Pars plana vitrectomy and removal of the internal limiting membrane in diabetic macular edema unresponsive to grid laser photocoagulation.

PURPOSE: To evaluate the effectiveness of pars plana vitrectomy (PPV) with removal of the internal limiting membrane (ILM) in diabetic patients with macular edema unresponsive to grid laser photocoagulation. METHODS: In this randomized controlled study, 20 eyes of 10 patients with diabetic macular edema unresponsive to grid laser photocoagulation were evaluated. PPV with ILM removal was performed randomly in one eye each of 10 patients and taken as the study group; the untreated fellow eyes were taken as the control group. Main outcome measures were foveal thickness changes measured with optical coherence tomography and preoperative and post-operative visual acuity. Mann-Whitney U, Wilcoxon, and chi-square tests were used in statistical analysis. RESULTS: The mean age of the patients was 61.5+/-6 years (range 51 to 71). All patients were followed up for 12 months. In the study group, mean foveal thickness was 391.3+/-91.6 microm preoperatively and 225.5+/-49.4 microm postoperatively (p=0.009). In the control group, mean foveal thickness was 356.2+/-140 microm at baseline and 318.4+/-111.1 microm at 12-month follow-up (p=0.138). Mean decrease in foveal thickness was 165.8+/-114.8 microm in the study group and 37.8+/-71.2 microm in the control group (p=0.016). In the study group, best-corrected log-MAR visual acuity was 0.71+/-0.43 preoperatively and 0.54+/-0.45 postoperatively (p=0.125). In the control group, best-corrected logMAR visual acuity was 0.43+/-0.44 at baseline and 0.59+/-0.55 at 12-month follow-up (p=0.235). In the study group, visual acuity improved by two or more lines in 4 eyes (40%) and remained stable in 6 eyes (60%). In the control group, visual acuity improved by two or more lines in 1 eye (10%) and decreased by two or more lines in 3 eyes (30%). CONCLUSIONS: PPV with ILM removal appears to be an effective procedure for reducing diabetic macular edema unresponsive to grid laser photocoagulation. A further study with a large number of patients is required to assess the effectiveness and safety of this procedure.

25-Gauge transconjunctival sutureless pars plana vitrectomy.

PURPOSE: To evaluate the effectiveness, feasibility, and safety of the transconjunctival sutureless vitrectomy (TSV) system for a vriety of vitreoretinal diseases. METHODS: In this retrospective study, the authors evaluated 71 eyes of 63 patients who underwent pars plana vitrectomy (PPV) with the 25-gauge TSV system. The indications for surgical intervention were diabetic vitreous hemorrhage (29 eyes), diabetic macular edema (14 eyes), macular epiretinal membrane (13 eyes), endophthalmitis (5 eyes), vitreous opacities secondary to Behcet's disease (4 eyes), vitreous hemorrhage secondary to branch retinal vein occlusion (4 eyes), and vitreous hemorrhage secondary to age-related macular degeneration (2 eyes). Epiretinal membrane and internal limiting membrane removal, endolaser photocoagulation, and air-fluid exchange were performed when required. RESULTS: Mean follow-up was 3.6 months (range 1-8 months). Mean overall visual acuity (VA) was counting fingers (range light perception to 0.4) preoperatively and 0.2 (range 0.1 to 0.8) postoperatively (p=0.000). Statistically significant VA improvement was observed in eyes with vitreous hemorrhage, diabetic macular edema, and macular epiretinal membrane. VA improved postoperatively in all eyes with endophthalmitis and vitreous opacities secondary to Behcet's disease. The surgery was completed without conjunctival and scleral suturing in all eyes. Mean intraocular pressure (IOP) was 17.2 mmHg (range 10-26 mmHg) preoperatively, 12.4 mmHg (range 6-24 mmHg) on the first postoperative day, 16.6 mmHg (range 10-33 mmHg) at 1 week, and 15.4 mmHg (range 10-20 mmHg) at 1 month postoperatively. On the first postoperative day, IOP was below 10 mmHg (between 6 and 9 mmHg) in 12 eyes (16.9%). In these eyes, IOP was normalized within 1 week without affecting the visual outcome. Five eyes (7%) had transient increase of IOP controlled by topical antiglaucomatous medications. Vitreous washout using 25-gauge TSV system was performed in two eyes, in which vitreous hemorrhage recurred. CONCLUSIONS: The TSV system was observed to be feasible, effective, and safe for a variety of vitre o retinal diseases. This minimally invasive and completely sutureless (transconjunctival) technique appears to decrease the convalescence period, operating time, and postoperative inflammatory response, and improve patient comfort.

