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Purpose: To evaluate the risk factors for retinal tear (RT) or rhegmatogenous retinal detachment (RRD) associated with acute, symptomatic posterior vitreous detachment (PVD) in a large comprehensive eye care setting., Design: Retrospective cohort study., Participants: A total of 8305 adult patients in the Kaiser Permanente Northern California Healthcare System (KPNC) during calendar year 2018 who met inclusion criteria., Methods: The KPNC electronic medical record was queried to capture acute, symptomatic PVD events. Each chart was reviewed to confirm diagnoses and capture specific data elements from the patient history and ophthalmic examination., Main Outcome Measures: Presence of RT or RRD at initial presentation or within 1 year thereafter., Results: Of 8305 patients who presented with acute PVD symptoms, 448 (5.4%) were diagnosed with RT and 335 (4.0%) were diagnosed with RRD. When considering variables available before examination, blurred vision (odds ratio [OR], 2.7; confidence interval [CI], 2.2-3.3), male sex (OR, 2.1; CI, 1.8-2.5), age < 60 years (OR, 1.8; CI, 1.5-2.1), prior keratorefractive surgery (OR, 1.6; CI, 1.3-2.0), and prior cataract surgery (OR, 1.4; CI, 1.2-1.8) were associated with higher risk of RT or RRD, whereas symptoms of flashes were mildly protective (OR, 0.8; CI, 0.7-0.9). Examination variables associated with a high risk of RT or RRD included vitreous pigment (OR, 57.0; CI, 39.7-81.7), vitreous hemorrhage (OR, 5.9; CI, 4.6-7.5), lattice degeneration (OR, 6.0; CI, 4.7-7.7), and visual acuity worse than 20/40 (OR, 3.0; CI, 2.5-3.7). Late RTs or RRDs occurred in 12.4% of patients who had vitreous hemorrhage, lattice degeneration, or a history of RT or RRD in the fellow eye at initial presentation but only 0.7% of patients without any of these 3 risk factors. Refractive error had an approximately linear relationship with age at presentation of PVD, with myopic patients presenting at a younger age (r = 0.4)., Conclusions: This study, based in a comprehensive eye care setting, found the rate of RT and RRD associated with acute PVD to be lower than rates previously reported by retina subspecialty practices. Several patient features strongly predicted the presence of initial and late complications of acute PVD., (Copyright © 2021 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the outcomes of vitreoretinal surgery after choroidal tumor biopsy., Design: Retrospective, single-center, consecutive case series., Participants: A total of 739 consecutive patients undergoing choroidal tumor biopsy., Methods: All subjects who underwent transretinal or transscleral choroidal tumor biopsy for diagnostic or prognostic purposes between May 1993 and May 2013 were identified in our database. We then reviewed patients who subsequently required secondary vitreoretinal surgery for complications arising from such biopsies., Main Outcome Measures: Reason for vitreoretinal surgery, association with biopsy procedure, best-corrected visual acuity (BCVA; logarithm of the minimum angle of resolution [logMAR]), intraocular or extrascleral tumor dissemination, resolution of vitreous hemorrhage, reattachment of the retina with a single vitreoretinal procedure, number of additional vitrectomies undertaken, and number of enucleations., Results: A total of 20 of 739 eyes (2.7%) underwent vitreoretinal surgery for complications arising from choroidal tumor biopsy. The tumors consisted of choroidal melanoma in all 20 eyes. The reasons for the secondary surgery included persistent vitreous hemorrhage in 1.9% (14/739), rhegmatogenous retinal detachment in 0.7% (5/739), and endophthalmitis in 0.14% (1/739). Median BCVA improved from 2.0 logMAR (mean, 1.92 logMAR; range, 0.8-2.7 logMAR) before vitrectomy to 0.72 logMAR (mean, 0.88 logMAR; range, -0.14 to 2.7 logMAR) after vitrectomy and 0.76 logMAR (mean, 1.14 logMAR; range, 0.1-3.0 logMAR) at the final visit (P < 0.0001, t test). Permanent resolution of vitreous hemorrhage was achieved in 6 of 14 patients, and reattachment of the retina was achieved in 2 of 5 patients after the first vitrectomy. A median of 1 (mean, 1.5; range, 1-3) additional vitrectomy was performed. Enucleation was necessary in 3 of 20 eyes (15%). There were no cases of intraocular invasion or extrascleral extension after vitrectomy., Conclusions: Vitrectomy for complications of choroidal tumor biopsy is rare. Such corrective surgery is complex and is best undertaken by specialized ocular oncologists or vitreoretinal surgeons with experience in managing this problem., (Copyright © 2014 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To report various types of maculopathy caused by momentary exposure to a high-power handheld blue laser., Design: Consecutive case series., Participants: Fourteen eyes of 14 patients., Methods: Patients with a history of eye exposure to a blue laser device (450 nm and a power range of 150-1200 mW) to a single institution were included. Evaluation included a full ophthalmic examination, fundus photography, macular spectral-domain optical coherence tomography, and fundus fluorescein angiography., Main Outcome Measures: Analysis of the types of maculopathy and vitreoretinal pathologic features., Results: All patients were young males. The most common setting for injury was accidental at play. The types of maculopathies encountered were: a full-thickness macular hole (FTMH) in 4 eyes, a premacular subhyaloid hemorrhage in 5 eyes, premacular sub-internal limiting membrane hemorrhage in 2 eyes, an outer retinal disruption at the fovea in 1 eye, an epimacular membrane in 1 eye, and a schisis-like cavity in 1 eye. Best-corrected Snellen visual acuity at presentation ranged from 20/40 to 4/200 (mean, 20/290). Only 4 eyes (29%) improved spontaneously with increase in vision, whereas 10 eyes (71%) required intervention. The latter consisted of neodymium:yttrium-aluminum-garnet hyaloidotomy in the 5 eyes with subhyaloid hemorrhage and pars plana vitrectomy (PPV) for the eyes with FTMH and epimacular membrane. All 4 FTMH were closed successfully after PPV. Final mean best-corrected visual acuity in all cases was 20/35 (range, 20/15-20/300)., Conclusions: Exposure to high-power handheld laser devices can cause a variety of maculopathies that can reduce central vision permanently. Although vision may improve spontaneously, most cases require intervention. Unrestricted access to commercially available high-power handheld laser devices is dangerous and public awareness should be encouraged., (Copyright © 2014 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To report an association of congenital optic nerve anomalies with peripheral retina nonperfusion and to describe the clinical manifestations and treatment., Design: Retrospective, observational case series., Participants: Fifteen patients with congenital optic nerve anomalies referred for pediatric retina consultation were studied. Sixteen eyes of 9 patients with optic nerve hypoplasia and 8 eyes of 6 patients with other congenital optic nerve anomalies, including optic nerve coloboma, morning glory disc, and peripapillary staphyloma, were included., Methods: All patients underwent examinations under anesthesia. Wide-angle retina photographs and fluorescein angiograms were reviewed. The severity of nonperfusion was graded. The presence of fibrovascular proliferation (FP), vitreous hemorrhage (VH), and tractional retinal detachment (TRD) were documented. Anatomic outcome after treatment was recorded., Main Outcome Measures: Severity of nonperfusion, occurrence of secondary complications, and the anatomic outcome of patients who underwent laser treatment., Results: In patients with optic nerve hypoplasia, 12 of 16 eyes (75%) had severe peripheral nonperfusion, 12 of 16 eyes (75%) had FP, 3 of 16 eyes (19%) had VH, and 10 of 16 eyes (63%) had TRD. Six of these eyes with severe nonperfusion received laser photocoagulation to the nonperfused retina; laser-treated retinas remained attached in all 6 eyes. In patients with the other optic nerve anomalies, 7 of 8 eyes (88%) had mild to moderate nonperfusion, 2 of 8 eyes (25%) had FP, 1 of 8 eyes (12%) had VH, and 2 of 8 eyes (25%) had TRD. Six of 9 patients (67%) with optic nerve hypoplasia and 1 of 6 patients (17%) with other anomalies had a coexisting congenital brain disease., Conclusions: Congenital optic nerve anomalies may be associated with peripheral retina nonperfusion and the secondary complications of FP, VH, and TRD. In this select group of patients, the nonperfusion associated with optic nerve hypoplasia seemed to be more severe and associated more frequently with secondary complications. Peripheral retina examination in eyes with optic nerve anomalies may identify nonperfusion or FP. Laser treatment of the avascular retina may have helped prevent complications from proliferative retinopathy in eyes clinically observed to have progressed or considered at risk for progression to proliferative retinopathy., (Copyright © 2013 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To investigate in The Standard Care versus COrticosteroid for REtinal Vein Occlusion (SCORE) Study: (1) incidences of neovascular events and retinal capillary nonperfusion (abbreviated as "nonperfusion"), and their relationship with treatment groups; (2) neovascular incidences by nonperfusion status; and (3) pertinent baseline factors for their potential risk for neovascular events., Design: Two multicenter, randomized clinical trials, 1 evaluating participants with central retinal vein occlusion (CRVO) and the other evaluating participants with branch retinal vein occlusion (BRVO)., Participants: At 36 months, data were available for 81 participants with CRVO and 128 with BRVO., Intervention: Standard care (observation or grid photocoagulation) versus 1 or 4 mg intravitreal triamcinolone., Main Outcome Measures: Neovascularization of the iris (NVI), neovascular glaucoma (NVG), disc or retinal neovascularization (NVD/NVE), preretinal or vitreous hemorrhage (PRH/VH), and nonperfusion., Results: The cumulative 36-month incidences for CRVO and BRVO eyes, respectively, were 8.5% and 2.4% for NVI or NVG; 8.8% and 7.6% for NVD/NVE or PRH/VH. There were no differences in incidences of neovascular events or risk of nonperfusion when comparing the 3 treatment groups within diseases. For CRVO at 36 months, 16.6% of eyes with ≥5.5 disc areas of nonperfusion versus 4.0% of eyes with <5.5 disc areas of nonperfusion developed NVG (P = 0.0003); for BRVO at 36 months, 14.6% versus 2.4% developed NVD/NVE (P<0.0001). Similar results were noted for most other neovascular events. Nonperfusion was the only significant baseline factor for neovascularization in BRVO, with the risk of a neovascular event increasing with greater disc areas of nonperfusion, and the highest risk noted at ≥5.5 disc areas., Conclusions: In the SCORE Study, triamcinolone treatment was not associated with lower incidences of neovascular events or nonperfusion status compared with observation or grid photocoagulation. Cumulative 36-month incidences for most neovascular events were significantly higher for nonperfused than perfused eyes. Greater baseline disc areas of nonperfusion increased the risk of neovascularization in BRVO but not CRVO eyes, possibly owing to obscuration of retinal capillary details caused by dense hemorrhage at baseline for CRVO eyes. Increased risk of neovascularization was noted below the historical threshold of 10 disc areas of nonperfusion for retinal vein occlusion., (Copyright © 2011 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe clinical characteristics, including visual acuity (VA), genetic analysis, and management of complications, over a 30-year period in an African American family with macular dystrophy of the retina, locus 1 (MCDR1), commonly referred to as "North Carolina macular dystrophy.", Design: Observational, cohort study., Participants: Twelve family members from a 4-generation pedigree., Methods: A total of 12 African American patients in an affected family were examined. Clinical examination was documented during 2 different follow-up periods from 1979 to 1982 in 10 patients and from 2005 to 2009 in 11 patients. Genetic analysis was performed in 4 affected members during this time. Foveal microperimetry, fundus autofluorescence, and spectral domain optical coherence tomography (OCT) data were also obtained., Main Outcome Measures: Change in VA of 8 members followed over 3 decades and clinical data and management of complications for all patients., Results: Nine of 11 living family members had classic findings ranging from disease grade 2 (confluent foveal drusen, 8 eyes) to grade 3 (central coloboma-like lesion, 10 eyes). Two members developed choroidal neovascularization (CNV) requiring laser ablation, and 1 member developed non-clearing vitreous hemorrhage and underwent 25-gauge pars plana vitrectomy. Another family member developed exotropia and amblyopia in 1 eye by age 7 years. Those without CNV had no significant change in VA over 30 years. Linkage studies of 4 affected family members showed the same short tandem repeats on markers spanning D6S249 and D6S283 within the MCDR1 region of chromosome 6q16. Microperimetry analysis of an affected member with grade 3 MCDR1 revealed absent function in the region of the central coloboma-like lesions, corresponding to photoreceptor absence on OCT, although there were preserved foveal function and intact photoreceptors adjacent to the lesion., Conclusions: This African American family shares similar clinical findings as other MCDR1 pedigrees and the same haplotype as the originally described family from North Carolina. Clinical characteristics, including retinal features and stable VA in the absence of amblyopia and CNV, are similar to those in other reports. Eccentric viewing around impaired photoreceptors may explain good VA in patients with clinically severe-appearing macular lesions. Sequencing of the MCDR1 interval may help identify a protein responsible for early macular development., Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references., (Copyright © 2011 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To estimate the risk of hemorrhagic complications associated with 25-gauge pars plana vitrectomy (PPV) when warfarin (Coumadin; Bristol-Myers Squibb, New York, NY) or clopidogrel (Plavix; Bristol-Myers Squibb) are continued throughout the surgical period, as compared with a control group., Design: A single-center, retrospective, cohort study of 289 consecutive patients receiving either warfarin therapy or clopidogrel therapy or neither of those therapies who underwent 25-gauge PPV., Participants: Included were 61 patients (64 eyes; 64 PPV procedures) in the warfarin group and 118 (125 eyes; 136 PPV procedures) in the clopidogrel group. Warfarin patients were subdivided into 4 groups by international normalized ratio (INR). A control group included 110 patients (110 eyes; 110 PPV procedures) who were not receiving warfarin or clopidogrel., Methods: Retrospective chart review for which the criteria included: 25-gauge PPV, minimum age of 19 years, warfarin or clopidogrel use, and, if taking warfarin, an INR obtained within 5 days of surgery., Main Outcome Measures: Incidence of intraoperative and postoperative hemorrhagic complications., Results: The most common indications for anticoagulation therapy included: atrial fibrillation (38%), valvular heart disease (17%), and thromboembolic disease (16%). The most common indications for antiplatelet therapy included: cardiac stent (49%), coronary artery bypass grafting (24%), and history of transient ischemic attack (16%). No patient experienced anesthesia-related hemorrhagic complications resulting from peribulbar or retrobulbar block. Transient vitreous hemorrhage occurred in 1 (1.6%) of 64 PPV procedures in the warfarin group (P = 0.6531), 5 (3.7%) of 136 PPV procedures in the clopidogrel group (P = 1.0), and 4 (3.6%) of 110 PPV procedures in the control group. No choroidal or retrobulbar hemorrhages occurred in any patient., Conclusions: The rate of 25-gauge PPV hemorrhagic complications in patients who underwent systemic anticoagulation or who were receiving platelet inhibitor therapy is extremely low. Given the risks associated with stopping these therapies, the authors recommend that patients continue their current therapeutic regimen without cessation., (Copyright © 2011 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the incidence of neovascularization of the inner sclerostomy wound and occurrence of postoperative vitreous cavity hemorrhage (POVCH) after vitrectomy for proliferative diabetic retinopathy (PDR)., Design: Consecutive prospective longitudinal clinical study., Participants: Seventy-three eyes (58 patients) undergoing primary vitrectomy for PDR., Methods: Twenty-megahertz (MHz) high-resolution anterior segment ultrasonography was performed on all sclerostomy sites 2 months postoperatively and repeated at the time of any POVCH. The appearance of the inner sclerostomy wound was divided into 4 classes (normal, spheroidal, tent, and trapezoidal, representing entry site neovascularization). The occurrence, degree, and duration of POVCH and need for revision surgery with vitreous cavity washout (VCW) were recorded. Postoperative vitreous cavity hemorrhage was divided into 3 groups-namely, mild, moderate, and major., Main Outcome Measures: Inner sclerostomy wound appearance on ultrasonography, degree and timing of POVCH, and need for VCW., Results: There were 15 eyes in total with POVCH (20%): one patient had a persistent POVCH that required VCW. Fourteen other eyes (19%) had recurrent POVCH. Four (28%) of these 14 eyes with recurrent POVCH were classified as mild and 3 (21%) moderate: all cleared spontaneously with no further intervention needed. None of these had a trapezoidal image. Seven of the 14 eyes with recurrent POVCH were classified as major. Five of these 7 eyes had a trapezoidal image at 2 months postoperatively, and 4 required VCW (5.5% of total no. of eyes in study). All patients with a trapezoidal image experienced some degree of recurrent vitreous cavity hemorrhage (P = 0.0000024). The odds ratio was approximately 330:1. There was a significant correlation between the severity of POVCH and entry site appearance on ultrasound. In the first year of follow-up, all patients requiring VCW after recurrent POVCH had a trapezoidal image present at 2 months postoperatively (P = 0.009)., Conclusion: The appearance of a trapezoidal image on 20-MHz high-resolution anterior segment ultrasonography at a sclerostomy site after vitrectomy for PDR was highly correlated with the occurrence of nonclearing POVCH and need for VCW. Conversely, the absence of a trapezoidal image in patients with POVCH was associated with spontaneous hemorrhage clearance.

