Comparison of Visual Outcomes in Coats' Disease: A 20-Year Experience.

PURPOSE: To report differences in visual acuities among patients with Coats' disease who sought treatment at a tertiary care university-based practice. DESIGN: Single-center retrospective cohort study. PARTICIPANTS: Patients with Coats' disease diagnosed clinically, angiographically, or both from 1995 through 2015. METHODS: Patients were divided into 2 groups based on date of presentation: decade 1 (1995-2005) and decade 2 (2006-2015). MAIN OUTCOME MEASURES: Visual acuity (VA). RESULTS: Thirty-nine eyes of 39 patients were included with 19 eyes presenting in decade 1 and 20 eyes presenting in decade 2. Three patients demonstrated bilateral disease, but only the worse eye was included for analysis. Forty-seven percent of eyes in decade 1 demonstrated advanced stages of disease (stage 3B or worse) compared with 20% of eyes in decade 2. There was a trend for the mean initial presenting VA (±standard deviation) for decade 1 eyes to be worse (2.05±1.29 logarithm of the minimum angle of resolution [logMAR]) than for decade 2 eyes (1.45±0.99 logMAR; P = 0.1). From initial to final follow-up visit, mean VA also worsened for decade 1 eyes (P = 0.03), but remained stable for decade 2 eyes (P = 1.0). At the end of follow-up, there was a trend for mean VA for decade 1 eyes (2.28±1.17 logMAR) to be worse than for decade 2 eyes (1.60±1.15 logMAR; P = 0.07). Eight eyes were observed initially in decade 1 compared with 1 eye in decade 2, and only 1 of the observed eyes (in decade 2) developed painful glaucoma requiring enucleation. Decade 2 eyes had a higher average number of procedures per eye (6.5±4.9) compared with decade 1 eyes (1.4±1.7; P < 0.001). CONCLUSIONS: The earlier presentation of disease in decade 2 suggests improvements in disease detection over time. Furthermore, there was a trend for eyes to have better final VA in this decade. This is due to a combination of factors, including earlier presentation of disease, fewer eyes being observed without treatment, and eyes, when treated, receiving a higher number of procedures.

Unanticipated vision loss after pars plana vitrectomy.

Although advances in vitreoretinal surgical techniques and technology have helped to minimize the risks associated with surgical manipulation of the retina, retinal pigment epithelium, and optic nerve, unanticipated or unexplained visual loss still occurs. We review causes of vision loss encountered after pars plana vitrectomy, including retinal toxicities, vascular events, and optic neuropathies, and we suggest strategies to limit or prevent them.

Vitrectomy without laser treatment or gas tamponade for macular detachment associated with an optic disc pit.

PURPOSE: To evaluate the clinical outcomes after vitrectomy, without gas tamponade or laser photocoagulation to the margin of the optic nerve, for the treatment of macular detachment associated with optic disc pits and to characterize retinal manifestations during treatment of optic pit maculopathy using optical coherence tomography (OCT). DESIGN: Noncomparative, retrospective, interventional case series. PARTICIPANTS: Eight consecutive patients (8 to 56 years of age) with unilateral macular detachment associated with optic disc pit. INTERVENTION: Pars plana vitrectomy with induction of a posterior vitreous detachment (PVD) was performed in all eyes. No laser or gas injection was performed in any eye during the original surgery. Patients were followed up for 10 to 46 months (mean, 26 months) after surgery. MAIN OUTCOME MEASURES: Anatomic outcome as determined by OCT and postoperative visual acuities were the main outcome parameters. Fundus autofluorescence (FAF) images were obtained in 4 eyes to document anatomic changes in the macula. RESULTS: Although complete retinal reattachment was achieved in 7 of 8 eyes, up to about 1 year was necessary for the retinal detachment to resolve fully. The 1 eye in which macular detachment failed to resolve completely underwent revision of vitrectomy with a gas tamponade and laser photocoagulation in the peripapillary area. In the early postoperative period, despite persistent macular detachment, the visual acuities improved in 7 eyes. These improved acuities corresponded with remodeling of the photoreceptor outer segments on OCT and the appearance of granular hyperfluorescence on FAF imaging. CONCLUSIONS: Vitrectomy with induction of a PVD at the optic disc without gas tamponade or laser photocoagulation seems to be an effective method of managing macular detachment resulting from optic disc pits. The OCT scanning before and after surgery suggests that peripapillary vitreous traction with the passage of fluid into the retina through the pit is the cause of the schisis-like separation seen in optic disc pit maculopathy.

Dislocation of the donor graft to the posterior segment in descemet stripping automated endothelial keratoplasty.

