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To investigate differences between women and men in the repair of rhegmatogenous retinal detachments (RRDs) in the United States.Retrospective cohort study.Setting: A large insurance claims database.Subjects with an incident RRD between 2007 and 2015.Demographic data, comorbid ocular conditions associated with RRD, systemic comorbidities, and surgical intervention (pneumatic retinopexy [PR], pars plana vitrectomy [PPV], laser barricade, or scleral buckle [SB]) were collected.Odds of receipt of surgical intervention for incident RRD, time to repair, type of intervention, and the rate of reoperation by sex.The study period included 133 million eligible records with 61,071 cases of incident RRD among which 43% (n = 26,289) were women. The primary outcome model had 23,933 confirmed RRD cases with a 93% retinal detachment repair rate. Women had 34% reduced odds of receipt of surgical repair of an RRD (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.59, 0.73; P.001) after adjusting for confounders. This effect persisted in all sensitivity models. Among patients who received repair, women were more often delayed (0.17 days, P = .04). Women were more likely to undergo primary laser barricade (relative risk ratio [RRR] 1.68, P.001), primary SB (RRR 1.15, P.001), and PR (RRR 1.07, P.04) than men. The odds of reoperation were lower in women (OR 0.91, 95% CI 0.85, 0.96; P = .002) after adjustment.Insured women are less likely than insured men to receive surgical intervention for an RRD. Based on the results of this study, if the odds of repair were equal between women and men in the United States, then 781 more women would receive surgery each year, or 7,029 more during the study period. Women are more likely to have the repair performed with scleral buckle, laser barricade, and pneumatic retinopexy. The reason for these sex differences in RRD repair remains unknown and requires further investigation.

Purpose To provide a first-hand account of a retinal detachment suffered by one of the authors and how it relates to electronic health record (EHR) interoperability. Design Single-patient, observational. Methods 1) Personal patient perspective - symptom, surgery, recovery and the worry about potential long lasting sequelae, and the need to reiterate detailed medical information several times during a stressful period. 2) U.S. National perspective regarding EHRs. S etting : Out-patient and community hospital. P atient or S tudy P opulation : Single patient. I ntervention or O bservation P rocedure(s) : Retinal surgery. M ain O utcome M easure(s) : Visual acuity. Results Patient had a favorable outcome, but was required to provide medical history data multiple times to multiple providers. Only 41% of hospitals in the United States have EHR from outside providers or sources when treating a patient. Physicians in outpatient settings fare worse with only 14% of office-based physicians sharing data with providers outside of their organization. Conclusions While adoption and use of EHRs are incentivized by the federal government in the United States, the lack of interoperability between different physician and hospital systems means that we are far from achieving meaningful digitization of records. This case report provides a close look at how it may be difficult to receive care in a fragmented health care model in which physician and hospital do not share the same EHR. Information blocking, now prohibited by federal law, still remains an obstacle to interoperability. It will take continued effort and commitment from key stakeholders such as health care providers, patients, the federal government, and industry to bring this dream to fruition.

Purpose To assess the prevalence of proliferative vitreoretinopathy (PVR) and prognosis of cytomegalovirus (CMV) retinitis–related retinal detachment (RD) surgery in the era of highly active antiretroviral therapy (HAART). Design Retrospective interventional cohort study. Methods Thirty-five human immunodeficiency virus (HIV)-positive patients with CMV retinitis–related RD who underwent surgical repair were assessed for PVR, CD4-positive T cell counts, and use of HAART. Main outcome measures included anatomic and functional outcomes of RD surgery as well as the presence of PVR and CD4-positive T cell counts. Results PVR was present in 10 of 35 patients (29%) at the time of the first surgery. The presence of PVR was associated with worse preoperative and postoperative visual acuity ( P = .017 and P = .009, respectively), with the CD4-positive T cell counts above 200 cells/μL ( P = .054), and with a longer interval between the diagnosis of RD and surgery ( P = .025). The odds ratio for development of PVR in patients with CD4-positive T cells above 200 cells/μL was 11.3 (95% confidence interval 1.01-125). PVR was not associated with age, gender, or duration of HIV infection. Anatomic reattachment was obtained in 31 patients (89%), though the functional outcomes were limited. The central location of CMV retinitis was associated with postoperative visual acuity (VA) of less than 0.1 ( P = .000). Postoperative logMAR VA was associated with preoperative logMAR VA ( P P = .009). Conclusion PVR was present in 29% of CMV retinitis–related RD and was associated with higher CD4-positive T cell counts and longer interval between the diagnosis of RD and surgery.

