Cyclitic Membrane Research Articles

Incising the Thick Retrolental Fibrovascular Tissue With a Hooked Sclerotome in Persistent Hyperplastic Primary Vitreous

A technique for incising thick retrolental fibrovascular tissue and extensive cyclitic membrane is reported in a case of anterior persistent hyperplastic primary vitreous. A membranectomy was performed in a 1-month-old post-lensectomy baby via a limbal approach. A sclerotome tip was hooked to cut through an extremely thick fibrovascular tissue by rotating the sclerotome by its grip. Sutherland microscissors (Grieshaber, Switzerland) and a vitrectomy cutter were used for further membranectomy. The baby was followed-up until age 18 months. A total of 3 membranectomy sessions were required because of rapid cyclitic membrane formation, severe centripetal retraction of the membrane on the ciliary processes, and posterior synechia. Thorough membranectomy and cutting the iris edge maintained a clear pupillary area during the 13-month postoperative period. Extremely thick retrolental fibrovascular tissue is a challenging condition that can be dealt with by delicate instrumentation.

Intraocular lens removal patients with uveitis

PURPOSE: To report a series of patients with uveitis and cataract who had undergone cataract extraction with posterior chamber intraocular lens implantation and who subsequently had the intraocular lens removed because of progressive intraocular damage from inflammation.METHODS: Review of the records of 19 patients after removal of a posterior chamber intraocular lens. The decision to perform surgery was based on standard criteria after evaluation at a single uveitis referral center.RESULTS: The complications leading to intraocular lens removal were perilental membrane (eight eyes), chronic low-grade inflammation not responding to anti-inflammatory treatment (eight eyes), and cyclitic membrane resulting in hypotony and maculopathy (three eyes). After intraocular lens removal the inflammation subsided and the visual acuity improved or stabilized in 14 of the 19 eyes. The causes of further reduction in the visual acuity of the other five patients were macular edema (two patients), maculopathy resulting from hypotony (one patient), retinal detachment (one patient), and vitreous hemorrhage (one patient).CONCLUSIONS: Intraocular lens implantation can form part of a reasonable plan for visual rehabilitation of patients with uveitic cataract, but inclusion of an intraocular lens in the plan is not always in the overall long-term best interest of the patient. Intraocular lens removal may salvage useful vision for patients who continue to exhibit complications secondary to uveitis after cataract extraction and intraocular lens implantation, provided the intraocular lens is removed before irreparable damage has been done to macula or optic nerve.

Vitrectomy in treatment of eyes with complicated uveitis

Vitrectomy serves as an important treatment modality in uveitis, removing inflamed vitreous body and eliminating secondary complications. The aim of our retrospective study was to evaluate the value of vitrectomy in the treatment of complications in uveitis. We included 50 eyes of 50 patients suffering from chronic uveitis, which underwent vitrectomy surgery during the period of 1990 to 1993. The study only included patients who had vitrectomy for uveitis for the first time. Indications leading to surgery were density of optic media, retinal detachment, cyclitic or preretinal membranes. The mean follow-up was 455 (range 48-1420) days. Vitrectomy was performed at a mean delay of 452 days after initial presentation. The mean visual acuity at the time of surgery was 0.05. The best visual acuity postoperatively was measured at a mean time of 118 days after vitrectomy. Overall, at the last control, eyes with preoperative retinal detachment presented a much worse final functional result (visual acuity of 0.02) than eyes without detachment (visual acuity of 0.5). Ten eyes resulted in hypotonia after surgery (7 eyes with persisting hypotonia). Most frequent complications in the postoperative course were macular pucker (11 eyes), secondary glaucoma (10 eyes), macular edema (6 eyes) and retinal detachment (6 eyes). Fifty percent of all complications occurred within the first 3 months following surgery. Vitrectomy leads to a permanent increase in visual acuity through the treatment of complications, on the condition that a stable retinal situation was present preoperatively.

Leukocoria Caused by Occult Penetrating Trauma in a Child

To report a child with leukocoria caused by occult penetrating trauma. Case report. The clinical findings and surgical repair of acquired leukocoria of the right eye in a 2-year-old boy are presented. In the right eye, slit-lamp examination disclosed a retrolenticular cyclitic membrane and moderately severe (3+) cells and flare anterior chamber reaction. The eye was hypotonous, and B scan showed that the membrane was associated with a retinal detachment. Surgery was performed to repair the retinal detachment and to remove the retrolenticular membrane. Two months before initial examination, the patient had been attacked by a rooster. Occult penetrating trauma should be considered in the differential diagnosis of pediatric leukocoria.

