Internal limiting membrane peeling in macular hole surgery.

PURPOSE: To evaluate prospectively the ability to peel epiretinal membranes and to correlate the degree of membrane peeling to anatomic success rates. DESIGN: Consecutive, noncomparative, interventional case series. PARTICIPANTS: One hundred ninety-three patients. METHODS: The extent of membrane peeling and other intraoperative features were correlated to endpoints. MAIN OUTCOME MEASURES: Anatomic success (inducing hole closure), visual acuity of 20/50 or better, and visual improvement of two or more Snellen lines. RESULTS: One hundred ninety-three eyes were eligible for the study by virtue of having a minimum follow-up interval of 6 weeks. The overall anatomic success rate was 93% in these cases. There was a two-line or more improvement in 72%; 56% attained 20/50 or better visual acuity. The internal limiting membrane was peeled completely in 23%, partially in 43%, and not at all in 34%. The degree of internal limiting membrane peeling was not correlated with the duration of the hole or rate of two-line visual improvement, but was inversely correlated with the rate of anatomic success (P = 0.045). Final visual acuity was correlated with a better preoperative visual acuity, shorter preoperative duration of macular hole, and more complete internal limiting membrane peeling. CONCLUSIONS: Peeling of the internal limiting membrane is not essential for anatomic or visual success in macular hole surgery, but it may be a means to standardize inducement of the proper degree of gliosis. Excessive, unsuccessful attempts at internal limiting membrane peeling may decrease visual success. Techniques delivering a more reproducible, complete, atraumatic peeling of the internal limiting membrane should be studied.

Acrylic intraocular lens placement in conjunction with pars plana vitrectomy.

PURPOSE: To report the results of placing a foldable acrylic intraocular lens through a clear cornea incision in eyes undergoing pars plana vitrectomy. METHODS: This interventional case series is a retrospective report of 15 eyes of 15 consecutive patients undergoing foldable (acrylic) intraocular lens insertion in conjunction with pars plana vitrectomy in a single academic institution. Outcome measures included visual acuity and complications. RESULTS: The intraocular lens was successfully implanted and retained in position in all 15 cases. The intraocular lens did not pose difficulty in examining the fundus or cause any vitreoretinal complications. With mean follow-up of 4.5 months (range, 1--10 months), final median postoperative visual acuity range was 20/200 (range, 20/40--2/200) and consistent with the level of vitreoretinal disease. CONCLUSION: Acrylic intraocular lenses may be safely implanted in conjunction with pars plana vitrectomy in selected cases.

Long-term follow-up of unoperated macular holes.

OBJECTIVE: To investigate the anatomic and visual acuity outcomes among patients with unoperated macular holes and at least 5 years of follow-up. DESIGN: Retrospective, noncomparative case series from an institutional practice setting. PARTICIPANTS: All patients with unoperated full-thickness macular holes evaluated at Bascom Palmer Eye Institute between January 1, 1968 and December 31, 1993 and observed for at least 5 years. METHODS: Demographic and clinical data were abstracted from patients' medical records and ophthalmologic photography records. For patients with bilateral macular holes, only one eye was included. MAIN OUTCOME MEASURES: Visual acuity and clinical features on initial examination, at 5 years, and at final follow-up. RESULTS: The study included 65 eyes of 65 patients with a median age of 65 years (range, 52-85 years) and a median follow-up of 9.3 years (range, 5-29 years). On initial examination at Bascom Palmer Eye Institute, the macular hole was stage 2 in 15 eyes (24%), stage 3 in 23 eyes (37%), and stage 4 in 25 eyes (40%). At final follow-up, the macular hole was stage 3 in 10 eyes (16%) and stage 4 in 53 eyes (84%). Visual acuity was 20/200 or worse in 35 eyes (54%) on initial examination, in 43 eyes (74%) at 5 years, and in 53 eyes (82%) at final follow-up. Poorer visual acuity on initial examination was a significant predictor of poorer final vision (P < 0.01). Other accompanying clinical features such as the presence of operculum, posterior vitreous detachment, and epiretinal membrane were not significantly associated with final vision. Throughout follow-up, there was a redistribution and reduced number of yellow nodular opacities at the level of the retinal pigment epithelium at the base of the macular holes and the development of retinal pigment epithelial atrophy around the macular holes. CONCLUSIONS: Long-term follow-up of unoperated macular holes demonstrates progression in hole size and stage, vision loss which generally stabilizes at the 20/200 to 20/400 level, a redistribution and reduced number of yellow nodular opacities at the level of the retinal pigment epithelium, and the development of retinal pigment epithelial atrophy surrounding the macular hole, resulting in a "bull's-eye" macular appearance.