Purpose To evaluate the recurrence rate of ocular surface squamous neoplasias (OSSN) after excision and cryotherapy in an academic cornea practice and to determine factors associated with recurrence. Design Retrospective interventional case series. Methods All cases of OSSN from 1998 through 2013 that were treated with excisional biopsy and adjunctive cryotherapy were retrospectively reviewed. Clinical characteristics upon presentation including size of lesion, location, and atypical features were noted. All recurrences of OSSN after excision and cryotherapy were noted and categorized in relation to clinical characteristics, pathologic grade, and margin involvement. Results Forty-three cases of OSSN from 42 patients were analyzed with a median follow-up of 29 months. A total of 32.6% of subjects had dysplasia and 67.4% had squamous cell carcinoma (SCC). A total of 83.7% of subjects had both corneal and conjunctival involvement while 16.3% had conjunctival involvement only. Overall, 3 recurrences were observed, all of which had margin involvement; nonetheless, the majority of incompletely excised OSSN (25/28) showed no recurrence. The recurrence rate at 6 months was 2.3%. Recurrence at 1 year, 2 years, and 5 years remained stable at 7.1%. Conclusions Excision with cryotherapy is an effective treatment for the majority of OSSN cases, even among cases with pathologic evidence of tumor at the margin, with an overall recurrence rate of 7.1% at 1 year, 2 years, and 5 years.

Purpose To study the characteristics and management of macular holes that develop after prior rhegmatogenous retinal detachment (RD) repair. Design Retrospective, interventional, consecutive case series. Methods The setting was a clinical practice. The case records of all of our patients (n = 12) who developed a new full-thickness macular hole after prior RD repair over an 8-year period were examined. Patients who developed a macular hole after prior RD repair were offered either surgical repair of the macular hole or continued observation. For eyes that underwent macular hole repair, main outcome measures included macular attachment status and postoperative visual acuity. Results Twelve full-thickness macular holes were detected in a series of 2,380 eyes (0.5% prevalence), which had undergone surgery for prior primary RD. Ten macular holes developed after scleral buckling surgery, two after pneumatic retinopexy, and none were seen after primary vitrectomy. The fovea had been detached in 11 of the 12 eyes at the time of RD. The median time to macular hole diagnosis after RD repair was 3.4 months (range, 0.3–161 months). Eight of the eight eyes (100%) undergoing surgical repair achieved macular reattachment with a median of 3.5 lines of visual improvement at a median of 14.8 months of follow-up. Seven of these eight eyes had an improvement in visual acuity of at least 3 Snellen lines, and four of the eight had at least 20/40 visual acuity postoperatively. Four eyes with macular holes were observed. Conclusions Macular holes developed in less than 1% of eyes that had previously undergone repair of rhegmatogenous RD. In our series, these atypical holes were seen predominantly after macula-off detachments, most commonly occurring after scleral buckling procedures. They were effectively repaired using conventional pars plana vitrectomy with long-acting gas tamponade and a variety of adjuvant therapies. A good visual outcome is possible with this approach.

PURPOSE: To evaluate the choroidal drainage route after scleral buckling for retinal detachment. METHODS: We performed wide-angle indocyanine green angiography with a scanning laser ophthalmoscope in 22 eyes of 22 patients with rhegmatogenous retinal detachment that had been treated with scleral buckling and cryopexy. The 22 eyes had at least one retinal break located posterior to the equator where vortex veins were present. The period between angiography and retinal detachment surgery was less than 3 months in 10 eyes, 3 to 12 months in five eyes, and more than 1 year in seven eyes. RESULTS: At the site of the silicone exoplant and cryopexy for retinal breaks, one vortex vein was occluded in seven eyes and two in five eyes. Choroidal veins were congested in the quadrant of the occluded vortex vein in two of 12 eyes that had angiography less than 3 months after retinal detachment surgery. In 10 of 12 eyes that had angiography 3 months or more after retinal detachment surgery, new drainage routes developed that connected the sector of the occluded vortex veins to that of the intact vortex veins with venovenous anastomoses. No venous congestion was found in the areas of the occluded vortex veins in the 10 eyes. Venous collaterals formed between the superior and inferior vortex in all 10 eyes and between the temporal and nasal vortex in two eyes. CONCLUSIONS: New venous drainage routes, which were connected to the intact vortex veins, formed in eyes with occluded vortex veins resulting from scleral buckling surgery and compensated for choroidal venous congestion. The choroidal veins have a great deal of plasticity that enables remodeling of the drainage routes, depending on the pressure gradient.

Purpose To examine the behavior of surgically repaired macular holes when subsequent retinal detachment with submacular fluid develops and to correlate these observations with current theories of macular hole formation and closure. Methods We reviewed the medical records of four patients who underwent successful surgical closure of macular holes and subsequently developed rhegmatogenous retinal detachment with macular involvement. Results No reopening of the original macular hole occurred in any of the four patients. No focal macular attachment was seen that would suggest firm adherence of the macular hole edges to the underlying retinal pigment epithelium. Conclusions When retinal detachment with submacular fluid develops in patients with a successfully closed macular hole, sustained closure of the macular dehiscence is typically seen. These findings support reapproximation of the hole edges with an associated retinal wound healing response as the mechanism of hole closure.

