Pars plana vitrectomy for vitreoretinal interface disorders coincident with intermediate stage age-related macular degeneration.

BACKGROUND AND AIMS: Currently around 67 million people in Europe are affected by some form of age-related macular degeneration (AMD). As most known types of vitreoretinal (VR) interface disorders can coexist with AMD and as we can favourably affect the former with vitreoretinal surgery, our goal was to evaluate the results of vitreoretinal interface disorder surgery with macular peeling in relation to coincident intermediate stage AMD. METHODOLOGY: This was a retrospective evaluation of eyes operated with 25-gauge pars plana vitrectomy (PPV). The monitored parameters were anatomical and functional findings and, safety of the procedure. The surface of the macula was stained with trypan blue and treated (peeling) with a disposable microforceps. 10% perfluoropropane, or the air tamponade was used. Distance visual acuity was examined on the ETDRS chart, the macular finding was monitored by OCT and photodocumented. The post-operative face-down position was 3-5 days. The follow-up period was 6 months. RESULTS: 17 eyes (14 patients, woman 86%) mean age 74 years. The primary indications for the procedure were: idiopathic macular hole (IMD) 59%, epiretinal membrane 29% and vitreomacular traction syndrome 12%. Ophthalmoscopic and OCT findings of intermediate dry form of AMD (100%), in 24% was drusoid ablation of the pigment leaf. In all cases of IMD, primary closure occurred. Input visual acuity 0.1-0.6 improved to 0.2-0.9 at the end of the follow-up period (P<0.05). No complications during surgery or progression of AMD in the follow-up period were observed. CONCLUSION: PPV for vitreoretinal interface disorders have similar anatomical results, whether the outer part of the retina is disrupted by intermediate AMD or not. Functional results are affected by possible disruption of the RPE or the outer layers of the neuroretina by AMD. The PPV procedure has a standard security profile. It is safe and does not affect the progression of AMD in the short term.

Intraoperative intraocular pressure fluctuation during standard phacoemulsification in real human patients.

INTRODUCTION: To evaluate the results of the fluctuations of intraocular pressure (IOP) and calculated mean ocular perfusion pressure (MOPP) during the usual steps of standard phacoemulsification. METHODS: Nine human eyes were evaluated. The IOP was measured indirectly by electronic applanation tonometer. The MOPP was calculated using the systolic blood pressure (SBP), the diastolic blood pressure (DBP) and the IOP: MOPP = 2/3x[DBP + 1/3x(SBP - DBP)] - IOP. The operations were performed with the INFINITI® Vision System: main incision 2.2 mm, coaxial handpiece, 2 paracenteses 1.1 mm, bimanual irrigation/aspiration, bottle height 100 cm. As ocular viscoelastic device (OVD) Hypromel 2.5% (UNIMED) was used. RESULTS: The initial and final IOPs were 17-30 Torr (median 18) and 6-16 Torr (median 8), respectively. The IOP values oscillated between 4 and 63 Torr during the procedure. The highest values of the IOP were achieved at the beginning of phacoemulsification (from 42 to 63 Torr). The maximum pressure higher than 50 mmHg and 60 mmHg was found in 89% and 30% of cases, respectively. The mean ocular perfusion pressure (MOPP) at the beginning of the procedure was 46.4-67.0 (median 53.3) and 0.4-42.0 (median 19.3) during the maximum intraocular pressure. CONCLUSIONS: Measured IOP as well as MOPP varied in all normal steps of real phacoemulsification. High values of intraoperative IOL induced by irrigation may compromise the intraocular perfusion. These fluctuations may induce impairment of the optic nerve perfusion, as well as retina, or choroid.

Correlation Between Ischemic Index of Retinal Vein Occlusion and Oxygen Saturation in Retinal Vessels.

PURPOSE: To evaluate the relationship between the ischemic index and the oxygen saturation in retinal vessels in patients with retinal vein occlusion. DESIGN: Prospective, cross-sectional study. METHODS: We performed a prospective study. The cohort consisted of 43 eyes of 43 patients with retinal vein occlusions (RVO), 23 of whom had central retinal vein occlusions (CRVO) and 20 who had branch retinal vein occlusions (BRVO). We evaluated the retinal vessel saturation using an automatic retinal oximetry device. The retinal ischemic index (ISI) was determined using ultra-widefield fluorescein angiography. RESULTS: Mean arterial saturation (±SD) was 100% ± 11%, mean vein saturation was 52% ±13%, and mean A-V difference was 48% ± 16% in eyes with BRVO. The average ISI in the same group was 0.48 (range 0-1). There was no statistically significant correlation between the retinal ischemic index and retinal saturation in the BRVO group. The affected eye in the CRVO group had a mean arterial saturation of 101% ± 6%, vein saturation of 44% ± 11 % and A-V difference of 58% ± 10%. The average ISI in the CRVO group was 0.54 (range 0-1). A statistically significant negative correlation between ISI and vein saturation was found in the CRVO group (r = -0.686; P =.0003). A significant positive correlation between ISI and the A-V difference was found in the CRVO group (r = 0.893; P <.0001). CONCLUSIONS: Oxygen saturation in the retinal vein and the arteriovenous difference correlated with the ischemic index in CRVO patients. No correlation was found for BRVO patients.

