Bidirectional inferior vena cava-pulmonary artery shunt.
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Animals↗
Biomedical subjects
J A Haller
Publications and source records attributed to J A Haller.
Management of endophthalmitis in a silicone oil-filled eye.
PURPOSE: To describe the management of endophthalmitis in an eye filled with silicone oil for prolonged internal retinal tamponade. METHODS: A patient with a silicone oil-filled eye developed endophthalmitis postoperatively. Results of clinical examination, diagnostic procedures, and surgical management are described. RESULTS: Removal of the silicone oil, injection of antibiotics into the fluid-filled vitreous cavity, and reinjection of silicone oil resulted in resolution of the endophthalmitis and improvement in vision. CONCLUSIONS: Aggressive management of endophthalmitis in an eye requiring silicone oil tamponade may salvage useful vision.
Anti-Bacterial Agents↗
Cataract extraction after retinal detachment.
Cataract surgery is a known risk factor for retinal detachment. The risk for retinal redetachment after cataract surgery in eyes that have previously undergone retinal detachment repair is not well documented but has recently been investigated. Eyes that have undergone previous scleral buckling surgery have good potential for positive visual outcome after cataract surgery, with a low rate of intraoperative complications and a low risk for recurrent retinal detachment. Eyes with complicated retinal detachments that have undergone vitrectomy as part of surgical repair may have a higher rate of intraoperative complications, including difficulty with nuclear expression during planned extracapsular cataract extraction and capsular tears during irrigation and aspiration. The risk for recurrent retinal detachment in these eyes is not known.
Cataract↗
Multicenter trial of transscleral diode laser retinopexy in retinal detachment surgery.
PURPOSE: To evaluate the safety and efficacy of transscleral diode laser for retinopexy in rhegmatogenous retinal detachment surgery in a multicenter trial. DESIGN: 67 patients with primary rhegmatogenous retinal detachment underwent scleral buckling surgery, using transscleral diode laser for retinopexy, at five study centers. STUDY PARTICIPANTS: 72 patients with primary rhegmatogenous retinal detachments were enrolled. No patient with chronic detachment, a retinal break greater than 90 degrees, history of uveitis or infectious retinopathy, or proliferative vitreoretinopathy was enrolled. Five eyes were excluded because they required additional nonprotocol treatment at the time of surgery (vitrectomy or supplementary cryotherapy due to probe malfunction). MAIN OUTCOME MEASURES: Retinal reattachment at six months after one operation. Secondary measures: visual acuity and complications, including choroidal, retinal, and vitreous hemorrhage, inflammation, and scleral damage. RESULTS: Six months or greater follow-up information was available on 65 eyes. Retinas were attached at 6 months with a single operation in 58 (89%) of these eyes. Complications included apparent pinpoint breaks in Bruch is membrane in 15 eyes, scleral thermal effect in 14 eyes, and limited hemorrhage, which was intraretinal in 10 eyes, and extended into the vitreous in 3 eyes. In one case, hemorrhage was judged to have contributed possibly to initial surgical failure. The other complications had no known adverse effects. Complications were significantly associated with the physicians experience with transscleral laser retinopexy. CONCLUSION: In this multicenter series, transscleral diode laser retinopexy served as a safe and effective means of creating chorioretinal adhesion during retinal reattachment surgery. Minor complications were minimized by increasing experience with the technique.
Adolescent↗
Visual field loss following vitreous surgery.