Surgery for idiopathic macular holes associated with extensive subretinal fluid.

PURPOSE: To study the baseline characteristics and outcomes of surgery for idiopathic macular holes associated with localized macular detachment. METHODS: In this case-control study, eight consecutive patients with idiopathic macular hole associated with localized macular detachment (cases) and 30 randomly selected patients with idiopathic macular hole not associated with macular detachment underwent macular hole surgery. RESULTS: The mean age (62.1 versus 68.2 years; P = 0.086), mean refractive error (-0.13 versus +0.23 diopters; P = 0.68), average duration of symptoms (5.9 versus 4.6 months; P = 0.47), and macular hole stage (P = 0.43) were similar in the cases and controls. The baseline visual acuity ranged from 20/50-20/80 (1 [13%] versus 1 [3%]) to 20/100-20/200 (2 [25%] versus 24 [80.0%]) to < 20/200 (5 [63%] versus 5 [17%]) (P = 0.10). Single-operation anatomic success was achieved in 2 (25%) cases and 24 (80%) controls (P = 0.007). Visual acuity 3 months after the last macular hole surgery was worse in cases compared to controls: > or = 20/40 in 0 versus 6 (20%), 20/50-20/80 in 1 (13%) versus 13 (43%), 20/100-20/200 in 4 (50%) versus 10 (33%), and < 20/200 in 3 (38%) versus 1 (3%) (P = 0.003). The mean improvement in visual acuity was 0.2 logMAR units in cases versus 0.4 logMAR units in controls (P = 0.054). CONCLUSIONS: Surgical outcomes for idiopathic macular hole associated with a localized macular detachment compare poorly with the outcomes for macular hole not associated with extensive surrounding subretinal fluid.

Outcomes of vitreoretinal surgery for complications of branch retinal vein occlusion.

OBJECTIVE: To investigate outcomes of vitreoretinal surgery for complications of branch retinal vein occlusion (BRVO). DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: The medical records of all patients who underwent vitreoretinal surgery for complications of BRVO at Bascom Palmer Eye Institute between January 1, 1991 and December 31, 1998 were reviewed. Thirty-six eyes from 36 consecutive patients were identified. MAIN OUTCOME MEASURES: Visual acuity outcomes include preservation of preoperative visual acuity and visual acuity greater than or equal to 20/40, 20/200 and 5/200. When preoperative retinal detachment was present, the anatomic outcome assessed was complete retinal attachment. Postoperative event rates of retinal detachment, vitreous hemorrhage, epiretinal membrane (ERM), and cataract were tabulated. All outcomes were assessed at 6 months. RESULTS: Surgical indications included nonclearing vitreous hemorrhage (17 patients), traction retinal detachment involving the macula (15), and ERM (4). Mean follow-up was 19 months. Preoperatively, best-corrected vision was greater than or equal to 20/200 in 19/36 (53%) eyes. Six months postoperatively, best-corrected vision was greater than or equal to 20/40 in 12/36 (33%) eyes, greater than or equal to 20/200 in 27/36 (75%) eyes, and greater than or equal to 5/200 in 31/36 (86%) eyes. Postoperative complications included retinal detachment (2/36; 6% eyes), ERM (3; 8%), vitreous hemorrhage (2; 6%), suprachoroidal hemorrhage (1; 3%), central retinal vein occlusion (1; 3%), and central retinal artery occlusion (1; 3%). Clinical features associated with better visual outcome include better preoperative visual acuity (P: = 0.05), absence of preoperative afferent pupillary defect (P: = 0.01), and absence of preoperative macular edema (P: = 0.08). CONCLUSIONS: Following surgery, retinal attachment and improved visual acuity were achieved in the majority of patients. Pre-existing pathology and postoperative complications may limit final vision in eyes with BRVO.

