congenital rubella syndrome and the other with previous ocular trauma). In his series, the
mean
time between de¬
velopment of symptoms from BrownMcLean syndrome and cataract sur¬
was 14.5 years. Patients with Brown-McLean syn¬ drome typically show epithelial and stromal edema involving the periph¬ eral cornea except for the superior 10to 2-o'clock positions, which usually remain clear, as does the central pu¬ pillary zone (5 to 7 mm). The edematous corneal areas also show punctate orange pigmentation of the underlying endothelium. It has been hypothesized that after removal of the lens, either through ex¬ traction or spontaneous résorption, prolonged iridodonesis and endophthalmodonesis in an aphakic eye may lead to the development of BrownMcLean syndrome.3 To date, the exact etiology and histopathologic findings of this unusual syndrome remain un¬ known. Jennifer I. Lim, MD Sheridan Lam, MD Joel Sugar, MD Chicago, Ill
gery
Fig 1.—Slit-lamp photograph of the right eye showing the peripheral corneal haze and irreg¬ ularity due to the corneal edema. Note the uninvolved superior cornea.
This study was supported in part by core grant EY01792 from the National Eye Institute, Bethesda, Md, and by an unrestricted grant from Re¬ search to Prevent Blindness Ine, New York, NY. Reprint requests to the University of Illinois Eye and Ear Infirmary, 1855 W Taylor St, Chi¬ cago, IL 60612 (Dr Sugar). 1. Brown SI, McLean JM. Peripheral corneal edema after cataract extraction. Trans Am Acad
Ophthalmol Otolaryngol, 1969;73:465-470. 2. Brown SI. Peripheral corneal edema after cataract extraction. Am J Ophthalmol. 1970; 70:326-328. 3. Charlin R.
Peripheral
corneal edema after
cataract extraction. Am J
Ophthalmol. 1985;
99:298-303.
Rhegmatogenous Retinal Detachment Treated by Continuous Vitreous Insufflation
Continuous vitreous insufflation of air into the vitreous cavity can reattach rhegmatogenous retinal detachments in rabbits.1 A pars plana cannula is connected to a vitrectomy air injector to form an intravitreal air bubble, which, after many hours, essentially fills the vitreous cavity, occludes retinal breaks, and leads to reattachment. This method may have the following advantages in patients: (1) there is direct, reliable, virtually constant occlusion of retinal breaks; (2) the number, size, and location of retinal breaks are
relatively unimportant (giant tears and substantial proliferative retinopathy are contraindications); (3) there is minimal dependence on patient positioning; (4) the intraocular pressure is controlled; (5) surgery is simplified; and (6) no unapproved, nonphysiologic gases are used. We conducted a pilot study to evaluate the efficacy and safety of continuous vitreous insufflation in patients. Report of Cases.\p=m-\OurInstitutional Review Board approved the study. Seven eyes of seven patients (three men and four women), with a mean (\m=+-\SD)age of 47 ± 8.3 years, were studied. Each patient had a rhegmatogenous retinal detachment un¬
likely to respond to pneumatic retinopexy or gas-fluid exchange (usually because of inferior breaks) or was unable or unwilling to undergo scierai buckling. Four eyes were phakic, two were aphakic, and one was pseudophakic. Three eyes with prolifera¬ tive diabetic retinopathy had undergone vitrectomy, one with a scierai buckle. In the operating room each eye under¬ went sterile pars plana placement of a plastic vitrectomy cannula through which 0.06-cm tubing (Silastic, Dow Corning, Mid¬ land, Mich) had been passed. After secure suturing, the conjunctiva was closed around the tube with copious amounts of Fig 2.—Retroillumination of the right eye re¬ veals orange pigmented deposits along the endothelial surface of the
cornea.
antibiotic ointment. The tube was then passed down the face under adhesive tape to an assembly on the chest with a 0.22-µ filter, a three-way stopcock, and a one-way
valve. The tubing was connected via an¬ other 0.22-µ filter to a vitrectomy air pump set to yield an intraocular pressure of about 37 mm Hg. After surgery, patients received 250 mg of acetazolamide four times a day, and an¬ tibiotic drops and 0.5% timolol maléate twice a day. They were instructed to assume the face-down position for 2 minutes each hour. Cryopexy or laser therapy preceded removal of the cannula by at least 1 day in all but two patients. Throughout the proce¬ dures, patients were hospitalized (about 3
days).