OBJECTIVE: To assess possible causes of visual field loss following vitreous surgery. DESIGN: Charts of 8 patients prospectively identified, who developed visual field loss following vitreous surgery, were reviewed to characterize this newly recognized syndrome and assess possible causes. RESULTS: Two patients had preexisting chronic open-angle glaucoma and 1 had ocular hypertension. Indications for surgery included 4 eyes with macular holes, 1 eye with epiretinal membrane, 2 eyes with rhegmatogenous retinal detachment, and 1 eye with retinal detachment and giant retinal tear. All patients received retrobulbar anesthesia. Seven of 8 patients had fluid/gas exchange with installation of long-acting bubbles. In 1 patient with a macular hole, a small hemorrhage was noted along a vessel coming off the nerve superotemporally while attempting to engage the posterior cortical vitreous intraoperatively. This patient developed an inferior visual field defect. No intraocular pressure (IOP) measurements greater than 26 mm Hg were recorded in any eye perioperatively. Visual field defects included 4 eyes with inferotemporal defects, 2 eyes with inferior altitudinal defects, 1 eye with a cecocentral scotoma, and 1 eye with a superonasal defect. Only 1 patient had worsened visual acuity. A relative afferent pupillary defect was observed in 4 eyes and disc pallor in 5 eyes. CONCLUSIONS: Central or peripheral visual field loss can now be recognized as a possible complication of vitreous surgery. In some cases, a relative afferent pupillary defect and optic disc pallor are present, suggesting that the optic nerve is the site of injury. Possible mechanisms include ischemia due to elevated IOP or fluctuations in IOP, optic nerve damage from retrobulbar injection, direct intraoperative mechanical trauma to the optic nerve, indirect injury from vigorous suction near the optic nerve leading to shearing of peripapillary axons or vessels, or a combination of these. Certain optic nerves may be more susceptible to injury because of preexisting compromise from glaucoma or vascular disease.
Adult↗
Chest wall constriction after too extensive and too early operations for pectus excavatum.
BACKGROUND AND METHODS: Since 1990 we have evaluated 12 children and teenagers in whom severe cardiorespiratory symptoms have developed due to failure of chest wall growth after very extensive pectus excavatum operations (removal of five or more ribs) at very early ages (< 4 years). RESULTS: Apparently these extensive procedures have removed or prevented growth center activity, which resulted in restriction of chest wall growth with marked limitation of ventilatory function. The forced vital capacity ranged from 30% to 50% of predicted and the forced expiratory volume in 1 second from 30% to 60%. All patients are symptomatic with mild exercise and cannot compete in running games. Our protocol for critical evaluation includes exercise pulmonary function studies and axial computed tomographic reconstruction. CONCLUSIONS: This report is an alert to recognize such patients and also to recommend delay in operative repair in small children until at least 6 to 8 years of age. The younger the patient the more limited the chest wall resection for pectus excavatum should be. Five of these patients have had a chest cavity expansion operation with encouraging early results.
Adolescent↗
Cardiorespiratory function before and after corrective surgery in pectus excavatum.
OBJECTIVE: To determine whether pectus excavatum (PE) results in cardiopulmonary abnormalities, and whether surgical repair results in improvement. METHODS: We performed pulmonary function testing and incremental exercise testing in 36 adolescents with PE (aged 16 +/- 3 (SD) years) and 10 age-matched, healthy control subjects. Fifteen PE subjects were reexamined postoperatively, as were six control subjects. RESULTS: Preoperatively, PE subjects had a significantly lower forced vital capacity than control subjects had (81% +/- 14% vs 98% +/- 9% of the predicted value; p < 0.001). Chest computed tomography ratios of internal transverse to antero-posterior diameters correlated inversely with total lung capacity (r = 0.56; p < 0.01). Fifty-eight percent of PE subjects had subjective complaints of exercise limitation. PE subjects exercised at a workload similar to that of control subjects. Maximal heart rate and O2 pulse did not differ between the two groups. Respiratory measurements during exercise were similar between the two groups. Respiratory measurements during exercise were similar between the two groups. Postoperatively there was no change in forced vital capacity (as a percentage of the predicted value). The PE subjects exercised for a slightly longer period and had a slightly higher O2 pulse, whereas control subjects showed no change. CONCLUSION: Some subjects with PE have mild restrictive lung disease, which is not affected by surgical repair. Postoperatively they have a slight increase in exercise tolerance and O2 pulse, which suggests improved cardiac function during exercise. However, the clinical implications of this modest improvement are unclear.
Adolescent↗
Phacoemulsification after retinal detachment surgery.
