Patient ignorance is the main reason for treatment delay in primary rhegmatogenous retinal detachment in The Netherlands.

AIMS: Treatment delay of progressive vision-threatening conditions should be minimal. In this study, the treatment delay of patients with a rhegmatogenous retinal detachment (RRD) undergoing retinal detachment surgery was quantified, and causes for this delay were evaluated. MATERIALS AND METHODS: Consecutive patients (n=205) presenting with a primary RRD between June 2006 and June 2007 at the tertiary referral center (TRC) were interviewed. Five categories of delay were discerned in the following: 'patient delay,' 'general practitioner's delay,' 'referring ophthalmologist's delay,' 'delay at the TRC' and 'delay before surgery at the TRC'. In addition, overall delay was calculated. RESULTS: In total, 186 eyes were included in the analysis. Median overall delay between the patients' first symptoms and RRD surgery was 10 days. Almost 60% of this overall delay time was due to patient delay and the delay of the general practitioner. More than 50% of patients had a delay owing to unawareness of the symptoms. The median patient delay was significantly lower in patients with a vitreous hemorrhage and in patients with a history of a RRD in the fellow eye. CONCLUSIONS: The major reason for patient delay with a RDD was the patients' unawareness and unfamiliarity with the symptoms of a retinal detachment.

Risk factors for redetachment and worse visual outcome after silicone oil removal in eyes with complicated retinal detachment.

PURPOSE: The goal of this study was to identify risk factors for redetachment and/or a worse visual outcome after silicone oil removal (SOR) for complicated retinal detachment. METHODS: The authors retrospectively analyzed 287 consecutive eyes with SOR between January 1999 and December 2003. RESULTS: Anatomic success after SOR was achieved in 81% of the eyes. The overall anatomic success at the end of follow-up was 94%. Postoperative ocular hypertension was found in 8% of the eyes, hypotony in 6% of the eyes, and keratopathy in 29% of the eyes. After SOR 43% of the eyes had an improvement in visual acuity of at least two Snellen lines. After multivariate analysis, male sex, the presence of preoperative rubeosis, and proliferative diabetic retinopathy (PDR) were found to be risk factors for recurrent retinal detachment. Male sex, preoperative visual acuity of <0.1 Snellen lines, PDR, the performance of three more operations, any size of retinectomy, and hypotony were found to be associated with a poor visual outcome of Snellen visual acuity <0.1. CONCLUSIONS: Retinal detachment after SOR in the current unselected series of eyes occurred in approximately 20%, which is comparable to the Silicone Oil Study reports, published approximately 20 years ago. However, preoperative selection was then made, and less than 50% of the silicone oil-filled eyes had SOR. The higher overall anatomic success in the current study may be due to improved vitreoretinal surgical techniques.

Selective blockade of phosphodiesterase types 2, 5 and 9 results in cyclic 3'5' guanosine monophosphate accumulation in retinal pigment epithelium cells.

AIM: To investigate which phosphodiesterase (PDE) is involved in regulating cyclic 3'5' guanosine monophosphate breakdown in retinal pigment epithelium (RPE) cells. METHODS: cGMP content in the cultured RPE cells (D407 cell line) was evaluated by immunocytochemistry in the presence of non-selective or isoform-selective PDE inhibitors in combination with the particulate guanylyl cyclase stimulator atrial natriuretic peptide (ANP) or the soluble guanylyl cyclase stimulator sodium nitroprusside (SNP). mRNA expression of PDE2, PDE5 and PDE9 was studied in cultured human RPE cells and rat RPE cell layers using non-radioactive in situ hybridisation. RESULTS: In the absence of PDE inhibitors, cGMP levels in cultured RPE cells are very low. cGMP accumulation was readily detected in cultured human RPE cells after incubation with Bay60-7550 as a selective PDE2 inhibitor, sildenafil as a selective PDE5 inhibitor or Sch51866 as a selective PDE9 inhibitor. In the presence of PDE inhibition, cGMP content increased markedly after stimulation of the particulate guanylyl cyclase. mRNA of PDE2,PDE5 and PDE9 was detected in all cultured human RPE cells and also in rat RPE cell layers. CONCLUSIONS: PDE2, PDE5 and PDE9 have a role in cGMP metabolism in RPE cells.

