Complete ILM Peeling Versus Inverted Flap Technique for Macular Hole Surgery: A Meta-Analysis.

BACKGROUND AND OBJECTIVE: To compare complete internal limiting membrane (ILM) peeling with the inverted flap technique for macular hole (MH) surgery. PATIENTS AND METHODS: An electronic database search on PubMed, CENTRAL, and ClinicalTrials.gov was performed. Inclusion criteria were comparative prospective/retrospective studies including patients with MH of any size with at least 6 months of follow-up. The primary outcome was MH closure rate. Secondary outcomes were best-corrected visual acuity improvement and surgery-related adverse events. RESULTS: Sixteen papers enrolling 1,403 eyes were included (733 ILM peeling, 670 inverted flap). MH mean minimum diameter and time of symptomatic evolution were higher in the inverted flap group (531.1 µm ± 188.8 µm vs. 602.8 µm ± 223.8 µm; 10.4 ± 20.2 months vs. 12.0 ± 18.4 months; P < .01). Overall, MH closure rate was superior with the inverted flap technique (risk-ratio [RR]: 1.25; 95% confidence interval [CI], 1.14-1.38; P < .0001), as well as in all subgroups: idiopathic large MH (n = 362; RR: 1.12; 95% CI, 1.05-1.20; P < .001), myopic MH without retinal detachment (n = 133; RR: 1.35; 95% CI, 1.14-1.59; P < .001), and MH retinal detachment (n = 198; RR: 1.89; 95% CI, 1.31-2.73; P < .001). CONCLUSION: This meta-analysis suggests the inverted flap technique is more effective in achieving MH closure. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:187-195.].

INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUES AND OUTER RETINAL LAYER STRUCTURES.

PURPOSE: To examine the influence of the inverted flap (IF) internal limiting membrane (ILM) technique in macular hole (MH) closure on outer retinal layers after MH surgery. METHODS: Retrospective study. Postoperative position of ILM, recovery rate of external limiting membrane and ellipsoid zone, and best-corrected visual acuity were evaluated. The Inserted group, where the IF is placed inside the hole, was compared with the Cover group, where the IF completely covers the hole. RESULTS: Sixty-two eyes of 58 patients who underwent vitrectomy and ILM peeling with the IF technique for large MHs (>400 µm) with successful MH closure and a follow-up of 12 months were evaluated. In the 24 eyes of the Inserted group, there was no regeneration of external limiting membrane or ellipsoid zone after 12 months. In the 38 eyes of Cover group, external limiting membrane recovered in 55.3% of patients 1 month after surgery, and in 86.1% after 12 months. The elipsoid zone layer was present in 58% of the patients. CONCLUSION: Poorer anatomical and visual results were associated with the IF technique where ILM insertion occurs compared with ILM placed over the hole. These findings suggest that insertion of the ILM in the hole might prevent outer retinal layers realignment and visual recovery in MH surgery.

Tomographic Structural Changes of Retinal Layers after Internal Limiting Membrane Peeling for Macular Hole Surgery.

PURPOSE: To highlight tomographic structural changes of retinal layers after internal limiting membrane (ILM) peeling in macular hole surgery. METHODS: Nonrandomized prospective, interventional study in 38 eyes (34 patients) subjected to pars plana vitrectomy and ILM peeling for idiopathic macular hole. Retinal layers were assessed in nasal and temporal regions before and 6 months after surgery using spectral domain optical coherence tomography. RESULTS: Total retinal thickness increased in the nasal region and decreased in the temporal region. The retinal nerve fiber layer (RNFL), ganglion cell layer (GCL), and inner plexiform layer (IPL) showed thinning on both nasal and temporal sides of the fovea. The thickness of the outer plexiform layer (OPL) increased. The outer nuclear layer (ONL) and outer retinal layers (ORL) increased in thickness after surgery in both nasal and temporal regions. CONCLUSION: ILM peeling is associated with important alterations in the inner retinal layer architecture, with thinning of the RNFL-GCL-IPL complex and thickening of OPL, ONL, and ORL. These structural alterations can help explain functional outcome and could give indications regarding the extent of ILM peeling, even though peeling seems important for higher rate of hole closure.

