Perfluorocarbon liquid assisted large retinal epithelium patching in sub-macular hemorrhage secondary to age related macular degeneration.

BACKGROUND: We investigate the safety and feasibility of large retinal pigmentary epithelium (RPE)-Choroid-free graft after surgical drainage of massive sub-macular hemorrhage (SMH) due to age-related macular degeneration (ARMD). METHODS: Four previously untreated patients (three females and one male) underwent to three port pars plana vitrectomy, induction of retinal detachment and peripheral temporal 180 degrees retinotomy. The retina was then folded nasally, to allow access for removal of sub-macular Hg and CNV complex. A full-thickness-large autologous Chorio-RPE patch was grafted. Silicone oil was used as endotemponade for approximately 12 weeks. After removal of silicone oil, the patients were followed-up for 6 months. RESULTS: SMH was completely removed in all cases. It was possible to graft a large RPE patch safely that is sufficiently large to cover the entire defect of macular RPE. At last follow-up, improvement in visual acuity (from 3 +/- 0.9 to 55 +/- 9 ETDRS letters) and recovery of central fixation was observed in all patients. CONCLUSIONS: Our surgical technique for large elevated SMH seems to be feasible and efficacious approach to harvest and relocate large RPE patch and to save limited vision in selected patients.

[Densiron-68 heavy silicone oil in cases of PVR. Anatomic and functional outcomes]. / Schweres Silikonöl bei PVR. Anatomische und funktionelle Ergebnisse.

PURPOSE: To evaluate the safety and efficacy of Densiron-68 heavy silicone oil in the clinical management of complex retinal detachments with proliferative vitreoretinopathy (PVR). METHODS: We present a prospective, interventional noncomparative case series of 80 eyes of 79 consecutive patients. The primary end point was anatomical reattachment of the retina, defined as retinal reattachment in the absence of any tamponade agent. The secondary end point was to record the visual function and surgical complications. Inclusion criteria were PVR stages B-CA4, including posterior or inferior retinal breaks and the patient's inability to posture. RESULTS: Patients were 59.1 (+/-18.1) years old, male:female =48:32, R:L=40:40. Fifty-six patients (70%) had previous unsuccessful retinal surgery, and 24 (30%) received heavy silicone oil at their first procedure. The extent of the detachments was 2.46 quadrants (+/-0.83) with macular involvement in 49 cases (61%). Fifty-six (67.5%) patients achieved retinal reattachment with one retinal operation and no tamponade, 64 (80%) achieved retinal reattachment with more than one operation and no tamponade, and 72 (90%) achieved a flat retina with tamponade in situ. Visual acuity rose from 1.48 LogMar (+/-0.91) to 1.12 (+/-0.82; p=0.009). Densiron was removed after 126 days (+/-55.1). CONCLUSION: The treatment of PVR remains challenging. No tamponade agent can provide simultaneous support for the superior as well as the inferior retina; therefore, a tamponade agent that "sinks" is a welcome new tool for the surgeon. We regard the use of heavy as well as conventional silicone oil as complementary to each other.

Can a preoperative bevacizumab injection prevent recurrent postvitrectomy diabetic vitreous haemorrhage?

AIMS: To evaluate the recurrence rate of vitreous haemorrhage (VH) in patients treated with one intravitreal bevacizumab (IVB) injection (2.5 mg/0.1 ml) before planned pars plana vitrectomy for treatment of diabetic non-clearing VH. METHODS: Prospective pilot study of 32 eyes of 31 consecutive diabetic patients who underwent IVB injection within 1 week before surgery for persistent VH in the presence of active proliferative diabetic retinopathy. Three masked retinal specialists graded the amount of VH from grade 0 to grade 3 with slit-lamp biomicroscopy. Main outcome measures were the rate of recurrence of the VH, improvement in visual acuity, incidence of cataract formation, and postoperative complications through a follow-up of 6 months. RESULTS: The percentage of severe recurrent VH with no fundus details (grade 3) was 3% at 1 week follow-up and 3, 6, and 6% respectively at 1-, 3-, and 6-month follow-up. The mean best-corrected visual acuity (BCVA) improved from 1.6 (1/60) to 0.40 (6/15) logMAR (P=0.02) in 29 out of 32 eyes (91%). In all, 12 out of 22 (54%) phakic eyes developed cataract during the follow-up period, and 10 (31%) of them underwent cataract surgery. CONCLUSIONS: Our study suggests that IVB injection few days before planned surgery seems to be efficacious and safe as an adjuvant treatment to prevent rebleeding in eyes undergoing pars plana vitrectomy for treatment of diabetic vitreous haemorrhage. IVB facilitates the surgery and reduces the need for extensive delamination and segmentation, decreasing the possibility of significant early active postoperative VH.

