Influence of Surgical Procedures and Instruments on the Incidence of Suprachoroidal Hemorrhage during 25-gauge Pars Plana Vitrectomy.

PURPOSE: To evaluate the influence of surgical procedures and instruments that are associated with intraocular pressure (IOP) fluctuations on the incidence of suprachoroidal hemorrhage (SCH) during 25-gauge pars plana vitrectomy (25G-PPV), and to investigate the clinical features of SCH during 25G-PPV. DESIGN: Retrospective, comparative case series. PARTICIPANTS: A total of 3034 cases that underwent initial 25G-PPV at a single surgical center. METHODS: Univariate analysis was performed to evaluate the relationships between the incidence of SCH during 25G-PPV and the surgical procedures and instruments that were associated with IOP fluctuations. The participants were divided into 4 groups that underwent the following procedures: neither fluid-air exchange nor vitreous shaving under scleral depression (group 1, n = 1144); fluid-air exchange alone (group 2, n = 463); vitreous shaving under scleral depression alone (group 3, n = 639); and both procedures (group 4, n = 788). The incidence of SCH in each group was compared. The clinical features and surgical outcomes of SCH during 25G-PPV were also investigated. MAIN OUTCOME MEASURES: The incidence of SCH during 25G-PPV and the clinical features and surgical outcomes of SCH during 25G-PPV. RESULTS: The incidence of SCH was significantly higher in cases that underwent fluid-air exchange (P = 0.0047) or vitreous shaving under scleral depression (P = 0.0157). There were no significant relationships between the incidence of SCH and the use of surgical instruments. The incidence of SCH in group 4 (8/788, 1.02%) was significantly higher than that in groups 1 (1/1144, 0.09%), 2 (0/463, 0%), and 3 (0/639, 0%) (P = 0.01). Almost all SCH cases were localized, and there were no cases of SCH involving the posterior pole. Of all the SCH cases, only one case required reoperation for retinal redetachment. No cases required secondary surgical management for SCH. CONCLUSIONS: There remains a slight risk of SCH during 25G-PPV in cases that require both fluid-air exchange and vitreous shaving under scleral depression. Even if SCH occurs during 25G-PPV, the surgical outcomes after SCH may not be substantially worse.

Retrospective comparisons of vitrectomy with and without air tamponade to repair lamellar macular hole.

BACKGROUND AND OBJECTIVE: To investigate the surgical outcomes of vitrectomy with to that without air tamponade in eyes with a lamellar macular hole. PATIENTS AND METHODS: The medical records of 23 eyes that underwent 25-gauge vitrectomy with air tamponade and 18 eyes that underwent 25-gauge vitrectomy alone were reviewed. RESULTS: The pre- and postoperative best corrected visual acuities (BCVAs) in logarithm of the minimum angle resolution units were 0.26 ± 0.27 and 0.12 ± 0.15 in eyes with tamponade and 0.35 ± 0.30 and 0.14 ± 0.23 in eyes without tamponade. There were no significant differences in BCVAs between the two groups both pre- and postoperatively. Postoperative BCVA was significantly improved in eyes with tamponade (P = .023) and without tamponade (P < .001). None of the cases developed a full-thickness macular hole postoperatively. CONCLUSION: These results suggest that air tamponade may not be required during vitrectomy to achieve good BCVA and anatomic closure in eyes with a lamellar macular hole.

Retrospective comparison of 25-gauge vitrectomy for repair of proliferative vitreoretinopathy with or without anterior proliferation.

PURPOSE: The purpose of the study was to compare the outcomes of 25-gauge vitrectomy for the repair of rhegmatogenous retinal detachment (RRD) complicated by proliferative vitreoretinopathy (PVR) with and without anterior PVR (A-PVR). METHODS: We reviewed the medical records of 26 eyes of 26 patients who underwent 25-gauge vitrectomy for grade C PVR with A-PVR and 16 eyes of 16 patients who underwent the same procedure for grade C PVR without A-PVR. RESULTS: The number of previous surgeries for RRD was significantly higher in A-PVR cases than in those without A-PVR (P = 0.021). Scleral buckling and retinotomy/retinectomy were performed significantly more frequently in A-PVR eyes than in those without A-PVR (P = 0.017 and <0.001, respectively). The A-PVR eyes required longer surgical times than those without A-PVR (P =0.001). Final anatomical success was achieved in 24 of 26 (92.3 %) eyes with A-PVR and 16 of 16 (100 %) eyes without A-PVR (P =0.517). Best-corrected visual acuity before and six months after vitrectomy was 1.41 ± 0.96 and 0.86 ± 0.78 logarithm of minimal angle of resolution (logMAR) units, respectively, in eyes with A-PVR and 1.17 ± 0.87 and 0.63 ± 0.72 logMAR units, respectively, in eyes without A-PVR (P =0.355 and 0.276, respectively). CONCLUSIONS: These results indicate that 25-gauge vitrectomy can be used for both types of PVR, although eyes with A-PVR may require scleral buckling and retinotomy/retinectomy more often and may require longer surgical times.