Decreased levels of cGMP in vitreous and subretinal fluid from eyes with retinal detachment.

BACKGROUND: Cyclic guanosine monophosphate (cGMP) is produced in different retinal cells, including photoreceptor cells, wherein cGMP mediates photo-transduction. CGMP is degraded by phosphodiesterases (PDE). The aim was to investigate whether retinal detachment alters intraocular cGMP levels in human eyes. METHODS: cGMP and PDE were determined in vitreous fluid from 50 eyes with a retinal detachment (group I) and in 20 control samples (group II) of vitreous fluid from eyes without retinal detachment. Group III consisted of subretinal fluid samples from 70 eyes with retinal detachment. RESULTS: cGMP in vitreous fluid from eyes with retinal detachment (6.5 (SD 1.7) nM) was decreased compared to controls (67.1 (10.0) nM) (p<0.0001). In subretinal fluid, the mean level of cGMP was 2.4 (0.2) nM. No PDE could be detected in any of the intraocular fluid samples of patients nor controls. A decrease in the mean level of cGMP in subretinal fluid of eyes with retinal detachment correlated with a longer duration of detachment (r = -0.45, p = 0.007). CONCLUSIONS: Retinal detachment was found to be associated with a decrease in vitreous cGMP concentration. In subretinal fluid, a low cGMP level correlated inversely with the duration of the detachment.

Levels of basic fibroblast growth factor, glutamine synthetase, and interleukin-6 in subretinal fluid from patients with retinal detachment.

PURPOSE: To investigate the presence of basic fibroblast growth factor, glutamine synthetase activity, and interleukin-6 in subretinal fluid from patients with retinal detachment. METHODS: In a prospective study we measured basic fibroblast growth factor, glutamine synthetase activity, interleukin-6, and total protein in subretinal fluid samples from 96 eyes from 94 consecutive patients with a retinal detachment corrected by a conventional scleral buckling operation in our clinical practice. As controls, vitreous fluid samples from eyes with a macular hole (n = 6) or pucker (n = 11) were used. Laboratory data of the patient group were compared with the control group and correlated with various clinical data. RESULTS: Levels (median, range) of basic fibroblast growth factor, glutamine synthetase activity, interleukin-6, and total protein were significantly higher in patients than in controls (P <.0001). An increased level of glutamine synthetase and total protein correlated with a longer duration of the retinal detachment (r =.4, P =.002, and r =.34, P =.001, respectively). Interleukin-6 and basic fibroblast growth factor levels did not correlate with the duration of the detachment. After multivariate logistic regression analysis, no significant relation was found between any of the tested subretinal proteins and a low visual outcome or redetachment. CONCLUSIONS: We found increased levels of basic fibroblast growth factor and glutamine synthetase in subretinal fluid from patients with retinal detachment. Basic fibroblast growth factor and glutamine synthetase may play a role in the pathogenesis and recovery after retinal detachment. The questions of whether the increased levels of basic fibroblast growth factor and glutamine synthetase result from leakage of dying glia cells (including Müller cells) and neurons and if basic fibroblast growth factor is actively produced to protect the photoreceptor cells need further research.

[Age-related macular degeneration; therapeutic options]. / Leeftijdsgebonden maculadegeneratie; mogelijke therapieën.

The prevalence of age-related macular degeneration varies from 1% in patients aged 65 to 74 years, to 10% in patients aged 85 years and older. In the Netherlands, there is now a total of around 55,000 patients with age-related macular degeneration, and this figure is expected to rise to approximately 114,000 by 2025. Loss of central vision is caused by a degeneration of photoreceptors cells and pigment epithelium. Age-related macular degeneration is subdivided into a dry, atrophic form and an exudative form with neovascularisations. Many international studies have been published over the past ten years on potential new therapies for neovascular macular degeneration. For conventional laser treatment, it has been shown that visual loss in the long term is less marked in the treated group than in the observation group, despite the immediate destruction of the retina. Photodynamic therapy seems a promising new form of local therapy with few side-effects. For both therapies, however, the indication is limited to patients with the classic type of neovascularisation. Data on radiotherapy, submacular surgery and macular translocations are not sufficiently well-founded for firm conclusions to be drawn.

