Predictors and Outcomes of Vitrectomy and Silicone Oil Injection in Advanced Diabetic Retinopathy

PURPOSE: To evaluate visual and anatomical results and identify factors that influence vitrectomy and silicone oil (SO) injection outcomes in proliferative diabetic retinopathy (PDR). METHODS: This retrospective study included 236 eyes with PDR that were undergoing vitrectomy and SO injection with >3-month follow-up. The primary outcomes were final best-corrected visual acuity (BCVA) and retinal attachment rate. RESULTS: At the final visit (mean, 88 ± 58 weeks), complete, partial, and no retinal attachment were observed in 86.9%, 10.6%, and 2.5% of patients, respectively. A total of 155 eyes had experienced SO removal, while 81 had SO in place. The mean initial BCVA was 1.9 ± 0.7 logarithm of the minimum angle of resolution (logMAR) and significantly improved to 1.7 ± 0.8 logMAR (p = 0.001). Initial macular detachment (adjusted odds ratio [AOR], 0.25), development of iatrogenic break (AOR, 0.25), and use of heavy SO (AOR, 0.13) were independently associated with a lower risk of final retinal attachment, and SO removal was associated with a higher incidence (AOR, 7.55). Better baseline BCVA was associated with a higher risk of final BCVA ≥20 / 200. CONCLUSIONS: Despite an encouraging outcome based on anatomical data in advanced PDR treated with vitrectomy and SO, the functional prognosis was not satisfying for patients. Eyes with better vision at baseline had a more favorable prognosis, whereas eyes with initial macular detachment, intraoperative iatrogenic break, or heavy SO showed more unfavorable outcomes. In selected cases, extending the time of SO use did not worsen the prognosis.

Patterns of uveitis in the Middle East and Europe

To compare the patterns of uveitis, emphasizing similarities and discrepancies, in the Middle East and Europe. Six articles reporting uveitis patterns from the Middle East including a total of 2, 693 cases, and seven articles with a sum of 4, 379 cases from Europe were analyzed and patterns in each region were defined and compared. In both regions, uveitis was most commonly seen in the fourth decade of life with anterior uveitis being the most common anatomical form. Idiopathic cases accounted for the majority of anterior and intermediate uveitis; toxoplasmosis was the most frequent entity in posterior uveitis while Behcet's disease and idiopathic forms were the next most common causes in the Middle East and in Europe, respectively. Since patterns of uveitis differ in various geographic regions, discovering these patterns would be helpful for the diagnosis and treatment of this broad category of conditions. This necessitates applying a universal diagnostic classification system to enable accurate comparisons

Childhood pars planitis; clinical features and outcomes

To evaluate the demographic and clinical features of childhood pars planitis, and to determine the therapeutic and visual outcomes of the disease. Medical records of pediatric patients [less than 16 years of age at diagnosis] with pars planitis and at least 6 months of follow-up who were referred to Labbafinejad Medical Center, Tehran, Iran over a 22 year period were reviewed. Overall, 117 eyes of 61 patients including 51 [83.6%] male subjects were included. Mean age at the time of diagnosis was 7.8 +/- 3.2 [range, 3-16] years. Mean best corrected visual acuity [BCVA] was 0.88 +/- 0.76 logMAR at presentation which improved to 0.39 +/- 0.51 logMAR at final visit [P<0.001]. Endotheliitis was present in 23 [19.6%] eyes and was significantly more prevalent in subjects younger than 9 years [P=0.025]. Cataract formation [41.9%] and cystoid macular edema [19.7%] were the most prevalent complications. Univariate regression analysis showed that better baseline visual acuity [OR=0.38, 95%CI 0.21-0.70, P=0.002], age older than 5 years at disease onset [OR=0.36, 95%CI 0.14-0.9, P=0.029], absence of endotheliitis [OR=0.39, 95%CI 0.15-0.99, P-0.047] and female gender [OR=3.77, 95%CI 1.03-13.93, P=0.046] were significantly associated with final BCVA of 20/40 or better. Childhood pars planitis was much more common among male subjects. Endotheliitis may be a sign of inflammation spillover and is more prevalent in younger patients. Visual prognosis is favorable in most patients with appropriate treatment