Anatomic and functional outcomes of 25-gauge vitrectomy for repair of eyes with rhegmatogenous retinal detachment complicated by proliferative vitreoretinopathy.

BACKGROUND: The purpose of this study was to evaluate the outcome of 25-gauge vitrectomy for repair of rhegmatogenous retinal detachment (RRD) complicated by proliferative vitreoretinopathy (PVR). METHODS: Twenty-seven eyes of 27 patients who had undergone 25-gauge vitrectomy for grade C PVR were investigated retrospectively. The surgical procedures, anatomic success, and best-corrected visual acuity were assessed. RESULTS: The mean number of operations was 1.4 (range 1-4). During the 25-gauge vitrectomy, 20-gauge instruments were needed in eleven eyes (40.7%) to remove resilient fibrous preretinal membranes, to extract subretinal proliferations, or to remove or infuse silicone oil. The retina was reattached in 21 eyes (77.8%) after the initial vitrectomy and in 25 eyes (92.6%) at the final examination. The mean best-corrected visual acuity in logarithm of the minimal angle of resolution units was 1.36 ± 0.81 before vitrectomy and 0.79 ± 0.71 at one month, 0.73 ± 0.72 at 3 months, 0.73 ± 0.75 at 6 months, and 0.75 ± 0.78 at 12 months after vitrectomy. The best-corrected visual acuities were significantly improved compared with the preoperative ones at all postoperative assessments (P<0.001). CONCLUSION: Twenty-five gauge vitrectomy is a relatively safe and efficacious method of treating RRD with PVR, although combined use of 20-gauge instruments may be needed for certain surgical procedures.

Hyperautofluorescent ring in eyes with macular holes.

BACKGROUND: Fundus autofluorescence studies in eyes with macular holes (MHs) have shown a hyperautofluorescent spot corresponding to the hole and a hypoautofluorescent ring corresponding to the fluid cuff surrounding the hole. The purpose of this report is to present three cases of MH with a different fundus autofluorescence pattern. CASE REPORTS: Case 1 was a 62-year-old woman who did not know the duration of the MH in her left eye. Her decimal best-corrected visual acuity (BCVA) was 0.08. The left eye had a one-half disc diameter MH with a depigmented ring surrounding the area of the fluid cuff. Fundus autofluorescence showed a hyperautofluorescent ring corresponding to the depigmented ring. After vitrectomy, fundus autofluorescence showed the same size hyperautofluorescent ring despite the decreased size of the opened MH. Case 2 was a 69-year-old woman who had been diagnosed with MH in the right eye 13 years earlier. Her decimal BCVA was 0.1. The right eye had a one-half disc diameter MH with a depigmented ring surrounding the area of the fluid cuff. Fundus autofluorescence showed a hyperautofluorescent ring corresponding to the depigmented ring. Postoperative fundus autofluorescence showed the same size hyperautofluorescent ring despite the hole being closed. The decimal BCVA was 0.2 in her right eye 6 months after vitrectomy. Case 3 was a 71-year-old woman who had been diagnosed with MH in the right eye 15 years earlier. Her decimal BCVA was 0.1. The right eye had a one-half disc diameter MH with a depigmented ring which corresponded with a hyperautofluorescent ring. Postoperative fundus autofluorescence showed the same size hyperautofluorescent ring despite the hole being closed. The decimal BCVA was 0.2 in her right eye 6 months after vitrectomy. CONCLUSION: Our findings suggest that a hyperautofluorescent ring in eyes with MHs may be an indicator of a poor surgical prognosis both anatomically and functionally.