Primary vitrectomy with Densiron-68 for rhegmatogenous retinal detachment.

BACKGROUND: To report a retrospective non-comparative interventional study on the effectiveness and ocular tolerance of a heavy silicone oil tamponade (HSO, Densiron-68) for primary inferior rhegmatogenous retinal detachment (RRD). METHODS: Forty-one eyes of 41 consecutive patients were recruited between January 2004 and August 2006. Primary vitrectomy with Densiron-68, a heavy silicone oil, was used in all cases. Inclusion criteria were primary RRD with at least one retinal break between 4 and 8 clock hours. The study protocol consisted of a minimum of eight clinic visits: baseline, surgery, 1 week, 1 month and 3 months after the initial surgery; removal of oil and 1 week, 1 month and 3 months postoperatively. The primary endpoint was anatomical re-attachment of the retina. Cases were judged successful when there was reattachment of the retina in the absence of any tamponade agent. The secondary endpoint was to record the visual function and any complications arising from the surgery. Out of 41 patients initially included in the study, 33 completed all follow-up visits. RESULTS: Anatomical success was achieved in 91% of cases (30 out of 33) with one retinal operation, and rose to 94% (31 out of 33) with additional surgery. Mean visual acuity improved from logMAR 1.19 (SD 0.9) to 0.5 (SD 0.51, p = 0.001). No significant ocular hypertension, clinically significant emulsification of the tamponade or inflammation developed during follow-up. CONCLUSION: With Densiron-68, high anatomical and functional success rates can be achieved with primary vitrectomy for RRD and predominantly inferior pathology.

A guide to the removal of heavy silicone oil.

AIM: Heavy silicone oil removal can be challenging and differs considerably from conventional oil. Traditionally, strong active aspiration had to be applied through a long 18G needle just above the optic disc. We present a novel technique using a much shorter (7.5 mm) and smaller (20G) needle allowing its removal "from a distance." METHOD: Active aspiration on a vacuum of 600 mm Hg of the "viscous fluid injector" was applied using the 20G cannula in a polymethylmethacrylate model eye chamber that was surface-modified to mimic the surface properties of the retina. Measurements were taken using still photographs. RESULTS: Under injection the maximum diameter of a silicone oil bubble supported by interfacial tension alone was 5 mm for a steel and 7 mm for a polyurethane cannula. Under suction, the silicone bubble changed shape and became conical, thus further increasing the cannula's reach. This conical shape illustrated "tubeless siphoning," which is a physical property of non-Newtonian fluids. DISCUSSION: The use of shorter and smaller gauge cannula for removal of Densiron obviates the need to enlarge the sclerotomy beyond 20G or to apply suction in close proximity to disc and fovea. This potentially reduces the risk of iatrogenic damage such as entry site tears or postoperative hypotony.

Heavy tamponade 2 Densiron 68 in routine clinical practice: anatomical and functional outcomes of a consecutive case series.

