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Purpose: We report a case of multiple extramedullary plasmacytoma (EMP) of the choroid and conjunctiva as a sign of multiple myeloma (MM) relapse. Methods: An observational case report with clinicopathologic correlation is presented. Results: A 45-year-old man with a 2.5-year history of MM presented with left eye pain. Examination revealed a conjunctival nodule and choroidal infiltrate in the left eye. Excisional biopsy demonstrated plasmacytoma of the conjunctiva and choroid. Despite radiotherapy and chemotherapy, multiple EMP recurred and the patient died 8 months after initial presentation. Conclusions: Multiple EMP of the choroid and conjunctiva has a poor prognosis and can present as a sign of MM relapse. Our imaging demonstrates the clinical manifestations of this tumor and can aid future diagnoses. Our radiation dose (20 Gy) was inadequate, which is an important reportable factor for future patients.

We report the case of a juvenile patient presenting with periocular eczema, a milky white cataract in the right eye, and iridoschisis. Although cataracts are commonly associated with iridoschisis, only 1 previous case of periocular eczema and iridoschisis has been reported. Our case raises the possibility of a pathophysiologic link between iridoschisis, juvenile cataract formation, and periocular eczema.

To describe the development of uveitis and retinal vasculitis in association with pembrolizumab treatment for metastatic uveal melanoma. A case report and a brief review of the literature are presented. Information collected and reported include the patient's clinical course, physical examination findings, fluorescein angiogram images, retinal photographs, and her response to treatment. A 54-year-old woman was diagnosed with a large choroidal malignant melanoma and had the affected eye enucleated. Pathology confirmed a mixed cell choroidal melanoma, and gene expression profiling was Class 2. Seventeen months after enucleation, the patient was diagnosed with metastatic uveal melanoma to the liver. Disease progression was observed during ipilimumab treatment. Pembrolizumab treatment was initiated, and after four infusions, she presented to clinic complaining of floaters and blurred vision. Examination revealed a nongranulomatous panuveitis characterized by perivascular retinal pigment epithelium pigmentary changes, retinal venous sheathing, 1+ anterior chamber and vitreous cellular reaction, 2+ vitreous haze, and optic disk edema. A dexamethasone sustained-release implant was administered and the uveitis regressed. A relapse in symptoms occurred but quickly subsided with a repeat injection. Pembrolizumab may induce a uveitic reaction. There is mounting evidence that patients using prembrolizumab should be educated and monitored for signs of uveitis.

Purpose To describe a new classification of stellate nonhereditary idiopathic foveomacular retinoschisis (SNIFR). Design Retrospective case series and literature review. Participants A total of 17 patients from 5 institutions. Methods Detailed case history, multimodal imaging, and genetic testing were reviewed for patients with macular schisis without a known predisposing condition. Patients with a stellate appearance centered on the fovea with correlating confirmed expansion of the outer plexiform layer (OPL) by optical coherence tomography (OCT) were included. Exclusion criteria included a family history of macular retinoschisis, a known genetic abnormality associated with retinoschisis, myopic traction maculopathy, epiretinal membrane, vitreoretinal traction, optic or scleral pit, or advanced glaucomatous optic nerve changes. Main Outcome Measures Clinical features, anatomic characteristics, and visual acuity. Results A total of 22 eyes from 16 female patients and 1 male patient with foveomacular schisis were reviewed from 5 institutions. Initial visual acuity was ≥20/50 in all eyes (mean, 20/27), but visual acuity in a single eye decreased from 20/20 to 20/200 after the development of subfoveal fluid. The refractive status was myopic in 16 eyes, plano in 3 eyes, and hyperopic in 2 eyes. Three eyes had a preexisting vitreous separation, and 19 eyes had an attached posterior hyaloid. Follow-up ranged from 6 months to >5 years. Conclusions In this largest known series of patients with SNIFR, all patients demonstrated splitting of the OPL in the macula with relatively preserved visual acuity (≥20/40) except in a single patient in whom subretinal fluid developed under the fovea.

We report a patient with clinical anophthalmia, partial eyelid fusion and a hypoplastic socket on the right. The left eye has microphthalmia involving the anterior and posterior segments, microcornea, iris coloboma, chorioretinal dysgenesis, macular dysplasia, absence of retinal vessels, and optic nerve aplasia. Systemic abnormalities include microcephaly, bilateral hearing loss, and duodenal atresia. Electrophysiologic testing showed no response from either eye. Cytogenetic testing revealed a de novo interstitial deletion of chromosome 14q22.3q23.1. The literature of similar interstitial deletions and ongoing candidate gene studies are reviewed.

PURPOSE The purpose of this study was to describe an unusual presentation of retinoblastoma in an adult. METHODS Retrospective case report. RESULTS A 48-year-old woman with floaters was found to have an amelanotic intraocular mass with localized vitreous seeds in the superior fundus. Metastatic workup was negative. Cytologic examination of the vitrectomy specimen showed a malignant neoplasm with neuroendocrine differentiation, suspicious for carcinoid tumor. The patient later was found to have a lung lesion presumed to be a carcinoid tumor. She was treated with external beam radiation to the eye, but 1 year later, a new retinal tumor was discovered inferiorly requiring plaque radiotherapy. Soon thereafter, she developed massive intraocular recurrence. The eye was enucleated. Histopathology revealed small round blue cells with round hyperchromatic nuclei. Rosettes were also present within the tumor consistent with retinoblastoma. CONCLUSION Late-onset retinoblastoma can occur in adults, and the diagnosis can be challenging.

Purpose: To report the macular hole closure rate and visual outcomes of patients with residual triamcinolone acetonide in the fovea after macular hole repair. Methods: We reviewed the medical records of consecutive patients who underwent macular hole surgery at our institution between 2005 and 2008. Only patients with visible triamcinolone in the fovea in the first postoperative month were included. Results: Six patients with Stage III or IV macular holes were included. All patients underwent pars plana vitrectomy, internal limiting membrane peeling, and gas tamponade. Triamcinolone acetonide was used to visualize the vitreous in every patient, and diluted indocyanine green was used to stain the internal limiting membrane in five patients. The median preoperative best-corrected visual acuity was 20/200, which improved to a median of 20/40 at the last follow-up. Five patients eventually developed retinal pigment epithelial alterations. Anatomic hole closure was achieved in every patient. The mean follow-up was 23 months (range, 3-36 months). Conclusion: Residual triamcinolone sequestered in the fovea after macular hole surgery did not affect hole closure or prevent improvement in visual acuity. It is unclear whether the retinal pigment epithelial alterations in our patients represent toxicity or are unrelated to the triamcinolone exposure.

PURPOSE To report a patient with bilateral choroidal metastasis from a malignant paraganglioma. METHODS Clinicopathologic case report and literature review. RESULTS A 68-year-old woman presented with bilateral amelanotic focal choroidal lesions. A thorough systemic work-up for a primary cancer revealed a paraganglioma (extraadrenal pheochromocytoma) and a pheochromocytoma of the left adrenal gland. Fine-needle aspiration biopsy of the choroidal lesion was consistent with metastatic paraganglioma. CONCLUSION Metastatic paraganglioma, although rare, has the ability to metastasize to the choroid.

