Vitreoretinale Zweiteingriffe nach elektiver Makulachirurgie

Incidence of Retinal Detachment after Macular Surgery

Macular surgery has become an increasingly atraumatic procedure for the eye with the surgical methods that have been further developed in recent years. The most common complications include cystoid macular oedema and retinal detachment, more rarely endophthalmitis. The aim of this retrospective study is to record the number of retinal detachments following elective macular surgery. In this study we included all patients who underwent pars plana vitrectomy (ppV, 20 or 25 gauge) in the years 2009 - 2016. We then identified the patients who were hospitalised again because of retinal detachment. For the affected patients, the rate of retinal detachment, functional outcomes and possible risk factors were recorded. A total of 904 eyes were identified, of which 667 had surgery for epiretinal membrane, 188 for macular hole, and 49 for vitreomacular traction with a 20 or 25 gauge ppV. Of these 904, retinal detachment occurred in 17 (1.88%) cases. The mean time between first ppV and second ppV with retinal detachment was 248 days (3 - 1837 days). Two of the 17 patients had at least one retinal break before or during surgery. The retinal break was located inferior in six cases, superior in four; in four cases PVR retinal detachment and in three cases the foramina were distributed. Mean visual acuity was 0.27 (decimal) before macular surgery and 0.28 at the time of last presentation. Modern vitrectomy techniques reduce the complications in elective macular surgery, but do not replace the surgeon's experience.

Prophylactic Circumferential Retinal Cryopexy to Prevent Pseudophakic Retinal Detachment after Posterior Capsule Rupture during Phacoemulsification

Purpose. To evaluate whether prophylactic circumferential retinal cryopexy (CRC) can prevent pseudophakic retinal detachment (PRD) development after posterior capsule rupture (PCR) during phacoemulsification. Methods. Retrospective patient chart analysis of eyes experiencing a PCR during phacoemulsification. Comparison of PRD development between eyes receiving CRC (cryo+ group) or not (cryo- group). Results. Overall 106 patients were analyzed, thereof 61 (58%) in the cryo+ and 45 (42%) in the cryo- group. In both clusters a total of 10 PRDs (9.4%) occurred, thereof 3 (30%) in the cryo+ as well as 7 (70%) in the cryo- group (p = 0.087), 79.8 ± 81.58 weeks after PCR. Relative/absolute risk reduction in CRC-treated eyes was calculated to be 68%/11%. Prophylactic CRC reduced PRD development 0.3-fold. Number needed to treat was estimated to be 9.4. Conclusion. Prophylactic CRC might be a useful treatment option in eyes with PCR to hamper PRD development in the further course. Further research is indicated to evaluate this beneficial effect between eyes with and without a rupture of the anterior vitreous cortex and accompanying vitreous loss in an expanding number of eyes.

Iatrogenic retinal breaks in 25-gauge vitrectomy under air compared with the standard 25-gauge system for macular diseases

PURPOSE

To evaluate the incidence rates of iatrogenic retinal breaks in eyes that underwent 25-gauge vitrectomy under air compared with 25-gauge standard vitrectomy for idiopathic macular holes or idiopathic epiretinal membranes.

METHODS

In this retrospective, comparative interventional study, 435 eyes were enrolled. In all patients after core vitrectomy and epiretinal/inner limiting membrane peeling, complete vitrectomy of the base was performed, respectively under air (air group) or under fluid infusion (standard group).

RESULTS

The number of eyes with iatrogenic retinal breaks was significantly lower in the air group than in standard group (4/197 and 16/238, 2% and 7%, respectively; P = 0.035). A postoperative retinal detachment developed in 2 eyes (1%) in the standard group, and in no eyes of the air group (0%). Factors related to the occurrence of retinal breaks were surgically induced posterior vitreous detachment (P = 0.006), standard vitrectomy (P = 0.023), and surgery for macular hole (P = 0.030).

CONCLUSION

The 25-gauge vitrectomy under air is associated with a lower incidence rate of retinal breaks compared with the standard 25-gauge vitrectomy.

