Endoretinal biopsy in immunosuppressed and healthy patients with retinitis. Indications, utility, and techniques

Endoretinal biopsies were taken using pars plana vitrectomy techniques in 13 eyes with inflammatory or infectious retinitis complicated by retinal detachment (RD). The surgical technique has evolved over a 4-year period. The authors review the surgical technique including techniques of removal of the vitreous, appropriate hemostasis, selection of the biopsy site, and atraumatic removal of the tissue from the vitreous cavity. Careful processing of the material for histopathology, immunopathology, and electron microscopy is necessary and has provided useful information in patient diagnosis and management. The authors have used the technique in cases of rhegmatogenous RD complicating presumed viral retinitis. The technique has proven to be useful in confirming the clinical diagnosis and is relatively safe when used in selected cases.     

Combined phacoemulsification, foldable intraocular lens implantation, and 25-gauge transconjunctival sutureless vitrectomy

We describe a technique for combined cataract and vitreoretinal surgery using a 25-gauge transconjunctival sutureless vitrectomy system. This technique was successfully performed in 20 consecutive cases. Outcomes were assessed in terms of visual acuity, intraocular pressure, postoperative refractive error, and incidence of complications. The technical feasibility, rationale, and advantages and disadvantages of this technique are discussed.     

The pterygium, Autologous conjunctiva-limbus transplantation as treatment]

Based on a new concept of the limbus as a junctional zone for separating the vascularized conjunctiva from the avascular cornea, this study presents conjunctival/limbal autograft transplantation for 22 cases of pterygium. The pterygia were primary in 17 eyes, cicatricial in 1 and recurrent in 4. In all cases a free transplant of the superotemperal limbus with an adjacent piece of thin conjunctiva was placed in the excision area. Postoperative follow-up ranged from 1 1/2 to 17 months, with a mean of 8.7 months. Only two pterygia recurred. In all other cases ideal anatomic reconstruction was achieved without any side effects. The authors believe that conjunctival/limbal transplantation is an encouraging technique for treating a pterygium surgically.     

Anti-retinal auto-antibodies in Vogt-Koyanagi-Harada syndrome, Behcet's disease, and sympathetic ophthalmia

Sera of patients diagnosed as having the active Vogt-Koyanagi-Harada (VKH) syndrome, Behcet's syndrome or sympathetic ophthalmia as well as normal controls were evaluated by ELISA and by staining of normal human retinal tissue using the avidin-biotin-peroxidase complex (ABC) technique for anti-retinal antibodies. No anti-retinal S-antigen antibodies were detected by ELISA. However, autoimmune antibodies were found against the outer segments of photoreceptors and Müller cells in patients with the VKH syndrome, with lower titers in some patients with Behcet's syndrome, and in a few patients with sympathetic ophthalmia. These results suggested anti-retinal antibodies were present and that retinal autoimmunity may play a role in pathogenesis in varieties of posterior uveitis. In addition, the indirect immunoperoxidase staining technique may facilitate the diagnosis of VKH in uncertain cases.     

Preserving injured lenses by microsurgical management of capsule wounds. Indications, technic, results and problems

Following perforating injuries the lens may, in rare cases, heal up with only local scarring and otherwise normal transparency. An analysis of 83 consecutively treated lens injuries and extensive experimental research have shown that this favorable course is so rare in man because the posttraumatic secretion of fibrinogen into the anterior chamber is usually insufficient. However, this can now be substituted by microsurgical treatment of the capsular lesion, including closure with human fibrinogen tissue adhesive. The method was tested on more than 200 isolated human lenses and has been applied clinically since 1982. The microsurgical procedure, including the fibrinogen application technique, is briefly described. Three cases, treated for anterior capsule injuries and through-and-through perforation of the lens, respectively, and followed up for several years, are presented. This is followed by a compilation of results in the first 31 consecutively treated patients. Among the 12 cases of anterior capsule perforation, 7 healed with acceptable visual acuity (1.0 to 0.3) even in this first series. In a total of 19 through-and-through perforations, there were only 2 good results in the first consecutive series of 15 with the method originally used. It was therefore decided to switch to translental fibrinogen application in such cases; in the following 4 patients anterior and posterior capsule wound healing and fairly good visual acuity were achieved with this technique. While the time interval between the trauma and treatment of the injury is important, the tendency toward spontaneous healing, though insufficient in the subsequent course, helps to overcome the first few hours and sometimes even days following the accident.(ABSTRACT TRUNCATED AT 250 WORDS)     

Luxación posterior bilateral del cristalino en una paciente agitada, ¿causa o consecuencia?

