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Four young male patients with keratoconus had traumatic dehiscence of the surgical wound after penetrating keratoplasty. Two were rendered aphakic by the trauma, and in one patient the lens was dislocated posteriorly. In each case the dehiscence was repaired by resuturing the original corneal graft. Despite marked corneal oedema in the immediate postoperative period all four grafts deturgesced and subsequently cleared. The follow-up has been a minimum of 23 months. We recommend therefore primary resuturing of traumatic wound dehiscence after keratoplasty, anterior vitrectomy if the lens dislodged, and prophylactic antibiotics postoperatively. The clearing of the initially oedematous grafts in each case illustrates the resilience of the corneal endothelium. [ABSTRACT FROM PUBLISHER]

Objective: To characterize 20 cases of retinal detachment (RD) following surgical repair of macular holes., Methods: Retrospective review of 20 eyes in 16 patients (4 patients [25%] had bilateral macular hole repairs with subsequent RD) who developed RD in the same eye in which surgical repair of a macular hole had been performed., Results: Twenty detachments in 16 patients were reviewed. The average duration between macular hole repair and presentation of RD was 5.5 weeks. The inferior retina was involved more frequently than the superior retina. A total of 76% of all breaks were located inferiorly. Ten of the 20 eyes were asymptomatic at the time the detachment was diagnosed. Of the 20 eyes, 19 underwent surgical repair, all with anatomic reattachment. At final follow-up, the macular hole was closed in all 20 eyes, and 60% of the patients had final visual acuity improved by 2 lines or more over that before their macular hole repair., Conclusion: Retinal detachment is a complication of macular hole surgery. These detachments tend to occur within the first 2 months of follow-up, and have a high success rate of anatomic reattachment with surgery. The occurrence of RD does not preclude improved final visual acuity.

Purpose: The differentiating characteristics in blebitis and early and late endophthalmitis after glaucoma filtration surgery are reviewed., Methods: All admission records and operative reports, as well as available office notes, on patients with blebitis or bleb-associated endophthalmitis admitted to a large referral eye center from 1985 to 1995 were reviewed retrospectively., Results: Ten cases of blebitis and 33 cases of bleb-associated endophthalmitis were identified. One patient with blebitis progressed to culture-positive endophthalmitis. Of the 33 cases of bleb-associated endophthalmitis, there were 6 cases of early endophthalmitis (before postoperative week 6) and 27 cases of late endophthalmitis. In early endophthalmitis, Staphylococcus epidermidis was isolated on vitreous culture in 4 (67%) of 6 cases, whereas in late endophthalmitis, this organism was isolated in only 1 (4%) of 27 cases. In the 27 late cases, Streptococcus species and gram-negative organisms comprised 48% of isolates; of 33 cases of endophthalmitis, 15 (45%) demonstrated no growth on vitreous culture. Patients with endophthalmitis fared more poorly than those with blebitis in terms of visual outcome., Conclusions: Because blebitis may be prodromal to endophthalmitis, aggressive antimicrobial therapy, perhaps with oral quinolones, is warranted. In addition, patients with blebitis should be observed closely to identify extension into the vitreous cavity so that intravitreous antibiotics can be administered in a timely fashion. Finally, clinicians should not extrapolate the results of the Endophthalmitis Vitrectomy Study to the postfiltration surgery endophthalmitis given the differing pathogenesis and unique spectrum of organisms.

We report three cases of uveal lymphoid neoplasia that were diagnosed early in their course. One case exhibited a posterior form, presenting with progressive hyperopia from a serous-macular detachment and choroidal involvement along with retrobulbar involvement. This patient was treated with proton beam irradiation. Two cases displayed an anterior form, with fixed fleshy epibulbar masses resembling salmon patches, and choroidal involvement. The histologic findings from biopsy of these anterior masses are presented. One of these patients was treated with complete excision of the mass and double freeze-thaw cryotherapy of the scleral bed, and the other patient was treated with conventional photon beam irradiation. The clinical features of uveal lymphoid neoplasia in its early form are discussed. Evaluation and treatment strategies for these early forms of uveal lymphoid neoplasia are reviewed.

