Primary pars plana vitrectomy versus scleral buckle surgery for the treatment of pseudophakic retinal detachment: a randomized clinical trial.

OBJECTIVE: To compare the anatomical and functional outcome of scleral buckle (SB) surgery with that of pars plana vitrectomy (PPV) alone in the treatment of primary rhegmatogenous pseudophakic retinal detachment (RD). METHODS: In this prospective, randomized clinical trial, 150 eyes of 150 patients with pseudophakic RD and proliferative vitreoretinopathy (PVR) stage B or less were randomized to SB surgery (75 eyes) or primary PPV (75 eyes). SB surgery involved break localization, cryotherapy, placement of a circumferential 240 style 2.5-mm solid silicone band, combined with a local buckle when indicated, and transscleral drainage of subretinal fluid. PPV included extensive vitreous removal, perfluoro-n-octane injection or endodrainage of subretinal fluid to flatten the retina, cryopexy treatment of breaks, and fluid/air exchange with injection of 20% SF6. Postoperative follow-up was 1 year. Break diagnosis, operating time, intraoperative and postoperative complications, retinal reattachment rate for single as well as multiple surgeries, axial length changes, and best-corrected visual acuity at 1 year after surgery were the main outcome measures. RESULTS: The number of eyes that were diagnosed with additional breaks inter-operatively was higher in the PPV group (P=0.004, chi test). Mean operating time was significantly less (P=0.0001, t-test) in the PPV group. With a single surgery, the retina was reattached in 62 eyes (83%) in the SB surgery group and in 71 eyes (94%) in the PPV group (P=0.037, Fisher exact test). With subsequent surgeries, final anatomical reattachment was achieved in 71 cases in the SB surgery group and in 74 cases in the PPV group (P=0.37, Fisher exact test). Mean axial length change at 1 year was 0.95 mm in the SB surgery group and 0.1 mm in the PPV group (P=0.0001, t-test). Mean final best-corrected visual acuity (logMAR) was 0.40 in the SB surgery group and 0.33 in the PPV group (P=0.26, t-test). CONCLUSIONS: Primary PPV offers potential advantages over SB surgery in the treatment of pseudophakic RD, including less operating time, accurate diagnosis of breaks, higher reattachment rate with a single surgery, and no postoperative axial length changes. Retinal reattachment rate with multiple surgeries and final visual acuity at 1 year were similar for SB surgery and PPV.

Non-contact holmium:YAG laser thermal keratoplasty for hyperopia: two-year follow-up.

PURPOSE: We evaluated the safety and efficacy of the non-contact holmium:YAG laser thermal keratoplasty (LTK) for the treatment of mild to moderate hyperopia without astigmatism. METHODS: A prospective, non-comparative case series included 50 eyes of 28 patients (aged > or =40 years) who had stable refraction and an astigmatic component < +0.50 diopters (D). We applied the non-contact pulsed holmium:YAG laser to treat the hyperopic spherical component using the Hyperion LTK System. All patients had minimum 12-month follow-up and 64% (18 patients) had 24-month follow-up. RESULTS: The mean age of patients was 48.4 +/- 8.23 years (range: 40 to 62 years). The preoperative hyperopic mean spherical equivalent refraction was +2.32 +/- 0.975 D (range: +1.00 to +4.75 D). Postoperatively, the subjective manifest refraction decreased from the preoperative mean value of +2.32 D to a mean -0.09 D at 1 month after surgery and regressed to +0.315 D at the last follow-up examination, resulting in a mean correction of +2.005 +/- 0.81 D at 24 months after surgery. Preoperatively, mean uncorrected visual acuity in LogMAR units was 0.798 +/- 0.353 and at 12 months after surgery, it was a mean 0.108 +/- 0.136. Keratometric power increased from 42.595 +/- 1.949 D before surgery to 44.605 +/- 1.626 D at 24 months after surgery. CONCLUSIONS: Holmium:YAG LTK was an acceptable alternative for the correction of mild to moderate hyperopia in this middle-aged population.

