LATE PRESENTATION OF RETINAL DETACHMENT: CLINICAL FEATURES AND SURGICAL OUTCOMES

PURPOSE

To describe and evaluate demographic, clinical features, prognostic factors, and rate of success of surgery and visual outcomes in patients with late presentation of retinal detachment.

METHODS

A retrospective, comparative, observational case series of patients with late presentation retinal detachment, defined as retinal detachment with the loss of central vision for 4 weeks or more, over a period of 12 months.

RESULTS

The mean of onset of central visual loss was 12.7 weeks (SD, 21.3). Proliferative vitreoretinopathy at the first operation was identified in 69% of eyes. The overall primary success rate was 69.2%, significantly less than that was found in outcomes for nonselected retinal detachment (primary success rate, 86%; P = 0.006). The initial best-corrected visual acuity was 20/500, and the final was 20/160 (P = 0.0027). There were no identifiable statistically significant socioeconomic factors related to late presentation.

CONCLUSION

A high rate of established proliferative vitreoretinopathy on presentation was identified, and although cases can be treated with good anatomical results, visual outcomes are often less favorable. Primary surgical success is lower, and more reoperations are required compared with standard retinal detachments.

Surgical outcomes and prognostic factors following vitrectomy in acquired immune deficiency syndrome patients with cytomegalovirus retinitis-related retinal detachment

To determine the surgical outcomes and prognostic factors of cytomegalovirus (CMV) retinitis-related retinal detachment (RD) in acquired immune deficiency syndrome (AIDS) patients following vitrectomy.A retrospective charts review was carried out on AIDS patients who were diagnosed with CMV retinitis-related RD and treated with vitrectomy between 2002 and 2016. The main outcome measures were the rates of primary anatomical success and final visual acuity (VA) success defined as postoperative VA ≥20/200. Kaplan-Meier curves on the time to retinal redetachment were performed. Multivariate logistic regression models based on a directed acyclic graph were used to identify independent factors associated with achieving VA success.Forty five AIDS patients (52 eyes) were included. Over a mean follow-up period of 41.7 months, primary anatomical success was achieved in 44 eyes (84.6%) and VA success was achieved in 34 eyes (65.4%). Receiving highly active antiretroviral therapy (HAART) prior to RD (adjusted odds ratio [aOR]=4.9, P = .043), better preoperative VA (aOR = 4.3, P = .006), undergoing vitrectomy within 3 months (aOR=6.7, P = .008), absence of optic atrophy (aOR=58.1, P < .001), and absence of retinal redetachment (aOR=38.1, P = .007) increased the odds of achieving final VA success.Vitrectomy provided favorable anatomical reattachment in AIDS patients with CMV retinitis-related RD. Majority of patients was able to retain functional vision postoperatively. The use of HAART and early vitrectomy increased the probability of achieving both anatomical and VA success.

Visual and Anatomical Outcomes With Vitrectomy in Posterior or Combined Persistent Fetal Vasculature in an Asian Population

BACKGROUND AND OBJECTIVE

To investigate clinical features and surgical outcomes of vitrectomy in posterior or combined persistent fetal vasculature (PFV) in an Asian pediatric population.

PATIENTS AND METHODS

This study was a retrospective, noncomparative, interventional case series relating the surgical outcome of PFV. Eyes that underwent pars plicata vitrectomy and/or lensectomy for posterior or combined PFV between 2006 and 2015 were included. The main outcome measures were the anatomic and functional results as well as the complications after the vitrectomy with or without lensectomy.

RESULTS

A total of 25 eyes of 18 patients younger than 8 years of age were included in the study. The mean age of the patients receiving first pars plicata vitrectomy and/or lensectomy was 15.2 months ± 21.7 months (range: 1 month to 83 months). Postoperatively, successful anatomic correction in the posterior segment was observed in 20 eyes (80%). In addition, 19 of the 25 eyes (76%) had visual acuity (VA) better than 20/4000, and the mean logMAR VA of these 19 eyes was 1.74 (range: 0.48 to 2.30). The mean change of axial length of the eyes receiving surgery was 0.7 mm ± 1.4 mm (range: -1.0 mm to 2.4 mm; P = .18). None of the patients ended up with phthisis or glaucoma.

CONCLUSIONS

This study suggests that vitrectomy and/or lensectomy in patients with posterior or combined PFV with macular involvement may result in an acceptable anatomical outcome; however, the functional outcome remained poor despite surgical intervention in these patients. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:377-384.].

Results of vitrectomy in giant tear retinal detachments

INTRODUCTION

Giant tear retinal detachments have long been recognized for their management difficulties and poor anatomical surgical prognosis.

METHOD

Retrospective, descriptive study of 15 patients collected from IOHRT Department A. These patients were treated for rheumatogenic retinal detachment by giant tear. All patients underwent endocular vitreoretinal surgery. A visual acuity, FO and OCT check was performed at 7 days, 21 days, 45 days and 3 months, 6 months and 1 year postoperatively.

RESULTS

Our study included 15 eyes from 15 patients with rheumatogenic giant tear retinal detachments. The average follow-up is 9 months. The average age of the patients was 45 years. Six patients were severely short-sighted; 30% of patients had stage C vitreous proliferations at diagnosis. Immediate postoperative anatomical reapplication was achieved in 85% of patients. After 1 year, anatomical reapplication was achieved in 100% of patients. The average visual acuity was 2/10.

CONCLUSION

Surgery for rheumatogenic retinal detachment caused by a giant tear is a procedure that is still considered difficult with uncertain results. The progress of endocular surgery and tamponade methods has made it possible to revolutionize the prognosis of these detachments.

Frequency of post-operative hypotony after 23-gauge transconjunctival vitrectomy with locally made instruments

The objective of this study was to discern the frequency of post-operative hypotony after 23-gauge vitrectomy with locally made instruments. This study was conducted at the Department of Ophthalmology, Lahore General Hospital, Lahore from July 2012 to June 2016. A total of 300 patients underwent 23-gauge pars-plana vitrectomy. Locally made 23-gauge trocar cannula system was used in all the patients. Post-operative Intraocular Pressure(IOP) was measured using Goldman Applanation Tonometer on the first post-operative day. IOP of less than 06mmHg was termed as hypotonic. In our study, mean post-operative intraocular pressure was recorded as 8.32±3.04mmHg and frequency of post-operative hypotony after 23-guage vitrectomy with locally made instruments reveals 10.67% (n=32) while 89.33% (n=268) had no findings of hypotony. We concluded that the frequency of post-operative hypotony after 23-gauge vitrectomy with locally made instruments is slightly higher when compared with other studies and this instrument can be used for further surgeries.

Pars plana vitrectomy versus scleral buckling for repairing simple rhegmatogenous retinal detachments

BACKGROUND

Rhegmatogenous retinal detachment (RRD) is a separation of neurosensory retina from the underlying retinal pigment epithelium. It is caused by retinal tears, which let fluid pass from the vitreous cavity to the subretinal space. Pars plana vitrectomy (PPV), scleral buckling surgery and pneumatic retinopexy are three accepted management strategies whose efficacy remains controversial. Pneumatic retinopexy is considered in a separate Cochrane Review.

OBJECTIVES

The primary objective of this review was to assess the efficacy of PPV versus scleral buckling for the treatment of simple RRD (primary RRD of any extension with up to two clock hours large break(s) regardless of their anterior/posterior localisation) in people with (phakia) or without (aphakia) a natural lens in the eye, or with an artificial lens (pseudophakia). A secondary objective was to assess any data on economic and quality-of-life measures.

