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the very young, congenital glaucoma pa­ tients until further studies are done. SUMMARY

A 2-week-old premature child with congenital glaucoma secondary to anteri­ or cleavage syndrome was treated with timolol maleate and cyclocryotherapy. The patient had apneic spells of up to 30 seconds that stopped soon after timolol maleate therapy was discontinued. No apnea was seen before timolol maleate administration, and no further spells were noted after subsequent cyclocryotherapy without timolol maleate treatment. Possible central nervous system toxicity of timol maleate or its metabolic by­ products in neonates with immature blood-brain barriers was noted. REFERENCES 1. Zimmerman, T. J., and Kaufman H. E.: Timo­ lol. Dose response and duration of action. Arch. Ophthalmol. 95:605, 1977. 2. : A beta-adrenergic blocking agent for the treatment of glaucoma. Arch. Ophthalmol. 95: 601, 1977. 3. Boger, W. P., I l l , Puliafito, C. A., Steinert, R. R., and Langston, D. P.: Long-term experience with timolol ophthalmic solution in patients with open-angle glaucoma. Ophthalmology 85:259,1978. 4. Zimmerman, T. J., Gillespie, J. E., Kass, M. A., Yablonski, M. E., and Becker, B.: Timolol plus maximum-tolerated antiglaucoma therapy. Arch. Ophthalmol. 97:278, 1979. 5. Cserr, H. F.: Physiology of the choroid plexus. Physiol. Rev. 51:273, 1971. 6. Cameron, G.: Secretory activity of the choroid plexus in tissue culture. Anat. Rec. 117:115, 1953. 7. Pollay, M., and Davson, H.: The passage of certain substances out of the cerebrospinal fluid. Brain 86:137, 1963. 8. Davson, H., and Pollay, M.: Influences of vari­ ous drugs on the transport of 131 I and PAH across the cerebrospinal-fluid-blood barrier. J. Physiol. 167:239, 1963. 9. Barany, E. H.: Bile acids as inhibitors of the liver-like anion transport systems in the rabbit kid­ ney, uvea and choroid plexus. Acta. Physiol. Scand. 92:195, 1974. 10. Johnson, J. T., Holloway, L. S., Heisey, S. R., and Hook, J. B.: Substrate stimulation of organic anion transport in newborn dog kidney and choroid plexus. Biochem. Pharmacol. 23:754, 1974. 11. Tochino, Y., and Schanker, L. S.: Active

JULY, 1979

transport of biologic amine compounds by the rab­ bit choroid plexus. Pharmacology 6:177, 1964. 12. : Active transport of quaternary ammo­ nium compounds by the choroid plexus in vitro. Am. J. Physiol. 208:666, 1965. 13. Loizou, L. A.: The development of monamine-containing neurons in the brain of the albino rat. J. Anat. 104:588, 1969. 14. Hellenbrecht, D., Lemmer, B., Wiethold, G., and Gobecker, H.: Measurement of hydrophobicity, surface activity, local anesthesia, and myocardial conduction velocity as quantitative parameters of the non-specific membrane affinity of nine betaadrenergic blocking agents. Arch. Pharmacol. 277: 211, 1973. 15. Vareilles, P., Silverstone, D., Plazonnet, B., LeDouarec, J. C., Sears, M. L., and Stone, C. A.: Comparison of the effects of timolol and other adrenergic agents on intraocular pressure in the rabbit. Invest. Ophthalmol. Vis. Sci. 16:987, 1977.

MASSIVE SUBRETINAL EXUDATE AFTER RETINAL D E T A C H M E N T SURGERY R O B E R T H. W A L L Y N , M. Monterey,

D.

California

Coats' disease is associated with retinal telangiectasis and progressive exudative retinal detachment occurring in one eye of young males. 1 However, massive subretinal exudation has been observed in the course of other primary diseases such as involutional macular degeneration. 2 Although Aaberg documented the phe­ nomenon of choroidal exudation of clear serous fluid after retinal cyrosurgery, 3 to my knowledge, this is the first report of massive subretinal lipoidal exudation after successful retinal reattachment sur­ gery. CASE REPORT A 70-year-old woman was referred for surgical repair of a retinal detachment. She had noticed From the Department of Ophthalmology, Univer­ sity of California Medical Center, San Francisco, California. Reprint requeste to Robert H. Wallyn, M.D., 1001 Pacific St., Monterey, CA 93940.