PURPOSE: Previous studies have documented a 3% to 15.5% risk of retinal redetachment in eyes with prior scleral buckling procedures that later undergo intracapsular or extracapsular cataract extraction. The authors reviewed the records of patients with a history of retinal detachment (RD) surgery and subsequent phacoemulsification to assess the risk of retinal redetachment and the visual outcomes. METHODS: Forty-seven eyes of 44 patients with a history of scleral buckling surgery who subsequently underwent phacoemulsification were identified. Features found before, during, and after surgery were reviewed. RESULTS: No retinal redetachments occurred on a mean follow-up of 2.3 years. Eyes with RD repair were more myopic than fellow eyes (P=<0.001), had longer axial lengths (P=0.001), had steeper keratometry readings (P=0.03), and had larger differences in K readings between principal meridians (P=0.01). Postoperative visual acuity was 20/40 or better in 72.3% of eyes and 20/80 or worse in 6.4% of eyes. Preexisting macular pathology was responsible for poor outcomes. CONCLUSION: The risk of redetachment after phacoemulsification in eyes with previous RD surgery is low. Despite retinal and cataract surgery, these eyes can achieve useful vision.
Adolescent↗
Blunt trauma to the abdomen.
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Abdominal Injuries↗
Determination of the real size of fundus objects from fundus photographs.
PURPOSE: The purpose of this research was to study the accuracy of measurements that rely on Littmann curves to determine the real size of fundus images. METHODS: Retinal tacks of known dimensions were placed near the optic disc in one eye of each of two cynomolgus monkeys. Images of the retinal tack and optic nerve head of these two eyes were then obtained with a Zeiss Fundus camera. The dimensions of the retinal tacks and optic discs were measured directly on the film from the Zeiss fundus camera. These measurements were then corrected with Littmann's mathematical approximations. RESULTS: In the cynomolgus eye with 19.9 mm axial length, Littmann's mathematical approximations of the real sizes of the retinal tack and optic disc from measurements on the Zeiss film had median percent bias [(calculated size-real size)/real size] of -0.2% (range, -3.2% to 3.9%). In the other eye with 17.9 mm axial length, the median percent bias was 14.7% (range, 5.1% to 29.7%). CONCLUSION: The estimation of the real size of fundus images with Littmann's mathematical approximations from images on Zeiss film have < 4% bias if the eye's dimensions fall in the range over which Littmann's curves were produced.
Animals↗
Transvitreal endocyclophotocoagulation.
PURPOSE: Transvitreal endophotocoagulation of the ciliary processes is a little-used option for eyes with refractory glaucoma. No histopathologic studies of animals or humans have described its effects. We sought to characterize this cilioablative procedure in an animal model, examine its effects in human eyes histopathologically, and evaluate its clinical safety and efficacy in a large series of patients with long-term follow-up. METHODS: ANIMAL MODEL: Rabbit eyes were treated with lensectomy, vitrectomy, and transvitreal photocoagulation of the ciliary processes. Eyes were enucleated immediately after surgery and at weekly intervals up to 1 month. Light and electron microscopic evaluation of histopathologic changes was performed. Human Eyes: The pathology laboratory files were searched for cases with a history of endocyclophotocoagulation prior to enucleation, and three eyes were identified. Histopathologic sections were retrieved and examined. Clinical Series: A retrospective clinical review was performed of a single surgeon's experience with endolaser to the ciliary processes, including all cases with adequate data on ocular history, preoperative and postoperative visual acuity, intraocular pressure (IOP), and glaucoma medications, and details of surgery. Only eyes with at least 6 months' follow-up were included. RESULTS: ANIMAL MODEL: Histopathologic examination of rabbit eyes treated with endocyclophotocoagulation demonstrated acute changes of ciliary process destruction, proteinaceous exudate, stromal edema, nuclear pyknosis, and pigment dispersion. Vascular congestion was seen with some hemorrhage. Later, replacement by fibrous or fibrovascular scar developed with loss of the pigmented and nonpigmented ciliary epithelia, absence of ciliary architectural elements, and pigment rounding and clumping. Human Eyes: Histopathologic examination of enucleated human eyes revealed total ablation of