Outcomes of macular hole surgery in severely myopic eyes: a case-control study.

PURPOSE: To evaluate the outcomes of macular hole surgery in highly myopic eyes and to compare these outcomes with a control group of eyes that were not severely myopic. METHODS: The study design was a matched, case-control, retrospective chart review. The participants included 26 eyes of 24 patients who had vitreous surgery for macular holes. The eyes were divided into two groups: 13 consecutive eyes with severe myopia (defined as -6.00 diopters of refractive error or greater) and 13 control eyes without severe myopia that were operated on immediately before or after each study eye, with the most recently operated eye chosen. The main outcome parameters were preoperative and final follow-up visual acuity, macular hole closure rates, reoperation rates, duration of preoperative symptoms, and follow-up time. RESULTS: Using the Snellen equivalent of logarithm of minimal angle of resolution (logMAR) units, visual acuity improved after macular hole surgery in severely myopic eyes from 20/152 to 20/89 (P =.041) and in control eyes from 20/152 to 20/47 (P <.001). At final follow-up, visual acuities were lower in severely myopic eyes compared with control eyes (P =.048). Macular hole closure rates, reoperation rates, duration of pre-operative symptoms, and follow-up intervals were not significantly different statistically between groups. CONCLUSIONS: Macular hole surgery results in anatomical and visual improvements in severely myopic eyes but generally yields poorer visual acuity outcomes compared with eyes that are not severely myopic.

Outcomes and complications associated with perfluoro-n-octane and perfluoroperhydrophenanthrene in complex retinal detachment repair.

OBJECTIVE: To compare rates of perfluorocarbon liquid (PFCL) intraocular retention, anatomic and visual acuity outcomes, and complications associated with intraoperative perfluoro-n-octane (Perfluoron) versus perfluoroperhydrophenanthrene (Vitreon) in retinal detachment repair. DESIGN: Retrospective noncomparative consecutive case series. PARTICIPANTS AND METHODS: Records of consecutive patients who underwent retinal detachment repair with intraoperative Perfluoron (n = 78) or Vitreon (n = 84) at the Bascom Palmer Eye Institute between November 1, 1991, and October 31, 1994, were retrospectively reviewed. MAIN OUTCOME MEASURES: Comparison of PFCL intraocular retention rates, retinal reattachment rates, visual acuity outcomes, and postoperative complication rates between the Perfluoron and Vitreon groups at postoperative day 1, week 1, month 1, month 3, and month 6. To assess the study's generalizability, the Perfluoron data obtained in the current study were compared with results of the Perfluoron Multicenter Clinical Study. RESULTS: Retained Perfluoron was noted less frequently (P < 0.03) than retained Vitreon at each postoperative visit assessed. At 6 months postoperatively, the cumulative rate of retained PFCL (noted at any of the study postoperative visits) was 7.8% of patients in the Perfluoron group and 38.3% in the Vitreon group (P < 0.001). No significant difference was found between the groups in retinal reattachment rates; at 6 months postoperatively, the retina was attached in 45 of 61 (74%) patients in the Perfluoron group and 36 of 57 (63%) patients in the Vitreon group (P = 0.2). There was a trend (P = 0.055) toward better 6-month visual acuity in the Perfluoron group compared with the Vitreon group. The incidence of corneal abnormality at any study visit was 46.7% in the Perfluoron group and 77.4% in the Vitreon group (P < 0.001). At 6 months postoperatively, the cumulative rate of elevated intraocular pressure (>25 mmHg) was 13 +/- 4% and 37 +/- 5%, respectively (P = 0.004). No significant difference was found between the groups in rates of postoperative hypotony. Results of this study are comparable with those observed in the Perfluoron Multicenter Clinical Study. CONCLUSIONS: In this study, Perfluoron was retained intraocularly less frequently than Vitreon. Although no significant difference was found between groups in retinal reattachment rates, Perfluoron is associated with slightly better 6-month visual acuity and lower rates of corneal abnormality and elevated intraocular pressure compared with Vitreon.