SEARCH METHODS

We searched CENTRAL, which contains the Cochrane Eyes and Vision Trials Register; MEDLINE; Embase; LILACS; the ISRCTN registry; ClinicalTrials.gov and the WHO ICTRP. The date of the search was 5 December 2018.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing PPV versus scleral buckling surgery with at least three months of follow-up.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology. Two review authors independently extracted the data and study characteristics from the studies identified as eligible after initial screening. We considered the following outcomes: primary retinal reattachment, postoperative visual acuity, final anatomical success, recurrence of retinal detachment, number of interventions needed to achieve final anatomical success, quality of life and adverse effects. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

This review included 10 RCTs (1307 eyes of 1307 participants) from Europe, India, Iran, Japan and Mexico, which compared PPV and scleral buckling for RRD repair. Two of these 10 studies compared PPV combined with scleral buckling with scleral buckling alone (54 participants). All studies were high or unclear risk of bias on at least one domain. Five studies were funded by non-commercial sources, while the other five studies did not report source of funding.There was little or no difference in the proportion of participants who achieved retinal reattachment at least 3 months after the operation in the PPV group compared to those in the scleral buckling group (risk ratio (RR) 1.07, 95% confidence intervals (CI) 0.98 to 1.16; 9 RCTs, 1261 participants, low-certainty evidence). Approximately 67 in every 100 people treated with scleral buckling had retinal reattachment by 3 to 12 months. Treatment with PPV may result in 4 more people with retinal reattachment in every 100 people treated (95% confidence interval (CI) 2 fewer to 11 more).There was no evidence of any important difference in postoperative visual acuity between participants in the PPV group compared to those in the scleral buckling group (mean difference (MD) 0.00 logMAR, 95% CI -0.09 to 0.10, 6 RCTs, 1138 participants, low-certainty evidence).There was little or no difference in final anatomical success between participants in the PPV group and scleral buckling group (RR 1.01, 95% CI 0.99 to 1.04, 9 RCTs, 1235 participants, low-certainty evidence). There were 94 out of 100 people treated with control (scleral buckling) that achieved final anatomical success compared to 96 out of 100 in the PPV group.Retinal redetachment was reported in fewer participants in the PPV group compared to the scleral buckling group (RR 0.75 (95% CI 0.59 to 0.96, 9 RCTs, 1320 participants, low-certainty evidence). Approximately 28 in every 100 people treated with scleral buckling had retinal detachment by 3 to 36 months. Treatment with PPV may result in seven fewer people with retinal detachment in every 100 people treated (95% CI 1 to 11 fewer).Participants treated with PPV on average needed fewer interventions to achieve final anatomical success but the difference was small and data were skewed (MD -0.20, 95% CI -0.34 to -0.06, 2 RCTs, 682 participants, very low-certainty evidence).Very low-certainty evidence on quality of life suggested that more people in the PPV group were "satisfied with vision" compared with the scleral buckling group (RR 6.22, 95% CI 0.88 to 44.09, 1 RCT, 32 participants).All included studies reported adverse effects, however, it was not always clear whether they were reported as number of participants or number of adverse effects. Cataract development or progression was more prevalent in the PPV group (RR 1.71, 95% CI 1.45 to 2.01), choroidal detachment was more prevalent in the scleral buckling group (RR 0.19, 95% CI 0.06 to 0.65) and new/iatrogenic breaks were observed only in the PPV group (RR 8.21, 95% CI 1.91 to 35.21). Estimates of the relative frequency of other adverse effects, including postoperative proliferative vitreoretinopathy, postoperative increase in intraocular pressure, development of cystoid macular oedema, macular pucker and strabismus were imprecise. Evidence for adverse effects was low-certainty evidence.

AUTHORS' CONCLUSIONS

Low- or very low-certainty evidence indicates that there may be little or no difference between PPV and scleral buckling in terms of primary success rate, visual acuity gain and final anatomical success in treating primary RRD. Low-certainty evidence suggests that there may be less retinal redetachment in the PPV group. Some adverse events appeared to be more common in the PPV group, such as cataract progression and new iatrogenic breaks, whereas others were more commonly seen in the scleral buckling group such as choroidal detachment.

Vitreous rebleed following sutureless vitrectomy: Incidence and risk factors

Purpose

This study aims to evaluate the incidence and risk factors for vitreous rebleed (VRB) following 25-gauge sutureless vitrectomy for vitreous hemorrhage (VH) in diabetic retinopathy.

Methods

A retrospective review of 190 diabetic patients having undergone vitrectomy for VH at a tertiary eye care center was analyzed. Demographic data of patients along with risk factors such as blood sugar levels (BSL), blood pressure (BP), anticoagulant use, and pan-retinal photocoagulation status (PRP) were tabulated. Depending on the commencement of VRB, patients were divided into immediate rebleed-within 2 weeks and delayed rebleed-beyond 2-4 weeks.

Results

Forty-one patients had VRB, out of which 18 patients had immediate VRB and 23 patients had delayed VRB. The average duration between vitrectomy and VRB was 3.28 months. Twenty-eight patients were male and 13 were females. Average age at presentation was 53.8 years. Thirty-four patients (82.9%) were found to have high BSL and 28 patients (68.3%) had high BP and they developed rebleed (P < 0.01) after an initial hemorrhage-free period (average = 5.15 months). Fifteen patients (36.6%) underwent first time PRP intraoperatively, and they had immediate rebleed (P < 0.01) without any hemorrhage-free period (average = 0.9 months). Eight patients (19.5%) were on perioperative anticoagulants; however, their statistical significance did not persist in the multivariable model. There were neither age nor gender predilection toward rebleed (P > 0.05).

Conclusion

The incidence rate of VRB was found to be 21.6%. Age and gender did not contribute to rebleed. Intraoperative PRP was a risk factor for immediate rebleed. Poor glycemic and BP control was a risk factor for delayed rebleed.

Analysis of the vitreoretinal surgery learning curve

OBJECTIVE

To describe intra- and post-operative complications, as well as the evolution of the surgical technique in first 4years of work of a novice retina surgeon, and evaluate minimal learning time required to reduce its complications, deciding which pathologies should still be referred to higher level hospitals, until further experience may be achieved.

METHODS

A study was conducted on patients that had undergone vitreoretinal surgery by a novice surgeon in Tarragona between 23rd October 2007 and 31st December 2011. The primary diagnosis, surgeon learning time, surgical technique, intra-operative and post-operative complications were recorded.

RESULTS

A total of 247 surgeries were studied. The percentage of use of 20G and 23G calibres during the time, marks a change towards trans-conjunctival surgery from the ninth trimester (98 surgeries). Surgical complications decreased towards twelfth trimester (130 surgeries) with an increase in the previous months.

CONCLUSIONS

The shift towards 23G technique around 100 surgeries is interpreted as greater comfort and safety by the surgeon. Increased surgical complications during the following months until its decline around 130 surgeries can be interpreted as an 'overconfidence'. It is arguable that the learning curve is slower than what the surgeon believes. An individual analysis of the complications and surgical outcomes is recommended to ascertain the status of the learning curve.

Postoperative Endophtalmities: therapeuthic results and Early vitrectomy

BACKGROUND

Postoperative endophthalmitis is a public health issue due to its bad prognosis; its treatment is both surgical and medical. Classically, surgical treatment was done if visual acuity is limited to light perception only.

AIM

To evaluate therapeutic results Of postoperative endophtalmitieS and to Compare therapeutics almost used intravitreal injection of antibiotics versus early vitrectomy.

METHODS

It's a retrospective comparative study  includIng 120 cases of acute postoperative endophthalmitis hospitalized in a referral ophthalmology department between July 2007 and June 2013. A comparison was conducted between two groups of 24 and 94 patients; the first-line treatment was early vitrectomy for the first group and intravitreal antibiotic injection alone for the second group.

RESULTS

The overall incidence rate was 0.38 %, Streptococcus and Staphylococcus Epidermidis where the most common bacterial strain (16 patients each). The treatment outcome was very favorable for 11 patients with final visual acuity  higher or equal to 2/10, the outcome was intermediate for 43 patients and poor for 66 patients because of final visual acuity lower than or equal to 1/20, loss of media transparency or anatomical or functional loss of the eye. The prognostic factors statistically correlated to treatment outcome where intense initial inflammation (p<0.001), high bacterial virulence (p=0.002), bacteria culture positive to Streptococcus (p=0.024), a defectuous operative incision (p= 0.012), age over 80 (p=0.022) and posterior capsule rupture (p=0.013). Early vitrectomy group (group1) achieved a higher percentage of good outcome (60% vs 41.5%,  p=0.098 ).

CONCLUSION

Functional result is better in the Vitrectomy group than in the antibiotic intravitreal injections group whereas not Statically signifiant.

Changes Of Intraocular Pressure In Vitrectomised Eyes After Removal Of Silicone Oil

BACKGROUND

Patients with Rhegmatogenous retinal detachment develop raised intraocular pressure (IOP) when they undergo pars plana vitrectomy with silicone oil. The present study was done to document changes in IOP with silicone oil and after its removal.

METHODS

The interventional study was conducted at Eye department of Lady Reading Hospital Peshawar, from August 2012 to July 2014 on 30 patients with Rhegmatogenous retinal detachment in whom pars plana vitrectomy with silicone oil injection was indicated. IOP readings were obtained on 1st postoperative day, at one month and at 6 months; the silicone oil was removed after the third reading and the IOP readings obtained after 2 weeks.

RESULTS

Of the 30 patients selected for the study, there were 25 (83.3%) males and 5 (16.7%) females with ages ranging from 12-80 years (mean age 41.83±21.43 years). The mean of three pre silicone oil removal IOP readings was 27.35±9.20 mmHgwhich was reduced to a mean of 16.10±6.14mmHg following the removal of silicone oil at 6 months (p<0.001). Postoperative raised IOP values were highly predictive of persistently elevated IOP readings in patients after six months.