Purpose: To describe the presentations, etiologies, and visual outcomes of spontaneous and traumatic vitreous hemorrhage in children., Design: Retrospective case series of patients seen over 8 consecutive years., Participants: One hundred sixty-eight patients (186 eyes), younger than 18 years, with vitreous hemorrhage not secondary to active retinopathy of prematurity (ROP)., Methods: Charts were reviewed and data were compiled with special attention to demographic information, diagnosis, examination findings, visual acuity (VA) on presentation and last follow-up, treatment type, and length of follow-up., Main Outcome Measures: Etiologies, presenting symptoms, initial and final VAs, and management modalities., Results: Among 168 patients (186 eyes), the most common presenting symptom was decreased VA in older patients and strabismus and nystagmus in younger patients. Seventy-three percent of cases occurred secondary to manifest and occult trauma, with blunt (29.6%) and penetrating (24.7%) trauma being most common. Twenty-seven percent of hemorrhages occurred spontaneously, with regressed ROP being most common. Of the cases, 90.5% were unilateral and 9.5% were bilateral. Shaken baby syndrome accounted for 50% of bilateral cases. The most common management modalities were observation (50.0%) and incisional surgery (45.7%), but frequency of management modality varied by etiology. Visual outcomes, which were limited by variable follow-up and nonstandardized acquisition, were poorest with penetrating trauma and best with regressed ROP. There was no statistical difference in severe vision loss between children older than 8 years and younger than 8., Conclusions: Pediatric vitreous hemorrhage may have multiple etiologies, but manifest and occult trauma are most common. Regressed ROP is a common cause of spontaneous vitreous hemorrhage. A substantial proportion of patients with vitreous hemorrhage had severe vision loss, but outcomes were highly dependent on underlying etiology.