Purpose To review the clinicopathologic features of eyes enucleated after failed transpupillary thermotherapy. Design Retrospective review. Methods Pathology reports in the L.F. Montgomery Laboratory between 1998 and 2002 were searched for enucleated eyes with choroidal melanoma that had been treated only by transpupillary thermotherapy (TTT) prior to enucleation. The clinical features of the patients, including ultrasonography examination, were reviewed and compared with the pathologic findings. Results Seven eyes from seven patients had been enucleated, representing 8% of eyes treated with TTT at our institute during the period studied. The primary indication for enucleation was tumor growth. The melanomas tended to grow laterally, with minimal if any increase in thickness. Five of the seven eyes histologically demonstrated extrascleral extension, which was detected by ultrasonography prior to enucleation in only one of those eyes. Conclusions Choroidal melanoma may continue to grow along a path of least resistance after TTT. The melanoma may extend laterally in the choroid and through emissary canals. Early extrascleral extension may be difficult to detect by ultrasonography.

Objective To evaluate the safety and effect on visual acuity of photodynamic therapy with verteporfin (Visudyne, Novartis AG) in patients with subfoveal choroidal neovascularization (CNV) secondary to the ocular histoplasmosis syndrome (OHS). Design Open-label, three-center, noncomparative prospective case series. Participants OHS patients with subfoveal CNV lesions no larger than 5400 μm in greatest linear dimension (GLD) with classic or occult CNV extending under the geometric center of the foveal avascular zone and best-corrected visual acuity letter score of 73 to 34 (approximate Snellen equivalent 20/40–20/200). Methods Twenty-six patients received verteporfin (6 mg/m 2 ) infused IV over 10 minutes. Fifteen minutes after the start of infusion, a laser light at 689 nm delivered 50 J/cm 2 at an intensity of 600 mW/cm 2 over 83 seconds using a spot size with a diameter 1000 μm larger than the GLD of the lesion. At 3-month follow-up examinations, retreatment with the same regimen was applied if angiography showed fluorescein leakage. Safety assessments were also made. Main outcome measures Visual function measurements were the changes from baseline in visual acuity and contrast sensitivity scores and the proportion of patients who, based on best-corrected visual acuity scores, (1) gained 7 or more letters, (2) lost 8 or more letters, and (3) lost 15 or more letters. Results One patient was omitted from the study at the month 3 examination for not meeting the visual acuity eligibility requirements at baseline. By the month 12 examination, but excluding any retreatment at that visit, patients had received an average of 2.9 treatments of a maximum of 4 possible treatments. The month 12 median improvement from baseline in visual acuity of the remaining 25 patients was 7 letters, and median contrast sensitivity improved by 2 letters. Median visual acuity improvement was also 7 letters when three patients, who failed to meet all photographic eligibility requirements at baseline, were excluded. At the month 12 examination, 14 (56%) patients gained 7 or more letters of visual acuity from baseline, whereas 4 (16%) patients lost 8 or more letters, of which 2 (8%) lost 15 or more letters. No serious systemic or ocular adverse events were reported. Conclusions Median visual acuity improved after verteporfin therapy for at least 1 year in a small uncontrolled prospective case series of patients with subfoveal CNV caused by OHS. Verteporfin therapy seemed to be safe and well tolerated in these patients. Two-year data from this study will provide important, additional information on the safety and effect of verteporfin therapy for the treatment of subfoveal CNV secondary to OHS.

Purpose: During the past decade, laser photoablation has supplanted cryotherapy as the standard treatment for threshold retinopathy of prematurity (ROP). We evaluated the progression and the complication rate in a cohort of infants with threshold ROP treated with a confluent technique. Methods: We retrospectively studied 47 patients with ROP (91 eyes), treated with confluent diode laser photoablation. Four main outcomes were evaluated: (1) the rate of progression, (2) the frequency of laser retreatment, (3) postoperative complications, and (4) postoperative refractive error. Results: A mean of 1943 ± 912 laser burns were administered in a confluent pattern to 91 eyes with threshold ROP. Progression to stage 4 or 5 disease occurred in 13 of 29 eyes (44.8%) with zone I and posterior zone II and in 2 of 51 eyes (3.9%) with anterior zone II ROP (P = .01). Eyes with anterior zone II ROP that received more than or equal to 2000 burns progressed more than those that received fewer than 2000 burns. Only 1 eye (1%) needed a supplemental laser treatment. Postoperative complications included corneal edema (2.3%), anterior segment ischemia (2.3%), vitreous hemorrhage (7.9%), posterior synechiae (2.3%), cataract (4.9%), and macular ectopia (12%).The mean spherical equivalent at the last follow-up was −4.52 ± 5.63 D. Conclusions: In our series, infants received more laser burns than infants reported in the literature receiving scatter or near-confluent treatment. While confluent treatment almost eliminated supplemental treatment, it was associated with a similar rate of progression and complications as has been reported with other patterns of laser treatment. (J AAPOS 2002;6:81-5)

PURPOSE: To report the results of macular hole surgery using indocyanine green to improve visualization and facilitate peeling of the internal limiting membrane. METHODS: A retrospective noncomparative review of a consecutive series of 22 patients (22 eyes) who underwent macular hole repair using indocyanine green to facilitate visualization of the internal limiting membrane was performed. One patient was excluded because of a history of a rhegmatogenous retinal detachment. All patients underwent a three-port pars plana vitrectomy with internal limiting membrane peeling. Indocyanine green (0.1% solution) was used to assist in the visualization of the internal limiting membrane. The main outcome measures were postoperative visual acuity, macular hole status, and postoperative retinal pigment epithelial changes. RESULTS: In 21 eyes, the median preoperative best-corrected visual acuity was 20/200 (range, 20/60 to counting fingers at 5 feet). The median postoperative visual acuity was 20/400 (range, 20/60–1/200) with an average follow-up of 13 weeks. The macular hole was closed in 18 eyes (86%) at the most recent follow-up. Ten eyes were found to have atrophic retinal pigment epithelium changes in the area of the previous macular hole. CONCLUSIONS: Indocyanine green assists in visualization of the internal limiting membrane in macular hole surgery. In our series, 10 eyes had unusual atrophic changes in the retinal pigment epithelium at the site of the previous macular hole, or in the area where the indocyanine green solution would have had direct access to the bare retinal pigment epithelium cells. Although the use of indocyanine green improves visualization and assists with peeling of the internal limiting membrane, the safety and potential toxicity of indocyanine green to the retinal pigment epithelium require further investigation.

Objective To report the authors' clinical experience with submacular surgery for subfoveal membranes in children and to evaluate the histopathologic findings of membranes in children with various etiologies of choroidal neovascularization. Design Retrospective, noncomparative, interventional case series. Participants Twelve eyes of 12 consecutive children with subfoveal choroidal neovascularization treated by vitrectomy and excision of the choroidal neovascular complex. Intervention Vitrectomy, excision of the choroidal neovascular complex, and air-fluid exchange. Main outcome measures Visual acuity and recurrence of choroidal neovascular membrane. Results Preoperative visual acuities ranged from 20/60 to 20/800 (median, 20/300). Postoperative visual acuities ranged from 20/25 to 20/400 (median, 20/80) after an average follow-up of 20 months (range, 7–62 months). Ten of 12 eyes improved from immediate preoperative visual acuity, and four eyes developed recurrence of neovascular membranes over a mean follow-up of 18 months. Histopathologic examination of six excised membranes showed that the most common components of the membranes were retinal pigment epithelium, fibrocytes, vascular endothelium, and collagen. Conclusion Selected eyes of children with subfoveal neovascular membranes and no evidence of membrane regression may benefit from submacular surgery. The histopathologic findings were similar to adult choroidal neovascularization not associated with age-related macular degeneration.