CONCLUSIONS

Vitrectomised eyes with silicone oil raised intraocular pressure which was reduced after silicone oil removal.

Panretinal Photocoagulation vs Intravitreous Ranibizumab for Proliferative Diabetic Retinopathy: A Randomized Clinical Trial

IMPORTANCE

Panretinal photocoagulation (PRP) is the standard treatment for reducing severe visual loss from proliferative diabetic retinopathy. However, PRP can damage the retina, resulting in peripheral vision loss or worsening diabetic macular edema (DME).

OBJECTIVE

To evaluate the noninferiority of intravitreous ranibizumab compared with PRP for visual acuity outcomes in patients with proliferative diabetic retinopathy.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial conducted at 55 US sites among 305 adults with proliferative diabetic retinopathy enrolled between February and December 2012 (mean age, 52 years; 44% female; 52% white). Both eyes were enrolled for 89 participants (1 eye to each study group), with a total of 394 study eyes. The final 2-year visit was completed in January 2015.

INTERVENTIONS

Individual eyes were randomly assigned to receive PRP treatment, completed in 1 to 3 visits (n = 203 eyes), or ranibizumab, 0.5 mg, by intravitreous injection at baseline and as frequently as every 4 weeks based on a structured re-treatment protocol (n = 191 eyes). Eyes in both treatment groups could receive ranibizumab for DME.

MAIN OUTCOMES AND MEASURES

The primary outcome was mean visual acuity change at 2 years (5-letter noninferiority margin; intention-to-treat analysis). Secondary outcomes included visual acuity area under the curve, peripheral visual field loss, vitrectomy, DME development, and retinal neovascularization.

RESULTS

Mean visual acuity letter improvement at 2 years was +2.8 in the ranibizumab group vs +0.2 in the PRP group (difference, +2.2; 95% CI, -0.5 to +5.0; P < .001 for noninferiority). The mean treatment group difference in visual acuity area under the curve over 2 years was +4.2 (95% CI, +3.0 to +5.4; P < .001). Mean peripheral visual field sensitivity loss was worse (-23 dB vs -422 dB; difference, 372 dB; 95% CI, 213-531 dB; P < .001), vitrectomy was more frequent (15% vs 4%; difference, 9%; 95% CI, 4%-15%; P < .001), and DME development was more frequent (28% vs 9%; difference, 19%; 95% CI, 10%-28%; P < .001) in the PRP group vs the ranibizumab group, respectively. Eyes without active or regressed neovascularization at 2 years were not significantly different (35% in the ranibizumab group vs 30% in the PRP group; difference, 3%; 95% CI, -7% to 12%; P = .58). One eye in the ranibizumab group developed endophthalmitis. No significant differences between groups in rates of major cardiovascular events were identified.

CONCLUSIONS AND RELEVANCE

Among eyes with proliferative diabetic retinopathy, treatment with ranibizumab resulted in visual acuity that was noninferior to (not worse than) PRP treatment at 2 years. Although longer-term follow-up is needed, ranibizumab may be a reasonable treatment alternative, at least through 2 years, for patients with proliferative diabetic retinopathy.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01489189.

Rates of Reoperation and Retinal Detachment after Macular Hole Surgery

PURPOSE

To evaluate rates of reoperation and retinal detachment (RD) after macular hole surgery.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

Patients in the insurance claim-based MarketScan databases from 2007 through 2013 with a record of macular hole surgery.

METHODS

Patients with macular hole surgery were identified. Cases of definite (the same eye was coded both times) and presumed (the eye laterality was not coded) macular hole reoperations within 2, 3, and 12 months were queried. In addition, cases of postoperative RD within 2, 3, and 12 months were captured.

MAIN OUTCOME MEASURES

Rates of macular hole reoperation and postoperative RD, including subgroup analysis based on presence or absence of internal limiting membrane (ILM) peeling.

RESULTS

Records of 23465 macular hole surgeries among 20 764 patients were analyzed. Among presumed reoperations, the rates of reoperation were 4.3% (4.1% after ILM peeling and 5.0% after no ILM peeling; P = 0.01) within 2 months of surgery, 5.5% (5.3% after ILM peeling and 6.2% after no ILM peeling; P = 0.03) within 3 months of surgery, and 9.5% (9.0% after ILM peeling and 11.0% after no ILM peeling; P = 0.01) within 12 months of surgery. The rates for definite reoperations were 1.3% (1.2% after ILM peeling and 1.8% after no ILM peeling; P = 0.04) at 2 months, 1.7% (1.6% after ILM peeling and 2.5% after no ILM peeling; P = 0.004) at 3 months, and 4.1% (3.3% after ILM peeling and 7.5% after no ILM peeling; P < 0.001) at 12 months. The cumulative rate of postoperative RD was 1.81±0.09% to 2.18±0.5% after 2 months, 2.27±0.10% to 3.18±0.67% after 3 months, and 3.92±0.16% to 5.70±1.1% after 12 months. Internal limiting membrane peeling was associated negatively with postoperative RD at 2 months (2.3% vs. 1.7%; P = 0.007), 3 months (2.8% vs. 2.1%; P = 0.004), and 12 months (4.7% vs. 3.3%; P < 0.001).

CONCLUSIONS

In this sample, reoperations for macular hole were performed at low rates. Internal limiting membrane peeling was associated with lower rates of reoperation and RD.

Intensive diabetes therapy and ocular surgery in type 1 diabetes

BACKGROUND

The Diabetes Control and Complications Trial (DCCT) showed a beneficial effect of 6.5 years of intensive glycemic control on retinopathy in patients with type 1 diabetes.

METHODS

Between 1983 and 1989, a total of 1441 patients with type 1 diabetes in the DCCT were randomly assigned to receive either intensive diabetes therapy or conventional therapy aimed at preventing hyperglycemic symptoms. They were treated and followed until 1993. Subsequently, 1375 of these patients were followed in the observational Epidemiology of Diabetes Interventions and Complications (EDIC) study. The self-reported history of ocular surgical procedures was obtained annually. We evaluated the effect of intensive therapy as compared with conventional therapy on the incidence and cost of ocular surgery during these two studies.

RESULTS

Over a median follow-up of 23 years, 130 ocular operations were performed in 63 of 711 patients assigned to intensive therapy (8.9%) and 189 ocular operations in 98 of 730 patients assigned to conventional therapy (13.4%) (P<0.001). After adjustment for DCCT baseline factors, intensive therapy was associated with a reduction in the risk of any diabetes-related ocular surgery by 48% (95% confidence interval [CI], 29 to 63; P<0.001) and a reduction in the risk of all such ocular procedures by 37% (95% CI, 12 to 55; P=0.01). Forty-two patients who received intensive therapy and 61 who received conventional therapy underwent cataract extraction (adjusted risk reduction with intensive therapy, 48%; 95% CI, 23 to 65; P=0.002); 29 patients who received intensive therapy and 50 who received conventional therapy underwent vitrectomy, retinal-detachment surgery, or both (adjusted risk reduction, 45%; 95% CI, 12 to 66; P=0.01). The costs of surgery were 32% lower in the intensive-therapy group. The beneficial effects of intensive therapy were fully attenuated after adjustment for mean glycated hemoglobin levels over the entire follow-up.

CONCLUSIONS

Intensive therapy in patients with type 1 diabetes was associated with a substantial reduction in the long-term risk of ocular surgery. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others; DCCT/EDIC ClinicalTrials.gov numbers, NCT00360893 and NCT00360815.).

Long-term incidence of vitrectomy and associated risk factors in young Danish patients with Type 1 diabetes: the Danish Cohort of Paediatric Diabetes 1987

AIMS

To examine the long-term incidence of vitrectomy in young people with Type 1 diabetes.

METHODS

We prospectively studied 324 people with Type 1 diabetes who participated in baseline examinations in 1995. Surgical history was obtained from the Danish National Patient Registry in April 2012.

RESULTS

During the 17-year study period, 39 people (12.0%) underwent vitrectomy at least once. The mean age and diabetes duration at first vitrectomy were 29.8 and 22.9 years, respectively, and 64.1% of the participants were men. In multivariable Cox regression analysis, baseline age (hazard ratio 0.81 per 1 year increase), BMI (hazard ratio 1.21 per 1 kg/m(2) increase), HbA1c (hazard ratio 1.72 per 1% increase) and diabetic retinopathy (hazard ratio 2.85 and 6.07 for mild and moderate/severe diabetic retinopathy vs none, respectively) were independent predictors of vitrectomy (P < 0.05 for all variables).

CONCLUSIONS

Vitrectomy is a relatively common procedure in young people with Type 1 diabetes, with poor glycaemic control being the strongest modifiable risk factor.

