Adverse Events during Vitreoretinal Surgery under Adequacy of Anesthesia Guidance-Risk Factor Analysis.

Vitreoretinal surgeries require the administration of general anesthesia (GA) in selected groups of patients. The administration of intraoperative rescue narcotic analgesia (IRNA) during GA poses the risk of postoperative nausea and vomiting (PONV). The surgical pleth index (SPI), a crucial component of the adequacy of anesthesia (AoA) guidance of GA, optimizes the intraoperative titration of IRNA. The current analysis evaluated the risk factors for the occurrence of PONV and the oculo-cardiac reflex (OCR) in patients undergoing pars plana vitrectomy (PPV) under AoA guidance. In total, 175 patients undergoing PPV were randomly allocated to receive either GA with SPI-guided IRNA administration using fentanyl alone or in addition to different preoperative analgesia techniques. Any incidence of PONV or OCR was recorded. Obesity, overweight, smoking status, motion sickness, postoperative intolerable pain perception, female gender, fluid challenge and arterial hypertension did not correlate with an increased incidence of PONV or OCR under AoA guidance. Diabetes mellitus, regardless of insulin dependence, was found to correlate with the increased incidence of PONV. The AoA regimen including SPI guidance of IRNA presumably created similar conditions for individual subjects, so no risk factors of the occurrence of PONV or OCR were found, except for diabetes mellitus. We recommend using AoA guidance for GA administration to reduce OCR and PONV rates.

360° inverted internal limiting membrane flap technique for idiopathic macular holes ≤ 250 µm, > 250 and ≤ 400 µm, and > 400 µm.

PURPOSE: To study the functional and morphological results of the inverted internal limiting membrane (ILM) flap technique for the treatment of idiopathic macular holes (MHs) sized ≤ 250 µm, > 250 and ≤ 400 µm, and > 400 µm. METHODS: Retrospective, nonrandomized interventional study of 65 eyes with primary idiopathic MHs who underwent pars plana vitrectomy (PPV) with the inverted ILM flap technique. Closure rate, best-corrected visual acuity (BCVA), and integrity of external limiting membrane (ELM) and ellipsoid zone (EZ) were analyzed by optical coherence tomography (OCT). RESULTS: Total closure rate was 96.9% with 100% in the ≤ 250 µm group, 100% in the > 250 and ≤ 400 µm group, and 91.7% in the > 400 µm group. Mean BCVA significantly improved after treatment: from 0.7 to 0.3 LogMAR in the ≤ 250 µm group (n = 15, p < 0.001), from 0.9 to 0.4 LogMAR in the > 250 and ≤ 400 µm group (n = 26, p < 0.001), and from 1.0 to 0.5 LogMAR in the > 400 µm group (n = 24, p < 0.001). A total of 16 patients had follow-up over 14 months: BCVA increased from 0.9 LogMAR preoperatively to 0.4 after 1 month (p < 0.00001) and to 0.3 LogMAR after 14 months (p = 0.03). A recovered ELM could be observed in 56.3% after 1 month and in 87.5% after 14 months. A recovered EZ could be observed in 18.8% after 1 month and in 68.8% after 14 months. CONCLUSION: The study demonstrates a high closure rate with corresponding restitution of outer retinal layers. In addition to its importance for the treatment of MHs > 400 µm, the inverted ILM flap technique also appears to be effective and safe for the treatment of MHs < 400 µm. TRIAL REGISTRATION: WHO: DRKS00021241.

[Closure of Persisting Full Thickness Macular Holes by Subretinal Fluid Application: Technical Approach and Surgical Considerations]. / Verschluss von persistierenden Makulalöchern durch subretinale Flüssigkeitsapplikation: technisches Vorgehen und chirurgische Überlegungen.