Early vitreous hemorrhage after vitrectomy with preoperative intravitreal bevacizumab for proliferative diabetic retinopathy.

PURPOSE: To evaluate the effect of preoperative intravitreal bevacizumab (IVB) on surgical procedures, visual prognosis, and postoperative complications, especially postoperative vitreous hemorrhage, in cases with proliferative diabetic retinopathy (PDR). MATERIALS AND METHODS: Seventy-one eyes of 54 consecutive patients (23 eyes of 18 women, 48 eyes of 36 men) were investigated in this study. Twenty-five eyes received IVB one to 30 days before the vitrectomy (Bevacizumab Group) and the other 46 eyes had the vitrectomy alone (Control Group). The surgical procedures, best-corrected visual acuities at baseline, 1, 3, and 6 months after the vitrectomy, and postoperative complications in the Bevacizumab Group were compared to the Control Group. RESULTS: The patients were significantly younger in the Bevacizumab Group compared to the Control Group (P = 0.008). The incidence of preoperative vitreous hemorrhage, tractional retinal detachment, and iris neovascularization was significantly higher in the Bevacizumab Group than in the Control Group (P = 0.017, 0.041, and 0.018, respectively). The surgical procedures performed and the visual acuity at all time points was not significantly different between groups (P > 0.05, all comparisons). The incidence of early (≤ 4 weeks) postoperative vitreous hemorrhage was significantly higher in the Bevacizumab Group (27%) than in the Control Group (7%; P = 0.027) although the rate of late (>4 weeks) postoperative vitreous hemorrhage was not significantly different between groups (P > 0.05). CONCLUSION: Vitrectomy with preoperative IVB may have no detrimental effect on surgical procedures and achieves the surgical outcomes for repair of PDR equal to vitrectomy alone despite the obvious selection bias of the patients in this study. However, special monitoring is highly recommended for early postoperative vitreous hemorrhage because bevacizumab in the vitreous may be washed out during vitrectomy.

Faster recovery after 25-gauge microincision vitrectomy surgery than after 20-gauge vitrectomy in patients with proliferative diabetic retinopathy.

BACKGROUND AND METHODS: We compared surgical procedures and outcomes, including duration of recovery period, in eyes with proliferative diabetic retinopathy that underwent 25-gauge microincision vitrectomy surgery with those that underwent 20-gauge vitrectomy. Seventy-two eyes from 53 patients that underwent 20-gauge vitrectomy in 2006 and 87 eyes from 55 patients that underwent 25-gauge vitrectomy in 2010 were studied. The surgical procedures, ie, number of vitreous procedures, operating time, and ratio of type of intraocular tamponade were compared between the two groups. In addition, the outcomes, ie, postoperative complications, anatomical success, postoperative best-corrected visual acuity (BCVA), and duration of hospitalization as an indicator of the postoperative recovery period were also compared. RESULTS: There were no significant differences in surgical procedures or ratio of cases with postoperative complications between cases with 20-gauge and 25-gauge vitrectomy. The final anatomical success rate was 100% in the two groups. BCVA at 6 months after the final vitrectomy was significantly better than the preoperative BCVA for both types of vitrectomy (P < 0.05), and was not significantly different between the two groups. The average duration of hospitalization was 19.5 days after 20-gauge vitrectomy, which was significantly longer than the 11.0 days after 25-gauge vitrectomy (P < 0.001). CONCLUSION: These results indicate that the anatomical and functional improvements after 25-gauge microincision vitrectomy surgery are not significantly different from those after 20-gauge vitrectomy in eyes with proliferative diabetic retinopathy. However, the significantly shorter recovery period after 25-gauge microincision vitrectomy surgery suggests that it is less traumatic than 20-gauge vitrectomy.

25-gauge vitrectomy versus intravitreal bevacizumab for macular edema secondary to branch retinal vein occlusion: 1 year follow-up.