Confocal scan features of keratic precipitates in granulomatous versus nongranulomatous uveitis

To compare the morphologic features of keratic precipitates [KPs] by confocal microscopy in granulomatous versus nongranulomatous noninfectious uveitis. KP morphology was determined by confocal scan in patients with noninfectious granulomatous and noninfectious nongranulomatous uveitic cases. One hundred and twenty-seven eyes of 90 subjects with noninfectious uveitis were studied. Thirty-nine eyes had granulomatous and 88 had nongranulomatous uveitis. Smooth-rounded KPs were significantly more common in the granulomatous subgroup [P<0.001] while cruciform and dendritiform KPs were more frequent in nongranulomatous uveitis [P<0.001 and P<0.005 respectively]. Confocal scan may be used as an adjunctive tool for differentiating granulomatous from nongranulomatous uveitis. Smooth-rounded KPs are strongly suggestive of granulomatous inflammation

Sustained release intraocular drug delivery devices for treatment of uveitis

Corticosteroids have been the mainstay of uveitis therapy. When intraocular inflammation is unresponsive to steroids, or steroid related side effects become a concern, steroid-sparing medications may be administered which can be classified into immunosuppressive and immunomodulatory agents. Uveitis treatment can be delivered systemically, topically, periocularly or intraocularly. All of the above mentioned medications can entail significant systemic side effects, particularly if administered for prolonged durations, which may become treatment-limiting. Some medications, particularly hydrophobic compounds, may poorly cross the blood-retinal barrier. Topical medications, which have the least side effects, do not penetrate well into the posterior segment and are unsuitable for posterior uveitis which is often sight-threatening. Intraocular or periocular injections can deliver relatively high doses of drug to the eye with few or no systemic side effects. However, such injections are associated with significant complications and must often be repeated at regular intervals. Compliance with any form of regular medication can be a problem, particularly if its administration is associated with discomfort or if side effects are unpleasant. To overcome the above-mentioned limitations, an increasing number of sustained-release drug delivery devices using different mechanisms and containing a variety of agents have been developed to treat uveitis. This review discusses various current and future sustained-release ophthalmic drug delivery systems for treatment of uveitis

Idiopathic retinal vasculitis, aneurysms and neuroretinitis syndrome associated with positive perinuclear antineutrophil cytoplasmic antibody

To report a case of idiopathic retinal vasculitis, aneurysms and neuroretinitis [IRVAN] syndrome associated with positive perinuclear antineutrophil cytoplasmic antibody [P-ANCA]. A 51-year-old man presented with loss of vision in his right eye since many years ago and blurred vision in his left eye over the past year. Ophthalmologic examination revealed optic atrophy and old vascular sheathing in the right eye and blurred disc margin, macular exudation, flame shaped hemorrhages, retinal vascular sheathing and multiple aneurysms at arterial bifurcation sites in the left eye, findings compatible with IRVAN syndrome. On systemic workup, the only notable finding was P-ANCA positivity. IRVAN syndrome may be a retinal component of P-ANCA associated vasculitis

Bilateral primary intraocular lymphoma

To report a case of bilateral primary intraocular lymphoma. A 33-year-old man presented with bilateral blurred vision since two years ago. Examination revealed large keratic precipitates, anterior chamber reaction, posterior subcapsular cataracts, and vitreous infiltration. After a short trial of topical and periocular steroids, diagnostic 25-gauge pars plana vitrectomy was performed and cytologic evaluation of the aspirate confirmed a diagnosis of intraocular lymphoma. The patient was subsequently managed with intravitreal methotrexate in both eyes and responded favorably. Central nervous system workup for lymphoma was negative. Primary intraocular lymphoma should be considered in young adults suffering from chronic recalcitrant panuveitis