Cryotherapy for retinopathy of prematurity (ROP) is effective in reducing the incidence of blindness in premature infants. However, macular complications associated with successful treatment have not yet been well studied.Eighteen very low birth-weight (1,251 g) infants (32 eyes) who received cryotherapy for ROP were examined serially for regression of disease and for development of macular abnormalities. Patient characteristics and treatment factors were evaluated to identify risk factors associated with the development of macular abnormalities after successful cryotherapy.Eleven of 32 eyes (34.4%) that had undergone cryotherapy developed significant macular abnormalities, including macular coloboma-like change (six eyes), macular hyperpigmentation (two eyes), irregularly mottled macular hyperpigmentation and hypopigmentation (two eyes), and macular hyperpigmentation and hypopigmentation with subretinal proliferation (one eye). Corrected visual acuity in affected eyes ranged from 0.15 to 0.03 (20/133 to 20/666) compared with 1.0 to 0.2 (20/20 to 20/100) in treated eyes without macular abnormality (P = .0002). No difference in gestational age was noted between infants who did or did not develop macular coloboma-like lesions or pigment abnormalities. Eyes with macular abnormality had more posterior disease (P = .037) and received significantly more cryotherapy than did eyes without macular abnormality (P = .0005).In very low birth-weight infants receiving cryotherapy for ROP, development of macular coloboma-like lesions and macular pigment abnormalities were related to greater severity of ROP and a greater amount of cryotherapy. Macular abnormalities were associated with markedly worse visual outcomes than were treated eyes without macular abnormality.

N THIS ISSUE OF THE JOURNAL, AN ARTICLE BY SAITO and associates describes a macular complication in eyes with retinopathy of prematurity (ROP) that have received cryotherapy; the complication occurred particularly in the very smallest premature infants. This article gives us occasion to realize that only 50 years ago this disease we now call ROP was practically unknown. After retrolental fibroplasia (as it was originally named) was recognized in 1942, its inci­ dence burgeoned rapidly through the next decade. This major threat to the sight of premature infants developed as improvements in technology permitted more efficient delivery of supplementary inhaled oxy­ gen. When it was realized that for certain cases therapeutic oxygen increased the incidence of ROP and blindness even as it improved the rate of infant survival, attempts to refine the dosage of oxygen administration began that continued into the 1980s and 1990s. Despite the discovery about oxygen, the number of eyes damaged by ROP seems to have increased during the past 30 years because a growing number of extra-small premature infants are surviv­ ing. During 1986 and 1987, 36.5% of a large sample of infants born in the United States at only 24 weeks of gestation survived the critical first four weeks of life. Those infants were a subgroup of those born weighing less than 1,251 g who participated in the Multicenter Trial of Cryotherapy for Retinopathy

PURPOSE: To report a case of retinoblastoma that recurred 12 years after brachytherapy. DESIGN: Interventional case report. METHODS: A 2-month-old boy presented in December 1983 with bilateral retinoblastoma and was treated with bilateral 198 Au plaque radiotherapy, photocoagulation, and cryotherapy. He maintained a visual acuity of 20/200 in both eyes. In December 1995, he had a sudden decrease of vision in the right eye and vitreous hemorrhage with fluffy opacification. RESULTS: In January 1996, cytopathologic examination of large keratic precipitates in the right eye demonstrated cells consistant with retinoblastoma. The right eye was enucleated and diffuse retinoblastoma was noted histopathologically. Systemic chemotherapy was given, and there has been no local recurrence or extraocular metastasis for 5 years. CONCLUSIONS: This case emphasizes that long-term follow-up is essential for managing retinoblastoma after eye-preserving conservative therapy.

Purpose To determine the frequency of peripheral iatrogenic retinal breaks in eyes undergoing small-gauge pars plana vitrectomy. Design Prospective, single-center, noncomparative interventional case series. Methods A consecutive series of patients that underwent 23- or 25-gauge vitrectomy between July 2010 and the end of October 2010 were included in the study. We excluded patients with retinal detachment, dislocated crystalline lens from complicated cataract surgery, endophthalmitis, and previous history of eye trauma or vitrectomy. We recorded prospectively the frequency of all retinal breaks noted during surgery of patients undergoing 23- or 25-gauge vitrectomy. The indications for vitreoretinal surgery were recorded, as were the location of retinal breaks, the presence or absence of an intact posterior hyaloid, status of lens, method of retinopexy, and use of a tamponade, together with the onset of a rhegmatogenous retinal detachment during the 3-month follow-up interval. Main outcome was rate of entry site breaks in small-gauge vitrectomy. Results We included 184 patients in this study. The mean age was 65.6 years (SD 13.2) and 46% were male. Retinal breaks occurred in 29 patients (15.7%) but breaks in only 6 (3.2%) were deemed to be related to the sclerotomies. Entry site breaks were not linked to the gauge of the instruments, but retinal breaks were more common in 23-gauge surgeries, although this was not statistically significant. One rhegmatogenous retinal detachment occurred in the postoperative period. Conclusions Entry site retinal breaks are not common in small-gauge vitrectomy.