Combined pars plana vitrectomy and glaucoma drainage implant placement for refractory glaucoma.

PURPOSE: To report visual acuity and intraocular pressure outcomes among patients who have undergone combined pars plana vitrectomy and placement of a glaucoma drainage implant. METHODS: The medical records of all patients who underwent combined pars plana vitrectomy and placement of a glaucoma drainage implant at the Bascom Palmer Eye Institute by one of the authors between January 1, 1990, and February 28, 1998, were reviewed. Forty patients (40 eyes) were identified, including 14 patients with neovascular glaucoma secondary to proliferative diabetic retinopathy or central retinal vein occlusion, 15 patients with other posterior segment disease, seven patients with secondary angle-closure glaucoma, and four patients with aphakia with ruptured anterior hyaloid face. Main outcome measures included visual acuity and intraocular pressure at 1 year postoperatively. RESULTS: At 1 year postoperatively, 31 (77.5%) of 40 patients had stable or improved visual acuity; three eyes (7. 5%) had a final visual acuity of no light perception and three additional eyes (7.5%) were enucleated (because of chronic pain in two eyes and endophthalmitis in one eye). Mean preoperative intraocular pressure was 34 mm Hg and the median number of preoperative antiglaucoma medications was two. At 1 year postoperatively, mean intraocular pressure was 13 mm Hg and the median number of antiglaucoma medications was zero. Twenty-two patients (55.0%) achieved an intraocular pressure greater than 5 mm Hg and less than or equal to 21 mm Hg without antiglaucoma medication, and an additional seven patients (17.5%) achieved this level of intraocular pressure control with medication. Only one patient (2.5%) underwent further glaucoma surgery for uncontrolled intraocular pressure. CONCLUSIONS: Although combined pars plana vitrectomy and placement of a glaucoma drainage implant is often a successful management option in selected patients with refractory glaucoma, visual outcome may be poor because of severe underlying ocular disease and postoperative complications.

Surgical management and outcomes of dislocated intraocular lenses.

OBJECTIVE: To evaluate the surgical management and visual acuity outcomes in a large series of patients with dislocated intraocular lenses (IOLs). DESIGN: Retrospective consecutive noncomparative case series. PARTICIPANTS: All patients who underwent surgical management of dislocated IOLs by two vitreoretinal surgeons at one institution between January 1, 1991, and March 31, 1998. METHODS: Demographic and clinical data were abstracted from patients' medical records. MAIN OUTCOME MEASURES: Visual acuity at final follow-up and surgical complications. RESULTS: The study population consisted of 110 patients, with a median follow-up interval of 50 weeks after dislocated IOL management. Surgical techniques included IOL repositioning in 93 (84.5%) eyes, IOL exchange in 16 (14.5%) eyes, and IOL removal in 1 (1 %) eye. Final visual acuity was > or =20/40 in 63 patients (57%) patients, 20/50-20/200 in 34 (31%) patients, and <20/200 in 13 (12%) patients. Ninety-nine (90%) patients had stable or improved final vision. Observed complications included postoperative retinal detachment in 7 (6.3%) eyes, chronic cystoid macular edema in 19 (17%) eyes, and suprachoroidal hemorrhage in 1 (1%) eye. CONCLUSIONS: Surgical management of dislocated IOLs usually results in satisfactory visual outcomes. Pre-existing ocular pathology and postoperative complications may limit final vision.