Ocular findings at initial pan retinal photocoagulation for proliferative diabetic retinopathy predict the need for future pars plana vitrectomy

PURPOSE

To determine the 1-year and 2-year likelihood of vitrectomy in diabetic patients undergoing initial pan retinal photocoagulation (PRP).

METHODS

Diabetic eyes receiving initial PRP for proliferative diabetic retinopathy (PDR) were analyzed to determine their risk for vitrectomy based on clinical findings.

RESULTS

In total, 374 eyes of 272 patients were analyzed. The percentage of eyes undergoing vitrectomy 1 year and 2 years following initial PRP was 19.1% and 26.2%, respectively. Of the eyes in Group 1 (PDR alone), Group 2 (PDR and vitreous hemorrhage), and Group 3 (PDR and iris neovascularization, vitreous hemorrhage with traction or fibrosis, or fibrosis alone), the percentage receiving pars plana vitrectomy at 1 year and 2 years was 9.73% (18/185) and 15.7% (29/185), 26.9% (43/160) and 34.4% (55/160), and 37.9% (11/29) and 48.3% (14/29), respectively. Eyes in Group 2 had 2.78 times greater likelihood (P < 0.0001) and eyes in Group 3 had 3.54 times higher likelihood (P < 0.0001) of requiring pars plana vitrectomy within 2 years than those with PDR alone.

CONCLUSION

Eyes receiving PRP for PDR with associated hemorrhage or traction were more likely to undergo pars plana vitrectomy within 1 year and 2 years following initial PRP compared with eyes with only PDR, providing important prognostic information for PRP-naive patients.

Ratio of primary episcleral buckling surgery versus primary vitrectomy for rhegmatogenous retinal detachment

PURPOSE

To assess the ratio of the frequency of primary scleral buckling procedures versus the frequency of vitrectomies performed as treatment for rhegmatogenous retinal detachments in a primary retinal surgical department.

METHODS

The study included all patients with rhegmatogenous retinal detachments who underwent retinal or vitreoretinal surgery in the study period from 2002 to 2006. The size of the retinal defect and the amount of proliferative vitreoretinopathy were not exclusion criteria. Patients with tractional retinal detachment due to proliferative ischemic retinopathies were excluded.

RESULTS

In the study period, 875 primary retinal and vitreoretinal surgeries were performed on 875 eyes. Among the surgeries, episcleral sponges (42.9%) formed the largest part, followed by pars plana vitrectomies (35.0%) and encircling bands (22.2%). Combining episcleral sponges and encircling bands into an episcleral surgery group revealed that two thirds (65%) of the surgeries were episcleral interventions. In the episcleral sponge group, the retinal re-detachment rate after the first surgery was 13%.

CONCLUSION

In a university department as a primary referral unit for retinal detachments, episcleral retinal surgery can still outnumber vitreoretinal interventions, with retinal re-detachment rates which do not differ markedly from the re-detachment rates reported in randomized trials comparing vitreoretinal surgery with episcleral surgery.

Vitrectomy in uveitis patients

PURPOSE

To evaluate the causes and success rates of pars plana vitrectomy (PPV) in uveitis patients.

METHODS

Retrospective study of the charts of 26 uveitis patients (28 eyes) who underwent PPV between the years 2008 and 2011. We examined surgical indications and success rates, based on visual outcomes, complications and diagnosis in case of vitreous biopsy.

RESULTS

(1) Therapeutic PPV (TV) was performed in 36% of the eyes, (2) TV combined with epiretinal membrane (ERM) peeling in 21% and (3) diagnostic PPV (DiV) was performed in 64% of the eyes. Eight eyes (28,6%) underwent a combined cataract and vitreous surgery. Visual acuity (VA) improved in 16 eyes (57%), with a mean improvement of -0,9 log of the minimum angle of resolution (logMAR), although the effect was transient in 7% of the cases. VA remained stable in 11 eyes (39%) and decreased in 1 (4%). Post-operative complications were cystic macular oedema (CMO) in 3 eyes (11%), cataract in 5 eyes (18%) and retinal detachment in 2 eyes (7%). Diagnostic tests were performed in 18 eyes with a success rate of 55%.

CONCLUSIONS

In our series of patients with uveitis, a good andstable improvement of VA was found when PPV was performed with ERM peeling while the effect on VA was more transient in the other cases. A good success rate of diagnosis was also found in DiV. However, considering the possible severe complications, diagnostic vitrectomy should be limited to selected cases.

[Efficacy of vitreorretinal surgery to improve best corrected visual acuity in diabetics with retinopathy]

BACKGROUND

complications of proliferative diabetic retinopathy require surgical treatment. In 2007 Flaxel reported visual improvement after vitreoretinal surgery in 37% of Latino diabetics; in our country it is estimated that a higher proportion of patients improves, but this has not been documented.

AIM

to identify the efficacy of vitreoretinal surgery for improving best corrected visual acuity, in diabetic patients treated at a hospital in Mexico City.

METHODS

an observational, longitudinal, retrospective, descriptive study was conducted in diabetics who underwent vitreoretinal surgery (2007-2010) with one year follow-up. Visual acuity was measured before surgery and one year after, and it was registered when the retinopexy orphacoemulsification was performed, or silicone tamponade wasused. The proportions and 95% confidence intervals (CI) of patients whose visual acuity improved, did not change or worsened, were compared with those reported by Flaxel in Latino patients (χ(2), relative risk [RR]).

RESULTS

63 patients, mean age 58.5 ± 11.6 years, 26 with retinal detachment (41.3%), phacoemulsification was performed in 50 (79.4%), and silicone was used in 27 (42.9%). BCVA worsened in 12 patients (19%), did not change in 5 (8%) and improved in 46 (73%, 95% CI 62-84); the latter proportion exceeded that reported by Flaxel (p = 0.0005, RR 1.97, 95% CI 1.25-3.1).

DISCUSSION

although the difference was not clinically significant, the efficacy of vitreoretinal surgery to improve visual acuity in the sample was consistently higher than that reported by Flaxel in Latinos, and did not vary from other studies. These results do not support an association between an ethnic group and a lower surgical efficacy.

Diabetic retinopathy and complexity of retinal surgery in a general hospital

BACKGROUND

Usual retinal surgery (vitrectomy or surgery for retinal detachment) may require additional procedures to deal with complex cases, which increase time and resource use and delay access to treatment. We undertook this study to identify the proportion of primary retinal surgeries that required complex procedures and the associated causes.

METHODS

We carried out an observational, descriptive, cross-sectional, retrospective study. Patients with primary retinal surgery were evaluated (January 2007-December 2010). The proportion and 95% confidence intervals (CI) of preoperative diagnosis and cause of the disease requiring retinal surgery as well as the causes for complex retinal surgery were identified. Complex retinal surgery was defined as that requiring lens extraction, intraocular lens implantation, heavy perfluorocarbon liquids, silicone oil tamponade or intravitreal drugs, in addition to the usual surgical retinal procedure. The proportion of complex retinal surgeries was compared among preoperative diagnoses and among causes (χ(2), odds ratio [OR]).

RESULTS

We studied 338 eyes. Mean age of subjects was 53.7 years, and there were 49% females. The most common diagnoses were vitreous hemorrhage (27.2%) and rhegmatogenous retinal detachment (24.6%). The most common cause was diabetes (50.6%); 273 eyes required complex surgery (80.8%, 95% CI: 76.6-85). The proportion did not differ among diagnoses but was higher in diabetic retinopathy (89%, p <0.001, OR 3.04, 95% CI: 1.63-5.7).

CONCLUSIONS

Of the total sample, 80.8% of eyes required complex surgical procedures; diabetic retinopathy increased by 3-fold the probability of requiring these complex procedures. Early treatment of diabetic retinopathy may reduce the proportion of complex retinal surgery by 56%.

Retinal detachment surgery at Nepal Eye Hospital

INTRODUCTION

Retinal diseases are one of the important causes of blindness in Nepal. This study is done with objectives of finding the outcome of retinal detachment surgery.

METHODS

A retrospective analysis of 110 patients who underwent retinal detachment surgery over five year period was conducted in Nepal.

RESULTS

Retinal re-attachment was achieved in 94.4% and postoperative visual acuity of 6/36 to 6/6 was achieved in 52.7% (As possible risk factors, myopia was present in 34.5% ophkia in 29%, trauma in 9%, and lattice) degeneration was 5.4%.

CONCLUSIONS

The study has shown a promising result for the retinal detachment surgery.

[Survey of the use of long-lasting expanding gases in ophthalmology in Japan]

PURPOSE

To survey the use of long-lasting expanding gases in ophthalmology in Japan.

SUBJECTS AND METHODS

A questionnaire was sent to 1,236 teaching hospitals approved by the Japanese Ophthalmological Society requesting information regarding indications, methods, efficacy and complications related to the use of long-lasting expanding gases administered from January through December 2005.