Congenital Neoplasms of the Nonpigmented Ciliary Epithelium (medulloepithelioma)

Most reports on intraocular medulloepithelioma have been single case descriptions. The authors reviewed ten patients with intraocular medulloepithelioma, discuss some little known clinical features of this entity, and make diagnostic and therapeutic recommendations. The records of the authors' patients with histopathologically confirmed medulloepithelioma were reviewed, and the clinical features, diagnostic problems, management, histopathology, and prognosis were assessed. Of the ten patients, nine were children, ranging in age from 2 months to 10 years, and one patient was 58 years of age at the time of clinical presentation. In seven patients, there was a delay in diagnosis, ranging from 3 to 28 months, and four patients underwent surgery for cataract, glaucoma, or other secondary conditions while the tumor was unsuspected. All patients had a nonpigmented ciliary body mass and a notched or subluxated lens, and six had neovascular glaucoma and evident cysts in the mass. The authors' initial management was enucleation in four patients and local resection in six. Of the six patients managed by local resection, five eventually required enucleation, four because of local tumor recurrence and one because of ocular inflammation and discomfort. Pathologically, nine tumors were classified as malignant (5 teratoid, 4 nonteratoid) and one as benign. In one patient (the adult), metastasis to the parotid gland developed. Intraocular medulloepithelioma generally occurs in the first decade of life as a nonpigmented ciliary body mass. It has a tendency to cause secondary neovascular glaucoma, a characteristic lens notch and subluxation, and a neoplastic cyclitic membrane. Enucleation is the best treatment for advanced cases. For smaller circumscribed lesions, local resection may be attempted, but such treatment is followed frequently by local recurrence. Although most medulloepitheliomas are cytologically malignant, distant metastasis is uncommon.

Immunohistochemistry of cellular proliferation in eyes with longstanding retinal detachment.

To further characterize the content and nature of cyclitic membranes (n = 4), ringschwielen (n = 3) and a subretinal strand on sections of complete globes with long-standing retinal detachment after trauma (n = 7) or retinal reattachment surgery (n = 1), we applied a panel of cellular and extracellular antibodies using the APAAP (alkaline phosphatase and monoclonal anti-alkaline phosphatase) technique. Only one cyclitic membrane from an eye that was enucleated two months after trauma was positive for glial fibrillary acidic protein, demonstrating the presence of glial cells. All cyclitic membranes contained macrophages and expressed intracellular contractile proteins. Ringschwielen stained consistently for cells of epithelial origin (RPE) with cytokeratin and for macrophages. The subretinal strand stained for cytokeratin, macrophages and alpha-smooth muscle actin, supporting cellular contraction in the genesis of this form of proliferative vitreoretinopathy.

High-Resolution Ultrasound Biomicroscopy of the Anterior Segment in Patients With Dense Corneal Scars

Preoperative evaluation and surgical planning for penetrating keratoplasty in patients with dense corneal scars is often difficult because of poor visualization of the anterior segment. We performed ultrasound biomicroscopy (50-megahertz frequency, 50-micron resolution) on five eyes of five patients with dense corneal opacities of different etiologies to evaluate the anatomic relationships of the iris, lens, angle, and ciliary body. Corneal thickness, the presence or absence of iridocorneal adhesions, peripheral anterior synechiae, and cyclitic membranes, intraocular lens position, and relationships among intraocular structures could be evaluated in vivo. Ultrasound biomicroscopy is the optimal method of obtaining reliable, high-resolution images delineating anatomic relationships and pathology in the anterior segment. This information aids in surgical planning for penetrating keratoplasty and anterior segment reconstruction.

