Primary vitrectomy for pseudophakic retinal detachment: a prospective non-randomized study.

PURPOSE: To compare the anatomic and functional results of primary vitrectomy alone or vitrectomy-scleral buckling for pseudophakic retinal detachment (RD). Vitrectomy permits a detailed view of the peripheral retina, so otherwise undetectable holes or additional small lesions can be found which, left untreated, may cause a residual RD. PATIENTS AND METHODS: Twenty-four consecutive pseudophakic eyes with pseudophakic RD were operated by vitrectomy and encircling band (Group I) and 27 additional cases were operated on by vitrectomy alone (Group II). Internal subretinal fluid drainage, using liquid perfluoro-n-octane, endolaser, and/or cryocoagulation and fluid-air exchange with SF6 20%, was applied in all cases. Preoperative findings and intraoperative and postoperative complications as well as final results were analyzed. RESULTS: Preoperatively undetected retinal holes were identified in 7 of the 51 eyes and additional retinal holes were found in 21. The mean follow-up was 14 months for Group I and 11.5 months for Group II. The retina was successfully reattached with a single operation in 22 of 24 eyes (92%) in Group I. One eye had a recurrence of RD due to an unsuccessfully treated preexisting retinal tear. Proliferative vitreoretinopathy (PVR) was observed in one case with recurrence of RD. In both cases, a second operation achieved retinal reattachment. In Group II, the retinas were attached with a single operation and visual acuity improved by an average of four or more lines in 62.5% of the vitrectomy-buckling group and in 55.5% of the vitrectomy group. The most frequent complication was a transient hypertony, in 21 cases. CONCLUSIONS: Surgical treatment of pseudophakic RD, combining vitrectomy and scleral buckling or vitrectomy alone, achieves very good anatomic and functional results. The advantages include more efficient detection of the peripheral detachment causing retinal lesions, and a lower redetachment rate than after extraocular surgery only.

TGF-beta1, TGF-beta receptor II and ED-A fibronectin expression in myofibroblast of vitreoretinopathy.

PURPOSE: Formation of scarlike epiretinal membranes (ERMs) constitutes potentially the end stage of evolution of proliferative vitreoretinopathy (PVR) and proliferative diabetic retinopathy (PDR). Among various cellular populations, ERMs contain cells with contractile features typical of myofibroblasts. The current study was conducted to investigate the presence of transforming growth factor (TGF)-beta1, TGF-beta receptor II (RII) and ED-A fibronectin (FN), the main inducers of myofibroblastic differentiation in ERMs in PDR and PVR. METHODS: Samples of ERM were obtained from 23 patients during microsurgery for PVR or PDR. Electron microscopy, immunohistochemistry, and confocal microscopy with antibodies recognizing beta-smooth muscle (SM) actin, desmin, TGF-beta1, TGF-beta receptors I and II, and ED-A FN were performed. RESULTS: alpha-SM actin was detected in all ERMs, whereas desmin was present in 50% of the cases. ED-A FN was expressed in all ERMs in close relation with alpha-SM actin-positive myofibroblasts. In addition, TGF-beta1 and TGF-beta R II were always present, TGF-beta RII being expressed in both alpha-SM actin-positive and negative fibroblastic cells. CONCLUSIONS: Myofibroblast accumulation is a key event in ERM-associated traction retinal detachment occurring during PVR and PDR. The current results suggest that the presence of alpha-SM actin-positive myofibroblasts is probably dependent on the concomitant neoexpression of TGF-beta1, TGF-beta RII, and ED-A FN. The results furnish new data on the mechanism of alpha-SM actin stimulation in fibroblasts in a human pathologic setting.

[Laser photocoagulation of occult choroidal neovascularization guided by angiography using indocyanine green. A pilot study]. / La photocoagulation au laser des néovaisseaux occultes guidée par l'angiographie au vert d'indocyanine. Une étude pilote.