PURPOSE: To evaluate the safety and efficacy of Densiron 68 in the clinical management of complex vitreoretinal cases with inferior retinal pathology. METHODS: We present a prospective interventional non-comparative case series of 122 eyes of 121 consecutive patients. The primary end point was anatomical re-attachment of the retina, defined as retinal re-attachment in the absence of any tamponade agent. The secondary end point was to record the visual function and surgical complications. Inclusion criteria were proliferative vitreoretinopathy, posterior or inferior retinal breaks, and the patient's inability to posture. RESULTS: Patients were 59.9 years (+/- 19.6), (m/f= 72:49), (R/L=65:57). Seventy-seven (63.1%) had previous unsuccessful retinal surgery and 45 had Densiron 68 at first procedure. The extent of the detachments was 2.21 quadrants (+/- 1.07) with macular involvement in 66 cases (54%). Eighty-seven (71.3%) patients achieved retinal re-attachment with one retinal operation and ultimately no tamponade, 102 (83.6%) achieved retinal re-attachment with more than one operation and ultimately no tamponade, and 112 (91.3%) patients achieved flat retina with tamponade in situ. Visual acuity rose from 1.38 LogMar (+/- 0.87) to 1.06 (+/- 0.83) (P=0.007). Densiron was removed after 135 days (+/- 73.2; range 35-405). CONCLUSION: No tamponade agent can provide simultaneous support for the superior as well as the inferior retina; therefore, a tamponade agent that 'sinks' is a welcome new tool at the surgeon's disposal. The sequential use of heavy silicone oil followed by conventional silicone oil may be an acceptable management strategy in recurrent detachment.

Peel and peel again.

AIM: To determine if the internal limiting membrane (ILM) was present in the epiretinal membrane (ERM) when we deliberately tried to perform a "double peel" for macular pucker. METHODS: Pars-plana vitrectomy and a "double peel" were carried out. The ERM and ILM were stained with Trypan Blue and peeled separately over the same area. The amount of ERM present in ILM specimens and the amount of ILM present in ERM specimens were evaluated by histological examination. RESULTS: Seventeen eyes in 17 patients were included. It was possible to double peel in all cases. Five of 17 ERM specimens (29%) contained ILM fragments. When ILM was present on the ERM, it represented less than 50% of the sample. One ILM specimen was lost as result of an administrative error; of the remaining 16 specimens, residual ERM was found in six, and cellular remnants were observed on the vitreous surface in a further six of the ILMs. Clinically, no recurrence of ERM was found. CONCLUSION: ILM was present in some ERM specimens seemingly over the same area that an intact ILM was subsequently peel. We speculate that the ILM in the ERM represent a secondary basement membrane and that the surgical plane of dissection for most ERM peel is between the ERM and the native ILM, making it feasible to double peel routinely.

Optical coherence tomographic pattern may predict visual outcome after intravitreal triamcinolone for diabetic macular edema.

OBJECTIVE: To identify an optical coherence tomography (OCT) pattern predictive of visual outcome in patients with diabetic macular edema (DME) who underwent a single dose of intravitreal triamcinolone. DESIGN: Retrospective case analysis with prospective data collection for controls. PARTICIPANTS: Ninety-three cases and 25 controls. METHODS: Two independent masked observers retrospectively examined preoperative macular OCTs of 93 eyes of 93 patients who were given a single dose (4 mg in 0.1 ml) of intravitreal triamcinolone for DME and categorized them as belonging to 2 groups: 1, comprised of eyes with high reflectivity (bright colors) from inner retinal layers, and 2, comprised of eyes that had low reflectivity (darker colors) from inner retinal layers. Logarithm of the minimum angle of resolution visual acuity (VA) and macular thickness measured by OCT were assessed preoperatively and postoperatively at 1 and 3 months. MAIN OUTCOME MEASURES: Optical coherence tomographic appearance of inner retinal layers. RESULTS: All patients completed 3 months of follow-up. In group 1, 45 of 51 eyes (88%) experienced visual improvement of > or =2 lines on an Early Treatment Diabetic Retinopathy Study (ETDRS) chart at 1 month of follow-up. Forty-four of 51 patients (86%) experienced visual improvement of > or =2 lines on an ETDRS chart at 3 months of follow-up. In group 2, 18 of 42 patients (43%) experienced visual improvement of > or =1 lines on an ETDRS chart at 1 and 3 months of follow-up. For the remaining patients, VA remained unchanged during the postoperative course of 3 months. CONCLUSIONS: Patients in whom OCT demonstrated the high reflectivity of inner retinal layers achieved greater VA though macular thickness decreased significantly after intravitreal triamcinolone in both groups. It may be hypothesized that a lower optical reflectivity of inner retinal layers is related to the atrophy of the inner retinal layers, thus resulting in a failure of VA recovery in these patients. The level of reflectivity from inner retinal layers on OCT may provide objective criteria in predicting the response of DME to intravitreal triamcinolone and help in preoperative counseling of patients with DME.