the ciliary processes with fibrosis and pigment clumping in areas of treatment. Abrupt transitions between treated and untreated regions could be identified. In some areas fibrocellular membrane proliferation was found extending over the scars that replaced the ciliary processes. Clinical series: Seventy-three patients were identified ranging in age from 2 to 85 years (mean, 57.7), with follow-up of 6 to 130 months (mean, 28.6). Mean number of previous operations was 3.5; mean number of previous glaucoma operations was 1.3. Preoperative mean IOP was 38 mmHg (range, 19 to 75), postoperative mean IOP was 16 mmHg (range, 1 to 50). At 6 months, 58 of 72 eyes (81%) with available IOP data had IOP greater than 5 mmHg and less than 22. At 12 months 48 of 55 (87.3%) were successfully controlled by these criteria, and at last follow-up 50 of 73 (68%). Fifty-six of 73 eyes (77%) were considered clinically stable at the last follow-up in terms of visual acuity, anatomic integrity, and IOP < or = 23 off all glaucoma medications. Visual acuity was stable or improved in 53 of 73 eyes (73%). Complications developed in 9 eyes (12%), including IOP < or = 6 mmHg in 6 eyes (8.2%), peripheral choroidal effusion in 4 (5.5%), fibrinous anterior chamber reaction in 3 (4.1%), phthisis in 2 (2.7%), and choroidal hemorrhage in 1. Thirty-five eyes had penetrating keratoplasty performed before or at the same time as endolaser (an average of 2.14 grafts each), Graft rejection occurred in 4 eyes (11%), and long-term failure of grafts occurred in 11 of 35 (31%). In 31 eyes, additional surgical procedures were performed at the time of endocyclophotocoagulation. CONCLUSIONS: Endocyclophotocoagulation successfully ablates the ciliary processes, which are replaced with fibrous scar. Surgical results compare favorably with other methods of glaucoma therapy in complicated eyes in terms of IOP control, visual preservation, and complication rate. Endolaser to the ciliary body was especially successful in glaucomatous eyes after keratoplasty, although corneal graft prognosis
Adolescent↗
Severe chest wall construction from growth retardation after too extensive and too early (< 4 years) pectus excavatum repair: an alert.
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Adolescent↗
Class III beta-tubulin in human retinal pigment epithelial cells in culture and in epiretinal membranes.
The class III beta-tubulin isotype (beta III) is expressed exclusively by neurons within the normal human retina and is not present in normal retinal pigment epithelial (RPE) cells in situ or in 1 day-old primary cultures; however, beta III is present in RPE cells in 5-day primary cultures and in passaged RPE cells grown in monolayer cultures as determined by immunohistochemistry and Western blotting. beta III-positivity in cultured RPE cells is not affected by cell density or hydroxyurea- or retinoic-acid-mediated growth inhibition, but only a few cells weakly express beta III in cyclohexamide-treated cultures and RPE cells maintained in serum-free medium fail to produce beta III. When monolayer-cultured RPE cells grown in normal, serum-containing medium, are transferred to irradiated bovine vitreous, beta III is undetectable in most cells. Cultured RPE cells coexpress beta III with keratin and cellular retinaldehyde-binding protein (both RPE cell markers), but not with glial fibrillary acidic protein. Some cultured RPE cells also express neuron-specific (gamma) enolase, which is neuron-associated but not neuron-specific, and occasional cells in confluent or super-confluent cultures contain the 200-kDa neurofilament protein. Retinal glia, fibroblasts, endothelial cells, and smooth muscle cells do not express beta III under the same culture conditions. We have detected beta III in 45 of 56 epiretinal membranes, frequently in cells with a bipolar or dedifferentiated morphology, where its expression coincides with other RPE cell-associated antigens. Cells with morphological features resembling normal RPE cells in epiretinal membranes are usually negative for beta III, but RPE cells appearing to be in the early stages of dedifferentiation express the isotype weakly. Electron microscopic immunocytochemistry localizes beta III to microtubules, ribosomes and cytoplasm. beta III may be a useful marker for recognizing the fraction of RPE cells in epiretinal membranes that are no longer identifiable by morphological criteria or other RPE cell markers. These findings demonstrate that mature human RPE cells have the capacity to express a neuron-associated gene in response to conditions that promote dedifferentiation.