Effect of sulfur hexafluoride gas on antibacterial activity of antibiotics in vitro against agents causing endophthalmitis.

BACKGROUND: We conducted a study to evaluate the effect of sulfur hexafluoride gas (SF(6)) on the antibacterial activity of antibiotics in vitro against Staphylococcus aureus, Staphylococcus epidermidis and Pseudomonas aeruginosa, which are common endophthalmitis-causing agents. METHODS: In this experimental study, antibiotic susceptibility tests were prepared according to the National Committee for Clinical Laboratory Standards macrobroth dilution method. Müller-Hinton broth was the test medium. Standard P. aeruginosa (ATCC 27853), S. epidermidis (ATCC 12228) and S. aureus (ATCC 29213) strains were studied. For P. aeruginosa ceftazidime, ofloxacin and tobramycin dilutions, and for S. epidermidis and S. aureus, cefazolin, ofloxacin and tobramycin dilutions were prepared identically in two sets of tubes. One set of tubes, into which pure SF(6) was injected, was defined as the SF(6) group. The other set of tubes, into which no SF(6) was injected, was taken as the control group. To determine the minimal bactericidal concentrations of the antibiotics, subcultures were made onto Müller-Hinton agar, and the colonies were counted after 18 h of incubation at 37 degrees C. RESULTS: The minimal inhibitory concentrations of the antibiotics in the SF(6) group were found to be identical with those of the control group. However, the minimal bactericidal concentrations of the antibiotics were found to be at least two dilutions lower in the SF(6) group than in the control group, except for the minimal bactericidal concentration of cefazolin for S. aureus, which was found to be one dilution lower in the SF(6) group. CONCLUSION: SF(6) was found to potentiate the in vitro antibacterial activity of ofloxacin and tobramycin against S. aureus, S. epidermidis and P. aeruginosa, ceftazidime against P. aeruginosa, and cefazolin against S. epidermidis. Experimental animal studies are required to determine the role of SF(6) in the management of endophthalmitis.

A comparative study of the effectiveness of disinsertion and anterior transposition of the inferior oblique in the treatment of unilateral superior oblique palsy.

PURPOSE: To compare the effectiveness of disinsertion of the inferior oblique muscle (DIO) with anterior transposition of the inferior oblique muscle (ATIO) in the treatment of vertical deviations resulting from superior oblique palsy. METHODS: In this prospective randomized study, 22 patients with unilateral superior oblique palsy were evaluated. Eleven patients underwent the DIO procedure (DIO group), and the other eleven underwent the ATIO procedure (ATIO group). Statistics were analyzed using the Wilcoxon and Mann-Whitney U tests. RESULTS: The mean preoperative primary-position hypertropia was 22.2 +/- 6.2 prism diopters (Delta) in the DIO group and 23.1 +/- 6.6 Delta in the ATIO group; the mean preoperative hypertropia in adduction was 31.7 +/- 6.9 Delta in the DIO group and 31.8 +/- 8.1 Delta in the ATIO group. The mean follow-up was 18.8 months (SD: 10.2, range: 6-40 months). The mean reduction of hypertropia in primary-position in the ATIO group (mean: 18.5 +/- 3.9 Delta) was found to be significantly greater than in the DIO group (mean: 13.3 +/- 1.9 Delta) (p = 0.001). Even though the mean reduction of hypertropia in adduction in the ATIO group (mean: 27.7 +/- 9.6 Delta) was greater than in the DIO group (mean: 20.6 +/- 6.2 Delta), no statistically significant difference was found (p = 0.067). There was residual hypertropia in three (27.3%) patients who underwent the DIO procedure. No major postoperative complication was encountered in any of the patients. CONCLUSION: In vertical deviations resulting from superior oblique palsy, ATIO was found to be more effective than DIO in the reduction of primary-position hypertropia.

Tamoxifen retinopathy in a male patient.

PURPOSE: To report a case of tamoxifen retinopathy in a male patient. METHODS: Case report. A 68-year-old man, who had received a cumulative tamoxifen dose of 60 g over 33 months for unresectable hepatocellular carcinoma, was evaluated. RESULTS: A peculiar, bilateral, symmetric, inner retinal crystalline deposition associated with mild macular edema was discovered. No other ocular toxicity of tamoxifen was observed. CONCLUSION: To our knowledge, this is the first report of tamoxifen retinopathy in a male.