The natural evolution of idiophatic epimacular membrane.

BACKGROUND AND AIMS: Epiretinal membrane (ERM) refers to a semi-translucent tissue layer found on the inner surface of the retina especially in older people. Surgical treatment remains controversial, optimal timing for such treatment is difficult to determine and data on the natural evolution of this disorder are limited. In this study we evaluated the natural course of idiopathic epimacular membrane in 49 patients (53 eyes). MATERIALS AND METHODS: Retrospective evaluation of a group of 49 patients (53 eyes) with idiopathic epimacular membrane confirmed by biomicroscopy, photography and optical coherence tomography (OCT). RESULTS: Patient age ranged from 51-85 years (median 72). The average follow-up was 21.3 months (± 14). Between the initial and final best corrected visual acuity (BCVA) there was no statistically significant difference although there was a significant tendency to decrease in BCVA (Spearman P=0.05) during the follow-up. Initial BCVA correlated with initial central retinal thickness (CRT), final CRT, final volume, and age. The final BCVA significantly correlated with all parameters measured. CONCLUSION: BCVA during follow-up tended to decrease: difference of starting BCVA and final BCVA values depending on the time of monitoring is significant. This we attribute to a slow gradual progression of macular changes. But, initial and final BCVA measurements were not substantially different at the end. Thus, in the absence of any clear signs of ERM progression, we can safely postpone the decision whether to perform PPV.

Microincision 25G pars plana vitrectomy with peeling of the inner limiting membrane and air tamponade in idiopathic macular hole.

PURPOSE: To evaluate the success of a mini-invasive technique for operation of idiopathic macular hole (IMH). METHODS: We retrospectively examined 29 patients (30 eyes) in whom 25-G pars plana vitrectomy (PPV), peeling of the inner limiting membrane (ILM), and application of air tamponade were performed. The group of the patients included 7 males and 22 females (76%), age range 57-79 years (median 70). The follow-up period was 3-47 months (median 17). RESULTS: Pars plana vitrectomy was indicated only in the stages of full-thickness macular hole. Prior to operation, 13 eyes (43%) were in stage 2, 15 eyes (50%) in stage 3, and 2 eyes (7%) in stage 4. The IMH healed in 28 eyes after operation. Persistence of IMH occurred in 2 eyes (7%). After subsequent reoperation with extension of the peeling zone of the ILM and gas tamponade (with 10% C3F8), these macular holes also healed (100%). Prior to carrying out PPV, best-corrected visual acuity (BCVA) ranged between 20/40 and 20/500 (median 20/125). At the end of the follow-up period, BCVA was improved to 20/40 (median). The change in the final BCVA compared to the initial visual acuity was statistically significant (p = 0.008; Wilcoxon). CONCLUSIONS: The 25-G PPV with peeling of the ILM and air tamponade is an effective technique and presents no increased risks in comparison with routine procedures. The main benefit of the intervention is its good tolerance by the patient, particularly with respect to painfulness and postoperative irritation.

Intraoperative Optical Coherence Tomography in Vitreoretinal Surgery.

