ANATOMIC AND FUNCTIONAL OUTCOME AFTER 23-GAUGE VITRECTOMY, PEELING, AND INTRAVITREAL TRIAMCINOLONE FOR IDIOPATHIC MACULAR EPIRETINAL MEMBRANE

Anatomical and functional changes after internal limiting membrane peeling

Internal limiting membrane (ILM) peeling has been an acceptable step in vitrectomy surgeries for various retinal diseases such as macular hole, chronic macular edema following epiretinal membrane (ERM), and vitreoretinal traction. Despite all the benefits, this procedure has some side effects, which may lead to structural damage and functional vision loss. Light and dye toxicity may induce reversible and irreversible retina damage, which will be observed in postoperative optical coherence tomography scans. Retinal nerve fiber layer damage is attributed to ganglion cell degeneration and axonal transport alteration and dissociated optic nerve fiber layer is due to Müller cell damage. Eccentric MHs and recurrence of previous MHs may also lead to vision loss. Iatrogenic retinal damage may cause structural retinal changes without significant vision loss or progression to choroidal neovascularization. The mechanism of persistent macular edema after membrane peeling is still unclear, but it has been related to tractional trauma and blood-retina barrier damage. The reappearance of ERM is another cause of decreased vision after ILM peeling, which might be secondary to incomplete membrane removal. In glaucoma patients, ILM peeling is associated with significantly worsening the mean deviation on the visual field test after the surgery. We discussed various causes of vision loss and structural changes following ILM peeling. These causes may be attributed to the surgical procedure itself or the associated steps, instruments, and dyes used during the ILM peeling procedure.

Intravitreal Dexamethasone Implant in Vitreoretinal Surgery: An Overview of the Literature

BACKGROUND

The sustained-release intravitreal 0.7 mg dexamethasone implant (DEX implant) (Ozurdex®, Allergan®, an AbbVie Company, North Chicago, Illinois, USA) is widely used to treat various inflammatory retinal disorders. Notably, its application is expanding in the field of vitreoretinal surgery.

METHODS

We conducted a comprehensive literature search across the Web of Science, PubMed, EMBASE, and ScienceDirect databases for articles related to Ozurdex and its applications in vitreoretinal disorders. Additionally, relevant studies were identified from the reference lists of retrieved articles. Our search was limited to studies written in English or those in other languages that provided an English abstract with sufficient information.

RESULTS

Multiple studies have demonstrated the efficacy and safety of the DEX implant across a broad spectrum of vitreoretinal and post-surgical conditions. Notably, the implant's unique pharmacokinetics remain largely unaffected by the vitrectomized status of the eye, ensuring consistent effectiveness in vitreoretinal surgery. Our research highlights the primary off-label applications of the DEX implant, which include epiretinal membrane (ERM), rhegmatogenous retinal detachment (RRD), post-surgical cystoid macular edema (PSCME), and refractory diabetic macular edema (DME).

CONCLUSION

This review highlights the increasing role of the DEX implant in vitreoretinal surgery, emphasizing its effectiveness and safety in various surgical and post-surgical settings, while also addressing associated complications.

Evaluation of the Efficacy and Safety of Preoperative Intravitreal Triamcinolone Acetonide Combined with Internal Limiting Membrane Peeling for the Treatment of Idiopathic Macular Epiretinal Membrane

PURPOSE

To assess the efficacy and safety of preoperative intravitreal triamcinolone acetonide (IVTA) combined with internal limiting membrane (ILM) peeling for idiopathic epiretinal membrane (IMEM).

METHODS

This was a retrospective study. Thirty-six phakic eyes of 35 patients were included in this study. IVTA was administered to 18 patients (18 eyes, Group IVTA) 7 days before vitrectomy, while the other 17 patients (18 eyes, Group no-IVTA) only underwent vitrectomy and ILM peeling. Patients were followed up for at least 6 months. Data on best-corrected visual acuity (BCVA), intraocular pressure (IOP), central macular thickness (CMT), inner retinal thickness (IRT), vascular parameters (measured by optical coherence tomography angiography, OCTA), mean macular sensitivity (MMS), 63% bivariate contour ellipse area (BCEA) and P1 (measured by macular integrity assessment, MAIA) were collected.

RESULTS

There were significant differences in BCVA and IRT between the IVTA group and the no-IVTA group at 6 months after surgery (p = .000 and p = .010). The CMT and MMS of the two groups significantly changed from the preoperative values; however, there were no differences between the 2 groups during the entire study period (p = .242 and p = .849). The changes in vascular parameters, including foveal avascular zone (FAZ) area and vessel densities of superficial and deep capillary plexus (SCP VD and DCP VD), in the two groups were not statistically significant. There were no statistically significant differences in 63% BCEA and P1 either.

CONCLUSION

Macular morphology and macular integrity improved after vitrectomy combined with ILM peeling surgery. Compared with the no-IVTA group, preoperative intravitreal triamcinolone acetonide can improve best corrected visual acuity and accelerate the absorption of intraretinal fluid in terms of a significant reduction in IRT.

Persistence and recurrence after removal of idiopathic epiretinal membrane

OBJECTIVES

To analyse the incidence of persistence and recurrence after the peeling of idiopathic epiretinal membrane (ERM) and to describe its clinical features.

METHODS

This retrospective study included 666 eyes (645 patients) that underwent macular surgery for ERM removal. Optical coherence tomographic (OCT) images taken within three months after surgery and at the following visits, clinical parameters and surgery related factors were analysed to investigate the incidence and associated factors of ERM persistence and recurrence. Postoperative ERM types were categorised depending on the size ( < 100 µm, ≥100 µm) and the location (foveal, parafoveal, outside the parafovea) RESULTS: The mean follow-up time was 29.4 months. ERM persistence (examination within 3 months) was found in 29.6% of all eyes. Only 1.9% of the eyes presented foveal ERM persistence. Foveal recurrence, defined as reappearance or growth of persistent ERM covering the fovea, was found in 8.2%. In 84.4% of eyes with foveal ERM recurrence, postoperative persistence of ERM of varying severity were identified. None of the pre-operative or surgery related factors were found significantly associated with ERM recurrence. Persistent ERM within the parafovea was the most significant risk factor for foveal ERM recurrence.

CONCLUSION

Recurrence of ERM is generally preceded by the persistence of ERM fragments found in the early postoperative period. Growth of ERM persistence from the parafoveal region was often the origin of foveal ERM recurrence. Insufficient peeling seems to be the most significant predisposing factor for foveal ERM recurrence.

Suprachoroidal injection of triamcinolone acetonide as adjuvant to surgical treatment of epiretinal membrane

BACKGROUND

To analyse the effect of suprachoroidal injection (SChI) of triamcinolone acetonide (TA) on macular thickness (CRT), ectopic inner foveal layer thickness (EIFL-T) and best corrected visual acuity (BCVA) in pseudophakic patients undergoing vitrectomy for epiretinal membrane (iERM) compared to intravitreal injection of TA (IVTA).

METHODS

Prospective matched comparison of patients undergoing vitrectomy for Govetto stage 3 and 4 iERM. 25 eyes receiving IVTA (G-1) were compared to 23 eyes receiving SChI-TA (G-2) during vitrectomy. Primary outcome was change in BCVA, CRT, EIFL-T before surgery and 1, 3 and 6 months after surgery. Secondary outcome was the incidence of cystoid macular edema (CME).