A case of traumatic globe luxation.

We observed a case of traumatic globe luxation. A 26-year-old man who was sitting at the back seat of the car without fastening his safety belt was admitted to the emergency room after an automobile accident. He was in semi-comatose condition. His left globe was dislocated anteriorly, and the lids were tightly closed behind it. No laceration was observed in cornea, sclera and extraocular muscles. The pupil was dilated and did not respond to light stimulation. Computerized tomography scan analysis revealed a normal optic nerve, but multiple fractures in the nasal, inferior and temporal walls of the orbit and in the nasal bone. Phthisis of the eye was detected by the end of second month. We believe that the back seats of automobiles should also be furnished with air bags for better security of passengers.

Intraoperative mitomycin C in the treatment of pterygium.

PURPOSE: To evaluate the effectiveness of intraoperative mitomycin C in preventing the recurrence of primary pterygium. METHODS: In this prospective, randomized study, 38 eyes of 35 patients with primary pterygium were evaluated. In 19 eyes, the "bare sclera technique" combined with intraoperative application of 0.2 mg/mL (0.02%) mitomycin C for five minutes was performed (mitomycin C treated group). The other 19 eyes--taken as control group--underwent surgical excision alone. Statistics were analyzed using the Mann-Whitney U test and the Fischer's exact test. RESULTS: Patients were 20-38 years of age. The mean age was 25.29 +/- 5.08 in the mitomycin C treated group and 25.00 +/- 5.19 in the control group. During the mean follow-up of 17.04 months (range, 12-36 months; SD = 5.89), 4 recurrences (21%) were observed in the mitomycin C treated group and 11 (57.8%) in the control group. The difference between the two groups was significant (p = 0.045). No postoperative complication was encountered in both groups except for recurrences. CONCLUSION: Intraoperative mitomycin C was found to be effective in preventing the recurrence of primary pterygium.

The effect of povidone iodine on the corneal endothelium.

PURPOSE: Povidone iodine has been proven to be a valuable antiseptic solution in preparing the eye for surgery and is an alternative to postoperative topical antibiotics. No study has addressed the intraocular toxicity of povidone iodine after injection into the anterior chamber. We investigated the potential toxicity of povidone iodine on the corneal endothelium after injections into the anterior chamber in a rabbit model. METHODS: In this study we used 24 eyes of 12 albino rabbits. The eyes were divided into the following three groups according to the drugs tested: group A, 5% povidone iodine; group B, 10% povidone iodine; group C, balanced salt solution. The injected eyes were evaluated by biomicroscopy, specular microscopy, corneal pachymetry, and transmission and scanning electron microscopy. RESULTS: Corneal edema was observed in all eyes of groups A and B. In groups A and C, the endothelial cell morphology was not significantly changed and the mean endothelial cell count of the eyes did not change significantly (p = 0.5054). There was no significant difference in corneal thickness between groups A and C (p = 0.3823), but there was a significant difference between groups B and C ( = 0.0002). Transmission and scanning electron microscopy results were normal in group C but not in groups A and B. CONCLUSION: Povidone iodine in both 5% and 10% concentrations demonstrates severe toxicity when one drop of either concentration is placed directly in the anterior chamber. When povidone iodine is used in preparing the eye for intraocular surgery and as an alternative to postoperative antibiotics, the inadvertent leakage of povidone iodine into the anterior chamber must definitely be prevented.

Photorefractive keratectomy for hyperopia and aphakia with a scanning spot excimer laser.

OBJECTIVE: To study the safety, efficacy, predictability, and stability of photorefractive keratectomy (PRK) for hyperopia and aphakia. METHODS: Fifteen eyes of 15 patients (mean age, 33 +/- 5.95 yrs) were enrolled in the study and divided into three groups. The first group was comprised of six eyes that had hyperopia ranging from +1.75 to +4.75 D; the second group had seven hyperopic eyes ranging from +5.00 to +9.75 D; the third group included two eyes of two aphakic patients. All eyes had PRK with a 193 nm argon fluoride excimer laser (Chiron-Technolas, Keracor 116) with a 10 Hz repetition rate and a fluence of 120 mJ/cm2. The total follow-up time in all eyes was 12 months. RESULTS: In the lower hyperopia group, 0% eyes were within +/- 0.50 D and 66% (N = 4) of eyes were within +/- 1.00 D of emmetropia with the other two eyes between +1.00 and +2.00 D at 1 year after PRK. In the higher hyperopia group, all eyes had at least +3.00 D of hyperopia at 1 year. In the aphakic group, both eyes achieved less than 50% of the target correction of +10.00 D at 1 year. Final uncorrected visual acuity ranged from 20/20 to 20/30 in the lower hyperopia group, 20/30 to 20/50 in the higher hyperopia group, and count fingers in the aphakic group. CONCLUSIONS: PRK is a relatively safe, stable, and effective procedure with reasonably good predictability for eyes with less than +5.00 D of baseline hyperopia, and poor predictability for eyes with more than +5.00 D of baseline hyperopia. PRK is ineffective in the correction of aphakia.