Objective The purpose of the study was to evaluate the incidence of acute-onset (within 6 weeks after surgery) postoperative endophthalmitis and to assess the visual acuity outcomes after treatment over a 10-year period at one institution. Patients and methods This retrospective study reviews all surgical cases performed between January 1, 1984 and December 30, 1994 at the Anne Bates Leach Eye Hospital, Bascom Palmer Eye Institute, University of Miami Medical Center, for the occurrence of nosocomial acute-onset postoperative endophthalmitis. Results The overall 10-year incidence of acute-onset postoperative endophthalmitis after intraocular surgery was 0.093% (54/58, 123). The incidences of culture-proven acute-onset postoperative endophthalmitis by surgical category were as follows: cataract surgery with or without intraocular lens (IOL) (0.082%, 34/41, 654), pars plana vitrectomy (PPV) (0.046%, 3/6557), penetrating keratoplasty (0.178%, 5/2805), secondary IOL placement (0.366%, 5/1367), glaucoma surgeries (0.124%, 4/3233), combined trabeculectomy and cataract surgery (0.114%, 2/1743), and combined penetrating keratoplasty and cataract surgery (0.194%, 1/515). The median visual acuity after endophthalmitis treatment was 20/200. The median visual acuities after endophthal- mitis treatment by procedure were as follows: cataract surgery with or without IOL (20/133), PPV (no light perception), penetrating keratoplasty (2/200), secondary IOL implantation (20/40), glaucoma surgery (20/80), and combined trabeculectomy and cataract surgery with or without IOL (20/150). Conclusions The overall incidence of endophthalmitis after intraocular surgery was 0.093%. The incidence of endophthalmitis was higher after secondary IOL implantation than after cataract extraction ( P = 0.008, Fisher's exact test). After treatment, the visual acuity outcomes were worse in the patients who developed endophthalmitis after PPV than after cataract extraction, glaucoma procedures, or secondary IOL implantation ( P P

To evaluate a tissue sealant (autologous cryoprecipitate activated with bovine thrombin) as an adjuvant in macular hole surgery.Sixty-nine patients with stage 2, 3, or 4 full-thickness macular hole were enrolled consecutively in a prospective pilot study. Anatomic closure of the macular holes with a single operation was the primary outcome. Fifty-eight patients had pre- and postoperative standardized measurements including best refracted visual acuity, reading speed, and contrast sensitivity. Group A patients (45) had primary macular holes; Group B patients (13) had recurrent macular holes or macular holes with "other" retinal pathology. Surgical technique was standardized and membrane dissections were optional.The anatomic closure rate was 80% with a minimum of 6 months follow-up. Mean improvement in visual acuity for Group A (2.9+/-0.4 lines) was significantly better than for Group B (0.8+/-0.5 lines; P = 0.008). Eyes that underwent internal limiting membrane (ILM) dissections had an anatomic closure rate of 96% (23/24), compared with 71% (32/45) in "non-ILM" cases (P = 0.034). Adverse reactions included sterile hypopyon (10%), intraretinal hemorrhage (9%), pigmentary hyperplasia (3%), and retinal detachment (3%).Tissue sealants should be evaluated as an adjuvant in macular hole surgery in a randomized clinical trial. Inflammatory reactions may occur in some patients. Internal limiting membrane dissection may improve anatomic closure rates without adversely affecting the visual acuity.

Purpose To report giant retinal tear and retinal detachment as a complication of attempted removal of intravitreal lens fragments at the time of cataract surgery and to evaluate the anatomic and visual acuity outcomes of pars plana vitrectomy and retinal reattachment surgery. Methods Retrospectively, 10 patients with giant retinal tear, retinal detachment, and intravitreal lens fragments in 10 eyes were reviewed. Results In 10 eyes, retrieval of intravitreal lens fragments using the limbal approach by deep vitrectomy, copious vitreous cavity irrigation, or deep vitreous cavity phacoemulsification had been attempted by the anterior segment surgeon at the time of cataract surgery in each patient. The average interval from cataract surgery to the initial vitreoretinal consultation was 8 days. Each of the 10 eyes had a giant retinal tear involving the inferior retina: in four eyes, of between 90 degrees and 180 degrees; in four, equal to 180 degrees; and in two, of greater than 180 degrees. After pars plana vitrectomy and retinal detachment repair, nine (90%) of 10 eyes had retinal reattachment, but seven patients required more than one operation. One eye had persistent retinal detachment, and one eye had corneal graft failure. Seven (70%) of the 10 eyes had best-corrected final visual acuity of 20/200 or better; three eyes had light-perception, hand-motion, and counting-fingers vision. Conclusions Aggressive attempts at intravitreal lens fragment retrieval from a limbal-based approach should be avoided because these procedures may result in serious retinal complications, such as formation of a giant retinal tear.

Purpose To develop a classification system for mechanical injuries of the eye. Methods The Ocular Trauma Classification Group, a committee of 13 ophthalmologists from seven separate institutions, was organized to discuss the standardization of ocular trauma classification. To develop the classification system, the group reviewed trauma classification systems in ophthalmology and general medicine and, in detail, reports on the characteristics and outcomes of eye trauma, then established a classification system based on standard terminology and features of eye injuries at initial examination that have demonstrated prognostic significance. Results This system classifies both open-globe and closed-globe injuries according to four separate variables: type of injury, based on the mechanism of injury; grade of injury, defined by visual acuity in the injured eye at initial examination; pupil, defined as the presence or absence of a relative afferent pupillary defect in the injured eye; and zone of injury, based on the anteroposterior extent of the injury. This system is designed to be used by ophthalmologists and nonophthalmologists who care for patients or conduct research on ocular injuries. An ocular injury is classified during the initial examination or at the time of the primary surgical intervention and does not require extraordinary testing. Conclusions This classification system will categorize ocular injuries at the time of initial examination. It is designed to promote the use of standard terminology and assessment, with applications to clinical management and research studies regarding eye injuries.

Purpose To determine visual acuity outcome after indocyanine green angiography-guided laser photocoagulation of choroidal neovascularization associated with pigment epithelial detachment in eyes with age-related macular degeneration. Methods We retrospectively reviewed pretreatment and posttreatment visual acuity after laser photocoagulation to well-demarcated hyperfluorescent areas seen with indocyanine green angiography adjacent to or within pigment epithelial detachments in 20 eyes of 20 patients with age-related macular degeneration and suspected choroidal neovascularization. Results Visual acuity before and after laser photocoagulation was followed up for 3 to 24 months (median, 9 months). At 3 months after laser photocoagulation, visual acuity had improved 2 or more Snellen lines in two eyes (10%), worsened by 2 or more lines in 10 (50%), and remained unchanged in eight of 20 (40%). By 6 months after laser photocoagulation, visual acuity had improved by 2 or more lines in two eyes (12%), worsened by 2 or more lines in nine (53%), and remained unchanged in six of 17 (35%). At 9 months after laser photocoagulation, visual acuity had improved by 2 or more lines in one eye (9%), worsened by 2 or more lines in nine (82%), and remained unchanged in one of 11 (9%). Conclusions Indocyanine green angiography-guided laser photocoagulation may temporarily stabilize visual acuity in some eyes with choroidal neovascularization associated with pigment epithelial detachments, but final visual acuity decreases with time.