RESULTS

Six months after surgery, G2 had a greater mean reduction in CRT (-222 µm vs -131 µm) and EIFL-T (-200 µm vs -104 µm) than G1. BCVA improved more in G2 than in G1 (p = 0.02). Foveal depression reformed in 43% of cases in G-2 and 16% of cases in G-1. Incidence of postoperative CME was 16% in G-1 and 4.3% in G-2.

CONCLUSIONS

During vitrectomy for iERM, SChI-TA was more effective than IVTA in reducing CRT and EIFL-T and improving BCVA. SChI-TA was effective in preventing postoperative CME. SChI-TA treatment was safe and reproducible and did not affect postoperative IOP. Trial registration NP6289-June 18th, 2024 (retrospectively registered).

Evaluation of combined epiretinal membrane removal with intravitreal triamcinolone injection utilizing ectopic inner foveal layer staging scheme

OBJECTIVE

To investigate the macular morphological and visual outcomes of combined idiopathic epiretinal membrane (iERM) removal with triamcinolone acetonide (TA) injection based on consideration of the ectopic inner foveal layer (EIFL) staging scheme.

METHODS

Retrospective case-control study. The clinical data of 84 eyes of 84 patients who underwent vitrectomy for iERM between 2018 and 2022 were reviewed. The enrolled subjects were divided into the TA and non-TA groups. Fifty-one eyes received intravitreal TA injection following vitrectomy and ERM peeling (TA group), and 33 were only treated by standard vitrectomy and ERM peeling (non-TA group). Preoperative and postoperative EIFL stages, central foveal thickness (CFT), and best-corrected visual acuity (BCVA) were compared between both groups.

RESULTS

After a mean follow-up of 7.69 ± 3.68 months, both groups exhibited significant improvement in EIFL stages (P < 0.01), with no discernible advantage observed in the TA group. The TA and non-TA groups demonstrated improvement in the EIFL stages in 56.86 and 63.64% of eyes, respectively (P = 0.43). The CFT and BCVA significantly improved in both groups at the final visit (P < 0.01). However, CFT in the non-TA group displayed a more significant reduction during the follow-up (P < 0.03). Subgroup analysis revealed no significant differences in postoperative CFT and BCVA between the two groups in cases with or without continuous EIFL (P > 0.10).

CONCLUSION

Our findings indicate that combined intravitreal TA injection following ERM removal conferred no significant benefits in alleviating macular thickening or improving visual acuity in iERM.

Microvascular Changes after Epiretinal Membrane Vitrectomy with Intraoperative Intravitreal Dexamethasone Implant: An OCT Angiography Analysis

BACKGROUND

We aimed to explore microvascular changes evaluated with optical coherence tomography angiography (OCTA) in patients undergoing epiretinal membrane (ERM) pars-plana vitrectomy (PPV) combined with intravitreal Ozurdex implantation, compared with standard PPV. (2) Methods: Prospective interventional analysis on 25 eyes undergoing PPV + Ozurdex (Group A) and 25 eyes undergoing PPV alone. Best corrected visual acuity (BCVA) and OCTA parameters, such as vessel density (VD) of the superficial and deep capillary plexi (SCP and DCP) in the whole 6.4 mm × 6.4 mm and fovea area, were evaluated preoperatively and 3 months after surgery. (3) Results: Postoperative BCVA significantly improved in both groups. No cases of post-operative cystoid macular edema (CME) were reported in Group A vs. two eyes in Group B. In Group A we found a statistically significant increase of SCP's VD in either the whole image (from 42.1 ± 4.1 to 45.6 ± 4.3%, p = 0.01) and the fovea image (from 38.5 ± 7.5 to 41.7 ± 4.2%, p = 0.03). In Group B, we reported no significant variations in the SCP's VDs. In the DCP, VD significantly increased only in the whole image in Group A. Stage 4 ERMs showed the greatest improvement in VD, especially in Group A. (4) Conclusions: Intraoperative Ozurdex prompted a significant BCVA recovery and limited the occurrence of postoperative CME compared to the standard procedure. Moreover, Ozurdex implant is associated with a better restoration of microvascular structure in SCP and DCP.

Vitrectomy and ILM peeling in rhesus macaque: pitfalls and tips for success

BACKGROUND

The non-human primate (NHP) model is ideal for pre-clinical testing of novel therapies for human retinal diseases due to its similarity to the human visual system. However, intra-ocular delivery of gene therapy or cell transplantation to the retina gets hampered by the sticky vitreous body and poorly permeable inner limiting membrane (ILM) in primates. Although vitrectomy and ILM peeling are commonly performed in patients, many pitfalls exist in carrying out these procedures in the rhesus macaque, which have not been reported previously.

METHODS

We summarised common surgical pitfalls after performing vitrectomy and ILM peeling in four eyes of two rhesus macaques (one male and one female). We provided corresponding hands-on technical tips based on our surgical experience and literature search. Orbital CT scans were compared between adult rhesus macaques and humans. High-resolution surgical videos were recorded to demonstrate each critical surgical step.

RESULTS

Due to size difference, poor post-operative compliance, and high-standard requirements of a controlled experiment, there were eleven common surgical pitfalls during vitrectomy and ILM peeling in rhesus macaque. Falling into these pitfalls may produce discomfort, add fatigue, cause surgical complications, or even lead to the exclusion of the NHP from an experimental group.

CONCLUSION

Recognition and circumvention of these pitfalls during vitrectomy and ILM peeling in NHP are essential. By focusing on these surgical pitfalls, we can better carry out preclinical tests of novel therapies for retinal diseases in the NHP model.

Clinic study on macular epiretinal membrane in patients under the age of 40 years

BACKGROUND

To describe the risk factors and clinical characteristics of macular epiretinal membrane (MEM) disease in patients up to the age of 40 years and to evaluate the therapeutic effect of IVTA on MEM.

METHODS

Clinical records were reviewed and the etiology of each case and the age distribution data were collected in this retrospective, cohort study. The clinical characteristics of MEM and the factors affecting VA were analyzed. Additionally, we contrasted the effects of MEM peeling with and without intravitreal triamcinolone acetonide on visual acuity (VA) and central foveal thickness (CFT).

RESULTS

In young patients, the incidence of partial posterior vitreous detachment (P-PVD) was considerably higher in IMEM than SMEM (P = 0.007). Furthermore, patients with stage 3 MEM had lower BCVA values than patients with stage 4 MEM (P < 0.001). Patients who live in urban had lower BCVA values than patients in rural (P < 0.001). Patients with IS/OS integrity had lower BCVA values than patients without IS/OS integrity (P < 0.001). The BCVA values in patients with IMEM were significantly lower than those of patients with SMEM (P < 0.001). BCVA was associated most commonly with etiology (P = 0.001), followed by region (P = 0.002). All patients had a decrease in logMAR Vas and CFT, but the combination of intraoperative IVTA resulted in a more significant decrease in logMAR Vas (P = 0.007) and CFT (P = 0.046).

CONCLUSION

In young patients, the incidence of P-PVD was significantly higher in IMEM cases than in SMEM cases. The region, MEM stage, IS/OS integrity, and etiology influenced VA. Etiology was associated most commonly with BCVA. In individuals under 40, the combination of intraoperative IVTA resulted in a more significant decrease in logMAR Vas and CFT.

