Scleral Depression Research Articles

Pigmentation on Anterior Chamber Angle in Eyes of Patients With Atopic Dermatitis

Purpose: To evaluate pigmentation on the anterior chamber angle in patients with atopic dermatitis. Methods: This study includes 61 patients suffering from atopic dermatitis who visited our hospital between 1991 and 1995. Gonioscopy, cycloscopy, and fundus examinations with a scleral depressor were performed on every patient during the initial visit, and were repeated every 6 months. Pigmentation on the anterior chamber angle was classified according to Scheie. Results: The pigmentation on the anterior chamber angle at the initial visit was evaluated as grade 0 (15 eyes), grade 1 (81 eyes), grade 2 (21 eyes), and grade 3 (5 eyes). Retinal detachment was found in 9 eyes of the 26 eyes with grade 2 or 3 pigmentation, but in only one of the 96 eyes with grade 0 or 1. The pigmentation on the anterior chamber angle correlated significantly with the incidence of retinal detachment ( P < .0001). Causative breaks were found in the peripheral retina or ciliary epithelium in all eyes. Conclusions: Moderate to dense pigmentation on the anterior chamber angle in patients with atopic dermatitis seems to be a sign of breaks in the retina or ciliary epithelium, and the fundus of these patients should be examined carefully for signs of retinal detachment.

Ultrasound biomicroscopy for detection of breaks and detachment of the ciliary epithelium

PURPOSE: To elucidate details of the pathologic changes in the ciliary epithelium associated with atopic dermatitis and blunt ocular trauma. METHODS: We examined prospectively 52 eyes of 42 patients with detachment of the nonpigmented epithelium of the ciliary body associated with atopic dermatitis and blunt ocular trauma. All the eyes underwent ultrasound biomicroscopic examination as an adjunct to binocular indirect ophthalmoscopy with scleral depression and slit-lamp biomicroscopy. RESULTS: Of the 52 eyes examined, high-resolution ultrasound biomicroscopy and conventional diagnostic methods (that is, binocular indirect ophthalmoscopy with scleral depression and slit-lamp biomicroscopy) disclosed breaks at the anterior vitreous base border in 40 eyes, at the pars plicata of the ciliary body in 27 eyes, and at the white midline (that is, the line located in the mid pars plana anterior to the anterior vitreous base border) in four eyes. In 40 eyes the breaks at the anterior vitreous base border could be detected with conventional methods but in only 28 eyes could they be diagnosed with ultrasound biomicroscopy. Conversely, in 27 eyes the breaks of the pars plicata could be observed with ultrasound biomicroscopy but in 25 eyes they were detected with conventional methods. In 21 eyes with breaks only at the anterior vitreous base border, the detachment of the nonpigmented ciliary epithelium was limited posterior to the white midline. In all 27 eyes with the nonpigmented ciliary epithelial detachment anterior to the white midline, the breaks of the pars plicata were identified by ultrasound biomicroscopy. CONCLUSION: Because of the minimum deformation of the globe during examination, ultrasound biomicroscopy contributed to the diagnosis of detailed structural change in the ciliary body associated with atopic dermatitis and blunt ocular trauma in relation to the white midline. In our sample of patients, the white midline may act as a barrier against ciliary nonpigmented epithelial detachment, and detachment of the nonpigmented epithelium anterior to the white midline indicated the presence of the pars plicata break in most cases.

Prevalence of retinopathy of prematurity in very low birth weight infants

Evaluate the prevalence of retinopathy of prematurity (ROP) in very low birthweight infants (birthweight<1500 g). A prospective examination was conducted on 102 neonates with very low birthweight admitted to the BAM-HC (FMUSP) between 01/01/92 and 12/31/93. The mapping of the retina with scleral depression was first conducted between 3rd and the 8th weeks of life, and it was repeated every 1 to 4 weeks until the vascularization of the retina was complete or the ROP was present. To classify the ROP the International Classification of ROP was used. For the purposes of statistical analysis, the most serious phase of ROP presented by the neonate was considered. In this study retinopathy of prematurity was present in 29.09% of the neonates, in 78.5% of those under 1,000 g of birthweight, and 72.73% of those with less than 30 weeks of gestational age. Among the newborns with ROP, 77.05% were in phase 1, 13.11% in phase 2, and 9.84% in phase 3. Oxygen in mechanical ventilation and "CPAP" were statistically significant factors for the development the ROP. The ophthalmologic examination between the 3rd and 4th weeks of life was an important instrument for the detection of RP and should be done in all very low birth weight infants (weight<1,500 g), especially in neonates with less than 1,250 g and/or gestational age under 34 weeks.

