Discussion by thomas R. Friberg, MD

Objective

To evaluate the visual and anatomic results of surgically repaired macular holes in eyes with intermediate or large-sized macular drusen.

Lens-sparing vitreous surgery for tractional stage 4A retinopathy of prematurity retinal detachments.

PURPOSE: To assess the efficacy of lens-sparing vitrectomy in tractional 4A retinopathy of prematurity (ROP) retinal detachments in reducing progression to stage 4B or 5 ROP. DESIGN: Retrospective, noncomparative consecutive case series. PARTICIPANTS: Forty eyes (31 patients) with stage 4A ROP at 38 to 42 weeks post-conceptional age. INTERVENTION: Lens-sparing vitrectomy. MAIN OUTCOME MEASURES: Retinal attachment status and presence/absence of fixation behavior. RESULTS: The range of follow-up was 6 to 22 months (mean, 12 months). Ninety percent (36 of 40) of eyes showed retinal reattachment and fixation behavior at their last follow-up visit. CONCLUSIONS: These results suggest that vitreous surgery can interrupt progression of ROP from stage 4A to stages 4B or 5.     

Autologous plasmin enzyme in the surgical management of diabetic retinopathy

PURPOSE: This is a pilot study to assess the use of autologous plasmin enzyme (APE) as an adjunct to vitreous surgery in eyes with advanced diabetic retinopathy. DESIGN: Prospective noncomparative interventional case series. PARTICIPANTS: Seven patients with advanced diabetic retinopathy selected at random from our practice population. METHODS: Seven eyes were treated with APE as an adjunct to standard vitreous surgery. Six eyes had macular tractional retinal detachments, and one eye had refractory macular edema. Three fellow eyes had standard vitreous surgery performed for macular tractional retinal detachments without APE. All 10 eyes had macular edema and background diabetic retinopathy. MAIN OUTCOME MEASURES: The main outcome measures included induction of a posterior vitreous detachment, retinal reattachment, improvement in visual acuity, and resolution of macular edema. RESULTS: All seven APE-treated eyes achieved spontaneous or easy removal of the posterior hyaloid including one eye that had vitreoschisis over areas of detached retina. All eyes treated with APE had resolution of intraretinal edema. Retinas of all eyes treated with APE were reattached. The three fellow eyes were treated by vitreous surgery without APE. Two of the three fellow eyes had reattached retinas, but none had resolution of intraretinal edema without further focal photocoagulation treatment. Mean visual acuity improvement was 0.7 logarithm of the minimum angle of resolution (LogMAR) units in APE-treated eyes and 0.1 LogMAR units in eyes without APE. The average follow-up period was 14 months. CONCLUSIONS: This pilot study suggests that APE may be beneficial in the surgical management of diabetic retinopathy.     

Late-onset diffuse lamellar keratitis following laser in situ keratomileusis

Objective

To analyze 12 cases of late-onset diffuse lamellar keratitis (DLK) following uncomplicated LASIK and propose a method of management.

Incidence of retinal detachment and visual outcome in eyes presenting with posterior vitreous separation and dense fundus-obscuring vitreous hemorrhage

PURPOSE: To determine visual outcomes and the incidence of retinal detachment in eyes presenting with posterior vitreous separation and dense fundus-obscuring vitreous hemorrhage. DESIGN: Retrospective consecutive noncomparative interventional case series. PARTICIPANTS: Thirty-six eyes (15 right eyes and 21 left eyes) of 34 patients (18 female and 16 male) ranging in age from 42 to 94 years. Mean follow-up was 14 months. METHODS: A comparison of the best-corrected initial visual acuities versus final visual acuities after spontaneous resolution of vitreous hemorrhage or surgical intervention. The number of eyes that were found to have retinal tears or that had a rhegmatogenous retinal detachment develop was documented. Logarithm of the minimum angle of resolution-converted visual acuities was used for comparison. Categorical data were analyzed by Fisher's exact test, and population means were compared by Student's t test. MAIN OUTCOME MEASURES: Final mean visual acuities, number of eyes with at least one retinal tear, location of retinal tears, number of eyes that had retinal detachment develop, and the number of eyes repaired with scleral buckling surgery and/or pars plana vitrectomy. RESULTS: Twenty-four of 36 eyes (67%) were found to have at least one retinal break (range, 0-4 breaks), with 88% of breaks located in the superior retina. Eleven eyes (31%) had more than one retinal break. Fourteen of 36 eyes (39%) had a rhegmatogenous retinal detachment develop that was repaired with pars plana vitrectomy and scleral buckling. An additional 14 eyes (39%) underwent vitrectomy for nonclearing vitreous hemorrhage. The incidence of retinal detachment in eyes with a history of retinal detachment in the contralateral eye was 75% (P = 0.04). Seven of 14 eyes (50%) with retinal detachment had coexisting proliferative vitreoretinopathy. Most retinal breaks and detachments occurred in emmetropic or myopic eyes. For all 36 eyes the mean preoperative visual acuity was 20/1233, and the mean final visual acuity was 20/62 (P < 0.0001). Eyes that had a macula-off retinal detachment develop had worse final visual outcomes (20/264; P = 0.01), as did eyes that had proliferative vitreoretinopathy develop (20/129; P = 0.04). CONCLUSIONS: Acute, spontaneous, nontraumatic posterior vitreous separation with dense fundus-obscuring vitreous hemorrhage is associated with a high incidence of retinal tears and detachment. Close follow-up with clinical examination and ultrasonography is necessary, because many of these eyes may eventually require surgical intervention. Aggressive management with early vitrectomy should be considered when there is a history of retinal detachment in the contralateral eye.     

Treatment of acute comitant esotropia in Chiari I malformation

PURPOSE: To explore the appropriate treatment of acute comitant esotropia in patients with Chiari I malformation. DESIGN: Interventional case reports and literature review. PARTICIPANTS: Two patients with Chiari I malformation presenting with acute comitant esotropia are described. INTERVENTION: Strabismus surgery, then neurosurgical decompression of the Chiari I malformation was performed. MAIN OUTCOME MEASURE: Both patients were evaluated for resolution of esotropia and other ocular motility problems. RESULTS: After initially successful strabismus surgery, both patients developed recurrent esotropia with diplopia, which resolved on suboccipital decompression. CONCLUSION: Comitant esotropia may recur and other eye movement disorders may develop after initially successful strabismus surgery in patients with Chiari I malformation. The data suggest that the appropriate sequence of treatment should first be suboccipital decompression, then strabismus surgery if spontaneous realignment does not occur, but further studies are needed to confirm this impression.