Idiopathic Epiretinal Membranes: Visual Outcomes and Prognostic Factors

Objectives

To evaluate the associations between anatomical changes and visual outcomes in patients with idiopathic epiretinal membrane (ERM).

Materials and Methods

We performed a prospective study of 130 consecutive idiopathic ERM patients and report their visual outcomes and the factors associated with visual outcome and anatomical changes.

Results

Of 130 eyes of 130 patients, 87 eyes underwent surgery, while the remaining 43 eyes were observed. At 6-month follow-up, the best-corrected visual acuity (BCVA) increased in the whole population. Mean Early Treatment Diabetic Retinopathy Study letter score changed from 51 to 65 in the surgical group and from 67 to 68 in the non-surgical group. The surgical group had improvement in BCVA at all ERM stages and grades of disorganization of the retinal inner layers (DRIL) (p<0.01). In multivariable analysis of the surgical group, factors associated with BCVA of ETDRS 60 letters or more were no or mild DRIL and the absence of ellipsoid zone disruption at baseline (p=0.002 and p=0.034, respectively) and this statistically significant positive correlation was still maintained at 12-month follow-up.

Conclusion

Baseline DRIL grade and presence of ellipsoid zone disruption were the most informative prognostic factors in patients with idiopathic ERMs. Patients with severe DRIL and/or advanced ERMs had improved vision after ERM removal.

A prospective randomized clinical trial comparing nepafenac, intravitreal triamcinolone and no adjuvant therapy for epiretinal membrane

PURPOSE

To compare the efficacy of topical nepafenac 0.1% versus intravitreal triamcinolone acetonide (IVTA) at the conclusion of vitrectomy surgery versus no adjuvant therapy (NAT) in improving macular morphology post-operatively in patients undergoing vitrectomy for epiretinal membrane (ERM), as measured by optical coherence tomography (OCT) imaging and best-corrected visual acuity (BCVA).

METHODS

Design: Prospective randomized clinical trial Setting: Multi-centre 80 patients scheduled to undergo vitrectomy surgery for idiopathic ERM were randomized to receive either IVTA (4 mg/0.1 cc) at the end of surgery, topical nepafenac sodium 0.1% TID for 1 month post-operation or no adjuvant treatment (NAT). Optical coherence tomography (OCT) imaging, best-corrected visual acuity and intraocular pressure (IOP) were measured before surgery, and 1 and 2 months post-operation.

RESULTS

Although all three groups showed reduction in macular thickness post-operation, the NAT group showed the most improvement, with a reduction of 136.18 ± 29.84 μm at two months. There was no statistically significant difference in macular thickness between the groups at each time point, p = 0.158. The NAT group also had the best recovery in BCVA with an improvement of 0.207 logMAR (10.35 letters) at two months post-operation. There was no statistically significant difference in BCVA between the groups, p = 0.606. There was statistically significant difference in the IOP between the three groups, p = 0.04 only at 1-month visit. The IVTA group had the highest rise in average IOP at both 1 and 2 months post-operation (2.72 and 1.58 mmHg, respectively).

CONCLUSION

Our study data suggest there was no advantage in the use of topical nepafenac or IVTA for post-vitrectomy ERM surgery.

Effect of Periocular Triamcinolone Acetonide on Prevention of Postsurgical Intraretinal Cystoid Changes after Vitrectomy with Membrane Peeling

BACKGROUND

Newly developed intraretinal cystoid changes after vitrectomy with membrane peeling for removal of epiretinal membranes have the potential to lead to worse postsurgical results compared to patients without. The aim of the present study was to evaluate the feasibility of additional periocular application of triamcinolone acetonide as a routine adjunct at the end of vitrectomy with membrane peeling, and to compare the presence of postsurgical intraretinal cystoid changes in the first 3 months after surgery among patients with idiopathic epiretinal membranes to a historical group of patients that did not receive triamcinolone acetonide.

PATIENTS AND METHODS

The medical records of 41 eyes of 41 patients that underwent 23 G or 25 G pars plana vitrectomy with membrane peeling for removal of epiretinal membranes and additional periocular triamcinolone acetonide application at the end of surgery were retrospectively reviewed. Optical coherence tomography findings during routine follow-ups at 3 - 5 days, 1 month, and 3 months and visual acuity at 3 months after surgery were evaluated and compared to preoperative findings. Furthermore, postsurgical intraocular pressure was assessed.

RESULTS

Periocular triamcinolone acetonide at the end of surgery was well tolerated among all patients. In total, 10% of patients had an increased intraocular pressure at least at one follow-up. Best-corrected visual acuity improved in 91% of patients with idiopathic epiretinal membranes with a mean improvement of + 3 ± 2 lines (Snellen) and was comparable to a historic group of patients (p = 0.307). Early transient macular edema could not be detected in any of the patients, while there were cases with this pathology in the historic group of patients, but neither occurrence of newly developed intraretinal cystoid changes nor macular thickness at 3 months after surgery were significantly different between patients with and without triamcinolone acetonide (p = 0.385 and p = 0.879).

CONCLUSIONS

Periocularly applied triamcinolone acetonide at the end of vitrectomy with membrane peeling was well tolerated and showed prevention of early transient macular edema but did not prevent the development of new postoperative intraretinal cystoid changes.

Comparative study of pars plana vitrectomy with or without intravitreal dexamethasone implant for idiopathic epiretinal membrane

Purpose:

To investigate if use of adjunctive intravitreal dexamethasone implant during pars plana vitrectomy (PPV) leads to faster visual recovery and reduction of retinal thickness in idiopathic epiretinal membrane (ERM).

Methods:

In this non-randomized, comparative, interventional study 30 eyes (from 30 patients with idiopathic ERM) were enrolled. In the control group (n = 15), patients underwent 25-G pars plana vitrectomy (PPV) and ERM peeling. In the study group (n = 15), each patient underwent the same procedure as those in the control group, and also received an additional dexamethasone implant. Primary outcome after treatment was mean gain in best corrected visual acuity (BCVA), and secondary outcome was reduction in central retinal thickness (CRT). Data were analyzed using Fisher's exact test, Wilcoxon rank sum test, and two-sample t-test.

Results:

The mean gain in BCVA (logMAR) from baseline at 1-month follow-up was significantly higher in the study group (median = - 0.3, IQR = - 0.4, - 0.1) than in the control group (median = 0, IQR = - 0.1, 0.3; P < 0.008). However, no significant difference in mean gain in BCVA between the two groups was detectable at the 6-month follow-up (P < 0.55). At 1-month follow-up, one and seven patients in the control and study groups gained ≥15 letters of BCVA (P < 0.05), respectively. The mean reductions in CRT at the 1-month follow-up were significantly higher in the study group than in the control group (Mean = - 60 μm, SD = 92.1; P < 0.014; 95% CI = 19.75–156.54). The difference in mean reduction of CRT at 6 months was not significant (P < 0.24).

Conclusion:

Adjunctive dexamethasone implant can aid faster visual recovery after PPV in idiopathic ERM, although the implants do not affect long-term gains in visual acuity.