Purpose: To evaluate anterior and posterior segment complications and their management after iodine 125 plaque brachytherapy (IBT) for large uveal melanoma., Design: Retrospective nonrandomized interventional study., Participants: Ninety-six patients with a large uveal melanoma according to the Collaborative Ocular Melanoma Study criteria., Methods: The patients underwent primary IBT (median dose to tumor apex, 87 Gy). The median tumor height and diameter were 10.7 mm (range, 4.5-16.8) and 16.5 mm (range, 7.3-25.0), respectively, and the median follow-up time was 3.5 years (range, 0.3-10.4). Cumulative incidence analysis and competing risks regression were used to analyze the time to individual complications and to identify risk factors. Death and secondary enucleation were analyzed as competing risks., Main Outcome Measures: Cataract, iris neovascularization, glaucoma, maculopathy, optic neuropathy, vitreous hemorrhage, and persistent exudative retinal detachment (RD)., Results: The 5-year cumulative incidences of cataract, iris neovascularization, and glaucoma were 69% (95% confidence interval [CI], 57%-78%), 62% (95% CI, 50%-71%), and 60% (95% CI, 48%-70%), respectively. Posterior segment complications were less common. The 5-year incidences of maculopathy and optic neuropathy were 52% (95% CI, 35%-65%) and 46% (95% CI, 30%-61%), and those of vitreous hemorrhage and persistent RD were 36% (95% CI, 23%-48%) and 25% (95% CI, 15%-36%), respectively. More than 80% of complications were diagnosed within 3 years. Cataract was the earliest complication to appear. Except for cataract, the cumulative incidence of dying without developing a particular complication was 0.24 to 0.62 times that of first developing the complication. Increasing tumor height, which correlates to increasing doses to adjacent tissues, was associated with time to cataract (P = 0.017), iris neovascularization (P = 0.087), and RD (P = 0.046). Maculopathy and optic neuropathy were associated primarily with distance to the fovea (P = 0.015) and optic disc (P = 0.015), respectively. Of 57 patients with cataract, 47% underwent cataract extraction, and 12% of 51 patients with glaucoma were treated with cyclophotocoagulation. The prevalences of cataract, elevated intraocular pressure, and RD were 43%, 39%, and 13%, respectively, at 5 years., Conclusions: The frequency with which ocular complications develop after IBT is notably influenced by competing risks. Cumulative incidence and prevalence analysis provide realistic estimates for patient counseling.