INTRODUCTION: This study aims to compare the long-term efficacy of 25-gauge vitrectomy to that of intravitreal bevacizumab (IVB) for the treatment of macular edema (ME) secondary to branch retinal vein occlusion (BRVO). MATERIALS AND METHODS: The medical records of 46 eyes of 46 consecutive patients were reviewed. Twenty-seven eyes underwent 25-gauge vitrectomy (VIT Group) and 19 eyes received 1.25 mg of IVB (IVB Group). The best-corrected visual acuities (BCVAs) in logarithm of minimum angle resolution units and central macular thicknesses (CMTs) were evaluated before and 3, 6, and 12 months after the initial treatment. RESULTS: There was no significant difference in the pre-treatment BCVA and CMT between the 2 groups. In the VIT Group, the preoperative BCVA was 0.59 and the CMT was 587.3 µm and the BCVA was 0.35 and the CMT was 286.6 µm, 12 months after the vitrectomy. Both values were significantly (P <0.05) better at 12 months than the preoperative values. In the IVB Group, the average number of IVB was 2.4 during the 1-year period. The BCVA was 0.69 and the CMT was 590.9 µm before the IVB, and the BCVA was 0.36 and the CMT was 360.1 µm, 12 months after the initial IVB. The improvements of these 2 parameters were significant (P <0.05) at 12 months after the initial IVB. The differences in the BCVA and CMT at 12 months between the 2 groups were not significant. CONCLUSION: These results suggest that the 25-gauge vitrectomy and IVB have similar effects in improving the BCVA and CMT in eyes with ME secondary to BRVO. However, IVB often required several injections to preserve the improvement.

[Long-term prognosis of 5 cases with stage 3A Coats disease after vitrectomy].

PURPOSE: The effectiveness of laser photocoagulation and/or cryopexy to the abnormal retinal vessels for the treatment of eyes with Coats disease is reported. However, in Coats cases with serous detachment laser photocoagulation and/or cryopexy is sometimes not enough to coagulate and consecutively scar the abnormal vessels, leading to persistent subretinal fluid and multiple courses of treatment. Therefore, we investigated the long-term prognosis of Stage 3A Coats cases with macular detachment which underwent vitrectomy. METHODS: Five eyes of 5 cases (all men) with Stage 3A Coats disease, which underwent primary vitrectomy between 1999 and 2009, were investigated retrospectively. The average age at vitrectomy was 13.8 years (range; 6-21 years) and the average preoperative visual acuity in decimal equivalent was 0.1 (range; 0.04-0.5). The average follow-up period after vitrectomy was 83 months (range; 13-137 months). In the vitrectomy, posterior vitreous detachment either occurred or was confirmed. An intentional retinal hole was made and the subretinal fluid was drained through the hole. The abnormal vessels were coagulated by endo-diathermy and/or laser photocoagulation. The vitreous fluid was replaced with long-lasting gas or air. The visual acuity and the findings from the ocular fundus both before and after the vitrectomy were investigated. RESULTS: The average best-corrected visual acuities in decimal equivalent before, 3 and 12 months after the vitrectomy, and at the final visit were 0.1, 0.2, 0.2, 0.4, respectively. There was a statistically significant (p = 0.007) difference between the 4 time points, and the visual acuities at 12 months after vitrectomy and the final visit were significantly (p < 0.05) better than before the vitrectomy. The macular part of the retina in all 5 cases was attached once the gas in the vitreous cavity had disappeared. The foveal exudation which was observed before the vitrectomy in all 5 cases was completely absorbed after the vitrectomy. The average period from the vitrectomy to the complete absorption of the exudation was 20 months. Subfoveal fibrosis was observed in 4 of the 5 eyes and chorioretinal atrophy occurred in 3. CONCLUSIONS: Vitrectomy for eyes with Stage 3A Coats disease may be effective for visual prognosis compared to conventional therapy, i.e., laser photocoagulation and cryopexy, by enabling retinal attachment in the early postoperative period and by causing the foveal exudation to disappear.

[Retrospective comparison of 25-gauge vitrectomy with 20-gauge vitrectomy in the repair of retinal detachment complicated with proliferative vitreoretinopathy].