INTRODUCTION: Firm adhesions between the retina and adjacent retinal pigment epithelium (RPE) may prevent the closure of macular holes (MH) after chromovitrectomy. Controlled application of subretinal (SR) fluid with BSS may release these adhesions leading to closure of the retracted retina in large and or refractory macular holes. METHODS: For a standardized procedure, it is recommended to exclude residues of epiretinal membranes on the retinal surface preoperatively at OCT or intraoperatively by means of vital dyes. Intraoperatively, a perfluorocarbon (PFO) bubble is placed above the MH and lowers the infusion bottle of 20 mmHg. Subsequently, SR-fluid blebs are applied in the upper, temporal and inferior quadrants with a subretinal 41-gauge cannula. After removing decalin bubble, the SR-detachment is enlarged toward the foveal center. This is essential to achieve a complete detachment of the outer macular edges from the RPE. The MH can be closed by a temporary gas endotamponade. RESULTS: With a standardized procedure, the operation can be carried out safely and with minimal effort. Additional measures, such as care for bubble-free SR-fluid sands or machine assistance, were added. In a pilot study, experienced VR surgeons performed the SR-fluid application safely and without complications. The preoperative diameter of the MH was 1150 µm (651 - 2350 µm). The secondary closure rate for our PMH was 80.9%. CONCLUSION: SR-adhesions seem to have a previously unnoticed component in persistent macular holes. An SR-fluid application can be carried out quickly, safely and with minimal material effort. The initial results show a high secondary closure rate.

Calculating the individual probability of successful ocriplasmin treatment in eyes with VMT syndrome: a multivariable prediction model from the EXPORT study.

BACKGROUND/AIMS: To evaluate predictive factors for the treatment success of ocriplasmin and to use these factors to generate a multivariate model to calculate the individual probability of successful treatment. METHODS: Data were collected in a retrospective, multicentre cohort study. Patients with vitreomacular traction (VMT) syndrome without a full-thickness macular hole were included if they received an intravitreal injection (IVI) of ocriplasmin. Five factors (age, gender, lens status, presence of epiretinal membrane (ERM) formation and horizontal diameter of VMT) were assessed on their association with VMT resolution. A multivariable logistic regression model was employed to further analyse these factors and calculate the individual probability of successful treatment. RESULTS: 167 eyes of 167 patients were included. Univariate analysis revealed a significant correlation to VMT resolution for all analysed factors: age (years) (OR 0.9208; 95% CI 0.8845 to 0.9586; p<0.0001), gender (male) (OR 0.480; 95% CI 0.241 to 0.957; p=0.0371), lens status (phakic) (OR 2.042; 95% CI 1.054 to 3.958; p=0.0344), ERM formation (present) (OR 0.384; 95% CI 0.179 to 0.821; p=0.0136) and horizontal VMT diameter (µm) (OR 0.99812; 95% CI 0.99684 to 0.99941, p=0.0042). A significant multivariable logistic regression model was established with age and VMT diameter. CONCLUSION: Known predictive factors for VMT resolution after ocriplasmin IVI were confirmed in our study. We were able to combine them into a formula, ultimately allowing the calculation of an individual probability of treatment success with ocriplasmin in patients with VMT syndrome without FTHM.

Intravitreal Sustained-Release Steroid Implants for the Treatment of Macular Edema following Surgical Removal of Epiretinal Membranes.

PURPOSE: To evaluate the efficacy of intravitreal dexamethasone implant for the treatment of postoperative persistent cystoid macular edema (CME) following macular pucker surgery. METHODS: In this multicenter study, we retrospectively reviewed the data of 37 patients (39 eyes) who had been treated with intravitreal dexamethasone implant (Ozurdex®) for persistent CME following macular pucker surgery. Main outcome measures were change in best-corrected visual acuity (BCVA) and central retinal thickness (CRT). RESULTS: All eyes underwent spectral domain optical coherence tomography examination within 130 days after implantation. We observed a significant decrease in mean CRT from 519.9 to 392.9 µm (p < 0.0001). By this time, mean BCVA had improved from 0.60 to 0.43 logMAR (p = 0.003). Seventeen eyes (43.6%) required at least 1 repeat injection of dexamethasone. Of these, 8 (47%) eyes received a total number of 3 or more dexamethasone injections. CONCLUSION: Intravitreal dexamethasone implant injection is an effective treatment option for persistent CME following macular pucker surgery.

