Choroidal Neovascularization After Epiretinal Membrane Removal

Pitchfork sign following pars Plana vitrectomy for idiopathic epiretinal membrane: A case report

PURPOSE

To report a case of pitchfork sign following pars plana vitrectomy for idiopathic epiretinal membrane.

STUDY DESIGN

Case report.

RESULTS

A 75-year-old man was referred to the surgical retina service due to a quantitative and qualitative decline in vision in the left eye (LE) for several months. Optical coherence tomography (OCT) examination revealed the presence of a stage III epiretinal membrane (ERM) according to the Govetto classification. Seven days after undergoing a 25-gauge pars plana vitrectomy (PPV) with ERM peeling and balanced salt solution (BSS) tamponade, OCT examination revealed the presence of the 'pitchfork sign' in the macular region, along with the detection of a choroidal neovascularization (CNV) through OCT-A examination. After receiving two monthly intravitreal anti-VEGF injections, a complete regression of the MNV was observed.

CONCLUSIONS

We reported, for the first time, the iatrogenic onset of the pitchfork sign following vitreoretinal surgery. This discovery highlights the unique presentation of the pitchfork sign in the context of surgical procedures, expanding our comprehension of its range of causes.

OUTCOMES OF ANTI-VEGF THERAPY IN CHOROIDAL NEOVASCULARIZATION AFTER MACULAR SURGERY

PURPOSE

To report treatment outcomes of anti-vascular endothelial growth factor (VEGF) therapy in choroidal neovascularization (CNV) presenting after macular surgery.

METHODS

Retrospective analysis of 7 eyes of 7 patients, who were diagnosed to have CNV after macular surgery and were treated with anti-vascular endothelial growth factor therapy. Collected data included demographic details; history of present illness; surgical procedure; and clinical examination including visual acuity at presentation and follow-up with imaging and management. Main outcome measures were resolution of CNV activity at the last follow-up. Secondary outcomes included change in visual acuity at final follow-up from baseline, number of injections, treatment free interval, and adverse events.

RESULTS

Seven eyes of 7 patients (2 females and 5 males), which underwent macular surgery (4 macular hole repairs and 3 epiretinal membrane (ERM) removal), were included in this study. Two eyes had drusen at the time of surgery; however, five eyes had no preexisting conditions. Mean interval between surgery and CNV development was 21.07 ± 38.55 months (range, 2 months-9 years). All patients had undergone intravitreal anti-vascular endothelial growth factor injections (range, 2-15; mean number: 5.85) with one eye requiring additional photodynamic therapy (PDT) and focal laser. Visual acuity was unchanged with inactive CNV at the last visit in all eyes after anti-vascular endothelial growth factor therapy. The mean follow-up duration after the development of CNV was 35.5 months (range, 6.5 months-8 years).

CONCLUSION

Choroidal neovascularization occurring after otherwise successful macular surgery is uncommon with unknown predisposing factors. This entity appears to have poor visual outcome with currently available anti-vascular endothelial growth factor therapy.

Epiretinal Membrane Surgery Outcomes in Eyes with Subretinal Drusenoid Deposits: A Case Control Study

PURPOSE

To evaluate outcomes of epiretinal membrane (ERM) surgery in eyes with subretinal drusenoid deposits (SRDDs) and to compare them with those with isolated ERM.

DESIGN

Retrospective case-control study of consecutive patients who underwent pars plana vitrectomy (PPV) with ERM peeling.

PARTICIPANTS

Twenty-five patients with SRDDs on spectral-domain (SD)-OCT who underwent surgery for ERM were included in the study. From the same cohort, for each case, we selected 2 age-matched control participants (50 eyes with isolated ERM). Preoperative best-corrected visual acuity (BCVA) also was matched as closely as possible.

METHODS

All participants underwent PPV and ERM peel for primary ERM.

MAIN OUTCOME MEASURES

Postoperative BCVA, improvement in BCVA, preoperative and postoperative central macular thickness, surgical complications, and development of age-related macular degeneration (AMD) were recorded.

RESULTS

At final examination, mean postoperative BCVA was significantly less for eyes with SRDDs (0.51 logarithm of the minimal angle of resolution [logMAR] vs. 0.21 logMAR; P = 0.0001). Eyes with SRDDs demonstrated less improvement in BCVA after ERM surgery (0.13 logMAR vs. 0.30 logMAR; P = 0.0032). Eyes with SRDDs were significantly less likely to gain 2 or more Snellen lines of BCVA after ERM surgery (28% vs. 56%; P = 0.028). Three of 25 patients (12%) undergoing ERM surgery showed worsening of Snellen BCVA by 2 lines or more. Three of 25 eyes (12%) with SRDDs demonstrated advanced AMD after surgery, compared with 0 participants in the control group (P = 0.034).

CONCLUSIONS

Epiretinal membrane surgery in eyes with SRDDs is associated with less favorable visual outcomes. Fewer patients demonstrate gain in BCVA, whereas a significant number show a deleterious decline. After surgery, AMD incidence seems high and patients may have an increased risk of raised intraocular pressure. These findings require further study to establish whether this represents a causal relationship. Surgeons should be vigilant for these complications. Appropriate patient counseling during the consenting process must be made.

Iatrogenic choroidal neovascularization following idiopathic epiretinal membrane peel

Choroidal neovascularization is an uncommon complication of macular surgery. The functional outcome is poor despite various treatment options, including laser photocoagulation, photodynamic therapy, and a variety of surgical procedures. We report a case of iatrogenic choroidal neovascularization in a 69-year-old woman at the site of inadvertent retinal trauma 5 weeks after an epiretinal membrane peel. Visual acuity was 6/15 at the time of diagnosis. Four intravitreal bevacizumab injections were administered over a period of 6 months; treatment was discontinued when a disciform scar was noted. At last follow-up, 21 months after surgery, the patient's visual acuity was counting fingers.

Vitrectomy after anti-VEGF therapy for epiretinal membranes coincident with age-related subfoveal choroidal neovascularization

BACKGROUND AND OBJECTIVE

To report the visual acuity results in a small case series of eyes undergoing membrane peeling for epiretinal membrane presenting with age-related subfoveal choroidal neovascularization.

PATIENTS AND METHODS

Retrospective chart review of all eyes undergoing vitrectomy with epiretinal membrane peeling after intravitreal anti-vascular endothelial growth factor injection treatment for age-related subfoveal choroidal neovascularization presenting between February 2005 and January 2007 to a private vitreoretinal subspecialty practice.

RESULTS

Four eyes of four patients observed for 10-23 months (median = 20.5 months) were identified. All eyes presented with an angiographically ill-defined choroidal neovascular membrane and epiretinal membrane by optical coherence tomography. After anti-vascular endothelial growth factor therapy, visual acuity improved 1 to 5 Snellen lines (median = 2 lines). After vitrectomy, visual acuity further improved 1 to 6 lines (median = 2 lines). Final visual acuity was unchanged in 1 eye and improved in 3 eyes, with an overall improvement of 0 to 7 Snellen lines (median = 3.5 lines) after 5 to 14 months (median = 8 months) of follow-up following the vitrectomy.

CONCLUSION

In selected eyes presenting with epiretinal membrane and age-related subfoveal choroidal neovascularization after anti-vascular endothelial growth factor therapy, pars plana vitrectomy with membrane peeling may offer further improvement in visual acuity.