New instrumentation and technique for epiretinal surgery.

A multifunctional probe for vitreous surgery, which combines fiberoptic endoillumination, microforceps, bipolar diathermy, and infusion/aspiration, has allowed the development of an original technique for the peeling of very adherent preretinal membranes.

A new device for noncontact wide-angle viewing of the fundus during vitrectomy.

Noncontact wide-angle viewing of the fundus during vitrectomy has heretofore relied on an image inverter and a 90-diopter lens fixed with a tube under the microscope. A new device in which the 90-diopter lens is not connected to the microscope but, rather, is connected to an independent support system is described. This device offers many advantages: (1) focusing on the various parts of the eye during vitreous surgery need not be done manually but is achieved by the up or down movement of the microscope, (2) translation of the microscope is easier during tilting of the eye, (3) a lateral slit-lamp can be easily added for illumination of the fundus, and (4) there is no risk that the 90-diopter lens will touch the cornea.

The effect of liquid silicone on the rabbit retina. Histologic and ultrastructural study.

Silicone oil was injected into 23 rabbit eyes, which had undergone vitrectomy and which were then examined in the electron microscope six weeks later. Retinal lesions were observed in the outer plexiform layer. They consisted mainly of a subtotal disappearance of the processes of horizontal and bipolar cells and of the synaptic terminals of the photoreceptors. The lesions were seen only in areas of the retina that had been in permanent contact with the oil bubble. They did not depend on the purity of the silicone oil injected.

Modified Zeiss beam splitter for operating microscope and television camera.

I have designed an asymmetrical 50/70 beam splitter that allows a television camera to be coupled directly to the Zeiss operating microscope. This device provides more light for the surgeon.

Temporary silicone oil tamponade in the management of retinal detachment with proliferative vitreoretinopathy.

Silicone oil was used as a temporary (four to six weeks) tamponade in conjunction with vitreous surgery in the management of 146 eyes with retinal detachment complicated by proliferative vitreoretinopathy. A success rate of 62% (90 of 146 cases) was achieved six months after the silicone was removed. Clinical complications directly related to silicone oil were rare and did not progress or develop after the removal of silicone except for opacification of the lens in phakic eyes. This occurred frequently (43 of 55 eyes) and progressed many months after the withdrawal of silicone.

A new approach to treating retinal detachment with macular hole.

Six consecutive cases of retinal detachment with macular hole were treated successfully by vitrectomy, partial gas-fluid exchange, and prone positioning of the patient for 12 hours. Macular coagulation and macular buckling were not necessary. In five cases the retina remained flat during follow-up periods ranging from one to 16 months. In one case a small detachment recurred 13 months after surgery. A renewed partial gas-fluid exchange resolved the problem. This new technique simplifies the treatment of such cases and macular function is preserved rather than destroyed. We believe than many detachments with macular holes are caused by vitreous traction.

A new mobile armrest.

We have developed a weight-and-pulley armrest for surgeons to use during ocular microsurgery. The armrest is mobile, sterilizable, and allows the weight stress on the forearm to be regulated.

New approach to managing vitreous loss and dislocated lens fragments during phacoemulsification.

I performed a one-port pars plana vitrectomy during phacoemulsification to manage vitreous loss with and without posterior dislocation of lens fragments in nine consecutive cases. I used a 1 mm vitrectomy instrument with an infusion sleeve for the vitrectomy; the coaxial light of the microscope and an infusion contact lens held on the cornea provided intraocular illumination. Eight of the nine cases achieved a visual acuity equal to or better than 20/25 after a mean follow-up of 5.7 months. One patient's visual acuity was 20/70 because of severe background diabetic retinopathy.

Change in capsulorhexis size with four foldable loop-haptic lenses over 6 months.

