Pneumatic release of focal vitreomacular traction

Effect of pneumatic vitreolysis in management of patients with symptomatic focal vitreomacular traction

PURPOSE

To evaluate the efficacy of single intravitreal injection of an expansile concentration of sulphur hexafluoride gas (SF6) in treating patients with symptomatic focal vitreomacular traction (VMT) documented by spectral domain optical coherence tomography (SD-OCT) preoperatively.

METHODS

This is a prospective interventional case series including 30 eyes of 29 patients with symptomatic focal VMT evident on SD-OCT. Pre-operatively, mean best corrected visual acuity (BCVA) was 20/125 (range 20/400-20/40). Mean central foveal thickness (CFT) was 382 μm (range 149-576 μm; SD ± 91.88). All eyes received single intravitreal injection of 0.3 mL of 100% SF6 gas. Postoperatively, we performed SD-OCT at one week, one month, and three months for all eyes. Primary outcome measure was release of VMT. Secondary outcome measures were changes in postoperative BCVA andCFT.

RESULTS

Overall, VMT release occurred in 24 of 30 eyes by the final follow-up visit (80% final release rate); furthermore, 76.9% of eyes with diabetic maculopathy and 25% of eyes with concurrent epiretinal membrane (ERM) had successful VMT release. VMT release was documented on SD-OCT at an average of 3 weeks (range, 1-12 weeks). The rate of release in phakic eyes was 90% (18 of 20 eyes) versus 60% in pseudophakic eyes (6 of 10 eyes). One patient developed a retinal break at upper nasal retina after two weeks of injection.

CONCLUSION

Pneumatic vitreolysis (PVL) with limited face-down position is a viable option for treating focal VMT with few adverse events. Further studies are needed to evaluate its indications, benefits, and risks.

Foveal-Sparing ILM Peeling in a Case with Vitreomacular Traction and Foveal Detachment

A pseudophakic female patient, 80 years of age, presented with a vitreomacular traction and foveal detachment at her right eye. To avoid development of a full-thickness macular hole during surgery, foveal-sparing ILM peeling was performed. After surgery, distance-corrected visual acuity increased from 0.3 to 0.6 (Snellen) 3 months after surgery and fovea was re-attached again with restoration of the retinal layers.

Immediate Release of Vitreomacular Traction After Pneumatic Vitreolysis Followed by the Drinking Bird Technique

Purpose:

To report a case of release of vitreomacular traction (VMT) in a patient with a full thickness macular hole (FTMH) immediately following pneumatic vitreolysis (PV) combined with head bobbing movements.

Methods:

A 71-year-old female with VMT and an FTMH presented with blurred vision for 2 months to the level of 20/400. At her 1-month follow-up visit, PV was performed using C3F8 gas and she was instructed to perform the drinking bird technique for ten minutes.

Results:

Optical coherence tomography performed ten minutes after PV with head bobbing showed VMT release and a smaller FTMH. Visual acuity improved to 20/150 immediately afterwards and to 20/80 two months later.

Conclusions:

Using the drinking bird technique for a continuous period of time immediately following PV may encourage rapid VMT release. PV may be a feasible option for patients with VMT and FTMH who do not want surgery.

COMPARING INTRAVITREAL AIR AND GAS FOR THE TREATMENT OF VITREOMACULAR TRACTION

PURPOSE

To compare the effect of intravitreal injections of air with gas on vitreomacular traction (VMT) release and attempt to analyze predictive factors for success.

METHODS

The medical records of patients with symptomatic VMT undergoing intravitreal injections (0.3 mL) of either octafluoropropane (C3F8) or air were retrospectively reviewed. The VMT release (primary end point) and the best-corrected visual acuity (secondary end point) were noted 1 month after injection. At baseline and 1 month after the injection, a macular optical coherence tomography was performed.

RESULTS

Twenty-four eyes of 22 patients were included. Vitreomacular traction was released in 10 cases, 7 among 11 C3F8-injected eyes (63%) and 3 among 13 air-injected eyes (23%) (P = 0.045). In eyes with released VMT, ETDRS improved from 61 ± 35 (0-100) to 65 ± 37 (0-100) 1 month after the injection (P = 0.03). All patients with VMT release had a horizontal vitreomacular adhesion of less than 600 µm. Five eyes (23%) underwent vitrectomy after the injection of gas or air.

CONCLUSION

Posterior vitreous detachment in VMT can be observed with both air and gas injection with a low complication rate. The occurrence of VMT release observed with air seemed to be less frequent than that observed with gas.

Pneumatic Vitreolysis for the Treatment of Vitreomacular Traction Syndrome

Objectives:

To evaluate the posterior vitreous release rates after a single injection of expansile gas in patients with vitreomacular traction (VMT) syndrome with or without associated full-thickness macular hole (FTMH).

