Intraoperative Three-Dimensional Fluorescein Angiography-Guided Pars Plana Vitrectomy for the Treatment of Proliferative Diabetic Retinopathy: The Maximized Utility of the Digital Assisted Vitrectomy.

PURPOSE: To show the usefulness of the intraoperative three-dimensional fluorescein angiography (3D-FA)-guided pars plana vitrectomy. METHODS: The NGENUITY 3D visualization system was used for the digital assisted vitrectomy. Three-dimensional fluorescein angiography-guided pars plana vitrectomy was performed in three patients with vitreous hemorrhage secondary to proliferative diabetic retinopathy. We investigated both whether several angiographic findings can be successfully displayed on the screen during 3D-FA and whether pars plana vitrectomy can be performed simultaneously on the same screen while implementing 3D-FA. RESULTS: In all cases, the abnormal FA findings including hypofluorescence due to non-perfusion areas, and the hyperfluorescence due to macular edema and fibrovascular proliferative membrane were successfully displayed on the screen. The segmentation and delamination of fibrovascular proliferative membrane and panretinal photocoagulation for detected non-perfusion areas were able to be performed on the same screen while implementing 3D-FA. CONCLUSION: Three-dimensional fluorescein angiography-guided pars plana vitrectomy is a novel approach that fully utilizes the advantages of digital assisted vitrectomy and a promising option for the treatment of proliferative diabetic retinopathy.

THE LONG-TERM EFFECT OF CYSTOTOMY WITH FIBRINOGEN CLOT REMOVAL FOR A CYSTOID MACULAR EDEMA SECONDARY TO IDIOPATHIC MACULAR TELANGIECTASIA TYPE 1: A CASE REPORT.

PURPOSE: To report the case of a patient with cystoid macular edema secondary to idiopathic macular telangiectasia (MacTel) Type 1, which was successfully treated by cystotomy and en bloc removal of the fibrinogen-rich component of the cystoid lesion. METHODS: An 80-year-old man was referred to our department because of a visual defect in his right eye. His best-corrected decimal visual acuity was 0.7 (Snellen equivalent, 20/30). A fundus examination revealed clustered temporal juxafoveal microaneurysms and foveal cystoid macular edema. The patient refused to undergo conventional treatments, including direct retinal photocoagulation for microaneurysms, intravitreal anti-vascular endothelial growth factor injection, and intravitreal triamcinolone injection. However, he provided consent to undergo cystotomy and en bloc removal of the fibrinogen-rich component of the cystoid lesion. RESULTS: His best-corrected decimal visual acuity was 0.2 (Snellen equivalent, 20/100) just before the surgery. A 27-gauge vitrectomy with internal limiting membrane peeling was performed. Cystotomy was performed during the surgery, and the fibrinogen clot visible in the cystoid cavity was also removed. Cystoid macular edema rapidly disappeared after the surgery. Three years postoperatively, the patient had best-corrected decimal visual acuity of 0.5 (Snellen equivalent, 20/40) at the last medical examination, and the cystoid macular edema had not recurred. CONCLUSION: Cystotomy and en bloc removal of the fibrinogen-rich component of the cystoid lesion could be valid treatment options for cystoid macular edema secondary to MacTel Type 1.

INTRAOPERATIVE THREE-DIMENSIONAL FLUORESCEIN ANGIOGRAPHY-GUIDED PARS PLANA VITRECTOMY FOR BRANCH RETINAL VEIN OCCLUSION.