RESULTS

Four-hundred and fifty-nine hospitals responded to the survey (response rate 37.1%). A total of 174,221 ophthalmic surgeries were performed during the survey period, with long-lasting expanding gases used in 19,816 of cases (11.4%). The surgical procedure was vitrectomy in 89.6% of cases in which gas was administered. The most frequent indication for gas use was rhegmatogenous retinal detachment, for which SF6 was the preferred gas. Industrial use gas was utilized in 76.1% of cases, while 22.4% of cases received medical use gas. Increase in intraocular pressure was the most common complication of intraocular gas tamponade (3121 cases, 15.7%), followed by cataract formation. Ninety-eight percent of ophthalmologists responding supported the use of long-lasting expanding gases with vitrectomy, 85% with scleral buckling procedures, and 84% with surgery to remove subretinal hemorrhage. The consensus was that substantial deterioration of surgical results would occur if long-lasting expanding gases could not be used.

CONCLUSIONS

Long-lasting expanding gases are being widely administered in ophthalmology in Japan, and appear to have good efficacy for a variety of indications. Several complications related to the use of these gases were reported, however the rates of complications were low.

Determinants of pediatric cataract program outcomes and follow-up in a large series in Mexico

PURPOSE

To report determinants of outcomes and follow-up in a large Mexican pediatric cataract project.

SETTING

Hospital Luis Sanchez Bulnes, Mexico City, Mexico.

METHODS

Data were collected prospectively from a pediatric cataract surgery program at the Hospital Luis Sanchez Bulnes, implemented by Helen Keller International. Preoperative data included age, sex, baseline visual acuity, type of cataract, laterality, and presence of conditions such as amblyopia. Surgical data included vitrectomy, capsulotomy, complications, and use of intraocular lenses (IOLs). Postoperative data included final visual acuity, refraction, number of follow-up visits, and program support for follow-up.

RESULTS

Of 574 eyes of 415 children (mean age 7.1 years +/- 4.7 [SD]), IOLs were placed in 416 (87%). At least 1 follow-up was attended by 408 patients (98.3%) (mean total follow-up 3.5 +/- 1.8 months); 40% of eyes achieved a final visual acuity of 6/18 or better. Children living farther from the hospital had fewer postoperative visits (P = .04), while children receiving program support had more visits (P = .001). Factors predictive of better acuity included receiving an IOL during surgery (P = .04) and provision of postoperative spectacles (P = .001). Predictive of worse acuity were amblyopia (P = .003), postoperative complications (P = .0001), unilateral surgery (P = .0075), and female sex (P = .045).

CONCLUSIONS

The results underscore the importance of surgical training in reducing complications, early intervention before amblyopia (observed in 40% of patients) can develop, and vigorous treatment if amblyopia is present. The positive impact of program support on follow-up is encouraging, although direct financial support may pose a problem for sustainability. More work is needed to understand reasons for worse outcomes in girls.

Vitrektomie bei Uveitis im Kindes- und Jugendalter

PURPOSE

The role of vitrectomy in pediatric uveitis has as yet not been established. Addressing this question has been reinforced since the recent introduction of the new and relatively well tolerated medical treatment options using biologicals, i. e. TNFalpha blocking agents.

METHODS

A systematic review of literature has been supplemented by results of vitrectomy performed in 41 consecutive eyes of 33 children and adolescents at our institution and followed for 0.5 to 10 years.

RESULTS

No single controlled study on the role of vitrectomy for uveitis has been identified. Beyond a total of 44 case series including 1762 eyes within the last 25 years, 3 papers specifically focussed on vitrectomy for pediatric uveitis including 73 eyes. This series included 29 eyes of our series. Published and recent own data indicate 2 specific findings consistent for all series: reduction of CME presence from 36 to 6.9% with a resulting visual improvement in 79.1% of cases and a quietening down of inflammatory activity postoperatively allowing to taper down or stop steroid and immunosuppressive therapy from preoperatively 80 and 30% to approximately 30 and 10%, respectively.

CONCLUSION

In the absence of evidence-based results, the data from case series indicate that vitrectomy for pediatric uveitis at least meets the expectations from vitrectomy in adult forms of uveitis regarding the reduction of cystoid macular edema and required systemic steroid and immunosuppressive therapies.

Subthreshold diode micropulse panretinal photocoagulation for proliferative diabetic retinopathy

PURPOSE

To report the visual acuity and clinical outcomes of a pilot study of subthreshold diode micropulse (SDM) panretinal photocoagulation (PRP) for treatment of diabetic retinopathy.

METHODS

A retrospective chart review of all patients undergoing PRP for diabetic retinopathy between April 2000 and February 2003 was performed. Treated conditions ranged from severe non-proliferative to severe proliferative diabetic retinopathy. An SDM PRP protocol designed to avoid detectable laser lesions was employed. Treatment failure end points included the development of vitreous haemorrhage or the performance of vitrectomy.

RESULTS

Ninety-nine eyes of 63 patients undergoing SDM PRP were identified. Median follow-up was 1.0 year (range of 0.3-2.7 years). Treatment sessions per eye ranged from 1 to 6 (with a median of two sessions per eye). Overall visual acuity remained unchanged. The probability of treatment failure end points at 12 months post-treatment was 12.5% for vitreous haemorrhage and 14.6% for vitrectomy (from Kaplan-Meier survival analysis). Age, sex, diabetes type, and baseline retinopathy status were not significantly associated with the risk of either failure event. No treatment complications were observed. No eye demonstrated any laser lesion detectable clinically or by fluorescein angiography postoperatively.

CONCLUSION

SDM pan retinal photocoagulation minimized retinal damage and treatment complications in the management of high-risk non proliferative and proliferative diabetic retinopathy. Visual loss was prevented with a low rate of vitreous haemorrhage and vitrectomy postoperatively. Further study of the safety, efficacy, and optimal treatment parameters of SDM pan retinal photocoagulation for diabetic retinopathy is warranted.

Veränderungen der Indikationen für die perforierende Keratoplastik über 20 Jahre, 1985 - 2004

BACKGROUND

The aim of the study was to determine the changing indications for penetrating keratoplasty (PK) over the 20 years from 1.1.1985 through 31.12.2004 at our Ophthalmology Department as well as to identify additional surgical interventions.

PATIENTS AND METHODS

Medical records of all 268 patients (290 eyes) who underwent PK at our Ophthalmology Department Teaching Hospital Maribor over the 20-year period (1985-2004) were reviewed retrospectively. All PK were divided into two groups: the first group comprised 121 eyes operated in the first 10 years (1985-1994) and the second one comprised those operated in the last 10 years (1995-2004).

RESULTS

During the period of 20 years (1984-2004), the most common indication for PK was aphakic/pseudophakic bullous keratopathy (23.1 %). Keratoconus was the second most common indication for PK (21.7 %), followed by corneal scars (21.4 %). In the first 10 years of the study (1985 to 1994) the most common indications were corneal scars (28.9 %), keratoconus (22.3 %) and corneal dystrophy (19.8 %). Over the second 10 years (1995 to 2004) the three most common indications were bullous keratopathy (29 %), keratoconus (21.3 %) and corneal scars (16.9 %). There was a dramatic increase in the number of PK for failed corneal transplants, from 3.3 % in the first to 12.4 % in the second period (+ 275.8 %) and for bullous keratopathy (+ 94.6 %) as well as a decrease for corneal scarring (-41.5 %) and corneal dystrophy (-40.4 %). Additional surgical interventions increased from 21.5 % in the first 10 years to 28.4 % (+ 32.1 %) in the second 10 years.

CONCLUSIONS

Bullous keratopathy was the leading indication for PK during the last 10 years (1994-2005). Keratoconus was the second leading indication in both 10 year periods. Regrafting showed a significant increasing trend in the last 10 years.

[Current strategies for macular hole surgery in Germany, Austria and Switzerland]

BACKGROUND

Main aim of this study was to determine how macular hole surgery is currently being performed in Germany, Austria and Switzerland.

METHODS

A questionnaire concerning the different aspects of surgery for stage 3 macular hole was developed and sent out to the 380 members of the German Retina Society.

RESULTS

This analysis is based on 129 returned questionnaires from colleagues who perform macular hole surgery. A total of 95% (n=123) of the surgeons routinely perform vitrectomy with posterior vitreous detachment, peeling of epiretinal tissue and internal limiting membrane (ILM) peeling. Some 86% (n=106) stain the ILM, with 80% of these (n=85) using indocyanine green (ICG) in concentrations ranging from 0.005% up to 10%. Fourteen percent of ICG users perform a fluid-air exchange before applying the dye. Platelet concentrate is used by 8% of the surgeons with 97% (n=125) performing a gas tamponade using SF6 (53%), C3F8 (22%), C2F6 (16%) or just air (5%) (multiple answers: 4%). Simultaneous cataract surgery is routinely performed by 8%; by 73% only if there is significant cataract.