Rhegmatogenous Retinal Detachment after Molteno Glaucoma Implant Surgery

The Molteno implant is a device used for surgical treatment of complicated glaucoma. Rhegmatogenous retinal detachment (RD) is a relatively rare complication of Molteno implant surgery. This study was undertaken to evaluate the clinical features including the surgical management and postoperative outcome of patients with rhegmatogenous RD after Molteno implant surgery. The authors reviewed 350 consecutive patients who had Molteno surgery and identified 16 patients with subsequent rhegmatogenous RD. They also studied one patient referred for RD repair after Molteno surgery at another institution. The risk of rhegmatogenous RD was 5%. Seventy percent (12/17) of the patients presented within 4 months of the Molteno procedure. Dialysis and flap tear were the most common types of retinal break found. Forty-one percent (7/17) of the patients had proliferative vitreoretinopathy. In three patients, clinical features suggested RD resulting from the Molteno procedure. In other patients, previous ocular surgery and underlying ocular disease may have contributed to the development of RD. Retinal detachment repair was attempted in all patients. Among 16 patients with at least 6 months of follow-up, 56% (9/16) had successful retina attachment. Forty-four percent (7/16) of the patients maintained formed vision. Eighteen percent (3/16) of the patients maintained visual acuity of at least 20/40. Intractable glaucoma did not develop in any of the patients with an attached retina. Recurrent RD, endophthalmitis, cyclitic membrane, or intractable glaucoma led to phthisis bulbi or enucleation in 44% (7/16) of the patients. A combined approach by vitreoretinal and glaucoma surgeons can restore vision and maintain glaucoma control in patients with rhegmatogenous RD associated with Molteno implant surgery.

Non-invasive methods to evaluate the blood-aqueous barrier function

We used vitreous fluorophotometry to supplement standard clinical techniques and fluorescein angiography to study 23 eyes in 12 patients with pars planitis. All eyes leaked abnormal amounts of fluorescein into the vitreous. The leakage was generalized in the posterior segment of the eye. In milder cases, leakage was greater posteriorly; more severe cases showed preferential leakage from the equatorial and midperipheral regions.There was no predilection for leakage in the inferior fundus. The eyes in which greater leakage occurred inferiorly tended to be those with greater overall leakage; all but one involved early cyclitic membrane formation or heavy neovascularization of the pars plana membrane.The amount of cystoid macular edema demonstrated by fluorescein angiography correlated well with vitreous fluorophotometric values, as did vitreous haze, the extent and density of the inferior membrane, and visual acuity.

Molteno Implantation for Glaucoma in Young Patients

Seventy patients younger than 21 years of age underwent Molteno implantation for nonneovascular glaucoma. Fifty-three (76%) patients had failed angle and/or conventional filtering surgery. Final intraocular pressure less than 22 mmHg (but over 5 mmHg) was achieved in 40 (62%) of the 65 patients with at least 6-month follow-up (range, 6 to 59 months; mean ± standard deviation, 22.7 ± 14.1 months); however, only 22 (34%) were controlled after the initial Molteno implantation procedure, and 54 (83%) patients underwent further glaucoma and/or nonglaucoma surgical procedures. The visual acuities remained within one line of their preoperative levels or improved in 25 (68%) of the 37 patients on whom Snellen acuities were available. The most frequent complications -included: tube-cornea touch (20%, transient in 3%), corneal edema (17%), retinal detachment (16%), tube block (10%), cataract (9%), chronic hypotony or phthisis (9%), pupillary or cyclitic membrane (9%), hyphema (7%), flat anterior chamber (6%), and large postoperative choroidal effusion (6%). Despite the high rates of subsequent surgical interventions and complications, Molteno implantation has been a useful approach for achieving intraocular pressure reduction in young patients with glaucoma.

Intraocular Pressure Following Intravitreal Silicone Oil Injection

The clinical features of 100 consecutive cases and the histopathology of six enucleated eyes, all having undergone silicone oil injection for complicated retinal detachments, were studied with regard to the incidence and mechanisms of postoperative intraocular pressure changes. Preoperatively, five patients had glaucoma and 35 had hypotony (7 mm Hg or less). Immediately after surgery, 43 patients had glaucoma and 14 had hypotony, while seven had glaucoma and 39 had hypotony in the late postoperative period (average follow-up of 1 year). In most cases, the mechanism of intraocular pressure change did not appear to be directly related to the presence of silicone, but rather to the preoperative status of the eye and other aspects of the vitreoretinal surgery. When silicone was a factor, the resulting intraocular pressure appeared to represent a balance between mechanisms obstructing aqueous outflow (pupillary block and the reaction to silicone bubbles in the anterior chamber angle) and mechanisms reducing aqueous production (cyclitic membranes and retinal detachment).

