Effect of macular hole volume on postoperative central macular thickness / O efeito do volume de buraco macular da espessura macular central pós-operatória

ABSTRACT Purpose: To evaluate the association between macular hole volume (MHV) and postoperative central macular thickness (CMT) using spectral-domain optical coherence tomography (SD-OCT). Methods: Thirty-three eyes of 30 patients with a large full-thickness idiopathic macular hole with or without vitreomacular traction who underwent surgical intervention were included in this cross-sectional study. Complete ophthalmological examination, including SD-OCT, was performed for all participants during the pre- and postoperative visits. MHV was preoperatively measured using SD-OCT, which captured the widest cross-sectional image of the hole. For normal distribution analysis of the data, the Kolmogorov-Smirnov test was performed, and for statistical analyses, chi-square, Student's t-test, Mann-Whitney U test, and Pearson's correlation coefficient test were performed. Results: Mean preoperative best-corrected visual acuity (BCVA) and MHV were found to be 0.99 ± 0.36 (range, 0.3-2.0) logMAR and 0.139 ± 0.076 (range, 0.004-0.318) mm3, respectively. Mean follow-up was 16.3 ± 14.3 (range, 3-50) months. No statistical correlations were found between MHV and postoperative BCVA (p=0.588) and between MHV and disease recurrence (p=0.544). A weak negative correlation existed between MHV and final CMT scores (p=0.04, r=-0.383). Conclusions: Greater MHV was found to be weakly associated with lower postoperative CMT scores.

RESUMO Objetivo: Avaliar a relação entre o volume do buraco macular (MHV) e a espessura macular central pós-operatória (CMT) por meio da tomografia de coerência óptica de domínio espectral (SD-OCT). Método: Trinta e três olhos de 30 pacientes com buracos maculares idiopáticos de espessura total grandes, com ou sem tração vitreorretiniana, que foram submetidos a intervenção cirúrgica foram incluídos neste estudo transversal. O exame oftalmológico completo, incluindo SD-OCT foi realizado nas visitas pré e pós-operatórias de todos os participantes. MHV foi medido a partir da imagem de SD-OCT pré-operatória que capturou a imagem mais larga da secção transversal do buraco. Após a análise distribuição nomral da população do estudo ter sido realizada com o teste Kolmogorov-Smirnov, os testes de qui-quadrado, t de Student, Mann-Whitney U e teste de correlação de Pearson foram utilizados para as estatísticas. Resultados: As médias pré-operatórias da melhor acuidade visual corrigida (BCVA) e MHV foram 0,99 ± 0,36 logMAR (variação de 0,3-2,0) e 0,139 ± 0,076 mm3 (variação de 0,004-0,318). O seguimento médio foi de 16,3 ± 14,3 meses (variação de 3-50). Não foram encontradas correlações estatísticas entre MHV e BCVA pós-operatória (p=0,588), bem como MHV e recorrência da doença (p=0,544). Uma fraca correlação negativa estava presente entre MHV e pontuações finais CMT (p=0,04, r=-0,383). Conclusões: Maior MHV foi fracamente relacionado com CMT mais baixo, no pós-operatório.

Enxerto de retalho escleral de doador como tratamento definitivo de maculopatia hipotônica pós trabeculectomia / Scleral patch as a definitive treatment for hypotonic maculopathy after trabeculectomy

RESUMO Paciente do sexo feminino, portadora de glaucoma juvenil sem controle clínico adequado, foi submetida à trabeculectomia com mitomicina C, após a qual, desenvolveu hipotensão ocular refratária às medidas conservadoras, evoluindo com um quadro de maculopatia hipotônica. Foi realizado um implante de enxerto de retalho escleral de doador sobre a fístula, com resolução do quadro e ganho de acuidade visual. A enxertia de retalho escleral de doador mostrou-se uma terapia adequada para correção da hipotensão ocular por bolha hiperfiltrante pós trabeculectomia. O cirurgião deve considerar o emprego dessa técnica ao programar a revisão destes casos.

ABSTRACT A female patient with juvenile glaucoma without clinical control underwent a trabeculectomy with mitomycin C, and developed eye hypotension which did not respond to conservative treatment, with subsequent hypotonic maculopathy. The patient was treated using a scleral patch provided by a donor above the fistula, which improved intraocular pressure and visual acuity. The use of the scleral patch above the fistula seems an adequate therapy to treat ocular hypotension due to the over-filtering trabeculectomy bubble. The surgeon should consider this technique when planning surgical solutions for such cases.