Pars plana vitrectomy and scleral buckling were performed on 22 eyes of 19 patients for treatment of perforating eye injuries from shotgun pellets. We reviewed the intraoperative findings at the time of vitrectomy to determine what factors might influence final visual acuity. The presence of a total retinal detachment at vitrectomy portended a poor prognosis when compared with eyes without total retinal detachment, as only one of ten eyes with total retinal detachment obtained useful vision (P = .002). Preoperative separation of the posterior vitreous was associated with a favorable outcome when compared with the absence of posterior vitreous detachment (P = .035), as ten of 16 eyes with posterior vitreous detachment at the time of vitrectomy ultimately achieved functional vision. The locations of the exit wounds did not affect visual success in the overall series of patients. However, in the patients who achieved visual success, exit wounds outside the vascular arcades were more likely to be associated with final visual acuities of, or better than, 20/70 than were those within the arcades (P = .022). Other prognostic factors, such as the number of perforations and the use of cryotherapy, were also examined for their effects on final visual outcome. However, these factors did not appear to affect visual outcome statistically.

We treated three patients(four eyes) in whom posteriorly situated retinoschisis-detachments became symptomatic because of elevation of a limited area of full-thickness retina at the macula adjacent to these lesions. Laser photocoagulation alone was successful in achieving long-term macular reattachment in one eye but failed in both eyes of a bilaterally affected patient. In this patient, retinal cryopexy , external drainage of subretinal and retinoschisis cavity fluid, and intravitreal air injection attained long-term macular reattachment and retinoschisis cavity collapse in both eyes. In the third patient, cryopexy , drainage of subretinal and retinoschisis cavity fluid, and scleral buckling failed to reattach the retina. Subsequent laser photocoagulation induced reabsorption of subretinal fluid but without retinoschisis cavity collapse. Alternative management strategies for these unusual cases include retinal cryopexy alone and vitrectomy techniques.

To determine current practices in the management of ocular toxoplasmosis, 72 of 85 uveitis specialists (85%) in the American Uveitis Society completed a detailed questionnaire. Questions involved the indications for beginning treatment, choice of antiparasitic/ antimicrobial agents, and experience with treatment of ocular toxoplasmosis in special situations including pregnancy, neonatal infections, and immunocompromised patients. Most of the respondents treat patients whose visual acuity had decreased to worse than 20/200, lesions located in the peripapillary, perifoveal, or maculopapillary bundle regions, and lesions associated with severe vitreous inflammation. Most would not treat patients who retained visual acuity of 20/20, lesions located in the far peripheral retina, or lesions associated with only trace to mild vitreous inflammation. Treatment of other combinations of factors remains controversial. Eight different antimicrobial drugs are used in various combinations for lesions threatening the macula or optic nerve head. Systemic corticosteroids are used by 59 of 62 respondents (95%) as part of their initial treatment regimen. The most commonly used regimens are pyrimethamine/sulfadiazine/corticosteroids (20 of 62 [32%]) and pyrimethamine/ sulfadiazine/clindamycin/corticosteroids (17 of 62 [27%]). Adjunctive therapies (photocoagulation, cryotherapy, or vitrectomy) have been used by 20 of 60 respondents (33%). Most alter treatment during pregnancy, in newborn patients, and in patients with the acquired immunodeficiency syndrome.

PURPOSE: To report live, active trophozoites in an eye with Acanthamoeba keratitis that resembled Acanthamoeba polyphagia in the anterior chamber fluid obtained by transcorneal tap. METHOD: After prediagnostic therapy had failed, we performed cryosurgery to break the corneal cell walls and treated the patient with oral fluconazole. RESULTS: The condition resolved after 8 weeks of oral fluconazole therapy. Residual leukoma was treated by corneal graft. CONCLUSION: Live, motile Acanthamoeba can be isolated from an anterior chamber tap; combination therapy with oral fluconazole after corneal cryosurgery may be effective.

To investigate the effects of peripheral retinal cryotherapy on accommodative amplitude in patients with retinal lattice degeneration.Prospective, observational case series.We studied 92 eyes in 69 patients (age range, 13 to 79 years) treated with cryotherapy for lattice degeneration between December 2001 and September 2004. Pretreatment and posttreatment accommodative amplitudes were measured. Acute accommodative loss was calculated from the difference between accommodative amplitudes before treatment and one week after treatment. We investigated the time course of accommodative amplitudes, acute accommodative loss in different age groups and in pretreatment accommodative amplitude groups, the influence of cryotherapy numbers on accommodative amplitude, and the influence of cryotherapy sites on accommodative amplitude.No significant difference was noted between pretreatment and posttreatment accommodative amplitudes in the overall subject cohort. Dividing subjects by age revealed significant decreases in accommodative amplitude only among patients in their 10s and 20s at one and three weeks after treatment. Accommodative amplitude was lowest among those in their 10s, followed by that among those in their 20s (P.01). Accommodative amplitudes recovered to pretreatment level by six weeks. Acute accommodative loss was greatest in those in their 10s compared with other age groups (P.01). A significant correlation was observed between acute accommodative loss and cryotherapy numbers (P = .03; r = 0.41).The decrease in accommodative amplitude was greatest at one week after treatment and recovered to pretreatment levels after six weeks. Accommodative amplitude showed the greatest decrease after cryotherapy among patients in their 10s and 20s. A decrease in accommodative amplitude was observed with increased numbers of cryotherapy spots administered.