Posterior capsule rupture and vitreous loss during phacoemulsification with or without the use of an anterior chamber maintainer.

PURPOSE: To compare the incidence of posterior capsule rupture and vitreous loss during phacoemulsification with and without the use of an anterior chamber maintainer (ACM) SETTING: Aristotle University Eye Clinic, Thessaloniki, Greece. METHODS: The surgical records of patients who had phacoemulsification by experienced surgeons over a 2-year period were reviewed. The cases were divided into 2 groups: surgery performed without the use of an ACM (no-ACM group) and surgery performed with the use of an ACM (ACM group). RESULTS: The no-ACM group comprised 231 cases and the ACM group, 312 cases. Posterior capsule rupture occurred in 19 cases (8.22%) and 22 cases (7.05%), respectively. Of the patients with posterior capsule rupture, 6 (31.57%) in the no-ACM group and 16 (72.72%) in the ACM group had vitreous loss and required an anterior vitrectomy; the difference between the 2 groups was statistically significant (P =.03). CONCLUSIONS: The use of an ACM in phacoemulsification provided a consistently deep anterior chamber and approximately the same rate of complications as with a standard technique in the hands of experienced surgeons. However, when posterior capsule rupture occurred, the incidence of vitreous loss was significantly higher in eyes with an ACM.

A-scan quantitative echography of senile cataracts and correlation with phacoemulsification parameters.

PURPOSE: To study the echographic appearance of various types of senile cataracts using a-scan quantitative echography and correlate these findings with phacoemulsification parameters indicating surgical lens hardness. METHODS: The study involved 71 eyes with senile cataracts and 20 additional eyes with normal human lenses. Cataract and clear lenses were studied using A-scan quantitative echography and with a tissue sensitivity gain setting of 74 db. We assessed the lens internal reflectivity in the A-scan echograms within a range of 0% to 100%, and calculated the mean of all spikes. All eyes with cataract underwent clear corneal phacoemulsification. At the end of the operation we recorded the phacoemulsification time and mean percent power. We determined the correlations of echographic and phacoemulsification data. RESULTS: Quantitative echography in the 71 studied eyes with cataract revealed acoustic reflections having various configurations according to the biomicroscopic type of cataract, i.e. cortical, nuclear, corticonuclear, brunescent, white intumescent. The mean of all echographic spikes within the cataract lenses varied from 3% (in some brunescent very sclerotic lenses) to 53%. Echographic reflections were not observed in the A-scan echograms of 20 additional eyes with normal human lenses. The mean of internal lens spikes correlated negatively with phacoemulsification time (p < 0.001; r = -0.703) and mean percent phacoemulsification power (p < 0.001; r = -0.57). CONCLUSIONS: The results indicate that A-scan quantitative echography may be used as an adjunctive tool in the preoperative evaluation of cataracts, particularly in cases with compromized visualization of the lens (small pupil, corneal opacities).

Perfluorocarbon liquid utilization in primary vitrectomy repair of retinal detachment with multiple breaks.

PURPOSE: To evaluate the efficacy of pars plana vitrectomy in conjunction with intraoperative perfluoro-n-octane (PFO) use as initial treatment of retinal detachment (RD) with multiple breaks located at various distances from the ora serrata. METHODS: Twenty-two consecutive eyes (15 phakic, 2 aphakic, and 5 pseudophakic) presenting with RD with multiple breaks and tears underwent primary pars plana vitrectomy, PFO retinal reattachment, transcleral cryopexy or endolaser treatment of breaks, PFO/air exchange, and final injection of 18% perfluoropropane (C3F8). Scleral buckles were not used. The mean follow-up period was 29 months. RESULTS: Temporary PFO utilization attached the posterior retina and facilitated the safe removal of vitreous at its base and around the retinal tears. Intraoperative complications included new breaks (3 eyes), enlargement of breaks (2 eyes), and a small bubble of subretinal PFO (1 eye). Postoperatively, the retina remained attached during follow-up in 19 eyes. Cataract developed or progressed in 13 phakic eyes. CONCLUSIONS: Pars plana vitrectomy in conjunction with intraoperative PFO utilization is effective as initial treatment of RDs with multiple breaks. The main limitation of this technique is the postoperative progressive cataract formation in phakic eyes.