A large bubble formed in each eye in 1 to 2 days, which led to reattachment of the retina. The re-formed vitreous appeared surprisingly normal after bubble dissipa¬ tion. Four retinas remained attached. In two of these successful cases, pneumatic retinopexy had failed. Three eyes developed
second retinal detachments within several
days. One of these patients had acquired immunodeficiency syndrome with severe cytomegalovirus retinitis and refused al¬
ternative surgery both before and after in¬ sufflation. The second patient had diabe¬ tes, had previously undergone vitrectomy, and had severe cardiac disease that pre¬ cluded more invasive surgery. Poor pupil¬ lary dilation and lens opacities prevented laser therapy for posterior breaks through the bubble. In the third patient, the cannula was removed the day of laser treatment; scierai buckling produced reattachment. The duration of follow-up was 8.1 ± 3.2 months. Complications included lens opac¬ ities in two patients and late-onset cystoid macular edema in one patient. There were no new retinal breaks, subretinal air, infec¬ tions, wound problems, cannula avulsions, proliferative vitreoretinopathy, flat ante¬ rior chambers, or hemorrhage.
Comment.—Continuous vitreous in¬ sufflation can reattach the retina in patients with rhegmatogenous retinal detachment. Human eyes generally tolerate the procedure. Redetachment appeared to be related to inadequate chorioretinal adhesion around the ret¬ inal breaks or to complicated detach¬ ments. After more is learned about the technique and case selection, this method may acquire a role in the treatment of rhegmatogenous retinal detachment. Norman P. Blair, MD
Chicago,
Ill
This study was supported in part by research grant EY07794 and core grant EY01792 from the National Eye Institute; a grant from the Illinois Eye Fund; and an unrestricted research grant from Research to Prevent Blindness Ine, New York, NY. This study was presented in part at the meeting of the Association for Research in Vision and Ophthalmology, Sarasota, Fla, April 29, 1990. Reprint requests to the Laboratory of Retinal Circulation and Metabolism, Eye and Ear Infir¬ mary, University of Illinois at Chicago, 1855 W Taylor St, Chicago, IL 60612 (Dr Blair). 1. Blair NP, Shaw WE, Floro C. Retinal reattachment by continuous vitreous insufflation. Arch Ophthalmol. 1989;107:1217-1219.
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 06/05/2015
mean
time between de¬
velopment of symptoms from BrownMcLean syndrome and cataract sur¬
was 14.5 years. Patients with Brown-McLean syn¬ drome typically show epithelial and stromal edema involving the periph¬ eral cornea except for the superior 10to 2-o'clock positions, which usually remain clear, as does the central pu¬ pillary zone (5 to 7 mm). The edematous corneal areas also show punctate orange pigmentation of the underlying endothelium. It has been hypothesized that after removal of the lens, either through ex¬ traction or spontaneous résorption, prolonged iridodonesis and endophthalmodonesis in an aphakic eye may lead to the development of BrownMcLean syndrome.3 To date, the exact etiology and histopathologic findings of this unusual syndrome remain un¬ known. Jennifer I. Lim, MD Sheridan Lam, MD Joel Sugar, MD Chicago, Ill
gery
Fig 1.—Slit-lamp photograph of the right eye showing the peripheral corneal haze and irreg¬ ularity due to the corneal edema. Note the uninvolved superior cornea.
This study was supported in part by core grant EY01792 from the National Eye Institute, Bethesda, Md, and by an unrestricted grant from Re¬ search to Prevent Blindness Ine, New York, NY. Reprint requests to the University of Illinois Eye and Ear Infirmary, 1855 W Taylor St, Chi¬ cago, IL 60612 (Dr Sugar). 1. Brown SI, McLean JM. Peripheral corneal edema after cataract extraction. Trans Am Acad
Ophthalmol Otolaryngol, 1969;73:465-470. 2. Brown SI. Peripheral corneal edema after cataract extraction. Am J Ophthalmol. 1970; 70:326-328. 3. Charlin R.
Peripheral
corneal edema after
cataract extraction. Am J
Ophthalmol. 1985;
99:298-303.