An Applicator-Shaped Scleral Depressor for Vitreoretinal Surgery

This article describes an instrument that combines a standard T-shaped scleral depressor at one end with a cotton applicator-shaped depressor at the other end. The applicator-shaped depressor has a matted surface to prevent slippage. This simple instrument has several advantages over depressors now available for intraoperative use.

Ultrasound-Guided Cryotherapy for Retinal Tears in Patients With Vitreous Hemorrhage

The goal was to utilize ultrasound-guided cryotherapy as an immediate, low-risk, noninvasive, precise method of treating retinal tears obscured by vitreous hemorrhage. Eleven patients with sudden onset of vitreous hemorrhage were referred for diagnosis and management. Ophthalmoscopy with scleral depression was unsuccessful at localizing peripheral retinal tears, and all of the patients were examined with ultrasound using the techniques of standardized echography. The cryoprobe was positioned for cryotherapy using both transverse and longitudinal B-scan approaches following the indentation of the globe as it appeared on the oscilloscope. On follow-up examination after the vitreous hemorrhage cleared, 10 of the 11 tears were examined by ophthalmoscopy and were thought to have been adequately treated. One patient had a retinal detachment after remaining stable for 3 months. Two patients were treated with laser to enhance the cryotherapy seal. One patient was observed by another physician and underwent vitrectomy due to vitreous hemorrhage that persisted 2 months following cryotherapy. After vitrectomy, the physician reported a successful cryotherapy reaction at the treated tear. One final patient in the series required vitrectomy and scleral buckle before the hemorrhage had cleared, and the treatment did not appear to be complete. Ultrasound-guided cryotherapy provides a noninvasive, inexpensive treatment alternative for retinal tears obscured by vitreous hemorrhage.

THE USE OF PANORAMIC VIEWING SYSTEM IN RELAXING RETINOTOMY AND RETINECTOMY

Retinotomies and retinectomies are surgical procedures mainly devoted to the peripheral retina that require optimal visibility and adequate magnification to make the surgeon's task easy, quick, and safe. The purpose of present study was to estimate to what extent the introduction of wide-angle viewing systems can help the surgeon perform safer and more effective retinotomy procedures. The authors retrospectively analyzed the records of patients undergoing retinotomy procedures between 1993 and 1995 and divided them into two groups according to the viewing system used during the retinotomy procedures. Group 1 included 86 eyes that underwent surgery between July 1991 and June 1993 with Lander's plano-concave and prismatic lenses (Optikon, Rome, Italy), and group 2 included 96 eyes that underwent surgery between July 1993 and June 1995 with the Advanced Vitreoretinal Instruments system (New York, NY). Outcome measures were divided into preoperative (diagnosis at baseline, anterior proliferative vitreoretinopathy grade and extension, and visual acuity), intraoperative (size of retinotomy, number of laser spots, need for scleral depression, lensectomy, intraocular lens and capsule removal, and duration of treatment) and postoperative (anatomic success rates, visual acuity, postoperative intraocular pressure, and need for postoperative laser treatment and follow-up treatment). Among preoperative parameters, there were no significant differences between the two groups. For intraoperative parameters, eyes in group 2 underwent significantly shorter surgical procedures, had less of a need for scleral depression, and, as a group, had a higher average number of laser spots. For postoperative parameters, eyes in group 2 had a significantly lower need for laser treatment at the edge of retinotomy after surgery. Our results suggest that the use of a panoramic viewing system significantly decreases the time required for intervention, allowing more complete laser treatment along the edge of the retinotomy and lowering the need for scleral depression. The need for completion of laser treatment along the edge of the retinotomy after surgery also is reduced significantly, possibly increasing patient comfort because, especially in the early postoperative days, postoperative laser treatment can be extremely uncomfortable for the patient and difficult to perform for the surgeon. No prognostic benefit has been proven for any of the two groups because anatomic and visual results were overlapped.

Pathogenic mechanisms in proliferative vitreoretinopathy.

Landmarks in the development of treatment of retinal detachment include the recognition of the significance of retinal breaks that resulted in the distinction between rhegmatogenous retinal detachment (RRD) and exudative retinal detachment, the development of indirect ophthalmoscopy and scleral depression that allow better visualization of the peripheral area of the retina and better identification of retinal breaks, the recognition of the need to seal all retinal breaks, and the realization that vitreous traction is the major underlying cause of retinal tears and RRD. Scleral buckling procedures combine retinopexy to provide a scar around retinal breaks to seal them and scleral indentation to neutralize vitreous traction; they provided the first effective treatment of RRD. As surgeons gained experience with scleral buckling, they became aware that some RRDs, particularly those with fixed folds and/or a funnel configuration, often could not be repaired using this approach. It was thought that excessive vitreous traction was at fault, and the condition was called "massive vitreous retraction."