Vitrectomia e troca fluido-gasosa para o tratamento do descolamento seroso da mácula por fosseta de disco óptico: avaliação de longo prazo / Vitrectomy and gas-fluid exchange for the treatment of serous macular detachment due to optic disc pit: long-term evaluation

OBJETIVO: Avaliar 5 olhos com descolamento seroso da mácula devido à fosseta de disco óptico que foram submetidos à vitrectomia via pars plana e seguidos por pelo menos 7 anos. MÉTODOS: Os pacientes foram submetidos à vitrectomia via pars plana, remoção da membrana hialoide posterior, injeção de soro autólogo e troca fluido-gasosa, sem aplicação de fotocoagulação a laser, e foram testados quanto à acuidade visual, tela de Amsler, retinografia e, recentemente, retinografia com autofluorescência e OCT de alta resolução. RESULTADOS: Todos os 5 olhos operados tiveram significativa melhora da visão após o procedimento cirúrgico, mantendo boa visão durante todo período de acompanhamento. A acuidade visual pré-operatoria média foi de 20/400 enquanto a acuidade visual final foi de 20/27 com um tempo médio de seguimento de 13,6 anos. Não foram observadas recorrências do descolamento seroso da mácula e os exames de OCT mostraram a retina perfeitamente aplicada até a margem da fosseta de disco óptico. CONCLUSÃO: Descolamentos serosos da mácula causados por fosseta de disco óptico são adequadamente tratados com vitrectomia via pars plana e troca fluido-gasosa, sem a necessidade de fotocoagulação da retina, mantendo excelente acuidade visual por vários anos após o procedimento, sem o aparecimento de recorrências.

PURPOSE: To evaluate 5 patients with serous macular detachment due to optic disc pit that were submitted to pars plana vitrectomy and were followed for at least 7 years. METHODS: Patients were submitted to pars plana vitrectomy, posterior hyaloid removal, autologous serum injection and gas-fluid exchange, without laser photocoagulation, and were evaluated pre and post-operatively with visual acuity and Amsler grid testing, retinography, and recently, with autofluorescence imaging and high resolution OCT. RESULTS: All 5 eyes improved visual acuity significantly following the surgical procedure maintaining good vision throughout the follow-up period. Mean pre-operative visual acuity was 20/400 and final visual acuity was 20/27 with a mean follow-up time of 13.6 years. No recurrences of serous detachments were observed. OCT examinations demonstrated an attached retina up to the margin of the pit. CONCLUSION: Serous macular detachments due to optic disc pits were adequately treated with pars plana vitrectomy and gas fluid exchange, without the need for laser photocoagulation, maintaining excellent visual results for a long period of time.

Triamcinolone-assisted 3D-vitrectomy in diabetic vitreomacular traction / Vitrectomia 3D guiada por triancinolona na tração vitreomacular do diabetes

PURPOSE: To evaluate the efficacy of triamcinolone as an aid in vitreous visualization during 3D-vitrectomy for the treatment of diabetic vitreomacular traction. METHODS: Prospective interventional study in patients with symptomatic vitreomacular traction. Pre- and postoperative assessments included visual acuity, retinography, intraocular pressure and optical coherence tomography. All patients were operated by the same surgeon (OOMJ). Triamcinolone was used as a visual enhancer during surgery. The parameters of the vitreophage (Accurus 800CS, Alcon) were set to the 3D- system (dual dynamic drive), contact lenses (plain and wide angle) being used for visualization. Peripheral 360º vitreous circumcision at high cut rate was performed, carefully releasing the vitreomacular adhesion at the posterior pole by means of an appropriate pic or vitreoretinal forceps. RESULTS: The sample consisted of five consecutive patients (five eyes), three female and two male, with symptomatic vitreomacular traction. Their age ranged from 54 to 71 years (mean 62.6 ± 6.3 years). During the surgical procedure, the areas with vitreomacular traction were properly visualized and identified after the application of triamcinolone. No complications were recorded during or after surgery. There was a statistically significant improvement in visual acuity after the surgical procedure (p=0.0313). CONCLUSION: Triamcinolone facilitates the surgical treatment of vitreomacular traction by improving visibility of both the vitreous humor and the vitreous-retina interface. Triamcinolone-assisted 3D vitrectomy proved to be an effective procedure in these cases.