[Risk factors of postoperative proliferative vitreoretinopathy in giant tears]. / Facteurs de risque de PVR sévère postopératoire dans les déchirures géantes.

BACKGROUND: In eyes with giant retinal tears, the rate of severe postoperative PVR and failure to permanently reattach the retina remains especially high in spite of technical advances in surgical management. This study was conducted to elucidate the clinical and surgical risk factors for severe postoperative PVR in such eyes. PATIENTS AND METHODS: We reviewed the records of 68 consecutive patients (69 eyes) with giant retinal tears. Univariate and multivariate statistical analyses were used to evaluate the risk factors for severe PVR. RESULTS: The rate of severe postoperative and failure to permanently reattach the retina were 43.5% (30/69 eyes). It was influenced at a statistically significant level by two independent risk factors: 1) the presence and severity of preoperative PVR and 2) the use of cryotreatment as compared to the use of ALP treatment. Severe postoperative PVR occurred in 63.6% (14/22 eyes) of eyes managed with cryotreatment versus 31.1% (14/45 eyes) of eyes managed with ALP treatment (P < 0.02). The rate of severe postoperative PVR was 64% (16/25 eyes) in eyes with grade C-D PVR preoperatively versus 31.8% (14/44 eyes) in eyes with no PVR or grade B PVR preoperatively (P < 0.01). In eyes managed with the use of ALP treatment the rate of severe postoperative PVR remained influenced at a statistically significant level (P < 0.005) by the presence of grade C-D PVR preoperatively. Grade C-D PVR was significantly more frequent preoperatively in patients with visual symptoms of 3 week-duration or more at initial examination (23/24 patients, 95.8%), than in those with visul symptoms under 3 week-duration (8/41 patients, 19.5%) (P: 0.0005). CONCLUSION: The results suggest that the high incidence of severe postoperative PVR in giant retinal tears may be decreased by 1) early management before the occurrence of PVR and 2) the use of argon laser photocoagulation rather than cryotreatment as the method of creating a chorioretinal scar.

[Treatment of macular detachment complicating optic disk coloboma pits. Long-term results of the photocoagulation-gas combination]. / Traitement du décollement maculaire compliquant une fossette colobomateuse de la papille. Résultats à long terme de l'association photocoagulation-gaz.

We managed 19 eyes of 19 patients with serous macular detachment associated with optic nerve pits with photocoagulation of the temporal edge of the optic disc combined with intravitreal injection of an expanding gas. SF6 was used in 8 eyes, and C3F8 in 11 eyes at the initial treatment. Eight eyes (42%) had repeated treatment because of failed initial treatment and/or late recurrence(s). Eighteen patients were followed up for 4 to 110 months (mean follow-up: 39 months). At the last examination the macula was attached in 17 of 18 eyes (94.4%). However 3 patients (17.6%) showed a limited serous retinal detachment distant from the macula. The results achieved after single treatment were better with C3F8 than with SF6 (78.5% versus 57% anatomical success rate). During the follow-up period, 5 eyes (27.7%) developed one or two late recurrences. Macular reattachment occurred spontaneously in 2 eyes and after repeated C3F8 injection in 3 eyes. The final visual acuity was improved by 0.1 to 0.6 as compared to the initial visual acuity in 12 patients (66.6%). Ten patients (55.5%) had a final visual acuity > or = 0.5 and > or = Parinaud scale no. 2. We believe that photocoagulation treatment combined with C3F8 intravitreal injection is a valuable approach to the management of serous macular detachment associated with optic nerve pits. However the treatment also shows limitations, in particular the need for repeated treatment in failed eyes and/or eyes with late recurrences.