PURPOSE: To report a series of dislocations of the donor graft into the posterior segment associated with Descemet stripping endothelial keratoplasty (DSAEK) and to identify possible risk factors for dislocation and clinical outcomes. DESIGN: Retrospective case series. METHODS: Cases of donor graft dislocation into the posterior segment associated with endothelial keratoplasty were identified from the clinical experience of 7 surgeons. Observations included the preoperative surgical history of each eye, preoperative and postoperative visual acuity, management of the complication, and the postoperative clinical course. No identified cases were excluded from this series. RESULTS: Eight posterior graft dislocations were associated with DSAEK surgery. Each eye had a history of vitrectomy. Five eyes had sutured posterior chamber intraocular lenses, 1 eye had a sulcus intraocular lens, and 2 eyes were aphakic. Each eye required repeat grafting, and in 6 of 8 eyes, pars plana vitrectomy was used to remove the dislocated graft. Final visual acuities ranged from 20/30 to no light perception. CONCLUSIONS: Graft dislocation into the posterior segment is a rare complication of DSAEK surgery that can lead to permanent vision loss. It has occurred in eyes that have undergone previous vitrectomy and complicated intraocular lens placement or were aphakic. As is the case with a dropped lens nucleus during cataract extraction, visual acuities after a dropped DSAEK graft range from very good to no light perception. Better postoperative results seem to be associated with prompt removal of the posteriorly dislocated graft.

Intravitreal triamcinolone acetonide in the treatment of macular retinal detachment associated with morning glory anomaly.

PURPOSE: To report the successful treatment of a case of recurrent macular retinal detachment associated with morning glory anomaly using intravitreal triamcinolone acetonide. METHODS: A 53-year-old man with a history of bilateral morning glory anomaly and recurrent macular detachment of the left eye refractory to multiple surgical interventions, including 3 vitrectomies with endolaser photocoagulation, gas tamponade, and fibrin glue, underwent an intravitreal injection of 4 mg triamcinolone acetonide. RESULTS: A single treatment with intravitreal triamcinolone acetonide resulted in resolution of a macular retinal detachment and intraretinal fluid within 2 weeks. CONCLUSION: Treatment with intravitreal triamcinolone acetonide may be beneficial in cases of macular retinal detachment associated with morning glory anomaly.

Natural history of foveolar lucencies observed by optical coherence tomography after macular hole surgery.

PURPOSE: To describe the incidence, course, and anatomic and functional outcomes of foveolar lucencies observed by optical coherence tomography after macular hole surgery. METHODS: Retrospective chart review of all idiopathic macular hole surgeries performed between February 2002 and August 2003. Available data involving eyes with foveolar lucencies after macular hole surgery were collected regarding best-corrected visual acuity, lens status, slit-lamp biomicroscopy, and optical coherence tomography before and at follow-up visits ranging from 1 week to 27 months after macular hole surgery. RESULTS: Thirty-five eyes of 35 patients were identified. Foveolar lucencies were detected by optical coherence tomography in 9 of the 35 eyes (26%). Operative procedures included creation of a posterior vitreous detachment in 8 eyes and indocyanine green-assisted internal limiting membrane peeling in 5 eyes. Intraocular tamponade consisted of 30% sulfur hexafluoride gas in 6 eyes and 20% perfluoropropane gas in 3 eyes with at least 1 week of face-down positioning. Postoperative visual acuity showed gradual improvement coinciding with decreasing size and eventual disappearance (3 to 11 months) of the foveolar lucency. CONCLUSION: Foveolar lucencies observed by optical coherence tomography are a common finding after macular hole surgery (26%). They occur with and without indocyanine green-assisted internal limiting membrane peeling. Earlier disappearance of the foveolar lucency does not correlate with the type of gas used for tamponade. They gradually decrease and eventually resolve with time without additional surgical intervention and with further improvement of visual acuity.

A prospective, open-label, dose-escalating study of low molecular weight heparin during repeat vitrectomy for PVR and severe diabetic retinopathy.

BACKGROUND: To determine the maximum tolerated dose (MTD) of enoxaparin, a low molecular weight heparin (LMWH) was used during repeat vitrectomy for rhegmatogenous retinal detachment with proliferative vitreoretinopathy (PVR) and severe diabetic retinopathy. METHODS: From 25 patients, 29 eyes undergoing repeat vitrectomy for PVR (CP3 or greater) or severe diabetic retinopathy were included in the study. Patients had previously undergone an average of 2.1 previous vitrectomies (range 1-5). Enoxaparin was added to the infusion fluid in an escalating dose from 0.1 IU/ml to 6.0 IU/ml as tolerated. Intraoperative bleeding, postoperative fibrin, hyphema and vitreous hemorrhage were graded in an unmasked fashion using previously described grading scales. RESULTS: All patients completed the study, and the study was able to achieve the 6.0 IU/ml maximum dose on the dose escalation schedule. No patient experienced dose-limiting toxicity. Analysis showed no increase in intraoperative bleeding complications between low dose (1.0 IU/ml) enoxaparin (Mann-Whitney Test, P=0.029). CONCLUSIONS: Enoxaparin dose escalation did not result in a dose-dependent increase in acute side effects. The establishment of a well-tolerated dose of enoxaparin during repeat vitrectomy for PVR and severe diabetic retinopathy (6.0 IU/ml) provides a foundation for future studies.

