A randomized comparison of parecoxib/valdecoxib and placebo for the prevention of cystoid macular edema after scleral buckling surgery.

AIMS: To assess the impact of valdecoxib on the incidence of macular edema, after scleral buckling surgery. METHODS: Prospective randomized double masked placebo controlled study. Patients undergoing scleral buckle surgery over 18 months were recruited and randomized to receive either oral valdecoxib or placebo. Patients also received two doses of either parecoxib (pro-drug of valdecoxib) intravenously 40 mg 6 hourly day one postoperative or identical placebo injection Patients underwent retinal examination, optical coherence tomography and retinal thickness analyzer scan of the macula preoperatively, and at 2 and 6 weeks postoperatively. Outcome measures were the incidence of macular edema, retinal thickness, visual acuity, contrast sensitivity and presence of persistent subretinal fluid. RESULTS: Interim analysis was performed with 116 patients were recruited, 58 to each treatment arm. The incidence of macular edema in all patients was 5% at visit 1 and 2.2% at visit 2 postoperatively. This incidence was much lower than the expected incidence used in the power calculation to determine study size. It was therefore apparent that a much larger study population would be required to test for an effect and that this was not achievable within the study time period. The study was therefore terminated early. There was no evidence of a difference between COX 2 inhibitor and placebo groups in the incidence of edema, retinal thickness or visual outcome. The presence of residual subretinal fluid at the macula was significantly reduced by COX 2 inhibitor treatment. CONCLUSIONS: The rate of cystoid macular edema after scleral buckling surgery is low and is not influenced by prophylactic use of valdecoxib. The rate of residual subretinal fluid was reduced by COX 2 inhibitor treatment. Enhanced antiinflammatory therapy has the potential to improve outcomes in scleral buckling surgery.

Optical coherence tomography analysis of the macula after scleral buckle surgery for retinal detachment.

OBJECTIVE: To define the incidence, pattern, duration, and clinical consequences of persistent localized submacular fluid after scleral buckle surgery for retinal detachment (RD). DESIGN: Prospective observational cohort series. PARTICIPANTS: Ninety-eight patients were identified and recruited to the study. METHODS: Patients aged > or =18 years undergoing scleral buckle surgery for uncomplicated primary RD over an 18-month period were recruited. All patients underwent clinical examination and optical coherence tomography (OCT) scan of the macula preoperatively and at 6 weeks postoperatively. Those patients who had an abnormality on OCT 6 weeks after surgery underwent follow-up with repeat of the study investigations at 3, 6, 9, 12, and 18 months after surgery until the abnormality resolved. If no abnormality was seen at the 6-week examination, no further investigation was undertaken. MAIN OUTCOME MEASURE: Presence of submacular fluid on OCT 6 weeks after surgery. Other outcome measures were duration of persistent fluid and associations with poor visual outcome, type, or duration of detachment. RESULTS: Of the 98 patients recruited into the study, 54 (55%) had subretinal fluid (SRF) on OCT 6 weeks after surgery. We identified 3 patterns of submacular fluid: confluent fluid, a single discrete bleb of fluid, and multiple blebs of fluid. Fluid was associated with delayed visual recovery. Of those with SRF, 78% had persistent fluid at 6 months; resolution of fluid took a median of 10 months and was associated with an improvement in vision. CONCLUSIONS: Optical coherence tomography is a useful noninvasive diagnostic method that can detect SRF not seen on clinical examination. Persistent SRF 6 weeks after scleral buckle surgery occurs in approximately half of patients, may persist for many months, and can cause delayed visual recovery.

Optical coherence tomography analysis of the macula after vitrectomy surgery for retinal detachment.

OBJECTIVE: To define the incidence, duration, and clinical associations of persistent localized submacular fluid after pars plana vitrectomy (PPV) retinal detachment surgery. DESIGN: Observational cohort series. PARTICIPANTS: One hundred patients were identified and recruited into the study. METHODS: Patients aged 18 years and older who had undergone PPV and gas as a primary procedure for rhegmatogenous retinal detachment and postoperative follow-up were recruited from February through August 2004. All patients underwent clinical examination, optical coherence tomography (OCT) scan of the macula, and retinal thickness analysis scan of the macula. Those patients in whom an abnormality was seen on OCT at 6 weeks after surgery underwent follow-up with repeat of the study investigations at 3, 6, 9, 12, and 18 months after surgery until the abnormality resolved. If no abnormality was seen at the 6-week examination, no further investigation was undertaken. Demographic data, including detachment characteristics, were collected retrospectively from the patient case notes. MAIN OUTCOME MEASURES: The principle outcome measure was the presence of subretinal fluid (SRF) on OCT at 6 weeks after surgery. Other outcome measures included duration of persistent fluid and association with visual outcome and type and duration of detachment. RESULTS: One hundred patients were recruited; 15 of these had SRF on OCT performed at 6 weeks after surgery. Subretinal fluid was associated with significantly worse visual acuity (VA) at 6 weeks (P = 0.033, Wilcoxon rank-sum); those with SRF had a median VA of 0.4, and those with no SRF had a median VA of 0.3. The fluid took a median of 5.5 months to resolve. Seven patients had combined PPV and scleral buckle surgery; none of these had fluid at 6 weeks. CONCLUSIONS: Optical coherence tomography is a useful noninvasive diagnostic method that can detect SRF not appreciated on clinical examination. Persistent SRF after PPV and gas surgery occurred in 15% of patients in this study and was still present in 53% of these at 6 months. The presence of SRF at 6 weeks after surgery was associated with a poorer visual outcome at this time point.