PURPOSE: Age related macular degeneration (AMD) is the most common cause of legal blindness in the Western world in people over 50 years of age. The most severe visual loss occurs in patients with AMD complicated by choroidal neovascular membranes (CNV). Indocyanine green angiography (ICG) account for visualization in up to 60% of the cases that are classified as occult on fluorescein angiography (up to 70% of the cases). ICG-guided laser photocoagulation of CNV is currently a mater of debate. We conducted a pilot study to determine wether it could be beneficial for patients presenting with occult CNV on fluorescein angiography. MATERIAL AND METHODS: Twenty consecutive patients (20 eyes) with occult CNV in AMD were included. All showed occult CNV on fluorescein angiography and a well defined juxta- or extrafoveal hot spot or plaque hyperfluorescence on ICG. Fibrovascular retinal pigment epithelial detachments were excluded. The patients had serial controls, including fluorescein angiography and ICG, at 15 days, 1, 2, 3, 6, 9 and 12 months after photocoagulation. RESULTS: At the end of follow-up visual acuity (VA) was stable (within +/- 3 lines) compared to the initial one in 80% (16) of the cases. A complete resolution of exudative signs was observed in 75% (15) of the cases. CONCLUSIONS: ICG-guided laser photocoagulation of occult CNV in AMD account for better visual acuity than natural course of the disease at 12 months follow-up. However, a prospective randomized clinical trial is warranted to evaluate definitively this treatment approach.

[Idiopathic giant retinal tears: treatment with vitrectomy and temporary silicone oil tamponade]. / Déchirures géantes idiopathiques: traitement par vitrectomie et tamponnement temporaire par huile de silicone.

PURPOSE: Vitrectomy with intraoperative use of perfluorocarbon liquids facilitates the treatment of giant retinal tears and permits the reattachment of the retina. This surgical technique maximizes the anatomic results with decreasing of failures and complications associated with the extraocular surgical approach. MATERIAL: and METHODS: Fourteen patients were operated on for idiopathic giant retinal tears without proliferative vitreoretinopathy. All patients underwent pars plana vitrectomy, unfolding of the giant retinal tears by perfluoro-n-octane, endophotocoagulation, cryoapplication and temporary silicone oil tamponade (ablation after 2 months). Visual acuity, anterior segment examination and fundus examination with a contact lens were performed preoperatively, followed by a control one week later, as well as monthly for 6 months and after that every 3 months postoperatively. RESULTS: Visual acuity at the end of the follow-up (mean 22 months) was increased by 3 lines or more in all cases but one. Postoperatively the retina was reattached in all of the cases. A recurrence of localized retinal detachment secondary to a focal proliferative vitreoretinopathy was observed in one case. Cataract formation (80% of the cases) and epiretinal macular membranes (50% of the cases) were the most frequent complications. CONCLUSION: The treatment of idiopathic giant retinal tears with vitrectomy and temporary silicone oil tamponade maximizes the functional results and permits the definitive reattachment of the retina in detriment of the classic complications of vitrectomy.

[Pseudophakic retinal detachment: treatment by vitrectomy and scleral buckling. Pilot study]. / Décollement de rétine du pseudophake. Traitement par vitrectomie et cerclage. Etude pilote.

INTRODUCTION: Localization of retinal tears generating a pseudophakic retinal detachment (RD) is not always possible; subsequently, segmental indentation by external compression often causes a residual RD. Vitrectomy enables a detailed view of the peripheral part of the retina and better detection of small size retinal breaks. Our pilot survey report anatomic and functional results of a surgical treatment of pseudophakic RD, associating vitrectomy and scleral buckling. MATERIAL AND METHODS: Twenty three consecutive pseudophakic eyes showing an RD were operated on with scleral buckling, vitrectomy, internal subretinal fluid drainage, endolaser and fluid-air exchange by SF(6) 20%. Preoperative findings, intraoperative and postoperative complications, and final results were analyzed. RESULTS: The retina was successfully reattached with a single operation in 21 eyes (92%). One eye presented a recurrence of RD due to a preexisting retinal tear. PVR was observed in one case with the recurrence of the RD. In both cases, a second operation achieved the retinal reattachment. After surgery, visual acuity improved on an average of 3 lines. The most frequently occurring complication was a transitory hypertony in 6 cases (26%). CONCLUSION: Surgical treatment of the pseudophakic RD, combining vitrectomy and scleral buckling shows very good anatomic and functional results; it seems to offer the advantage of a better localization of peripheral retina tears, which enables a recovery with a lower recurrence rate than by extra-ocular surgery only.