Punctate inner choroidopathyl, multifocal choroiditis2, and multifocal choroiditis associated with progressive subretinal fibrosis3 may all appear quite similar clinically. Patients affected with these conditions, which may represent either variants of single disorder or a spectrum of disease, have a similar profile: they are commonly young myopic females with multiple focal areas of inflammation at the level of the choroid/Bruchs’ membrane/retinal pigment epithelium complex. The aetiology and incidence of these conditions is unknown. Visual outcome in punctate inner choroidopathy is generally good, barring the development of subfoveal choroidal neovascularization (CNV)1.

Background: As part of the design of the Silicone Study, a new classification of proliferative vitreoretinopathy (PVR) was developed that distinguishes the different types of contraction found in PVR. In contrast to the original Retina Society system that emphasized the post-equatorial retinal pathology (posterior PVR), the Silicone Study classification system included the characteristic types of contraction found in both the equatorial region and the pre-equatorial retina and vitreous base (anterior PVR). Methods: The authors contrast (1) preoperative and intraoperative findings and (2) vision and anatomic outcomes in the cohort of anterior PVR eyes with the cohort of posterior-only PVR eyes. For the cohort of eyes randomized to perfluoropropane gas (C 3 F 8 ) or silicone oil, the authors carry out univariate and multivariate analyses to assess the predictive value of baseline and intraoperative parameters on vision and anatomic outcome. Results: Anterior PVR was present in 321 eyes (79%)and was more prevalent in eyes that had undergone an unsuccessful vitrectomy before study entry than in eyes that underwent a primary vitrectomy for PVR (88% versus 73%; P P P = 0.003), (3) have more hypotony (24% versus 11 %; P = 0.03), more edema (8% versus 2%; P = 0.04), more aqueous flare ( P = 0.02), more macular pucker (69% versus 52%; P = 0.005), and more intravitreal contraction (21 % versus 6%; P = 0.002). When compared with eyes that had anterior PVR, eyes with posterior PVR had a better outcome at the 6-month postoperative examination: complete attachment of the retina (76% versus 62%; P = 0.04), visual acuity of 5/200 or better (64% versus 45%; P = 0.006), and normal intraocular pressure (86% versus 71 %; P = 0.04). For eyes with anterior PVR, significant predictors of poor ( 3 F 8 gas as the intraocular tamponade. Conclusion: The Silicone Study classification of anterior PVR permits greater specificity in characterizing PVR and is prognostic of anatomic and vision outcome. Eyes with anterior PVR and clinically significant posterior PVR changes had a better visual prognosis if silicone oil was used. With the current understanding of the pathoanx ~ atomy of anterior PVR and the recent development of new surgical techniques, the incidence of anterior PVR in eyes that previously underwent vitrectomy may decline, and the prognosis in eyes with anterior PVR may improve.

Purpose: To investigate the efficacy of ciliary body endophotocoagulation during pars plana vitrectomy in eyes with medically uncontrolled glaucoma and concomitant vitreoretinal disorders. Methods: The authors compared preoperative and postoperative intraocular pressure (IOP) and visual acuity in 21 eyes of 21 patients undergoing ciliary body endophotocoagulation with pars plana vitrectomy. Results: Preoperative IOPs ranged from 22 to 59 mmHg (median, 46 mmHg). Visual acuity ranged from 20/200 to light perception (median, hand motions). Follow-up ranged from 3 to 18 months (median, 10 months). Postoperative IOPs ranged from 11 to 19 mmHg (median, l 6 mmHg) at 6 weeks, 4 to 20 mmHg (median, l 4 mmHg) at 3 months, 1 to 26 mmHg (median, l 2 mmHg) at 6 months, and 0 to 48 mmHg (median, l2 mmHg) at 12 months. Postoperative visual acuity was statistically improved from preoperative visual acuity by 6 weeks. Conclusion: Ciliary body endophotocoagulation combined with pars plana vitrectomy can effectively treat concomitant glaucoma and vitreoretinal disorders.

Silicone oil has been in use as a vitreoretinal surgical adjunct for more than 30 years. The literature from late 1993 through 1994 is dominated by reports from the Silicone Study, which addresses outcome differences after primary versus repeat vitrectomy, combined retinotomy and retinectomy, and silicone oil removal, as well as the problem of postoperative intraocular pressure abnormalities. Contemporary retrospective series reporting on the use of silicone oil for pediatric, cytomegalovirus retinitis-related, and diabetic retinal detachments are also reviewed.

9575Background: Most uveal melanoma (UM) patients do not present with metastatic disease at diagnosis, yet 50% will develop metastases following primary tumor control. A validated 15-gene expressio...

Purpose: The purpose of this study is to assess the benefit of vitreous surgery in preventing full-thickness macular holes in patients with impending (stage 1) macular holes. Methods: A prospective randomized multicenter clinical trial was conducted on patients with full-thickness macular holes in their first eye (stage 3 or 4) and signs and symptoms of stage 1 macular holes in their fellow eye (study eye). The study eye was randomized to vitreous surgery or observation. Outcome was assessed by standardized measurement of visual acuity, detailed clinical examination, fundus photographs, and fluorescein angiography. Results: A full-thickness macular hole developed in 10 (37%) of 27 patients in the vitrectomy group compared with 14 (40%) of 35 patients randomized to observation ( P = 0.81). This difference of 3% has a 95% confidence interval of (-21%,27%). Conclusion: The study was terminated because of low recruitment. The authors were unable to prove (or disprove) the benefit of vitreous surgery in patients with stage 1 macular holes. The authors can state, however, that should a beneficial effect from vitrectomy exist, it would probably be minimal. Considering the cost and morbidity of vitreous surgery, a conservative approach for stage 1 macular hole might be appropriate.

The ultrastructural features of three surgically excised idiopathic subfoveal neovascular membranes were examined. Ultrastructural features of the cellular components in the membranes included retinal pigment epithelium, endothelial-lined vascular channels, photoreceptor cells, macrophages, myofibroblasts, glial cells, erythrocytes, and ghost erythrocytes. Extracellular constituents included 200-nm to 250− nm collagen fibrils, 100-nm collagen fibrils and fibrin. The findings in this study are consistent with previously reported findings of subfoveal neovascular membranes in age-related macular degeneration and the ocular histoplasmosis syndrome, with the exception of the presence of basal laminar deposit in membranes from age- related macular degeneration.

The immunohistochemical and histochemical properties of 16 surgically excised subretinal neovascular membranes from 16 patients with age-related macular degeneration were studied. Primary antisera to c-retinaldehyde-binding protein; leukocyte common antigen; factor VIII-related antigen; S-100 protein; glial fibrillary acid protein; muscle-specific actin; neuron-specific enolase; collagen types I, II, III, IV, and V; laminin; and fibronectin were used for immunohistochemical characterization of the membranes. Histochemical staining for lipid and mucopolysaccharide was performed. The results of the staining in conjunction with histologic examination showed the cellular components of the membranes to be composed of retinal pigment epithelium, inflammatory cells, vascular endothelium, glial cells, myofibroblasts, photoreceptor cells, and fibrocytes. The extracellular matrix of the membranes contained collagen types I, III, IV, and V; fibronectin; laminin; mucopolysaccharide; and lipid. These findings are consistent with the concept that subretinal neovascular membranes in age-related macular degeneration are composed of localized intra-Bruch's membrane granulation tissue proliferation associated with diffuse drusen.