Purpose: To evaluate the frequency of fibrovascular ingrowth (FVIG) at sclerotomy sites in vitrectomized eyes of diabetic patients with postoperative vitreous hemorrhage referred for ultrasound biomicroscopy (UBM)., Design: Retrospective observational case series., Participants: Twenty-six eyes of 23 diabetic patients with recurrent, nonclearing postoperative vitreous hemorrhage subsequent to pars plana vitrectomy (PPV) for proliferative diabetic retinopathy (PDR)., Methods: Ultrasound biomicroscopy evaluation of all sclerotomy sites in patients referred for postoperative nonclearing or recurrent vitreous hemorrhage after PPV for PDR. Correlation with intraoperative findings was obtained in eyes undergoing revision of the vitrectomy. Eight eyes underwent repeat UBM after revision of the vitrectomy, and changes at previous sclerotomy sites were evaluated., Main Outcome Measures: Ultrasound biomicroscopy images at each sclerotomy site were classified into 3 categories: none (grade 0), minor (grade 1), and major (grade 2). The UBM characteristics of each category were defined by the examiner. Logistic regression analysis was performed to identify prognostic factors associated with development of FVIG in the study patients., Results: Grade 1 or 2 FVIG was detected in 85% of cases, and grade 2 FVIG was identified in >/=1 sclerotomy site in 58% of cases. Grade 1 or 2 FVIG was detected in 56% of microvitrector sites, 41% of infusion sites, and 61% of light port sites. Ten patients underwent repeat vitrectomy because of recurrent nonclearing vitreous hemorrhage and UBM images showing FVIG. Inspection of the sclerotomy site confirmed the UBM findings in every case. Eight of these patients underwent follow-up UBM evaluation subsequent to the repeat vitrectomy. In 6 of the 8 patients, follow-up UBM showed no residual FVIG., Conclusions: Ultrasound biomicroscopy showed FVIG in a high proportion of eyes that experienced recurrent nonclearing vitreous hemorrhage after PPV for PDR. Ultrasound biomicroscopy is capable of detecting and characterizing FVIG at sclerotomy sites and may aid in reoperative planning.

Objectives: To introduce and evaluate the infusion and aspiration rates and operative times of the 25-gauge transconjunctival sutureless vitrectomy system (TSV) DESIGN: In vitro experimental and comparative interventional study., Participants and Controls: Twenty eyes of 20 patients underwent a variety of vitreoretinal procedures using the 25-gauge TSV, including idiopathic epiretinal membrane (n = 10), macular hole (n = 4), rhegmatogenous retinal detachment (n = 3), branch retinal vein occlusion (n = 2), diabetic vitreous hemorrhage (n = 1), and 20 cases similar in diagnosis and severity were matched to provide comparison between duration of individual portions of the surgical procedures with the existing 20-gauge vitrectomy system., Methods: Description of the 25-gauge TSV is provided; infusion and aspiration rates of the 25-gauge and standard 20-gauge vitrectomy system were measured in vitro using balanced saline solution and porcine vitreous for several levels of aspirating power and bottle height, and operating times of individual portions of surgical procedures were measured for the 25-gauge and 20-gauge vitrectomy system., Main Outcome Measures: Infusion, aspiration rates, and operative times of the 20-gauge and 25-gauge vitrectomy system., Results: Infusion and aspiration rates of the 25-gauge TSV system were reduced by an average of 6.9 and 6.6 times, respectively, compared with the 20-gauge system when balanced saline solution was used. The average flow rate of the Storz 25-gauge cutter (at 500 mmHg, 1500 cuts per minute [cpm]) was 40% greater than that of the 20-gauge pneumatic cutter (at 250 mmHg, 750 cpm) but about 2.3 times less than the 20-gauge high-speed cutter (at 250 mmHg, 1500 cpm). Mean total operative time was significantly greater for the 20-gauge high-speed cutter (26 minutes, 7 seconds) than for the 25-gauge vitrectomy system (17 minutes, 17 seconds) (P = 0.011)., Conclusions: Although the infusion and aspiration rates of the 25-gauge instruments are lower than those for the 20-gauge high-speed vitrectomy system, the use of 25-gauge TVS may effectively reduce operative times of select cases that do not require the full capability of conventional vitrectomy.

Purpose: To identify the incidence of Terson's syndrome in children., Design: Prospective, observational case series., Participants: Fifty-seven consecutive children with known intracranial hemorrhage from nonabuse causes., Methods: Dilated fundus examination to detect intraretinal hemorrhages or other abnormalities., Main Outcome Measures: Presence or absence of intraretinal hemorrhages or other abnormalities., Results: Fifty-five patients (96%) had no evidence of intraretinal or vitreous hemorrhage. Two patients had abnormal retinal examinations. One patient had a single dot hemorrhage associated with presumed infectious white retinal lesions. The second patient had three flame and two deeper dot intraretinal hemorrhages after a motor vehicle accident (1.5% incidence of retinal hemorrhage)., Conclusions: Retinal hemorrhage is uncommon in children with intracranial hemorrhage not resulting from shaken baby syndrome. The maximal incidence of intraretinal hemorrhage in children with nonabuse intracranial hemorrhage is 8%.

Objective: To report the prevalence of vitreous hemorrhage in pars planitis and to compare the prevalence of hemorrhage for children and adults with the disease., Design: A retrospective, cross-sectional observational study., Participants: One hundred eighteen consecutive patients with pars planitis who were evaluated at the Oregon Health and Science University Uveitis Clinic between September 1985 and April 2000., Method: A review of clinical records., Main Outcome Measures: For all patients, we recorded presence or absence of vitreous hemorrhage, as well as laterality and cause. Children were defined as being age 16 years or younger at diagnosis, and adults were defined as being aged 17 years or older at diagnosis., Results: Fourteen percent of patients with pars planitis experienced vitreous hemorrhage. Persons with hemorrhage were significantly younger at the time of disease diagnosis than persons without hemorrhage (P = 0.040). The difference in prevalence of vitreous hemorrhage between children (28%) and adults (6%) was statistically significant (P = 0.003). The difference in prevalence of hemorrhage as a presenting feature between children (20%) and adults (1%) was also statistically significant (P = 0.001)., Conclusions: Children with pars planitis are more likely than adults to experience vitreous hemorrhage. Pars planitis should be considered in the differential diagnosis of pediatric vitreous hemorrhage.

