Three-port lens-sparing vitrectomy for aggressive posterior retinopathy of prematurity: early surgery before tractional retinal detachment appearance.

PURPOSE: Aggressive posterior retinopathy of prematurity (APROP) may suddenly develop into tractional retinal detachment (TRD), often resulting in poor vision if untreated. The aim of the current study is to examine the anatomic results and complications of lens-sparing vitrectomy (LSV) for stage 3 APROP, before TRD appearance. METHODS: A retrospective, noncomparative, consecutive case series of 13 eyes of 9 patients (mean gestational age 24.1+/-0.9 weeks [range: 23-25 weeks], mean birthweight of 725.8+/-107.9 grams [range: 598-897 grams]) with stage 3 APROP was carried out. The eyes did not respond to at least one session of retinal laser photocoagulation, showing signs of disease progression. All eyes underwent 20-gauge LSV before retinal detachment appearance. RESULTS: All eyes underwent 20-gauge three-port LSV and intraoperative additional laser photocoagulation. At the end of the surgery, five eyes were tamponaded with air; in eight eyes, a balanced salt solution was left in the vitreous cavity. After 13.5+/-5.3 months of follow-up (range: 4-22), the retina was completely attached in all eyes, without any signs of progression. The authors did not observe any intraoperative or postoperative complications. CONCLUSIONS: Surgical approach to stage 3 APROP refractory to laser photocoagulation could be effective and safe in order to avoid the progression of the disease.

Combined surgical ablation and intravitreal triamcinolone acetonide for retinal angiomatous proliferation.

PURPOSE: Neovascular age-related macular degeneration (ARMD) with retinal angiomatous proliferation (RAP) has a poor natural history and the efficacy of any treatment has not yet been established. The authors describe a combined surgical treatment. METHODS: A 76-year-old woman presented with a best-corrected visual acuity (BCVA) of 20/600 in the right eye and macula with stage 3 RAP as identified by fluorescein angiography (FA), indocyanine green angiography (ICGA), and optical coherence tomography (OCT). After a standard three-port pars plana core vitrectomy (PPV), endodiathermy of the arteriolar and venous feeder vessels of each lesion was performed, intraretinal RAP feeder vessels were cut with manual vertical intraocular scissors, and 0.1 mL of triamcinolone acetonide (TAAC) was injected intravitreally. At 1 and 4 weeks and at the sixth month, the patient underwent a complete eye examination, FA, ICGA, and OCT to assess outcomes and complications. RESULTS: Six months later, BCVA was stable at 20/300, intraocular pressure was 15 mmHg, anterior segment and vitreous cavity were clear without evidence of TAAC granules, and retina was attached. FA and ICGA showed a complete occlusion of the RAP and absence of leakage or ischemia and OCT demonstrated decreased macular thickness with resolution of both intraretinal edema and pigment epithelium detachment, and the restoration of the normal macular profile. At the end of follow-up, the authors did not observe any ocular or systemic complication. CONCLUSIONS: Surgical approach to RAP stage 3 with intravitreal injection of 4 mg of TAAC was safe and anatomically effective.

Variable outcome of photodynamic therapy for choroidal neovascularization associated with choroidal nevus.

PURPOSE: To report five cases of classic choroidal neovascularization (CNV) associated with choroidal nevus treated with photodynamic therapy (PDT) with verteporfin. METHODS: The patients underwent an ophthalmologic evaluation, including fluorescein angiography and indocyanine green angiography. Clinical and angiographic data were retrospectively analyzed to evaluate visual acuity outcomes and both clinical evolution and angiographic evolution. RESULTS: Two patients presented with subfoveal CNV, and three had juxtafoveal CNV. The mean follow-up was 25.8 months. Visual outcomes were extremely variable. Indeed, best-corrected visual acuity decreased in three eyes, stabilized in one case, and improved in the other case. The number of PDT sessions necessary to obtain CNV stabilization with cessation of fluorescein leakage varied from one to six. CONCLUSION: Bearing in mind that both the natural history and the post-PDT outcome may be extremely variable, further studies are needed to assess the real benefit of PDT for classic CNV secondary to choroidal nevus.