Intravitreal Dexamethasone Implant for Postoperative Macular Oedema Secondary to Vitrectomy for Epiretinal Membrane and Retinal Detachment: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the efficacy of intravitreal dexamethasone implant (DEX) for the treatment of macular oedema secondary to vitrectomy for epiretinal membrane (ERM) and retinal detachment (RD) by conducting a systematic review with meta-analysis of published studies.

METHODS

Studies reporting clinical outcomes of DEX use for the treatment of macular oedema secondary to ERM and RD vitrectomy were searched on PubMed and Embase databases. The primary outcome was best-corrected visual acuity (BCVA) change between baseline and post-DEX treatment, reported as mean difference (MD) with 95% confidence interval (CI). Mean central macular thickness (CMT) change was assessed as a secondary outcome. Postimplant adverse events, including intraocular pressure rise and cataract development, were reported as well.

RESULTS

Five uncontrolled studies, 1 nonrandomized controlled study, and 1 randomized controlled study were included, with a total of 5 cohorts and 3 cohorts in the ERM group and RD group, respectively. Considering the last available follow-up, a significant improvement in postimplant BCVA was found in the overall population, irrespective of the indication for vitrectomy (MD = -0.28, 95% CI = -0.37, -0.20; p < 0.001), but with significant heterogeneity. In either group, mean BCVA significantly improved following the implant (in the ERM group, MD = -0.31, 95% CI = -0.40, -0.22; in the RD group, MD = -0.22, 95% CI = -0.41, -0.03), with no difference between the two groups (p=0.41). However, there was significant heterogeneity in both groups. Considering the last available follow-up, a significant CMT reduction was found in the overall population, irrespective of the indication for vitrectomy (MD = -129.75, 95% CI = -157.49, -102.01; p < 0.001). In the ERM group, a significant CMT reduction was shown following DEX (MD = -133.41, 95% CI = -155.37, -111.45; p < 0.001), with no heterogeneity. In the RD group, mean CMT reduction was borderline significant (MD = -128.37, 95% CI = -253.57, -3.18; p=0.040), with significant heterogeneity. No difference in CMT improvement was found between the two groups (p=0.94).

CONCLUSION

This meta-analysis showed that DEX yielded a significant improvement in visual and anatomical outcomes, even if limited by significant heterogeneity. Dexamethasone implant represents an effective treatment for postoperative macular oedema secondary to ERM and RD vitrectomy.

Epiretinal Membrane Vitrectomy With and Without Intraoperative Intravitreal Dexamethasone Implant: A Systematic Review With Meta-Analysis

Purpose: To evaluate the efficacy of vitrectomy combined with intravitreal dexamethasone implant vs. vitrectomy without the implant in patients with epiretinal membrane (ERM) by conducting a systematic review and meta-analysis.

Methods: Studies that compared ERM vitrectomy with and without intraoperative dexamethasone implant with a follow-up ≥3 months were included. The primary outcome was mean best corrected visual acuity (BCVA) change between eyes undergoing ERM vitrectomy combined with dexamethasone implant (DEX group) and eyes undergoing ERM vitrectomy alone (control group) at 3 months. Secondary outcomes included mean BCVA change at 6 months and mean optical coherence tomography central macular thickness (CMT) change at both 3-months and 6-months follow-up. Mean differences (MDs) with their 95% confidence interval (95%CI) were calculated. Meta-analyses were based either on random effect model or fixed effect model according to heterogeneity.

Results: Four studies were included. At 3 months, ERM vitrectomy combined with dexamethasone implant yielded a greater visual gain compared to vitrectomy alone (MD = 9.7; 95%CI = 2.6–16.8; p = 0.01). However, significant heterogeneity was found. A sensitivity analysis excluding the only retrospective non-randomized study confirmed a greater visual gain in the DEX group (MD = 7.1; 95%CI = 2.7–11.6; p < 0.01), with no heterogeneity. At 6 months, a non-significant but borderline difference in visual gain was shown between in the two groups (MD = 5.1; 95%CI = −0.3–10.5; p = 0.06), with no heterogeneity. Three-month analysis of CMT revealed a greater reduction in the DEX group (MD = −80.2; 95%CI =−149.1–11.2; p = 0.02), but with significant heterogeneity. A sensitivity analysis excluding the only retrospective non-randomized study allowed to reduce heterogeneity, but no difference in 3-months CMT change was found between the two groups (MD = −50.0; 95%CI = −106.2–6.2; p = 0.08). At 6 months, no difference in CMT change was shown between the two groups (MD = −48.5; 95%CI = −120.5–23.5; p = 0.19), with significant heterogeneity.

Conclusions: Intraoperative dexamethasone implant in eyes undergoing vitrectomy for ERM provided a better visual outcome at 3 months compared to ERM vitrectomy without the implant, with limited evidence of better anatomic outcome as well. Further studies are needed to ascertain whether dexamethasone implant would ensure a significant long-term visual benefit as a result of a faster reduction of macular thickening.

COMBINED VITRECTOMY WITH INTRAVITREAL DEXAMETHASONE IMPLANT FOR REFRACTORY MACULAR EDEMA SECONDARY TO DIABETIC RETINOPATHY, RETINAL VEIN OCCLUSION, AND NONINFECTIOUS POSTERIOR UVEITIS

PURPOSE

To compare the efficacy of intraoperative intravitreal dexamethasone implant for macular edema secondary to diabetic retinopathy (DME), retinal vein occlusion (RVO), and noninfectious posterior uveitis.

METHODS

A retrospective review of 62 patients (29 men and 33 women; mean age 51.19 ± 14.41 years; 65 eyes) was performed. Best-corrected visual acuity (in logarithm of the minimal angle of resolution), central foveal thickness, intraocular pressure, and postoperative edema-free period were postoperatively assessed up to 1 year. The preoperative and postoperative numbers of other intravitreal injections needed were compared.

RESULTS

Best-corrected visual acuity gradually improved in the DME group (from 0.87 to 0.51) but failed to improve from Month 3 onward in the RVO and uveitis groups. Central foveal thickness decreased in all groups, especially in the DME group (from 550.93 to 338.10 μm). Edema-free period was longest in the DME group (19.34 ± 15.12 months), followed by the uveitis (12.91 ± 7.85 months) and RVO (8.50 ± 8.76 months) groups. Subjects in the uveitis group used more intraocular pressure-lowering agents (1.00 ± 1.27) than those in the DME (0.13 ± 0.49) and RVO (0.36 ± 0.79) groups. Increased intraocular pressure events were most frequent in postoperative Week 1, especially in the uveitis group.

CONCLUSION

Vitrectomy combined with intravitreal dexamethasone implant for DME, RVO, and noninfectious posterior uveitis had a favorable clinical outcome.

LATE-ONSET OCULAR HYPERTENSION AFTER VITRECTOMY: A Multicenter Study of 6,048 Eyes

PURPOSE

To determine the incidence and risk factors for late-onset ocular hypertension (LOH) after vitrectomy.

METHODS

From the electronic medical records of consecutive patients who underwent primary vitrectomy, from January 2010 to December 2015, at 5 tertiary vitreoretinal centers in Italy, patient demographics, systemic, ophthalmic, operative, and postoperative data were drawn. Main outcome measure was the presence of LOH, defined as intraocular pressure >21 mmHg detected more than 2 months after vitrectomy on at least 2 consecutive visits.