Electroretinogram changes following silicone oil removal

To evaluate electroretinogram [ERG] changes after silicone oil removal. Scotopic and photopic ERGs, and best-corrected visual acuity [BCVA] were checked before and shortly after silicone oil removal in eyes that had previously undergone vitrectomy and silicone oil injection for complex retinal detachment. Pre- and postoperative ERG a- and b-wave amplitudes were compared. Twenty-eight eyes of 28 patients including 20 male and 8 female subjects with mean age of 39.3 +/- 0.06 [range, 12 to 85] years were studied. Mean interval from primary vitreoretinal surgery to silicone oil removal was 21.04 +/- 0.52 [range, 7 to 39] months. Mean duration from silicone oil removal to second ERG was 13.04 +/- 1.75 [range, 10 to 16] days. Before silicone oil removal, mean a-wave amplitudes in maximal combined response, rod response and cone response ERGs were 27.4 +/- 19.9, 7.2 +/- 4.5 and 5.5 +/- 3.4 micro v, respectively. These values increased to 48.8 +/- 31.9, 15.1 +/- 14.4 and 17.4 +/- 22.2 micro, respectively after silicone oil removal [P < 0.001]. Mean b-wave amplitudes in the same order, were 69.41 +/- 51, 41.2 +/- 30.4 and 25.1 +/- 33.9 microvolts before silicone oil removal, increasing to 165.6 +/- 102.5, 81.7 +/- 53.7 and 44.7 +/- 34.1 micro respectively, after silicone oil removal [P < 0.001]. Mean BCVA significantly improved from 1.10 +/- 0.34 at baseline to 1.02 +/- 0.33 logMAR after silicone oil removal [P < 0.001]. The amplitudes of ERG a- and b-waves under scotopic and photopic conditions increased significantly shortly after silicone oil removal. An increase in BCVA was also observed. These changes may be explained by the insulating effect of silicone oil on the retina

Increased latency of visual evoked potentials in healthy women during menstruation

To evaluate the latency of visual evoked potentials [VEPs] in healthy women during and after menstruation. Pattern and flash VEPs were performed in 15 healthy women aged 18 to 25 years on the maximum bleeding day [luteal phase] and 7 days after the menstrual cycle [follicular phase]. Mean latency was 119.6 msec on the maximum bleeding day and 100.8 msec one week after menstruation on pattern VEP [P < 0.001]. Corresponding values for flash VEP were 124.5 msec and 112.7 msec, respectively [P < 0.001]. Prolonged VEP latency on the maximum bleeding day indicates that high progesterone levels may have an inhibitory effect on optic nerve conduction velocity

Characteristics and surgical outcomes of rhegmatogenous retinal detachment following myopic LASIK

To describe the clinical features and surgical outcomes of rhegmatogenous retinal detachment [RRD] following myopic laser in situ keratomileusis [LASIK]. In a retrospective, non-comparative case series, 46 eyes that had undergone vitreoretinal surgery for management of RRD following myopic LASIK were identified. Data was reviewed with emphasis on characteristics of the RRD, employed surgical techniques, and anatomic and visual outcomes. Mean pre-LASIK myopia was -9.7 +/- 3.9 [range -4.00 to -18.00] diopters [D]. Mean interval between LASIK and development of RRD was 11.6 +/- 11.2 months. Posterior vitreous detachment was present in 44 eyes [95.6%]. The retinal breaks included flap tears in 36 [78.3%] eyes, giant tears in 8 [17.4%] eyes and atrophic holes in 2 [4.3%] eyes. In eyes with flap tears, the breaks were multiple, large or posterior to the equator in 24 [66.7%] eyes. Retinal breaks were related to lattice degeneration in 20 [43.5%] eyes of which, three had history of prophylactic barrier laser photocoagulation. Scleral buckling was performed as the initial procedure in 32 [69.6%] eyes and primary vitrectomy was undertaken in 14 [30.4%] eyes. The initial surgical procedure failed in 14 [30.4%] eyes due to proliferative vitreoretinopathy [PVR]. Retinal reattachment was finally achieved in 43 [93.4%] eyes. Postoperative visual acuity >/= 20/40 and >/= 20/200 was achieved in 16 [34.8%] and 25 [54.3%] eyes, respectively. Post-LASIK retinal detachment has a complex nature in eyes with moderate to high myopia. The retinal detachment is complex in terms of size, number and location of retinal breaks, is associated with a high rate of PVR and entails unfavorable visual outcomes

