Letters to the Journal
Vol. 110, No.2
Fig. 2 (McCarthy, Pulido, and Soukup). Damaged spectacle lens of patient showing a large disk of glass dislodged from posterior surface. ing illumination. The forceps were partly opened in the eye and the foreign body was tilted slightly, which enabled two of the prongs to extend beneath it while another prong remained anterior to the foreign body. The assistant then retracted the prongs, which allowed the foreign body to be firmly grasped and removed through a limbal incision. Argon green endolaser photocoagulation was applied around the retinal tears. An air-fluid exchange was performed, and CaF g gas was injected into the eye. In the first two postoperative months the retina has remained attached. The patient has subsequently been lost to follow-up.
209
Inquiries to Maurice B. Landers III, M.D., Department of Ophthalmology, University of California, Davis, 1603 Alhambra Blvd., Sacramento, CA 95816. Proliferative vitreoretinopathy is a major cause of failure in retinal reattachment surgery. The anterior component of proliferative vitreoretinopathy often involves cellular proliferation in the region of the vitreous base and the separated posterior hyaloid.' The resulting anterior vitreous traction often pulls the retina anteriorly. In severe cases, the peripheral retina is pulled forward over the pars plana and even up onto the posterior surface of the iris. Successful treatment of this condition requires surgical release of this vitreoretinal traction.v" Although it is desirable to use a standard, three-port vitreous surgery technique when possible, the anteriorly displaced retina often causes a problem." Entry into the vitreous cavity through a sclerotomy site in the pars plana may create new retinal tears. It would be desirable to carry out the vitrectomy without the use of vitreous instruments, such as the infusion cannula, perforating this anteriorly displaced retina at any time during the procedure. To avoid the damage to the displaced retina, a new infusion cannula has been designed (Fig. 1). This cannula is placed at the corneo scleral limbus through a standard microvitreoretinal knife incision. The cannula enters the eye parallel to the iris. It is then angled posteriorly at the
References 1. Zinn, K. M.: Removal of an intraocular foreign body from the optic nerve head. Am. J. Ophthalmol. 90:317, 1980. 2. Charles, S.: Illuminated intraocular foreignbody forceps for vitreous surgery. Arch. Ophthalmol. 99:1399,1981. 3. Norris, J. L., and Cleasby, G. W.: Intraocular foreign body removal by endoscopy. Ann. Ophthalmol. 14:371, 1982.
A New Infusion Cannula for Advanced Proliferative Vitreoretinopathy Maurice B. Landers III, M.D., H. Christopher Semple, M.D., and Lawrence S. Morse, M.D.
Department of Ophthalmology, University of California, Davis.
Fig. 1 (Landers, Semple, and Morse). View of infusion cannula from below (top) and side (bottom). Note base for positioning on sclera with mattress suture.
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AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 2 (Landers, Semple, and Morse). Infusion cannula in position showing its relationship to anterior structures. pupillary margin so that the flow of infusion fluid is downward into the vitreous cavity of the aphakic eye and, hence, away from the corneal endothelium (Fig. 2). The infusion cannula can be sewn onto the sclera in a manner similar to that of a standard pars plana infusion cannula. It is thus possible to approach the vitreous base with a minimal chance of the infusion cannula creating new retinal tears. We have used this infusion cannula successfully on several patients who had severe proliferative vitreoretinopathy and in trauma patients who have dense vitreous hemorrhage and preoperative ultrasonic evidence of a retinal detachment.
References 1. De Juan, E., Jr., and McCuen, B. W., II: Management of anterior vitreous traction in proliferative vitreoretinopathy. Retina 4:258,1989. 2. Aaberg, T. M.: Management of anterior and posterior proliferative vitreoretinopathy. XLV Edward Jackson memorial lecture. Am. J. Ophthalmol. 106:519,1988. 3. Charles,S.: Anterior loop traction. In Vitreous Microsurgery, ed. 2. Baltimore, Williams & Wilkins, 1987, p. 137.
Optic Disk Neovascularization in Juvenile Rheumatoid Arthritis H. Christopher Semple, M.D., Maurice B. Landers III, M.D., and Lawrence S. Morse, M.D.
Retinal Service, Department of Ophthalmology, University of California, Davis.