RESULTS

Among 6,048 patients, LOH was found in 294 (4.9%) vitrectomized eyes and in 87 (1.4%) fellow eyes, (chi square; P < 0.001). Multivariable logistic regression showed that significant risk factors for developing LOH included intraoperative triamcinolone use (odds ratio [OR], 7.62; P < 0.001), longer axial length (OR, 1.55; P = 3.023), preoperative higher intraocular pressure (OR, 1.81; P = 0.003), and postvitrectomy pseudophakic/aphakic status (OR, 2.04; P < 0.001). Decision-tree analysis showed that the stronger predictor of LOH was intraoperative triamcinolone use (P < 0.001). Secondary predictors were a preoperative intraocular pressure more than 15 mmHg (P < 0.001) in eyes that use triamcinolone, and postvitrectomy pseudophakic/aphakic status (P = 0.007) in eyes that did not use triamcinolone.

CONCLUSION

Late-onset ocular hypertension occurred in 4.9% of vitrectomized eyes. The main risk factors were intraoperative use of triamcinolone and postvitrectomy pseudophakic/aphakic status.

Intraoperative Dexamethasone Intravitreal Implant (Ozurdex) in Vitrectomy Surgery for Epiretinal Membrane

Objective: To study the effectiveness and safety of the intravitreal dexamethasone implant 0.7 mg (Ozurdex®) in vitrectomy surgery for epiretinal membrane.Methods: This is a prospective, multicenter, pilot study. Inclusion criteria included visually significant (<20/50) idiopathic epiretinal membrane. All patients underwent 23-gauge pars plana vitrectomy with membrane peeling and Ozurdex implant injection. The primary outcome measure was best corrected visual acuity (BCVA) change at 3 months. Secondary outcomes included BCVA at 6 months and changes in central retinal thickness (CRT). Intraocular (IOP) changes were monitored and cataract progression in phakic patients was documented.Results: 15 patients were enrolled in the study, 12 eyes of 12 patients were included in the analysis. Mean preoperative BCVA was 50.67 ETDRS letters and improved significantly to 63.67 (+12.91 letters, p = .008) at 3 months. Mean CRT improved from 548 to 409 microns (p = .002) at 3 months. The IOP showed mild elevation at months 1 and 2 and returned almost to baseline at month six. There were no complications related to the steroid implant injection procedure in an air-filled eye.Conclusions: Intra-operative injection of Ozurdex® at the conclusion of PPV can be done safely. The peak IOP and lowest CRT after 2 months strengthens the findings of prior studies demonstrating Ozurdex activity up to 3 months in vitrectomized eyes.

Long-term natural history of idiopathic epiretinal membranes with good visual acuity

BACKGROUND/OBJECTIVES

To evaluate the long-term progression of idiopathic epiretinal membranes (iERMs) with good baseline visual acuity, and to identify predictors of visual decline.

DESIGN

Retrospective case series SUBJECTS METHODS: We reviewed records of 145 eyes with iERM and best-corrected visual acuity (BCVA) of 20/40 or greater at presentation, including BCVA, lens status, and central macular thickness (CMT) at yearly visits; as well as anatomic biomarkers including vitreomacular adhesion, pseudohole, lamellar hole, intraretinal cysts, disorganization of the inner retinal layers (DRIL), and disruption of outer retinal layers. Linear mixed effects and mixed-effects Cox proportional hazards models were used to identify clinical and anatomic predictors of vision change and time to surgery.

RESULTS

At presentation, mean BCVA was 0.17 ± 0.10 logMAR units (Snellen 20/30) and mean CMT was 353.3 ± 75.4 μm. After a median follow-up of 3.7 years (range 1-7 years), BCVA declined slowly at 0.012 ± 0.003 logMAR units/year, with phakic eyes declining more rapidly than pseudophakic eyes (0.019 ± 0.003 vs. 0.010 ± 0.004 logMAR units/year). Metamorphopsia, phakic lens status, lamellar hole, and inner nuclear layer cysts were associated with faster visual decline. Cumulative rates of progression to surgery were 2.9, 5.6, 12.2, and 21.1% at years 1-4. Visual symptoms, metamorphopsia, greater CMT, and disruption of outer retinal layers were associated with greater hazard for surgery.

CONCLUSION

Eyes with iERM and visual acuity ≥ 20/40 experience slow visual decline, with 21% of eyes requiring surgery after 4 years. Clinical and anatomic predictors of vision loss may be distinct from factors associated with earlier surgical intervention.

Treatment of Macular Edema after Pars Plana Vitrectomy for Idiopathic Epiretinal Membrane Using Intravitreal Dexamethasone Implant: Long-Term Outcomes

PURPOSE

The aim of this study was to investigate the efficacy and safety of intravitreal dexamethasone implant for the treatment of macular edema after pars plana vitrectomy (PPV) for epiretinal membrane (ERM) removal.

METHODS

This prospective study included 27 patients who were diagnosed with macular edema after PPV for ERM removal and who were treated with either intravitreal dexamethasone implant (n = 15) or were observed without intervention (n = 12). Changes in best-corrected visual acuity (BCVA) and central retinal thickness (CRT) were assessed 1, 6, and 12 months -after treatment.

RESULTS

Patients treated with intravitreal dexamethasone implant showed significant improvement in BCVA and reduction in CRT at months 1, 6, and 12 after treatment, while patients in the control group showed improvement that did not reach statistical significance. The two groups differed significantly in terms of BCVA and CRT at all time points of the follow-up period, in favor of the dexamethasone implant group. Eighty percent of the patients treated with intravitreal dexamethasone needed only one implant until month 12, while no serious adverse events were noticed in any group.

CONCLUSIONS

Intravitreal dexamethasone implant was found to be effective and safe for the treatment of macular edema after PPV for ERM removal.

Dexamethasone Intravitreal Implant (Ozurdex) for Long-Term Macular Edema after Epiretinal Membrane Peeling Surgery

Purpose

To investigate the functional and anatomical outcome of the 0.7 mg dexamethasone (Ozurdex) intravitreal implant (IVD) in eyes with long-term macular edema after macular epiretinal membrane removal.

Methods

We enrolled 40 eyes with persistent macular edema at least 12 months after epiretinal membrane removal. Twenty eyes in the IVD group received IVD and the other 20 eyes were in the control group. The main outcome measures were change in best-corrected visual acuity (BCVA) and central foveal thickness (CFT).

Results

For eyes in the IVD group, the mean BCVA improved by 3.45 lines to 0.47 logMAR one month after IVD. However, the mean BCVA improved by only 0.14 lines to 0.74 logMAR at the same time in eyes in the control group. Six months later, the mean BCVA improved to 0.31 and 0.74 logMAR in the IVD and control groups, respectively. In the IVD group, the mean CFT decreased rapidly by 116.8 μm to 333.9 μm one month after IVD. Thereafter the CFT decreased at a slower pace. In the control group, the CFT remained static during the follow-up period. However, in the IVD group, 6 months after IVD, the CFT seemed to have a tendency to increase.

Conclusions

Single IVD could significantly decrease macular edema and improve visual outcome for eyes with persistent long-term macular edema after macular ERM removal and the effect can be sustained as long as 6 months after the initial injection. However, in order to maintain the visual and anatomical outcome, repeat IVD might be considered if macular edema recurs.