Macular epiretinal membranes.

Epiretinal membranes (ERM) are a common finding in older patients. Although they may be associated with numerous clinical conditions, most epiretinal membranes occur in the absence of ocular pathology. Patients symptoms range from asymptotic to complaints of severe vision loss and metamorphopsia. Epiretinal membranes are commonly classified according to their density, to the severity of retinal distortion and to associated biomicroscopic changes. Pars plana vitrectomy has been found to be effective in removing ERM from the macula, improving the visual acuity and decreasing metamorphopsia. Both idiopathic and secondary ERMs do well after surgery, although secondary ERMs showed a greater amount of improvement than idiopathic ones. Complications are frequent including accelerated postoperative nuclear sclerosis, retinal breaks and RD, macular edema, RPE and, occasionally, macular hole and hypotony. However only RD involving the macula have a worsening prognosis on final outcome.

ICG-guided laser photocoagulation of juxtafoveal and extrafoveal occult choroidal neovascularization.

BACKGROUND: The most common cause of legal blindness in the Western world in people over 50 years of age is age-related macular degeneration (AMD) complicated by choroidal neovascular membranes (CNV). We conducted a prospective pilot study to evaluate the functional and anatomical results of indocyanine green (ICG)-guided laser photocoagulation of juxta- and extrafoveal occult CNV. METHODS: Seventeen consecutive patients (17 eyes) with occult CNV in AMD were included. All showed occult CNV appearing as late-phase fluorescein leakage of undetermined source on fluorescein angiography and as a well-defined hot spot or plaque hyperfluorescence on ICG angiography. Fibrovascular retinal pigment epithelial detachments (PED) and serohemorrhagic PED were excluded. Laser photocoagulation was performed using an argon green laser. The patients had serial follow-up examinations, including fluorescein and ICG angiography, at 15 days and 1, 2, 3, 6, 9 and 12 months after photocoagulation. RESULTS: At the end of the follow-up, the visual acuity (VA) was stable (within +/-3 lines of the initial VA) in 76% (13) of the eyes. A moderate decrease in VA was observed in 24% (4). A complete resolution of exudative signs was observed in 65% (11). CONCLUSION: ICG-guided laser photocoagulation of occult CNV, presenting at baseline examination as late-phase fluorescein leakage of undetermined source and as a well-defined hyperfluorescent lesion on ICG angiography, may constitute a subgroup of occult CNV that benefits from ICG-guided laser photocoagulation. A multicentric randomized controlled clinical study is, however, mandatory to confirm this result.

[Secondary complications in surgery of epiretinal membranes]. / Complications secondaires à la chirurgie des membranes épirétiniennes.

MATERIAL AND METHODS: Preoperative findings, intraoperative and postoperative complications as final results of 70 consecutive cases of idiopathic or secondary ERM operated by the same retina surgeon were analyzed. RESULTS: In all cases the ERMs were successfully removed from the fovea. The mean v.a. increased from 0.34 +/- 0.2. to 0.54 +/- 0.31, (p < 0.05) postoperatively. Idiopathic and secondary ERMs both showed significant improvement after surgery. Complications included intraoperative hemorrhage and retinal tears. Postoperative progressive nuclear sclerosis, retinal tears causing detachments, macular edema and retinal pigmentary epitheliopathy. CONCLUSIONS: Performing surgery for ERMs is worthwhile on eyes with major decreased v.a. and on eyes with metamorphopsia but only moderately reduced vision. Postoperative complications are frequent but can usually be managed successfully. Of them only retinal detachment is of some worse prognosis on the final functional outcome.