CONCLUSIONS

There is common consent on the basic surgical steps, but several surgical details, e.g. ILM staining, are performed in substantially different ways.

Chirurgie du trou maculaire avec et sans pelage de la limitante interne à l’aide du vert d’infracyanine

PURPOSE

To investigate the possibility of an adverse effect of infracyanine-guided internal limiting membrane (ILM) removal on functional results of macular hole surgery.

PATIENTS AND METHODS

A retrospective study of two consecutive groups of patients operated for macular hole between January 1998 and December 2001. In group 1 (21 patients), no attempt was made to remove the internal limiting membrane. In group 2 (21 patients), the ILM was peeled using infracyanine green (ICG).

RESULTS

In group 1, 17 of 21 (81%) macular holes were closed by one surgery and 20 of 21 (95%) in group 2; however, this was not statistically significant. Mean preoperative visual acuity was close to 1 on the Logmar scale in both groups. Postoperative visual acuity was 0.6 in group 1 and 0.5 in group 2: four Snellen lines of improvement in group 1 and five lines in group 2. Postoperative visual acuity was the same or better in 16 of 21 patients in group 1 and in 18 of 21 in group 2. These differences were not statistically significant. Late reopening of the hole was statistically less frequent in group 2. Three cases of atrophic patterns at the level of foveal pigment epithelium were noted in each group as was one case of phototraumatism in group 1. These results were stable after more than 18 months of follow-up. All eyes became pseudophakic.

CONCLUSION

In this study, infracyanine-guided removal of the internal limiting membrane did not significantly improve the results of macular hole surgery. No adverse effect of infracyanine on visual function or retinal toxicity was found and late reopening was less frequent.

[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.

[Value of different measurements of the preoperative visual acuity and perception of Purkinje's vessel shadows for prediction of the postoperative visual acuity after vitrectomy in diabetic vitreous hemorrhage]

BACKGROUND

In cases of strong vitreous hemorrhage due to diabetic vitreo-retinopathy there is an uncertainty for the prediction of postoperative visual acuity after vitrectomy. This study compares the value of different preoperative measurements for the prognosis of postoperative visual acuity.

METHOD AND PATIENTS

We evaluated retrospectively the reports of all patients who have been operated by vitrectomy due to diabetic vitreous hemorrhage at our hospital in 2004 (first vitreoretinal surgery). The following measurements were evaluated: preoperative distance and reading VA, last known VA before hemorrhage, laser interference VA, Purkinje's vessel shadow and postoperative distance VA.

RESULTS

42 patients had entire documentation of all evaluated parameters. The preoperative distance VA was 20/1000 (light perception to 20/60), only 3 patients had a reading VA. Laser interference VA was better than red light perception in 13 patients (7 without red light perception). Purkinje's vessel shadows were positive in 22 patients, negative in 17 patients, but 3 patients did not understand the procedure. Prehemorrhage VA was known in 19 patients. Laser interference VA and last known VA prior to hemorrhage (in mean 20 months old) had the best correlation to postoperative VA (p > 0.05). Purkinje's vessel shadow predicts -- if positive -- a postoperative VA of 20/300 or better.

CONCLUSIONS

Postoperative VA after vitrectomy due to diabetic vitreous hemorrhage is best predicted by prehemorrhage VA or laser interference VA, especially if no prehemorrhage VA is known. Positive Purkinje's vessel shadow predicts a postoperative VA of 20/300 or better.

[Pars plana vitrectomy for idiopathic vitreous floaters]

BACKGROUND

The aim of this study was to evaluate the role of pars plana vitrectomy (PPV) in patients with persistent vitreous floaters (VF) in phakic (56.7 %) or pseudophakic (43.3 %) eyes.

SUBJECTS AND METHODS

A retrospective study of 24 consecutive patients (30 eyes) who underwent a 2-port-PPV using indirect opthalmoscopy between 1992 and 2003 was carried out. Main outcome measures were postoperative visual acuity (PVA), incidence of postoperative complications and patient satisfaction, which has been assessed retrospectively using a detailed questionnaire.

RESULTS

Symptoms resolved in all patients. PVA was significantly better (0.91 +/- 0.2 vs. 0.84 +/- 0.2 preoperative visual acuity) or equal in 25 patients (83.3 %). One pseudophakic patient (3.3 %) experienced a retinal detachment 48 months after surgery. In 5 of 17 phakic eyes (35 %) a cataract extraction had to be performed during the follow-up period. All patients were satisfied with their overall visual function.

DISCUSSION

This study shows PPV to be a safe and effective primary treatment for visually disturbing VF. In spite of the small number of cases with a lower PVA (5 eyes/16.7 %), which in the most severe case corresponded to a reduction of VA from 1.0 to 0.6 due to a nuclear sclerosis of the lens, all patients were satisfied. As vitreoretinal complications may occur, a critical patient selection and a careful preoperative assessment of specific risks of vitrectomy are mandatory.

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.

[Vitreo-retinal pediatric surgery: epidemiologic factors, etiology and prognosis]

The features of pediatric vitreoretinal surgery are different from those of the adult population. In order to identify those differences, our retrospective study, dealing with a consecutive series of 2230 patients who underwent vitreoretinal surgery, analyzes several parameters for the 43 young patients (under 19 years old) (2%). Two main results can be withdrawn from the study. First, trauma is a major cause of vitreoretinal surgery in children (30% of the cases), proportionally much more frequent than in adults. Second, patient's age is the only factor that significantly influences the surgical prognosis, with a success rate of 35% under the age of 10 years, and 73% above this age (p < 0.05). We conclude that pediatric vitreoretinal surgery has a more guarded prognosis compared to the one performed in the adult population.

Open globe injuries: epidemiological study of two eye clinics in Germany, 1981-1999

AIM

To analyze the epidemiology of open eye globe injuries and their treatment outcomes in patients treated at two university eye clinics in Germany in the past two decades.

METHODS

Retrospective analysis was performed of medical records of 1,026 patients with open globe injuries primarily treated at the Universities of Freiburg and Wurzburg between January 1981 and December 1999. Final visual function was determined as a parameter of age, extent of injury, sex, cause of injury, and activity at the time of injury. Relative risk was calculated.

RESULTS

After correction for the demographic distribution, the risk for open globe injury was 1.7 times the average for young adults and 0.6 for seniors. In the recent years, the risk for severe eye injury has been more equally distributed and is increasing for old people. The proportion of injuries at work decreased over the studied period from 42% to 32% for all open globe injuries, and the proportion of injuries in traffic accidents decreased from 30% to 4%. The number of eye injuries related to hobby activities increased. The proportion of enucleations and blindness decreased. Social life and income was moderately or severely impaired in 27% of patients after severe unilateral eye trauma. The median follow up of patients was 7 months.

CONCLUSION

The prevalence and types of open globe injuries changed over the years, especially in relation to the law requiring seat belt use in traffic. The progress in surgical techniques led to a significant reduction in the number of blind eyes after injury. The proportion of enucleations and blindness decreased partly due to better surgical techniques, but mostly due to the decrease in injuries with usually poor outcome, such as gunshots, ruptures, and windscreen injuries.

Vitreoretinale Zweiteingriffe nach elektiver Makulachirurgie

OBJECTIVE

The spectrum of reoperations after macular surgery was investigated retrospectively in a large group of patients. All secondary surgical procedures except for cataract surgery were considered.

METHODS

Between July 1995 and June 2001 353 eyes underwent macular surgery (218 due to macular pucker, 135 due to macular hole) with a pars-plana vitrectomy (PPV), creation of vitreous detachment, membrane peeling and SF(6)/air-instillation. The vitrectomies were performed by 4 different surgeons. In all patients a preoperative circular peripheral cryoretinopexy was performed 3-4 weeks before macular surgery. The follow-up was 20.9 months on average. The number of revitrectomies as well as the postoperative retinal detachment rate were investigated.

RESULTS

In 33 cases (9.3%) a second vitrectomy had to be performed due to an unsatisfying postoperative macular finding: 17/218 (7.8%) after macular pucker surgery with a recurrent pucker and 16/135 (11.8%) after macular hole surgery with persistent or recurrent macular hole. In 7/353 (2.0%) a postoperative rhegmatogenous retinal detachment was observed and in 2/353 (0.6%) a postoperative endophthalmitis had to be treated.

CONCLUSION

In 9.3% of our patients a second PPV due to an unsatisfying macular finding became necessary. The rate of postoperative retinal detachment of 2.0% is considerably lower than in most other studies. Therefore, a possible prophylactic effect of the preoperative circular peripheral cryoretinopexy is suggested to reduce the risk of postoperative retinal detachment.