Ocular coherence tomographic examination of postoperative foveal architecture after scleral buckling vs vitrectomy for macular off retinal detachment.

AIMS: This pilot study uses Optical Coherence Tomography (OCT) imaging to compare the difference in foveal architecture after successful retinal detachment (RD) surgery by scleral buckling or pars plana vitrectomy (PPV). METHODS: Prospective recruitment of patients with macular off RDs. Detachment surgery was undertaken by scleral buckling, external drainage, and air injection (group 1) or by PPV (group 2). Postoperatively patients had clinical examinations and OCT at 1, 3, 6, and 12 months. If abnormalities persisted, a further OCT was obtained at 18 months. RESULTS: Retinal reattachment, including clinical macular reattachment, was achieved in all cases within 24 h postoperatively. In group 1 (n=22), postoperative OCT showed persistent foveal detachment in 63% of cases (n=14) at 1 and 3 months. At 6 and 12 months, 36% (n=8) and 9% (n=2) had a persistent foveal detachment, respectively, and at 18 months, foveal detachment eventually. In group 2 (n=21), postoperative OCT showed an attached fovea in all cases; however, foveal thickening suggesting intraretinal oedema was present in all cases. The oedematous appearance of retina on OCT settled in 1-3 months. No foveal abnormality was seen at 6 and 12 months postoperatively. CONCLUSIONS: A high proportion of patients with successful retinal reattachment surgery by scleral buckling had foveal detachments postoperatively. No cases who had PPV had foveal detachments; however, transient retinal oedema was evident in all cases. The aetiology of these changes is unknown and warrants further investigation, as there is the potential of a long-term effect on vision.

Histological findings of a choroidal neovascular membrane removed at the time of macular translocation in a patient previously treated with intravitreal bevacizumab treatment (Avastin).

AIM: To report the findings in a patient treated by repeated intravitreal bevacizumab (Avastin) injections, followed by macular relocation and excision of subfoveal choroidal neovascular membrane (CNV). METHODS: Histopathological evaluation of the CNV specimen, including immunohistochemical assessment. RESULTS: During surgical excision, the CNV seemed to be avascular and its underlying bed did not bleed. Histopathological examination revealed that the CNV comprised avascular fibrous subretinal tissue containing fibroblastic retinal pigment epithelial (RPE) cells, fragments of irregular thickened Bruch's membrane and fibrotic choroidal tissue containing some medium-sized vessels but no choriocapillaris. CONCLUSIONS: The development of an RPE tear during the course of Avastin treatment may reflect contraction of the avascular subretinal tissue, whereas the lack of capillaries in both choroidal and subretinal components may be caused by the increased access of Avastin to the choriocapillaris in the presence of the RPE tear.

External trabeculectomy with T-Flux implant.

