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The Branch Vein Occlusion Study is a multi-center, randomized, controlled clinical trial designed to answer several questions regarding the management of complications of branch vein occlusion. This report discusses the question, "Is argon laser photocoagulation useful in improving visual acuity in eyes with branch vein occlusion and macular edema reducing vision to 20/40 or worse?" One hundred thirty-nine eligible eyes were assigned randomly to either a treated or an untreated control group. Comparing treated patients to control patients (mean follow-up 3.1 years for all study eyes), the gain of at least two lines of visual acuity from baseline maintained for two consecutive visits was significantly greater in treated eyes (P = .00049, logrank test). Because of this improvement in visual acuity with argon laser photocoagulation of macular edema from branch vein occlusion, we recommend laser photocoagulation for patients with macular edema associated with branch vein occlusion who meet the eligibility criteria of this study.

Purpose To describe the ocular presentation of disseminated mycobacterial disease occurring during immune-recovery in a patient with acquired immune deficiency syndrome (AIDS). Study design Case report and literature review. Participants A 41-year-old AIDS patient with a prior diagnosis of cytomegalovirus retinitis. Methods The patient developed progressive, bilateral multifocal choroiditis with panuveitis 2 months after beginning and responding to highly active antiretroviral therapy. His left eye became blind and painful and was enucleated. Pathologic examination revealed massive choroiditis with well-formed, discrete granulomas and multiple intracellular and extracellular acid-fast organisms within the choroidal granulomas. Culture and polymerase chain reaction of vitreous specimens revealed Mycobacterium avium complex (MAC). Results Empiric, and later sensitivity-guided, local and systemic antibiotic therapy was used to treat the remaining right eye, but it continued to deteriorate. Despite medical therapy, three vitrectomies and repeated intravitreal injections of amikacin, a total retinal detachment ensued. One week after the third vitrectomy, the patient died from mesenteric artery thrombosis in the setting of disseminated mycobacterial disease. Conclusions This is the first report of ocular inflammation as the presenting finding in the recently recognized syndrome of immune-recovery MAC disease. Pathogenesis of this entity is related to an enhanced immune response to a prior, subclinical, disseminated infection. The formation of discrete granulomas, normally absent in MAC infections in AIDS, reflects this mechanism.

Purpose: The authors determine if specific features of the clinical presentation of acute postoperative endophthalmitis correlate with the microbiologic culture results. Methods: A total of 420 patients who had clinical evidence of endophthalmitis within 6 weeks after cataract surgery or secondary intraocular lens implantation were evaluated as part of a randomized clinical trial. Results of cultures performed on aqueous and vitreous specimens obtained at presentation were categorized as follows: gram-positive coagulase-negative micrococci, "other" gram-positive, gram-negative, and equivocal/no growth. Results: Eleven features of the initial clinical presentation were associated with significant differences in the microbiologic spectrum ( P Conclusions: The presenting characteristics of acute endophthalmitis after cataract surgery may be helpful in predicting the most likely culture results. Such predictions do not appear sufficiently strong to guide the initial empiric choice of intravitreal antibiotics.

A 59-year-old Oriental male with chronic uveitis associated with vitiligo, poliosis, tinnitus and sunset glow fundus was diagnosed as having chronic Vogt-Koyanagi-Harada syndrome. He was treated successfully with steroids (systemic and sub-Tenon's) for two years, but then developed intractable vitritis and visual loss that worsened with the addition of azathioprine. A vitreous biopsy showed large B-cell lymphoma; a mass was also apparent in the subretinal space in the operated eye. Evaluation of the central nervous system was negative for lymphoma. Combined radiation treatment and chemotherapy resulted in dramatic resolution of the intraocular tumor. The possible role of immunosuppression in the development and progression of this tumor is discussed.

Although several recent papers have focused on the results of cataract surgery in patients with uveitis, little has been published on specific surgical techniques that are most appropriate to such cases. We have found that a combined anterior and posterior approach using extracapsular techniques (usually phacoemulsification) and pars plana vitrectomy, with or without intraocular lens placement, is best suited for selected uveitis patients who have cataract, vitreous opacities, and cystoid macula edema. This paper discusses the surgical techniques that we have found to be best for the management of these cases.

Background Endogenous fungal endophthalmitis (EFE) is a rare intraocular infection that has recently increased in incidence over the last few decades. The most common causative organism of endogenous endophthalmitis is Candida albicans. Treatment generally is initiated with an antifungal drug systemically and, depending on the ocular findings, may also include a vitrectomy with the injection of an intraocular antifungal agent. Specific predisposing factors may make a patient more at risk for development of an ocular infection. Case report We present a case of presumed Candida endogenous endophthalmitis in an 83-year-old white man with a Candida albicans urinary tract infection and describe the general characteristics, treatment, and management of this condition. Conclusion Endogenous fungal endophthalmitis is a potentially blinding condition that can signal an underlying systemic infection. Without a dilated fundus examination in the presence of ocular inflammation, the condition easily can be misdiagnosed. Fungal infection may lead to retinal and vitreal lesions that can be visually debilitating if left untreated. Prognosis for visual outcome is dependent on timely diagnosis and initiation of treatment.