August, 1990
Inquiries to Maurice B. Landers III, M.D., Department of Ophthalmology, University of California, Davis, 1603 Alhambra Blvd., Sacramento, CA 95816. Juvenile rheumatoid arthritis is a chronic, progressive disease that occurs during childhood. The most common ocular manifestation of juvenile rheumatoid arthritis is iridocyclitis. Other ocular manifestations include cataract, secondary glaucoma, and band keratopathy, which are related to chronic iridocyclitis.' Patients with ocular involvement generally have the pauciarticular disease and lack the systemic manifestations, lymphadenopathy, and fever. The patients with ocular involvement have a negative rheumatoid factor, but 80% of the patients have a positive antinuclear antibody titer associated with the disease.! We report a patient with juvenile pauciarticular rheumatoid arthritis who developed optic disk neovascularization. A 4-year-old girl had juvenile rheumatoid arthritis. The patient's condition had been initially diagnosed by her pediatrician two years previously, when she had arthritis of her left wrist and right knee. An antinuclear antibody titer was performed and found to be positive. In the same year, she developed bilateral anterior uveitis, which required long-term topical corticosteroid therapy in both eyes to control the inflammation. The arthritis was controlled by oral prednisone. Minimal inflammation persisted over the next two years, and visual acuity remained 20/30 in each eye. At 31/2 years of age, the patient was referred to our institution in March 1989 when visual acuity began to deteriorate because of bilateral progressive cataracts in both eyes that were secondary to chronic inflammation and longterm topical corticosteroid therapy. Visual acuity was R.E.: 20/400 and L.E.: hand motions. The results of an anterior segment examination disclosed nasal band keratopathy in the right eye and a clear cornea in the left eye. There were trace cells and mild flare in the right eye and trace cells and no flare in the left eye. Extensive posterior synechiae were seen in the right eye. Intraocular pressure was R.E.: 11 mm Hg and L.E.: 18 mm Hg. A severe cortical cataract was noted in the right eye and a dense, white cataract was noted in the left eye. The patient had a red reflex in the right eye and no red reflex in the left eye. The patient's cataract was removed by using a vitrectomy instrument in the left eye on March 21, 1989, and in the right eye on June 6, 1989. The entire lens capsule was removed during
Vol. 110, No.2
Fig. 2 (McCarthy, Pulido, and Soukup). Damaged spectacle lens of patient showing a large disk of glass dislodged from posterior surface. ing illumination. The forceps were partly opened in the eye and the foreign body was tilted slightly, which enabled two of the prongs to extend beneath it while another prong remained anterior to the foreign body. The assistant then retracted the prongs, which allowed the foreign body to be firmly grasped and removed through a limbal incision. Argon green endolaser photocoagulation was applied around the retinal tears. An air-fluid exchange was performed, and CaF g gas was injected into the eye. In the first two postoperative months the retina has remained attached. The patient has subsequently been lost to follow-up.
209
Inquiries to Maurice B. Landers III, M.D., Department of Ophthalmology, University of California, Davis, 1603 Alhambra Blvd., Sacramento, CA 95816. Proliferative vitreoretinopathy is a major cause of failure in retinal reattachment surgery. The anterior component of proliferative vitreoretinopathy often involves cellular proliferation in the region of the vitreous base and the separated posterior hyaloid.' The resulting anterior vitreous traction often pulls the retina anteriorly. In severe cases, the peripheral retina is pulled forward over the pars plana and even up onto the posterior surface of the iris. Successful treatment of this condition requires surgical release of this vitreoretinal traction.v" Although it is desirable to use a standard, three-port vitreous surgery technique when possible, the anteriorly displaced retina often causes a problem." Entry into the vitreous cavity through a sclerotomy site in the pars plana may create new retinal tears. It would be desirable to carry out the vitrectomy without the use of vitreous instruments, such as the infusion cannula, perforating this anteriorly displaced retina at any time during the procedure. To avoid the damage to the displaced retina, a new infusion cannula has been designed (Fig. 1). This cannula is placed at the corneo scleral limbus through a standard microvitreoretinal knife incision. The cannula enters the eye parallel to the iris. It is then angled posteriorly at the
References 1. Zinn, K. M.: Removal of an intraocular foreign body from the optic nerve head. Am. J. Ophthalmol. 90:317, 1980. 2. Charles, S.: Illuminated intraocular foreignbody forceps for vitreous surgery. Arch. Ophthalmol. 99:1399,1981. 3. Norris, J. L., and Cleasby, G. W.: Intraocular foreign body removal by endoscopy. Ann. Ophthalmol. 14:371, 1982.