Epiretinal membrane surgery: an analysis of 2-step sequential- or combined phacovitrectomy surgery on refraction and macular anatomy in a prospective trial

PURPOSE

To assess the impact of combined phacoemulsification-vitrectomy and sequential surgery for idiopathic epiretinal membrane (ERM) on refractive error (RE) and macular morphology.

METHODS

In this prospective clinical trial, we allocated phakic eyes with ERM to (1) cataract surgery and subsequent pars plana vitrectomy (PPV) (CAT group), (2) PPV and subsequent cataract surgery (VIT group) or (3) phaco-vitrectomy (COMBI group). Examinations were at baseline, one month after each surgery, and at 3 months and 12 months of follow-up. Primary outcome was the RE (the difference between predicted and achieved spherical equivalent); secondary outcomes were best-corrected visual acuity (BCVA), and incidence of cystoid macular oedema (CME) defined as >10% increment of central subfield macular thickness (CSMT).

RESULTS

Sixty-two eyes were enrolled. The mean RE showed a small myopic shift of -0.36D in all groups 1 month after surgery, decreasing after 12 months to -0.17D. The absolute value of the RE (ARE) ranged 0.49-0.68D after 12 months. In the immediate postoperative period, there was a higher incidence of CME in the CAT group. There was no significant difference in final RE, ARE, BCVA and CSMT between the groups. Four cases (17%) in the CAT group had resolved visual complaints and improved BCVA after cataract surgery resulting in no need for PPV within the follow-up period.

CONCLUSION

Surgery for idiopathic ERM in phakic eyes with either phaco-vitrectomy or sequential surgery are equal approaches with respect to functional- (RE, BCVA) and anatomical outcomes (CME, CSMT). However, if starting with cataract surgery, 17% of the cases may not need subsequent PPV.

Lack of Evidence for Vasoactive and Inflammatory Mediators in the Promotion of Macular Edema Associated with Epiretinal Membranes

The development of symptoms in patients with epiretinal membranes (ERMs) often corresponds with the accumulation of interstitial fluid in the retina [i.e., the development of macular edema, (ME)]. To explore the potential value of pharmacologic therapeutic options to treat ME in patients with ERMs, we examine here the expression of vasoactive and inflammatory mediators in the vitreous of patients with idiopathic ERMs. We observed that vitreous concentrations of classic vasoactive factors (e.g., vascular endothelial growth factor) were similar in ERM patients with ME compared to controls. Using an array assessing the expression of 102 inflammatory cytokines we similarly did not observe a marked difference in cytokine expression in the vitreous of most ERM patients with ME compared to control patients. While the array data did implicate a group of inflammatory cytokines that were elevated in a subset of ERM patients who had severe ME (central subfield thickness ≥450 μm on spectral domain optical coherence tomography), expression of 3 of these inflammatory cytokines, all previously implicated in the promotion of ME in ischemic retinal disease, were not elevated by quantitative enzyme-linked immunosorbent assay. We conclude that therapies modulating vasoactive mediators or inflammatory cytokines may not affect ME in ERM patients.

25-Gauge Vitrectomy with Epiretinal Membrane and Internal Limiting Membrane Peeling in Eyes with Very Good Visual Acuity

PURPOSE

To evaluate the efficacy and safety of pars plana vitrectomy (PPV) in patients with epiretinal membrane (ERM) and preoperative visual acuity (VA) of 20/40 or better.

METHODS

44 eyes that underwent PPV and ERM peeling were included in this retrospective study. Data retrieved included demographic information, VA and intraocular pressure (IOP) preoperatively, after 1 month, 6 months and at final visit, presence of metamorphopsia, surgical reports, and occurrence of any complications.

RESULTS

Mean preoperative VA was 20/36 (0.24 ± 0.08 logMAR) and had improved to 20/27 (0.13 ± 0.11 logMAR) at the final follow-up (p < 0.001). Thirty (68.1%) eyes had improved by 1 line of vision or more, and 10 (22.7%) achieved final 20/20 vision. Significant improvement in vision was achieved earlier in eyes that underwent vitrectomy combined with cataract extraction. Preoperative OCT scans demonstrated preserved outer retinal layer structure.

CONCLUSIONS

PPV and ERM peeling is a safe and effective procedure in eyes with very good preoperative VA. PPV combined with cataract extraction offers a faster improvement in VA than PPV alone with deferred cataract surgery. PPV should be considered in symptomatic eyes with ERM and VA of 20/40 or better, in order to preserve and even improve the VA.

Quantification of metamorphopsia using the MacuFlow test before and after vitreoretinal surgery

BACKGROUND AND OBJECTIVE

This pilot study evaluated the clinical utility of the MacuFlow software in measuring metamorphopsia prior to and following surgery in patients with vitreoretinal diseases.

PATIENTS AND METHODS

Four patients with vitreoretinal disorders causing metamorphopsia were included in this pilot study. Visual acuity (VA), optical coherence tomography and MacuFlow scores were recorded prior to and following surgical intervention.

RESULTS

The mean preoperative VA was 0.59 ± 0.09 logMAR, central macular thickness 491.2 ± 41.3 µm and calculated macular volume 8.99 ±1.47 mm(3). These parameters improved postoperatively to a mean VA of 0.30 ± 0.22 logMAR, central macular thickness of 372.8 ± 85.4 µm and macular volume of 7.94 ± 1.34 mm(3) but did not reach statistical significance. The mean preoperative MacuFlow score was 14.02 ± 8.21, which significantly improved postoperatively to 5.4 ± 3.13 (p = 0.045).

CONCLUSIONS

This is the first study to demonstrate the clinical utility of MacuFlow for the quantification of metamorphopsia and its improvement or resolution following surgery. This simple method may be a valuable addition for the clinical assessment and monitoring of patients with retinal diseases causing metamorphopsia.

Role of Concomitant Triamcinolone Acetonide Injection in Small-Gauge Vitrectomy for Idiopathic Epiretinal Membrane Peel

PURPOSE

The concomitant use of triamcinolone acetonide (TA) at the completion of pars plana vitrectomy for the treatment of epiretinal membrane may speed up the anatomical and functional outcomes of surgery. We report the outcome of patients undergoing small-gauge vitrectomy for idiopathic epiretinal membrane peel with or without adjuvant TA therapy.

DESIGN

This is a retrospective, single-center case series.

METHODS

We included 75 eyes of 75 individual patients. Twenty-six patients (group A) had an adjuvant TA injection during surgery, whereas 49 patients (group B) were not injected. We assessed the patients for change in visual acuity (VA) and central macular thickness before and after surgery.

RESULTS

Group A had a mean logarithm of the minimum angle of resolution VA of 0.63 ± 0.33 and 0.51 ± 0.31 preoperatively and 3 months after surgery, respectively. Group B had a mean logarithm of the minimum angle of resolution VA of 0.47 ± 0.17 and 0.36 ± 0.17 preoperatively and 3 months after surgery, respectively. No significant difference was found between the groups in change of VA. The mean central macular thickness for groups A and B patients before surgery was 474.12 ± 120 μm and 445 ± 85 μm, decreasing to 369 ± 70 μm and 386 ± 60 μm at the final visit, respectively. The difference in macular thickness reduction between the groups was statistically significant.