Materials and Methods:

Thirteen eyes of 12 consecutive patients with VMT (11 eyes) or VMT+FTMH (2 eyes) were reviewed retrospectively. Intravitreal injection of 0.3 mL of pure sulfur hexafluoride (SF6) (9 eyes) or perfluoropropane (C3F8) (4 eyes) was performed. Bobbing the head forward and backward similar to ‘drinking bird’ head movements was instructed until VMT release. Full ophthalmic examination and optical coherence tomography was performed at each visit.

Results:

VMT was released in all patients (100%) and mean release time was 5.2 days (1-19 days). Macular hole closure was not achieved in either of the two eyes with FTMH. Mean central subfield thickness decreased significantly from 361 μm to 263 μm (p=0.007). The mean pretreatment visual acuity was 0.44 LogMAR, which significantly improved to 0.25 LogMAR at the last visit (p=0.003). One of 13 eyes had retinal tear after the procedure which was successfully treated with laser retinopexy. Gas migration to the anterior chamber occurred in one patient. No other complications were observed.

Conclusion:

Pneumatic vitreolysis with C3F8 and SF6 gases is a relatively safe, low-cost, and minimally invasive treatment modality for VMT. However, FTMH closure could not be achieved with pneumatic vitreolysis.

Intravitreal gas for symptomatic vitreomacular adhesion: a synthesis of the literature

Symptomatic vitreomacular adhesion (sVMA) is defined as visual loss secondary to foveal damage from vitreomacular traction (VMT) and includes isolated VMT, impending macular hole (MH), and full-thickness MH with persisting vitreous attachment. Management options include pars plana vitrectomy (PPV), intravitreal ocriplasmin, intravitreal gas injection or observation. This synthesis of the literature aimed to assess the safety and efficacy of intravitreal gas for sVMA. Articles describing patients with VMT or MH treated with intravitreal expansile gas were selected by systematic literature review using MEDLINE, EMBASE, and the Cochrane Database of Controlled Trials (CENTRAL) up to September 2016. The main outcomes at 1 month and final review were logarithm of the minimum angle of resolution (logMAR) visual acuity (VA), anatomical success (absence of both VMT and MH, without PPV) and adverse events (AEs). The intended comparator was observation. Nine of 106 identified articles were eligible, and none were randomized controlled trials. The mean VA of 91 eyes improved from 0.55 (Snellen equivalent 6/21) to 0.48 (6/18) logMAR at 1 month and to 0.35 (6/13) logMAR at final review. The mean VA at final review, prior to a vitrectomy, was 0.42 (6/16). Anatomic success was 48% at 1 month and 57% at final review. The reported AEs comprised retinal detachment in two highly myopic eyes. Intravitreal gas injection can relieve sVMA. Larger controlled studies are needed to determine safety and efficacy relative to observation, ocriplasmin, or vitrectomy.

Intravitreal Injection of Perfluoropropane is More Efficacious than Sulfur Hexafluoride In Releasing Vitreomacular Traction

SUMMARY – The aim was to compare the efficacy of a single intravitreal injection of perfluoropropane (C3F8) and sulfur hexafluoride (SF6) in releasing vitreomacular traction (VMT). This prospective study included two groups of patients with symptomatic VMT confirmed by spectral-domain optical coherence tomography (SD-OCT). Patients from both groups received a single intravitreal injection of expansile gas. One group (29 eyes) received 0.3 mL of 100% C3F8, and the other group (28 eyes) received 0.3 mL of 100% SF6. Eyes without VMT release one month after SF6 injection were secondarily injected with C3F8. The primary outcome was the ratio of eyes in each group with complete VMT release on OCT one month following primary treatment. The secondary outcome was the ratio of reinjected eyes with complete VMT release on OCT one month following second injection. Additional outcome was the ratio of VMT release in eyes with specific clinical characteristics. One month after the application, complete release of VMT on OCT was recorded in 18 out of 29 eyes (62%) in the C3F8 group, in 6 out of 28 eyes (21.4%) in the SF6 group, and in 7 out of 14 (50%) reinjected eyes. There was no statistically significant difference in age, width of vitreomacular attachment (WVMAT), central retinal thickness and presence of additional features between the two groups. In eyes with WVMAT <500 microns, there was no statistically significant difference between the two gases in releasing VMT. In eyes with WVMAT >500 microns, C3F8 was more efficacious (p=0.001). According to the results of our study, intravitreal C3F8 injection seems to be more efficacious in releasing VMT than SF6 in eyes with WVMAT larger than 500 microns.

INTRAVITREAL INJECTION OF AIR FOR THE TREATMENT OF VITREOMACULAR TRACTION

PURPOSE

To study the efficacy of a single intravitreal injection of air as a valuable alternative to current treatment options (conservative, pharmacological, and surgical) in patients with symptomatic, focal vitreomacular traction.