PURPOSE: To compare the change in continuous curvilinear capsulorhexis (CCC) size after implantation of four types of three-piece foldable intraocular lenses (IOLs) and determine whether initial CCC size and IOL characteristics play a role in the change. METHODS: This study comprised 133 eyes that had phacoemulsification and in-the-bag implantation of one of four types of foldable IOLs: Alcon AcrySof MA30BA (n = 36); lovision 127 (n = 29); Mentor ORC MemoryLens (n = 39); Allergan PhacoFlex II (n = 29). Photographs of the CCCs were taken with a digital retinograph 1 day and 6 months after surgery. Using image-analysis software, the CCC surface was measured and changes between 1 week and 6 months were evaluated. Characteristics of the IOLs including overall diameter, optic thickness, and haptic centrifugal force were measured with micrometric tools. RESULTS: The median change in CCC surface size at 6 months was +5.5% in the lovision group, indicating a slight enlargement. This finding was significantly different from that in the other three IOL groups (P < .0001), which had a tendency toward CCC contraction. Median change in CCC size was -2.3% in the MemoryLens group, -2.8% in the AcrySof group, and -6% in the PhacoFlex group. The MemoryLens was the most predictive IOL, with the smallest standard deviation; it was the only group in which no patient developed CCC contraction of more than 10%. Although the lovision and PhacoFlex IOLs have common physical characteristics except for optic thickness (lovision 30% thicker), the CCCs in the lovision group were significantly more stable (P < .0001). Results indicate that the high centrifugal haptic force associated with acrylate/methacrylate polymer optics of the AcrySof and MemoryLens IOLs may prevent CCC contraction of greater than 10% in 97.4% of cases. CONCLUSION: Although there were statistically significant differences, patients in all four three-piece foldable IOL groups had good CCC stability. However, the more stable and predictable CCCs were in the IOL groups that had the strongest centrifugal haptic force and an acrylate/methacrylate polymer optic (AcrySof and MemoryLens).

Change in capsulorhexis size after implantation of three types of intraocular lenses.

PURPOSE: To compare the change in size of continuous curvilinear capsulorhexis (CCC) used for implantation of three types of intraocular lenses (IOLs) and to determine the role of postoperative inflammation, initial CCC dimension, haptic design, and optic material. SETTING: Hôpital Ophtalmique Universitaire Jules Gonin, Lausanne, Switzerland. METHOD: Twenty-nine three-piece, silicone/poly(methyl methacrylate) (PMMA) IOLs (lovision 127), 26 one-piece PMMA IOLs (Pharmacia 812A), and 27 plate-haptic silicone IOLs (Staar AA4203) were implanted in the capsular bag after phacoemulsification. Photographs of the CCCs taken 1 day and 6 months after surgery were scanned and digitized on a computer. Using different software, the surface of the CCC was measured and the 6 month change evaluated. Flare, measured the day before surgery and postoperatively at days 1, 7, 30, and 180, was integrated to obtain a global estimate of inflammation during the 180 day follow-up. RESULTS: The CCCs used with three-piece, silicone/PMMA IOLs showed little changes in surface, with a mean enlargement of +0.57 mm2 +/- 1.15 (SD) (+3.5%). The CCCs used with the one-piece PMMA IOLs had a slight tendency to constrict, with a mean surface decrease of -0.59 +/- 2.16 mm2 (-4.3%). The CCCs used with plate-haptic silicone IOLs showed a marked and statistically significant constriction, with a mean decrease of -2.55 +/- 3.51 mm2 (-14.4%). The change in CCC size was not associated with the integrated flare, and no correlation was found between the initial CCC size and the magnitude of change. There was no statistically significant difference in CCC change between the PMMA optic IOL (Pharmacia) and silicone optic IOL (lovision and Staar) groups. The CCC in the plate-haptic IOL (Staar) group showed a significant (P < .0002) constriction when compared with that in the loop-haptic IOL (Pharmacia and lovision) group. CONCLUSION: The IOLs' haptic design seemed to play a major role in the evolution of the CCC. The CCC constriction seen with the Staar IOLs was related to their plate haptics.

Implantable contact lens for moderate to high myopia: short-term follow-up of 2 models.