A comparative study of panretinal photocoagulation and vitrectomy for advanced diabetic retinopathy

A retrospective, cohort study of patients with diabetic retinopathy was conducted, which assessed factors of age at the time of initial panretinal photocoagulation, sex, race [American Indian and non-Indian), and those requiring postpanretinal photocoagulation vitrectomy. Frequency analyses were used to categorize the study population by ethnicity and sex. Independent sample Student's t test were used to compare means of age, ethnicity, and sex. Layered chi2 analyses were performed to study the ethnic status of the men and women requiring vitrectomy, followed by an examination of the relationship of these three factors to the vitrectomy group using a logistic regression model. Within this 265 patient group, the American Indian male was noted to require vitrectomy more frequently and tended to receive initial panretinal phototcoagulation at a lower age.

Frequency of epithelial debridement during diabetic vitrectomy

PURPOSE

To survey active vitreoretinal surgeons to determine how often they intentionally debride the corneal epithelium during vitrectomy surgery for diabetic patients and to ascertain whether the selection of the surgical lens type influences the debridement rate.

DESIGN

Observational retrospective case series.

METHODS

Fifty-five vitreoretinal surgeons were asked to retrospectively report how many pars plana vitrectomies they performed in 1 year on diabetic eyes and in what percent of the cases was debridement of the cornea necessary. In a second query, they were asked to note which specific type of surgical lens system (hand-held irrigating, Landers sew-on, or Oculus BIOM noncontact) was used for their surgical intervention.

RESULTS

The total number of diabetic vitrectomies performed in 1 year by the respondents was 8,002. The frequency of epithelial debridement was 17.4%, with a range of 0% to 90%. The use of irrigating contact lenses was associated with a significantly higher rate of debridement compared with the use of sew-on or BIOM noncontact lenses (23.5% vs 12.1%, P <.001). Regarding the 41 surgeons who indicated a specific type of lens used, we found that the debridement rate for infusion lenses was 23.8% compared with 13.0% for sew-on lenses and 15.6% for noncontact BIOM lenses. The difference between these groups was statistically significant (P <.025).

CONCLUSIONS

Irrigating contact lenses appear to increase the need for epithelial debridement compared with other alternatives. Sew-on lenses with a viscoelastic cushion may provide the best corneal protection.

Analysis of risk factors for the outcome of primary retinal reattachment surgery in phakic and pseudophakic eyes

BACKGROUND

To compare the preoperative risk profiles of phakic and pseudophakic eyes with primary retinal detachment and to assess their impact on the outcome of primary reattachment surgery.

PATIENTS AND METHODS

220 consecutive patients with primary retinal detachment, 165 phakic and 55 pseudophakic eyes were operated with scleral buckling alone or additional vitrectomy and followed up for 6 months. Pre-, intra- and postoperative risk factors were recorded and their impact on anatomical outcome after primary surgery in phakic and pseudophakic eyes was then compared in a multivariate regression analysis.

RESULTS

The cumulative probability of anatomical success 6 months after surgery was similar in phakic (88.5 %) and pseudophakic eyes (86.3 %; log rank = 0.340). The most important risk factor for a different surgical outcome between phakic and pseudophakic eyes was the size of retinal detachment (p = 0.035). In phakic eyes the size of retinal detachment had no significant impact on surgical outcome (1 vs. 4 quadrants; log rank = 0.135); whereas in pseudophakic eyes a significant impairment on surgical outcome was found (1 vs. 4 quadrants; log rank < 0.001). The relative risk for failure of primary surgery due to retinal detachment of at least 3 quadrants was in phakic eyes 1.22 (CI: 0.71 - 1.70), in pseudophakic ones 1.81 (CI: 0.88 - 2.59).

CONCLUSIONS

The outcome of primary retinal reattachment surgery in phakic and pseudophakic eyes is similar for retinal detachments up to 3 quadrants. In retinal detachments of more than 9 clock times, the size of retinal detachment impairs the surgical outcome in pseudophakic eyes more than in phakic ones. The combination of extraocular surgery with vitrectomy in pseudophakic eyes with retinal detachment of more than 9 clock times contributes to a better outcome.

Triple cycle audit of primary retinal detachment surgery

PURPOSE

To determine the effect of increasing subspecialisation on the results of retinal detachment surgery in one city.

METHODS

Three audit cycles over a 10-year period when major subspecialisation and organisational changes were occurring. Retrospective case note reviews of all primary surgery for rhegmatogenous retinal detachments in each of the audit periods. Statistical analyses used contingency table/chi-square methods for comparing all three audits and Fisher's exact test/mean odds ratio with 95% confidence intervals (CIs) for the Audit 1 vs Audit 3 comparison.

RESULTS

A marked improvement in success rates occurred: primary reattachment rose from 67% in Audit 1 to 87% in Audit 3 (P = 0.0004), and final success from 84% to 97% (P = 0.0003). There was a dramatic change in operative techniques over the same period: the percentage of vitrectomies increased from 1.5% in Audit 1 to 48% in Audit 3, while that of 'open' conventional procedures decreased from 78% to 32%. However, the improvement in anatomical success was not mirrored by an increase in the percentage of patients with 6/12 or better visual acuity postoperatively (55% in Audit 1, 49% in Audit 3; P = 0.34, mean odds ratio = 0.78; 95% CI 0.48-1.2). The percentage of patients with 6/18-6/36 post op visual acuity did increase in Audit 3 (18% in Audit 1; 29% in Audit 3; P = 0.03, mean odds ratio = 1.9; CI 1.1-3.3), and the percentage with 6/60 or worse decreased (27% in Audit 1, 20% in Audit 3; P = 0.26, mean odds ratio = 0.71; CI 0.40-1.2).

CONCLUSIONS

With increased subspecialisation there has been an increase in anatomical success, but the goal of 100% reattachment is still not being attained. There remains scope for further improvement in anatomical and functional outcomes.

Eye healthcare services in eastern Europe: Part 2. Vitreoretinal surgical services

AIM

To describe vitreoretinal surgical services in 1998 in 12 eastern European countries and to identify ways for their further improvement.

METHODS

All inpatient eye departments in the 12 countries received a standardised questionnaire; the data obtained were processed at the international study coordinating centre in Prague.

RESULTS

All 458 eye departments in the region were involved. The number of retinal detachments treated by extraocular surgery, or pars plana vitrectomy, per one million inhabitants respectively, were as follows: Belarus (52; 6), Federation of Bosnia and Herzegovina (21; 2), Bulgaria (39; 19), the Czech Republic (78; 40), Estonia (60; 17), Hungary (81; 88), Latvia (82; 36), Lithuania (68; 6), Trans-Dniester Region of Moldova (6; -), Poland (70; data not available), Romania (24; 25), and Slovakia (67; 55). The number of people per one retinal laser was assessed (in millions): Belarus (1.26), Federation of Bosnia and Herzegovina (2.23), Bulgaria (0.59), the Czech Republic (0.22), Estonia (0.24), Hungary (0.23), Latvia (0.41), Lithuania (0.62), Poland (0.36), Romania (2.25), and Slovakia (0.14).

CONCLUSIONS

Conditions for posterior eye segment surgery in the central and eastern European region vary substantially. Underserved regions require (1) more eye doctors trained in surgical and laser retinal treatment; (2) improvement in screening for diabetic eye complications and retinopathy of prematurity; (3) technical equipment for places in need.

Eye health care in Hungary

PURPOSE

To describe eye health-care services provided by in patient Departments of Ophthalmology in Hungary as of 1998.

METHODS

A standardised questionnaire was sent to all Hungarian in-patient ophthalmic departments. The response rate was 100%, and data from six university departments and 56 hospitals with ophthalmic units are summarised.

RESULTS

During the 12-month period, a total of 78,008 ophthalmic operations were performed, by 489 ophthalmologists. They worked in 62 in-patient ophthalmic units having a total of 1952 beds. The cataract rate was 3564 operations per million inhabitants; intraocular lens implantation was performed on 97% of the cases. There were 591 corneal transplants, 1698 operations for retinal detachment and 510 vitrectomies for diabetic eye complications.

CONCLUSIONS

The level of ophthalmic care in Hungary, judged on the basis of key objective parameters including number of ophthalmic specialists, number of ophthalmic beds, and the rates of surgery, generally conforms to standards prevailing in Western Europe, in spite of financial difficulties and the consequent lack of investment in new equipment and instruments, both major and minor.

[Posterior vitrectomy for dislocated nuclear fragments during phakoemulsification: incidence, risk factors and prognosis of postoperative retinal detachment]

INTRODUCTION

Dislocated nuclear fragments during phakoemulsification are a well-known complication. The treatment is often surgical, and serious complications, among which a retinal detachment may occur. The purpose of this study was to evaluate its incidence, risk factors, and prognosis.

