Faculty Bibliography

PURPOSE/OBJECTIVE:To determine the intraocular tolerance of perfluorooctylbromide (perflubron) in vitrectomized rabbit and pig eyes and evaluated its use as a vitreous substitute in virteoretinal surgery. METHODS:Pars plana vitrectomy was performed on 33 Dutch pigmented rabbits and 11 micro mini pigs. After vitrectomy the eyes were filled with perflubron for 2 hours, 1 week, 2 weeks, 1 month, and up to 6 months. RESULTS:No clinical, electroretinographic, or light and electron microscopic evidence of adverse effects on the retina and lens were observed. Perflubron emulsified and dispersed into small bubbles after 2-3 weeks. The lens showed mild posterior subcapsular cataracts in pig eyes after long-term retention of perflubron. CONCLUSION/CONCLUSIONS:These findings indicate that perflubron is safe for intraoperative and for long-term use intravitreally. However, emulsification and the breakdown into small bubbles limits the view of the retina when perflubron is used as a long-term tamponade.

Acute retinal necrosis (ARN) is generally a progressive retinitis, often complicated by retinal detachment and a poor visual outcome. A series of 12 consecutive patients (13 eyes) with ARN is reported. All patients were examined early, with a limited extent of disease (in 77% of the eyes, less than 25% of retina involved). Patients were treated with high-dose intravenous acyclovir (10 mg/kg every 8 hours) and laser photocoagulation. During a follow-up period of 3 to 21 months, only 1 patient developed a rhegmatogenous retinal detachment resulting in visual loss. No patients developed bilateral disease once intravenous antiviral therapy was begun. Final visual acuity was 20/40 or better in 6 eyes (46%), and 20/400 or better in 12 eyes (92%). Two patients were examined within 6 weeks of extracapsular cataract extraction with intraocular lens implantation. In the majority of the cases, clinical findings were limited to several quadrants of the peripheral retina. Eyes with limited disease, if aggressively treated, have a relatively good visual prognosis.

Cytomegalovirus (CMV) retinitis has been well documented in the literature, both in patients with acquired immune deficiency syndrome (AIDS) and in other immunocompromised hosts. The clinical and histopathologic findings in three patients with AIDS and CMV retinitis are presented. In areas of healed retinitis, focal, yellow-white, plaque-like lesions and small refractile retinal lesions were noted clinically. Histopathologic studies confirmed the plaque-like lesions to be intraretinal calcifications. Detailed clinical pathologic correlation between fundus photographs and histologic material is made and its clinical importance discussed.

PURPOSE/OBJECTIVE:To analyze a phenomenon seen in patients with acquired immune deficiency syndrome (AIDS) with cytomegalovirus (CMV) retinitis undergoing systemic antiviral treatment: a persistent white border opacification on the edge of healed CMV retinitis. PATIENTS AND METHODS/METHODS:The authors prospectively evaluated a population of 137 patients with AIDS and CMV retinitis during a 44-month period. Eleven patients (12 eyes) who were undergoing maintenance antiviral treatment were identified with an atypical healing response--the persistence of a white flat border opacification that did not advance for many weeks to months. Patient records and photographs were reviewed. Results of one autopsy were analyzed with histopathology and special stains. RESULTS:The persistent white edge maintained (without advancement or smoldering) for an average of 11.6 weeks (range, 4 to 41 weeks). This border opacification was not affected by reinduction treatment in the six patients to whom reinduction was given. Results from histopathologic examination of one patient with a persistent white border are presented: these results show that dead cytomegalic cells formed stable structures within the retina, causing white opacification that could be confused with active lesions. Immunoperoxidase stains identified CMV antigens. CONCLUSION/CONCLUSIONS:This persistent white border opacification, which does not advance or smolder, represents an important clinical entity that should be recognized during antiviral treatment for CMV retinitis. It can often be observed. If it is not recognized as a stable configuration, patients may undergo unnecessary reinductions with potentially toxic doses of antiviral medications.

The authors performed retinal reattachment surgery in 29 eyes of 24 patients with acquired immune deficiency syndrome virus with retinal detachment associated with cytomegalovirus (CMV) retinitis and documented the course of eight additional untreated eyes. Retinal detachment repair using vitrectomy, posterior hyaloid removal, and intraocular tamponade with silicone oil or SF-6 gas resulted in a total retinal reattachment rate of 76% and a macular attachment rate of 90% in one operation. The mean postoperative visual acuity (best corrected) was 20/60, but, in some patients, the visual acuity decreased because of progressive retinitis. Prophylactic laser photocoagulation of fellow eyes to surround CMV lesions did not appear to prevent retinal detachment. The mean postoperative survival was 37 weeks (range, 8 to 127 weeks). The surgical techniques used and pathophysiology of these retinal detachments are discussed.

Patients with human immunodeficiency virus infection may have noninfectious and infectious retinopathies, as well as clinical symptoms consistent with optic nerve dysfunction. Noninfectious acquired immunodeficiency syndrome-related retinopathy is seen in most patients with AIDS. Morphologic studies have shown that the number of retrobulbar optic nerve fibers in patients with AIDS is decreased compared to the number of optic nerve fibers in normal control eyes. To determine whether these patients had a visual dysfunction consistent with damage to the macula and optic nerve, 78 subjects (156 eyes) were studied using color-vision and contrast-sensitivity testing. The Farnsworth-Munsell 100-Hue color-vision test was performed on all subjects and age-corrected color-vision scores for all groups were compared. A significant decrease in color discrimination was found in the patients with AIDS (P less than .001). Contrast-sensitivity testing disclosed a deficit of contrast threshold in patients with AIDS at four of five spatial frequencies and in patients with AIDS-related complex at three of the five spatial frequencies examined. This study demonstrated a functional visual deficit in eyes without retinitis consistent with dysfunction of the macula or optic nerve in patients with AIDS.

The role of repeat argon laser trabeculoplasty (RALT) in the management of open-angle glaucoma is controversial. To determine the long-term efficacy of RALT, the authors reviewed case records of 44 patients (50 eyes) who received RALT for uncontrolled glaucoma at the Wills Eye Hospital before 1986. Success was defined as a 3 mmHg or greater decrease in intraocular pressure (IOP) to less than 22 mmHg, and no further surgical intervention. By life table analysis, RALT was successful in 35% of eyes at 6 months, in 21% at 12 months, in 11% at 24 months, and in 5% at 48 months. Thirty-three percent of eyes in which primary ALT was successful for 1 year were successful 12 months after RALT. Complications included IOP spikes in 12%. In conclusion, RALT was generally not effective for long-term control of open-angle glaucoma, but may be useful as a temporizing measure. However, this use of RALT must be weighed against the risks of complications and the additional progression of disease before more definitive surgical intervention.

Serious complications of radial keratotomy are infrequent, but include: iridocyclitis, microbial keratitis, endophthalmitis, corneal perforation, and traumatic wound rupture. We report a case of retinal detachment following microperforation during radial keratotomy.