Dependency of endothelial cell loss on anterior chamber depth within first 4 years after implantation of iris-supported phakic intraocular lenses to treat high myopia.

PURPOSE: To evaluate the effect of the anterior chamber depth (ACD) on the central corneal endothelial cell density (ECD) in eyes after implantation of an iris-fixated phakic intraocular lens (pIOL). SETTING: Department of Ophthalmology, Goethe-University, Frankfurt, Germany. DESIGN: Retrospective nonrandomized case series. METHODS: An Artisan pIOL was implanted in eyes of highly myopic patients. Follow-up examinations at 1, 12, 24, 36, and 48 months included evaluation of ECD and adverse events. Three cohorts based on the ACD were established and their ECDs compared. All eyes had 1-year and 4-year postoperative ECD measurements available. Statistical analysis included linear regression analysis to evaluate the influence of ACD on ECD. RESULTS: The study comprised 95 eyes (52 patients). Four years after surgery the mean spherical equivalent changed from -11.06 diopters (D) ± 4.77 (SD) to -0.42 ± 0.47 D. Severe adverse events were not detected. There was a significantly higher ECD loss after 4 years in patients with an ACD of less than 3.00 mm than in those with an ACD greater than 3.40 mm (-224 cells/mm2) (P < .01). There was no significant difference in ECD between eyes with an ACD of 3.00 to 3.39 mm and eyes with an ACD less than 3.00 mm (P = .23) or more than 3.40 mm (P = .08). CONCLUSIONS: The iris-claw pIOL precisely and safely corrected high myopia. However, the loss in ECD can be considerable. Establishing stricter exclusion criteria for ACD might reduce this loss. FINANCIAL DISCLOSURE: Proprietary or commercial disclosures are listed after the references.

Clinical Evaluation of Functional Vision of +1.5 Diopters near Addition, Aspheric, Rotational Asymmetric Multifocal Intraocular Lens.

PURPOSE: To evaluate postoperative outcomes and visual performance in intermediate distance after implantation of a +1.5 diopters (D) addition, aspheric, rotational asymmetric multifocal intraocular lens (MIOL). METHODS: Patients underwent bilateral cataract surgery with implantation of an aspheric, asymmetric MIOL with +1.5 D near addition. A complete ophthalmological examination was performed preoperatively and 3 months postoperatively. The main outcome measures were monocular and binocular uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), uncorrected intermediate visual acuity (UIVA), distance corrected intermediate visual acuity (DCIVA), uncorrected near visual acuity (UNVA) and distance corrected keratometry, and manifest refraction. The Salzburg Reading Desk was used to analyze unilateral and bilateral functional vision with uncorrected and corrected reading acuity, reading distance, reading speed, and the smallest log-scaled print size that could be read effectively at near and intermediate distances. RESULTS: The study comprised 60 eyes of 30 patients (mean age, 68.30 ± 9.26 years; range, 34 to 80 years). There was significant improvement in UDVA and CDVA. Mean UIVA was 0.01 ± 0.09 logarithm of the minimum angle of resolution (logMAR) and mean DCIVA was -0.02 ± 0.11 logMAR. In Salzburg Reading Desk analysis for UIVA, the mean subjective intermediate distance was 67.58 ± 8.59 cm with mean UIVA of -0.02 ± 0.09 logMAR and mean word count of 96.38 ± 28.32 words/min. CONCLUSIONS: The new aspheric, asymmetric, +1.5 D near addition MIOL offers good results for distance visual function in combination with good performance for intermediate distances and functional results for near distance.

In Vivo Imaging of Intraocular Fluidics in Vitrectomized Swine Eyes Using a Digital Fluoroscopy System.