Complete posterior lens dislocation is an infrequent clinical entity. Trauma is the first cause of secondary lens dislocation. Most of the cases are unilateral, and bilateral cases are unusual. We report the uncommon case of a 70-year-old woman with evidence of a posterior bilateral dislocation of the lens in the context of an acute onset of confusional syndrome. We discuss about sensory deprivation as a trigger for acute confusion and agitation in patients with predisposing conditions. In addition, we describe the benefits that, in our experience, the refloating technique with perfluorocarbon liquid provides for the surgical approach to these cases.     

Utilising the Alexis Retractor for lateral orbital access,a case series

Lateral orbital surgery is challenging and typically involves the use of multiple traction sutures and retractors. This case series describes a novel technique utilising the Alexis retractor to provide access for lateral orbital surgery. Thirteen cases were included and the surgical technique has been described and illustrated. There were no post-operative infections or complications and the Alexis retractor provided excellent exposure whilst reducing the need for further surgical retractors.     

Indications, technic and results of the balloon operation

The present paper reports on 100 consecutive cases of retinal detachment treated by the balloon method. The patients were kept under observation for a minimum of 12 months postoperatively. Using the balloon method, a complete and lasting reattachment of the retina was achieved in 94% of the cases. Very careful preoperative evaluation and postoperative management are essential prerequisites for the application of this method. Multiple retinal holes can be treated provided they are close together. In order to reduce the redetachment rate due to material problems, episcleral fixation should be done routinely and the vent of the balloon secured. Additional laser coagulation is sometimes necessary postoperatively the balloon method is not only suitable for managing uncomplicated retinal detachment, but is also excellent for treating certain difficult types of detachment, e.g., in eyes previously operated on and glaucoma cases (because the intraocular pressure can be changed using the balloon). The balloon method is a new management technique for selected cases, enabling the experienced surgeon to reattach the retina with practically no complications.     

Phacoemulsification, persistent hypotony, and cyclodialysis clefts

A retrospective noncomparative case-note analysis of 3 men presenting with persistent hypotony after routine phacoemulsification cataract surgery was performed. All patients had a previous history of significant blunt ocular trauma. All patients had surgical repair of the cyclodialysis clefts, 1 with cleft cryopexy and 2 with formal cleft closure with a limbal-based double scleral flap technique. All patients achieved closure of the cyclodialysis clefts following surgical intervention with complete resolution of hypotony. Mean preoperative intraocular pressures improved from 3, 4 and 3 mm Hg in the 3 cases to 11, 16, and 17 mm Hg postoperatively. Visual acuities improved from preoperative readings of counting fingers, 6/36 and 6/24 in the 3 cases to 6/6, 6/9, and 6/9 postoperatively. Persistent hypotony because of possible activation of a preexisting doormant cyclodialysis cleft following routine atraumatic phacoemulsification cataract surgery in previously traumatized eyes has not been reported.     

Sutureless,Glueless, Scleral Fixation of Single-Piece and Toric Intraocular Lens: A Novel Technique

Sutureless, glueless, scleral fixation of an intraocular lens is a known technique of fixing a lens in the scleral pockets. However, this technique is applied to single-piece and toric lenses instead of 3-piece lenses, allowing the advantage of the use of premium lenses in patients with poor capsular support. Favourable results without complications of pigment dispersion, iris transillumination defects, dysphotopsia, elevated intraocular pressure, intraocular hemorrhage and cystoid macular edema with a well-centered, stable intraocular lens have been observed in the 3-month postoperative period in both cases.Key Words: Spherophakia, Aphakia, Scleral-fixated intraocular lens, Sutureless, Single-piece toric intraocular lens     

CT-Guided Fine Needle Aspiration Biopsy of Orbital Optic Nerve,Tumors

Biopsies were done for seven patients who had blinding optic nerve tumors or inflammations, using the fine needle aspiration technique guided by the CT scan. Cytologic material was recovered in this manner in all cases, which allowed the rendering of diagnoses. This allowed for therapeutic planning with minimal therapeutic invasion.     

Comparison of ultrasound, computed tomography and magnetic resonance imaging in diagnosis of orbital disorders

16 cases of confirmed orbital disorders, comprising orbital tumor 11 cases, inflammation 2 cases, ophthalmic Graves' disease 2 cases and carotid-cavernous sinus fistula 1 case, were studied with ultrasound, CT, and magnetic resonance imaging (MRI) in regard to identification and localization of the lesions. MRI excelled CT and ultrasound in histologic contrast resolution and spatial localization. The technique of MRI was particularly discussed.     