Prophylactic circumferential intraoperative laser retinopexy decreases the risk of retinal detachment after macular hole surgery

PURPOSE

Pars plana vitrectomy with peeling of the internal limiting membrane is a well-established technique for the treatment of idiopathic macular holes with high success rates. Complications such as retinal tears may result from vitreous incarceration at the sclerotomy sites. Prophylactic laser retinopexy (LR) has recently been shown to decrease incidence of postvitrectomy rhegmatogenous retinal detachment but its efficacy in macular hole repair has not been established. In this study we evaluated the safety and efficacy of prophylactic LR and compared the patients to a control group that did not receive prophylactic treatment.

METHODS

A retrospective, consecutive chart review was conducted comparing patients who underwent macular hole repair with LR to without LR. Patient demographics were collected and the number and time interval of retinal detachment in the 2 groups were compared. Statistical analysis was conducted between the 2 groups.

RESULTS

A total of 144 eyes underwent macular hole repair during the study period. A total of 76 eyes underwent LR and 68 eyes did not undergo LR. There were no significant differences in baseline characteristics between the 2 groups. At 1 year, RD occurred in 1 eye (1.31%) in the LR group and in 8 eyes (8.82%) without LR group (p<0.01).

CONCLUSIONS

Prophylactic LR decreases the incidence of postoperative retinal detachment a potentially disabling complication of macular hole repair surgery.

Longterm follow-up of pars plana vitrectomy for vitreous floaters: complications, outcomes and patient satisfaction

PURPOSE

Floaters caused by degenerative or postoperative changes in the vitreous can interfere with all aspects of visual functioning. The aim of this study is to report the longterm outcome of pars plana vitrectomy (PPV) for persistent vitreous opacities.

METHODS

In a retrospective, non-randomized, interventional case study we reviewed all cases of vitreous floaters that were vitrectomized at our department between 1997 and 2006. Patient complaints and satisfaction were assessed by a questionnaire administered at the end of follow-up.

RESULTS

Seventy-three consecutive cases were included (61 patients). Mean Snellen best corrected visual acuity (BCVA) before surgery was 0.81. Overall, 85% of patients complained of severe or very severe difficulty caused by floaters. A total of 42% of eyes were pseudophakic, four of which were operated with combined PPV and phacoemulsification. Mean follow-up time was 37 months. Of the phakic eyes, 60% were operated for cataract during follow-up. One retinal detachment (RD) occurred immediately postoperatively (1.3%) and another four eyes developed RD during longterm follow-up 24-44 months after PPV (5.5% of cases). Postoperative BCVA remained mostly unchanged. Overall, 88% of patients were satisfied with the results of the operation.

CONCLUSIONS

Some patients make considerable complaints as a result of vitreous opacities and their distress does not correlate with visual acuity. Vitrectomy is a safe and effective procedure with which to help these patients. Patients should be informed about the risk of cataract progression, unexpected inflammatory reaction and an increased risk for RD several years after PPV (5.5%).

Iatrogenic retinal breaks in 25-gauge macular surgery

PURPOSE

To describe the incidence and characteristics of iatrogenic retinal breaks in 25-gauge macular surgery.

DESIGN

Retrospective, noncomparative, interventional case series.

METHODS

We included 177 consecutive operations in 171 patients who underwent 25-gauge vitrectomy for idiopathic macular pucker or idiopathic macular hole. Main outcome measures were the incidence of breaks related to the sclerotomies, the incidence of breaks occurring elsewhere, the incidence of lesions suspicious for traction, the location of identified breaks, and intraoperative induction of posterior vitreous detachment (PVD).

RESULTS

Retinal breaks occurred in 15.8% of operations. In 6.2%, breaks were related to the sclerotomies, and in 10.7%, breaks were found elsewhere. In 8.5% of eyes, only lesions suspicious for traction were detected. Breaks or suspicious lesions were treated with external cryocoagulation in a total of 24.3% of cases. A statistically significant relation between PVD induction and presence of breaks elsewhere was identified. No correlation with lens status, initial diagnosis, or preoperative refraction was found. Retinal detachment occurred in 1.7% of cases.