Choroidal neovascularization following macular hole surgery.

BACKGROUND: Retinal pigment epitheliopathy, a recognized finding in eyes that have undergone macular hole surgery, may limit visual outcome and predispose to the development of choroidal neovascularization (CNV). This study reports on the features and outcomes of CNV following otherwise successful surgery for idiopathic macular holes. METHODS: Case series including three eyes of two patients who developed CNV following macular hole surgery. RESULTS: Choroidal neovascularization developed 3 to 30 months after macular hole surgery. The CNV was crescent-shaped, surrounding a central area of retinal pigment epithelial mottling that corresponded to the site of the macular hole in all three cases. All neovascular membranes were adjacent to the fovea and were associated with substantial leakage of fluorescein. The macular hole remained closed in all cases. CONCLUSION: Choroidal neovascularization is a rare complication following macular hole surgery. Retinal pigment epitheliopathy and defects in the Bruch's membrane, pre-existing or secondary to surgery, may be predisposing factors.

Quality of life of low-vision patients and the impact of low-vision services.

PURPOSE: To investigate the functional status and quality of life of patients at a low-vision clinic and to evaluate the impact of low-vision services. METHODS: Interviews, including the Medical Outcomes Study 36-Item Short Form (SF-36), the Visual Function-14 (VF-14), and the 51-item Field Test Version of the National Eye Institute Visual Functioning Questionnaire (NEI-VFQ), were administered to 156 consecutive patients 1 week before and 3 months after their low-vision clinic visit. RESULTS: Low-vision patients scored lower (P < .001) in physical functioning and role limitations caused by physical and emotional health problems than published SF-36 scores of the age-appropriate United States normal population, patients with congestive heart failure, and clinically depressed patients. Low-vision services were associated with improvement in the subjective functional status of 150 patients (98.7%) and were rated "very useful" by 82 (53.9%) patients. The SF-36 scores did not change significantly after low-vision services. The VF-14 mean score improved from 35.8 to 41.2 (P < .001). Four NEI-VFQ subscale scores improved significantly (P < .001): general vision, near activities, distance activities, and peripheral vision. CONCLUSIONS: The SF-36, VF-14, and NEI-VFQ demonstrate that low-vision clinic patients perceive marked impairment of functional status and quality of life. Low-vision services are associated with high patient satisfaction. Vision-targeted questionnaires are more sensitive than general health-related quality of life questionnaires to changes in functional status and quality of life after low-vision services, and they may help elucidate the outcomes of low-vision services.

Retinal detachment associated with macular hole surgery: characteristics, mechanism, and outcomes.

OBJECTIVE: To study the frequency, features, and outcomes of retinal detachment (RD) occurring after macular hole surgery. METHODS: Retrospective review of all cases of macular hole surgery. Cases with postoperative RD were identified for study. Outcome measures included baseline demographic and ocular characteristics, RD features, surgical procedure, macular hole status, and final visual and anatomic outcomes. RESULTS: Retinal detachment occurred in 8 (1.8%) of 438 eyes undergoing macular hole surgery. The rate of RD was 3.5% early in the course of the surgeon's experience (first 200 cases) and 0.4% later in the surgeon's experience (after 200 cases) (P = 0.026). Two of the eight eyes with RD had undergone previous macular hole surgery. All six primary cases occurred after repair of stage 3 macular holes, which had involved peeling of the posterior cortical face. The RD involved the inferior quadrants in seven eyes and the macula in two eyes. The pathogenic retinal break was in the equatorial region in four eyes, was anterior to the equator in two eyes, and remained undetermined in two eyes. The retina was attached and the macular hole was closed in all cases at the final follow-up examination (mean 30 months). The macular hole reopened 2 years following successful reattachment of the RD in one eye. Final visual acuity was > or =20/60 in four eyes and <20/200 in one eye. CONCLUSION: Retinal detachment after macular hole surgery is uncommon, and may be related to posterior cortical vitreous stripping. Early detection of RD minimizes adverse visual and anatomic outcomes.