Retropupilar positioning of foldable iris-claw intraocular lens for correction of aphakia with no capsular support.

SUMMARY: Iris-claw intraocular lens (ICIOL) for aphakia needs a large 5.4 mm corneal incision for its implantation. The technique needs corneal suture, associated with some postoperative astigmatism. Foldable ICIOL is used in phakic patients undergoing refractive surgery and has the advantage of a sutureless small corneal incision. We report a case of a high myopic patient with dislocated intraocular lens (IOL) and no capsular support. Dislocated IOL with its capsular bag was released with three-port, 23-gauge vitrectomy; placed in the anterior chamber; sliced; and extruded through a 3.2-mm corneal incision, where a foldable ICIOL was introduced and placed retropupillary. This technique achieved a stable fixation of the IOL. Retropupillary implantation of a foldable ICIOL on aphakic patients has advantages over that of a polymethylmethacrylate (PMMA) ICIOL due to smaller corneal incision. The technique may be safe and easy to perform. PURPOSE: The purpose of this report was to describe the technique of retropupillary implantation of a foldable iris-claw intraocular lens (ICIOL) in a patient with dislocated intraocular lens (IOL) in mid vitreous cavity. METHODS: Foldable ICIOL (Artiflex® Myopia Model 401) is used in phakic patients undergoing refractive surgery and has the advantage of a sutureless small corneal incision. We report a case of a high myopic patient with dislocated IOL and no capsular support. The calculation was a -5.0 D IOL for retropupilar position, and a foldable ICIOL was introduced through a 3.2-mm corneal incision and placed retropupillary. RESULTS: The technique was easy to achieve. IOL was properly positioned retropupillary and maintained stable. There was no ocular hypertension and no anterior chamber flare or iris atrophy. CONCLUSION: Retropupillary implantation of a foldable ICIOL on aphakic patients has advantages over that of a PMMA ICIOL due to smaller corneal incision. The technique may be safe and easy to perform.

Retropupillary iris claw intraocular lens implantation in aphakia for dislocated intraocular lens.

BACKGROUND: Nowadays, dislocated intraocular lenses (IOLs) and inadequate capsular support are becoming a challenge for every ophthalmic surgeon. Explantation of dislocated IOL and iris claw IOL (ICIOL) are the techniques that have been used in our ophthalmic department. The aim of this study is to report our technique for retropupillar ICIOL. METHODS: This study is a retrospective case series. A total of 105 eyes with dislocated IOL from the patients at the Department of Ophthalmology in Santa Maria Hospital, a tertiary reference hospital in Lisbon, Portugal, from January 2012 until January 2016, had been analyzed. Of these 105 eyes, 66 eyes had dislocated one-piece IOL and 39 eyes had dislocated three-piece IOL. The latter underwent iris suture of the same IOL and were excluded from this study. The remaining 66 eyes with dislocated one-piece IOL underwent pars plana vitrectomy, that is, explantation of dislocated IOL through corneal incision and an implantation of retropupillary ICIOL. Operative data and postoperative outcomes included best corrected visual acuity, IOL position, intraocular pressure, pigment dispersion, clinical signs of endothelial cell loss, and anterior chamber depth. RESULTS: The mean follow-up was 23 months (range: 6-48 months). The mean preoperative best corrected visual acuity was 1.260±0.771 logMAR, and postoperative best corrected visual acuity was 0.352±0.400 logMAR units. Mean vision gain was 0.909 logMar units. The patients had the following complications: 1) retinal detachment was found in one patient, 2) corneal edema was found in three patients, 3) high intraocular pressure was observed in twelve patients, 4) subluxation of the IOL was observed in one patient, and 5) macular edema was found in three eyes. CONCLUSION: The results demonstrate that retropupillary ICIOL is an easy and effective method for the correction of aphakia in patients not receiving capsule support. The safety of this procedure must be interpreted in the context of a surgery usually indicated in complicated cases.