Intravitreal bevacizumab versus combined bevacizumab and triamcinolone acetonide for neovascular age-related macular degeneration

To compare the short-term outcomes of intravitreal bevacizumab [IVB] with the combination of IVB and intravitreal triamcinolone acetonide [IVB/IVT] for treatment of neovascular age-related macular degeneration [AMD]. This randomized clinical trial was performed on 92 eyes of 90 patients with subfoveal and juxtafoveal choroidal neovascularization [CNV] secondary to AMD. The eyes were randomly assigned to receive IVB 1.25 mg alone [53 eyes] or in combination with IVT 2 mg [39 eyes]. Best-corrected visual acuity [BCVA] and fundus autofluorescence were assessed, and fluorescein angiography [FA] and optical coherence tomography [OCT] were performed at baseline and repeated 6 weeks after treatment. Mean age was 70.6 +/- 8.7 [range 50-89] years and 57.7% of the patients were male. BCVA improved from 1.03 +/- 0.40 to 0.93 +/- 0.38 logMAR [P=0.001] in the IVB group and from 1.08 +/- 0.33 to 0.91 +/- 0.38 logMAR [P=0.008] in the IVB/IVT group. There was a trend toward greater visual improvement with combined therapy [P=0.06]. BCVA improvement was greater in eyes with +1 versus those with +2 [P=0.049] and +3 [P < 0.001] fundus autofluorescence at baseline. Mean decrease in central macular thickness was 113 +/- 115 micro m [P < 0.001] in the IVB group versus 53.96 +/- 125 micro m [P=0.008] in the IVB/IVT group with no intergroup difference [P=0.38]. FA showed decreased leakage in 57.4%, increased leakage in 12.8% and no change in 29.8% of patients in the IVB group. Corresponding figures were 60.0%, 5.7% and 34.3% in the IVB/IVT group [P=0.556]. Addition of triamcinolone acetonide to bevacizumab for treatment of neovascular AMD does not seem to significantly increase its short-term efficacy. More severe fundus autofluorescence appears to be predictive of poorer response to treatment

Short-term results of two treatment regimens in ocular toxoplasmosis: trimethoprim/sulfamethoxazole versus pyrimethamine and sulfadiazine

To compare the efficacy of classic treatment for ocular toxoplasmosis [pyrimethamine, sulfadiazine and prednisolone] with a regimen consisting of trimethoprim/sulfamethoxazole [TMP/SMX] [co-trimoxazole] plus prednisolone. In a prospective randomized single-blind clinical trial, 59 patients with active ocular toxoplasmosis were randomly assigned to two treatment groups: 29 were treated with pyrimethamine/sulfadiazine and 30 patients received TMP/SMX. Treatment consisted of six weeks of treatment with antibiotics plus steroids. Anti-toxoplasmosis antibodies [IgM and IgG] were measured using ELISA. Outcome measures included changes in retinochoroidal lesion size after six weeks of treatment, visual acuity before and after intervention, adverse drug reactions during follow up and rate of recurrence. Active toxoplasmosis retinochoroiditis resolved in all patients over six weeks of treatment with no significant difference in mean reduction in retinochoroidal lesion size between the two treatment groups [61% reduction in the classic treatment group and 59% in the TMP/SMX group, P=0.75]. Similarly no significant difference was found in visual acuity after treatment between the two groups [mean visual acuity after treatment was 0.12 LogMAR [20/25] in classic treatment group and 0.09 LogMAR [20/25] in TMP/SMX group, P=0.56]. Adverse events were similar in both groups with one patient in each suffering from any significant drug side effects, The overall recurrence rate after 14 months of follow up was 6.7% with no significant difference between the treatment groups [P = 0.48]. Drug efficacy in terms of reduction in retinal lesion size and improvement in visual acuity was similar between a regimen of TMP/SMX and the classic treatment of ocular toxoplasmosis with pyrimetbamine and sulfadiazine. Therapy with TMP/SMX appears to be an acceptable alternative for the treatment of ocular toxoplasmosis