Purpose To quantitate the frequency and features of retinal breaks discovered at the time of vitrectomy and to evaluate the outcomes with prophylactic treatment. Design A consecutive, single-surgeon, retrospective, observational case series from a two-year period. Methods Medical records were reviewed for all patients who underwent primary, standard, three-port pars plana vitrectomy (PPV) between January 1, 2000, and December 31, 2001. Intraoperative findings recorded included the number, location, and categorization of retinal breaks and their method of management. Postoperative features recorded included the presence or absence of a retinal detachment (RD). Results There were 65 retinal breaks found in 48 (11.6%) of 415 eyes and included 30 (7.2%) eyes with definite breaks, nine (2.2%) with suspicious breaks, and nine (2.2%) with probably preexisting breaks. Breaks that were described as being large (n = 5) were more commonly associated with the right-hand sclerotomy (P = .041), although other categories of breaks were not. After surgery, the overall incidence of RD was 2.2% (nine of 415 eyes). The rate of RD among the 48 eyes with retinal breaks (of any category) was also 2.1% (one eye). All RDs in this series occurred more than three months after initial vitrectomy and, accordingly, were probably unrelated to retinal breaks that occurred during surgery. Conclusions Recognition of retinal breaks and intraoperative treatment with retinopexy and air–fluid exchange during vitrectomy reduces the postoperative risk of RD to that among eyes without observed intraoperative retinal breaks.

Purpose To investigate anatomic success after surgery for chronic retinal detachment. Design Retrospective, case series review. Methods The surgical outcomes of reattachment surgery for 36 eyes of 35 patients with chronic retinal detachments are reported and are compared with the outcomes for 129 fresh retinal detachments. Results After exclusion of retinal detachments secondary to retinal dialysis and of cases with proliferative vitreoretinopathy (PVR), success after a single procedure was seen in eight of 14 (57.1%) chronic retinal detachments, and this compares with 92 of 107 (86.0%) fresh retinal detachments (P = .0161). Conclusions Chronicity of retinal detachment at presentation is an important and poor prognostic indicator for reattachment surgery.

PURPOSE: To describe the use of an autologous serum-free derived cultivated conjunctival epithelial equivalent in the treatment of extensive recurrent viral papillomata. DESIGN: Interventional case report. METHODS: A 10-year-old child with extensive recurrent viral papillomata involving the superior and inferior tarsal, forniceal, and bulbar conjunctiva underwent surgical excision of all diseased areas and double freeze-thaw cryotherapy. Autologous serum-free cultivated conjunctival equivalents were used to reconstruct the ocular surface and conjunctival fornices. RESULTS: Almost complete epithelialization was achieved within 5 days postoperatively. A good cosmetic and functional result was obtained, and no recurrences or cicatricial complications developed during 12-month follow-up. CONCLUSION: Transplantation of autologous cultivated conjunctiva was effectively used in the reconstruction of the ocular surface after extensive excision of recurrent viral papillomata. This modality of treatment may be useful in the treatment of ocular surface disorders in which extensive conjunctival and fornix reconstruction is required.

Purpose To review management strategies for treatment of anterior chamber epithelial cysts. Design Retrospective review of consecutive interventional case series. Methods Charts of patients treated for epithelial ingrowth over a 10-year period by a single surgeon were reviewed. Cases of anterior chamber epithelial cysts were identified and recorded, including details of ocular history, preoperative and postoperative acuity, intraocular pressure (IOP), and ocular examination, type of surgical intervention, and details of further procedures performed. Results Seven eyes with epithelial cysts were identified. Patient age ranged from 1.5 to 53 years at presentation. Four patients were children. In four eyes, cysts were secondary to trauma, one case was presumably congenital, one case developed after corneal perforation in an eye with Terrien’s marginal degeneration, and one case developed after penetrating keratoplasty (PK). Three eyes were treated with vitrectomy, en bloc resection of the cyst and associated tissue, fluid–air exchange and cryotherapy. The last four eyes were treated with a new conservative strategy of cyst aspiration (three cases) or local excision (one keratin “pearl” cyst), and endolaser photocoagulation of the collapsed cyst wall/base. All epithelial tissue was successfully eradicated by clinical criteria; one case required repeat excision (follow-up, 9 to 78 months, mean 45). Two eyes required later surgery for elevated IOP, two for cataract extraction and one for repeat PK. Final visual acuity ranged from 20/20 to hand motions, depending on associated ocular damage. Best-corrected visual results were obtained in the more conservatively managed eyes. Conclusions Anterior chamber epithelial cysts can be managed conservatively in selected cases with good results. This strategy may be particularly useful in children’s eyes, where preservation of the lens, iris, and other structures may facilitate amblyopia management.

Purpose To report a rare case of ocular localization of Cowden disease. Design Case report. Methods A 50-year-old woman with a history of multiple tumors was diagnosed with Cowden disease. A PTEN gene mutation was found. Visual acuity of the left eye had decreased 2 years before diagnosis. Results Visual acuity was 20/20 in the right eye and 20/200 in the left eye. Right eye fundus examination showed an epiretinal membrane associated with a peripheral and temporal inferior angiomatous lesion. Treatment consisted of cryoapplication and surgical removal of the epiretinal membrane after central vitrectomy. Although the anatomic result was satisfactory, the patient’s visual acuity remained unchanged. Conclusions Hamartomatous ocular lesions have been described in Cowden disease. We are unaware, however, of such retinal angiomatous lesions in patients with PTEN gene mutations.

