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Importance Aggressive posterior retinopathy of prematurity (AP-ROP) rapidly progresses to retinal detachment despite application of photocoagulation. Early vitreous surgery might achieve prompt regression of neovascular activity and a high incidence of retinal reattachment. Objective To evaluate visual outcomes in eyes with AP-ROP after early vitreous surgery. Design Retrospective nonrandomized study of patients who underwent early vitreous surgery with lensectomy when retinal detachment developed despite photocoagulation. Aphakic correction with spectacles or contact lenses and the use of orthoptics were continued postoperatively. The best-corrected visual acuity (VA) was measured in eyes with a total retinal reattachment using the preferential looking technique in patients ranging in age from 8 months to no more than 3 years and a VA chart with Landolt rings or pictures for older children. The VA findings were converted to Snellen lines. Setting Institutional ophthalmology practice. Participants Of the 103 eyes (57 patients) that underwent early vitreous surgery for AP-ROP, the VA was measured in 58 (32 patients) at a corrected age ranging from 8 months to 4 years. Interventions Early vitreous surgery and VA measurement using the preferential looking technique and a VA chart. Main Outcomes and Measures Postoperative VA, ROP stage, extent of fibrovascular tissue (FT) growth, and laterality of the eyes that underwent surgery. Results The VAs ranged from 20/2000 to 20/40. The VA may not be related to the preoperative ROP stage 4A or 4B but may depend on the preoperative extent of FT growth. In 39 of 58 eyes (67.2%), the FT had not reached the vitreous base preoperatively, and foveal formation occurred postoperatively with nearly age-appropriate VA (range, 20/250 to 20/40). In 17 of 58 eyes (29.3%), the FT had reached the vitreous base, and no fovea formed (VA range, 20/2000 to 20/250). Two of 58 eyes (3.4%) had deprivation amblyopia with a VA worse than 20/1600. The difference in VA between both eyes of patients who underwent bilateral vitreous surgery depended on ROP progression; patients who underwent a unilateral procedure in which the fellow eyes with ROP stabilized after photocoagulation tended to have poor vision because of deprivation amblyopia. Conclusions and Relevance Early vitreous surgery may be beneficial for AP-ROP and should be performed before the FT reaches the vitreous base to facilitate foveal formation and good VA outcomes. The roles of photocoagulation, vitreous surgery, and anti–vascular endothelial growth factor therapy in the treatment of AP-ROP should be investigated in randomized trials regarding efficacy, safety, convenience, and cost.

Modern vitreous surgery has been greatly facilitated, if not made possible, by the intraocular fiberoptic light pipe. In its current state, the light pipe is a straight, bright illuminator that allows direct visualization of what it shines on. 1 This is limiting when used with small opacities that have a refractive index similar to their surroundings and for use with subtle vitreoretinal adhesions. In these instances, relationships can be difficult to discern by direct illumination. We have found that these shortcomings can be largely overcome by bending the light pipe ( Figure ) and taking advantage of the indirect illumination that results. This is not unlike the added visualization afforded by indirect and retroillumination in slit-lamp biomicroscopy, and it has allowed us to better appreciate the insertion of the vitreous base and the location of the posterior hyaloid face. By highlighting the presence and direction of anteroposterior and tangential vitreous traction, this

To define the vascular sequelae of retinectomy.Clinical and angiographic survey of patients who had undergone retinectomy procedures.Twenty consecutive patients with ambulatory vision and attached posterior retina after retinectomy procedures underwent ophthalmic examination, including retinal biomicroscopy, indirect ophthalmoscopy with scleral indentation, and peripheral retinal fluorescein angiography.Ten eyes (50%) showed anterior retinal neovascularization (NV), with vessels derived from the ciliary body or posterior retina. Neovascularization occurred in residual anterior retina adjacent to the retinectomy, in detached anterior retina demarcated by laser in quadrants not involved by retinectomy, and in fibrinous membranes extending anterior to the retinectomy edge. This was associated with postoperative vitreous hemorrhages in two patients. Iris NV and inferior iridectomy occlusion were strongly associated with retinal NV (Fisher's exact test, P.005). No patient had neovascular glaucoma or optic disc NV during a median follow-up of 250 days (range, 121 to 465).Retinectomy may have profound secondary effects on ocular vascular circulation, resulting in retinal NV in association with iris NV, occlusion of inferior iridectomies, and vitreous hemorrhage. Complete intraoperative removal of residual anterior retina to the ora serrata in quadrants involved by retinectomy, combined with prophylactic retinal laser treatment from the vitreous base to the ora in the remaining quadrants, is recommended to prevent the development of retinal NV and its associated complications.

• We describe a technique to facilitate visualization of the vitreous base, pars plana, and pars plicata during vitreous surgery. This technique takes advantage of an externally applied fiberoptic light source coupled with scleral depression to enable direct viewing of the ciliary processes and anterior vitreous base. No special instrumentation or alteration in pars plana vitrectomy techniques is required. We have used this technique to enhance anterior dissection during vitrectomy surgery in the aphakic and pseudophakic eye associated with proliferative vitreoretinopathy, diabetic retinopathy, epithelial down-growth syndromes, and postvitrectomy fibrin formation.