Vitrectomy in the management of diabetic retinopathy.

According to the Early Treatment Diabetic Retinopathy Study, at least 5% of eyes receiving optimal medical treatment will still have progressive retinopathy that requires laser treatment and pars plana vitrectomy. During the past decade, improvements in instrumentation and surgical techniques have allowed more difficult cases of diabetic retinopathy to be candidates for vitrectomy. However, although the thresholds for performing surgery within established indicated situations have been lowered, only a few additional indications have been established. Although vitrectomy improves the prognosis for a favorable visual outcome, preventive measures, such as improved control of glucose levels and timely application of panretinal photocoagulation, produce better results. The authors review the indications, techniques, and results of vitrectomy in the management of diabetic retinopathy.

Combined lensectomy, vitrectomy and scleral fixation of intraocular lens implant after closed-globe injury.

PURPOSE: To describe our experience in the surgical management of cataracts in patients with complications of closed-globe injury using pars plana lensectomy (PPL), pars plana vitrectomy (PPV), and scleral fixation of posterior chamber intraocular lens (PCIOL). METHODS: We retrospectively reviewed charts of all patients with closed-globe injury who underwent PPL, PPV and scleral fixation of PCIOL at our institution between January 1991 and July 1997. We identified 28 eyes; because of less than 2 weeks follow-up, 4 eyes were excluded from the current study. All eyes had lens subluxation/dislocation and visually significant cataract. Additional indications for surgery included secondary glaucoma (10 eyes), vitreous hemorrhage (3 eyes) and retinal detachment (1 eye). RESULTS: The postoperative follow-up interval ranged from 6 to 61 months (mean 18.5 months). Preoperative visual acuity (VA) ranged from 20/60 to hand motion and was 20/100 or better in 6 eyes (25%). Postoperatively, 19 eyes (79%) improved to 20/100 or better. Five eyes had subsequent surgery for the following indications: retinal detachment (2 eyes), poorly controlled glaucoma (2 eyes), and epiretinal membrane formation (1 eye). CONCLUSIONS: In patients undergoing PPL, PPV and scleral fixation of PCIOL for cataract after a closed-globe injury, a substantial visual improvement occurred in a majority of the involved eyes.

Reopening of macular holes after initially successful repair.

OBJECTIVE: To evaluate the frequency and prognosis of reopening of a macular hole after initially successful repair in a defined patient cohort. DESIGN: Retrospective consecutive noncomparative case series. PARTICIPANTS: Seventeen cases of reopened macular holes among 390 cases of idiopathic macular holes that previously had undergone macular hole surgery were studied. MAIN OUTCOME MEASURES: Assessment of demographics, visual acuity, preoperatively, postoperatively, after reopening of macular hole and after reoperation, if applicable, and precipitating factors. RESULTS: There were 17 (4.8%) of 353 cases in which the macular hole reopened after initial successful surgical closure. The mean visual acuity before reopening was 20/48 and was 20/133 after reopening. Twelve eyes underwent reoperation with improvement to a mean visual acuity of 20/54. The five eyes that were not reoperated on maintained a mean visual acuity of 20/200. Ten of the eyes had undergone cataract surgery between macular hole surgeries, but in only one did the reopening appear to occur in association with this procedure. CONCLUSIONS: Reopening of a previously successfully operated macular hole is uncommon and seems to be a spontaneous event. Reoperation generally yields results similar to those present before the reopening. Reopening of a macular hole associated with cataract surgery is rare.