Objective: To investigate outcomes of vitreoretinal surgery for complications of branch retinal vein occlusion (BRVO)., Design: Retrospective, noncomparative case series., Participants: The medical records of all patients who underwent vitreoretinal surgery for complications of BRVO at Bascom Palmer Eye Institute between January 1, 1991 and December 31, 1998 were reviewed. Thirty-six eyes from 36 consecutive patients were identified., Main Outcome Measures: Visual acuity outcomes include preservation of preoperative visual acuity and visual acuity greater than or equal to 20/40, 20/200 and 5/200. When preoperative retinal detachment was present, the anatomic outcome assessed was complete retinal attachment. Postoperative event rates of retinal detachment, vitreous hemorrhage, epiretinal membrane (ERM), and cataract were tabulated. All outcomes were assessed at 6 months., Results: Surgical indications included nonclearing vitreous hemorrhage (17 patients), traction retinal detachment involving the macula (15), and ERM (4). Mean follow-up was 19 months. Preoperatively, best-corrected vision was greater than or equal to 20/200 in 19/36 (53%) eyes. Six months postoperatively, best-corrected vision was greater than or equal to 20/40 in 12/36 (33%) eyes, greater than or equal to 20/200 in 27/36 (75%) eyes, and greater than or equal to 5/200 in 31/36 (86%) eyes. Postoperative complications included retinal detachment (2/36; 6% eyes), ERM (3; 8%), vitreous hemorrhage (2; 6%), suprachoroidal hemorrhage (1; 3%), central retinal vein occlusion (1; 3%), and central retinal artery occlusion (1; 3%). Clinical features associated with better visual outcome include better preoperative visual acuity (P: = 0.05), absence of preoperative afferent pupillary defect (P: = 0.01), and absence of preoperative macular edema (P: = 0.08)., Conclusions: Following surgery, retinal attachment and improved visual acuity were achieved in the majority of patients. Pre-existing pathology and postoperative complications may limit final vision in eyes with BRVO.

Objective: This study was aimed at assessing changes at the sclerotomy site using the ultrasound biomicroscope (UBM) in eyes that underwent primary pars plana vitrectomy for complications of proliferative diabetic retinopathy., Design: Prospective, observational case series., Participants: Eighty-six eyes of 84 patients with vitreous hemorrhage caused by proliferative diabetic retinopathy., Intervention: Three-port pars plana vitrectomy followed by UBM evaluation of all sclerotomy sites between 6 and 8 weeks after surgery. Correlation with intraoperative findings done in case of reoperations. Forty-one eyes had repeat UBM at 6 months., Main Outcome Measures: The changes at the sclerotomy site were classified into six groups: well healed, gape, plaque, vitreous incarceration, fibrovascular proliferation, and anterior hyaloidal fibrovascular proliferation (AHFVP). The UBM characteristics of each of the groups were defined. The findings at 6 months were compared with those at 6 to 8 weeks., Results: At 6 to 8 weeks after surgery, most sclerotomies were well healed or had either moderate to high reflective plaques bridging the site. Wound gape was seen in 22.1% of active ports, 32.6% of light ports, and 25.6% of infusion ports. Vitreous incarceration was seen most often at the infusion port (18. 6% of eyes). Fibrovascular proliferation was seen in 9.3% of active ports, 12.8% of light ports, and 15.1% of infusion ports. Thirteen eyes had recurrent vitreous hemorrhage 6 to 8 weeks after surgery. Cases with rebleeding and no fibrovascular proliferation at the sclerotomy on UBM did well with outpatient fluid-air exchange (two eyes) or observation only (three eyes). Those with fibrovascular proliferation on UBM (eight eyes) required more extensive surgery., Conclusions: UBM is helpful in detecting complications at the sclerotomy sites after pars plana vitrectomy and is an invaluable tool in the assessment of the patient before reoperation.

Objective: To report for the first time a case series of vitreoretinal pathologic conditions after laser in situ keratomileusis (LASIK) and to determine its incidence., Design: Case series., Participants: Five refractive surgeons and 29,916 eyes that underwent surgical correction of ametropia (83.2% were myopic) ranging from -0.75 to -29.00 diopters (D; mean: -6.19 D) and from +1.00 to +6.00 D (mean: +3.23 D) participated in this retrospective study., Main Outcome Measures: Vitreoretinal complications after LASIK., Results: The clinical findings of 20 eyes (17 patients) with LASIK-related vitreoretinal pathologic conditions are presented. Fourteen eyes experienced rhegmatogenous retinal detachments (RDs). Two eyes experienced corneoscleral perforations with the surgical microkeratome when a corneal flap was being performed (one experienced a vitreous hemorrhage and the other later experienced an RD). In four eyes, retinal tears without RDs were found. In one eye, a juxtafoveal choroidal neovascular membrane (CNVM) developed. Retinal tears were treated with argon laser retinopexy or cryotherapy. Corneoscleral perforations were sutured, and the RD was managed with vitrectomy. The remaining RDs were managed with vitrectomy, cryoretinopexy, scleral buckling, argon laser retinopexy, or pneumatic retinopexy techniques. The CNVM was surgically removed. The incidence of vitreoretinal pathologic conditions determined in our study was 0.06%., Conclusions: Serious complications after LASIK are infrequent. Vitreoretinal pathologic conditions, if managed promptly, will still result in good vision. It is very important to inform patients that LASIK only corrects the refractive aspect of myopia. Complications of the myopic eye will persist.