CONCLUSIONS

We report an incidence of retinal breaks that is higher than previously found for 20- or 25-gauge surgery. Despite the high incidence of breaks, the incidence of postoperative retinal detachment was low. A specific characteristic was the relatively high incidence of breaks elsewhere and their relation to PVD induction. Our findings underscore the importance of scrupulous full 360-degree internal search at the end of each procedure to identify and treat all breaks and suspicious lesions optimally.

Wiedereröffnungsrate von Makulaforamina nach Kataraktoperation

BACKGROUND

We set up this retrospective study to examine how different the functional and morphological results are following pars plana vitrectomy (ppV) for idiopathic macular holes in phakic eyes with later cataract surgery and in pseudophakic eyes, and to what extent cataract surgery can induce reopening of idiopathic macular holes after ppV.

METHODS

A total of 189 eyes were vitrectomized because of idiopathic macular hole (37 pseudophakic, 152 phakic); 120 (22 pseudophakic, 98 phakic) of these eyes were examined at follow-up of an average of 19 months after vitrectomy. Cataract surgery was performed in 65 of the phakic eyes in this period. The functional and morphological results recorded for these 22 pseudophakic and 65 phakic eyes were evaluated.

RESULTS

In the pseudophakic eyes preoperative visual acuity was 0.14, increasing to 0.20 postoperatively (p=0.16); in 1 case (4.5%) the macular hole was not closed at the time of the follow-up examination. Cataract extraction was performed in 65 of the phakic eyes an average of 10 months after ppV. The initial VA was 0.19 before ppV and increased to 0.37 (p<0.01) after cataract surgery; in 4 cases (6.2%) the macular hole was not closed by the time of the follow-up examination, but in each case this had already been noted when the cataract extraction was done. Reopening did not occur after cataract extraction in any of these cases.

CONCLUSION

With a rate of 5.7% for reopening or persistence of macular holes, our results are comparable to those recorded in other studies. Cataract surgery following ppV does not influence the reopening rate of macular holes.

Entry-site-related retinal detachment after pars plana vitrectomy

PURPOSE

Today, pars plana vitrectomy represents a standard surgical procedure for a number of retinal diseases that were previously considered inoperable. The aim of the present study is to investigate the entry site of pars plana vitrectomy as a possible source of retinal detachment.

METHODS

We reviewed retrospectively all cases of uncomplicated pars plana vitectomies because of macular hole, macular pucker and diabetic macular oedema performed in our department between 1 January 2001 and 7 July 2004.

RESULTS

Over 3.5 years, 244 pars plana vitrectomies because of macular disease were performed. Sclerotomy-related retinal detachment was observed in 11 (4.5%) cases. These retinal detachments occurred at a mean of 37 (2-100) days after surgery. They appeared within the first 4 weeks in 55% of the cases.

CONCLUSION

Iatrogenic retinal breaks and detachment continue to be a severe complication of pars plana vitrectomy, despite improvements in instrumentation and surgical techniques. A 4.5% incidence of sclerotomy-related retinal detachment after simple vitrectomy calls for action. Current approaches to reduce this complication - such as circular peripheral cryoretinopexy, scleral buckling or 360 degrees laser treatment - are invasive. We recommend extended vitreous base cleaning with scleral indentation and examination of the entry sites, performed with a three-mirror lens or via careful indirect ophthalmoscopy into the periphery, 4 weeks after surgery.

[Incidence and prophylaxis of retinal detachment following pars plana vitrectomy]

PURPOSE

The aim of this study was to investigate the incidence of retinal detachment (RD) following pars plana vitrectomy and the efficacy of prophylactic means by cryoapplication central to the superior sclerotomies.

PATIENTS AND METHODS

From February 2002 to January 2005 a total of 2,298 eyes received a pars plana vitrectomy in our department. Excluding eyes with previous peripheral coagulation therapy, preexisting retinal detachment, and endophthalmitis 1,640 eyes could be reexamined at least 6 months after surgery (mean: 17+/-12 months). The incidence of RD was compared between two groups: one with intraoperative cryoapplication central to the superior sclerotomies (n=533) and one without any prophylactic treatment (n=1,107).