Intravitreal triamcinolone acetonide in refractory pseudophakic cystoid macular edema: functional and anatomic results.

PURPOSE: To evaluate safety and efficacy of intravitreal triamcinolone acetonide (TAAC) injections in the treatment of refractory pseudophakic cystoid macular edema (CME). METHODS: Seven eyes of six patients (age range: 50-74) with pseudophakic CME resistant to standard treatment received intravitreal injections of 4 mg of TAAC with all vehicle. Mean preinjection duration of CME was 18.3 months. A mean of 2.1+/-1.2 (range 1 to 4) treatments were performed in four eyes (57.1 %) when visual acuity deteriorated towards baseline levels. Visual acuity assessment, optical coherence tomography (OCT), and fluorescein angiography (FFA) were performed pre- and postoperatively to evaluate results of TAAC injections. Intraocular pressure (IOP) and complications related to treatment were assessed. RESULTS: After 11.1+/-3.9 months, mean best-corrected visual acuity (BCVA) increased (p =0.019) from 20/132 to a best value of 20/38. Mean macular thickness decreased from 517.29+/-146.98 mm to a best value of 263.71+/-83.13 mm (p=0.0018). Area of fluorescein leakage decreased (p<0.0001) from 11.84+/-0.93 mm2 at baseline to a minimal value of 3.86+/-0.98 mm2. The anatomic and functional improvement appeared after 1 month from the intravitreal injection and persisted through at least 3 months of follow-up. At the end of follow-up BCVA, macular thickness, and area of fluorescein leakage did not differ from baseline. Four eyes (57.1 %) developed IOP values higher than 21 mmHg, controlled by topical treatment. Two patients developed an endophthalmitis-like reaction. CONCLUSIONS: Intravitreal TAAC was relatively safe and effective in resistant cases of pseudophakic CME with a temporary beneficial effect on visual acuity and macular edema.

Intravitreal triamcinolone acetonide: valuation of retinal thickness changes measured by optical coherence tomography in diffuse diabetic macular edema.

PURPOSE: The authors studied the efficacy of intravitreal triamcinolone acetonide in a case series of patients with diffuse diabetic macular edema without evidence of vitreous-macular traction refractory to laser photocoagulation. METHODS: Six eyes with clinically diffuse diabetic macular edema that failed to respond to at least two previous sessions of laser photocoagulation were included. The mean age of selected patients was 72.5+/-13.8 years, with a preoperative best-corrected visual acuity reduced to 1.48+/-0.18 logMar and a mean baseline intraocular pressure (IOP) of 15.17+/-2.64 mmHg. The authors also studied macular thickness measured by optical coherence tomography (OCT 2000 scanner, Humphrey Instruments, San Leandro, CA) - in the preoperative period it was 640.8+/-171.1 microm - and the fluorangiographic (Heidelberg Retina Angiograph, Heidelberg Engineering GmbH, Heidelberg, Germany) patterns, which showed pooling in tardy phases and leakage. Mean follow-up was 4 months. RESULTS: In each patient the authors observed a significant improvement, both functionally and anatomically. Mean best-corrected visual acuity increased in the postoperative period to 0.94+/-0.53 logMar. No patient showed decline of visual acuity at the end of follow-up. Base line macular thickness was reduced in the postoperative period to 312.2+/-157.65 microm measured by OCT and fluorangiographic patterns showed a reduction of pooling and of leakage. The most common complications described in the literature were not observed and the increase of mean IOP in the postoperative period to 18.76+/-5.72 mmHg was not significant. CONCLUSIONS: Intravitreal triamcinolone acetonide may decrease macular edema and improve visual acuity in eyes with diffuse diabetic macular edema.

Intravitreal triamcinolone acetonide: valuation of retinal thickness changes measured.