• A new ophthalmic electronic videoendoscope system has a 20-gauge probe for intraocular observation, a standard size for vitreous microsurgical instruments, and both endoscopic and operating microscopic images are displayed on a split-screen monitor system to provide surgeos a simultaneous view of both images. Using this endoscope system at any time during surgery, surgeons can examine the intraocular structure such as the ciliary sulcus, pars plana, or vitreous base and obtain valuable but otherwise unobtainable information for completing the surgry.

• The records of 74 patients—young and almost exclusively males—with retinal detachment due to ocular penetration were reviewed to study the characteristics and surgical results of this type of traumatic retinal detachment. There was a high incidence of industrial and domestic accidents. The incidence and degree of myopia were significantly lower than in nontraumatic cases of retinal detachment. The time interval between the injury and the detection of the retinal detachment was variable. Many of the eyes with longer latent intervals had classic signs of traumatic retinal detachment. The most common type of retinal break was a dialysis in the oral zone at the posterior vitreous base border. The most common cause of these retinal breaks was severe traction from contracting vitreous bands and membranes that followed the loss of vitreous gel from the eye. Surgical results were relatively poor; recurrence was common because of progressive vitreous pathology. Postoperative traction on the vitreous base by the continued shrinkage of vitreous membranes was noted in 50% of the eyes that contained such membranes preoperatively.

• In posterior-segment penetrating injuries, the role of cellular and extracellular structures for the development of traction retinal detachment is a matter of controversy. With the use of immunofluorescence techniques, we studied the cellular components of intravitreal membranes, with particular attention to the presence of intracellular contractile proteins. Our results demonstrate increasing concentrations of intracellular actin filaments in 12-to 21-day-old membrane specimens at the time when traction retinal detachment is most likely to occur in the rabbit eye. The sequence of events reflects the same process that occurs in the wound-healing response throughout the body. The specialized anatomy of the eye, particularly the vitreoretinal relationship at the vitreous base, accounts for the disastrous consequence of traction retinal detachment.

• All patients were examined preoperatively and postoperatively by indirect ophthalmoscopy and biomicroscopy with a three-mirror lens. The average follow-up was eight months. Our technique of sclerotomy consisted of an incision parallel to the limbus, measuring 1.5 times the diameter of the surgical instrument. The pars plana location was always verified with transillumination. A mattress suture over the lips of the sclerotomy was used to prevent any leakage during the procedure. The intraoperative complications included ciliary body laceration (1%), retinal tears (8%), and vitreous base incarceration in the wound. The postoperative complications consisted of retina dragged into the wound (4%), vitreous tract left by the instrument (6%), neovascular ingrowth (6%), and external symptoms from the Dacron (32%) or polyglycolic acid (5%) suture. The rate of complications is considered low for such high-risk surgery. (Arch Ophthalmol95:229-234, 1977)

In Reply. —In response to the letter of Drs Landers and Ehrenberg, I would like to make the following comments. In my series of dialyses, 36 cases involved the inferotemporal quadrant. In 21 of these patients, there was a positive trauma history, and eight showed at least one objective sign of injury, ie, avulsion of the vitreous base, tears in the pars plana epithelium, or angle recession. An additional four patients showed at least one of these objective signs, despite a negative trauma history. In the remaining 11 patients, who had a negative history of trauma and no objective evidence of injury, I believe forgotten trauma or trauma denied for social reasons was a more plausible cause of the inferotemporal dialyses than a genetic weakness of the inferotemporal retina. To rule out a genetic or inherited weakness, I examined family members of these 11 patients. Of a total of 42

Rarefaction and partial tears of the retina adjacent to blood vessels (paravascular retinal rarefaction and paravascular retinal tears) were studied to determine their morphologic features, incidence, distribution, and relationship to the vitreous body. Paravascular retinal rarefaction was seen adjacent to retinal venules and arterioles. This lesion was associated with an attached posterior vitreous. Paravascular retinal tears occurred in clusters between the equator and the posterior border of the vitreous base. These partial-thickness tears were always associated with posterior vitreous detachment. Both lesions appear to be due to vitreal traction at the site of paravascular vitreoretinal attachments. Such attachments are considered normal anatomic variations and probably explain the occurrence of clinically detectable full-thickness retinal tears in areas of normal appearing retina and why these tears commonly involve retinal blood vessels.

The relationship between enclosed or partially-enclosed ora bays and retinal tears was studied in 1,000 consecutive autopsy eyes. Enclosed ora bay was present in 4.0% and partially-enclosed ora bay in 0.6% of eyes. Retinal tear was associated with 16.7% of either type of ora bay, and occurred posterior to and meridionally aligned with such bays. All such tears occurred at the posterior border of the vitreous base and were a consequence of posterior vitreous detachment. Retinal tears associated with enclosed or partially-enclosed ora bays were present in 0.5% of the 1,000 eyes examined.

One hundred and three eyes of 71 patients with mild retrolental fibroplasia in the cicatricial stage were examined. The characteristic changes were usually located in the temporal fundus periphery. The most frequently observed changes were proliferation of the retinal pigment epithelium, chorioretinal scarring, a translucent vitreous membrane overlying the temporal periphery of the retina, retinal folds, dragged disc, macular lesions, and white with or without pressure. The vitreous body contained dense organized bands and membranes in the vitreous base, especially on the temporal side. Vitreoretinal traction was considered a major etiological factor in the fundus changes.