PURPOSE: To compare the surgical outcomes of 25-gauge vitrectomy with that of 20-gauge vitrectomy for the repair of retinal detachment complicated with proliferative vitreoretinopathy (PVR). METHODS: Forty-one eyes of 40 patients (17 women, 23 men), who underwent vitrectomy for grade C PVR and had at least 6 months of follow-up period, were investigated retrospectively. The mean age of the patients was 44.6 years (range; 13-78 years). Twenty eyes underwent vitrectomy with a 25-gauge system (25 G Group, including 5 cases with hybrid surgery, i.e., vitrectomy conducted mostly with a 25-gauge and partially with 20-gauge instruments) and 21 eyes had vitrectomy with a 20-gauge system(20 G Group). The intraoperative technique used for vitreous surgery, the number of vitrectomy procedures, the length of the surgery, the surgical success rate, the best-corrected visual acuity (BCVA) and intraocular pressure (IOP) both before and after the vitrectomy were compared between the two groups. RESULTS: There was no significant difference in preoperative background between the two groups. The number patients with inner limiting membrane peeling was significantly higher in the 25 G Group than in the 20 G Group (p = 0.020). There were no significant differences in the number of vitrectomies, surgical time and the rate of retinal reattachment between the two groups (25 G Group; 95.0%, 20 G Group; 85.7%). The BCVAs 6 months after the surgery were significantly better than preoperative BCVAs in both 25 G (p < 0.001) and 20 G Group (p = 0.003). In the 25 G Group, the BCVA was significantly improved 1, 3, and 6 month(s) after the surgery compared to before surgery (p < 0.05), while, in the 20 G Group, the BCVA was significantly improved 3 and 6 months after the surgery (p < 0.05). In addition, the BCVA 6 months after the surgery was significantly (p = 0.010) better in the 25 G Group than in the 20 G Group. There was no significant difference in either the pre- or the postoperative IOP between the two groups, while the rate of the cases with hypotony of less than 5 mmHg was significantly higher (p = 0.048) in the 20 G Group than in the 25 G Group. CONCLUSIONS: These results suggest that, although vitrectomy only with 25-gauge system proved insufficient, 25-gauge vitrectomy may achieve the surgical outcomes for the repair of retinal detachment complicated with PVR equal to or higher than 20-gauge vitrectomy.

[Comparison of vitrectomy outcomes for eyes with proliferative vitreoretinopathy with and without prior vitrectomy].

PURPOSE: To compare the surgical outcomes of vitrectomy for eyes with proliferative vitreoretinopathy (PVR) with and without prior vitrectomy. METHODS: Eighty-two eyes of 81 patients (35 women and 46 men), who underwent vitrectomy for grade C PVR and had at least 6 months of follow-up, were studied retrospectively. The mean age of the cases was 50.8 years (range; 8-84 years). Twenty-eight eyes had undergone prior vitrectomy (vitrectomized group) and 54 eyes had no prior vitrectomy (primary vitrectomy group). The intraoperative technique of vitreous surgery, number of vitrectomy procedures, surgical success rate, visual acuity and intraocular pressure before and 6 months after the vitrectomy of the two groups were compared. RESULTS: The rate of the anterior (type 4 and 5) PVR cases was significantly higher in the vitrectomized group than in the primary vitrectomy group (p = 0.028), whereas the rate of the only subretinal cases (type 3) PVR was significantly higher in the primary vitrectomy group (p<0.001). There were no significant differences in the preoperative visual acuity and intraocular pressure between the two groups. The rate of the cases who underwent retinotomy/retinectomy was significantly higher (p< 0.001)in the vitrectomized group than in the primary vitrectomy group. The surgical success rate and postoperative visual acuity were significantly better in the primary vitrectomy group than in the vitrectomized group (p = 0.040, <0.001, respectively). The postoperative intraocular pressure was significantly lower (p = 0.017) in the vitrectomized group than in the primary vitrectomy group, and the rate of the cases with hypotony of less than 5mmHg was significantly higher (p<0.001) in the vitrectomized group than in the primary vitrectomy group. CONCLUSIONS: Compared to the PVR eyes that had had no prior vitrectomy, the PVR eyes that underwent prior vitrectomy had a significantly higher rate of complications of anterior PVR and a significantly higher rate of retinotomy/retinectomy, leading to a significantly poorer surgical outcomes.

[Efficacy of intravitreal bevacizumab for age-related macular degeneration].