Vitrectomy results in diabetic macular oedema without evident vitreomacular traction.

PURPOSE: To determine the effectiveness of vitrectomy in eyes with diabetic macular oedema without evident traction from a thickened vitreous membrane. METHODS: Twenty-one consecutive eyes from 19 patients with diabetic macular oedema that had undergone vitrectomy were analysed retrospectively. All eyes had an attached posterior hyaloid membrane in the macular region, but without thickening and without evident traction on the macula. A standard pars plana vitrectomy with the creation of a posterior vitreous detachment was performed. RESULTS: Median duration of macular oedema at the time of vitrectomy was approximately 11.0 months (range 2-36 months). The median preoperative best-corrected visual acuity of 0.08 (range hand motions/0.003 to 0.4), improved by 5 lines to a median final postoperative best-corrected visual acuity of 0.25 (range 0.025-0.5) (P = 0.001). Seven eyes without preoperative macular photocoagulation had a median visual acuity improvement of 77%, range 32-400%, while 12 eyes with preoperative macular laser treatment had a median visual acuity improvement of 14.8%, range 0-66.1% (P = 0.02, CI 95%, after multivariate regression analysis). In all 21 eyes, macular oedema was no longer visible on microscopic examination after a median period of 3.0 months (range 1-9 months) after vitrectomy. CONCLUSIONS: In eyes with diabetic macular oedema without evident macular traction from a thickened vitreous membrane, vitrectomy resulted in the resolution of macular oedema, with an improvement in visual acuity in the majority of cases. Eyes without preoperative macular photocoagulation had a significantly higher percentage visual improvement than eyes without preoperative macular laser treatment. A randomised controlled prospective trial of primary vitrectomy versus macular photocoagulation is needed to determine the role of vitrectomy as treatment modality for diabetic macular oedema.

Results and complications of temporary silicone oil tamponade in patients with complicated retinal detachments.

BACKGROUND: To assess the results and complications of temporary silicone oil tamponade in the treatment of complicated retinal detachments. METHODS: Fifty-eight consecutive eyes undergoing silicone oil removal were studied in a retrospective fashion. Forty-two eyes with proliferative vitreoretinopathy, nine eyes with giant tears, and seven traumatized eyes were included. In addition to anatomic and visual results, the following complications and their associated preoperative and intraoperative variables were assessed: glaucoma, hypotony, and keratopathy. RESULTS: Anatomic success was achieved in 81% of the eyes. Postoperative glaucoma was found in 12%, hypotony in 9%, and keratopathy in 7% of the eyes. Twenty-six (45%) of the 58 eyes had an increase in visual acuity of at least two Snellen lines after silicone oil removal. After multivariate logistic regression analysis for all variables versus the visual and anatomic results and versus the complications of glaucoma, hypotony, and keratopathy successively, a total of three or more operations (P < 0.05; odds ratio, 14.7) and the absence of an encircling band (P < 0.05; odds ratio, 29.9) were associated with redetachment, and a retinectomy size of more than 180 degrees was associated with hypotonia (P < 0.05; odds ratio, 67.5). CONCLUSIONS: Temporary silicone oil tamponade may be associated with a lower incidence of complications than recent studies have reported. Despite the acceptable risk of recurrent retinal detachment, the early removal of silicone oil may yield a lower rate of anterior segment complications and an increase in visual acuity in approximately half the eyes.

Results of scleral buckling operations in primary rhegmatogenous retinal detachment.

Within the scope of a Retinal Fellowship of one year, we evaluated the anatomic and functional results of scleral buckling operations in primary rhegmatogenous retinal detachments. Eighty Consecutive non-selected patients with a primary retinal detachment were operated by one surgeon (Retinal Fellow-ELH). In 55 eyes an encircling band and radial buckle(s) were placed, the other 25 eyes were treated with a segmental buckle or a combination of both. In 62 eyes subretinal fluid was drained, and in 57 eyes air or SF-6 gas was injected. The anatomic success rate after one operation was 81% (65/80 eyes) and the final success rate was 99%. 38/65 (58%) of the eyes obtained a best corrected post-operative visual acuity of > or = 0.4. The most important cause of re-detachment was Proliferative vitreoretinopathy (PVR; 11%). Pre-operative variables that yielded an unfavourable outcome in this study were: PVR, pseudophakic eye, larger breaks, more than one break, longer duration of the detachment, and 3 or more quadrants of detachment. Our anatomic success rate and risk factors are in agreement with findings described in the literature, yet we had a high rate of PVR and many patients with a low visual acuity (58% < or = 0.3) pre-operatively.