Use of a pulsed picosecond Nd: YAG laser in 6,664 cases

We used a modulated picosecond Nd:YAG laser to perform preoperative anterior capsulotomies and posterior capsulotomies in eyes with and without an intraocular lens, and to cut a variety of cyclitic membranes, iridocapsular adhesions, and vitreous traction bands in more than 6,500 cases. The complications were transient bleeding when vascularized tissues were cut because the laser does not coagulate, temporary anterior chamber inflammation, and transient increased intraocular pressure. The last two were caused by released lens material and shock wave side effects.

Management of complications after cataract surgery by the pars plana approach.

Various ocular complications following cataract surgery were treated using vitrectomy instruments by the pars plana approach. A total of 11 eyes were operated. Eight of these eyes had various anterior segment problems: Secondary cataract (2 eyes), cyclitic pupillary membranes (2 eyes), up-drawn pupils (3 eyes), and occluding pupillary membrane following haemorrhage (1 eye). In 2 of these eyes opacities in the posterior vitreous were present as well. In addition, pars plana vitrectomy was performed in 3 eyes with presumed bacterial endophthalmitis. In one of these eyes, the vitreous was sterile at the time of the vitrectomy. The vitreous of the 2 other eyes contained Staphylococcus epidermidis, and Staphylococcus aureus, respectively. In the eyes with anterior segment problems, clear optical media were obtained in all cases. The visual outcome in these patients was determined by the condition of the retina at the time of surgery. Two of the eyes with endophthalmitis were saved with some preservation of vision. The third of these eyes which suffered from endopthalmitis caused by penicillinase-producing Staphylococcus aureus, was lost. In this case vitrectomy and adequate antibiotic therapy was delayed. The modern vitrectomy instruments designed for pars plana vitrectomies are highly suitable for management of anterior segment problems following cataract surgery. When these problems are combined with pathology of the posterior vitreous, both kinds of problems may be dealt with at the same operation. In cases of presumed bacterial endophthalmitis, early vitrectomy should be considered to remove infective organisms, to obtain a definite diagnosis, and at the same time the eye may be perfused with antibiotics.

Vitreous Fluorophotometry in Pars Planitis

We used vitreous fluorophotometry to supplement standard clinical techniques and fluorescein angiography to study 23 eyes in 12 patients with pars planitis. All eyes leaked abnormal amounts of fluorescein into the vitreous. The leakage was generalized in the posterior segment of the eye. In milder cases, leakage was greater posteriorly; more severe cases showed preferential leakage from the equatorial and midperipheral regions. There was no predilection for leakage in the inferior fundus. The eyes in which greater leakage occurred inferiorly tended to be those with greater overall leakage; all but one involved early cyclitic membrane formation or heavy neovascularization of the pars plana membrane. The amount of cystoid macular edema demonstrated by fluorescein angiography correlated well with vitreous fluorophotometric values, as did vitreous haze, the extent and density of the inferior membrane, and visual acuity.

Results of Surgery for Ocular Toxocara canis

It has been shown that the diagnosis of ocular Toxocara canis is highly accurate when the typical clinical findings are associated with a positive ELISA titer in the serum of 1:8 or greater. The inflammatory reaction in this disorder can be devastating and not infrequently leads to a tractional detachment of the posterior pole or a rhegmatogenous detachment and/or a progressive cyclitic membrane leading to phthisis bulbi. We have recently performed vitreoretinal surgery on 17 patients with complications secondary to ocular T canis. Fifteen patients had stability or improvement in visual acuity, and one patient had a decrease in visual acuity. There were no surgical complications present. The clinical features, operative techniques used, and postoperative course are summarized, and the indications for the used of various surgical procedures are presented.

Penetrating eye injuries: a histopathological review.