A Rare Manifestation of Uveitis-glaucoma-hyphema Syndrome.

AIMS: To report a case of a patient who developed uveitis-glaucoma-hyphema (UGH) syndrome after an uneventful cataract surgery and to discuss risk factors, diagnostic challenges, management options, and clinical implications. BACKGROUND: Uveitis-glaucoma-hyphema syndrome is a rare but potentially serious cataract surgery complication. Clinical manifestations include increased intraocular pressure (IOP), anterior chamber inflammation, and recurrent hyphema or microhyphema. Uveitis-glaucoma-hyphema Plus syndrome also includes accompanying vitreous hemorrhage. Although classically associated with rigid anterior chamber intraocular lenses (lOLs), cases of malpositioning and subluxated posterior chamber lOLs have also been described as possible triggers. CASE DESCRIPTION: We report a case of a 70-year-old Caucasian man who developed UGH Plus syndrome after an uneventful cataract surgery with an lOL implanted in the capsular bag. During postoperative follow-up, persistent intraocular inflammation, increased IOP, hyphema, and vitreous hemorrhage were consistent with this diagnosis. Slit-lamp examination demonstrated progressive localized iris atrophy, compatible with chafing of the posterior iris by the IOL haptic as the trigger for UGH syndrome. A pars plana vitrectomy was performed and a retropupillary intraocular lens was implanted. No further complications occurred during follow-up. CONCLUSION AND CLINICAL SIGNIFICANCE: Given the increasing prevalence of single-piece lOLs implanted in the capsular bag, it is important to recognize UGH syndrome as a rare but potentially serious complication. How to cite this article: Sousa DC, Leal I, Faria MY, Pinto LA. A Rare Manifestation of Uveitis-glaucoma-hyphema Syndrome. J Curr Glaucoma Pract 2016;10(2):76-78.

Retropupillary iris-claw intraocular lens in ectopia lentis in Marfan syndrome.

OBJECTIVE: To report visual outcomes, complication rate, and safety of retropupillary iris-claw intraocular lens (ICIOL) in ectopia lentis in Marfan syndrome (MFS). DESIGN: Retrospective study. METHODS: Six eyes of three MFS patients with ectopia lentis underwent surgery for subluxation lens and retropupillary ICIOL implantation from October 2014 to October 2015 at the Department of Ophthalmology, Santa Maria Hospital in Lisbon, Portugal. Demographics, preoperative and postoperative best-corrected visual acuity (BCVA), and intraocular pressure were evaluated. Endothelium cell count was assessed using specular microscopy; anterior chamber depth was measured using Pentacam postoperatively; and intraocular lens position was viewed by ultrasound biomicroscopy. All patients were female; mean age was 20±14.264 years (range: 7-38 years). RESULTS: The average follow-up period was 6.66 months (range: 4-16 months). Preoperative BCVA was 0.568±0.149 logMAR units, and postoperative BCVA was 0.066±0.121 logMAR units. The mean BCVA gain was -0.502±0.221 on the logMAR scale. Postoperative average astigmatism and intraocular pressure were 1.292±0.697 mmHg (range: 0.5-2.25 mmHg) and 16 mmHg (range: 12-18 mmHg), respectively. The average endothelial cell density decreased from 3,121±178 cells/mm(2) before surgery to 2,835±533 cells/mm(2) after surgery (measured at last follow-up visit) and in the last follow-up, representing an average endothelial cell loss of 9.16%. Mean anterior chamber depth was 4.01 mm (±0.77 mm), as measured by Pentacam. No complications were found intra- or postoperatively in any of the six studied eyes. CONCLUSION: Retropupillary ICIOL implantation is a safe and effective procedure in the treatment of aphakia in MFS eyes, without capsular support after surgery for ectopia lens. The six eyes that underwent lensectomy and retropupillary ICIOL implantation have had excellent visual outcomes with no complications so far.