CONCLUSIONS

Anatomical and functional improvement was found in both groups after surgery. Macular thickness was further reduced in the group of patients treated with adjuvant TA.

Idiopathic epiretinal membrane

BACKGROUND

Idiopathic epiretinal membrane (iERM) is a fibrocellular membrane that proliferates on the inner surface of the retina at the macular area. Membrane contraction is an important sight-threatening event and is due to fibrotic remodeling.

METHODS

Analysis of the current literature regarding the epidemiology, clinical features, and pathogenesis of iERM and fibrotic tissue contraction.

RESULTS

Epidemiologic studies report a relationship between iERM prevalence, increasing age, and posterior vitreous detachment. Clinically, iERM progresses through different stages characterized by an increased thickness and wrinkling of the membrane. Pathophysiologically, iERM formation is a fibrotic process in which myofibroblast formation and the deposition of newly formed collagens play key roles. Anomalous posterior vitreous detachment may be a key event initiating the formation of iERM. The age-related accumulation of advanced glycation end products may contribute to anomalous posterior vitreous detachment formation and may also influence the mechanical properties of the iERM.

CONCLUSION

Remodeling of the extracellular matrix at the vitreoretinal interface by aging and fibrotic changes, plays a significant role in the pathogenesis of iERM. A better understanding of molecular mechanisms underlying this process may eventually lead to the development of effective and nonsurgical approaches to treat and prevent vitreoretinal fibrotic diseases.

Subconjunctival injection of XG-102, a JNK inhibitor peptide, in patients with intraocular inflammation: a safety and tolerability study

PURPOSE

We aimed to investigate the safety, tolerability, and systemic diffusion of a single escalating dose of XG-102 (a 31-D-amino-acid peptide inhibiting JNK pathway activation), administered subconjunctivally in the treatment of post-surgery or post-trauma intraocular inflammation.

METHODS

This is a dose-escalating, tolerance Phase Ib study. Twenty patients with post-surgery or post-traumatic intraocular inflammation were assigned to 1 of the 4 dose escalating (45, 90, 450, or 900 μg XG-102) groups of 5 patients each. Patients were evaluated at 24, 48 h, 8, and 28 days following the administration of XG-102, including laboratory tests, standard eye examinations, vital signs, and occurrence of adverse events. A single plasma quantification of XG-102 was performed 30 min after administration, according to previous pharmacokinetics studies performed on volunteers.

RESULTS

A total of 17 non-serious adverse events, considered unrelated to the study treatment, were reported for 10 patients. The adverse event incidence was not related to the drug dose. All patients experienced a decrease in intraocular inflammation as of 24 h post-administration and this decrease was sustained up to 28 days thereafter. No patient required local injection or systemic administration of corticoids following the administration of XG-102. XG-102 was undetectable in the first 3 dose groups. In the fourth-dose group (900 μg) the XG-102 plasma levels were above the limit of detection for 3 patients and above the limit of quantification for 1 patient.

CONCLUSIONS

In this first clinical trial using XG-102, administered as a single subconjunctival injection as adjunct therapy, in patients with recent post-surgery or post-trauma intraocular inflammation is safe and well tolerated. Further studies are required to evaluate its efficacy.

Cataract formation following vitreoretinal procedures

Purpose

To evaluate the incidence and prevalence of cataract formation, progression, and extraction in patients that underwent vitreoretinal procedures and to evaluate factors that can potentially predispose patients to postoperative cataracts.

Materials and methods

The medical records of consecutive patients who underwent vitreoretinal surgery at the Yale Eye Center with at least 6 months of follow-up and no prior intraocular surgery were obtained. Preoperative, intraoperative, and postoperative data were recorded and analyzed in this retrospective observational study. The main outcome measures were defined as cataract extraction, formation, and progression after vitreoretinal procedures. The lens status of the surgical eye was recorded preoperatively and at 1 month, 3 months, 6 months, 12 months, 24 months, and 36 months postoperatively.

Results

A total of 193 eyes of 180 patients fulfilled the inclusion criteria. The percentages of eyes with mild lens change were 96% after 20-gauge pars plana vitrectomy (PPV), 72% after small gauge (23- and 25-gauge) PPV, 38% after scleral buckle (SB), 38% after pneumatic retinopexy (PR), and 91% after PPV plus SB (PPV+SB). Posterior subcapsular and nuclear sclerotic cataracts were the most common with almost all developing within 24 months. There was no statistically significant difference (P=1.00) between the rate of cataract extraction after 20-gauge (41%) and small gauge PPV (42%), but there was a statistically significant difference between PPV and non-PPV (SB, 6%; PR, 7%; P<0.001) and PPV and PPV+SB groups (69%; P=0.0063).

Conclusion

Cataracts were common following PPV regardless of the gauge. SB and PR led to the lowest while PPV+SB led to the highest risk of postoperative cataracts.

Visual acuity outcomes following surgery for idiopathic epiretinal membrane: an analysis of data from 2001 to 2011

PURPOSE

Pars plana vitrectomy (PPV) is commonly used to remove the epiretinal membrane (ERM), but the timing of surgical intervention guided by visual acuity (VA) performance at presentation is uncertain.

PATIENTS AND METHODS

Prospectively entered clinical data of 237 patients on an electronic patient record from 2001 to 2011 were analysed to determine visual outcomes, in particular in relation to pre-operative VA.

RESULTS

The mean age of the patients was 68.8 years and 54.4% were female. Median follow-up was 0.55 years. The median pre-operative logMAR VA was 0.60 (SD 0.48-0.78, Snellen equivalent 6/36) and post-operative VA was 0.30 (SD 0.18-0.60, 6/12, P<0.005). Pre-operative VA correlated with post-operative VA (linear R(2)=0.22, P<0.0001). In all, 69.6% of patients showed an improvement in VA, 15.2% showed no change, and the condition of 15.2% worsened. The number of patients with an improvement in logMAR VA of more than 0.3 was greatest in those who had a pre-operative VA of 1.0 (6/60) or worse, followed by those in the range of 0.6-0.9 and then those with pre-operative VA of 0.5 or better (P<0.001). The proportion of patients with visual improvement of logMAR VA of more than 0.3 increased statistically with progressing years (P=0.019).

CONCLUSION

In conclusion, this study shows improvement in VA after PPV and ERM removal. Patients with better initial VA achieve higher levels of visual outcome but those with poorer pre-operative VA show a greater change in VA following ERM surgery. Results of surgery improved over the time period of the study.

Changes of parafoveal retinal nerve fiber layer thickness analyzed by spectral-domain optical coherence tomography after pars plana vitrectomy

PURPOSE

To use spectral-domain optical coherence tomography to evaluate the postoperative retinal nerve fiber layer (RNFL) thickness changes in eyes undergoing vitrectomy.

METHODS

This is a retrospective study of 44 patients (44 eyes) who underwent monocular vitrectomy for an epiretinal membrane (19 eyes), macular hole (12 eyes), or vitreous hemorrhage (13 eyes). Quantitative analysis of the peripapillary RNFL by spectral-domain optical coherence tomography was performed before surgery and for 6 months postoperatively on both eyes.