Indirect Ophthalmoscope Perimetry in Patients With Retinal Detachment or Retinoschisis

We evaluated visual field testing, using indirect ophthalmoscopy, in patients with retinal detachment or retinoschisis. While performing ophthalmoscopy, we projected a shadow onto the schisis or detachment by holding a scleral depressor on the observer's side of the condensing lens. A response was recorded as positive if the patient saw the shadow. In all 20 detachment eyes, compared to zero of 12 schisis eyes, the response was positive. Indirect ophthalmoscope perimetry can help distinguish retinoschisis from retinal detachment.

The role of vitrectomy in rhegmatogenous retinal detachment.

Several conditions, such as detachment from posterior breaks or detachment with significant media opacities, may warrant vitrectomy as the primary procedure. In cases in which the preoperative retinal view is clear and a posterior break is definitively excluded, vitrectomy does not appear to offer significant advantage over scleral buckling other than a theoretically improved ability to examine the retina microscopically with scleral depression. Performing a vitrectomy for an uncomplicated retinal detachment from a small peripheral break in which scleral buckling would be the usual procedure of choice remains controversial. Although it may avoid the complications of scleral buckling, vitrectomy does have its own potential complications. The status of the lens, cornea, and configuration of the retinal tears and detachment should carefully be considered before vitrectomy. Proper patient selection and appropriate education are important factors in a successful outcome. Finally, from an economic viewpoint, the likelihood of success with vitrectomy in one procedure compared with other less expensive procedures should be considered.

A new scleral depressor for extremely premature infants.

A new scleral depressor has been designed that enables easy insertion into a small conjunctival sac, facilitating examination of the ocular fundus in extremely premature infants with retinopathy of prematurity. This new scleral depressor is also useful in mature infants and children.

Finding the Retinal Hole in the Pseudophakic Eye With Detachment

The recently developed wide-field indirect contact lenses, recommended and used for pancoagulation of the retina posterior to the equator, have proved to be unexpectedly advantageous for finding retinal breaks anterior to the equator in the pseudophakic eye. Through a 6-mm pupil, it is possible with some ocular rotations, tilting of the lens, and scleral depression to bring into view the retina anterior to the equator and frequently the ora serrata. We found or confirmed 45 small retinal breaks anterior to the equator in 24 retinal detachments in pseudophakic eyes with the wide-field indirect contact lens. The indirect contact lens eliminates the blur that occurs when viewing through the edge of the intraocular lens, and its image suffers less interference from lens and capsular opacities.

Posterior Retinal Folds Following Vitreoretinal Surgery-Reply

<h3>In reply</h3> We appreciate the comments and suggestions of Avins et al with regard to avoiding retinal fold formation. Their recommendations regarding complete transvitreal drainage of SRF rather than transscleral drainage and the benefit of early prone positioning echo the sentiments discussed in our report. With the recognition of the benefits of posterior retinotomy and "complete" drainage, we have, for all intents and purposes, abandoned the transscleral drainage approach. We have never attempted the technique Avins et al describe of scleral depression to drive fluid into the vitreous after partial fluid gas exchange in eyes drained internally. The use of a posterior retinotomy makes these types of complicated maneuvers unnecessary. We believe the benefit of early prone positioning comes from the fact that the border of previously detached/attached retina is not below (dependent) the bubble meniscus. As discussed in our report, we believe it is the dependent movement of residual

Pathological changes associated with equine arteritis virus infection of the reproductive tract in prepubertal and peripubertal colts

The nature and extent of changes associated with equine arteritis virus (EAV) infection of the reproductive tract was documented in 21 prepubertal and 15 peripubertal colts. This study was part of an investigation into the relationship between stage of reproductive tract maturity and susceptibility to the experimental establishment of persistent infection with EAV. After intranasal challenge with a field isolate of EAV, all colts developed clinical signs of equine viral arteritis (EVA) from which they recovered rapidly. Clinical signs during the acute phase consisted of fever, serous to mucopurulent ocular and nasal discharge, oedema of the limbs, scrotum or prepuce, scleral injection, conjunctivitis, icterus, cough, diarrhoea, stiff gait, lethargy, inappetence and depression. At necropsy, the most significant macroscopic lesions included excessive accumulation of fluid within the thoracic and abdominal cavities, lymph node enlargement and oedema of the reproductive tract. Colts killed 7 to 14 days after challenge had acute necrotizing vasculitis involving the testes, epididymides, vasa deferentia, ampullae, prostatic lobes, vesicular glands and bulbourethral glands. Vasculitis was characterized by striking fibrinoid necrosis of small muscular arteries with extravasation of erythrocytes and proteinaceous material into the media, adventitia and perivascular tissues. Colts examined on days 28-180 had lymphocytic and plasmacytic inflammatory cell infiltrates in the lamina propria and muscularis of the epididymides and accessory sex glands. The vascular lesions found during the acute phase of EAV infection contrasted with the multifocal lympho-plasmacytic infiltrates found within the parenchyma of the reproductive tract during the chronic phase. One peripubertal colt was found to be persistently infected with EAV 15 months after challenge. This colt had marked lympho-plasmacytic infiltrates in the ampullae at necropsy.

