Risk factors for epiretinal membrane formation and peeling following pars plana vitrectomy for primary rhegmatogenous retinal detachment, an OCT guided analysis.

BACKGROUND: To evaluate the rate and risk factors of epiretinal membrane (ERM) formation and need for ERM peeling after pars plana vitrectomy (PPV) for uncomplicated primary rhegmatogenous retinal detachment (RRD). METHODS: Retrospective, single-center, cohort study of 119 consecutive patients (119 eyes) that underwent RRD repair using PPV. The primary outcomes were ERM formation, classified using an optical coherence tomography grading system, and the rate of ERM peeling. Visual acuity, postoperative complications, and risk factors for ERM formation and peeling were also identified. RESULTS: Postoperative ERM formation occurred in 69 eyes (58.0%); 56 (47.1%) were stage 1, 9 (7.6%) stage 2, 3 (2.5%) stage 3, and 1 (0.8%) stage 4. Only 6 (5.0%) eyes required secondary PPV for a visually significant ERM, with a mean time to reoperation of 488 ± 351 days. Risk factors for ERM formation included intraoperative cryotherapy, more than 1000 laser shots, 360° laser photocoagulation, and choroidal detachment (p < 0.01). Eyes with more than 3 tears had a trend towards increased ERM surgery (p = 0.10). CONCLUSIONS: Visually significant ERM formation following PPV for primary RRD was uncommon in this cohort (5%). Half of the ERMs were detected after the first post-operative year, indicating that this complication may be underreported in studies with only 1-year follow-up.

Long-Term Visual Outcomes for a Treat-and-Extend Antivascular Endothelial Growth Factor Regimen in Eyes with Neovascular Age-Related Macular Degeneration: Up to Seven-Year Follow-Up.

PURPOSE: To report long-term visual and anatomical outcomes in eyes with neovascular age-related macular degeneration (nAMD) treated with a treat-and-extend regimen (TER) of intravitreal antivascular endothelial growth factor (anti-VEGF) injections in real-world settings. METHODS: Retrospective cohort study of consecutive patients with nAMD treated with a TER of anti-VEGF intravitreal injections by a single retina specialist (GC). Patients with nAMD who had at least one year of follow-up were identified using an electronic database. Best-corrected visual acuity (BCVA), comprehensive ophthalmologic examination, and macular OCT were performed at each visit. Patients received a loading dose of three monthly intravitreal injections and then were treated according to a TER of bevacizumab, ranibizumab, and/or aflibercept. The number of injections, BCVA, and central retinal thickness (CRT) were evaluated during the follow-up period. RESULTS: 180 eyes from 180 patients were included in the study. Mean age was 75 ± 9 (range: 51-96). Mean BCVA was 0.77 ± 0.64 LogMAR at baseline, 0.69 ± 0.58 LogMAR (p = 0.0057) after loading phase, 0.64 ± 0.55 LogMAR (p = 0.0001) after 6 months of TER, and 0.76 ± 0.71 LogMAR after 6 years of treatment (n = 32 at year 6). CRT decreased significantly after the loading phase (p = 0.0002). The mean number of intravitreal injections per year was 7.6 during the first three years of treatment and then decreased to 5.9 during year 4 to 7. CONCLUSIONS: This retrospective study of 180 nAMD patients treated with a TER of intravitreal anti-VEGF demonstrates an initial improvement of BCVA after loading phase, followed by long-term visual stabilization for at least six years. These results were obtained with a high number of injections, averaging close to six injections per year during long-term follow-up. In light of the natural evolution of nAMD, these data support the long-term efficacy of this treatment under real-world conditions of heterogeneity of patients and type of anti-VEGF used.

Displacement of Retained Subretinal Perfluorocarbon Liquid Through Therapeutic Retinal Detachment Induced by Balanced Salt Solution Injection.

PURPOSE: To report a case of displacement of retained subretinal perfluorocarbon liquid (PFCL) through therapeutic retinal detachment (RD) induced by balanced salt solution (BSS) injection. METHODS: This is a surgical case report. We present a case of a 61-year-old woman who presented with subretinal PFCL at the papillo-macular bundle with best-corrected visual acuity (BCVA) of 20/200 at four weeks following RD surgery in her right eye. She underwent a three-port pars plana vitrectomy with therapeutic RD of a portion of the posterior pole and inferior periphery induced by BSS injection, followed by complete air-fluid exchange, and kept an upright position for three days to force the displacement of the PFCL bubble towards the inferior retinal periphery. BCVA assessment, dilated fundus examination (DFE), and optical coherence tomography (OCT) were performed before and after the surgery. RESULTS: Two weeks after the procedure, BCVA improved to 20/40, the subretinal PFCL was not visible on DFE, and a control OCT confirmed displacement of the PFCL bubble with atrophy at the papillo-macular bundle. There were no complications. CONCLUSION: Displacement of retained subretinal PFCL through therapeutic RD induced by BSS injection seems to be an effective technique with fewer potential complications in comparison to the more traditional approach of removal by direct aspiration.