Removal of the internal limiting membrane under perfluorocarbon liquid to treat macular-hole-associated retinal detachment.

PURPOSE: To demonstrate the advantages and efficacy of internal limiting membrane removal under perfluorocarbon liquid in macular-hole-associated retinal detachment. DESIGN: Interventional case series. METHOD: Four patients with macular-hole-associated retinal detachment underwent pars plana vitrectomy, retinal reattachment with endodrainage through the macular hole, perfluoro-n-octane injection to seal the macular hole, indocyanine green injection under the perfluoro-n-octane bubble and removal of the indocyanine green-stained internal limiting membrane. Visual acuity and anatomic results were recorded, with a mean follow-up period of 18 months. RESULTS: Postoperatively, the retina was reattached in all four patients and closure of the macular hole was achieved in three eyes. Visual acuity improved in all eyes. CONCLUSIONS: In retinal detachment resulting from macular hole, staining of the internal limiting membrane with indocyanine green injected under perfluoro-n-octane can facilitate peeling of the membrane without exertion of excessive retinal traction and may prevent passage of indocyanine green into the subretinal space.

Sulcus implantation of a 3-piece, 6.0 mm optic, hydrophobic foldable acrylic intraocular lens in phacoemulsification complicated by posterior capsule rupture.

To evaluate the safety of implanting a 3-piece, 6.0 mm optic, foldable acrylic intraocular lens (IOL) in cases of posterior capsule rupture during phacoemulsification. Department of Ophthalmology, Ahepa Hospital, Aristotle University Medical School, and Interbalkan Medical Center, Thessaloniki, Greece. This prospective noncomparative case series included 28 eyes (28 patients) having phacoemulsification complicated by extensive posterior capsule rupture with or without vitreous loss. In all eyes, a 3-piece, 6.0 mm optic, foldable acrylic IOL (AcrySof MA60BM, Alcon) was implanted in the sulcus. Postoperative examination included best corrected visual acuity (BCVA), anterior segment biomicroscopy, IOL centralization and position, intraocular pressure (IOP), and fundus biomicroscopy. The follow-up was 6 months. The most common postoperative complications were transient corneal edema in 12 eyes and increased IOP in 11 eyes. Slight asymptomatic decentralization from the center of the pupil (1.0 to 2.0 mm) and pseudophacodonesis were observed in 5 eyes each. Friction of the IOL with the iris occurred in 1 eye. Clinically significant cystoid macular edema occurred in 3 eyes. The final BCVA was between 20/15 and 20/25 in 18 patients, 20/30 in 2, between 20/40 and 20/50 in 4, and between 20/60 and 20/200 in 4. AcrySof IOL implantation in the sulcus during phacoemulsification complicated by posterior capsule rupture preserved the advantages of small-incision surgery. The postoperative behavior and centralization of the IOLs resembled those of poly(methyl methacrylate) lenses.

Mitomycin C therapy for conjunctival-corneal intraepithelial neoplasia.

PURPOSE: To evaluate the efficacy and safety of topical mitomycin C (MMC) for conjunctival-corneal intraepithelial neoplasia (CCIN). METHODS: One patient with primary CCIN received seven applications for 3 minutes of mitomycin C 0.02%, for 2 weeks, on alternative days. The size of the CCIN before and after the treatment and ophthalmic mitomycin C related complications were evaluated. RESULTS: The lesion started to regress during the second month after the last application of mitomycin C, and by the third month it disappeared completely. The patient remains disease free after 36 months follow up. The complications of mitomycin C included a mild tearing and a slight conjunctival hyperemia that resolved 7 days after the end of the therapy. CONCLUSION: Multiple applications of mitomycin C could be an effective treatment for selected cases of CCIN.