Intraocular Pressure Fluctuations during Scleral Buckling Surgery

The purposes of this study are to measure real-time intraocular pressure (IOP) during scleral buckling and to determine the effects of elevated IOPs on ocular perfusion. A standard 4-mm, 20-gauge infusion cannula was inserted through the pars plana, connected to a standard hemodynamic monitoring unit with an electronic pressure transducer, and calibrated. The authors measured real-time IOP in 20 eyes undergoing scleral buckling surgery for primary rhegmatogenous retinal detachments and determined the IOP required to close the central retinal artery. Pressure measurements were read from the monitor videoscreen intraoperatively and from a continuous paper tracing postoperatively. The patients ranged in age from 24 to 88 years (mean, 59.7 years). The highest IOP elevations occurred during scleral depression and cryopexy, ranging up to 210 mmHg (mean, 116 mmHg). Pressures at which the central retinal artery closed ranged from 48 to 110 mmHg (mean, 79.2 mmHg). Manipulations of the globes caused IOPs greater than the central retinal artery perfusion pressures in 13 of the 20 patients. The duration of pressures in excess of the central retinal artery perfusion pressure ranged from 6 to 402 seconds (mean, 118.8 seconds). There were no intraoperative or postoperative complications from the infusion cannula. Conventional scleral buckling surgery causes wide fluctuations in IOP and may impair ocular perfusion. Additional studies are needed to determine the long-term consequences of these pressure elevations.

Microwave Diathermy of the Retina and Choroid

Microwaves were used to induce chorioretinal scar formation in normal rabbit eyes. We have developed a directional 6.8-gigahertz microwave applicator with a rectangular aperture. It was designed to mimic the shape and function of a T-shaped scleral depressor. For treatment, the applicator was placed on the conjunctiva over the sclera. Then, indentation was used to visualize probe placement during indirect ophthalmoscopy. Thermocouple-controlled heating was initiated such that conjunctival temperatures in a range of 51 degrees C to 65 degrees C were induced for 10 seconds per treatment. We found that treatment at temperatures of 51 degrees C or 52 degrees C for 10 seconds produced circular areas of acute retinal whitening. From these microwave-induced lesions, there evolved chorioretinal attenuation with and without evidence of retinal pigment epithelial hyperplasia. No evidence of scleral damage was noted at these thermal doses.

Comparison of Photocoagulation with the Argon, Krypton, and Diode Laser Indirect Ophthalmoscopes in Rabbit Eyes

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. 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. 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). 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.

A Multilens Case

To the Editor —Ophthalmologists carry several lenses and a scleral depressor for use in eye examinations. Most lenses are kept in individual protective cases that add bulk to laboratory coat pockets (Fig 1). A scleral depressor can easily fall out of a pocket. A wooden case designed to contain three lenses (ie, 20 diopter (D), 28 D, and 90 D) was recently described. 1 We describe an easy modification of an existing multilens case that holds a 20-D or panretinal lens, a 28-D or 30-D lens, a 90-D lens, a four-mirror gonioscopic lens, and a scleral depressor. A 15 × 10 × 2.5-cm case with precut openings for the large panretinal lens, 30-D lens, and 90-D lens was obtained (Indirect Conoid Lens Case, Volk, Mentor, Ohio). The scleral depressor was positioned above the two large precut openings, and a knife was used to cut the sponge the length of the

A Technique for Facilitated Visualization and Dissection of the Vitreous Base, Pars Plana, and Pars Plicata

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.

Screening: The need for a balance

Screening: The need for a balance

PHOTOCOAGULATION USING THE EISNER CONE

Thirteen patients with clinical or subclinical retinal detachments were treated with photocoagulation with the aid of a device for scleral depression and the three mirror contact lens. The Eisner cone has proven helpful in achieving clinically white retinal burns at the margins of retinal breaks by displacing subretinal fluid at the time of treatment. Patients selected for treatment had adequate pigmentation for a good photocoagulation response, nearly clear ocular media, and minimal vitreo retinal traction. Extent of retinal detachment was not a determinant, but minimal retinal elevation at break locations proved beneficial. No immediate flattening or adhesion of the retina was seen on release of scleral depression at the time of photocoagulation. White clinical burns remained visible. In 12 of 13 patients the retina was in apposition to the retinal pigment epithelium around the breaks at the first post-treatment examination. The remaining subretinal fluid absorbed in even the most extensive detachment in 2 weeks. One patient with multiple breaks at the equator failed to respond to this technique and required a scleral buckle.