OBJETIVO: Avaliar a eficácia da triancinolona como marcador vítreo na vitrectomia 3D para tratamento da tração vitreomacular do diabetes. MÉTODOS: Realizou-se um estudo prospectivo intervencionista numa série de portadores de tração vitreomacular sintomática. Na avaliação pré e pós-operatória foram realizadas a medida da acuidade visual, retinografia, pressão intra-ocular e tomografia de coerência óptica. Todos pacientes foram submetidos à vitrectomia pelo mesmo cirurgião (OOMJ). No intra-operatório, utilizou-se triancinolona como marcador vítreo. Os parâmetros do vitreófago (Accurus 800CS, Alcon) foram programados no sistema 3D (dual dynamic drive), sendo utilizadas lentes de contato (grande angular e plana) para visibilização. Realizou-se circuncisão vítrea periférica 360° com alto corte, desfazendo cuidadosamente as adesões vitreomaculares no pólo posterior por meio de gancho ou pinças vítreo-retinianas adequadas. RESULTADOS: A amostra foi composta por cinco pacientes (cinco olhos) consecutivos com tração vitreomacular sintomática. Três eram do sexo feminino e dois, do masculino. A idade variou de 54 a 71 anos (média de 62,6 ± 6,3 anos). Durante o procedimento cirúrgico, os locais de tração vitreomacular foram identificados com boa visibilidade após aplicação da triancinolona. Não foram observadas intercorrências tanto no intra quanto no pós-operatório. Houve melhora estatisticamente significante na acuidade visual após procedimento cirúrgico (p=0,0313). CONCLUSÃO: A triancinolona tem ação facilitadora no tratamento cirúrgico da tração vitreomacular, por melhorar visibilização tanto do humor vítreo quanto da interface vítreo-retina. A cirurgia de vitrectomia 3D, guiada por triancinolona, mostrou-se ser um procedimento eficiente nesses casos.

Arteriovenous Sheathotomy for Persistent Macular Edema in Branch Retinal Vein Occlusion

PURPOSE: To evaluate the efficacy of arteriovenous (AV) sheathotomy with internal limiting membrane peeling for persistent or recurrent macular edema after intravitreal triamcinolone injection and/or laser photocoagulation in branch retinal vein occlusion. METHODS: Twenty-two eyes with branch retinal vein occlusion (BRVO) with recurrent macular edema underwent vitrectomy with AV sheathotomy and internal limiting membrane peeling. All eyes had previous intravitreal triamcinolone injection and/or laser photocoagulation for macular edema. The best corrected visual acuity (BCVA), fluorescein angiography and optical coherence tomography (OCT) before and after surgery were compared. RESULTS: The mean preoperative BCVA (log MAR) were 0.79+/-0.29 and postoperative BCVA (log MAR) at 3 months was 0.57+/-0.33. And improvement of visual acuity > or =2 lines was observed in 10 eyes (45%). The mean preoperative fovea thickness measured by OCT was 595.22+/-76.83 micrometer (510-737 micrometer) and postoperative fovea thickness was 217.60+/-47.33 micrometer (164-285 micrometer). CONCLUSIONS: Vitrectomy with AV sheathotomy can be one treatment option for the patients with recurrent macular edema in BRVO.

Cirugía submacular en toxocariasis intraocular: una correlación clínico-patologica / Submacular surgery in ocular toxocariasis: a clinic-pathologic correlation

Objetivo: Presentar un reporte clínico-patológico de toxocariasis ocular en un paciente de nueve años de edad con una membrana fibrovascular submacular, que fue tratado mediante cirugía submacular. Materiales y Métodos: Un niño de nueve años de edad afectado por toxocariasis crónica en su ojo derecho recibió tratamiento. El examen de fondo de ojos reveló múltiples bandas vítreas adheridas a la retina en el cuadrante Inferonasal y una membrana submacular, rodeada por un desprendimiento macular exudativo. Se llevó a cabo una vitrectomía con remoción de la membrana submacular. Resultados: La agudeza visual mejoró de movimientos de manos a 20/400 luego de dos meses de seguimiento. Los hallazgos anatomopatológicos revelaron una cicatriz fibrovascular sin restos parasitarios en los cortes seriados del tejido. Conclusión: En este caso de toxocariasis ocular la cirugía submacular resultó ser una buena alternativa para mejorar la visión del paciente. Mediante este tipo de cirugía seria posible no sólo tratar las complicaciones vitreoretinlanas de esta enfermedad sino también resecar membranas submaculares y reaplicar la retina en el área macular.

Purpose: To present a clinico-pathologic report on ocular toxocariasis in a nine-year-old boy with a submacular fibravascular membrane who underwent submacular surgery. Materials And Methods: A nine-year-old boy affected by chronic ocular toxocariasis in his right eye was treated. Fundus examination disclosed multiple vitreous strands attached to the retina in the inferonasal quadrant and a submacular membrane with a surrounding exudative macular detachment. Vitrectomy surgery with submacular membrane removal was performed. Results: Visual acuity improved from hand motion to 20/400 after two months of follow-up. The pathological findings revealed a fibrovascular scar without parasitic remnants in the serial section of the tissue. Conclusion: In this case of ocular toxocariasis, submacular surgery turned out to be a good alternative treatment to improve the patient's visual acuity. Through this kind of surgery it could be possible not only to treat vitreoretinal complications of the disease but also to excise submacular membranes and reattach the retina in the macular area.