Objectives: An increasing number of cases are being recognized in which a periocular anesthetic for cataract surgery has been inadvertently injected directly into the globe under high pressure until the globe ruptures or "explodes." The objectives of the current study were to (1) analyze this injury clinically and histopathologically through a series of seven case reports; (2) reproduce the injury experimentally in human eyebank eyes, live anesthetized rabbit eyes, and human cadaveric eyes; (3) investigate the biophysical basis of the injury; and (4) outline recommendations to help decrease the risk of ocular rupture with periocular injections. DESIGNS/PARTICIPANTS: Clinical, histopathologic, experimental animal, autopsy eye, and theoretical biophysical study., Methods: The clinical and histopathologic findings of the patients' eyes were documented. Human eyebank eyes, live anesthetized rabbit eyes, and human cadaveric eyes were exploded via direct intraocular saline injection. The laws of Bernoulli, LaPlace, Friedenwald, and Pascal were used to investigate theoretically the biophysics of the injury., Results: The findings of anterior and posterior scleral rupture, retinal detachment, vitreous hemorrhage, and lens extrusion were observed clinically and experimentally. In some clinical and experimental cases, the anterior segment appeared entirely normal despite a posterior rupture. The surgeon proceeded with and completed the cataract surgery in two of the seven clinical cases without knowledge of the rupture. The pressure required to produce such an injury is in the range of 2800 to 6400 mmHg, and this pressure is more easily attained with a 3-ml syringe than with a 12-ml syringe., Conclusions: Explosion of an eyeball during the injection of anesthesia for ocular surgery is a devastating injury that may go unrecognized. The probability of an ocular explosion can be minimized by (1) the use of a blunt needle and a 12-ml syringe, (2) aspirating the plunger and wiggling the syringe before injection, (3) discontinuing the injection if corneal edema or resistance to injection is noted, and (4) inspecting the globe for evidence of intraocular injection before ocular massage or placement of a Honan balloon. On recognition of an ocular explosion, immediate referral to and intervention by a vitreoretinal surgeon is optimal.

Objective: To demonstrate the feasibility of trans-scleral diode laser photocoagulation for the treatment of proliferative sickle cell retinopathy., Design: Interventional case report., Intervention: Trans-scleral diode laser scatter photocoagulation was applied to both eyes of a 30-year-old man with hemoglobin SC disease., Main Outcome Measures: Regression of retinal vascular proliferation and of dye leakage on fluorescein angiography., Results: After coagulation, vascular proliferation receded completely. Vitreous bleeding was absorbed. There were no side effects during follow-up (22 months)., Conclusion: Trans-scleral diode laser photocoagulation proved to be an effective and safe treatment in a case of proliferative sickle cell retinopathy with vitreous bleeding.

Objective: To examine the anatomic features and surgical indications of familial exudative vitreoretinopathy (FEVR) complicated with rhegmatogenous or tractional retinal detachment., Design: Retrospective noncomparative case series., Participants: Twenty-eight eyes of 25 patients who had either clinically suspected or fully diagnosed FEVR. Of these, 25 had rhegmatogenous retinal detachment, 2 had tractional retinal detachment, and 1 had tractional retinal detachment plus vitreous hemorrhage., Interventions: The authors carefully observed the vitreoretinal interface during surgery, studied the clinical and anatomic features of FEVR, and then evaluated the surgical results., Results: The vitreoretinal adhesions were so strong in the peripheral avascular area that iatrogenic retinal breaks easily occurred in 22 of 28 eyes. In all cases, the bimanual technique with vitreous scissors and forceps was required to dissect the posterior vitreous membrane from the retinal surface. The retina was reattached in 24 of 28 cases (85.7%), and visual acuity improved in 20 eyes (71.4%)., Conclusion: Dissection of the vitreous in the peripheral avascular area is very difficult in FEVR, and those patients for whom this procedure was not successfully performed may have a poorer prognosis.

Objective: To evaluate the ocular effects of blunt trauma due to injury from a paintball pellet., Design: Noncomparative case series., Participants: Thirteen patients who suffered ocular injury from paintballs are described. The patients presented to six different civilian and military emergency departments in tertiary care medical centers., Intervention: Patients were treated for the ocular injury., Main Outcome Measures: Patients were evaluated for initial and final visual acuity. The reason for persistent loss of vision was delineated., Results: There were 12 males and 1 female with an average age of 21 years (range, 12-33 years). Eleven of the 13 had no ocular protection at the time of the ocular injury. On initial examination, nine patients had a hyphema, nine had a vitreous hemorrhage, six had a retinal tear or detachment, three had corneal or corneal-scleral ruptures, and one had traumatic optic neuropathy. The final visual acuity was 20/40 or better in two patients, 20/50 to 20/150 in three patients, and 20/200 or worse in eight patients., Conclusion: Injuries due to paintball pellets can result in severe ocular damage and significant loss of vision. Eyecare professionals should be aware of the risks of this sport and must strongly advise participants to wear adequate protection when involved in this activity.

Objective: The authors evaluated the clinical, fluorescein, and indocyanine green (ICG) angiographic characteristics of the macular variant of idiopathic polypoidal choroidal vasculopathy (IPCV)., Design: Observational case series., Participants: The records, photographs, and fluorescein and ICG angiograms of eight eyes of seven patients with IPCV lesions confined to the macula were reviewed., Main Outcome Measures: The visual acuity, fundus examination, fluorescein and ICG angiographic characteristics, and clinical course were compared., Results: All patients demonstrated polypoidal lesions arising from macular choroidal vessels on ICG angiography. One patient had bilateral lesions. These lesions appeared hyperfluorescent in the early phases of both fluorescein and ICG angiography. Late-phase leakage was seen in cases associated with subretinal fluid or exudate. None of these patients demonstrated polypoidal lesions arising from the peripapillary choroidal circulation or peripapillary choroidal neovascularization. Three eyes with polypoidal lesions that were associated with subretinal fluid and exudates were treated with photocoagulation. Five eyes were not treated. Final visual acuity ranged from 20/20 to hand motions. Severe visual loss was associated with vitreous and subretinal hemorrhage, but this resolved without permanent severe visual loss in several cases., Conclusions: In the macular variant of IPCV, ICG and fluorescein angiography demonstrate characteristic macular polypoidal lesions without evidence of peripapillary lesions. The vascular origin of these polypoidal lesions appears to be the macular choroidal circulation. This is distinguished from classic IPCV, in which lesions appear to arise from the peripapillary choroidal circulation. Visual prognosis appears to be good, with most patients retaining visual acuity of 20/80 or better. If subretinal fluid or exudates reduce visual acuity, photocoagulation should be considered.

Objective: This study aimed to review visual morbidity resulting from inadvertent globe penetration during administration of local anesthetic and to identify the most appropriate management., Design: The records of 20 consecutive patients referred to a specialist vitreoretinal unit over a 2-year period were reviewed., Participants: Twenty eyes of 20 consecutive patients were included., Intervention: Observations included type of local anesthetic administered (e.g., retrobulbar or peribulbar), level of training of person administering the block, type of needle used for the block, and findings at presentation to the vitreoretinal unit. The authors also observed results of B-scan ultrasound evaluation of the retina, interval between the recognition of the complication and referral, as well as nature and timing of subsequent surgical intervention., Main Outcome Measures: Final visual acuity and retinal status (attached versus detached) were measured., Results: The most common presentation was vitreous hemorrhage observed from the first postoperative day. Ten eyes were found to have an associated retinal detachment on initial assessment in the vitreoretinal unit. These eyes generally had a poor visual outcome despite vitrectomy with long-acting gas or silicone oil tamponade. Seven (70%) of the remaining eyes with attached retina at the time of presentation achieved good visual recovery after vitrectomy., Conclusions: The authors recommend prompt referral for consideration of early vitrectomy in eyes with dense vitreous hemorrhage after inadvertent globe penetration. This management may improve the overall visual prognosis by preventing subsequent retinal detachment.