PURPOSE: To show surgical results of the intraoperative 3D fluorescein angiography-guided pars plana vitrectomy for branch retinal vein occlusion with vitreous hemorrhage and neovascularization elsewhere. METHODS: The NGENUITY 3D visualization system was used for the digital-assisted vitrectomy. Three-dimensional fluorescein angiography-guided pars plana vitrectomy was performed in three patients with branch retinal vein occlusion with vitreous hemorrhage and neovascularization elsewhere. RESULTS: In all eyes, the scatter retinal photocoagulations for a nonperfusion area, depicted as hypofluorescein, and the segmentation and delamination of the perivascular fibrovascular proliferative membrane, depicted as hyperfluorescein, could be safely performed on the same screen while implementing intraoperative 3D fluorescein angiography. CONCLUSION: Three-dimensional fluorescein angiography-guided pars plana vitrectomy, a novel approach that fully uses the advantages of digital-assisted vitrectomy, can be one of the useful techniques for the treatment of branch retinal vein occlusion with vitreous hemorrhage and neovascularization elsewhere.

The contribution of the proximity of the retinal detachment to the fovea for postoperative metamorphopsia after 27-gauge pars plana vitrectomy for the primary rhegmatogenous retinal detachment.

PURPOSE: To investigate clinical factors contributing to metamorphopsia after 27-gauge pars plana vitrectomy (27GPPV) for primary rhegmatogenous retinal detachment (RRD) to reveal whether the proximity of the preoperative retinal detachment to the fovea is associated with postoperative metamorphopsia. METHODS: We retrospectively reviewed medical records of 77 eyes of 77 patients after 27GPPV for RRD. Patients were subdivided into three groups using optical coherence tomography findings: Group A, patients with RRD outside the vascular arcade; Group B, patients whose condition was present within the vascular arcade, but without foveal detachment; and Group C, patients with foveal detachment. RESULTS: The average metamorphopsia score (°) assessed with M-charts 12 months after surgery was 0.01 ± 0.04 in Group A (24 eyes), 0.08 ± 0.18 in Group B (20 eyes), and 0.49 ± 0.48 in Group C (33 eyes) (p<0.001). Logistic regression analysis revealed that metamorphopsia at 12 months after surgery significantly correlated with the proximity of the retinal detachment to the fovea (p = 0.007). CONCLUSION: Metamorphopsia after 27GPPV for RRD correlated with the proximity of the preoperative retinal detachment to the fovea. Attention should be paid to the possibility of postoperative metamorphopsia development when retinal detachment is present within a vascular arcade even if the fovea is not involved.

Clinical Factors Associated with Low-Contrast Visual Acuity after Reduced-Fluence Photodynamic Therapy in Patients with Resolved Central Serous Chorioretinopathy and Good Baseline Visual Acuity.

This retrospective study was conducted to investigate the clinical factors associated with low-contrast visual acuity after reduced-fluence photodynamic therapy (RFPDT) in patients with resolved central serous chorioretinopathy (CSC) and good baseline visual acuity. A total of 45 eyes of 45 patients with resolved CSC at post-RFPDT and best-corrected visual acuity of >1.0 (logarithm of the minimal angle of resolution [logMAR], 0) at baseline were examined. Visual acuities of both eyes were measured at four contrast levels (100%, 25%, 12%, and 6%) at post-RFPDT. The low-contrast visual acuity (6%, 12%, and 25%) was significantly lower than the 100% contrast visual acuity in the affected eyes. Visual acuities of affected eyes were significantly worse than those of fellow eyes at any contrast levels. The degree of changes in 6% and 100% contrast visual acuities was significantly greater in affected eyes than that in fellow eyes (p < 0.05). The 6% contrast visual acuities in affected eyes at post-RFPDT were significantly associated with the symptom duration (p < 0.05). Patients with a long duration of symptoms might have disturbed low-contrast visual acuities at post-RFPDT even if their baseline visual acuities were good.

Cystotomy with or without fibrinogen clot removal for refractory cystoid macular edema secondary to branch retinal vein occlusion.