PURPOSE: To report the optical coherence tomographic characteristics of persistent bleb-like subretinal lesions after retinal reattachment surgery, including scleral buckling and cryopexy. METHODS: Case reports. RESULTS: In two eyes of two patients yellow to yellowish-orange bleb-like lesions were found in the posterior pole after retinal reattachment surgery. The common aspects of the surgery were scleral buckling procedures and cryopexy. There were subretinal precipitates in some of the lesions. The lesions showed no associated leakage during fluorescein or indocyanine green angiography. Optical coherence tomography demonstrated that the bleb-like lesions were tiny retinal detachments. CONCLUSION: Optical coherence tomography examination of bleb-like subretinal lesions showed that they were actually retinal detachments. Our patients and previously reported patients developed these lesions after scleral buckling and cryopexy. These lesions may represent persistent retinal detachment because of the presence of protein in the subretinal fluid.

PURPOSE: To evaluate an indwelling retrobulbar catheter for repeatable postoperative retrobulbar injections of local anesthetics for titratable analgesia after intraocular surgery. METHODS: The prospective study included all 124 patients (124 eyes) who consecutively underwent retinal or cyclocryocoagulation (n = 22), pars plana vitrectomy, or retinal detachment surgery (n = 102), and who were operated on by the same surgeon with local anesthesia within a period of 12 months. Using commercially available retrobulbar needles with a diameter of 0.60 mm or 0.80 mm and a length of 38 mm, 5 ml of mepivacaine 2% with hyaluronidase were injected. Through the same needle, a 28-gauge commercially available flexible catheter was introduced into the retrobulbar space, the needle was withdrawn, and the catheter was fixed in place. When the patients started to feel pain after surgery, 2 ml of mepivacaine 2% or 2 ml of bupivacaine 0.75% were reinjected through the catheter. The catheter was removed 24 to 72 hours after surgery. RESULTS: Because of increasing pain in the postoperative period, 93 patients (93 of 124, or 75%) received a reinjection 4.2 ± 2.0 hours after the preoperative injection. Seventy patients received a second reinjection after an additional 2.7 ± 1.9 hours, and 42 patients received a third reinjection 3.1 ± 2.0 hours later. After each reinjection, the patients became pain free. Removal of the catheter after surgery was unremarkable. CONCLUSIONS: An indwelling retrobulbar catheter for repeatable postoperative injection of short-acting local anesthetics is useful and effective for titratable postoperative analgesia after intraocular surgery, and it allows patients to avoid the side effects of systemic analgesics and sedatives.

To compare pneumatic retinopexy and scleral buckling for repair of primary rhegmatogenous retinal detachment with respect to visual outcome, single-procedure reattachment rate, and development of proliferative vitreoretinopathy.A consecutive series of eyes initially treated with pneumatic retinopexy (n = 56) between March 1986 and February 1996 were compared with a selected group of eyes treated with scleral buckling (n = 86) with similar location and distribution of retinal breaks and absence of proliferative vitreoretinopathy. A regression model was developed to adjust for underlying differences between treatment groups, resulting in a cohort of 50 eyes in each group for final comparison. A minimum follow-up of 6 months was obtained.Single-procedure reattachment rate was significantly higher for scleral buckle eyes (42 of 50 eyes, 84%) than for pneumatic retinopexy eyes (31 of 50 eyes, 62%; Por = .01). Correspondingly, reoperation rate was significantly higher for pneumatic retinopexy eyes (19 of 50 eyes, 38%) than for scleral buckle eyes (7 of 50 eyes, 14%; Por = .01). Multiple regression analysis evaluating perioperative factors demonstrated that the use of pneumatic retinopexy was the sole factor predictive of retinal detachment after a single procedure (relative odds = 2.20, P = .02). Final reattachment rate, after reoperations, was 98% (49 of 50 eyes) in each group. Except for nonphakic eyes, final visual outcome and rate of postoperative proliferative vitreoretinopathy development did not differ significantly between the two procedures.In phakic eyes, pneumatic retinopexy was associated with a significantly higher reoperation rate than scleral buckling, but resulted in equivalent final visual outcome and reattachment rate after reoperations. If used, it must be incorporated into a strategy in which patient and physician are prepared for a greater chance of reoperation compared to initial management with scleral buckling.

