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Purpose: To describe our experience in the surgical management of cataracts in patients with complications of closed-globe injury using pars plana lensectomy (PPL), pars plana vitrectomy (PPV), and scleral fixation of posterior chamber intraocular lens (PCIOL)., Methods: We retrospectively reviewed charts of all patients with closed-globe injury who underwent PPL, PPV and scleral fixation of PCIOL at our institution between January 1991 and July 1997. We identified 28 eyes; because of less than 2 weeks follow-up, 4 eyes were excluded from the current study. All eyes had lens subluxation/dislocation and visually significant cataract. Additional indications for surgery included secondary glaucoma (10 eyes), vitreous hemorrhage (3 eyes) and retinal detachment (1 eye)., Results: The postoperative follow-up interval ranged from 6 to 61 months (mean 18.5 months). Preoperative visual acuity (VA) ranged from 20/60 to hand motion and was 20/100 or better in 6 eyes (25%). Postoperatively, 19 eyes (79%) improved to 20/100 or better. Five eyes had subsequent surgery for the following indications: retinal detachment (2 eyes), poorly controlled glaucoma (2 eyes), and epiretinal membrane formation (1 eye)., Conclusions: In patients undergoing PPL, PPV and scleral fixation of PCIOL for cataract after a closed-globe injury, a substantial visual improvement occurred in a majority of the involved eyes.

Background and Objective: To quantify and compare holmium:YAG (2.1 microns) and thulium:YAG (2.0 microns) laser-induced scleral shrinkage for retinal buckling procedures., Materials and Methods: Two overlapping spots of either laser radiation were applied at the equatorial sclera of 50 human cadaver eyes. Scleral shrinkage was expressed as a relative change of length between two reference points on the scleral surface, and quantified as a function of energy per pulse, total energy, scleral thickness, and intraocular pressure (IOP). Tissue effects were studied histopathologically., Results: Shrinkage was most dependent on total fluence and attained a maximum of 27% to 30% with an IOP of 4 mm Hg, regardless of scleral thickness or laser parameters, but decreased with increasing IOP. The thulium:YAG laser produced more efficient scleral shrinkage and less collagen damage than the holmium:YAG laser., Conclusion: The recommended parameters for laser-induced scleral shrinkage are the thulium:YAG laser, with 2.4 J/cm2 per pulse and 12.0 to 14.4 J/cm2 total fluence (5 to 6 pulses). IOP control (< or = 4 mm Hg) is crucial during laser scleral buckling.

Background and Objective: To assess the outcomes of vitreoretinal surgery in the treatment of vision-threatening posterior segment complications of X-linked retinoschisis., Patients and Methods: The authors performed a retrospective analysis of 16 eyes from 11 patients who underwent vitreoretinal surgery. All the patients had a documented positive family history of X-linked retinoschisis, and all patients had bilateral macular disease., Results: The ages of the patients ranged from 14 months to 37 years (mean age 15.1 years; median age 11.5 years), and postoperative follow-up ranged from 3 months to 10 years (mean 2.8 years; median 1 year). The indications for surgical intervention included rhegmatogenous retinal detachment (12 eyes), vitreous hemorrhage (2 eyes), progression of the schisis cavity through the fovea (2 eyes), cataract associated with a persistent hyperplastic primary vitreous-like condition (2 eyes), and exudative maculopathy (1 eye). The primary surgical intervention included pars plana vitrectomy alone (7 eyes), pars plana vitrectomy and pars plana lensectomy (4 eyes), and a scleral buckle procedure alone (5 eyes). Surgical success (defined as reattachment of the retina, removal of media opacities, or arrest of schisis progression) was achieved in 14 of 16 eyes, after an average of 1.2 procedures per eye. The major reason for reoperations was recurrent retinal detachment due to proliferative vitreoretinopathy. Two eyes were eventually enucleated due to pain associated with neovascular glaucoma resulting from recurrent retinal detachment. Of the remaining 14 eyes, visual acuity improved in 8 eyes and remained unchanged in 6 eyes., Conclusion: Vitreoretinal surgery is often helpful in stabilizing or improving visual function in patients with posterior segment complications from X-linked retinoschisis.

Background and Objective: To evaluate the efficacy of performing surgical techniques for macular holes without using adjunctive additives., Patients and Methods: A prospective study was completed of consecutive eyes treated for macular holes of 1 year or less duration that had not had previous vitreous surgery. The best-corrected visual acuity and hole flattening were determined., Results: Postoperative flattening of the hole was achieved in 39 (91%) of 43 eyes, with at least a 50% reduction of the minimum resolvable visual angle (3-line visual increase) in 65% of the eyes and a final vision of 20/40 or better in 40% of the eyes during the follow-up interval (mean 10.6 months)., Conclusions: The success rate of current macular hole surgical techniques suggests that adjunctive additives may not be necessary for most cases. Thus, new treatment modalities need to be evaluated with carefully controlled studies.