Cells, Cultured↗
An unusual case of cryptococcal endophthalmitis.
BACKGROUND: Cryptococcal endophthalmitis is a rare disorder, almost invariably diagnosed after enucleation or at postmortem examination. There are therefore few guidelines as to its identification or treatment. METHODS: A case of culture-positive cryptococcal endophthalmitis in a patient with chronic uveitis was diagnosed by vitreous biopsy at the time of retinal detachment repair. The patient was treated with oral fluconazole for 5 months. All reported cases of cryptococcal endophthalmitis were reviewed and compared. RESULTS: After oral fluconazole therapy, the patient was culture negative on repeat tap. Despite conversion to culture-negative status, however, visual acuity declined to hand motions because of hyphema and hypotony. The organism was successfully identified as a non-neoformans species, Cryptococcus laurentii, previously unreported as an ocular pathogen. CONCLUSION: This unique case demonstrates that cryptococcal disease can be diagnosed antemortem by vitreous biopsy, and should be added to the differential diagnosis in cases of chronic smoldering uveitis. A non-neoformans organism is also identified for the first time as a cause of ocular cryptococcosis. Fluconazole, used here for the only time of which we are aware to treat cryptococcal endophthalmitis, produced successful conversion to culture negativity and resolution of the uveitis.
Administration, Oral↗
Life-threatening injuries in children: what have we learned and what are the challenges?
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Adult↗
Pseudophakic Candida parapsilosis endophthalmitis with a consecutive keratitis.
We describe a case of Candida parapsilosis endophthalmitis with a consecutive keratitis after phacoemulsification and posterior chamber intraocular lens implantation in an otherwise healthy eye. Despite aggressive medical and surgical management during a 2-year period, multiple episodes recurred, with the development of an intracapsular plaque and an infectious nidus on the corneal endothelium 6 months after the initial presentation. After subtotal removal of the culture-positive capsule, intravitreal and topical amphotericin B, and oral fluconazole, the inflammation improved. However, the corneal endothelial plaque persisted with recurrent inflammation 2 months later, prompting debridement of the culture-positive plaque and further removal of the culture-negative capsular remnants and lens implant. The infection was quiescent for the subsequent 12-month period until recurrent intraocular inflammation developed with enlargement of the endothelial plaque. Culture of this plaque was again positive for C. parapsilosis. After debridement and intraocular and topical amphotericin B, the eye has now been quiescent for 13 months. This case demonstrates the development of a secondary keratitis in an eye affected by pseudophakic C. parapsilosis endophthalmitis, with the posterior cornea serving as a sanctuary site for the fungus despite aggressive management leading to recurrent infection 1 year after the clinical disease appeared to be quiescent.
Aged↗
The eye in bone marrow transplantation. VI. Retinal complications.
OBJECTIVE: To evaluate the posterior segment ocular complications of patients undergoing bone marrow transplantation (BMT). DESIGN: Retrospective analysis. SETTING: Academic ophthalmology department at a tertiary care hospital with a BMT unit. PATIENTS: Patients undergoing BMT were seen by an ophthalmologist for clinical care and enrolled in a long-term follow-up study, during which they were seen 6 and 12 months after the transplantation and annually thereafter. RESULTS: Of 397 patients undergoing BMT, 51 (12.8%) developed posterior segment complications. Fourteen patients (3.5%) developed hemorrhagic complications with either intraretinal and/or vitreous hemorrhages and 17 patients (4.3%) developed cotton-wool spots in the fundus of both eyes. Eleven patients (2.8%) had bilateral optic disc edema, with eight cases attributed to the toxic effects of cyclosporine and three to other causes. Two patients (0.5%) developed serious retinal detachments. Eight patients (2.0%) developed infectious retinitis and/or endophthalmitis. Fungal infections with Candida or Aspergillus usually occurred within 120 days after BMT, while viral infections with herpes zoster or cytomegalovirus and parasitic infections with Toxoplasma occurred later. Intraocular lymphoma occurred in one patient (0.2%). CONCLUSION: Severe, potentially vision-threatening, posterior segment complications following BMT occur due to a variety of causes.
Adult↗