To describe the ocular presentation of disseminated mycobacterial disease occurring during immune-recovery in a patient with acquired immune deficiency syndrome (AIDS).Case report and literature review.A 41-year-old AIDS patient with a prior diagnosis of cytomegalovirus retinitis.The patient developed progressive, bilateral multifocal choroiditis with panuveitis 2 months after beginning and responding to highly active antiretroviral therapy. His left eye became blind and painful and was enucleated. Pathologic examination revealed massive choroiditis with well-formed, discrete granulomas and multiple intracellular and extracellular acid-fast organisms within the choroidal granulomas. Culture and polymerase chain reaction of vitreous specimens revealed Mycobacterium avium complex (MAC).Empiric, and later sensitivity-guided, local and systemic antibiotic therapy was used to treat the remaining right eye, but it continued to deteriorate. Despite medical therapy, three vitrectomies and repeated intravitreal injections of amikacin, a total retinal detachment ensued. One week after the third vitrectomy, the patient died from mesenteric artery thrombosis in the setting of disseminated mycobacterial disease.This is the first report of ocular inflammation as the presenting finding in the recently recognized syndrome of immune-recovery MAC disease. Pathogenesis of this entity is related to an enhanced immune response to a prior, subclinical, disseminated infection. The formation of discrete granulomas, normally absent in MAC infections in AIDS, reflects this mechanism.

Objective: To correlate the initial echographic findings in eyes with infectious endophthalmitis with the visual prognosis and causative microorganism. Design: A retrospective review of the clinical and standardized ocular echographic findings in eyes with infectious endophthalmitis was performed. Setting: University-based ophthalmology department. Study Participants: One hundred thirty-seven eyes (136 patients) with infectious endophthalmitis that were evaluated by the ocular echography service of the Doheny Eye Institute, Los Angeles, Calif, between January 1, 1981, and December 31, 1992. Results: Four findings on initial echography were associated with poor initial vision: dense vitreous opacities, retinal detachment, macular detachment, and choroidal detachment. Five findings on initial echography correlated with poor final vision: dense vitreous opacities, vitreous membranes, the presence of retinal detachment, the extent of retinal detachment, and the presence of choroidal detachment. Change (decrease) in vision during the follow-up period was associated with the presence of combined vitreous and subhyaloid opacities, retinal detachment, and choroidal detachment. All eyes with initially clear vitreous on ocular echography had either early streptococcal or culture-negative endophthalmitis. Advanced streptococcal endophthalmitis correlated with the most severe vitreous inflammation, vitreous membranes, and the most extensive posterior vitreous detachment, whereas gram-negative endophthalmitis correlated with choroidal detachment on initial echography. Stepwise logistic regression analysis revealed that the presence of choroidal detachment, not gramnegative microorganisms, was the principal predictor of poor visual outcome in these eyes. Conclusion: Ocular echography is a useful method in the clinical evaluation and treatment of infectious endophthalmitis, especially in eyes with opaque media.

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

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

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

A retrospective study of 18 eyes in 17 patients with rhegmatogenous retinal detachments after neodymium-YAG laser posterior capsulotomy was performed to determine operative settings and to describe anatomic changes after the procedure in an effort to assess their relationship to subsequent retinal detachment. The laser energy required to create a capsulotomy did not appear to be excessive and the capsulotomy openings were not unusually large. The time between YAG capsulotomy and diagnosis of retinal detachment ranged from four to 82 weeks (mean, 28 weeks). The characteristics of the retinal detachments were similar to those after routine cataract extraction. Retinal reattachment surgery was ultimately successful in all 18 eyes. Both YAG laser and knife-needle posterior capsulotomies may increase the risk of subsequent rhegmatogenous retinal detachment as a result of opening the capsule.

Ten moderately myopic women had blurred vision, light flashes, or paracentral scotomas associated with small yellow-white lesions of the inner choroid and pigment epithelium. Most lesions had an overlying serous detachment, were hyperfluorescent, and leaked fluorescein during the acute phase. The lesions healed into atrophic scars and became progressively more pigmented with time. Subretinal neovascular membranes later developed from scars in six patients. Vision was usually only minimally affected unless the lesions were subfoveal or unless choroidal neovascular membranes subsequently occurred. Extensive laboratory studies were noncontributory.

The effect of intraocular liquid silicone on the electroretinogram (ERG) and on retinal morphology was studied in rabbits. After vitrectomy, liquid silicone (1000 centistokes) or balanced salt solution (BSS) was injected into the eyes. The intraocular silicone was well tolerated clinically in all eyes that were followed over a period of 3 days to 6 months. ERG responses were equivalent in operated control and silicone-injected eyes. Light and electron microscopy showed slight but comparable changes in both operated control and silicone-injected eyes that were consistent with either fixation artifact and/or surgical trauma. The results suggest that exposure to silicone for up to 6 months does not have a toxic effect on the rabbit retina.

Three hundred sixty-six cases of branch vein occlusion entered within the multicenter Branch Vein Occlusion Randomized Clinical Trial have been reviewed. Four cases that developed retinal neovascularization outside of the retinal area involved with the occlusion have been documented by photography and fluorescein angiography.