Visual recovery after buckling surgery for macula - off retinal detachment

The purpopse of this work is to study the postoperative course of the recovery of macular function. The visual recovery after a scleral buckling surgery for primary rhegmatogenous retinal detachment involving the macula was investigated retrospectively. 52 patients with 52 eyes had been treated with a segmental, radial or encircling scleral buckle. The follow up period was for more than 5 years. All cases with a history of trauma, macular diseases, cataract and previous vitreoretinal surgery were excluded from the study. A better postoperative visual recovery was obtained in cases with better preoperative visual acuity, short duration of macular detachment and also cases of emmetropia or a low degree of myopia. The best corrected visual acuities were better at 5 years postoperatively than at 3 months by two lines or more in 22 eyes [42%]. Good preoperative visual acuity and short duration of macular detachment carries a better postoperative visual recovery. The visual function may continue to improve over the long-term

Recent developments in vitreoretinal surgery.

In the past three decades, a great improvement has occurred in microsurgical techniques used in the management of various eye diseases involving retina and vitreous. Advances in instrumentation has made the surgery easier and refined. The instruments used are narrated widely in this article. Various vitreous substitutes have been developed and are required in vitreoretinal surgery. These are gases, silicone oil, perfluorocarbon liquids and fluorosilicone oil. Anterior segment indications for vitreous surgery are: Vitreous loss during cataract surgery, thick after cataracts that can't be managed with Nd: YAG capsulotomy, vitreocorneal touch, updrawn pupils, incarcerated vitreous in the wound causing cystoid macular oedema, malignant glaucoma, penetrating keratoplasty in aphakic patients, congenital cataracts and filtering procedures in aphakic eyes. In posterior segment indications, vitrectomy is useful in penetrating trauma, haemorrhage, retinal deetachment, intra-ocular foreign bodies and infection endophthalmitis Macular surgery involves peeling of epimacular membrane or proliferation, treating vitreomacular traction syndrome, idiopathic macular holes, retinal detachment associated with optic pit, evacuation of submacular haemorrhage and excision of choroidal neovascular membranes. Available options to treat retinal detachments are pneumatic retinopexy, scleral buckling and vitreous surgery. Proliferative vitreoretinopathy remains the important cause of failure and occurs in about 8-10% cases after retinal detachment. Vitreous surgery for ocular trauma, vitrectomy for proliferative diabetic retinopathy, macular hole surgery, submacular surgery are also discussed in detail.

Submacular surgery.

Modern vitreoretinal surgery is now one of the most effective tools for treating posterior segment diseases. In the last several years, there has been a surge of interest in submacular surgery which allows removal of submacular choroidal neovascular membranes and haematomas. Various aspects of this rapidly emerging modality of surgery are discussed in this review.

The rationale of argon green laser photocoagulation for diabetic maculopathy.

Eighty-four patients of bilateral diabetic retinopathy were divided into 2 groups: Group I comprised of 60 patients (mean age 46 yrs) having non-proliferative diabetic retinopathy with maculopathy (total no. of eyes = 120). Group II consisted of 24 patients (mean age 49.1 yrs) with proliferative diabetic retinopathy with maculopathy (total no. of eyes under study = 48). One eye of each patient in group I was treated as a control and the other was subjected to focal laser therapy. While 48/60 control Group I eyes (80%) had 6/24 vision at the outset, at one year follow-up only 39/60 cases (65%) had 6/24 vision. Diabetic maculopathy persisted in all the 60 control eyes at one year. In contrast, 44/60 eyes (73%) subjected to focal laser therapy in Group I, had 6/24 vision at outset but one year later, 49/60 eyes (81%) had 6/24 vision. Maculopathy completely regressed in 48/60 eyes (80%). The 48 eyes of Group II patients were subjected to focal and scatter laser therapy. 20/48 eyes (41.6%) had 6/24 vision prior to treatment but one year after treatment, 25/48 eyes (52%) had 6/24 vision. Neovascularization and macular edema regressed after one year in 42/48 eyes (87.1%) and only 4/48 eyes (8.3%) developed localized vitreous hemorrhage. Laser therapy in Group I improved visual acuity by reducing macular edema. In Group II, it improved the vision and reduced the risk of vitreous hemorrhage, detachment and glaucoma.