PURPOSE: To investigate the efficacy of intravitreal bevacizumab (IVB) for neovascular age-related macular degeneration (AMD). METHODS: We conducted a retrospective study of 29 eyes of 29 patients with AMD (19 eyes) and polypoidal choroidal vasculopathy (PCV; 10 eyes), who were followed up at least 1 year after the initial IVB (1.0 mg/0.04 ml). The eyes were classified according to the lesion type and size. Best-corrected visual acuity (BCVA) and central retinal thickness were examined before and 3 months, 6 months and 12 months after the IVB. RESULTS: The mean application times of IVB were 2.1 in 1 year. When classifying the eyes according to the lesion type, BCVA improved in 5 (26.3%) eyes with AMD and 1 (10.0%) eye with PCV by over 0.2 logarithmic minimum angle of resolution (logMAR) units. The BCVA decreased significantly 1 year after the IVB in eyes with PCV (p = 0.032). When classifying the eyes according to the lesion size, BCVA improved by over 0.2 logMAR units in the 4 (50.0%) eyes with a size of less than 1 disc diameter, 1 (10.0%) eye with the size of 1 to 3 disc diameters, and 1 (9.1%) eye with the size of over 4 disc diameters. The BCVA decreased significantly 1 year after the IVB in the eyes with the size of 1 to 3 disc diameters and with the size of over 4 disc diameters (p = 0.028, 0.013, respectively). The central retinal thickness did not change significantly at any time point compared to that before the IVB. CONCLUSIONS: These results suggest that IVB may be efficacious in preserving visual acuity in AMD eyes and in eyes with the size of less than 1 disc diameter.

Severe intraocular inflammation after intravitreal injection of bevacizumab.

PURPOSE: To report 5 cases of severe intraocular inflammation that developed after an intravitreal injection of the same lot of bevacizumab. DESIGN: Retrospective case series. PARTICIPANTS: Patients treated with an intravitreal injection of bevacizumab (lot B3003B01). METHODS: The clinical charts of 35 eyes of 35 consecutive patients who were treated with intravitreal injection of lot B3003B01 bevacizumab from December 18, 2008, through January 20, 2009, were reviewed. MAIN OUTCOME MEASURES: Incidence of intraocular inflammation, results of bacterial cultures, best-corrected visual acuity (BCVA), and endothelial cell density. RESULTS: Five (14.3%) of the 35 cases had severe intraocular inflammation, and the inflammation had some characteristics of toxic anterior segment syndrome (TASS). Five of the 5 cases had a predominantly anterior chamber reaction, and 4 of the 5 cases were accompanied by hypopyon. Undiluted samples collected from both the aqueous and vitreous of the 5 cases were culture negative. The BCVA was 0.66+/-0.29 (mean+/-standard deviations) logarithm of the minimum angle resolution (logMAR) units, and the endothelial cell density was 2683.6+/-97.3/mm(2) before the intravitreal bevacizumab. At the final visit, the BCVA was 0.44+/-0.36 logMAR units, and the cell density was 2679.0+/-217.5/mm(2). These differences were not significant (P = 0.171 and 0.964). CONCLUSIONS: These observations indicate that an intravitreal injection of bevacizumab can induce sterile endophthalmitis that has characteristics of TASS.

[Efficacy of treatments on vision-related quality of life in patients with diabetic retinopathy].

PURPOSE: To evaluate changes in the vision-related quality of life in patients with diabetic retinopathy with the 25-item National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25). Patients were categorized into three groups : without treatment, receiving pan-retinal photocoagulation, and those who had vitrectomy. SUBJECTS AND METHODS: Altogether 327 patients (131 without treatment, [observation group]; 60 receiving pan-retinal photocoagulation, [photocoagulation group]; and 136 patients who had vitrectomy, [vitrectomy group]). The VFQ-25 was recorded at the time of entry and 1 year later. The VFQ-25 score was compared between the time of entry and 1 year later for each group and among the three groups at both the time of entry and 1 year later. RESULTS: VFQ-25 scores (mean +/- standard deviations) at the time of entry and 1 year later were 91.3 +/- 7.8 and 92.2 +/- 7.8 in the observation group, 80.7 +/- 15.7 and 77.6 +/-19.1 in the photocoagulation group, and 67.4 +/-17.3 and 75.4 +/- 17.5 in the vitrectomy group. VFQ-25 scores in the observation group and in the photocoagulation group did not change statistically between the time of entry and 1 year later (p = 0.113, 0.169, respectively), while the score of the vitrectomy group increased statistically (p < 0.001). In addition, although VFQ-25 scores were statistically significant among the three groups at the time of entry (p < 0.05), the scores 1 year later were not statistically different between the photocoagulation group and vitrectomy group. CONCLUSIONS: These results suggest that vitrectomy for diabetic retinopathy may be effective in increasing the quality of life of patients with diabetic retinopathy.