[Retinal detachments and retinal surgery]. / Netvliesloslatingen en netvlieschirurgie.

The incidence of retinal detachment is approximately 1:10,000. Most retinal detachments occur between the ages of 50 and 65 years. A rhegmatogenous retinal detachment starts with a tear in the peripheral retina. Through this retinal tear liquefied vitreous may enter the subretinal space, resulting in a retinal detachment with progressive visual loss. In 50% prodromal light flashes are observed. Laser coagulation around a tear without subretinal fluid can make surgical intervention unnecessary in approximately 96% of cases. When subretinal fluid is present, conventional scleral buckling surgery is successful in 80-90% of the cases. In more complex retinal detachments or in re-detachment cases, a trans pars plana vitrectomy is indicated. Anatomical success can be achieved in approximately 96% of cases, sometimes after several operations. Functional success depends on preoperative pathology and duration of the detachment. Eyes with retinal detachment of the macula and with larger and complex defects have poorer visual prognosis.

Analysis of immunoregulatory cytokines in ocular fluid samples from patients with uveitis.

PURPOSE: To investigate the T-helper cell cytokine profiles in two well-defined clinical uveitis entities caused by an infectious mechanism. METHODS: Cytokines (interleukin [IL]-2, IL-4, IL-6, IL-10, and interferon [IFN]-gamma) were measured in ocular fluid samples obtained from patients with herpes simplex- or varicella-zoster virus-induced acute retinal necrosis (ARN; n = 17) and toxoplasma chorioretinitis (n = 27) using enzyme-linked immunosorbent assay techniques. The data were compared with data for 51 control samples taken during cataract surgery (n = 10), vitrectomy in diabetic retinopathy (n = 10), eye bank eyes (n = 10) and with samples from patients with "autoimmune" uveitis (n = 21). RESULTS: Interleukin-6 was detected in 44 of 51 control samples and 43 of 44 eyes of patients with uveitis. The highest levels in the control samples were detected in 9 of 10 vitreous samples from patients with diabetic retinopathy (mean, 648 pg/ml). In 8 of 10 samples taken from patients during cataract surgery and in 7 of 10 eye bank eyes the amount of IL-6 was significantly lower (mean, 10 pg/ml and 136 pg/ml, respectively). Interleukin-6 levels in patients with ARN (mean, 1436 pg/ml) were significantly higher than in those with toxoplasma chorioretinitis (mean, 272 pg/ml). Interleukin-2 was detected in one of the samples from patients with toxoplasma chorioretinitis (1105 pg/ml) and in three samples from the control subjects suffering from Fuchs' heterochromic anterior uveitis (mean, 752 pg/ml). No IL-4 (<2 pg/ml) was detected either in patient or control samples. Interferon-gamma could be detected in 7 of 17 ARN patients (range, 277-3483 pg/ml), in 13 of 27 samples from patients with toxoplasma chorioretinitis (range, 12-250 pg/ml), and in 1 of 21 of the samples from control subjects with uveitis (31 pg/ml) but was absent in nonuveitic control samples. Interleukin-10 was detected in 10 of 17 ARN patients (range, 29-3927 pg/ml), in 13 of 27 samples from patients with toxoplasma chorioretinitis (range, 4-67 pg/ml), and in only 3 of 51 control samples (6 pg/ml, 16 pg/ml, and 20 pg/ml). CONCLUSIONS: Various immunoregulatory cytokines (IL-6, IL-10, and IFN-gamma) were detected in ocular fluid samples from patients with uveitis. A separate role for either a T-helper type 1 or T-helper type 2 response in the pathogenesis of clinical uveitis could not be proven.