METHODS

This retrospective study included a consecutive series of 24 eyes undergoing posterior vitrectomy for dislocated nuclear fragments during phakoemulsification. The main outcome measures were the postoperative retinal detachment (incidence, risk factors, prognosis).

RESULTS

Two retinal detachments occurred after vitrectomy, an incidence of 8%. In both cases, a significant inflammation of the anterior chamber and corneal decompensation were noted before vitrectomy. More than 50% of the nucleus was dislocated. Intraocular implant manipulation did not intervene in either case. Two tears occurred during vitrectomy in one case. The prognosis of the detachment, with proliferation, was poor in both cases.

DISCUSSION

and conclusion: The high incidence of retinal detachment compares with that observed after phakoemulsification complicated by vitreous loss. Anterior segment deterioration, which compromises posterior segment visualization, and dislocation of more than 50% of the nucleus, that increases the risk of fragments falling on the retina during vitrectomy, may increase the occurrence of retinal detachment with a poor prognosis because of periretinal proliferation.

[Is scleral buckling still current?]

We report a survey among German-speaking vitreo-retinal surgeons, considering their decisive factors and preferred surgical techniques in simple and complicated rhegmatogenous situations. In cases of simple retinal detachment conventional buckling surgery is the favoured surgical approach. Minimal-invasive techniques like the balloon operation or pneumatic retinopexy are chosen by less than 5% of the surgeons. For more complicated retinal detachments a strong trend towards primary vitrectomy becomes apparent. In difficult rhegmatogenous situations which are still treatable with conventional buckling procedures, 45% of surgeons prefer a primary vitrectomy and only 55% chose scleral buckel or encircling band procedures.

Primary rhegmatogenous retinal detachment: 20 years of change

AIM

To compare characteristics, management, and outcome of two groups of patients with primary rhegmatogenous retinal detachment (RRD) presenting to the same vitreoretinal unit approximately 20 years apart.

METHODS

124 patients in 1979-80 and 126 cases in 1999 were compared.

RESULTS

More cases were pseudophakic and fewer aphakic in 1999 than 1979-80. More cases of giant retinal tear and fewer dialyses were operated on in 1999. Vitrectomy was a primary procedure in 63% of cases in 1999 but only 1% in 1979-80. Anatomical success rates were statistically similar: 79.8% primary and 88.8% final success in 1979-80, and 84% primary and 93.6% final success in 1999.

CONCLUSION

Surgical management of primary RRD has changed greatly in 20 years. Success rates have changed little, despite availability of differing surgical techniques.

Survey of surgical indications and results of primary pars plana vitrectomy for rhegmatogenous retinal detachments

BACKGROUND

Several surgical techniques to repair rhegmatogenous retinal detachment have been developed. Recently, both the method of reattaching the retina and of obtaining an early visual recovery are considered important factors when determining which surgical techniques to perform to treat retinal detachment.

CASES

The surgical outcome in a series of 63 consecutive patients, who were treated at Osaka Rosai Hospital between 1993 and 1996, was reviewed retrospectively to evaluate the efficacy of primary vitrectomy to treat uncomplicated rhegmatogenous retinal detachment associated with posterior hyaloid separation. The criteria for vitrectomy included the presence of not only posterior retinal breaks, but also of multiple peripheral retinal breaks.

OBSERVATIONS

The reattachment rate after the first surgery was 92.1% (58 eyes), and by the final examination it increased to 100%. Of the 46 eyes with macular detachment, good visual rehabilitation and a visual acuity improvement of 5 or more lines was obtained in 33 eyes (71.7%) by 1 month postoperatively. No statistically significant difference in the reattachment rate was found when eyes that underwent an encircling procedure were compared with those that did not. In eyes with lens opacity, cataract surgery was also performed and intraocular lenses were implanted uneventfully in all but one case with myopia. There was a high incidence (53.8%) of cataract progression in phakic eyes. However, no other serious complications, such as proliferative vitreoretinopathy, were found throughout the follow-up period.

CONCLUSIONS

The results indicate that vitrectomy performed to alleviate peripheral vitreoretinal traction is an effective surgical technique to treat primary rhegmatogenous retinal detachment. Vitrectomy combined with cataract surgery may also be a valuable surgical option in selected cases to maintain long-standing visual rehabilitation.

Surgical treatment for diabetic retinopathy: 5-year experience

To evaluate the surgical indications and results among patients undergoing pars plana vitrectomy for complications of diabetic retinopathy, the clinical records of all such patients treated by a single surgeon from January 1992 through August 1996 were reviewed. Pre- and postoperative visual acuity, indications for surgery, surgical methods, and anatomic outcomes were recorded and analyzed. A total of 106 eyes (92 patients) were included. Surgical indications included nonclearing vitreous hemorrhage (21 eyes), active fibrovascular proliferation (28 eyes), traction retinal detachment (42 eyes), premacular hemorrhages (3 eyes), combined traction and rhegmatogenous retinal detachment (7 eyes), severe macular edema (1 eye), and progressive macular or disc traction (4 eyes). Surgical techniques ranged from tissue segmentation to combined delamination and segmentation. Anatomical success was obtained in 90 eyes (84.9%). Visual acuity improved in 69 eyes (68.0%), stabilized in eight eyes (7.5%), and decreased in 29 eyes (28%). All 21 eyes with vitreous hemorrhage had anatomical success, while 10 of 42 (24%) eyes with traction retinal detachment eventually had retinal detachment. Fourteen eyes had postoperative persistent or recurrent vitreous hemorrhage requiring air-fluid exchange or vitreous lavage. Silicone oil was used in eight eyes. Surgical failure was mainly caused by iatrogenic breaks with persistent traction, or severe anterior or posterior reproliferation. These findings indicate that reasonably successful anatomical outcomes can be achieved with modern surgical methods. However, improvements in visual acuity may be less satisfactory. Eyes with widespread, thickened fibrovascular complexes with active neovascularization, and extensive traction retinal detachment have a poor prognosis.

[Vitrectomy for treatment of ocular complications in diabetes. III. Factors influencing results of vitrectomy]

The aim of this study was to find factors influencing results of pars plana vitrectomy for proliferative diabetic retinopathy.

MATERIAL AND METHODS

25 general and local factors which could influence results of pars plana vitrectomy (ppV) were selected and compared with functional results of surgery of 168 eyes with diabetic retinopathy.

RESULTS

The most significant general factor was the age during ppV and the age at diagnosis of diabetes. Glycosylated hemoglobin blood level had little influence on ppV results. The most important local factor was the morphological state of the retina before the surgery. Better functional results were also achieved in eyes treated with panretinal photocoagulation before ppV and treated with vitrectomy without silicone oil tamponade when visual acuity was better than 5/50.

CONCLUSIONS

General state of patients before ppV has little influence on functional results of ppV. Local factors are the main factors influencing this results.

[Compiling the data of vitrectomy patients. Waiting list organization and quality assurance]

Owing to an increasing frequency of ophthalmological operations and the necessity of shortening the patient's stay in hospital surgical scheduling and data compilation in ophthalmology can only be managed by means of electronic data processing. We present a computer program that compiles a waiting list for vitrectomies and organizes the scheduling of operations. On each patient's first visit a standardized form containing the essential clinical findings if filled out. On the basis of these data the computer, using a specially designed algorithm places the patient in an appropriate position on the waiting list and eventually informs him or her of the date of the operation. In a similar manner the postoperative findings and the results of the follow-up examinations are documented. The system allows effective scheduling based on the urgency of the operation and the prognosis of the disease. Furthermore, it facilitates prospective recording of the clinical course and the treatment outcome. The use of electronic data processing does not only mean an improvement in clinical organization and, especially, in surgical planning, but also facilitates a quick evaluation of clinical studies with a large number of patients.

Perfluorocarbon liquids (perfluorodecalin) in vitreoretinal surgery--a local experience

A low viscosity perfluorocarbon liquid (perfluorodecalin) known commercially as DKLine was used intraoperatively as a temporary vitreous substitute in 20 patients undergoing vitrectomy surgery for a variety of complicated vitreoretinal conditions. The indications for its use included giant retinal tears (9), proliferative vitreoretinopathies (2), dislocated lenses (2), dislocated posterior chamber implant (1), endophthalmitis with retinal detachment (2), traction retinal detachment (1), pseudophakic retinal detachment (2) and exudative retinal detachment (1). In all cases with retinal detachment, perfluorodecalin was successful in flattening the retina intraoperatively. It was also successful in permitting the safe removal of dislocated lenses that were lying on the retina. In all except four cases, removal of perfluorodecalin was complete. We observed no toxic effects from remnant bubbles of perfluorocarbon in the eye.