Analysis of the macula with optical coherence tomography after successful surgery for proliferative vitreoretinopathy.

OBJECTIVE: To use optical coherence tomography to assess the in vivo pathologic findings associated with incomplete visual recovery in patients who have undergone anatomically successful surgery to treat proliferative vitreoretinopathy. METHODS: Eligible patients were recruited in vitreoretinal outpatient clinics between April 1, 2002, and July 31, 2003. Patients were included who had undergone anatomically successful vitreoretinal surgery to treat proliferative vitreoretinopathy and, at least 3 months after surgery, had postoperative vision worse than expected (< or =6/12) with no identifiable cause at clinical examination. Patients underwent optical coherence tomography, stereo fundus fluorescein angiography was performed in a cohort of patients, and angiographic findings were compared with those on the optical coherence tomograms. Relevant clinical data were collected retrospectively from patient case notes. RESULTS: A total of 35 patients were recruited. Optical coherence tomograms revealed cystoid macular edema in 23 patients (66%) but did not identify any other specific intraretinal disease. Location of edema (outer or inner retina), determined with stereo fundus fluorescein angiography and optical coherence tomography, correlated well. CONCLUSIONS: Optical coherence tomography is a useful diagnostic tool for assessing poor postoperative visual acuity and can reveal disease undetected at clinical examination. Cystoid macular edema is a common finding on optical coherence tomograms in eyes with incomplete visual recovery after anatomically successful surgery to treat proliferative vitreoretinopathy.

Is post-trabeculectomy hypotony a risk factor for subsequent failure? A case control study.

BACKGROUND: Ocular hypotony results in an increased break down of the blood-aqueous barrier and an increase in inflammatory mediator release. We postulate that this release may lead to an increased risk of trabeculectomy failure through increased bleb scarring. This study was designed to try to address the question if hypotony within one month of trabeculectomy for Primary Open Angle Glaucoma (POAG), is a risk factor for future failure of the filter. METHODS: We performed a retrospective, case notes review, of patients who underwent trabeculectomy for POAG between Jan 1995 and Jan 1996 at our hospital. We identified those with postoperative hypotony within 1 month of surgery. Hypotony was defined as an intraocular pressure (IOP) < 8 mmHg or an IOP of less than 10 mmHg with choroidal detachment or a shallow anterior chamber. We compared the survival times of the surgery in this group with a control group (who did not suffer hypotony as described above), over a 5 year period. Failure of trabeculectomy was defined as IOP > 21 mmHg, or commencement of topical antihypertensives or repeat surgery. RESULTS: 97 cases matched our inclusion criteria, of these 38 (39%) experienced hypotony within 1 month of surgery. We compared the survival times in those patients who developed hypotony with those who did not using the log-rank test. This data provided evidence of a difference (P = 0.0492) with patients in the hypotony group failing more rapidly than the control group. CONCLUSION: Early post-trabeculectomy hypotony (within 1 month) is associated with reduced survival time of blebs.

Vitrectomy for a persisting macular fold in a case of resolved hypotony maculopathy.

PURPOSE: To describe a patient with resolved hypotony maculopathy with a persistent retinal fold (despite normalization of intraocular pressure [IOP]) who underwent successful surgical intervention by vitrectomy, internal limiting membrane peel, and gas tamponade. DESIGN: Interventional case report. METHODS: A 55-year-old man with a hypotony-induced macular retinal fold that did not improve following normalization of IOP underwent vitrectomy, internal limiting membrane peeling, and gas injection. Optical coherence tomography scans were performed both before and after surgery. RESULTS: Best-corrected visual acuity (BCVA) improved from 6/60 preoperatively to 6/9, with improvement in distortion. On repeat optical coherence tomography examination, the macular retinal fold had resolved. CONCLUSION: Vitrectomy, internal limiting membrane peeling and gas tamponade may be useful for cases of resolved hypotony maculopathy complicated by a persistent macular fold after normalization of IOP.

The results of surgery on macular holes associated with rhegmatogenous retinal detachment.

PURPOSE: Macular holes can occur as a secondary phenomenon with or after otherwise successful repair of uncomplicated macula-off rhegmatogenous retinal detachments with peripheral breaks. The purpose of this study was to evaluate the anatomical and visual outcomes of vitrectomy surgery to close the macular holes in these situations. METHODS: A retrospective record review was completed for patients with a retinal detachment with peripheral breaks and a macular hole or those patients developing macular holes within 2 weeks of successful primary external buckling surgery for macula-off retinal detachment. In those patients with a concurrent macular hole and retinal detachment, a primary vitrectomy was carried out to close the macular hole and reattach the retina. In those patients who developed a macular hole after successful primary external buckling surgery, a secondary vitrectomy was then carried out to close the macular hole. RESULTS: The authors reviewed the records of 10 patients. All had a preoperative visual acuity of 20/400 or worse. After surgery, one patient achieved a best-corrected visual acuity of 20/40; six patients achieved a best-corrected visual acuity of 20/80; and three patients achieved a best-corrected visual acuity of 20/120. CONCLUSION: These results suggest that macular hole surgery is worthwhile for these patients and can provide satisfactory results in terms of visual improvement.