Some heredomacular diseases share ophthalmoscopic and morphologic similarities despite being nosologically distinct. In part, this may arise from pathologic reaction patterns such as lipopigment accumulation and drusen deposition which are common to a variety of disorders of the photoreceptor--retinal pigment epithelium--Bruch's membrane complex. Two of these disorders, Stargardt's flavimaculatus and the pattern dystrophies of the retinal pigment epithelium may be especially difficult to differentiate clinically since they are characterised by both a similar ophthalmoscopic appearance and considerable inter and intrafamilial variation in their expression. Stargardt's flavimaculatus may, however, be distinguished from the retinal pigment epithelial pattern dystrophies by certain clinical and morphological features that are outlined below.

Monochromatic light accentuates details of different retinal layers because of its variable absorption and reflectance by structures both within and above these layers. Monochromatic photography was used to examine macular vitreoretinal interface abnormalities in 19 patients. Short wavelength photographs (490 nm) provided the best detail of inner retinal abnormalities, including epiretinal membranes, vitreoretinal traction, and the internal surface of confluent macular edema (pseudocyst). Although 540-nm red-free photography provided acceptable photographs, it did not provide optimal detail of inner or deep retinal abnormalities. Longer wavelengths, 585 and 610 nm, best disclosed the extent of deep retinal abnormalities, including the extent of confluent macular edema (pseudocysts) and retinal detachment that surrounded macular holes. The addition of short- and long-wave-length photography to traditional red-free photography may provide better localization, understanding, and documentation of the three-dimensional relationships in macular vitreoretinal interface disorders.

Purpose To evaluate the safety and effect of bevacizumab pretreatment on the incidence of recurrent vitreous hemorrhage and visual acuity after vitrectomy for proliferative diabetic retinopathy. Methods This was a consecutive, retrospective, and comparative cohort study. Patients undergoing vitrectomy from September 2006 through November 2007 at the Emory Eye Center for complications of proliferative diabetic retinopathy were identified and reviewed. A total of 33 eyes pretreated with bevacizumab and 104 untreated eyes were observed for postoperative vitreous hemorrhage and final visual acuity. Results Patients in the bevacizumab group were significantly younger than those in the untreated group (average age, 46.4 vs. 58.4 years) and were more likely to have 20-gauge instrumentation (58% vs. 36%). An average of 9.6 days passed between injection and surgery. Early (4-6 weeks) rebleed rates were 15% versus 13% in the bevacizumab and untreated groups, respectively, and not statistically different. Preoperative (7/200 vs. count finger at 4'), 1-month postoperative (20/200(-3) vs. 20/150), and 3-month postoperative visual acuity (20/100(-3) vs. 20/100(+2)) were not statistically different between groups. No statistical difference was found in rebleed rates regarding the gauge of vitrectomy. Conclusion Bevacizumab pretreatment for diabetic vitrectomy was not associated with any observed complications but did not influence rates of postoperative vitreous hemorrhage or final visual acuity in this retrospective series. The overall incidence of postoperative early vitreous hemorrhage in this series was 13% and seems lower than historically reported rates.

The histopathologic features of ten consecutive surgically excised subfoveal neovascular membranes from patients with age-related macular degeneration were examined. Ultrastructural features included the following in decreasing order of frequency: endothelium-lined vascular channels, new collagen, fibrocytes, retinal pigment epithelium, erythrocytes, and myofibroblasts. Chronic inflammatory cells were frequently evident and included macrophages, lymphocytes, and plasma cells. Basal laminar deposit or diffuse drusen were observed in six of the membranes. Photoreceptors and Bruch's membrane were each observed in three of the specimens, but were not associated with decreased postoperative visual acuity. Fibrin was observed in eight membranes, either within the stroma of the membrane or in association with subretinal hemorrhage.

To evaluate the incidence, effect on visual recovery, and predisposing risk factors of postvitrectomy macular edema (ME).Prospective cohort study.One-hundred nine eyes undergoing nonemergent vitrectomy surgery.Eyes were evaluated for postoperative day 1 inflammation, 1-month retinal thickness using optical coherence tomography, and preoperative and 1-month postoperative best-corrected visual acuity (BCVA). Macular edema was defined as central subfield thicknessor =272 microm.Retinal thickness, inflammation, and BCVA.Incidence of ME on optical coherence tomography was 47% (95% confidence interval [CI], 37%-56%). Mean 1-month visual acuity improved 3.3 lines (0.33 logarithm of minimum angle of resolution [logMAR] units) to 20/80(+1) (0.58+/-0.46 logMAR units) from 20/150(-2) (0.91+/-0.63 logMAR units) before surgery (P0.001). Mean 1-month center point thickness (CPT), central subfield (CSF), and total macular volume were 265+/-107 microm, 288+/-94 microm, and 7.8+/-1.2 mm(3), respectively. Severity of postoperative inflammation predicted retinal thickness at 1 month (P0.05). Intraoperative epinephrine use was associated with increased postoperative inflammation (P = 0.02). Eyes with greater reduction in CSF (or CPT) from baseline experienced more rapid visual recovery (r = -0.36; 95% CI, -0.61 to -0.06; P = 0.02).Postvitrectomy ME is common and delays visual recovery. Degree of postoperative inflammation is an important risk factor for ME and, in this series, was increased in the setting of intraocular epinephrine. Efforts to reduce or prevent inflammation after vitrectomy should be beneficial and therefore are encouraged.

PURPOSE: To investigate the efficacy of ciliary body endophotocoagulation during pars plana vitrectomy in eyes of pediatric patients with medically uncontrolled glaucoma. METHOD: We compared preoperative and postoperative intraocular pressure and visual acuity in five eyes of five patients aged between 10 months and 14.5 years who had 180 degrees of ciliary body endophotocoagulation with pars plana vitrectomy. RESULTS: Preoperative intraocular pressure on medical therapy for glaucoma ranged from 30 to 55 mm Hg (median, 35 mm Hg). Postoperative follow-up ranged from 12 to 24 months, with a median of 16 months. Postoperative intraocular pressure on medical therapy ranged from 12 to 35 mm Hg (median, 25 mm Hg) at 6 weeks, from 12 to 33 mm Hg (median, 29 mm Hg) at 6 months, and from 12 to 29 mm Hg (median, 27 mm Hg) at 12 months. Twelve months after surgery, mean intraocular pressure reduction of 20 mm Hg was statistically significant ( P = .020). CONCLUSION: Ciliary body endophotocoagulation during pars plana vitrectomy may be an effective treatment for pediatric patients with simultaneous uncontrolled glaucoma and vitreoretinal disorders.