PURPOSE: To confirm the safety, efficacy, and predictability of the surgical correction of moderate to high myopia by the ICM V3 and ICM V4 implantable contact lenses (ICLs), with emphasis on vaulting, intraocular pressure (IOP), and pigment dispersion. SETTING: University Eye Hospital, Lausanne, Switzerland. METHODS: Thirty-two eyes had implantation of an ICL. In 22 eyes with a mean spherical equivalent (SE) of -11.5 diopters (D), the target was emmetropia; in 10 eyes with a mean SE of -22.3 D, the goal was a reduction in the myopia. Nineteen eyes received the ICM V3 ICL and 13, the ICM V4 ICL. The mean follow-up was 7.4 months. RESULTS: The mean postoperative SE in the 32 eyes was -2.16 D. Best spectacle-corrected visual acuity was maintained or improved in all eyes. In the 22 eyes targeted to achieve emmetropia, 10 (45%) were within +/-1.00 D; 15 (68%) had an uncorrected visual acuity of 20/40 or better and 4 (18%), of 20/20 or better. Vaulting of the ICL over the crystalline lens was more pronounced with the V4 than with the V3, and the difference was statistically significant. Subtle, localized anterior subcapsular opacification was encountered in 4 eyes. In 3 of them, the ICL (model V3) vaulting was minimal and 1 ICL (model V4) did not show any vaulting. Eighteen eyes had an IOP higher than the preoperative level, and the difference was statistically significant. No correlation was seen between final IOP and vaulting. Pigment dispersion on the ICL did not appear to be related to vaulting or ICL thickness. CONCLUSION: Implantation of an ICL was effective in correcting moderate to high myopia of up to -17.50 D. Although the procedure appears to be safe, the predictability of the refractive outcome must be improved. The new generation of ICLs for myopia (ICM V4) offers a better vault over the crystalline lens than the older models (ICM V3), which should decrease the risk of cataract. No explanation was found for the IOP increase in several eyes 3 months or more after surgery.

Surgical treatment of retinal detachment owing to macular hole.

Retinal detachments owing to macular hole have a low prevalence and occur predominantly in myopic eyes. The choice of surgical technique is primarily based on the axial length of the globe and on the presence or absence of a posterior staphyloma and/or chorioretinal degenerations. Whereas patients with low myopia and no posterior staphyloma are best treated with primary pars plana vitrectomy and air tamponade, patients with marked myopia and large posterior staphylomas should be managed by combining a pars plana vitrectomy with laser photocoagulation of the macular hole rim under perfluorocarbon liquids and a temporary silicone oil tamponade. For the intermediate myopias the surgical technique has to be decided from patient to patient.

Temporary silicone oil tamponade and intraocular pressure: an 11-year retrospective study.

BACKGROUND: A retrospective study was conducted to evaluate the risk of increased intraocular pressure (IOP) following a temporary silicone oil (SO) tamponade and to study some parameters possibly involved in this hypertension. METHODS: Forty-four patients with retinal detachment complicated by proliferative vitreoretinopathy (PVR) were treated by vitreoretinal surgery and SO tamponade. One to 11 years after SO removal, they underwent full ophthalmic examination. All these patients had a healthy, non-operated, normotensive fellow eye. RESULTS: Six (14%) of 44 eyes had IOP higher than 20 mmHg. Five other eyes (11%) had their IOP controlled by beta blockers. Phakic and pseudophakic eyes had a very limited tendency to develop ocular hypertension and anyway responded well to beta blockers. Residual SO droplets in the eye after removal of the big bubble of SO disappeared exponentially with a mean disappearance time of three years. Eyes with residual SO were no more prone to ocular hypertension than those without (p > 0.50). No association was found between IOP and duration of SO tamponade (r = 0.13) or between IOP and flare (r = 0.14). CONCLUSION: This study suggests that the risk of developing ocular hypertension after a temporary SO tamponade is moderate. No satisfactory explanation could be found for this increase of IOP.

[Anterior ocular reconstruction (author's transl)]. / Chirurgie réparatrice de l'aire pupillaire.

Vitrectomy instruments are very helpful for anterior ocular reconstruction following trauma. Pars plana approach seems better than limbal approach. This latter is reserved for cases where micro-surgical scissors must be used in addition to the vitreous instrument. When pars plana approach is chosen, a phakofragmentation unit is needed for the removal of adult cataract with marked nucleus sclerosis.

[Phacoemulsification with incision of the clear cornea]. / Phakoémulsification avec incision en cornée claire.

METHODS: I reviewed the records of my first 33 phacoemulsifications with a clear cornea incision. The first 3 cases in the series had their temporal corneal incision sutured because of insufficiency in the self-sealing mechanism. RESULTS: Change of refraction induced by surgery was especially studied in 23 cases whose mean follow-up had been 3.5 months. This proved to be very moderate and stable from the first post-operative day up to the last control which took place 5-6 months later. CONCLUSION: The only drawback of the technique, was the occurrence in several cases of anterior capsule fibrosis which seemed related to the nature (silicone) and shape (plate haptics) of the foldable IOL.