Purpose To introduce a new approach for short-term external scleral buckling with pneumatic retinopexy for the management of rhegmatogenous retinal detachment with inferior retinal breaks. Design Retrospective, noncomparative, interventional case series. Methods A review of 33 consecutive eyes of 31 patients who underwent external buckling with pneumatic retinopexy for uncomplicated rhegmatogenous retinal detachment with inferior retinal breaks from December 2006 through December 2010. An external buckle was made of a 505 sponge sutured along the blunt side of a 279 tyre (MIRA Inc). The buckle was inserted deeply into the inferior fornix without suture after pneumatic retinopexy and was kept in place for 3 days. Primary and final anatomic outcomes, visual acuity, and adverse events were recorded. Results All patients tolerated the procedure. The mean follow-up period was 24.0 months (range, 9 to 61 months). Primary success, defined as successful retinal reattachment within 6 months without further treatment, was achieved in 29 (87.9%) eyes. All patients attained final retinal reattachment (100%). Overall, the mean best-corrected visual acuity improved significantly at the end of follow-up (0.30 logarithm of the minimal angle of resolution units; Snellen equivalent, 6/12), compared with the preoperative best-corrected visual acuity (0.82 logarithm of the minimal angle of resolution units; Snellen equivalent, 6/38; P Conclusions Short-term external buckling with pneumatic retinopexy is a novel and effective treatment for rhegmatogenous retinal detachment with inferior retinal breaks, with a comparable success rate with other treatment methods. This approach also can avoid complications of long-term buckle implantation. Further comparative cohort studies may be necessary to compare the clinical efficacy with other conventional operations.

Purpose We studied 294 eyes of 182 patients, to quantitate the amount of retinal ablation required for regression of proliferative diabetic retinopathy. Methods Eyes included in the study had two or more proliferative diabetic retinopathy risk factors, received panretinal photocoagulation, and had a minimum follow-up of one year. Laser photocoagulation or cryotherapy was given to eyes that failed to regress or had progression of retinopathy. Eyes treated by other physicians, treated with xenon arc photocoagulation, or undergoing laser treatment or vitrectomy for other retinal conditions were excluded. The total area of retina ablated was calculated and used as a quantitative measure of treatment. Results Regression was observed in 275 eyes (93%); 19 eyes (7%) failed to regress and eventually required vitrectomy. Panretinal photocoagulation alone successfully led to regression in 229 eyes (77%), whereas 46 eyes (15.6%) required both photocoagulation and peripheral anterior retinal cryotherapy. An average of 1.7 treatments per eye led to regression. Eyes were bimodally distributed by requirement for treatment, into low and high treatment groups. Low treatment eyes received an average of 510 mm 2 of retinal ablation (2,600 500-μm burns), and high treatment eyes, 1,280 mm 2 (6,500 500-μm burns). More extensive treatment was required with more retinopathy risk factors (P = .002 for four vs three risk factors and P=.0007 for four vs two risk factors); duration of diabetes mellitus longer than 15 years (P = .004), and onset of diabetes mellitus before 30 years of age (P = .0008). Conclusion Patients with proliferative diabetic retinopathy should be treated aggressively with panretinal photocoagulation, cryotherapy, or both. The amount of initial treatment required for regression may be considerably more than that recommended by the Diabetic Retinopathy Study.

Lymphoid tumors of the conjunctiva traditionally are treated with radiation therapy. Twelve patients with 42 lymphoid tumors were treated with liquid nitrogen spray and were followed up for 26 to 139 months (mean, 75 months). Twenty-eight (67%) tumors resolved with a single treatment, 39 (93%) with a second treatment, and 41 (98%) with a third treatment. Systemic lymphoma developed in two (17%) of 12 patients. These results are comparable to those with radiation therapy. The results of this case series indicate that cryotherapy for certain conjunctival lymphomatous tumors may be a viable option, because of fewer ocular and systemic complications and lower cost.

We treated a healthy soft contact lens wearer who developed Acanthamoeba sclerokeratitis in the left eye. The patient had severe pain and ring-shaped subepithelial infiltrates. The keratitis progressed and scleral nodules developed despite aggressive treatment with topical clotrimazole, dibromopropamidine isethionate, and corticosteroids. Corneal transplantation and cryotherapy were performed. The corneal button demonstrated Acanthamoeba cysts. Cultures of biopsy specimens taken from two different scleral nodules at two separate times were positive for Acanthamoeba. The disease progressed despite a second corneal graft and the addition of polyhexamethylene biguanide eyedrops. Enucleation of the left eye was required. Histopathologic examination of the specimen documented an Acanthamoeba cyst associated with a granulomatous inflammatory response deep in the sclera. Acanthamoeba scleritis may be associated with a poor prognosis, even with intensive medical and surgical treatment.

Although surgical excision, with or without adjunctive cryotherapy, is an accepted method of managing conjunctival squamous cell carcinoma, histologically verified tumor-free surgical margins cannot be assured by excision alone. We used a tissue conservation method, an adaptation of the Mohs' micrographic technique for cutaneous tumors, to monitor the conjunctival tissue margins by histologic review at initial tumor excision. We treated 19 patients with squamous cell carcinoma of the conjunctiva by this technique. Lamellar sclerectomy was used if the deep tissue margin was positive for residual tumor cell after the first stage review. Adjunctive cryotherapy was utilized in one patient because the deep scleral margin remained positive after lamellar sclerectomy, and further excision was not possible. In all patients, the tumor-free conjunctival defect was allowed to heal by secondary intention. During six months to 60 months of follow-up, no recurrences were documented. The only complication encountered was conjunctival scarring with secondary restricted motility in one patient. We believe this method of tissue margin surveillance offers a high cure rate for the treatment of conjunctival squamous cell carcinoma.