Purpose: The purpose of this study is to assess the rate of posterior segment complications after vitreous surgery for macular holes and to evaluate the effect of such complications on final visual outcome., Methods: The authors reviewed retrospectively all cases of vitreous surgery for macular holes performed between June 1990 and October 1993. Among 98 patients with a followup of 3 months or more, all patients with posterior segment complications during the postoperative course were identified. The rate of complications was compared with that seen after vitreous surgery for macular pucker performed by the same surgeons., Results: Posterior segment complications were noted in 23 (23%) of 98 patients. These included peripheral retinal breaks (3%), rhegmatogenous retinal detachment from a peripheral retinal break (14%), enlargement of the hole (2%), late reopening of the hole (2%), retinal pigment epithelium loss under the hole (1%), photic toxicity (1%), and endophthalmitis (1%). In 40% of these eyes, the final visual acuity was two lines or more below preoperative visual acuity. When compared with the macular pucker group, the rate of posterior segment complications, in particular the rate of peripheral retinal tears and detachments, was significantly higher (P < or = 0.05)., Conclusions: The authors conclude that visually significant posterior segment complications may occur after vitrectomy for macular hole, and the rate of these complications appears to be higher than expected.

Purpose: This study, comprising 60 patients with coagulase-negative staphylococcal endophthalmitis which occurred after cataract surgery, was designed to define the variation in disease presentation and visual outcome and to evaluate statistically the role of the primary surgery and its management., Methods: An intensive evaluation of microbiological, inpatient, outpatient, and cataract surgery charts was made retrospectively using a standardized protocol. The predictive value of surgical, iatrogenic, and clinical factors was analyzed for their influence on defined aspects of the disease pattern and of the visual results using multiple regression models, via a stepwise technique., Results: There was commonly a significant asymptomatic latent period after cataract surgery. The median diagnostic delay was 7 days; 22% of patients presented after 2 weeks and 12% after 1 month. Symptoms progressed longer than 3 days in 25% of patients. Ten percent had no pain. Clinical variation proved largely unrelated to cataract surgery events and postoperative management; bacterial factors were implicated. Good visual outcome was associated statistically with intensive topical corticosteroid in the symptomatic period, but was negatively associated with operative subconjunctival corticosteroid., Conclusions: The clinical variation in cases of postoperative coagulase-negative staphylococcal endophthalmitis poses particular problems for diagnosis in the outpatient setting. Surgical and perioperative events (except corticosteroid use) probably can be disregarded in studies of endophthalmitis management.

The authors conducted a retrospective review of 32 patients with posterior retinal folds following retinal reattachment surgery. Twenty-eight of these patients underwent combined pars plana vitrectomy, fluid-air exchange with either internal drainage through a preexisting retinal break or external drainage of subretinal fluid, and scleral buckle. We believe these drainage techniques resulted in incomplete elimination of subretinal fluid, with resultant sequestration of fluid at the dependent border between attached and detached retina. Metamorphopsia and decreased visual acuity were noted in patients with folds involving the macula. The likelihood of fold formation may be greatly reduced by internal drainage through a posterior retinotomy combined with more complete removal of slowly gravitating fluid as it flows dependently to the drainage site.

Purpose: The coagulase-negative staphylococci are the most common causes of postoperative endophthalmitis. This study investigates the variability in the disease spectrum and visual outcome of coagulase-negative staphylococcal endophthalmitis in a large, single-center series., Methods: Ninety consecutive cases of coagulase-negative staphylococcal endophthalmitis were investigated retrospectively from two time periods, 1978 to 1982 and 1985 to 1987, separated by a transitional period in cataract surgery technique. Using a detailed protocol, inpatient, outpatient, and microbiologic records were analyzed. Six-month visual acuity results were obtained., Results: Diagnosis frequently was delayed, often suspected only after hypopyon development. Thirty-seven percent of patients presented more than 1 week after the inoculating event, and 13% presented after more than 1 month. Variable asymptomatic intervals and gradually worsening inflammatory prodromes are noted. Painless endophthalmitis occurred in 16%. Non-epidermidis infections comprised 28%. With vitrectomy/intraocular antibiotic management, 38% and 68% achieved visual acuities of 20/50 and 20/400, respectively. Overall, 10% of patients developed late retinal detachments. This occurred in only 4% of patients, with endophthalmitis occurring after cataract surgery., Conclusion: Ophthalmologists should become familiar with the emerging concepts of delayed-onset, chronic, and often painless endophthalmitis in which the coagulase-negative staphylococci play a prominent role.