PURPOSE: The authors studied the efficacy of intravitreal triamcinolone acetonide in a case series of patients with diffuse diabetic macular edema without evidence of vitreous-macular traction refractory to laser photocoagulation. METHODS: Six eyes with clinically diffuse diabetic macular edema that failed to respond to at least two previous sessions of laser photocoagulation were included. The mean age of selected patients was 72.5 13.8 years, with a preoperative best-corrected visual acuity reduced to 1.48 0.18 logMar and a mean baseline intraocular pressure (IOP) of 15.17 2.64 mmHg. The authors also studied macular thickness measured by optical coherence tomography (OCT 2000 scanner, Humphrey Instruments, San Leandro, CA) in the preoperative period it was 640.8 171.1 m and the fluorangiographic (Heidelberg Retina Angiograph, Heidelberg Engineering GmbH, Heidelberg, Germany) patterns, which showed pooling in tardy phases and leakage. Mean follow-up was 4 months. RESULTS: In each patient the authors observed a significant improvement, both functionally and anatomically. Mean best-corrected visual acuity increased in the postoperative period to 0.94 0.53 logMar. No patient showed decline of visual acuity at the end of follow-up. Base line macular thickness was reduced in the postoperative period to 312.2 157.65 m measured by OCT and fluorangiographic patterns showed a reduction of pooling and of leakage. The most common complications described in the literature were not observed and the increase of mean IOP in the postoperative period to 18.76 5.72 mmHg was not significant. CONCLUSIONS: Intravitreal triamcinolone acetonide may decrease macular edema and improve visual acuity in eyes with diffuse diabetic macular edema. (Eur J Ophthalmol 2004; 14: 321-4).

Macular hole following conventional repair of bullous retinal detachment using air injection (D-ACE procedure).

PURPOSE: Sequential drainage of subretinal fluid (D), injection of air (A), cryotherapy (C), and application of local explants (E) (D-ACE) sequence was introduced in order to overcome the problems encountered in managing superior bullous detachments from multiple large equatorial breaks. The authors recently observed the occurrence of a full-thickness macular hole in one patient developing the day after he underwent a D-ACE procedure. METHODS: A 61-year-old man presented a bullous retinal detachment in the right eye extending from the 9:30 to the 2 o'clock position, and posteriorly to the vascular arcades two retinal tears were noted, at the equator at 11 o'clock, and anterior to the equator at 12 o'clock. The patient underwent a D-ACE procedure. Subretinal fluid was drained above the lateral rectus muscle at the equator. One and a half milliliters of air were injected 3.5 mm from the limbus midway between the superior and the medial rectus insertions. Cryotherapy was applied to the retinal breaks. A 240 encircling band was used in conjunction with a 276 tyre segment at the level of the tears. RESULTS: One day after surgery, the retina was flat, but a full-thickness macular hole could be seen with a surrounding cuff of subretinal fluid. CONCLUSIONS: The mechanisms proposed to explain the occurrence of full-thickness macular holes after D-ACE may involve the concurrence of scleral elongation and vitreofoveal traction by means of previous partial posterior vitreous detachment with persistent posterior attachments at the fovea.

Luxated intraocular lens fixation using anterior chamber slipknot of the haptic to the sclera: a simple procedure to fixate intraocular lens to the sclera.

PURPOSE: To describe a technique for suturing a luxated intraocular lens (IOL) in the vitreous cavity directly to the ciliary sulcus using intraocular slipknot without IOL extraction. DESIGN: Noncomparative interventional case series. MATERIALS AND METHODS: A three-port vitrectomy was performed in all cases. According to the Lewis procedure, two scleral flaps and relative sclerectomies were performed at 3 and 9 o'clock position. IOL was rescued from vitreous cavity by means of perfluorocarbon and stabilized in anterior chamber by intravitreal forceps. Corneal endothelium was preserved by a dispersive ophthalmic viscosurgical device coating. Double armed 10-0 polypropylene was introduced into the vitreous cavity through the 9 o'clock sclerotomy incision and both the needles were passed out of the eye by the 3-o'clock position sclerotomy, guided by a bent 27-gauge needle 1.5 mm from the limbus. Hooking the slipknot around the haptics of the IOL in the anterior chamber by means of vitreous forceps, the 10-0 polypropylene was pulled so that the IOL haptic was fixated onto the sulcus. The same procedure was used to fixate the opposite haptic to the ciliary sulcus at the opposite position. RESULTS: In all four cases, the IOL fixated stably and remained well positioned. No significant intraoperative or postoperative complications occurred. CONCLUSIONS: This technique enables secure fixation of the luxated IOL in the vitreous without extracting it.