%PURPOSE: To report the clinical history and surgical management of recurrent congenital iris stromal cyst. METHOD: Case report. Argon laser endophotocoagulation and cryotherapy were used to treat a recurrent iris stromal cyst in an 18-month-old boy. RESULTS: At 43 months of follow-up, there was no recurrence or evidence of epithelial ingrowth. CONCLUSION: Treatment with argon laser endophotocoagulation and cryotherapy resulted in complete resolution of a recurrent congenital iris cyst.

Purpose To evaluate the effects of liquid nitrogen cryotherapy on superior limbic keratoconjunctivitis (SLK). Design Interventional case series. Methods In this clinical practice case series, the effects of liquid nitrogen cryotherapy on SLK were observed. Liquid nitrogen cryotherapy was performed using a Brymill E tip spray (0.013-inch aperture) with a double freeze-thaw technique. All subjects were outpatients who had local anesthesia with a single drop of topical proparacaine. The main outcome measure was the resolution of the disease process after treatment. Results Four female patients (average age, 64 ± 13 years) and seven eyes with SLK were treated with liquid nitrogen cryotherapy. Resolution of signs and symptoms occurred within two weeks. Disease recurred in two patients and three of seven eyes, although repeat cryotherapy eradicated SLK in all cases. The repeat cryotherapy was performed at three months postoperatively. There were no adverse ocular events. Conclusions Liquid nitrogen cryotherapy appears to be an effective alternative treatment for SLK as all subjects studied achieved long-term cures. Repeat cryotherapy may be necessary in some instances and may be performed three months after the first treatment.

One hundred sixty-four patients (171 eyes) were treated for retinal breaks and the treatment outcomes were studied. One hundred two eyes were acutely symptomatic, 22 eyes were chronically symptomatic, and 47 eyes were asymptomatic. The reasons for further treatment in 38 of the 171 eyes (22%) included the following: (1) inadequate closure of the original break without detachment in eight eyes (5%), (2) new breaks without detachment in 15 eyes (9%), (3) an operation for retinal detachment caused by the original break in seven eyes (4%), or (4) retinal detachment caused by a new break in eight eyes (5%). Failure rates of treatment among acutely symptomatic, chronically symptomatic, and asymptomatic subgroups were not statistically significant. The risk of treatment failure was higher for aphakic and pseudophakic eyes, and in eyes with peripheral retinal abnormalities in the fellow eye. Among 38 patients with failed treatments, 20 (52%) returned for further examination within one month of initial treatment, whereas eight of the 38 patients with failed treatments (21%) returned six months or more after initial treatment. Peripheral retinal abnormalities were recognized initially in 65 of the 171 fellow eyes (38%) and subsequently developed in nine of the fellow eyes (5%) during the follow-up interval. Further treatment is often necessary after initial treatment of peripheral retinal breaks, emphasizing the need for careful long-term follow-up care.

We reviewed 28 cases of culture-proven infectious scleritis and keratoscleritis to clarify the role of an operation in this disorder. Surgical management in 11 patients with keratoscleritis included cryotherapy, five; penetrating corneal-scleral graft, two; lamellar corneoscleral graft, two; and tectonic penetrating keratoplasty, two; in addition to intensive fortified antibiotic eyedrops. Eight patients with keratoscleritis were treated medically only with intensive fortified frequent antibiotic eyedrops, one; intensive instilled plus intravenous antibiotics, three; and instilled, intravenous, and subconjunctival antibiotics, four. Seven of eight patients treated with antibiotics alone and two of 11 patients who received surgical intervention in addition to antibiotics eventually required evisceration or enucleation of the eye. These results suggest that cryotherapy, lamellar or penetrating corneoscleral graft, in addition to intensive antibiotic therapy, may improve the outcome of patients with infectious keratoscleritis. Five eyes with isolated scleritis without corneal involvement were treated with conjunctival recession and cryotherapy in addition to aggressive antibiotics, and four were treated with antibiotics alone. The infections of these nine patients resolved.

We treated two patients with primary squamous cell carcinoma of the cornea without involvement of the corneoscleral limbus. Superficial keratectomy and cryotherapy in one patient and penetrating keratoplasty in the other patient resulted in no recurrence of the tumor after 46 and nine months, respectively. Actinic damage and late manifestation caused by poor vision in both eyes of both patients may have been the risk factors for development of this tumor.

Purpose To show the association between conjunctival papillomas present during infancy and maternal infection with human papillomavirus. Method Case report of conjunctival papillomas occurring in an infant born to a mother with a human papillomavirus infection of the vulva during pregnancy. Result The infant developed conjunctival papillomas caused by human papillomavirus of the female genital tract. Conclusions Conjunctival papillomas present during infancy may be caused by vertical transmission of the human papillomavirus from mother to infant during delivery. Mothers of infants with conjunctival papillomas should be examined for diseases associated with human papillomavirus.