Radial optic neurotomy in the porcine eye without retinal vein occlusion.

OBJECTIVE: To demonstrate the histopathologic changes in the porcine eye without retinal vein occlusion after radial optic neurotomy (RON). METHODS: A RON was performed in 14 normal eyes of 12 Yorkshire Cross pigs. One radial stab incision at the edge of the nasal optic nerve head was made using a 20-gauge microvitreoretinal blade (Visitec) while the intraocular pressure was elevated. Surgery was concluded when hemostasis was achieved. Weekly ophthalmoscopic examinations were performed. Group 1 eyes (4 eyes of 2 pigs) were enucleated at the end of surgery. Group 2 eyes (4 eyes of 4 pigs) were enucleated 1 week postoperatively, and group 3 eyes (4 eyes of 4 pigs) were enucleated 3 weeks postoperatively. In group 4 (2 eyes of 2 pigs), animals underwent vitrectomy and RON, and eyes were enucleated 3 weeks postoperatively. RESULTS: Ophthalmoscopic examination demonstrated engorged blood vessels at the RON site up to 3 weeks after surgery with minimal or no hemorrhage. Histological examination of the optic nerve demonstrated foci of hemorrhage, interstitial edema, reactive gliosis, and rare inflammatory cells. At 3 weeks, there was complete axonal nerve fiber loss distal to the neurotomy site. CONCLUSIONS: After RON, marked gliosis and complete axonal nerve fiber loss occur at the neurotomy site. Although bleeding was rare intraoperatively in this porcine model, hemorrhage and interstitial edema were present within the optic nerve at the neurotomy site histologically. Clinical Relevance Radial optic neurotomy remains a controversial method of treatment for central retinal vein occlusion. To our knowledge, this is the first study in the literature describing the histopathologic findings after RON.

Effects of indocyanine green on the retina and retinal pigment epithelium in a porcine model of retinal hole.

PURPOSE: This study was designed to emulate human macular hole surgery and to test the effects of indocyanine green (ICG) on the retina and retinal pigment epithelium (RPE). METHODS: Yorkshire Cross pigs (n = 23) underwent vitrectomy, separation of the posterior cortical vitreous, and creation of a single retinal hole. In three study groups (n = 6, each group), air-fluid exchange was performed, following which balanced salt solution (BSS), 1.0% ICG, or 0.5% ICG was applied over the retinal hole. In one additional group (n = 5), 0.5% ICG was injected into the fluid-filled eye. At 4 weeks, the eyes were examined clinically, and fundus photographs were obtained before enucleation and light microscopic examination. RESULTS: Clinical evaluations documented a statistically significant difference between study groups (P = 0.036). There was a higher rate of moderate or severe RPE atrophy among animals where 1% or 0.5% ICG was applied in air-filled eyes (83% and 67%, respectively) compared with BSS controls (17%) and fluid-filled eyes receiving 0.5% ICG (40%). Histologic evaluation demonstrated a statistically significant difference between groups (P = 0.044), with extensive outer retinal degeneration observed in air-filled eyes receiving 1% or 0.5% ICG (66% and 60%, respectively) compared with BSS controls or fluid-filled eyes receiving 0.5% ICG (none of the eyes in either group). None of the study groups had any changes in the inner retina except at the retinal hole site. CONCLUSIONS: Retina exposed to ICG concentrations used in human vitreoretinal surgery had greater RPE atrophy and outer retinal degeneration than control eyes undergoing the same surgery without ICG. Eyes filled with infusion fluid during ICG injection had less damage to the RPE and outer retina than did air-filled eyes receiving ICG.

Comparison of silicone oil versus gas tamponade in the treatment of idiopathic full-thickness macular hole.