Primary rhegmatogenous retinal detachment with inferior retinal breaks postoperative prone positioning results: 1 day versus 7 days.

BACKGROUND: To compare the primary anatomical outcome of pars plana vitrectomy, 360° peripheral endolaser, and 15% octafluoropropane C3F8 gas tamponade in patients with uncomplicated rhegmatogenous detachment and inferior retinal breaks, after 24-h postoperative prone positioning to similar patients with 1 week postoperative prone positioning. METHODS: Records of 5500 patients who underwent pars plana vitrectomy between 2008 and 2015 were retrieved. Collected data included age, gender, number of retinal quadrants with retinal breaks, number of retinal breaks, macula status on presentation (attached or detached), phakic status (phakic, pseudophakic, or aphakic), and primary anatomical outcome (at 1 and 3 months post-operative). RESULTS: 270 patients met the study inclusion criteria (78 females, and 192 males). In the 24-h positioning arm (183 patients), the overall anatomical success rate was 96.2% at 1 month and 83.6% at 3 months. In the 1-week positioning group (87 patients), the overall anatomical success rate was 93% at 1 month and 79% at 3 months. Both positioning groups did not show statistical difference in outcome at 1 month (p-value = 0.7) or at 3 months (p-value = 0.39). Logistic regression analysis found that the number of retinal breaks correlates with the postoperative anatomical success at 3 months (odd ratio 0.8, p-value = 0.016). CONCLUSION: This short term retrospective study demonstrated that patients with uncomplicated rhegmatogenous retinal detachment due to inferior retinal breaks, who underwent pars plana vitrectomy, 360° endolaser, 15% C3F8 gas, and limited (24-h) prone positioning did not show statistical difference in the anatomical outcome (at 1, and 3 months) when compared with 1 week postoperative positioning. Larger prospective studies are warranted to further elucidate positioning role.

Factors associated with outcomes of pneumatic retinopexy for rhegmatogenous retinal detachments: a retrospective review of 422 cases.

BACKGROUND: To determine the factors associated with anatomical and visual outcomes, and complications when using pneumatic retinopexy in the management of rhegmatogenous retinal detachments. METHODS: On a whole, 406 patients having undergone 422 primary pneumatic retinopexies for the management of rhegmatogenous retinal detachment at a tertiary care hospital, between January 2004 and December 2009, with a minimum follow-up of 3 months were included in this case series. Multivariate logistic regression was used to estimate associations of demographic and clinical factors with anatomical and visual outcomes. RESULTS: The single operation success rate was 60.7%, and final anatomical success was 99.5%. Male gender and the presence of complications were associated with single operation failure, whereas age over 65 years, poor preoperative visual acuity, the presence of complications were associated with poorer visual outcomes. Better preoperative visual acuity and absence of complications were associated with obtaining both a good visual outcome and anatomical success after a single intervention. The most common complications included new or missed tears (16.3%), delayed subretinal fluid reabsorption (12.1%), and epiretinal membrane (10.2%). CONCLUSION: Several factors are associated with pneumatic retinopexy outcomes for rhegmatogenous retinal detachments. These factors should be taken into consideration when identifying patients who would benefit from pneumatic retinopexy and those who are at risk of requiring additional interventions.

Assessment of retinal and choroidal blood flow changes using laser Doppler flowmetry in rats.

PURPOSE: A new noninvasive laser Doppler flowmetry (LDF) probe (one emitting fiber surrounded by a ring of eight collecting fibers, 1-mm interaxis distance) was tested for its sensitivity to assess the retinal/choroidal blood flow variations in response to hypercapnia, hyperoxia, diverse vasoactive agents and following retinal arteries photocoagulation in the rat. MATERIALS AND METHODS: After pupil dilation, a LDF probe was placed in contact to the cornea of anesthetized rats in the optic axis. Hypercapnia and hyperoxia were induced by inhalation of CO(2) (8% in medical air) and O(2) (100%) while pharmacological agents were injected intravitreously. The relative contribution of the choroidal circulation to the LDF signal was estimated after retinal artery occlusion by photocoagulation. RESULTS: Blood flow was significantly increased by hypercapnia (18%), adenosine (14%) and sodium nitroprusside (16%) as compared to baseline values while it was decreased by hyperoxia (-8%) and endothelin-1 (-11%). Photocoagulation of retinal arteries significantly decreased blood flow level (-45%). CONCLUSIONS: Although choroidal circulation most likely contributes to the LDF signal in this setting, the results demonstrate that LDF represents a suitable in vivo noninvasive technique to monitor online relative reactivity of retinal perfusion to metabolic or pharmacological challenge. This technique could be used for repeatedly assessing blood flow reactivity in rodent models of ocular diseases.