RESULTS

A total of 66 rhegmatogenous RD occurred during the follow-up, 23 with prophylactic cryotherapy and 43 without. This difference does not reach the level of significance. Only a subgroup of eyes operated on for macular pucker and venous occlusions showed a strong trend to prove the efficacy of prophylactic cryotherapy (p=0.07). Comparing the first 934 surgeries performed with the last 706 the incidence of RD decreased from 5.25 to 2.41%.

CONCLUSIONS

The incidence of RD could be decreased significantly during the period investigated. Cryoapplication at the superior sclerotomies failed to reach statistical significance in the total group, though the results in eyes in two special subgroups showed a strong trend towards a protective effect of cryoapplication (p=0.07). Other factors may have contributed to the reduction of RD after pars plana vitrectomy.

[Visual quality of life after vitreoretinal surgery for epiretinal membranes]

PURPOSE

To date, the increase of visual acuity and morphological parameters have been used to assess the benefit of a surgical intervention. The aim of this prospective study was to evaluate changes in patients' visual quality of life due to vitreoretinal surgery for epiretinal membranes.

PATIENTS AND METHODS

Twenty patients with unilateral epiretinal membrane and good visual acuity of the fellow eye were included. Best corrected visual acuity and visual quality of life assessed by the visual function index (VF-14) were obtained preoperatively and 3 months after pars plana vitrectomy and peeling.

RESULTS

Median visual acuity increased from 0.28 to 0.4 postoperatively. Visual quality of life (VF-14 values) rose from 72.8+/-4.7 (SEM) to 83.3+/-2.9 (p<0.05). Analysis revealed that patients with preoperatively low VF-14 values and preoperatively low visual acuity notably profited from surgery. The increase of visual quality of life can be predicted better than increase of visual acuity. Combined cataract surgery had no significant influence.

CONCLUSION

In addition to best corrected visual acuity, quality of life measurements are important predictive and outcome parameters to estimate the value of vitreoretinal surgery.

Klassifikation biomedizinischer Forschungsberichte als Grundlage evidenzbasierter Medizin in der Augenheilkunde

BACKGROUND

Evidence-based medicine requires careful appraisal of published data derived from experimental and clinical studies. Based on classification of biomedical research reports, evidence levels can be determined and recommendations for therapeutic decisions can be made.

METHODS

A classification system for clinical studies was developed. It was evaluated in classifying the reports published in Der Ophthalmologe during 2003-2004 (study design: descriptive cross-sectional study, case series).

RESULTS

In the 2-year interval, 70 longitudinal and 95 cross-sectional studies were published. The vast majority of the longitudinal studies were interventional cohort studies. Not considering case reports, 73% of the original articles were longitudinal prospective studies, 1% were retrospective (case-control) studies, and 26% were cross-sectional studies.

CONCLUSIONS

The study design of all published articles could be classified using the classification system. This classification system proves to be applicable in the context of clinical studies in ophthalmology and may be helpful in the process of critical appraisal of the literature and synthesis of clinical evidence and an evidence-based recommendation.

Anatomische und funktionelle Ergebnisse nach elektiver Makulachirurgie

PURPOSE

The purpose of this paper is to assess the anatomical and functional results after macular surgery in a large group of patients.

METHODS

Between June 1995 and December 2001, 381 eyes underwent vitreous surgery for macular pucker (n=244) or macular holes (n=137) with a standard pars plana vitrectomy (PPV) with induction of posterior vitreous separation, membrane peeling, peeling of the internal limiting membrane (no ICG staining was used), and gas instillation (SF(6)).

RESULTS

A second surgical intervention due to vision-threatening complications after PPV had to be performed in 8 of 381=2.1%. In the macular pucker group, metamorphopsias improved in 46.6% and the median of visual acuity (VA) improved from preoperative 0.3 to postoperative 0.5. Hole closure of macular holes was obtained in 92.2%; the median of VA improved in this group from preoperative 0.2 to postoperative 0.4.

CONCLUSION

In our group a second vitreoretinal procedure due to vision-threatening complications had to be performed in 2.1%. Compared to the spontaneous course, PPV for macular pucker or macular hole has a very positive influence on functional parameters.