To demonstrate the long-term effect of cystotomy with or without fibrinogen clot removal for treatment-resistant cystoid macular edema (CME) secondary to branch retinal vein occlusion (BRVO). Retrospective clinical study. We retrospectively analyzed medical records of 22 eyes of 22 patients with treatment-resistant CME secondary to BRVO with 12 months observation after cystotomy with or without fibrinogen clot removal. Patients included 11 women and 11 men. The mean ± SD age was 72.7 ± 10.2 years. LogMAR-converted best corrected visual acuity (BCVA) was statistically better at 12 months after surgery (0.30 ± 0.30) than preoperative BCVA (0.39 ± 0.27) (p = 0.01). The central sensitivity of microperimetry (dB) was maintained during follow-up (preoperative sensitivity: 25.4 ± 4.1, postoperative sensitivity at 12 months after the surgery: 25.9 ± 4.2, p = 0.69). Twelve months after surgery, there was a significant improvement in the central retinal thickness (CRT) on optical coherence tomography (OCT) (303.7 ± 80.1) (µm) compared with the preoperative CRT (524.2 ± 114.8) (p < 0.01). In 12 months, CME recurred in 3 of 22 eyes. The preoperative reflectivity in cystoid cavity on OCT was significantly higher in patients with fibrinogen clot removal (n = 5) than in patients without fibrinogen clot removal (n = 17) (p < 0.01). For treatment-resistant CME secondary to BRVO, Cystotomy with or without fibrinogen clot removal may be one of the treatment options.

LONG-TERM EFFECT OF CYSTOTOMY WITH OR WITHOUT THE FIBRINOGEN CLOT REMOVAL FOR REFRACTORY CYSTOID MACULAR EDEMA SECONDARY TO DIABETIC RETINOPATHY.

PURPOSE: To show the long-term effect of cystotomy with or without fibrinogen clot removal for refractory cystoid macular edema secondary to diabetic retinopathy. METHODS: Retrospective analyses of the medical records of 30 eyes of 30 patients with refractory cystoid macular edema secondary to diabetic retinopathy who had followed up for 12 months after the surgery were performed. RESULTS: There were 15 men and 15 women. The mean ± SD age was 68.4 ± 7.9 years. The best-corrected visual acuity (logarithm of the minimal angle of resolution) at 12 months after the surgery (0.33 ± 0.25, Snellen equivalent, 20/42) was statistically better than the preoperative best-corrected visual acuity (0.45 ± 0.33, Snellen equivalent, 20/56) (P < 0.01). The central sensitivity on microperimetry (dB) was not statistically changed between preoperatively (24.0 ± 4.9) and 12 months after the surgery (24.1 ± 4.0) (P = 0.75). The central retinal thickness on optical coherence tomography (µm) at 12 months after the surgery (300.3 ± 99.0) was statistically improved compared with the preoperative central retinal thickness (565.6 ± 198.7) (P < 0.01). During the follow-up period, cystoid macular edema relapsed in seven of 30 eyes. The preoperative cystoid cavity reflectivity on optical coherence tomography in patients with fibrinogen clot removal (n = 16) was significantly higher than that in patients without fibrinogen clot removal (n = 14) (P < 0.04). CONCLUSION: The cystotomy with or without fibrinogen clot removal may be a promising treatment option for refractory cystoid macular edema secondary to diabetic retinopathy.

Predictive factors of metamorphopsia after reduced-fluence photodynamic therapy in patients with central serous chorioretinopathy with good baseline visual acuity.

This retrospective study was conducted to investigate the predictive factors associated with metamorphopsia after reduced-fluence photodynamic therapy (RFPDT) in patients with central serous chorioretinopathy (CSC) with good baseline visual acuity. A total of 36 eyes of 36 consecutive patients with resolved CSC after RFPDT and best-corrected visual acuity (BCVA) better than 1.0 (logarithm of the minimal angle of resolution (logMAR) 0) at baseline were examined. Metamorphopsia was measured using M-CHARTS at 12 months after RFPDT. An average of the horizontal and vertical M-CHARTS scores was applied for defining the extent of metamorphopsia. The association between M-CHARTS score at 12 months after RFPDT and clinical parameters (age, sex, duration of symptoms, BCVA, and findings of optical coherence tomography (OCT)) was investigated at baseline or 12 months after RFPDT. The M-CHARTS score at 12 months correlated significantly with duration of symptoms (P = 0.005), baseline outer nuclear layer (ONL) thickness (P = 0.009), central foveal thickness (CFT) (P = 0.001) at 12 months, and ONL thickness (P = 0.001) at 12 months after RFPDT. In the multivariate analysis of baseline-related factors, thinner ONL thickness before RFPDT (P = 0.010) was significantly associated with large metamorphopsia at 12 months after RFPDT in CSC patients with good baseline BCVA. Baseline ONL thickness may be a useful predictive factor of metamorphopsia after RFPDT in CSC patients with good baseline BCVA.