Purpose. To describe the characteristics of intraocular fluidics during cataract surgery in swine eyes with prior vitrectomy. Methods. We prepared three groups of enucleated swine eyes (nonvitrectomized, core, and totally vitrectomized). Irrigation and aspiration were performed (2.7 mm conventional sleeved phacosystem) using a balanced saline solution mixed with a water-soluble radiopaque contrast medium at 1 : 1 ratio. We imaged the eyes using a digital fluoroscopy system (DFS) during phacoemulsification and compared the characteristics of the intraocular fluid dynamics between the groups. Results. The anterior chamber depth (ACD) after the commencement of irrigation differed between groups (2.25 ± 0.06 mm; 2.33 ± 0.06 mm; 3.17 ± 0.11 mm), as well as the height of the fluid flowing from the anterior chamber into the posterior cavity that was identified by lifting up the iris to correct the infusion deviation syndrome (0.00 ± 0.00 mm; 0.41 ± 0.04 mm; 2.19 ± 0.35 mm). Conclusions. DFS demonstrated differences in fluid dynamics during phacoemulsification in swine eyes with or without prior vitrectomy. In completely vitrectomized eyes, the large ACD, which developed during phacoemulsification, could be reduced by lifting the iris and allowing the fluid to shift to the posterior cavity. Recognizing the differences in fluidics of vitrectomized eyes as compared to those of the nonvitrectomized eyes may reduce the frequency of intraoperative complications.

An Innovative Surgical Technique for Subretinal Transplantation of Human Embryonic Stem Cell-Derived Retinal Pigmented Epithelium in Yucatan Mini Pigs: Preliminary Results.

BACKGROUND AND OBJECTIVE: To develop a safe and efficient surgical procedure for subretinal implantation into porcine eyes of a human embryonic stem cell-derived retinal pigmented epithelium (hESC-RPE) monolayer seeded onto a Parylene-C scaffold. This implant is referred to as CPCB-RPE1. MATERIALS AND METHODS: Ultrathin Parylene-C scaffolds were seeded with hESC-RPE and surgically implanted into the subretinal space of Yucatan mini pigs (n = 8). The surgery consisted of pars plana vitrectomy, induction of a limited retinal detachment, and peripheral retinotomy for insertion of the monolayer using a novel tissue injector, followed by silicone oil tamponade injection, laser photocoagulation around the retinotomy site, and inferior iridectomy. Oral cyclosporine was administered from day 1 and during the entire follow-up period. Three months later, the animals were euthanized and the eyes and major organs were submitted for histological analysis. Adjacent sections underwent immunohistochemical analysis to detect human cells using anti-TRA-1-85 (human blood group antigen) antibody and DAPI antibodies. RESULTS: The cell monolayer was immunopositive for TRA-1-85 3 months after implantation and migration from the Parylene-C scaffold was not detected. One eye had a mild inflammatory reaction around the implant that was negative for human biomarkers. No intraocular or systemic tumors were detected. CONCLUSION: The hESC-RPE cells survived for 3 months in this animal model. The surgical procedure for subretinal implantation of CPCB-RPE1 is feasible and safe, without cell migration off the scaffold or development of ocular or systemic tumors.

A morphological study of amblyopic eyes in children failing to achieve normal visual acuity after electronically monitored long-term occlusion treatment.

PURPOSE: To search for morphological abnormalities in compliant unilaterally amblyopic children with poor occlusion treatment outcomes, for the first time with electronically recorded patching dosage. We included school children with remaining interocular logMAR (logarithm of the minimum angle of resolution) difference ≥ 0.3 after patching time of more than 22 months and 1300 h total in a previous prospective study. METHODS: Six patients with a mean age of 11.19 years were included. Four patients had anisometropic amblyopia and two patients had a mixed strabismic and anisometropic amblyopia. Best-corrected visual acuity, cycloplegic refraction, dilated fundus examination, optic disc morphology and macular thickness using optical coherence tomography (OCT), retinal visual acuity, color perception, and the presence of a relative afferent pupillary defect (RAPD) were assessed. Paired t tests were performed to compare optic disc values and macular thickness of the amblyopic eyes to those of the fellow eyes. RESULTS: Average (± SD) logMAR VA in the amblyopic eyes was 0.42 (±0.23) with a remaining average interocular difference (IOD) of 0.51 (± 0.23), despite electronically monitored occlusion treatment of more than 1300 h. All patients presented with hyperopia and a significantly different mean spherical equivalent of + 4.73 (± 2.73) D in the amblyopic eye compared with the fellow eye (p = 0.02). A statistically significant difference in macular thickness was found between amblyopic and fellow eyes, with amblyopic eyes having an increased average thickness (p = 0.0062) and total volume (p = 0.0091) of the macula. One patient had familial hereditary primary macrodisc in both eyes. CONCLUSIONS: Our results provide evidence that average macular thickness and total macular volume tended to be increased among these compliant amblyopic children with unsatisfactory occlusion treatment outcomes. Further studies are warranted to evaluate whether morphological changes may have an impact on the effectiveness of amblyopia treatment. Moreover, our findings suggest that greater magnitude of hyperopia and anisometropia as well as older age may be risk factors associated with a poor visual acuity outcome among compliant amblyopic children.