[Evaluation of the efficacy of intravitreal gas injection for submacular hemorrhages].

PURPOSE: To evaluate the efficacy of intravitreal gas injection for submacular hemorrhages(SMH). PATIENTS AND METHODS: The records of 29 patients with SMH, who were treated by pneumatic displacement with expansile gas, were reviewed retrospectively. RESULT: In observable cases, SMH had started moving within five days after the procedure. After 6 months visual acuity had been improved 2 or more lines in 23 eyes(79%). The causes of SMH were age-related macular degeneration (17 eyes) and microaneurysm (12 eyes). The larger the size of SMH, had the greater the risk of developing vitreous hemorrhage. Twelve eyes of the 29 eyes required vitrectomy owing to vitreous hemorrhage, insufficient removal of SMH, etc. but this pneumatic procedure often eliminated the need for vitrectomy. The visual acuity of the patients with additional vitrectomy was improved with only pneumatic displacement. None of the patients had serious complications with this pneumatic procedure and the vitrectomy. CONCLUSION: The first choice for SMH is intravitreal gas injection which saves foveal function, and improves the prognosis for better vision.

[Influence of vitrectomy for diabetic retinopathy on health-related quality of life].

PURPOSE: To evaluate the vision-related quality of life (QOL) in patients undergoing vitrectomy for diabetic retinopathy with the Japanese version of the 25-item National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25). SUBJECTS AND METHODS: Subjects were 87 patients undergoing vitrectomy for diabetic retinopathy of vitreous hemorrhage, macular edema, or fibrovascular membrane, only for the subject eye, or for subjects undergoing vitrectomy for the fellow eye within 6 months or later. The VFQ-25 date was recorded one month before and 6 months after the vitrectomy. The VFQ-25 data were compared before and after the vitrectomy. The subjects were classified by the pathological condition: 41 eyes with vitreous hemorrhage, 28 eyes with macular edema, and 18 eyes with fibrovascular membrane. RESULTS: The average VFQ-25 scores of all the patients increased in almost all of the 12 subscales. Vitrectomy for vitreous hemorrhage was most effective in improving the VFQ-25 score, in improving 10 of the 12 subscales in the VFQ-25, and in increasing VFQ-25 scores to almost the same level as in phacoemulsification and foldable intraocular lens implantation for cataract patients in both eyes. CONCLUSION: NEI VFQ-25 quantitatively clarified that vitrectomy for diabetic retinopathy is effective in increasing the QOL of diabetic retinopathy patients.

Evaluation of wound closure using different incision techniques with 23-gauge and 25-gauge microincision vitrectomy systems.

PURPOSE: To describe the anatomic and histopathologic outcomes using different incision techniques with transconjunctival 23-G and 25-G vitrectomy systems. METHODS: New Zealand rabbits were randomized to either 23-G or 25-G vitrectomy surgeries using angled incisions and straight incisions. After pars plana vitrectomy, the cannulas were removed and 0.1% trypan blue was injected to evaluate for leakage. The animals were killed on day 7 and the eyes enucleated for gross analysis and histopathologic analysis by frozen section. RESULTS: Leakage of trypan blue was noted from 10.8% and 5.7% of straight and angled incisions, respectively. There was no difference between 23-G and 25-G incisions (8.3%). On gross examination, the 25-G system resulted in 58% and 24% open external wounds for straight and angled incisions, respectively (P = 0.04). The 23-G system resulted in 83% and 39% open external wounds with straight and angled incisions, respectively (P = 0.017). The average wound area after the 23-G surgery was 223.1 microm(2) and 115.7 microm(2) for straight versus angled incisions, respectively (P = 0.02). The average wound area formed after the 25-G surgery was 160.3 microm(2) and 85.2 microm(2) for straight versus angled incisions, respectively (P = 0.001). CONCLUSIONS: Outcomes were similar for 23-G angled incisions, 25-G straight incisions, and 25-G angled incisions.

Oxidized phospholipids in the macula increase with age and in eyes with age-related macular degeneration.