[Nitric oxide donors and retinal vein occlusion]. / Donneurs de NO et occlusion veineuse rétinienne.

PURPOSE: The development of extended territories of nonperfused capillaries after branch vein occlusion (b.v.o.) is correlated to the secondary constriction of the arteriole crossing the occluded territory. Local NO release is impaired soon after b.v.o. and accounts for the secondary arteriolar constriction. In this report we present evidences showing that administration of an NO donor can reverse the secondary arteriolar vasoconstriction observed after b.v.o. MATERIAL AND METHODS: Simultaneous preretinal NO profiles and arteriolar diameter measurements were performed in miniature pigs after experimental b.v.o. The effect of preretinal microinjections of the NO-donor Sodium Nitroprusside on the arteriolar diameter was studied. RESULTS: A significant arteriolar vasoconstriction occurring in parallel with a preretinal [NO] decrease was observed 4 hours after b.v.o. Microinjection of the NO-donor SNP caused a segmental, reversible arteriolar dilatation. CONCLUSION: The present results, suggest that local NO supply in the first hours following b.v.o. may contribute to protect the retina against ischemic injury.

[Results and complications of surgery for idiopathic macular holes]. / Résultats et complications de la chirurgie des trous maculaires idiopathiques.

AIM OF THE STUDY: We conducted a retrospective study in order to evaluate the anatomical and functional outcomes of eyes with constituted idiopathic macular holes as well as the rate of peri and postoperative complications when patients are operated on by conventional surgery. MATERIAL AND METHODS: Twenty-nine consecutive eyes (26 patients) presenting idiopathic macular holes (stage II or III) were included in the study. Conventional vitreous surgery with a three-port system and a careful peeling of the internal limiting membrane and/or an epiretinal membrane was performed. History, preoperative eye examination, operative findings, postoperative course and final examination were reviewed. RESULTS: Anatomical closure was obtained in 76% of the cases after one operation and in 93% following additional operation. Cataract was the most frequent complication (71%). Peripheral iatrogenic, retinal tears were found in 14% of the cases perioperatively, and retinal pigment epithelial anomalies in 24% of the cases postoperatively. DISCUSSION: Conventional surgery of the idiopathic macular holes with careful peeling of the internal limiting membrane and/or an epiretinal membrane is successful for the anatomic closure of the hole in most of the cases. Complications are without major incidence in the visual function.

[NO donors and experimental retinal vein occlusion]. / Donneurs de NO et occlusion veineuse rétinienne expérimentale.

PURPOSE: The development of extended territories of nonperfused capillaries after branch vein occlusion (b.v.o.) is correlated to the secondary constriction of the arteriole crossing the occluded territory. Local NO release is impaired soon after b.v.o. and accounts for the secondary arteriolar constriction. In this report we present evidences showing that administration of an NO donor can reverse the secondary arteriolar vasoconstriction observed after b.v.o. MATERIAL AND METHODS: Simultaneous preretinal NO profiles and arteriolar diameter measurements were performed in miniature pigs after experimental b.v.o. The effect of preretinal microinjections of the NO-donor Sodium Nitroprusside on the arteriolar diameter was studied. RESULTS: A significant arteriolar vasoconstriction occurring in parallel with a pre-retinal [NO] decrease was observed 4 hours after b.v.o. Microinjection of the NO-donor SNP caused a segmental, reversible arteriolar dilatation. CONCLUSION: The present results, suggest that local NO supply in the first hours following b.v.o. may contribute to protect the retina against ischemic injury.

Vitrectomy for traction macular edema.