A New Infusion Cannula for Advanced Proliferative Vitreoretinopathy Maurice B. Landers III, M.D., H. Christopher Semple, M.D., and Lawrence S. Morse, M.D.
Department of Ophthalmology, University of California, Davis.
Fig. 1 (Landers, Semple, and Morse). View of infusion cannula from below (top) and side (bottom). Note base for positioning on sclera with mattress suture.
210
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 2 (Landers, Semple, and Morse). Infusion cannula in position showing its relationship to anterior structures. pupillary margin so that the flow of infusion fluid is downward into the vitreous cavity of the aphakic eye and, hence, away from the corneal endothelium (Fig. 2). The infusion cannula can be sewn onto the sclera in a manner similar to that of a standard pars plana infusion cannula. It is thus possible to approach the vitreous base with a minimal chance of the infusion cannula creating new retinal tears. We have used this infusion cannula successfully on several patients who had severe proliferative vitreoretinopathy and in trauma patients who have dense vitreous hemorrhage and preoperative ultrasonic evidence of a retinal detachment.
References 1. De Juan, E., Jr., and McCuen, B. W., II: Management of anterior vitreous traction in proliferative vitreoretinopathy. Retina 4:258,1989. 2. Aaberg, T. M.: Management of anterior and posterior proliferative vitreoretinopathy. XLV Edward Jackson memorial lecture. Am. J. Ophthalmol. 106:519,1988. 3. Charles,S.: Anterior loop traction. In Vitreous Microsurgery, ed. 2. Baltimore, Williams & Wilkins, 1987, p. 137.
Optic Disk Neovascularization in Juvenile Rheumatoid Arthritis H. Christopher Semple, M.D., Maurice B. Landers III, M.D., and Lawrence S. Morse, M.D.
Retinal Service, Department of Ophthalmology, University of California, Davis.
August, 1990
Inquiries to Maurice B. Landers III, M.D., Department of Ophthalmology, University of California, Davis, 1603 Alhambra Blvd., Sacramento, CA 95816. Juvenile rheumatoid arthritis is a chronic, progressive disease that occurs during childhood. The most common ocular manifestation of juvenile rheumatoid arthritis is iridocyclitis. Other ocular manifestations include cataract, secondary glaucoma, and band keratopathy, which are related to chronic iridocyclitis.' Patients with ocular involvement generally have the pauciarticular disease and lack the systemic manifestations, lymphadenopathy, and fever. The patients with ocular involvement have a negative rheumatoid factor, but 80% of the patients have a positive antinuclear antibody titer associated with the disease.! We report a patient with juvenile pauciarticular rheumatoid arthritis who developed optic disk neovascularization. A 4-year-old girl had juvenile rheumatoid arthritis. The patient's condition had been initially diagnosed by her pediatrician two years previously, when she had arthritis of her left wrist and right knee. An antinuclear antibody titer was performed and found to be positive. In the same year, she developed bilateral anterior uveitis, which required long-term topical corticosteroid therapy in both eyes to control the inflammation. The arthritis was controlled by oral prednisone. Minimal inflammation persisted over the next two years, and visual acuity remained 20/30 in each eye. At 31/2 years of age, the patient was referred to our institution in March 1989 when visual acuity began to deteriorate because of bilateral progressive cataracts in both eyes that were secondary to chronic inflammation and longterm topical corticosteroid therapy. Visual acuity was R.E.: 20/400 and L.E.: hand motions. The results of an anterior segment examination disclosed nasal band keratopathy in the right eye and a clear cornea in the left eye. There were trace cells and mild flare in the right eye and trace cells and no flare in the left eye. Extensive posterior synechiae were seen in the right eye. Intraocular pressure was R.E.: 11 mm Hg and L.E.: 18 mm Hg. A severe cortical cataract was noted in the right eye and a dense, white cataract was noted in the left eye. The patient had a red reflex in the right eye and no red reflex in the left eye. The patient's cataract was removed by using a vitrectomy instrument in the left eye on March 21, 1989, and in the right eye on June 6, 1989. The entire lens capsule was removed during