Purpose To report four cases of optic nerve neuropathy in three children treated with periocular carboplatin injections for unilateral or bilateral intraocular retinoblastoma. Design Retrospective, observational case series. Methods setting : University-based Ophthalmology Practice. study population : Four eyes of three children with retinoblastoma enucleated after nonsuccessful multimodality treatment including periocular carboplatin injections. observation procedures : The enucleated eyes were routinely processed and evaluated by light microscopy. A retrospective chart review of all four cases was performed. Results Three enucleated eyes (Reese-Ellsworth groups III and VB) were obtained from two children with bilateral multifocal retinoblastoma, and one eye (Reese-Ellsworth group IIB) was harvested from a child with unilateral retinoblastoma. All affected eyes underwent three to seven periocular carboplatin injections before enucleation. Additional treatment modalities included systemic chemotherapy, transpupillary thermotherapy, transscleral cryotherapy, and external beam radiotherapy. Histopathologic evaluation of the enucleated eyes revealed focal areas of ischemic necrosis or atrophy of the optic nerve along with dystrophic calcification and mild inflammation in the surrounding fibrovascular adipose tissue. Conclusions Periocular injections of carboplatin may be a useful treatment approach in the management of patients with advanced intraocular retinoblastoma and may minimize systemic side-effects. However, ophthalmologists and pediatric oncologists should be aware of potential marked local complications with periocular carboplatin delivery, including ischemic optic neuropathy. Modifying the injection site/location (for example, subtenon space) or adding other delivery routes adjuncts (for example, fibrin sealant) deserves further study.

To evaluate the efficacy of subconjunctival carboplatin in fibrin sealant in the treatment of transgenic murine retinoblastoma.Experimental study using LHbeta-Tag transgenic mice in a randomized controlled trial.Thirty-three 10-week-old LHbeta-Tag transgenic mice: 22 carboplatin-treated animals and 11 control animals.Three groups of 11 mice were treated with a single, 30 microl injection of fibrin sealant in the subconjunctival space of 1 eye; the opposite eye was left untreated as an internal control. Group 1 (low-dose group) received 37.5 mg/ml calculated concentration of carboplatin in fibrin sealant (0.66 mg measured total dose). Group 2 (high-dose group) received 75 mg/ml calculated concentration of carboplatin in fibrin sealant (1.23 mg measured total dose). Group 3 (control group) received fibrin sealant only. Mice were killed on day 22 after treatment. Eyes were serially sectioned, and retinal tumor burden was quantified by histopathologic analysis. For statistical analysis of treatment effects, eyes were divided into 6 groups: low-dose group, sealant-treated eyes; low-dose group, untreated eyes; high-dose group, sealant-treated eyes; high-dose group, untreated eyes; control group, sealant-treated eyes; and control group, untreated eyes.Main outcome measure was mean tumor burden per level per eye in each experimental group.The best therapeutic results were obtained in eyes treated with low-dose carboplatin in fibrin sealant, where no histopathologic evidence of toxicity was observed, and 6 of 11 eyes had zero tumor burden. Tumor burden in the remaining 5 eyes in this group was minimal (4 eyes) or moderate (1 eye) compared with mean control values. Mean tumor burden in this group was significantly smaller than mean tumor burden in untreated eyes from the same mice (P0.004), sealant-treated eyes in the control group (P0.004), and untreated eyes in the control group (P0.002). Although a similar reduction in mean tumor burden was observed in eyes treated with high-dose carboplatin in fibrin sealant, 5 of 10 eyes analyzed in this group also demonstrated histopathologic evidence of severe toxicity.Subconjunctival carboplatin in fibrin sealant is effective in the treatment of transgenic murine retinoblastoma. A single injection of low-dose carboplatin in fibrin sealant was sufficient to induce complete or near-complete intraocular tumor regression in 10 of 11 eyes (91%), with no associated histologic evidence of toxicity. These results suggest that subconjunctival carboplatin in fibrin sealant provides sustained release and could have clinical use in the treatment of intraocular retinoblastoma.

Purpose: To describe the clinical course and management of patients with late vitreous hemorrhage after scleral suturing of posterior chamber intraocular lenses (PCIOL). Methods: The authors reviewed patient demographics, ocular findings, and clinical course of six patients with late (>3 weeks) vitreous hemorrhage after sclera-sutured PCIOL. Intraoperative endoscopy was performed on two patients to better assess the haptic sulcus interaction. Results: Patient age ranged from 39 to 84 years (median 77 years). The interval between scleral suturing of the PCIOL and vitreous hemorrhage ranged from 3 weeks to 68 months (median 5 months). The number of hemorrhages ranged from one to four. The hemorrhage cleared spontaneously in three eyes. Three patients underwent surgery after the hemorrhages including sutured PCIOL removal with concurrent placement of an anterior chamber IOL (ACIOL) (two patients) and resuturing of a PCIOL in a different meridian (one patient). Follow-up ranged from 4 to 36 months, median 19.5 months, starting from the time of the initial postsuturing vitreous hemorrhage. Final vision ranged from 20/20 to hand motions, with four eyes having 20/40 or better vision. Endoscopy revealed a haptic embedded into the pars plicata in one eye but no evidence of neovascularization. Conclusion: Recurrent vitreous hemorrhage may occur as a complication of scleral suturing of PCIOL. The etiology of these hemorrhages does not appear to be related to neovascular proliferation at the haptic suture site, but may be secondary to erosion of the haptic into uveal structures. Not all eyes require reoperation after these hemorrhages; however, good visual results may be achieved by replacing the sutured PCIOL with an ACIOL or by suturing the PCIOL in a different meridian.

Objective To evaluate the safety, effect on visual function, and fluorescein angiographic appearance of subfoveal choroidal neovascularization (CNV) through 2 years after photodynamic therapy with verteporfin (Visudyne; Novartis AG, Basel, Switzerland) in patients with ocular histoplasmosis syndrome (OHS). Design Open-label, 3-center, uncontrolled clinical study. Participants Ocular histoplasmosis syndrome patients with subfoveal CNV (N = 26) with a greatest linear dimension no larger than 5400 μm with classic or occult CNV extending under the geometric center of the fovea, and best-corrected visual acuity letter score of approximately 20/40 to 20/200. Methods The methods were similar to those described in the 1-year results with follow-up examinations every 3 months continuing through the second year. During the second year, additional therapy was recommended if fluorescein angiography showed leakage at a scheduled visit. Main outcome measurements Visual function measurements included the changes from baseline in visual acuity and contrast sensitivity scores. Lesion size and leakage from classic and occult CNV were assessed at month 12 and month 24. Safety assessments also were made. Results A 24-month examination was completed in 22 of the 26 enrolled participants (85%). At the 24-month examination, median improvement from baseline in visual acuity of the 22 patients evaluated was 6 letters; median contrast sensitivity improved by 3.5 letters. At the 24-month examination, 10 patients (45%) gained 7 or more letters of visual acuity from baseline, whereas 4 patients (18%) lost 8 or more letters, including 2 patients (9%) who lost at least 15 letters. There was absence of fluorescein angiographic leakage from classic CNV in 17 of the 20 evaluable lesions (85%), and leakage from occult CNV was absent in all eyes. No serious ocular adverse events were reported, and no serious systemic event was considered to be associated with treatment. Conclusions Median visual acuity improved and fluorescein angiographic leakage decreased after verteporfin therapy in this small, uncontrolled clinical study of patients with subfoveal CNV resulting from OHS. Verteporfin therapy seemed to be relatively safe in these patients. The selected cases feature fluorescein angiographic examples of CNV that are important in determining when to apply verteporfin therapy.