Proteomics of vitreous humor of patients with exudative age-related macular degeneration.

BACKGROUND: There is absence of specific biomarkers and an incomplete understanding of the pathophysiology of exudative age-related macular degeneration (AMD). METHODS AND FINDINGS: Eighty-eight vitreous samples (73 from patients with treatment naïve AMD and 15 control samples from patients with idiopathic floaters) were analyzed with capillary electrophoresis coupled to mass spectrometry in this retrospective case series to define potential candidate protein markers of AMD. Nineteen proteins were found to be upregulated in vitreous of AMD patients. Most of the proteins were plasma derived and involved in biological (ion) transport, acute phase inflammatory reaction, and blood coagulation. A number of proteins have not been previously associated to AMD including alpha-1-antitrypsin, fibrinogen alpha chain and prostaglandin H2-D isomerase. Alpha-1-antitrypsin was validated in vitreous of an independent set of AMD patients using Western blot analysis. Further systems biology analysis of the data indicated that the observed proteomic changes may reflect upregulation of immune response and complement activity. CONCLUSIONS: Proteome analysis of vitreous samples from patients with AMD, which underwent an intravitreal combination therapy including a core vitrectomy, steroids and bevacizumab, revealed apparent AMD-specific proteomic changes. The identified AMD-associated proteins provide some insight into the pathophysiological changes associated with AMD.

Prospective, randomized, controlled clinical study evaluating the efficacy of Rheopheresis for dry age-related macular degeneration. Dry AMD treatment with Rheopheresis Trial-ART.

PURPOSE: To evaluate Rheopheresis for the treatment of patients with high-risk dry age-related macular degeneration and no therapeutic alternative. Rheopheresis is a method of therapeutic apheresis using the methodology of double filtration plasmapheresis to treat microcirculatory disorders. METHODS: The dry AMD treatment with Rheopheresis trial (ART) was a randomised, controlled clinical study. Patients with the diagnosis of AMD in both eyes, with the study eye presenting dry AMD and soft drusen (the fellow eye had advanced AMD) were randomly assigned in a 1:1 ratio to receive ten Rheopheresis treatments within 17 weeks or to remain untreated. The primary outcome was change in best-corrected ETDRS-visual acuity (mean logMar change) after 7.5 months compared to baseline visual acuity for both groups. RESULTS: Forty-three eyes of 43 patients (22 treatment and 21 control group) were analysed. The mean baseline BCVA in study eyes was 0.58 in the treatment group and 0.66 in the control group (n.s. p = 0.19). At the primary efficacy endpoint 7.5 months post baseline, there was a statistically significant mean difference of 0.95 ETDRS lines (p = 0.01) between the Rheopheresis and control groups. Nine percent of eyes in the group treated with Rheopheresis gained 2 or more ETDRS lines, as compared with 0% of eyes with no treatment. None of the treated patients had a loss in visual acuity in their study eyes, as compared with 24% of patients without treatment who lost 1 ETDRS line or more; 19% lost 2 ETDRS lines or more. Rheopheresis treatment was safe and well-tolerated. CONCLUSION: The results of ART provide further evidence that Rheopheresis is a safe and effective therapeutic option for high-risk patients with dry AMD and no therapeutic alternative. A series of Rheopheresis treatments can improve the natural course of AMD for selected patients.