Outcomes of surgical treatment for retinal detachment in highly myopic eyes with macular hole

To determine the type and outcome of surgery for retinal detachment resulting from macular hole in highly myopic eyes. This retrospective analysis was performed on the medical records of highly myopic patients who underwent surgery for retinal detachment [RD] resulting from macular hole at Labbafinejad Hospital, Tehran-Iran from 1992 to 2001. Variables included age, gender number and type of operations, visual acuity before and after the procedures and surgical success rate. Overall, 28 eyes of 27 patients [26 female and one male] with mean age of 59.8 +/- 11 years were included. Main follow-up was 17.3 [range 3-72] months. Mean axial length was 29 +/- 2.74mm [range: 24 to 35mm] and mean degree of myopia was -16.4 +/- 3.1 D [range -10 to -22 D]. Posterior staphyloma was present in 20 eyes [71%]. Seven eyes had undergone failed scleral buckling as the primary procedure prior to referral. lntravitreal SF[6] injection was the primary procedure in 12 eyes with localized detachments; the retina became attached in 5 [41.6%] of these eyes, however redetachment occurred in 7 [584%] eyes. Overall, 23 eyes [including 7 failed scleral buckling cases, 7 redetachments following SF[6] injection and 9 cases of primary surgery] underwent vitrectomy with use of high viscosity silicone oil. No major complications occurred during the operations. Overall, final anatomical success was 92.9% and visual improvement occurred in 85.7% of the eyes. In highly myopic eyes with RD due to macular hole, less invasive procedures such as SF[6] injection seem to be appropriate for eyes with localized detachment. In cases of total or subtotal RD and posterior staphyloma, pars plana vitrectomy and silicone oil tamponade seem to be the preferred procedure

Outcomes of lensectomy in hereditary lens subluxation

To evaluate the results of pars plana lensectomy in patients with hereditary lens subluxation. Hospital records of patients with hereditary lens subluxation who had undergone pars plana lensectomy at Labbafinejad Medical Center, Tehran-Iran from 1996 to 2003 were reviewed. Patients with more than 6 months of follow up were included. Underlying disorders, best corrected visual acuity [BCVA] before and after surgery, intraocular pressure [IOP], postoperative refraction and complications were evaluated. Overall, records of 87 eyes of 49 patients including 27 male and 22 female subjects were reviewed. Mean follow up duration was 20 +/- 18 months. Underlying disorders leading to lens subluxation included Marfan syndrome [79.5%], Weill-Marchesani syndrome [82%], simple ectopia lentis [8.2%], and homocystinuria [4.1%]. The most common indication for surgery was non-correctable refractive error [92.1%]. Mean BCVA was 1.13 LogMAR [20/250] preoperatively, which improved to 0.26 LogMAR [20/30-20/40] postoperatively [P<0.001]. BCVA >/= 20/40 was achieved in 82.8% of cases after surgery. Angle-supported anterior chamber intraocular lens [ACIOL] was implanted in 85.1% of the eyes. Prophylactic band was applied in 63 eyes [72.4%]. Retinal detachment developed in four eyes [4.6%] and was successfully treated. Lensectomy/anterior vitrectomy with implantation of an angle-supported ACIOL in patients with hereditary lens subluxation improves vision significantly without considerable complications