State-of-the-art phacoemulsification performed by residents in Buenos Aires, Argentina

PURPOSE: To analyze the learning curve for state-of-the-art phacoemulsification performed by residents. SETTING: Department of Ophthalmology, Hospital de Clinicas José de San Martin, University of Buenos Aires, Buenos Aires, Argentina. METHODS: The records of patients having phacoemulsification performed by residents from June 1996 to January 1998 were reviewed for preoperative and postoperative best corrected visual acuities and the occurrence of complications. The phacoemulsification technique used for the first 35 surgeries of each resident was compared with that of their last 35 surgeries. RESULTS: The records showed 249 cases of phacoemulsification by residents. Mean preoperative best corrected visual acuity was 0.19 +/- 0.19 (SD). One month postoperatively, it was 0.86 +/- 0.2. Nuclear fracture was performed in a mean of 28.33 +/- 5.0 of the first 35 surgeries by each resident, whereas chopping techniques were used in a mean of 23.33 +/- 1.5 of the last 35 cases. Vitreous loss occurred in 2.8% of cases. CONCLUSION: Residents learned cracking and chopping phacoemulsification techniques safely with satisfactory outcomes.     

No-Touch Technique and a New Donor Adjuster for Descemet's Stripping Automated Endothelial Keratoplasty

Purpose

One difficulty with Descemet''s stripping automated endothelial keratoplasty (DSAEK) is air management during surgery and donor endothelial lamella centering. We evaluated the no-touch technique for donor centering and the use of a newly developed DSAEK donor adjuster.

Methods

We evaluated the records of 12 consecutive patients (mean age 75.3 years) with bullous keratopathy who had undergone DSAEK. In all cases, the no-touch technique was attempted first. When the no-touch technique failed, a DSAEK donor adjuster with a 30-gauge cannula resembling a curved reverse Sinskey hook was used for donor centering. The adjuster allows air injection during donor centering.

Results

The no-touch technique using simple corneal surface massage to center the graft was successful in 4 cases (33.3%), while 4 cases required ocular tilting (33.3%) in addition to corneal surface massage. The no-touch technique was ineffective in 4 cases (33.3%), but the donor adjuster was used successfully and easily for these patients. Comparing the endothelial cell loss rate between the no-touch technique group and the donor adjuster group, there was no significant difference at 6 months.

Conclusions

The no-touch technique was useful for better control of DSAEK donor centering in most cases. When the no-touch technique was ineffective, the DSAEK donor adjuster was uniformly successful.Key Words: Descemet''s stripping automated endothelial keratoplasty, No-touch technique, Donor adjuster     

Comparing phacoemulsification and extracapsular cataract extraction in eyes with pseudoexfoliation syndrome, small pupil, and phacodonesis

BACKGROUND: This study aims to compare the frequency of intraoperative and postoperative complications between the modern phacoemulsification technique and the extracapsular cataract extraction technique in patients with pseudoexfoliation syndrome. PATIENTS AND METHODS: A prospective randomized study comprised 94 eyes with cataract, pseudoexfoliation syndrome, small pupil and slight to moderate phacodonesis. These eyes were randomly assigned into two groups. In the first group all patients (47 eyes) were operated on using a standard phacoemulsification technique (iris hooks, anterior capsule staining and capsular tension ring after capsulorhexis), while in the second group all patients (47 eyes) underwent a classic extracapsular cataract extraction. The main outcome measures were the frequency of intraoperative zonular tears, capsular rupture, vitreous loss and corneal edema, as well as the best-corrected visual acuity. RESULTS: Intraoperative zonular separation was recorded in one eye (2.1 %) and in 15 eyes (31.9 %) for the first and second groups, respectively (P < 0.001). Posterior capsule rupture with or without zonular separation occurred in two eyes (4.2 %) of the first group and in eight eyes (17.0 %) of the second group (P < 0.05). Vitreous loss also had a higher rate in the second group (17.0 % versus 4.2 %, P < 0.05). The postoperative difference in best-corrected visual acuity was also significant between the two groups, being higher in patients operated on using phacoemulsification technique (P < 0.001). CONCLUSIONS: In the difficult cases of cataract associated with pseudoexfoliation syndrome, small pupil and phacodonesis, the modern small-incision cataract surgery provides better results with a low rate of intraoperative and postoperative complications when compared with the extracapsular cataract extraction technique.     