Two Hispanic patients with Vogt-Koyanagi-Harada (VKH) syndrome each developed a disciform lesion involving the macula of one eye several months after the onset of symptoms. Each had extraocular manifestations which included pleocytosis of the cerebrospinal fluid. The disciform lesions were associated with retinochoroidal anastomoses, a finding not previously reported in VKH syndrome. Each patient had a separate extramacular disciform lesion in the same eye. Two other Hispanic patients with diffuse bilateral intraocular inflammation had ocular findings consistent with VKH syndrome. One of these patients developed bilateral peripapillary disciform lesions and the other developed a disciform macular scar in one eye. Fluorescein angiography in each patient showed early irregular hyperfluorescence with late intense staining. The disciform detachments occurred in areas of reactive proliferation of the retinal pigment epithelium, and we postulate that growth of subretinal new vessels occurred through areas of Bruch's membrane that were damaged by the inflammation.

A 15-year-old black girl had acute bilateral uveitis and other features of the Vogt-Koyanagi-Harada syndrome. Several months after the onset of her illness, she developed acquired retinal arteriovenous anastomoses in both eyes. By using fluorescein angiography, we documented that the anastomoses were collateral vessels developing in areas of damaged retinal pigment epithelium and retinal capillaries.

The clinical and pathological findings of an infant with severe, bilateral hemorrhagic retinopathy and unilateral retinal detachment are presented. Acceleration-deceleration forces may have caused the ocular damage in the absence of significant direct trauma to the head or eyes. This mechanism may account for injuries inflicted by physical child abuse, but without the usual associated findings of this syndrome.

We used new applications for a pars plana infusion cannula in three patients with retinal and choroidal detachments. Because the cannula maintained intraocular volume and form, it was helpful in treatment bullous retinal detachment and choroidal detachment.

Proliferative vitreoretinopathy occurred in three of seven cases of ocular perforation from retrobulbar injection, resulting in a visual acuity of 20/200 or worse. Direct macular injury and macular pucker occurred in two cases each. Needle injury exit sites were in the posterior pole in all cases. Predisposing factors were not experimentally verified, but associated conditions included axial myopia, multiple injections, traditional superonasal gaze position, previous retinal buckling procedure, and enophthalmos.

A 32-year-old male sustained a dense vitreous hemorrhage following a scleral buckle procedure for a traumatic retinal detachment in his right eye. The bright-flash ERG was nonrecordable on two occasions. At pars plana vitrectomy, a dense vitreous hemorrhage was removed, and the retina was noted to be attached. The patient sub-sequently regained good vision with progressive recovery of the ERG over several months. Although a nonrecordable bright-flash electroretinogram is usually a reliable indication of a detached or severely impaired retina, recordings should be interpreted with caution in cases of dense vitreous hemorrhage, particularly if ocular penetration has occurred.

Twenty-three patients had bilateral intraretinal talc microemboli, which were seen on ophthalmoscopic examination. Twelve of these patients had additional retinal vascular or choroidal abnormalities in the posterior pole that were confirmed by fluorescein angiography. Six patients had peripheral retinal neovascularization associated with peripheral retinal vascular nonperfusion. Of these six patients, three had associated vitreous hemorrhage, and two had optic disk neovascularization and traction retinal detachment. The progressive fundus changes seen in talc retinopathy were documented by fluorescein angiography and compared to those seen in sickle-cell retinopathy. One eye in one patient was treated by argon laser photocoagulation for proliferative retinopathy, and three eyes in two patients with vitreous hemorrhage were treated by pars plana vitrectomy.

We developed and evaluated clinically a series of three vitreoretinal dissection instruments with a constant-diameter shaft and various tip designs including a 90-degree hooked tip, a 130-degree hooked tip, and a blunt-tip right-angle spatula. The instruments, manufactured from a titanium alloy, are lightweight and glare resistant. We have used these instruments interchangeably with other vitreous surgery instruments introduced through a 20-gauge sclerotomy. They facilitate delicate manipulations associated with separation of epiretinal membranes from the inner retinal surface.

A 37-year-old black man had a clinically documented case of optic disk neovascularization associated with hemoglobin SC disease. Through medical evaluation, we ruled out other disorders associated with proliferative retinopathy. Extensive areas of retinal nonperfusion were associated with vasoproliferative retinopathy at the junction of the perfused and nonperfused retina; and a delicate network of neovascularization extended from the optic disk into the vitreous gel in one eye.

We used closed-eye endosurgery to treat 58 patients with anterior segment problems. These included nonsenile cataract, residual lens material, pupillary membranes, vitreocorneal touch, aphakic pupillary block glaucoma, intraocular lens complications, epithelial ingrowth, and total hyphema. Thirty-five eyes showed an increase in visual acuity of more than two Snellen lines, 13 eyes demonstrated no change, and ten eyes lost more than two lines. Complications included endophthalmitis, retinal detachment, retinal tears, increased intraocular pressure, postoperative hemorrhage, and bullous keratopathy.