METHODS

Interventional, nonrandomized clinical study including a consecutive series of patients who underwent a single injection of 0.3 mL of air for vitreomacular traction. Each patient underwent best-corrected visual acuity, and spectral domain optical coherence tomography before and after the procedure. Mean maximal horizontal vitreomacular adhesion and a maximal foveal thickness were measured manually.

RESULTS

Four eyes of four patients, all males, were included in the study. Mean age was 71 ± 6.7 years; mean best-corrected visual acuity was 0.3 ± 0.08 logarithm of the minimum angle of resolution (logMAR) (20/40 Snellen equivalent). One month following treatment, complete resolution of vitreomacular traction was achieved in 100% of eyes. Mean visual acuity postinjection was 0.18 ± 0.09 logMAR (20/32 Snellen equivalent) (Student's t test for repeated measures P = 0.03). No correlation has been found between horizontal vitreomacular adhesion and best-corrected visual acuity or maximal foveal thickness and best-corrected visual acuity (P = 0.7 and P = 0.9, respectively).

CONCLUSION

Intravitreal injection of air could offer a minimally invasive, low-cost alternative treatment in patients with symptomatic, persisting vitreomacular traction. Additional studies on a larger number of patients are required.

Pneumatic Vitreolysis for Management of Symptomatic Focal Vitreomacular Traction

Pneumatic vitreolysis (PVL) is the intravitreal injection of a small quantity of expansile gas for the purpose of achieving focal vitreomacular traction (VMT) release for eyes with symptomatic VMT, or inducing VMT release and closure of the macular defect for eyes with a small stage-2 macular hole (MH). Initially, there was limited interest in this technique upon its introduction for clinical treatment in human eyes in 1993. With the advent of optical coherence tomography allowing detailed observation of vitreomacular interface changes and rising importance of medical economics in recent years, there has been increasing interest in PVL, a low-cost procedure for managing symptomatic VMT. The success rates of VMT release in the literature have ranged from 60% to 100% and the rates of closure of small macular holes have ranged from 50% to 80% following PVL. In a recent retrospective consecutive series of 56 eyes in two centers undergoing C3F8 gas injection, Chan and Mein reported an overall success of 86% in VMT release and 60% closure of small macular holes with few adverse events (7% with retinal breaks, retinal detachment, or progression of VMT). Multiple recent studies have shown superior outcome utilizing C3F8 gas compared with SF6 gas for PVL. In conclusion, PVL is a promising, low-cost therapeutic option, with the potential for managing symptomatic focal VMT on a global scale.

State of the art und Zukunft der Vitrektomie – Techniken und Instrumente

Hintergrund

Durch die Einführung der Pars plana Vitrektomie ist eine Vielzahl von vitreoretinalen Erkrankungen behandelbar geworden. Kontinuierliche Verbesserungen der Geräte, Instrumente und zusätzliche Hilfsmittel sowie neue Techniken kennzeichnen den enormen Fortschritt der vitreoretinalen Chirurgie.

Methoden

In einer Literaturübersicht werden die Operationstechniken verschiedenster vitreoretinaler Eingriffe analysiert. Sofern aufgrund aktueller Entwicklungen verschiedene Optionen in der Operationstechnik bestehen, werden Experten auf dem Gebiet der vitreoretinalen Chirurgie über ihre Erfahrung und ihre Empfehlung befragt.

Ergebnisse

Die 20 Gauge Pars plana Vitrektomie wurde größtenteils durch die Verwendung von Trokaren (23, 25 und 27 Gauge) mit entsprechenden Instrumenten mit kleinerem Durchmesser abgelöst. Die Pars plana Vitrektomie ist nahtlos möglich, trotzdem kann es notwendig sein, eine zusätzliche Sicherung der Wunde mit einer Naht durchzuführen, um Leckage und Hypotonie zu vermeiden. Die Visualisierung des Glaskörpers erfolgt zunehmend mit Triamcinolon, epiretinale Gliosen und die Membrana limitans interna werden routinemäßig mit Vitalfarbstoffen dargestellt. Bei der Operationstechnik beim Makulaforamen und bei der Ablatio retinae zeigen sich sowohl bei aktuellen Publikationen als auch unter den Experten Variationen.

Schlussfolgerungen

Die Pars plana Vitrektomie hat sich aufgrund der Weiterentwicklung speziell im Bereich der Trokar Systeme, Vitrektome, der Weitwinkel-Beobachtungssysteme sowie dank neuer Techniken zu einer essentiellen OP-Methode für ein weites Indikationsspektrum entwickelt. Dies ist die Basis der Behandlung verschiedenster vitreoretinaler Erkrankungen mit immer weniger Operationstrauma, weniger intraoperativen und postoperativen Komplikationen und gutem Therapieerfolg. Unterschiedliche Operationsvarianten, neue Techniken und die Weiterentwicklung der Geräte und Instrumente sind die Basis für einen auch zukünftigen Fortschritt der Pars plana Vitrektomie.