Double-bridged flap procedure for nonmarginal, full-thickness, upper eyelid reconstruction

PURPOSE: To describe the technique and results of double-bridged flap reconstruction of full-thickness upper eyelid defects that spares the upper eyelid margin. METHODS: The surgical technique is described and illustrated in 2 patients who underwent this procedure. RESULTS: The 2 patients presented in this study achieved excellent functional and cosmetic results following the procedure. One patient subsequently underwent a frontalis sling procedure to correct residual ptosis. CONCLUSIONS: Double-bridged flap reconstruction of the upper eyelid that spares the eyelid margin can provide excellent functional and cosmetic results, particularly in cases of nonmarginal eyelid tumor excision, severe upper eyelid scarring, and severe cicatricial retraction.     

Pars plana vitrectomy, subretinal injection of tissue plasminogen activator, and fluid-gas exchange for displacement of thick submacular hemorrhage in age-related macular degeneration

PURPOSE: To evaluate a new procedure for displacement of large, thick submacular hemorrhage in patients with age-related macular degeneration. METHODS: Retrospective review of 11 eyes of 11 patients with age-related macular degeneration and thick submacular hemorrhage (defined as causing retinal elevation detectable on stereo fundus photographs) treated with vitrectomy, subretinal injection of tissue plasminogen activator (25 or 50 microg), and fluid-gas exchange with postoperative prone positioning. Outcome measures included displacement of hemorrhage from the fovea, best postoperative visual acuity, and final postoperative visual acuity. RESULTS: In the 11 affected eyes of 11 patients (seven men and four women; mean age, 76 years), preoperative visual acuity ranged from 20/200 to hand motions. With surgery, subretinal hemorrhage was displaced from the fovea in all 11 cases. Mean postoperative follow-up was 6.5 months (range, 1 to 15 months). Best postoperative visual acuity varied from 20/30 to 5/200, with improvement in nine (82%) cases and no change in two cases. Eight eyes (73%) measured 20/200 or better, with four of these eyes (36%) 20/80 or better. Final postoperative visual acuity ranged from 20/70 to light perception, with improvement in eight (73%) cases, no change in one case, and worsening in two cases. A statistically significant difference was found between preoperative and best postoperative visual acuity (P =.004) but not between preoperative and final visual acuity (P =.16). Hemorrhage recurred in three (27%) eyes, causing severe visual loss in one eye. CONCLUSIONS: This technique displaces submacular hemorrhage from the fovea and can improve vision in patients with age-related macular degeneration. However, recurrence of hemorrhage occurred in 27% of eyes and caused severe visual loss in one eye. A randomized, prospective clinical trial is necessary to determine the efficacy of this technique in comparison with other proposed treatments.     

超声乳化术中的硬核处理：翻核劈裂法

目的探讨安全有效的处理硬核的方法。方法对３６例（３６眼）核硬度在Ⅳ级以上的白内障翻核劈裂法碎核。翻核劈裂法：连续环形撕囊后,在水分离过程中将晶状体核作１８０度翻转,使其后极部朝上,然后用劈裂刀将核劈成数块,再乳化吸除。结果术后１ｗｋ矫正视力全部达０．５以上,其中１０例（２８％）术后视力达１．０以上;术中术后并发症包括１例虹膜损伤,６例短暂性角膜水肿。结论结果提示翻核劈裂法为一种有效的处理硬核的方法     

Experience in penetrating keratoplasty in children: graft survival, functional results and risk factors

Penetrating keratoplasty in children is related with a labor-consuming process of follow-up and care as well as with a high risk of graft rejection and a moderate vision improvement. Nonetheless, keratoplasty has been and still remains a surgery of choice due to a lack of an alternative procedure; its technique and results have been gradually promoted in practice. The authors analyzed 112 keratoplasties in childhood-age corneal opacifications of different types. The graft survival amounted to 71%, 61% and to around 55% after 1, 2 and 5 postoperative years, respectively. Neovascularization, glaucoma, repeated keratoplasty, an original vitreous pathology, an expanded surgical scope (reconstructions) etc. were attributed to risk factors. The visual acuity improved by more than 0.02 in 54% of cases; it remained unchanged or worsened in 22% of cases and it could not be assessed in 24% of cases. The best results were achieved in a group of patients with acquired corneal opacifications of the nontraumatic nature; the worst results were observed in congenital anomalies of the anterior eye segment. Finally, the success of penetrating keratoplasty in children was ensured through a careful selection of patients, an accurate surgical technique and through a fast treatment of postoperative complications.     

Prevention, diagnosis, and management of acute postoperative bacterial endophthalmitis

This distillation of the peer-reviewed scientific literature on infection after cataract surgery summarizes background material on epidemiology, etiology, and pathogenesis, describes the roles of surgical technique and antibiotic prophylaxis in prevention, and discusses diagnostic and therapeutic interventions in cases of suspected endophthalmitis.