INTRODUCTION: The objective of this article is to provide an overview of the current situation with the use of intraoperative optical coherence tomography (iOCT), and to present our own experience with this technology. METHODOLOGY: retrospective evaluation of case reports of typical pathologies of the retina which were resolved by means of standard pars plana vitrectomy (PPV) with the use of intraoperative optical coherence tomography (iOCT) integrated into the surgical microscope OPMI Lumera 700 / Rescan 700 (Zeiss). Auxiliary techniques: best corrected visual acuity (BCVA) was tested on ETDRS tables, biomicroscopy was performed with a 78D lens and optical coherence tomography (OCT) with a Zeiss Cirrus instrument. The operations were performed in retrobulbar anaesthesia, three-port 23G PPV and with the aid of the surgical unit Constellation (ALCON). RESULTS: we present three case reports of 2 women (pathology of type of disorder of the vitreoretinal interface) and 1 man (proliferative diabetic retinopathy), with an average age of 63 years. In the first 2 cases the observation period was 3 months, while the man with diabetic retinopathy was observed for 15 months. All surgical procedures with the use of iOCT were conducted without perioperative or postoperative complications. In all cases full anatomical success was achieved. In the first two cases BCVA improved substantially, and in the last case very good initial BCVA was stabilised over the long term. CONCLUSION: The use of iOCT provides the surgeon with simultaneous control both in surgical manipulations in close proximity to the retina and also in detailed virtualisation of the finding on the ocular fundus. The result is an excellent perioperative overview, up-to-date information for the surgeon, higher precision of the procedure and thus also improved postoperative results.Key words: intraoperative optical coherence tomography, vitreoretinal surgery.

Transient branch retinal artery occlusion in a 15-year-old girl and review of the literature.

BACKGROUND: Retinal artery occlusion is an extremely rare diagnosis in the pediatric population and the etiology with risk factors of retinal artery occlusion are poorly understood in younger individuals. METHODS AND RESULTS: This case report a rare case of transient branch retinal artery occlusion (BRAO) in a healthy young girl. A fifteen-year-old girl presented with painless decreased vision in her right eye. Fundus examination revealed in the right eye intensive edema of the part of superior half of the retina, but the vessels were absolutely normal. She was hospitalized for diagnosis and treatment. A thorough workup was performed to determine any etiologic factor. Her physical examination was normal, but from anamnesis has been found that patient began use oral contraception at the time of occurrence eye problems. The condition is evaluated as transient branch retinal artery occlusion by the course of the disease. The paper includes the review of the literature also. CONCLUSION: Though retinal arterial obstruction is rare in the pediatric population, this case highlights the importance of including this in the differential diagnosis of acute vision loss.

Re-operation of idiopathic macular hole after failed initial surgery.

BACKGROUND: Persistent idiopathic macular hole (IMH) after initial pars plana vitrectomy (PPV) appears in approx. 12% of cases. It is, therefore, one of the most common complications. IMH re-operation results tend to be better in eyes where IMH had been closed, while IMH re-operations in cases when the initial surgery had failed tend to be less successful: IMH often becomes even larger and visual acuity decreases, anatomical success rate of closure is about 60% and the resulting postoperative visual acuity is about 20/100. AIMS: To establish anatomical and functional success rate of repeated operations of recurrent idiopathic macular hole. MATERIALS AND METHODS: We evaluated the retrospective results of re-operations of persisting IMH that is cases in which the initial surgery did not result in closure: 6 eyes in 6 patients out of the overall 55 operated on IMH (primary PPV failed in almost 11% of cases). The follow-up period was 18 months (since the first surgery). RESULTS AND CONCLUSION: After the second PPV, the IMH was closed in 100% of operated eyes. It was not necessary to perform a third PPV during the follow-up period. In all cases the visual acuity improved. Anatomical and functional results of IMH treatment can be considered satisfactory. We consider the following combination of factors significant for the anatomical success rate of PPV: IMH size and stage, technical precision of the ILM peeling and the suction of the IMH contents, strict adherence to the recommended head positioning in early postoperative period, and IMH duration.

The importance of rheological parameters in the therapy of the dry form of age-related macular degeneration with rheohaemapheresis.

To date, rheological treatment is the only chance to control the advanced dry form of age-related macular degeneration and arrest its progression to legal blindness. Rheohaemapheresis can change the main rheological parameters, blood and plasma viscosity, as well as change erythrocyte aggregability, improve erythrocyte flexibility and lead to substantial improvement when other methods of therapy fail. In this study, we describe changes in the levels of rheological efficacy indicators after rheohaemapheresis and their clinical significance in the dry form of age-related macular degeneration (AMD). Seventy-two patients with AMD were randomised; 34 controls, and 38 patients were treated with rheohaemapheresis (separator Cobe Spectra + Evaflux filter). After the procedures, α2-macroglobulin levels decreased by approximately 58%, fibrinogen by approximately 65%, IgM by approximately 67%, LDL cholesterol by approximately 71%, apolipoprotein B by approximately 65%, and lipoprotein (a) by approximately 42%. These decreases correspond with a decrease in blood and plasma viscosity (14/12%), clinical improvement (arrest of disease progression, even visual improvement in some cases), and heretofore-unreported improvement (even reattachment) of drusen retinal pigment epithelium detachment. Our modification of rheohaemapheresis is safe (5.4% of patients experienced clinically insignificant side effects).