Comparison between the outcomes of fluorescein angiography-guided and indocyanine green angiography-guided half-time photodynamic therapy for central serous chorioretinopathy.

BACKGROUND AND OBJECTIVES: This study aimed to compare the efficacy of fluorescein angiography (FA)-guided and indocyanine green angiography (ICGA)-guided half-time photodynamic therapy (PDT) for central serous chorioretinopathy (CSC). SUBJECTS AND METHODS: Medical records of 61 eyes of 61 CSC patients who underwent half-time PDT were retrospectively reviewed. The irradiation area was determined using information from FA or ICGA with physicians' discretion. Best-corrected visual acuity (BCVA), central retinal thickness (CRT), subfoveal choroidal thickness (SCT), and resolution of subretinal fluid (SRF) were evaluated at baseline and 1, 3, 6, and 12 months after PDT. RESULTS: A total of 29 and 32 eyes received FA-guided PDT (irradiation area, 2898.3 ± 705.7 µm) and ICGA-guided PDT (irradiation area, 4993.8 ± 333.1 µm), respectively. A significant improvement in the mean BCVA was found at 1 month in the FA-guided group (P = 0.02), but not in the ICGA-guided group (P = 0.88). BCVA was significantly improved in both groups at 3, 6, and 12 months with no significant intergroup difference at any time points. CRT and SCT were significantly reduced in both groups at all time points with no significant intergroup differences. No significant intergroup differences were observed in the rate of recurrence and persistent SRF. However, there was a significant difference between groups in the rate of recurrence and/or persistent SRF (P = 0.04). Multivariate analysis revealed that choice of FA-guided was significantly associated with recurrence and/or persistent SRF (P = 0.04). CONCLUSION: Half-time PDT with ICGA-guided irradiation spot might be more effective than that with FA-guided in treating CSC patients in complete resolution of SRF.

Genetic factors associated with treatment response to reduced-fluence photodynamic therapy for chronic central serous chorioretinopathy.

Purpose: Reduced-fluence photodynamic therapy (RFPDT) has proven effective for some patients with chronic central serous chorioretinopathy (cCSC). Several clinicodemographic factors influencing treatment response have been identified, but associations with genetic factors have not been examined. Therefore, we investigated the associations of single nucleotide polymorphisms (SNPs) implicated in cCSC pathogenesis with clinical outcome following RFPDT. Methods: This was a retrospective study of 87 eyes from 87 patients with cCSC who underwent RFPDT and were followed up for more than 12 months. Patients were divided into a good response group (53 patients) and a poor response group (34 patients) based on either persistence or recurrence of subretinal fluid detected with spectral domain optical coherence tomography after the first application of RFPDT. SNPs in the genes encoding age-related maculopathy susceptibility protein 2 (ARMS2, SNP rs10490924) and complement factor H (CFH, SNP rs800292) were genotyped using TaqMan technology. Results: There were no statistically significant differences in the baseline characteristics between the response groups except the degree of hyperfluorescence on indocyanine green angiography (ICGA; p = 0.011). The minor (T) allele frequency of ARMS2 (rs10490924) were statistically significantly lower in the good response group than in the poor response group (24.0% versus 41.0%, p = 0.021). Further, the good response frequency was statistically significantly lower in patients with at least one minor allele (GT or TT) compared to the homozygous major allele group (GG; p<0.05). The baseline best-corrected visual acuity (BCVA) at 12 months after RFPDT was statistically significantly better in the GG carriers than in the GT or TT carriers (p<0.01). Logistic regression analysis showed less intense hyperfluorescence on ICGA, and the T allele of ARMS2 (rs10490924) was statistically significantly associated with poor response to PDT treatment (p = 0.012, p = 0.039, respectively). Conclusions: Carriers of the ARMS2 rs10490924 minor allele (GT or TT) demonstrated a higher subretinal fluid persistence or recurrence rate and poorer visual outcome following RFPDT. In addition to the ICGA findings, genotyping of ARMS2 (rs10490924) may assist in the selection of patients with cCSC most likely to benefit from RFPDT.