The effect of intravitreal injection of bevacizumab on retinal circulation in patients with neovascular macular degeneration.

PURPOSE: Intravitreal (ITV) injection of anti-VEGFs like bevacizumab are widely used to treat neovascular AMD. However, VEGF is essential for biologic functions such as blood pressure regulation. Indeed, anti-VEGF intravenous administration is associated with hypertension. Therefore, the effect of ITV bevacizumab on retinal circulation was examined. METHODS: Twenty-three patients with neovascular AMD treated with three repeat ITV injections of bevacizumab were recruited. Blood arteriolar diameter and flow measurements were performed with a bidirectional laser Doppler flowmeter at baseline, 1 week after the first injection, just before the second injection, and 5 weeks after the third injection. Scanning laser Doppler flowmetry was used to assess the effect of bevacizumab on tissue perfusion at the first and fourth visits. RESULTS: Arteriolar diameter significantly decreased from 122.5 ± 14.5 µm to 118.9 ± 14.0 µm (P = 0.03) during the first week to reach a mean value of 117.2 ± 13.7 µm at the end of the study (P < 0.01). Arterial blood flow did not change significantly. Neuroretinal rim perfusion decreased from 181.1 ± 84.1 arbitrary flow units to 167.7 ± 76.5 arbitrary flow units, which was borderline significant (P = 0.06). No significant change was observed in the peripapillary retina. CONCLUSIONS: Arteriolar diameter decreased significantly after the first injection and persisted until the end of the study suggesting a long-term effect of bevacizumab on vascular tone. However, the blood flow change is not significant. A borderline significant decrease in neuroretinal rim perfusion was observed and suggests that the neuroretinal rim may be more sensitive than the peripapillary retina to the effects of bevacizumab.

Fibrin sealant in the treatment of retinal detachment in morning glory syndrome.

PURPOSE: To report the usage of fibrin sealant in the treatment of retinal detachment in morning glory syndrome. METHODS: A case report of an 8-year-old boy with a recent, macula-off, inferior, bullous retinal detachment associated to his morning glory syndrome that was first treated by a pneumatic retinopexy. The following day, his examination revealed a total retinal detachment and subretinal gas. The patient underwent a 25-gauge pars plana vitrectomy, incomplete peeling of the glial tuft, 360° laser photocoagulation around the peripapillary staphyloma, 20% perfluoropropane endotamponade, and fibrin sealant injection to temporarily plug the slitlike retinal break visualized on the inferior border of the peripapillary staphyloma. RESULTS: Complete reattachment of the retina persisted after 6 months of follow-up with slight improvement in visual acuity noted by the patient. CONCLUSION: The authors believe that the usage of fibrin sealant seems to be a useful alternative in cases of retinal detachment related to morning glory syndrome with deep posterior peripapillary staphyloma, especially when persistent residual traction is suspected.

Possible venous air embolism during open eye surgery in a child.

PURPOSE: Although venous air embolism is a well recognized complication within most surgical subspecialties, it has only been reported recently during eye surgery in one adult, and never before in a child. We describe the case of a 17-month-old boy who sustained a possible air embolism during repair of an open trauma of his right eye. CLINICAL FEATURES: A vitrectomy through the pars plana with air-fluid exchange of the posterior chamber was performed under general anesthesia to remove a foreign body which had impaled the optic nerve. A few minutes after removal of the foreign body, a notable decrease in end-tidal CO(2), oxygen saturation and arterial blood pressure occurred, requiring administration of a high inspired oxygen fraction and vasopressors. Venous air embolism was strongly suspected after other causes of a decrease of end-tidal CO(2) and hypoxemia had been excluded. An arterial blood gas confirmed hypoxemia and respiratory acidosis. CONCLUSION: Although venous air embolism is a rare complication of eye surgery, it should nevertheless be considered as a possible complication during air-fluid exchange vitrectomy in children.

Chronic angle-closure glaucoma secondary to a suprachoroidal effusion induced by central retinal vein occlusion.

A 68-year-old woman presented to the ophthalmology emergency clinic with a painful left eye of a few hours' duration. One month prior, the patient had presented with a central retinal vein occlusion in the same eye. Examination revealed an intraocular pressure of 32 mm Hg in the left eye with 360 degree angle closure unaltered by indentation, a patent iridectomy from a previous combined phacoemulsification and trabeculectomy surgery, and no evident iris or angle neovascularization. Ultrasound biomicroscopic examination revealed a large suprachoroidal effusion with anterior rotation of the ciliary body and secondary angle closure in the left eye. The patient underwent successful pars plana vitrectomy, radial optic neurotomy, intra-vitreal triamcinolone acetonide injection, and goniosynechialysis.