PURPOSE: Traction macular edema may develop through contraction of macular epiretinal membranes (ERM), or due to persistent vitreomacular traction during the evolution of vitreomacular traction syndrome (VMS). The purpose of this retrospective study was to determine the effect of vitreous surgery and the release of the vitreomacular traction or the removal of epiretinal membranes, on the evolution of traction induced macular edema. MATERIAL AND METHODS: Fourteen eyes from 14 patients presenting with idiopathic or secondary epiretinal membranes, and 11 eyes from 10 patients presenting with vitreomacular traction syndrome, underwent vitrectomy for reduced vision and cystoid macular edema, identified by slit-lamp examination and fluorescein angiography. No coexistent ocular conditions that might have caused macular traction were present. History, preoperative eye examination, operative findings, postoperative course and final examination as well as pre- and postoperative fluorescein angiography were reviewed. RESULTS: In the ERM group, cystoid macular edema disappeared in all cases during the postoperative period and the mean visual acuity (VA) at the end of the follow-up (0.48 +/- 0.23) significantly increased compared to the preoperative one (0.29 +/- 0.2) (p=0.004). In the group of patients suffering from VMS, the posterior vitreous traction on the macula was released and macular edema disappeared in all cases but one. The mean v.a. at the end of the follow-up (0.42 +/- 0.24) significantly increased compared to the preoperative one (0.18 +/- 0.1) (p=0.01). Complications included intraoperative small petechias and postoperative progressive nuclear sclerosis, retinal detachment and retinal pigment epitheliopathy. CONCLUSIONS: Cystoid macular edema may develop secondary to vitreomacular traction syndrome or epiretinal membrane contraction. Vitrectomy is effective in releasing macular traction which, in turn, may induce a decrease of the macular edema with improvement of visual acuity.

Principles of treatment of choroidal neovascularization with photodynamic therapy in age-related macular degeneration.

Age-related macular degeneration (AMD) is a common cause of legal blindness in the developed countries in people older than 50 years of age. AMD complicated by choroidal neovascular membranes (CNV) accounts for 12% of AMD, but for 88% of legal blindness cases. Because of the progressive aging of the population, it is expected that AMD will be one of the greater public health problems in ophthalmology in the first half of the next century. Laser photocoagulation remains the only proven treatment for CNV in AMD, but unfortunately, is applicable only to a minority of patients presenting with CNV in AMD. Photodynamic therapy (PDT) is a new experiment treatment for CNV that combines the application of low-intensity light with a photosensitizing agent in the presence of oxygen to produce tissue effects. It uses the noninvasive potential of the laser light to cause a nonthermal localized chemotoxic reaction and obtain highly selective occlusion of the neovascular channels, with sparing of the overlying photoreceptors. Animal studies showed that PDT accounts for the effective closure of experimentally induced CNV. Phase I-II clinical studies showed that PDT using BPD can safely stabilize leakage from CNV in a majority of patients for up to 3 months. Phase III clinical studies to assess the long term prognosis of PDT-treatment of CNV in AMD are ongoing.

Complications of surgery for epiretinal membranes.

PURPOSE: Surgery has been successful in removing epiretinal membranes (ERM) from the macula, allowing some improvement in vision in 80-90% of patients; however, complications are relatively frequent. We conducted a retrospective study to evaluate the rate of peri- and postoperative complications and their influence on functional outcome of eyes having been operated on for ERM. MATERIAL AND METHODS: Preoperative findings, intraoperative and postoperative complications as final results of 70 consecutive cases of idiopathic or secondary ERM operated on by the same retina surgeon were analyzed. RESULTS: In all cases the ERMs were successfully removed from the fovea. The mean visual acuity (VA) increased from 0.34 +/- 0.2 to 0.54 +/- 0.31 (P < 0.05) postoperatively. Idiopathic and secondary ERM both showed significant improvement after surgery. Complications included intraoperative hemorrhage and retinal tears and postoperative progressive nuclear sclerosis, retinal tears causing detachments, macular edema and retinal pigmentary epitheliopathy. Final VA was not significantly different from the mean after complications, apart from when retinal detachments involved the macular area. CONCLUSIONS: Performing surgery for ERM is worthwhile in eyes with major decreased VA and in eyes with metamorphopsia but only moderately reduced vision. Postoperative complications are frequent but can usually be managed successfully. Of them, only retinal detachment has a negative effect on the final functional outcome.

[Serous central chorioretinopathy and endogenous hypercortisolemia]. / Choriorétinopathie séreuse centrale et hypercortisolémie endogène.