PURPOSE: To compare anatomic and functional outcomes of macular hole surgery with either silicone oil or C(3)F(8) gas tamponade. DESIGN: Retrospective comparative interventional study. PARTICIPANTS: Fifty-four eyes of 51 patients underwent pars plana vitrectomy for macular holes. Thirty-one eyes were treated with silicone oil tamponade, and 23 eyes were treated with C(3)F(8) tamponade. METHODS: Demographics, preoperative and postoperative characteristics, and complications were analyzed. MAIN OUTCOME MEASURES: Preoperative and postoperative visual acuity, initial hole closure, number of persistent or recurrent holes, number of reoperations, and final hole closure. RESULTS: The silicone oil and gas tamponade groups were demographically similar. The rate of hole closure after one operation with oil tamponade was significantly lower than that with gas tamponade (65% vs. 91%; P = 0.022). The percentage of patients undergoing a second operation was significantly higher in the oil group (35% vs. 4%; P = 0.006). However, with reoperations, the final rate of hole closure was similar between the oil and gas groups (90% vs. 96%; P = 0.628). The final median visual acuity for the gas group was significantly better than for the oil group (20/50 vs. 20/70; P = 0.047). CONCLUSIONS: C(3)F(8) gas proved to be a more effective tamponade than silicone oil with respect to achieving initial closure of macular holes. Eyes receiving an oil tamponade required significantly more reoperations to achieve a similar rate of hole closure compared with eyes undergoing a gas tamponade. Final visual acuity was better for gas-operated eyes than for silicone-operated eyes.

Lensectomy and vitrectomy decrease the rate of photoreceptor loss in rhodopsin P347L transgenic pigs.

BACKGROUND: Photoreceptor degeneration in retinitis pigmentosa (RP) runs an inevitable, gradually progressive course. A wide variety of growth factors of different origins have been shown to slow the rate of degeneration in some rodent models of RP. Recently, lens-derived neurotrophic factors have been shown to rescue degenerating ganglion cells in crush models of the optic nerve. Our objective was to evaluate the potential rescue effect of lensectomy and vitrectomy (L&V) on photoreceptor degeneration in a large-animal model, the rhodopsin P347L transgenic pig. METHODS: We operated on one eye of each of 49 3-week-old pigs--15 vitrectomies and 34 L&V, 6 of which received steroids. Retinal paraffin sections were prepared for all eyes, in addition to immunohistochemistry in four eyes, 8 weeks after L&V. RESULTS: At eight weeks after L&V, operated eyes showed significantly more nuclei in the outer nuclear layer (ONL) than the unoperated fellow eyes. The better preservation of the ONL persisted but was less prominent by 20 weeks after surgery. Steroid treatment did not markedly reduce the better preservation of the ONL seen at 8, 10, and 12 weeks after surgery. The significant difference in cell count between operated and unoperated eyes in the L&V group at 8 weeks was due to the difference in the number of rods, not the cones. CONCLUSION: Lensectomy and vitrectomy delay photoreceptor degeneration in rhodopsin P347L transgenic pigs. Lens-related rescue effect is a probable reason for the delayed degeneration.

RGD peptide-assisted vitrectomy to facilitate induction of a posterior vitreous detachment: a new principle in pharmacological vitreolysis.

PURPOSE: To evaluate a new concept in pharmacological vitreolysis by studying the efficacy of intravitreal RGD peptide-assisted vitrectomy in facilitating the separation of the posterior cortical vitreous from the retinal surface in an animal model. METHODS: Eight rabbits (16 eyes) received an intravitreal injection of 1 or 5 mg of RGD peptide in one eye and either RGE peptide (inactive control) or phosphate buffered saline in the fellow eye. After 24 hours, a pars plana vitrectomy with low aspiration (< or =30 mmHg) was performed in an attempt to create a detachment of the posterior cortical vitreous. A masked observer performed pre- and postoperative indirect ophthalmoscopy and B-scan ultrasonography. Postoperative scanning electron microscopy evaluated the vitreoretinal surface in selected eyes. Two additional rabbits received intravitreal injections of RGD peptide in one eye (1 mg and 5 mg) and 1 mg of RGE peptide in the fellow eye to examine apoptosis of the retinal cells by TUNEL assay. RESULTS: Based on postoperative ultrasound findings, six of the eight rabbits had a greater degree of posterior vitreous detachment in the RGD eye compared to the fellow eye (p = 0.03). The total number and the average number of detached quadrants in the group of RGD peptide eyes was twenty-three and 2.85 respectively compared to seven and 0.85 for the control fellow eyes (p = 0.02). Scanning electron microscopy confirmed the presence of postoperative posterior vitreous detachment. There was no evidence of retinal cell apoptosis in RGD injected eyes. CONCLUSION: RGD peptide-assisted vitrectomy facilitated posterior vitreous detachment in rabbit eyes, suggesting that RGD-containing peptides may prove to be effective adjuncts in producing posterior vitreous separation during vitreous surgery.