PURPOSE: There is good evidence that oxidative stress is involved in the pathogenesis of age-related macular degeneration (AMD). Because AMD has risk factors and histopathology similar to with atherosclerosis, we hypothesized that oxidized phospholipids, which contribute to the pathogenesis of atherosclerosis, would accumulate in the eyes of AMD patients. To test this hypothesis, we investigated whether oxidized phospholipids were present in normal eyes and whether the level changed with increasing age. We then, we determined whether the levels of oxidized phospholipids were higher in eyes with AMD. METHODS: Twenty normal human donor eyes and six eyes with AMD were studied. Immunohistochemistry was performed on a tissue strip from the macular region using an antibody against oxidized phosphatidylcholine. Western blot analysis was also performed on proteins extracted from the posterior retina of donor eyes. The immunoreactivity of the specimens and the bands were quantified with NIH image software. RESULTS: Immunohistochemistry showed oxidized phosphatidylcholine was present in the photoreceptors and retinal pigment epithelium of the normal human macular area, and their levels increased with age. Eyes with AMD showed more intense immunoreactivity for oxidized phospholipids than age-matched normal eyes. CONCLUSIONS: These findings suggest that oxidative stress is involved in the pathogenesis of AMD possibly by oxidizing phospholipids in the photoreceptors as demonstrated in the arterial intima of patients with atherosclerosis. It is likely that controlling oxidation of phospholipids may be a potential treatment for AMD.

Clathrin and adaptin accumulation in drusen, Bruch's membrane and choroid in AMD and non-AMD donor eyes.

Clathrin was identified in a recent proteomic analysis of Bruch's membrane from age-related macular degeneration (AMD) donor eyes. The present study was conducted to determine the localization of clathrin in AMD tissues and to compare this distribution and relative content with that in non-AMD control tissues. The distribution of adaptin, which is functionally linked to clathrin, was also evaluated. Human eyes were from donors between 66 and 94 years of age; 13 eyes were from donors with AMD and 13 from non-AMD donors. Bruch's membrane and choroid from the macula of each donor eye were prepared for immunohistochemistry and Western blotting. Differences in immunoreactivity were quantitated. Drusen, Bruch's membrane and choroid from AMD tissues showed greater immunoreactivity for clathrin and adaptin than did non-AMD tissues. Western blots also showed more intense clathrin and adaptin immunoreactivity in AMD tissues than were present in non-AMD samples. This study suggests that accumulation of clathrin and adaptin in drusen, Bruch's membrane and choroid may reflect a higher rate of clathrin mediated endocytosis in AMD tissues. Alternatively, the accumulation of these proteins in these extracellular compartments may reflect a higher susceptibility to oxidative damage.

Mitogen-activated protein kinase (MAPK) and phosphatidylinositol-3 kinase (PI3K) pathways differently regulate retinal pigment epithelial cell-mediated collagen gel contraction.

Retinal pigment epithelial (RPE) cell-mediated extracellular matrix contraction is believed to contribute to developing proliferative vitreoretinopathy. It has been shown that platelet-derived growth factor (PDGF) and its intracellular signaling pathway, including mitogen-activated protein kinase (MAPK) and phosphatidylinositol-3 kinase (PI3K), are mainly involved in this process. The aim of this study is to investigate how these downstream signaling pathways are related to RPE-mediated collagen gel contraction. We performed the gel contraction assay to evaluate the effect of PDGF in cultured ARPE-19 cells under the presence or absence of PD98059, MAPK inhibitor or wortmannin, PI3K inhibitor. Experiments treated with neutralizing antibody for various subtypes of integrin were also performed and the effect on PDGF-induced gel contraction was investigated. Expression changes of integrin alpha1, alpha2 and beta1 after PDGF stimulation was evaluated using quantitative real-time PCR and flow cytometry. The results showed that PDGF up-regulated ARPE-19 cell-mediated gel contractile activity. PDGF-induced collagen gel contraction was attenuated under presence of PD98059, wortmannin, or neutralizing antibody for integrin alpha1, alpha2, or beta1, all of which are critical subset for binding with type I collagen. The expression of integrin alpha1 and alpha2 was increased after PDGF stimulation in both real-time PCR and flow cytometry, however beta1 expression was not increased. PD98059 significantly attenuated integrin alpha1 and alpha2 expressions. However, wortmannin did not have the same effect. In conclusion, PDGF promotes ARPE-19 cell-mediated gel contraction via both MAPK and PI3K. This was probably due to an increased expression of integrin alpha1 and alpha2, which is mediated by MAPK, but not by PI3K. PI3K may regulate collagen gel contraction by another mechanism other than the up-regulation of integrin expression.