otherwise successful retinal reattachment surgery in 78 eyes (60%), (2) was idiopathic in 28 eyes (22%), (3) was associated with other ocular disorders in 20 eyes (15%), and (4) in four eyes may have been developmental. The abnormal tissue was successfully removed in 128 of 130 eyes, and vision improved at least two lines on the Snellen chart in 108 eyes (83%). Postoperative visual acuity was 20/20 in five eyes (4%), 20/25 to 20/40 in 41 eyes (31.5%), 20/50 to 20/100 in 64 eyes (49%), 20/200 in 15 eyes (11.5%), and 20/400 in five eyes (4%). Complications included one case of sterile endophthalmitis and one case of infective endophthalmitis (Staphylococcus epidermidis). Peripheral retinal tears occurred in six eyes (5%). No posterior retinal breaks occurred in this series. Later retinal detachment occurred in eight eyes (6%) requiring further retinal surgery. Progressive postoperative nuclear sclerotic lens changes occurred in 31 (34%) of 90 phakic eyes. Sizable amounts of epiretinal tissue recurred postoperatively in four eyes (3%).

One hundred seventy-nine eyes were analyzed to determine the incidence of postoperative complications after vitrectomy for proliferative diabetic retinopathy. One hundred twenty-nine (72%) of the 179 eyes achieved improved vision, and 117 (65%) were considered visual successes with final vision in the functional range of 5/200 or better. Corneal epithelial defects occurred in 51 eyes (28%), but severe corneal complications were rare, and no eye developed corneal clouding as the sole cause of later visual loss. The lens was retained in 128 eyes (75%), and visually significant lens opacities occurred later in 17% of the phakic eyes. Postoperative iris neovascularization was reduced by not removing the lens, and rubeosis iridis occurred in 15 (13%) of 114 phakic eyes and in 21 (32%) of 65 aphakic eyes (P = 0.012). Vitreous hemorrhage was present in 75% of eyes immediately after surgery and cleared in an average of 6.2 weeks in phakic eyes and 5.4 weeks in aphakic eyes. Fifty-two eyes (29%) had recurrent vitreous hemorrhage after the initial postoperative period. New retinal detachment occurred after surgery in 16% of eyes and was treated successfully in 38%. Reoperations were done in 45 eyes (25%), and 32 (71%) of these were for repair of retinal detachment or removal of nonclearing vitreous hemorrhage. Six eyes (3%) developed phthisis bulbi, and one other eye was enucleated.

Instruments designed for pars plana vitrectomy can be used to manage selected complicated congenital cataracts such as those with persistent hyperplastic primary vitreous (PHPV). We have applied closed-eye vitrectomy techniques through a limbal approach in seven eyes with PHPV. A clear pupillary space was achieved in all cases and two eyes achieved useful postoperative vision. The management of children with complicated congenital cataracts, such as with PHPV, is discussed.

Thirty-six pars plana vitrectomies were performed on 30 eyes of 17 patients with biopsy-proven vitreous amyloidosis. Reopacification of the retrolental vitreous was the most common reason for vitrectomy revision, required in 24% of patients. Complications of amyloid or vitrectomy included retinal detachment requiring scleral buckling in 17% of eyes and glaucoma requiring filtering surgery in 17% of eyes. After a mean 35-month post-vitrectomy follow-up, 48% of eyes had visual acuities of 20/40 or better, and 32% of eyes had visual acuities between 20/50 and 20/100. Twenty percent of eyes had visual acuities of 20/200 or worse due either to persistent retinal detachment, open angle glaucoma, or residual opacification of the vitreous.

The records of 596 consecutive vitrectomy cases performed for complications of diabetic retinopathy were reviewed to determine the incidence of intraoperative and postoperative vitreous hemorrhage and to determine if blood cleared more rapidly in aphakic compared to phakic eyes. Uncontrollable intraocular bleeding occurred in two eyes (0.5%). Vitreous hemorrhage was present on the first postoperative day in 278 eyes (63%). This early hemorrhage cleared in an average of 9.1 weeks in phakic eyes and 3.4 weeks in aphakic eyes. Further vitreous hemorrhage occurred in 88 eyes (23%). Sixty-four percent of later hemorrhages occurred in 88 eyes (23%). Sixty-four percent of later hemorrhages occurred within six months of the operation and 80% occurred within one year. Later vitreous hemorrhage cleared in an average of 16.2 weeks in phakic eyes and 5.3 weeks in aphakic eyes. Of the 311 eyes with vitreous hemorrhage at some time during the postoperative course, twenty-nine eyes (9%) underwent reoperation to remove nonclearing blood. Nonclearing vitreous hemorrhage was the main cause of final visual loss in only 15 (3.4%) of 438 eyes with adequate follow-up, and 6 of these 15 eyes had final vision of 5/200 or better.

The authors report 32 cases of histologically proven ocular reticulum cell sarcoma (RCS). Follow-up data are available for all patients. Twenty-six patients (81%) have died and the mean survival time was 20 months from the time of diagnosis of RCS. Diagnosis of ocular involvement was made by vitreous biopsy in 56% of cases, enucleation in 13%, and postmortem examination in 31%. The mean age at the time of diagnosis was 60 years. Central nervous system (CNS) involvement was present in 56% of patients, visceral involvement in 16%, and both CNS and visceral involvement in 6%. Isolated ocular disease occurred in 22% of patients. Results of head computed tomography (CT) and cerebrospinal fluid examination more often disclosed evidence of RCS than did body CT or nuclear medicine scans. Responses to treatment were variable, but prognosis for survival is poor.

Pneumatic retinopexy is advocated to treat some retinal detachment cases, in part to avoid the complication of induced strabismus sometimes associated with scleral buckling procedures (SBPs). Prospective evaluation of postoperative muscle imbalance was performed in 76 eyes of 69 patients undergoing SBP. Measureable limitation of ductions occurred in 40 (73%) of the 55 eyes for which a full set of duction measurements could be obtained. Among 53 patients without previous retinal surgery in either eye, postoperative deviations were associated with encircling scleral buckles (P = 0.00003), but not with radial scleral buckles (P = 0.6). Significant strabismus occurred in 12 patients (23%), and three required surgery or prism therapy. Candidates for pneumatic retinopexy can usually be treated by a radial scleral buckling procedure, and therefore the risk of postoperative strabismus is low if this technique is selected.

The management of congenital cataracts at the Wilmer Institute is presented, with emphasis on the need for careful preoperative assessment. The indications and techniques for surgery in uncomplicated cataracts are discussed, and the advantages of using vitrectomy instruments in complicated congenital cataracts, such as those associated with persistent hyperplastic primary vitreous, are described.