BACKGROUND: The exact pathogenic mechanism of the accumulation of subretinal fluid at the posterior pole of the fundus in cases of central serous chorioretinopathy (CSC) is not well established. Recently, it was reported that CSC is more frequent among patients with endogenous Cushing's syndrome. Thus, it has been suggested that glucocorticoids might be involved in the pathogenesis of CSC. Subsequently, additional observations, have confirmed the relationship between glucocorticoids and CSC. We present preliminary data on the endogenous cortisol secretion in patients with CSC. PATIENTS AND METHOD: Sixteen patients (14 men and 2 women, 35-65 years of age) suffering from CSC, not exposed to exogenous glucocorticoids and without clinical and/or biological stigmata of endogenous Cushing's syndrome, have been examined. Twenty four hour urinary free cortisol (24 h-UFC) secretion was measured within one week of their CSC episode. Twenty four hour urinary free cortisol of age and sex matched controls were also measured. RESULTS: Twenty four hour urinary free cortisol was 188.20 nmol/l +/- 34.1 for the patients suffering from CSC and 115.3 nmol/l +/- 63.4 for the control group (p < 0.05). CONCLUSION: These results give additional evidence that glucocorticoids may play a role in the pathogenesis of CSC. However, given the substantial variability of urinary free cortisol levels, as indicated by the increased SD, additional number of patients should be examined.

[Myofibroblasts and retinal fibrovascular membranes]. / Myofibroblastes et membranes fibrovasculaires rétiniennes.

INTRODUCTION: Epiretinal tissue proliferations occurring during the evolution of ischemic microangiopathies or preretinal diseases are tough to cause retinal detachment by traction mechanisms. Cellular migration/proliferations and finally contraction are tough to be the pathogenic element. Myofibroblasts are contractile cells having features intermediate between those of the fibroblasts and smooth muscle. We conducted a study to explore whether such cells are present in preretinal membranes. MATERIALS AND METHODS: 8 membranes, preelevated during vitrectomy for proliferative vitreoretinopathy or diabetic proliferative vitreoretinopathy, were analysed with immunostaining technique searching for alpha-actine smooth muscle, desmine, which are specific markers for myofibroblasts and TGF-beta1, that is considered as the mean factor promoting the transformation of fibroblasts into myofibroblasts. RESULTS: All the histological preparation showed abundant staining with antibody against alpha-actine smooth muscle, desmine and TGF-beta1. CONCLUSIONS: Myofibroblasts are one of the major cellular element of preretinal membranes. They are scattered throughout the membrane and seem to account for their contractile properties.

[Surgery of idiopathic epiretinal membranes: functional results and complications]. / La chirurgie des membranes épirétiniennes idiopathiques. Résultats fonctionnels et complications.

PURPOSE: Surgery has been successful in removing epiretinal membranes from the macula allowing some improvement in vision in 80 to 90% of patients, however complications are relatively frequent. We conducted a retrospective study to evaluate the rate of peri- and postoperative complications and their influence on functional outcome of eyes having been operated for idiopathic epiretinal membranes. MATERIAL AND METHODS: Preoperative findings, intraoperative and postoperative complications as well as outcome in 40 consecutive cases of idiopathic epiretinal membranes operated by the same retina surgeon were analyzed. RESULTS: In all cases the epiretinal membranes were successfully removed from the fovea. The mean visual acuity increased from 0.36 +/- 0.2 to 0.54 +/- 0.3, (p < 0.05) postoperatively. Peroperative complications included intraoperative hemorrhage (18%) and retinal tears (10%). Postoperatively progressive nuclear sclerosis was observed in 75% of the cases and retinal tears causing detachments in 10%. CONCLUSIONS: Performing surgery for ERMs is worthwhile on eyes with major decreased visual acuity (< 0.25) as on eyes with metamorphopsia but only moderately reduced vision. Postoperative complications are frequent but can usually be managed successfully. Of them only retinal detachment involving the macula is of worse prognosis on the final functional outcome.