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NOTES, CASES, INSTRUMENTS

decreased visual acuity in the left eye for several months. Examination disclosed visual acuity of R.R.: 6/15+ (20/50+) and L.E.: light perception. Results of external examination were unremarkable. Motility was within normal limits. Pupils dilated to 6 mm in both eyes. Slit-lamp examination disclosed minimal nasal band keratopathy, minimal cortical cataracts, and posterior vitreous detachment in both eyes. The vitreous flow time in the left eye was markedly reduced. Tension by applanation was 20 mm Hg in both eyes. Retinal examination of the right eye disclosed lattice degeneration inferiorly. The left eye revealed a total rhegmatogenous retinal detachment. A horseshoe retinal break was noted superiorly. Multiple white cascading folds indica­ tive of massive periretinal proliferation were seen. The surgery consisted of 360-degree cryotherapy, the drainage of subretinal fluid, and scleral buckling with a 4-mm silicone band. The band was cut so that its length was equal to the circumference of the undrained globe. After drainage, the ends of the band were overlapped 22 mm in an attempt to create a high 360-degree buckle. The posterior margin of the band was 16 mm posterior to the corneoscleral limbus and just anterior to the exit of the vortex veins. The patient's postoperative course was com­ plicated by moderate choroidal detachment, but this resolved within three weeks. One month after sur­ gery, the retina was completely reattached but mas­ sive subretinal exudation was noted. It was yellow in color and appeared in all four quadrants. Visual field examination did not reveal any impairment of peripheral vision caused by the subretinal exuda­ tion. Fluorescein angiography and angioscopy did not show any areas of retinal telangectasis or incom­ petence of the retinal vessels. In the ensuing months, the subretinal exudate underwent gradual resolution. By the sixth month after surgery, most of the subretinal exudate was reabsorbed. DISCUSSION

Massive subretinal exudation is a com­ plication of successful retinal reattachment surgery. The absence of significant fluorescein leakage or visible areas of retinal telangiectasis make a retinal source of the subretinal exudate unlikely. Large areas of cryotherapy, the hypotony during drainage of subretinal fluid, a high encircling scleral buckle, and postopera­ tive choroidal detachment make a choroi­ dal source of the subretinal exudate more likely. We believe the cause of the choroi­ dal detachment and exudation was vortex ampulla obstruction resulting from the encircling band. 4 ' 5 The subretinal exu­ date underwent gradual resolution and did not influence the anatomic result of the surgical procedure.

SUMMARY

A 70-year-old woman developed mas­ sive subretinal exudation after surgical repair of a rhegmatogenous retinal de­ tachment. Postoperative choroidal de­ tachment suggested a choroidal source of the subretinal exudate. We believe the cause of the choroidal detachment and exudation was vortex ampulla obstruction resulting from the encircling band. The subretinal exudate underwent gradual resolution and did not influence the ana­ tomic result of retinal reattachment. REFERENCES 1. Coats, G.: Forms of retinal disease with mas­ sive exudation. Roy. London Ophthal. Hosp. Rep. 17: 440, 1908. 2. Blair, C. J., and Aaberg, T. M.: Massive subret­ inal exudation associated with senile macular de­ generation. Am. J. Ophthalmol. 71:639, 1971. 3. Aaberg. T. M., and Pawlowski, G. J.: Exuda­ tive retinal detachments following scleral buckling with cryotherapy. Am. J. Ophthalmol. 74:245,1972. 4. Aaberg, T. M.: Experimental serous and hemorrhagic uveal edema associated with retinal detach­ ment surgery. Invest. Ophthalmol. 14:243, 1975. 5. Hayreh, S. S., and Baines, J. A. B.: Occlusion of the vortex veins. Br. J. Ophthalmol. 57:217,1973.

A WIREFORM SURGICAL DRAPE-RETRACTOR H E R B E R T J. N E V Y A S , Philadelphia,

M.D.

Pennsylvania

The presence of surgical drapes cover­ ing the nose and mouth can cause the patient to feel suffocation. Although this sensation is mainly psychological, it can cause the patient to become dyspneic, anxious, and restless. Patient discomfort is compounded by the moist warmth re­ tained by the newer waterproof plastic drapes. From the Department of Ophthalmology, Uni­ versity of Pennsylvania School of Medicine and the Scheie Eye Institute, Philadelphia, Pennsylva­ nia. Reprint requests to Herbert J. Nevyas, M.D., 1930 Chestnut St., Philadelphia, PA 19103.

Massive subretinal exudate after retinal detachment surgery.

122 AMERICAN JOURNAL OF OPHTHALMOLOGY the very young, congenital glaucoma pa­ tients until further studies are done. SUMMARY A 2-week-old premature...
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