This study determined the in vitro permeability of cisplatin through isolated human sclera as delivered by a collagen matrix vehicle. Short-term and long-term intraocular levels of cisplatin were also measured in the rabbit eye after a subconjunctival injection. Cisplatin in either a collagen matrix vehicle or a control balanced salt solution (BSS) vehicle was applied to human sclera mounted in a specially designed in vitro perfusion chamber. The amount of cisplatin that diffused across the sclera was measured in hourly samples for 24 h using atomic absorption spectrometry. In vivo studies were also performed in Dutch Belted rabbits given subconjunctival injections of cisplatin in collagen matrix or in BSS. Eyes were enucleated at 1.5 h and 2 weeks after injection, frozen, and dissected to determine the intraocular cisplatin concentrations. Cisplatin had a peak in vitro scleral permeability constant of 8.3+/-1.2 x 10(-6) and 20.1+/-1.8 x 10(-6) cm/s, delivered in collagen matrix and in BSS, respectively (mean+/-S.D.). At the end of the in vitro experiments, 35.9+/-4.6% of the cisplatin remained in the collagen matrix, while 0.8+/-0.2% remained in the BSS vehicle. Subconjunctival injection of cisplatin in the collagen matrix vehicle achieved 3.3+/-0.1 microg/ml in the vitreous humor at 1.5 h and 0.1+/-0.1 microg/ml at 2 weeks. This vehicle also achieved a cisplatin concentration of 73.5+/-23.9 microg/mg in the choroid and retina at 1.5 h and 3.2+/-1.3 microg/mg at 2 weeks. Compared to BSS, the collagen matrix vehicle provided a more controlled release of cisplatin, and after subconjunctival injection into rabbits, attained higher drug levels in several ocular tissues.

Purpose To describe two patients with unique lenticular nodular proliferations. Design Observational case reports. Methods The clinical histories and pathologic findings of two patients with lenticular nodular proliferations were reviewed. Results One patient with persistent hyperplastic primary vitreous and another patient with trauma developed lenticular nodular proliferations. The nodules were vascularized collections of foamy histiocytes, multinucleated cells, lens capsule, and lens epithelium that had undergone fibrous metaplasia. The lesions were classified as lenticular fibroxanthomatous nodules. Conclusions A lenticular fibroxanthomatous nodule is a unique clinicopathologic entity that should be differentiated from Soemmerring ring, Elschnig pearl, and other simulating entities such as juvenile xanthogranuloma.

Purpose To report the clinicopathologic features of intraocular osseous production in association with proliferative vitreoretinopathy. Method The clinical and histopathologic features of two patients with proliferative vitreo-retinopathy and intraocular bone formation are reviewed. Results Preretinal osseous tissue incorporated in the proliferative vitreoretinopathy was surgically removed in one patient, and osseous tissue was present in the proliferative vitreoretinopathy in the enucleated eye of the other patient. Conclusions Bone formation, presumably from metaplastic retinal pigment epithelium, may be present in proliferative vitreoretinopathy tissue. The intraocular bone is present internal rather than external to the neurosensory retina.

Purpose StarGen is an equine infectious anemia virus (EIAV)-based lentiviral vector that expresses the photoreceptor-specific adenosine triphosphate (ATP)-binding cassette transporter (ABCA4) protein that is mutated in Stargardt disease (STGD1), a juvenile macular dystrophy. EIAV vectors are able to efficiently transduce rod and cone photoreceptors in addition to retinal pigment epithelium in the adult macaque and rabbit retina following subretinal delivery. The safety and biodistribution of StarGen following subretinal delivery in macaques and rabbits was assessed. Methods Regular ophthalmic examinations, IOP measurements, ERG responses, and histopathology were carried out in both species to compare control and vector-treated eyes. Tissue and fluid samples were obtained to evaluate the persistence, biodistribution, and shedding of the vector following subretinal delivery. Results Ophthalmic examinations revealed a slightly higher level of inflammation in StarGen compared with control treated eyes in both species. However, inflammation was transient and no overt toxicity was observed in StarGen treated eyes and there were no abnormal clinical findings. There was no StarGen-associated rise in IOP or abnormal ERG response in either rabbits or macaques. Histopathologic examination of the eyes did not reveal any detrimental changes resulting from subretinal administration of StarGen. Although antibodies to StarGen vector components were detected in rabbit but not macaque serum, this immunologic response did not result in any long-term toxicity. Biodistribution analysis demonstrated that the StarGen vector was restricted to the ocular compartment. Conclusions In summary, these studies demonstrate StarGen to be well tolerated and localized following subretinal administration.

Purpose To describe the pathogenesis, clinical characteristics, management, and outcomes of patients in whom vitreomacular traction evolved pursuant to treatment of choroidal melanoma with transpupillary thermotherapy. Design Retrospective, uncontrolled, observational, interventional case series. Methods Vitreomacular traction with macular distortion, macular edema, and vision loss developed in 6 eyes of 6 patients after successful transpupillary thermotherapy for choroidal melanoma. Clinical examination, fluorescein angiography, fundus photography, and spectral-domain optical coherence tomography were performed. Symptomatic patients underwent pars plana vitrectomy (PPV). Primary outcome measures include visual acuity and resolution of macular distortion by clinical examination, spectral-domain optical coherence tomography, or both. Results In all 6 patients, the malignant lesions were treated successfully. The posterior hyaloid was attached in all eyes before transpupillary thermotherapy. All eyes demonstrated focal hyaloidal contraction and vitreomacular traction between the transpupillary thermotherapy scar and the macula. Mean time from transpupillary thermotherapy to PPV for treatment of vitreomacular traction was 23 ± 18 months. Mean length of follow-up was 11 months. Mean logarithm of the minimal angle of resolution visual acuity before transpupillary thermotherapy was 0.23 ± 0.38. Mean visual acuity after transpupillary thermotherapy was 0.53 ± 0.42. Mean visual acuity before membrane peel was 0.65 ± 0.34. Mean visual acuity after membrane peel was 0.44 ± 0.21. All patients undergoing PPV showed visual improvement. Conclusions Hyaloidal contraction can occur after transpupillary thermotherapy and is a reversible cause of vision loss. The mechanism of vision loss resulting from hyaloidal contraction is flat vitreomacular traction. PPV and membrane peeling are effective in improving macular anatomic features and visual function.

Cataract is common after silicone oil repair of retinal detachment due to necrotizing retinitis in acquired immunodeficiency syndrome. Surgical management has not been reported. Twenty-two eyes of 19 patients were reviewed. The majority underwent phacoemulsification with a posterior chamber convexoplano implant without iridotomy. Complications included capsular fibrosis and hyphema. Unpredictable refractions in the first 16 eyes prompted refinement of lens calculations and resulted in a reduction in refractive errors. A 3-step modification of intraocular lens calculations is recommended: (1) use of specific sound velocities to calculate axial length; (2) use of convexoplano lenses; and (3) addition of a constant to the lens power to compensate for the refractive index of silicone oil. Good surgical technique and accurate lens calculations should improve management of cataracts that arise after retinal detachment repair with silicone oil in patients with acquired immunodeficiency syndrome.