RESULTS

Mean patient age was 62.72 ± 9.11 years. Mean preoperative RNFL thickness did not differ significantly between vitrectomized eyes (88.33 ± 13.23 μm) and nonvitrectomized fellow eyes (87.49 ± 13.18 μm; P > 0.05). In vitrectomized eyes, the preoperative mean RNFL thickness in the superior quadrant was significantly different from that at 6 months after surgery (P = 0.02). Vitrectomized eyes with a macular hole showed significant changes in the mean RNFL thickness in the inferior quadrant (P = 0.04).

CONCLUSION

Retinal nerve fiber layer thickness was reduced in some of the quadrants of the vitrectomized eye during the 6-month postoperative follow-up period. Spectral-domain optical coherence tomography can be clinically useful for detection of localized RNFL defects in patients who underwent vitrectomy. Future prospective studies with more patients and longer follow-up duration are required.

Management of macular epiretinal membrane by vitrectomy and intravitreal triamcinolone

A patient underwent successful vitrectomy for macular epiretinal membrane with anatomical and functional improvement. 10 weeks later, there was a recurrence of macular edema with corresponding visual decline. An intravitreal injection of triamcinolone acetonide not only restored the macular anatomy but also improved the visual outcome beyond that achieved after surgery.

Epiretinal membrane surgery: anatomic and functional outcomes

OBJECTIVE

To study the influence of anatomic preoperative characteristics (based on the parameter, foveal central thickness, measured by optical coherence tomography) and functional characteristics (based on the parameter, best corrected visual acuity, [BCVA]) on functional recovery after epiretinal membrane (ERM) surgery.

METHODS

A total of 88 eyes (of 86 patients), on whom a vitrectomy due to ERM was performed during a 3 years period were reviewed in this longitudinal, prospective study. An analysis was made of, ERM aetiology, BCVA, presence or absence of metamorphopsia, lens status, and central foveal thickness. Data relating to surgery and local complications, changes in BCVA, and changes in foveal central thickness were collected during the follow-up period.

RESULTS

An improvement was in observed in BCVA in 82%, as well as a decrease in foveal thickness in 79% of the eyes which underwent surgery, both of these being statistically significant (P<.01). However, most of the patients showed different grades of oedema and/or macular thickening in the postoperative period. A significant correlation was found between preoperative and postoperative BCVA (P=.001), and also between preoperative and postoperative central foveal thickness (P=.004), but not between BCVA and foveal thickness.

CONCLUSIONS

There is functional recovery in terms of BCVA in more than 80% of the patients after ERM surgery. Most of the eyes showed persistent macular thickening, but this did not seem to have influenced the final BCVA. The best determinant of postoperative functional recovery (postoperative visual acuity) is, in our experience, the preoperative BCVA, and not the macular thickness.

Intraoperative intravitreal triamcinolone decreases macular edema after vitrectomy with phacoemulsification

Background

The purpose of this study was to evaluate the incidence and amount of macular edema by optical coherence tomography (OCT) after combined small gauge sutureless vitrectomy with phacoemulsification and intravitreal triamcinolone.

Methods

This retrospective case series included 194 consecutive eyes undergoing nonemergent vitrectomy with phacoemulsification and intravitreal triamcinolone. Ninety-one eyes had preoperative and postoperative OCT available and were included in the analysis. The eyes were evaluated for retinal thickness with preoperative and postoperative OCT, and for preoperative and postoperative best-corrected visual acuity. The main outcome measures were retinal thickness, OCT appearance, and best-corrected visual acuity.

Results

The incidence of macular edema in all eyes preoperatively was 64.8% and postoperatively was 50.5%. Mean central subfield and center point thickness in eyes with macular edema preoperatively were 361 μm and 349 μm, respectively, and postoperatively were 315 μm and 304 μm, respectively. In eyes without preoperative macular edema, mean preoperative central subfield and center point thickness were, respectively, 210 μm and 181 μm versus 220 μm and 192 μm postoperatively. Best corrected visual acuity improved from 20/190 preoperatively to 20/150 at postoperative month 1 and 20/110 at month 6. Postoperative intraocular pressure ≥ 25 mmHg was observed in 7.7% of eyes, none of which required surgical intervention for steroid-induced glaucoma.

Conclusion

Use of intravitreal triamcinolone with combined vitrectomy and phacoemulsification may play an important role in modulating postoperative macular edema. Adverse pressure rise is infrequent and usually limited.

Ocular hypertension after intravitreal triamcinolone with vitrectomy and phacoemulsification

OBJECTIVE

To evaluate the effect of adjunctive intravitreal triamcinolone (IVTA) on intraocular pressure (IOP) in the setting of combined vitrectomy with phacoemulsification.

DESIGN

Retrospective case series.

PARTICIPANTS

One hundred thirty-one consecutive eyes undergoing nonemergent vitrectomy with phacoemulsification and IVTA were reviewed and included in the analysis. All 131 eyes received 4 mg IVTA at the end of surgery.

METHODS

Pre-and postoperative IOP, use of pressure-lowering medications, and rate of glaucoma surgery were analyzed. Pre-operative risk factors were analyzed.

MAIN OUTCOME MEASURES

IOP, glaucoma medications, or glaucoma surgery.

RESULTS

Secondary ocular hypertension (defined as IOP ≥ 25 mmHg) was found in 28 eyes (21%), the majority during postoperative day 1 only. Twelve eyes (9%) had an elevated IOP measurement noted at a visit after the first postoperative day. Five (4%) had an IOP rise of ≥10 mmHg over baseline at any time after postoperative day 1. Six (5%) required glaucoma medications. One eye required a glaucoma drainage implant for diabetic neovascular angle closure glaucoma, and one eye required enucleation for intractable neovascular glaucoma due to radiation retinopathy. Elevated postoperative IOP was statistically associated with higher baseline IOP and presence of preoperative glaucoma.

CONCLUSIONS

Therapeutic intravitreal triamcinolone with combined vitrectomy and phacoemulsification causes infrequent and usually mild secondary ocular hypertension. Secondary ocular hypertension is associated with preoperative glaucoma and high IOP.

Primary 23-gauge vitreoretinal surgery for rhegmatogenous retinal detachment

AIM

To report the effectiveness and safety of primary 23-Gauge (G) vitreoretinal surgery for rhegmatogenous retinal detachment (RRD).

METHODS

In this retrospective study, 49 eyes of 49 consecutive patients who underwent primary 23-G transconjunctival sutureless vitrectomy (TSV) for RRD between January 2007 and July 2009 at our institution were evaluated.

RESULTS

Mean follow-up time was 8.9±7.7 months (1-28 months). Retinal reattachment was achieved with a single operation in 47(95.9%) of 49 eyes. In two eyes (4.1%), retinal redetachment due to new breaks was successfully treated with reoperation using the 23-G TSV system. Mean logMAR visual acuity was 2.01±0.47 preoperatively and 1.3±0.5 postoperatively (P<0.001, Paired t-test). Mean preoperative intraocular pressure (IOP) was 14.1±2.8mmHg. Mean postoperative IOP was 12.3±3.6mmHg at 1 day, 13.1±2.1mmHg at 1 week, 14.3±2.2mmHg at 1 month. Iatrogenic peripheral retinal break was observed in 1 eye (2.0%) intraoperatively. No sutures were required to close the scleral or conjunctival openings, and no eyes required convertion of surgery to 20-G vitrectomy.

CONCLUSION

Primary 23-G TSV system was observed to be effective and safe in the treatment of RRD.