The comparison of the surgical outcome of 27-gauge pars plana vitrectomy for primary rhegmatogenous retinal detachment between air and SF6 gas tamponade.

OBJECTIVES: To compare the surgical results between air and 20% sulfur hexafluoride (SF6) tamponade in 27-gauge pars plana vitrectomy (27GPPV) for rhegmatogenous retinal detachment (RRD). METHODS: A retrospective, observational, and consecutive study. All patients underwent 27GPPV for RRD were divided into two groups. Group A comprised patients who underwent 20% SF6 gas tamponade. Group B comprised patients who underwent air tamponade. The anatomical success rate, visual outcome, and the type and frequency of complications were investigated and compared between the groups. All patients were followed-up for 12 months after surgery. RESULTS: Seventy eyes were enrolled (Group A: 35 eyes, Group B: 35 eyes). Seventeen eyes in Group A and 13 eyes in Group B had RRD with superior retinal breaks, while 14 eyes in Group A and 19 eyes in Group B had RRD with inferior retinal breaks. There was no statistically difference in preoperative demographic date between the groups. The initial and final anatomical success rates were 97.1% and 100% in Group A and 94.3% and 100% in Group B, respectively. The success rates between the groups were not statistically different (p = 1). The best corrected visual acuity (BCVA) (logMAR) at 12 months after surgery was -0.02 ± 0.14 in Group A and -0.03 ± 0.27 in Group B. The BCVA between the groups was not statistically different (p = 0.27). CONCLUSIONS: The surgical results of air tamponade were not inferior to 20% SF6 tamponade in 27GPPV for RRD irrespective of retinal break locations in the present cohort.

Impact of Early Vitrectomy for Dense Vitreous Hemorrhage of Unknown Etiology.

BACKGROUND: Surgical intervention for dense vitreous hemorrhage (DVH) with unclear etiology is often delayed in favor of conservative follow-up despite possible disease progression and the availability of safe minimally invasive vitrectomy. OBJECTIVES: The aim of this study is to investigate the efficacy of early surgical intervention for DVH with unknown etiology. METHODS: Eighty-eight cases (88 eyes) of DVH with unknown origin were retrospectively reviewed. Inclusion criteria were as follows: (1) measured visual acuity (VA) of 20/200 or worse and (2) fundus invisibility requiring B-scan ultrasonography. Eyes with a history of diabetic retinopathy, recent trauma, or likely retinal detachment (RD) as revealed by B-scan ultrasonography were excluded. Outcome measures were a cause of vitreous hemorrhage and final VA following early (≤2 weeks after symptom onset) or delayed vitrectomy. RESULTS: The most frequently occurring causes of DVH were central or branch retinal vein occlusion (30 eyes, 34%) and retinal tear or RD (29 eyes, 33%). logMAR VA significantly improved after treatment (p < 0.001). Final VA was significantly higher for eyes treated within 2 weeks compared with eyes treated later than 2 weeks after symptom onset (p = 0.020). CONCLUSIONS: Surgical intervention within 2 weeks after symptom onset may prevent a lower visual outcome.