The clinical source of 62 eyes that had been coded for macular degeneration and fibrovascular retinal pigment epithelial (RPE) detachment on fluorescein angiography was reviewed; 17 eyes had signs of a choroidal neovascular membrane (CNVM) at initial examination, and 30 eyes developed a definite CNVM during follow-up examination. Thus, 47 of the 62 eyes (76%) developed a CNVM in association with fibrovascular RPE detachments. Features of fibrovascular RPE detachments include: 1) focal, tiny hyperfluorescent spots at the level of the RPE arising in the mid and late frames of the angiogram, which do not correspond to drusen or foci of depigmentation (stippled hyperfluorescence); 2) intensification of these spots in the later stages of the angiogram; 3) slight enlargement of the spots in the late frames of the angiogram; 4) occasional presence of scant overlying subretinal fluid; and 5) minimal elevation of the RPE. Fibrovascular RPE detachments appear to be a distinct form of an RPE detachment. It is concluded that this sign is associated with a high risk of developing a frank CNVM and is thus a reliable indicator of occult neovascularization.

Fifty-one eyes of 48 patients with perforating (through-and-through) injuries of the globe were treated with vitrectomy during a 12-year period. Functional success was obtained in 32 eyes (63%), anatomic success was obtained in nine eyes (17%), and treatment failed in 10 eyes (20%). In 16 eyes (32%), 20/20 to 20/100 visual acuity was obtained; in 17 eyes (33%), 20/200 to 5/200 visual acuity was obtained; and in 18 eyes (35%), less than 5/200 visual acuity was obtained. The mechanism of injury was an important prognostic indicator of final visual outcome. Eight (62%) of 13 eyes that sustained knife or nail injuries achieved a final visual acuity of 20/50 or better, while only six (16%) of 38 eyes [corrected] with missile injuries achieved a similar level of acuity. Final visual outcome correlated well with the state of the macula and was not predicted by preoperative visual acuity. Despite improvement in surgical techniques and instrumentation, no trend toward improved visual outcomes was identified during the 12-year period.

Five patients presented with vision-threatening retinal tumors and systemic signs of neurofibromatosis, including neurofibromatosis type 1 (four patients) and familial cafe-au-lait spots (one patient). These tumors included large retinal astrocytic hamartomas, multiple retinal capillary hemangiomas, and combined hamartomas of the retina and retinal pigment epithelium, which resulted in rubeotic glaucoma, vitreous hemorrhage, and retinal detachment. Surgical therapy included retinal cryopexy, xenon and argon photocoagulation, scleral buckling, and pars plana vitrectomy with excisional retinal biopsy. Retinal tumors may result in marked visual loss in patients with neurofibromatosis, and vitreoretinal surgery may restore useful vision in some of these patients.

Histologic specimens from 32 human eyes that had been enucleated at different intervals after servere injuries were studied. Following the rules of general wound repair, intraocular proliferations start two to four days after the injury and may be massively developed within one week after injury. Their cell composition and extent are related to the site and extent of tissue damage and the amount of hemorrhage. The findings support the recommendation of a primary vitreous repair in severely injured eyes.

Transmission electron microscopy studies of cornea, iris and lens from a case of ocular siderosis due to a retained intraocular foreign body (IOFB) and vitreous hemorrhage are presented. We observed widespread degeneration of lens epithelium, iris stromal cells and iris pigment epithelium associated with intra- and extracellular siderosomes. A direct relationship was found between the degree of cell degeneration and the number of intracellular siderosomes in lens epithelium. This is contrary to findings in other siderotic tissues which show intracellular iron deposition to be associated with increased ability to detoxify iron. The cornea showed siderosomes only within keratocytes, and there was no evidence of a relationship between siderosome accumulation and cell degeneration. The literature on ultrastructural studies of ocular siderosis is reviewed and the current theory of the mechanism of chronic iron toxicity is discussed.