This study reports the histological findings in human eyes after severe penetrating trauma. The findings confirm the high incidence of retinal detachment in eyes with severe penetrating injuries. The retina was detached in 32 out of the 34 eyes examined, with 27 having evidence of traction on the retina. These eyes were characterized histologically by intraocular cellular proliferation producing cyclitic, epiretinal, and retroretinal membranes. Intraocular cellular proliferation was discernible or established within 1 week of injury and typically resulted in a cyclitic membrane at about 6 weeks. Epiretinal and retroretinal membranes were found between 1 and 2 weeks after injury in eyes with a detached retina. The results indicate that a damaged lens, the admixture of lens material and vitreous, and the presence of vitreous haemorrhage were all factors promoting intravitreal fibroblastic proliferation. Vitreous surgery may be a rational method of treatment for these severely injured eyes by removing the stimulus and vitreous scaffold for intravitreal fibroblastic proliferation. From this series it would appear that vitrectomy should not be delayed beyond the second week of injury, by which time massive cellular ingrowth may already be under way.

Pars Plana Vitrectomy in Ocular Trauma

Visual improvement was achieved in 62% of 100 consecutive patients with ocular trauma treated by pars plana vitrectomy. Anterior segment injuries had a better prognosis than posterior segment injuries, and retinal detachment was a poor prognostic sign. Patients undergoing vitrectomy during the two weeks after injury had a better visual prognosis than those who had delayed vitrectomy. Pars plana vitrectomy has increased the recovery rate in traumatized eyes which previously were deemed inoperable and frequently were enucleated. Most such eyes have intraocular fibrocellular proliferations, resulting in traction retinal detachments, cyclitic membranes, and phthisis, as documented in clinicopathological and experimentally produced specimens of penetrating ocular trauma. Vitrectomy can interrupt this sequence, if performed one to 14 days after injury, by removing the vitreous scaffold onto which proliferation occurs, together with the elements of hemorrhage, damaged lens, vitreous, and foreign material which may incite proliferation. We believe four to ten days after injury to be the optimal time for vitrectomy to avoid the hazards of immediate intervention, while removing damaged tissue before serious sequenlae occur.

Histology of Wound, Vitreous, and Retina in Experimental Posterior Penetrating Eye Injury in the Rhesus Monkey

We performed a histologic study to support our clinical observations on the mechanisms responsible for traction retinal detachment after a penetrating injury in the rhesus monkey eye. The monkey eyes (40 eyes; 40 monkeys) were characterized by intraocular fibrosis with the formation of a cyclitic membrane and epiretinal and subretinal membranes. The progression to a fibrous ingrowth from the wound occurred only in eyes with blood in the vitreous. The intravitreal fibroblastic proliferation had its origin mainly from the stroma of the ciliary body and choroid at the wound but probably also from the nonpigmented ciliary epithelium. A fibroblastic response was present within the vitreous as early as four days after injury, and had progressed to form a cyclitic membrane by six weeks. Epiretinal membranes were identified as early as four weeks after injury. They were most prominent over the peripheral retina anterior to the equator. It is likely that they are derived from multiple cellular sources including the fibrous ingrowth from the wound but they were also connected to the surface of the retina by bridges of tissue indicating a glial origin. The subretinal membranes appeared to be derived from both retinal pigment epithelium cells and glial cells.

Vitreous Wick Syndrome

A 67-year-old man had vitreous wick syndrome after an uncomplicated intracapsular cataract extraction with a sector iridectomy in the left eye. The intraocular infection cleared with antibiotic therapy including intravitreal antibiotic injection, but a residual anterior cyclitic membrane and shallow anterior chamber persisted. An anterior vitrectomy was performed later in the course of treatment after the intraocular infection subsided, to relieve the shallow anterior chamber, prolonged hypotony, and ciliary body detachment. Final visual acuity was 6/15+(20/50+) in the left eye.

Vitrectomy Techniques in the Management of Selected Penetrating Ocular Injuries

Closed vitrectomy techniques provide new capabilities to treat severe penetrating ocular injuries involving posterior segment structures. With these methods damaged iris tissue, lens, and vitreous can be removed and intraocular opacities can be cleared to identify and treat any retinal damage. Removal of damaged vitreous also prevents later cyclitic membrane formation and traction on the retina. The vitrectomy technique can be combined with additional methods to treat other conditions including nonmagnetic intraocular foreign bodies. We present the rationale and technique of vitrectomy together with the results of treatment in 51 consecutive cases of penetrating ocular trauma. Guidelines are offered for management of severe penetrating injuries.