Rhegmatogenous Retinal Detachment Treated by Continuous Vitreous Insufflation
Continuous vitreous insufflation of air into the vitreous cavity can reattach rhegmatogenous retinal detachments in rabbits.1 A pars plana cannula is connected to a vitrectomy air injector to form an intravitreal air bubble, which, after many hours, essentially fills the vitreous cavity, occludes retinal breaks, and leads to reattachment. This method may have the following advantages in patients: (1) there is direct, reliable, virtually constant occlusion of retinal breaks; (2) the number, size, and location of retinal breaks are
relatively unimportant (giant tears and substantial proliferative retinopathy are contraindications); (3) there is minimal dependence on patient positioning; (4) the intraocular pressure is controlled; (5) surgery is simplified; and (6) no unapproved, nonphysiologic gases are used. We conducted a pilot study to evaluate the efficacy and safety of continuous vitreous insufflation in patients. Report of Cases.\p=m-\OurInstitutional Review Board approved the study. Seven eyes of seven patients (three men and four women), with a mean (\m=+-\SD)age of 47 ± 8.3 years, were studied. Each patient had a rhegmatogenous retinal detachment un¬
likely to respond to pneumatic retinopexy or gas-fluid exchange (usually because of inferior breaks) or was unable or unwilling to undergo scierai buckling. Four eyes were phakic, two were aphakic, and one was pseudophakic. Three eyes with prolifera¬ tive diabetic retinopathy had undergone vitrectomy, one with a scierai buckle. In the operating room each eye under¬ went sterile pars plana placement of a plastic vitrectomy cannula through which 0.06-cm tubing (Silastic, Dow Corning, Mid¬ land, Mich) had been passed. After secure suturing, the conjunctiva was closed around the tube with copious amounts of Fig 2.—Retroillumination of the right eye re¬ veals orange pigmented deposits along the endothelial surface of the
cornea.
antibiotic ointment. The tube was then passed down the face under adhesive tape to an assembly on the chest with a 0.22-µ filter, a three-way stopcock, and a one-way
valve. The tubing was connected via an¬ other 0.22-µ filter to a vitrectomy air pump set to yield an intraocular pressure of about 37 mm Hg. After surgery, patients received 250 mg of acetazolamide four times a day, and an¬ tibiotic drops and 0.5% timolol maléate twice a day. They were instructed to assume the face-down position for 2 minutes each hour. Cryopexy or laser therapy preceded removal of the cannula by at least 1 day in all but two patients. Throughout the proce¬ dures, patients were hospitalized (about 3
days).
A large bubble formed in each eye in 1 to 2 days, which led to reattachment of the retina. The re-formed vitreous appeared surprisingly normal after bubble dissipa¬ tion. Four retinas remained attached. In two of these successful cases, pneumatic retinopexy had failed. Three eyes developed
second retinal detachments within several
days. One of these patients had acquired immunodeficiency syndrome with severe cytomegalovirus retinitis and refused al¬
ternative surgery both before and after in¬ sufflation. The second patient had diabe¬ tes, had previously undergone vitrectomy, and had severe cardiac disease that pre¬ cluded more invasive surgery. Poor pupil¬ lary dilation and lens opacities prevented laser therapy for posterior breaks through the bubble. In the third patient, the cannula was removed the day of laser treatment; scierai buckling produced reattachment. The duration of follow-up was 8.1 ± 3.2 months. Complications included lens opac¬ ities in two patients and late-onset cystoid macular edema in one patient. There were no new retinal breaks, subretinal air, infec¬ tions, wound problems, cannula avulsions, proliferative vitreoretinopathy, flat ante¬ rior chambers, or hemorrhage.
Comment.—Continuous vitreous in¬ sufflation can reattach the retina in patients with rhegmatogenous retinal detachment. Human eyes generally tolerate the procedure. Redetachment appeared to be related to inadequate chorioretinal adhesion around the ret¬ inal breaks or to complicated detach¬ ments. After more is learned about the technique and case selection, this method may acquire a role in the treatment of rhegmatogenous retinal detachment. Norman P. Blair, MD
Chicago,
Ill
This study was supported in part by research grant EY07794 and core grant EY01792 from the National Eye Institute; a grant from the Illinois Eye Fund; and an unrestricted research grant from Research to Prevent Blindness Ine, New York, NY. This study was presented in part at the meeting of the Association for Research in Vision and Ophthalmology, Sarasota, Fla, April 29, 1990. Reprint requests to the Laboratory of Retinal Circulation and Metabolism, Eye and Ear Infir¬ mary, University of Illinois at Chicago, 1855 W Taylor St, Chicago, IL 60612 (Dr Blair). 1. Blair NP, Shaw WE, Floro C. Retinal reattachment by continuous vitreous insufflation. Arch Ophthalmol. 1989;107:1217-1219.
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 06/05/2015