A reproducible model of double perforating injury of the posterior segment of the rabbit eye was developed. Immediately after injury, a viterous condensation was visible between wounds. The scleral exit wound was sealed by fibroblastic proliferation of probable episcleral origin by the fourth day and the entrance similarly by the seventh day. Cellular proliferations originating in the wounds crossed the vitreous cavity following the vitreous injury tract or condensed vitreous to the disc or to the vitreous base. The earliest intraocular proliferations, composed of spindle-shaped, fibroblast-like cells, were seen at day 4. Occasional pigment epithelia were present in and on these proliferations. Other proliferations occurred directly on the retinal surface adjacent to the wounds. The transvitreous proliferations employed the vitreous as a scaffold, while the surface proliferations used the retinal surface for contact guidance.

One hundred eyes in 98 patients were studied by fluorescein angiography and stereo color photography six weeks after successful scleral buckling surgery. Twenty-five percent of 67 phakic eyes and 40% of 33 aphakic eyes demonstrated cystoid macular edema. Older phakic patients were at significantly greater risk to develop cystoid macular edema than younger phakic patients. Seventeen percent of successfully repaired eyes demonstrated distortion of the macula by preretinal membranes; 16 of these 17 eyes showed leakage of fluorescein dye into the surrounding retina sometimes also causing cystoid edema. Either cystoid macular edema or macular distortion was present in 38% of the phakic eyes and 64% of the phakic eyes after successful retinal detachment surgery.

Of 106 eyes with trauma involving the posterior segment, 12 could not be repaired, 74 were treated with vitrectomy, and 20 without vitrectomy. Fifty-five eyes (52%) achieved functional success (defined as a final visual acuity of 6/30 [20/100] or better or as a postoperative improvement in visual acuity from light perception or worse to 6/240 [5/200] or better), 16 (15%) attained anatomic success (attached retinas and generally clear media) but were functional failures, and 35 (33%) were both anatomic and functional failures. The prognosis was better in cases with intraocular foreign bodies and worse in cases with retinal detachments, marked vitreous hemorrhage, and large scleral lacerations. Traumatic involvements of the lens did not appear to affect the prognosis. Prophylactic scleral buckling appeared to lessen the incidence of postoperative retinal detachment. The eyes that underwent vitrectomy within 14 days of the injury had a better final visual outcome than those that underwent later vitrectomy.

Eighteen patients with endophthalmitis involving anaerobic bacteria are presented. Endophthalmitis followed cataract surgery in seven patients, penetrating trauma in six, a corneal graft in two, and an infected filtering bleb in two; there was one case of endogenous endophthalmitis. Propionibacterium acnes was the most frequent anaerobe isolated (78% of cases). Thirty-two percent of the patients had polymicrobial infection with mixed aerobic and anaerobic species. Six cases of acute P. acnes endophthalmitis were clinically indistinguishable from other cases of mild to moderately severe endophthalmitis. Four patients presented, after cataract surgery, with chronic, low-grade endophthalmitis of 1 to 15 months' duration, emphasizing that "sterile" endophthalmitis cannot be satisfactory diagnosed clinically. The visual prognosis of treated P. acnes endophthalmitis was often good. Based on principles of anaerobic microbiology, recommendations are made for vitreous collection, transport, and culture.

Perforating injuries were produced in the posterior segments of rabbit eyes. A control group had no surgery; a second group underwent closed vitrectomy immediately after injury; and a third group had closed vitrectomy delayed two weeks following injury. The eyes were then observed for four weeks. Transvitreal proliferation, which was found in each of the control eyes, was effectively prevented in the eyes that underwent immediate vitrectomy. Established transvitreal proliferation was removed and its recurrence prevented by delayed vitrectomy. These results establish the principle that vitreous acts as a scaffold for proliferation. Removal of the vitreous eliminates the structures along which proliferation can occur and thus effectively prevents transvitreal proliferation. Early removal of vitreous in severely injured eyes with vitreous damage is recommended.