Background and Objective: Attention to the pathogenesis and clinical features of macular hole formation has increased with the advent of therapy. The purpose of this study is to present three cases that occurred in atypical settings that may have important pathogenic implications., Patients and Methods: The authors conducted a retrospective study of three patients who presented with macular holes that developed 10 months to 5.5 years after previous vitrectomy. In each case, the cortical vitreous layer was absent in the region of the macula at the time of operation for the macular hole., Results: The macular hole was successfully sealed and the visual acuity improved in all patients. All three cases in this report lacked an operculum, occurred long after vitreous removal, and had no evidence of any residual cortical vitreous., Conclusions: Macular hole formation in the absence of cortical vitreous suggests the possibility that the etiology of macular holes may involve a spontaneous umbo dehiscence rather than vitreous-induced surface traction. A mechanism involving a cystic degenerative process is proposed as the cause of atypical and typical macular hole formation.

Background and Objective: To review prevalence of organisms, associated factors, and treatment outcomes from one medical center's 10-year experience managing culture-proven endogenous fungal endophthalmitis (EFE)., Patients and Methods: The authors retrospectively reviewed the microbiology and corresponding clinical records of patients diagnosed as having culture-proven EFE at the Bascom Palmer Eye Institute during a 10-year period., Results: Culture-proven EFE occurred in 20 eyes of 18 patients. Candida species occurred in 17 of 20 eyes (85%), and Aspergillus species occurred in 3 of 20 eyes (15%). The most common association was long-term intravenous line placement, which was present in 12 patients (67%). Whereas 12 patients (67%) had a history of recent hospitalization, only 2 (11%) had a documented history of systemic fungal infection. After initial examination, only 2 patients had a systemic culture positive for a fungal organism (none had a positive blood culture). Treatment after initial examination included pars plana vitrectomy in 17 of the 20 eyes (85%), intravitreal amphotericin B in 19 eyes (95%), and systemic antifungal medication in 16 eyes of 15 patients. Thirteen of the 17 eyes (76%) with Candida endophthalmitis and 0 of 3 eyes with Aspergillus endophthalmitis achieved visual acuity of 20/400 or better., Conclusion: The most common cause of culture-proven EFE at the authors' institution is Candida species. The overall visual outcomes were more favorable for Candida cases than they were for Aspergillus cases. In the treatment of patients with marked vitreous infiltrates from EFE, pars plana vitrectomy, intravitreal amphotericin B injection, and administration of appropriate systemic antifungal medication (fluconazole for Candida) are generally recommended.

Background and Objective: To investigate the efficacy of pars plana vitrectomy and oral fluconazole without injection of intravitreal antimycotic agents in the treatment of vitritis resulting from Candida endophthalmitis., Patients and Methods: Six eyes of five patients with suspected Candida endophthalmitis were treated with pars plana vitrectomy and systemic fluconazole for at least 3 weeks. Patients were observed postoperatively for at least 4 months., Results: Clinical signs of infection cleared and visual acuity improved postoperatively in all six cases. One recurrent case was attributed to a retained indwelling venous catheter., Conclusions: Treatment of advanced endogenous Candida endophthalmitis with vitrectomy and systemic fluconazole offers an effective alternative to management with intravitreal amphotericin B in selected cases.

Background and Objective: Retinal detachment is a complication of dislocated crystalline and intraocular lenses. The purpose of this study was to compare the frequency and management of coexisting or subsequent retinal detachment in patients with retained lens fragments or dislocated posterior chamber intraocular lenses (PC IOLs)., Patients and Methods: A retrospective, consecutive series of patients undergoing vitrectomy for dislocated PC IOLs (99 eyes) or removal of retained lens material (80 eyes) were studied., Results: Eyes with retinal detachment and retained lens fragments (2 cases) or dislocated PC IOLs (2 cases), or retinal detachment following vitrectomy for removal of retained lens fragments (2 cases) or repair of dislocated IOL (1 cases) were identified. The prevalence of coexisting or postoperative retinal detachment and retained lens fragments (5% total) was slightly higher than the prevalence of coexisting or postoperative retinal detachment and dislocated PC IOLs (3% total). The retina was reattached in all cases using the standard scleral buckling and vitrectomy techniques., Conclusion: The rate of retinal detachment associated with retained lens material is decreased compared with previous reports. This may possibly be a results of increasing attention to minimizing surgical trauma by the cataract surgeon at the time of lens fragment loss and by the vitrectomy surgeon during primary repair.

Background and Objective: To determine the status of filtering bleb function following pars plana vitrectomy., Patients and Methods: The authors retrospectively reviewed patients with functioning filtering blebs undergoing pars plana vitrectomy., Results: Twenty-three eyes with functioning filtering blebs underwent pars plana vitrectomy. Postoperatively, 7/23 (30 percent) of the eyes had moderate (5 to 20 mm Hg) intraocular pressure (IOP), 8/23 of the eyes had IOP persistently greater than 20 mm Hg, and 7/23 of the eyes had IOP of less than 5 mm Hg. One of 7 eyes that underwent vitrectomy within 6 weeks after trabeculectomy maintained bleb function, whereas 6 of 16 eyes that underwent trabeculectomy 6 weeks or later maintained bleb function. Loss of bleb function occurred in the early postoperative period in the majority of the patients. Prior antimetabolite therapy was not associated with preservation of bleb function., Conclusion: There is a substantial risk of bleb failure following vitrectomy, which is in part related to the often severe nature of the diseases requiring vitreoretinal surgery.