PURPOSE: To evaluate the efficacy and safety of T-Flux implant in nonpenetrating glaucoma surgery. METHODS: This clinical interventional case series study included 35 eyes of 35 patients with medically uncontrolled primary open angle glaucoma. External trabeculectomy with T-Flux (ETTF) is a technique of nonpenetrating glaucoma surgery, in which after removing deep scleral tissue and un-roofing the canal of Schlemn (CS) the external trabecular tissue is peeled off to enhance the aqueous drainage without opening the anterior chamber. A non-absorbable T-Flux implant (IOL TECH Laboratories, France) was sutured in deep intrascleral space to keep it patent. Snellen's best-corrected visual acuity, slit lamp biomicroscopy, intraocular pressure (IOP), gonioscopy, funduscopy, and optic disc assessment were performed preoperatively and postoperatively at 1 day, 1 week, and 1, 3 , 6, and 12 months. Visual field testing was performed preoperatively and at 6 and 12 months postoperatively. RESULTS: For three eyes, surgery was converted to standard trabeculectomy owing to the perforation of trabeculo-Descemet's membrane and iris prolapse and excluded from the study. The results of the remaining 32 eyes were included in the study. Preoperative IOP (mean +/- SD) of 32.88 +/- 5.7 mmHg decreased to 15.44 +/- 1.6 mmHg after 12 months. Ten eyes (28.6%) had microhyphema that resolved spontaneously; 3 eyes (8.6%) had microperforation without iris prolapse so ETTF was proceeded routinely. The preoperative number of antiglaucoma medications per patient reduced from (mean +/- SD) 2.74 +/- 0.61 to 0.11 +/- 0.32 postoperatively at 12 months. Visual acuity and visual fields remained stable. CONCLUSIONS: ETTF appears to provide significant control of IOP and have low incidence of complications.

Intravitreal triamcinolone for diffuse diabetic macular oedema.

AIM: To evaluate the efficacy of intravitreal triamcinolone (IVTA) for the treatment of diffuse diabetic macular oedema (DME) refractory to conventional argon macular laser therapy. METHODS: A prospective, consecutive, and noncomparative case series was undertaken involving 38 eyes of 38 patients with refractory DME. Triamcinolone acetonide (4 mg) in 0.1 ml was injected intravitreally. LogMar visual acuity (VA) and macular thickness measured by ocular coherence tomography (OCT) were assessed preoperatively and postoperatively at 1, 3, and 6 months. RESULTS: All patients completed 6 months of follow up. VA (mean+/-SD) improved from 0.905+/-0.23 to 0.605+/-0.28, 0.555+/-0.29, and 0.730+/-0.30 at 1, 3, and 6 months, respectively. Macular thickness baseline (mean+/-SD) on OCT was 418.7+/-104.2 microm and this decreased to 276.9+/-72.6 microm, 250.6+/-53.1 microm, and 308.8+/-87.3 microm at 1, 3, and 6 months, respectively. CONCLUSIONS: IVTA may be a potential temporary treatment for refractory DME. It is effective in decreasing macular thickness and improving VA but the effect lasts approximately for 6 months in the majority of patients. Further investigations are required to establish the safety of IVTA for the treatment of DME.

Foveal detachment after successful retinal reattachment for macula on rhegmatogeneous retinal detachment: an ocular coherence tomography evaluation.

PURPOSE: Foveal detachment after apparently successful retinal reattachment surgery for macula-on retinal detachments (RDs) has been previously documented. This pilot study aimed to utilize ocular coherence tomography (OCT) imaging to investigate foveal architecture after routine retinal detachment surgery and correlate this to visual acuity. METHODS: Prospective recruitment of patients attending one unit with macula-on RDs. Patients underwent full clinical examination including OCT preoperatively and RD surgery undertaken by scleral buckling, external drainage and air injection. Postoperatively patients had clinical examinations and OCT at 1 week, 1, 3, 6, and 12 months. RESULTS: A total of 12 consecutive patients were recruited into the study. All had macula-on RDs and normal OCTs at onset. There were no operative or postoperative complications. Retinal reattachment was achieved in all cases within 24 h postoperatively. At 1 month six of 12 patients (50%) showed foveal detachment on OCT, which was invisible on clinical examination. At 3 months, the foveal detachment persisted in four (33%) of these patients. In these cases the foveal detachment persisted at 6 months follow-up, however, a reduction in subfoveal fluid was noted. All cases had foveal reattachment by 12 months postoperatively. Visual acuity was closely correlated to the presence of foveal attachment. DISCUSSION: A high proportion of patients with successful retinal reattachment surgery had foveal detachments postoperatively. This phenomenon was associated with reduced visual acuity. The aetiology of this occurrence is unknown and warrants further investigation as there is the potential of a long-term effect on vision.