A clinicopathologic study of ten consecutive patients (ten eyes) undergoing surgery for rhegmatogenous retinal detachment with anterior proliferative vitreoretinopathy and a subsequent histopathologic, immunohisto-chemical, and ultrastructural study of ten enucleated eyes with anterior proliferative vitreoretinopathy were performed in order to elucidate relevant pathogenetic mechanisms. Our findings suggest that the pathogenetic evolution of anterior proliferative vitreoretinopathy occurs in three consecutive stages: (1) traction on the ciliary body and peripheral retina induced by fibrocellular contraction of the vitreous base; (2) incorporation of tractionally denuded components of the ciliary body and peripheral retina into the fibrocellular membranes overlying the vitreous base; and (3) proliferation of the incorporated components and fibrovascular ingrowth from the uvea, the retina, or both, into the fibrocellular membranes. Tractional disruption of the epithelium of the ciliary body pars plicata and breakdown of the ciliary blood-aqueous barrier are the principal pathogenetic mechanisms of chronic intractable hypotony and the postvitrectomy fibrin syndrome in anterior proliferative vitreoretinopathy.

We studied the results of surgical excision of ten consecutive subfoveal choroidal neovascular membranes in ten patients with age-related macular degeneration. The criteria for surgical eligibility included the following: (1) a clearly identifiable subfoveal membrane occupying the entire foveal avascular zone, (2) a visual acuity of 20/200 or worse, (3) minimal subretinal hemorrhage, and (4) an associated exudative macular detachment. Six of the ten patients showed visual improvement at one-month and three-month follow-up visits and seven showed visual improvement by the six-month examination. All ten maculae remained attached without recurrence of subfoveal neovascular membranes throughout the follow-up period. These results suggested that surgical excision is a viable alternative to laser photocoagulation in patients with subfoveal neovascularization in age-related macular degeneration.

The Cryotherapy for Retinopathy of Prematurity Study demonstrated the benefit of intervention for threshold disease. The authors reviewed their experience with cryotherapy, investigating the questions of treatment for bilateral disease. Between 1985 and 1990, 71 eyes from 41 infants with threshold retinopathy of prematurity were treated. Of the 65 eyes with a minimum of 3 months follow-up, only 7 eyes (11%) progressed to stage 4, although an additional 8 eyes (13%) developed a posterior retinal fold. Although the overall results are comparable to those repeated by the Cryotherapy for Retinopathy of Prematurity Study, the authors recommend treating both eyes if they reach threshold, and treating the two eyes at the same sitting.

During the last two years, we performed vitreoretinal surgery on 37 eyes with retinal detachments and recurrent severe proliferative vitreoretinopathy in 37 patients who had had previous failed scleral buckling and vitreous surgery for proliferative vitreoretinopathy. Anterior proliferative vitreoretinopathy was present in 32 of 37 eyes (86%); posterior proliferative vitreoretinopathy of fixed retinal folds in four quadrants of narrow or closed funnel shape occurred in 23 of 37 eyes (62%); and subretinal proliferation was noted in 16 of 37 eyes (43%). The retinas in 12 eyes (32%) redetached from new or recurrent anterior proliferative vitreoretinopathy in nine eyes, reopening of pre-existing retinal breaks in two eyes, or recurrent posterior periretinal proliferation in one eye. With additional vitreoretinal procedures in six eyes and after a mean follow-up period of 11 months, 27 of 37 retinas (73%) were totally reattached, and an additional five eyes (13%) had retinal reattachment posterior to the scleral buckle. Of the 32 patients with posterior retinal reattachment, final visual acuity of 5/200 or better was attained in 19 eyes (59%).

Human recombinant tissue plasminogen activator (25 micrograms) was injected into seven eyes of six patients who had developed massive fibrin deposition after vitrectomy surgery for diabetes. Six eyes had developed pupillary membranes and recurrence of tractional retinal detachment from fibrin membranes, and one eye had developed only a pupillary membrane. All pupillary membranes resolved within one hour of administration of tissue plasminogen activator, and five tractional retinal detachments resolved within 24 hours. All eyes developed evidence of intraocular bleeding after tissue plasminogen activator injection. Subsequently, six of seven eyes developed recurrence of fibrin accumulation and tractional retinal detachment.

• Functional and anatomic success after relaxing retinotomy may be limited by recurrent retinal detachment or severe hypotony. Fifty-four consecutive eyes undergoing relaxing retinotomy for proliferative vitreoretinopathy (42 eyes) and trauma (12 eyes) were analyzed to determine whether perioperative factors, including size and location of the retinotomy, influenced visual or anatomic outcome. After 6 months' minimum follow-up, anatomic success (retina attached posterior to buckle and an intraocular pressure of 3 mm Hg or more) was achieved in 35 eyes (64%). Functional success (visual acuity of 5/200 or better) was achieved in 14 eyes (26%). Factors predicting functional success by stepwise logistic regression analysis included a preoperative visual acuity of hand motions or better and location of the retinotomy in the superior four clock hours of the fundus. Causes of anatomic failure included proliferative vitreoretinopathy (11 eyes) and severe hypotony or phthisis (8 eyes). Superior location of the retinotomy and visual acuity of hand motions or better favorably influenced visual outcome after relaxing retinotomy.

Purpose To report a case of Neisseria meningitidis endophthalmitis in association with a leaking filtering bleb and to consider antibiotic prophylaxis of those people with whom the patient had contact. Method We treated an 81-year-old man who had a chronic, leaking filtering bleb and who developed exogenous N meningitidis endophthalmitis. Result N meningitidis endophthalmitis was controlled with antibiotic therapy. Antibiotic prophylaxis for those with whom the patient had contact was not recommended. Conclusion In this case, the N meningitidis strain was not considered invasive because the bacteria apparently entered the eye through a leaky filtering bleb and not through the bloodstream. Recovery of noninvasive N meningitidis does not require prophylaxis for patient contacts. In cases of endogenous or idiopathic N meningitidis endophthalmitis, antibiotic prophylaxis of close patient contacts may be warranted.

Objective To investigate the efficacy of verteporfin and photodynamic therapy in the treatment of large retinal capillary hemangiomas. Methods Case reports of 3 patients with large retinal capillary hemangiomas treated with photodynamic therapy using verteporfin. Standard verteporfin dosages (6 mg/m 2 of body surface area) were given. Both standard and modified photodynamic protocols were followed. Modified protocols included shorter verteporfin infusion times and longer light exposure times. Results Pretreatment best-corrected Snellen visual acuity of the 3 affected eyes were 20/100, 20/50, and 2/200, respectively. All cases had associated exudative retinal detachments involving the macula. Cases 1 and 2 were classic endophytic retinal capillary hemangiomas. Case 3 was a reactive retinal capillary hemangioma. Case 1 had 2 photodynamic therapy treatments, and after 8 months, visual acuity improved to 20/40. Two years after initiating photodynamic therapy, the visual acuity was 20/30 and there was no reperfusion of the hemangioma. Case 2 had 3 photodynamic therapy treatments. The hemangioma was fibrotic, and 20 months after initiating photodynamic therapy visual acuity improved to 20/30. Case 3 had 1 treatment, 11 weeks later and visual acuity improved to 20/400. Four months after treatment, visual acuity returned to counting fingers because of tractional elevation of the macula as the capillary hemangioma fibrosed. Vitrectomy surgery was performed, and choroidal and retinal neovascularization was discovered. Three months after vitrectomy visual acuity was 20/400. In cases 1 and 2, the capillary hemangioma ultimately regressed, and the exudative detachment resolved. Conclusions Verteporfin and photodynamic therapy were effective in achieving closure of large retinal capillary hemangiomas. In all cases, the hemangioma underwent fibrosis with consequent macular puckering due to retinal traction. In all cases, the visual acuity improved.