Purpose: To quantitate the effect of diabetic vitrectomy on each patient's visual system and function., Methods: The anatomic and visual acuity outcomes of diabetic vitrectomy among three surgeons at one institution over a 4-year time interval were studied. Outcome parameters describing the visual system function were defined and applied to quantitate the effect on visual system disability., Results: The anatomic and visual success rates and prognostic factors in the cohort of 213 patients by standard statistical analysis were similar to previous studies. The study eye was the eye with better vision in 68 (32%) patients at the conclusion of the study, and vision was equal to the fellow eye in 35 (16%) patients. The mean impairment of the visual system by the American Medical Association Guidelines for Disability was reduced from 61% preoperatively to 50% postoperatively. The factor associated with greatest degree of reduction of impairment of the visual system was a previtrectomy diagnosis of vitreous hemorrhage. There was at least a one-step improvement of visual system function in 65 (31%) patients., Conclusions: Vitrectomy for complications of severe proliferative diabetic retinopathy is especially valuable in improving the patient's overall visual function.

Purpose: To determine if adjunctive endolaser photocoagulation has further improved the outcome of early vitrectomy for severe vitreous hemorrhage in young patients with type I insulin-dependent diabetes., Method: The authors reviewed clinical records and fundus photographs of all primary diabetic vitrectomies performed at the Yale Eye Center between July 1986 and June 1993. Only young patients with type I diabetes who underwent vitrectomy within 6 months of vitreous hemorrhage were included., Results: Of 197 vitrectomies for diabetic retinopathy, 12 eyes of ten patients met the Diabetic Retinopathy Vitrectomy Study Group criteria. Patients ranged in age from 24 to 29 years (mean, 27.3 years) and had 11 to 21 years (mean, 17.2 years) of history of diabetes. Preoperative visual acuity was 5/200 in seven eyes, 2/200 in three eyes, hand motions in one eye, and light perception in one eye. The duration of vitreous hemorrhage was approximately 1 month in two eyes, 1 to 3 months in five eyes, and 3 to 6 months in five eyes. Neovascularization was documented in 12/12 eyes. Preoperatively, all patients had received panretinal photocoagulation with 1937 to 5328 burns (mean, 4126). Postoperative follow-up ranged from 12 to 38 months (mean, 24.6 months). Best-corrected postoperative visual acuity was 20/40 or better in 7 eyes (58.33%) and 20/70 or better in 11 eyes (91.66%). Neovascularization involuted in 11/12 eyes and remained so till the last follow-up., Conclusion: Patients with type I diabetes with severe vitreous hemorrhage benefit from early endolaser photocoagulation combined with current vitrectomy techniques. The authors' findings are consistent with those of the Diabetic Retinopathy Vitrectomy Study Group, and patients can expect both improved visual acuity and anatomic success.

Background: In several reports, early vitrectomy has been proposed for eyes with vitreous hemorrhage due to Terson syndrome as a means to hasten visual recovery. But the development of nuclear sclerosis and the neurologic problems arising from this disease encourage surgeons to wait for spontaneous resorption, especially with young patients. Although the formation of epiretinal membranes has been described, to the authors' knowledge retinal detachment with proliferative vitreoretinopathy in Terson syndrome never has been observed., Methods: The authors report five eyes from four patients with Terson syndrome due to spontaneous aneurysm rupture, in whom retinal detachment with proliferative vitreoretinopathy developed., Results: The early onset and the severe clinical course of proliferative vitreoretinopathy in these eyes showed parallels to traumatic proliferative vitreoretinopathy. The retina in all eyes could be reattached., Conclusion: The authors point out the necessity for accurate and close follow-up and early, extensive surgical treatment in Terson syndrome, especially in patients with a reduced general state of health.

Purpose: The authors sought to provide relevant data regarding the demographic and clinical aspects of spontaneous and traumatic vitreous hemorrhages to guide clinicians in better delineating the expected etiologic patterns of these hemorrhages in an urban environment., Methods: The records of 253 consecutive patients with newly diagnosed vitreous hemorrhage seen in a general eye clinic were selected for retrospective analysis. To minimize selection bias of a tertiary care center, patients who were referred to the clinic by outside ophthalmologists for vitreoretinal consultation or those with a history of recent intraocular surgery, postoperative complications, or loss to follow-up were excluded from study. Demographic, ocular, and general medical variables were tabulated for the 200 patients (230 eyes) who met our inclusion criteria., Results: Fifty percent of the patients were black, 26% were white, 23% were Hispanic, and 1% was Oriental. The causes of vitreous hemorrhage were proliferative diabetic retinopathy (PDR) (35.2%), trauma (18.3%), retinal vein occlusion (7.4%), retinal tear without a detachment (7.0%), posterior vitreous detachment (6.5%), proliferative sickle retinopathy (5.7%), retinal tear with a detachment (4.8%), subretinal neovascularization from macular degeneration (2.2%), hypertensive retinopathy (1.7%), unknown (2.5%), and other causes (8.7%). Among black patients with spontaneous vitreous hemorrhage, sickle cell retinopathy and retinal vein occlusion were major causes, each accounting for more than 15% of the cases. Systemic hypertension was associated with vitreous hemorrhage from retinal vein occlusion., Conclusion: The authors propose that despite the wide array of causative factors of vitreous hemorrhage, the evaluation of demographic, ocular, and medical variables can significantly aid clinicians in identifying its etiologic patterns.

Background: Perimacular retinal folds have been reported in the shaken baby syndrome, but have not been described in adults with Terson syndrome., Methods: The authors present two patients with perimacular retinal folds in adults with Terson syndrome. In one patient, electron microscopy was used to examine the membrane spanning the fold., Results: The membrane spanning the perimacular fold was found to be internal limiting membrane. The pathogenesis of these perimacular folds found in adults sustaining direct head trauma is probably different from that previously described for folds seen in infant eyes with shaken baby syndrome., Conclusion: Retinal folds occurring in Terson syndrome are clinically similar to those seen in the shaken baby syndrome.

Purpose: A study was performed to determine if diabetic subjects who fail to respond to initial panretinal photocoagulation with regression of retinopathy risk factors do better with supplemental panretinal photocoagulation., Methods: Thirty-five patients with 3 or more retinopathy risk factors who failed to respond to panretinal photocoagulation with regression to less than 3 retinopathy risk factors by 3 weeks after initial panretinal photocoagulation were prospectively randomized to augmentation laser panretinal photocoagulation (MORE) or to no additional treatment (NOMORE)., Results: Six months after initial treatment, the MORE group (n = 16) had regressed a mean of -0.94 retinopathy risk factors (with 95% confidence interval [CI] -1.60 to -0.26), compared with -0.21 retinopathy risk factors (95% CI -0.69 to 0.27) in the NOMORE (n = 19) group (P = 0.055). However, by 1 year, there was no statistically significant difference in the amount of regression of retinopathy risk factors with a mean decrease of -1.12 (95% CI -2.0 to -0.24) versus -1.05 retinopathy risk factors (95% CI -1.80 to -0.28) in the 2 groups, respectively. Similarly, for visual acuity, there was no difference in outcome. For all study patients, the persistence of three or more retinopathy risk factors was associated with a poorer visual result than if there was regression to less than three retinopathy risk factors., Conclusion: This study shows that although augmentation panretinal photocoagulation achieved faster regression of retinopathy risk factors, by 1 year, there was no difference in either mean regression of retinopathy risk factors or visual acuity between eyes treated or not treated with augmentation panretinal photocoagulation. In addition, the study shows that the persistence of 3 or more retinopathy risk factors 1 year after treatment was associated with a poorer visual result. Because sample size limited the power of the study to find small differences between groups, and because in proliferative diabetic retinopathy small differences could be important clinically, the authors do not recommend changes in current clinical practice.

Purpose: The purpose of this study is to compare photocoagulation with the argon green, krypton red, and diode infrared laser indirect ophthalmoscopes in an experimental setting., Methods: Photocoagulation was performed with each of the laser indirect ophthalmoscopes in a grid pattern within one sector of the same eye of 14 Dutch-belted rabbits. Treatment was performed either with or without scleral depression. Measurements of the retinal burn diameters were performed after hemisecting the globes, and the burns were examined with light microscopy., Results: Variation in burn intensity and diameter (10% to 28%) was common with all 3 laser indirect ophthalmoscopes. Five times more output energy was required to make equivalent burns with the diode laser indirect ophthalmoscope than with the argon or krypton laser indirect ophthalmoscopes. Choriovitreal hemorrhages only occurred during scleral depression. Histopathologically, the argon green laser indirect ophthalmoscope burns spared the choroid and inner sclera, while the intense krypton and diode burns had full-thickness choroidal involvement and even thermal injury to the inner sclera. Scleral depression reduced the mean energy required to create equivalent burns with all three laser indirect ophthalmoscopes. There was a 10% to 40% reduction in the mean retinal burn diameter with scleral depression (argon green, P < 0.0005; krypton red, P < 0.0005; and diode, P < 0.025)., Conclusion: Photocoagulation with the argon green, krypton red, or diode infrared laser indirect ophthalmoscopes is a safe and effective method of retinal ablation. Decreasing the posterior nodal distance of the eye with scleral depression will produce a smaller spot on the retina with the laser indirect ophthalmoscope.

The authors studied prospectively the incidence of and risk factors for high altitude retinal hemorrhages among 14 members of the 1989 American Everest Expedition. All subjects had comprehensive eye examinations and fundus photography performed at sea level before the expedition and again at the Mt. Everest Base Camp after 6 weeks of exposure to altitudes between 5300 and 8200 meters. Asymptomatic intraretinal hemorrhages were found in five eyes of four climbers. An additional eye of one of these climbers had a central retinal vein occlusion with vitreous hemorrhage, which reduced visual acuity to counting fingers. Higher baseline intraocular pressure and use of nonsteroidal anti-inflammatory drugs were found to be significant risk factors for development of altitude retinopathy.

The authors assessed the relationship between early objective response to panretinal photocoagulation (PRP) and the subsequent long-term visual outcome in 59 eyes of 59 consecutive patients who developed proliferative diabetic retinopathy while under the care of a retinal specialist. Thirty five eyes (59%) had regression of high-risk retinopathy characteristics within 3 months of treatment. Eighteen of these eyes (52%) had a final visual acuity of 20/20 or better with a mean follow-up of more than 4 years. Only 2 of the 24 nonresponder eyes (8%) had visual acuity of 20/20 or better. Thirteen of the responder eyes (37%) sustained a delayed vitreous hemorrhage, which was usually self-limited. Three responders underwent vitrectomy with excellent visual results. The authors conclude that the beneficial effect of PRP on visual outcome is directly related to the regression of retinopathy risk factors and that the long-term visual prognosis in high-risk eyes manifesting a favorable initial response to PRP is excellent.

Forty-four patients with acquired immune deficiency syndrome with cytomegalovirus (CMV) retinitis (64 eyes) intolerant of or refusing systemic antiviral therapy received 710 intravitreal injections of ganciclovir at the dosage of 400 micrograms per injection. The patients were followed for a mean period of 9 weeks. Induction therapy consisted of two injections a week until healing. Maintenance therapy consisted of one injection a week until relapse. All but 1 of 53 induction courses led to cicatrization, after a mean of 6.6 injections. In 54 maintenance courses, the 8-week relapse rate was 53%. During intravitreal therapy, involvement of the fellow eye occurred in 11% of the patients and CMV infection developed in a nonocular site in 16% of the patients. Five retinal detachments and two intravitreal hemorrhages occurred. No endophthalmitis or cataract was noted. Intravitreal ganciclovir appears to be a safe and effective alternative in patients intolerant of intravenous anti-CMV drugs.

The charts of 23 patients with needle penetration of the globe during retrobulbar or peribulbar injections between January 1980 and May 1990 were reviewed. Possible needle penetration risk factors included high myopia, previous scleral buckling procedures, injection by nonophthalmologists, and poor patient cooperation during the injection. Of the 23 cases of ocular penetration, 16 (70%) were from sharp (22-, 23-, and 25-gauge) needles, and 7 (30%) were from blunt (23- and 25-gauge) needles. Management options depended on the severity of the intraocular injury. Retinal breaks without retinal detachment were treated by laser photocoagulation (four cases) or cryopexy (one case) and were observed in three cases. More advanced complications (retinal detachment and vitreous hemorrhage) were usually treated by pars plana vitrectomy with or without a scleral buckle (12 of 14 cases). The final visual acuity was 20/400 or better in only 2 of the 14 retinal detachment cases. In cases without retinal detachment, the final visual acuity was 20/50 or better in 7 of 9 cases.

Between February 1988 and May 1990, the authors treated 12 perforating ocular injuries caused by anesthetic injections around the eye. All 12 injections were performed by nonophthalmologists. Eleven were performed by anesthesiologists and one by a certified nurse anesthetist. Five were caused by blunt needles and seven by sharp needles. Two of the eyes had multiple posterior exit wounds. The five eyes that had sharp needle, single perforations (i.e., one entrance wound and one exit wound) were easily managed with cryopexy, laser, or observation. All five of these eyes have a visual acuity of 20/40 or better. Six vitrectomies were performed on the five patients with single perforations caused by blunt needles; three of these eyes have a visual acuity of counting fingers or worse. The two patients who had multiple posterior exit wounds required a total of four procedures. The visual acuity in these eyes is 20/400 and light perception. Anesthesia personnel should be well trained before attempting ocular anesthesia. The use of blunt needles does not prevent ocular penetration.