Vitreous attachment in age-related macular degeneration, diabetic macular edema, and retinal vein occlusion: a systematic review and metaanalysis.

PURPOSE: To determine if there is an association of vitreous attachment and wet age-related macular degeneration (AMD), diabetic macular edema, and retinal vein occlusion. METHODS: Systematic review and metaanalysis. RESULTS: Sixteen of 1,025 articles were eligible. In wet AMD, the prevalence of vitreomacular adhesion and posterior vitreous detachment was 23% (654 eyes) and 41% (251), respectively. Vitreomacular adhesion prevalence was 2.15 times that of controls (95% confidence interval, 1.34-3.48; p = 0.002) and 2.54 times that of dry AMD (confidence interval, 0.88-7.36; p 0.09); posterior vitreous detachment prevalence was lower than controls (relative risk 0.77; confidence interval, 0.64-0.93; p = 0.007) and dry AMD (0.56; confidence interval, 0.27-1.14; p = 0.11). It was not possible to determine the prevalence of vitreous attachment in diabetic macular edema, but vitreomacular traction was present in 29% of 188 surgical cases. The prevalence of posterior vitreous detachment in eyes with central and branch retinal vein occlusion was 30% (56 eyes) and 31% (71 eyes), respectively, versus 25% (64 eyes) in controls. CONCLUSION: Observational studies of sufficient quality indicate that eyes with wet AMD have double the expected prevalence of vitreomacular adhesion and are less likely to have a posterior vitreous detachment. More controlled studies of diabetic macular edema and retinal vein occlusion are needed.

Pars plana vitrectomy for vitreomacular traction syndrome: a systematic review and metaanalysis of safety and efficacy.

PURPOSE: To determine the safety and efficacy of pars plana vitrectomy for vitreomacular traction. METHODS: Articles reporting visual acuity change before and after pars plana vitrectomy were selected using a systematic literature review with predefined eligibility criteria. Visual acuities were converted to logarithm of the minimum angle of resolution (logMAR), weighted for study size, and pooled across studies. Safety outcomes were also pooled across studies. RESULTS: Twenty-one of 460 articles were eligible. Mean (±standard deviation) logMAR visual acuity improved from 0.67 ± 0.55 to 0.42 ± 0.45 (n = 259 eyes) after pars plana vitrectomy (from 20/94 to 20/53 Snellen). In series of at least 20 eyes, mean visual acuity improved in all 5 studies (sign test, P = 0.0625). Of 392 eyes, 9.2% lost visual acuity, 11.7% were unchanged, and 64.3% improved; 32.9% of 217 eyes gained ≥2 Snellen lines. The most common postoperative complications were cataract (34.7% of 304 eyes; 63.2% of 68 phakic eyes), epiretinal membrane (5.7% of 348 eyes), and retinal detachment (4.6% of 348 eyes). Cataract surgery was undertaken in 10.5% of eyes. CONCLUSION: The visual acuity gains after pars plana vitrectomy for vitreomacular traction are relatively modest, but visual acuity change may not fully reflect symptomatic relief.

Intravitreal gas for symptomatic vitreomacular adhesion: a synthesis of the literature.

Symptomatic vitreomacular adhesion (sVMA) is defined as visual loss secondary to foveal damage from vitreomacular traction (VMT) and includes isolated VMT, impending macular hole (MH), and full-thickness MH with persisting vitreous attachment. Management options include pars plana vitrectomy (PPV), intravitreal ocriplasmin, intravitreal gas injection or observation. This synthesis of the literature aimed to assess the safety and efficacy of intravitreal gas for sVMA. Articles describing patients with VMT or MH treated with intravitreal expansile gas were selected by systematic literature review using MEDLINE, EMBASE, and the Cochrane Database of Controlled Trials (CENTRAL) up to September 2016. The main outcomes at 1 month and final review were logarithm of the minimum angle of resolution (logMAR) visual acuity (VA), anatomical success (absence of both VMT and MH, without PPV) and adverse events (AEs). The intended comparator was observation. Nine of 106 identified articles were eligible, and none were randomized controlled trials. The mean VA of 91 eyes improved from 0.55 (Snellen equivalent 6/21) to 0.48 (6/18) logMAR at 1 month and to 0.35 (6/13) logMAR at final review. The mean VA at final review, prior to a vitrectomy, was 0.42 (6/16). Anatomic success was 48% at 1 month and 57% at final review. The reported AEs comprised retinal detachment in two highly myopic eyes. Intravitreal gas injection can relieve sVMA. Larger controlled studies are needed to determine safety and efficacy relative to observation, ocriplasmin, or vitrectomy.

Infantile high myopia in Bohring-Opitz syndrome.

Bohring-Opitz syndrome is a rare genetic condition of uncertain inheritance. It was first delineated by Bohring and coworkers in 1999 and up to 15 possible cases have been reported. It has both ophthalmic and systemic features and represents a unique syndrome considered to be distinct from Opitz C trigonocephaly syndrome. The classic features of Bohring-Opitz syndrome include prominent metopic suture, exophthalmos, hypertelorism, cleft lip and palate, flexion deformities of the upper limbs, nevi flammei, and significant neurodevelopmental delay. We report a child with Bohring-Opitz syndrome and infantile high myopia. Bohring's original description of the phenotype did not include myopia but since then both this case and two others have reported this association. The presence of high myopia may be helpful in identifying suitable candidate genes and elucidating the genetic mechanism, as well as alerting ophthalmologists to the importance of refraction for affected children.

Measuring the effect of pars plana vitrectomy on vitreous oxygenation using magnetic resonance imaging.

PURPOSE: To study the effect of pars plana vitrectomy (PPV) on vitreous oxygenation (pO2) using magnetic resonance imaging (MRI). METHODS: Patients due to undergo PPV for either macular hole or epiretinal membrane were recruited. MRI scanning was performed 1 week before and at least 3 months after PPV. MRI T1 mapping was performed using an inversion recovery-true fast imaging with steady-state precession (TrueFISP) sequence at several inversion times, from a single slice positioned through the center of both eyes in the axial oblique plane. Additional phantom data were measured in porcine vitreous, to define the relationships between T1 relaxation times and balanced salt solution (BSS), to simulate human vitreous and aqueous, respectively, for a suitable pO2 range (5-70 mm Hg). Pre-PPV pO2 was also measured intraoperatively using a polarographic oxygen probe. RESULTS: Eleven participants (age range 59-84) were recruited; two declined the post-PPV scan. Corrected T1 times indicated that the mean (±SD) pO2 increased significantly following PPV, from 13.2 ± 5.8 to 34.5 ± 8.0 mm Hg (P < 0.001). In the nonsurgical (control) eye, pO2 did not change significantly from the first to second MRI scan (13.7 ± 7.8 vs. 16.3 ± 8.7 mm Hg, P = 0.239). Mean pO2 measured intraoperatively was 7.2 ± 0.6 mm Hg (n = 10). CONCLUSIONS: These results confirm that vitrectomy substantially increases vitreous pO2. MRI is a noninvasive technique that can be used to study vitreous oxygenation in both vitrectomized and nonvitrectomized eyes.

Vitreomacular adhesion and neovascular age-related macular degeneration.

We explore the hypothesis that vitreomacular adhesion (VMA) and vitreomacular traction (VMT) play a role in the pathogenesis and clinical course of neovascular ("wet") age-related macular degeneration (AMD). Several biological theories are offered to explain this possible association, including direct tractional force, altered vitreous oxygenation, altered diffusion coefficients of intravitreal molecules, and alterations in the pharmacokinetics of intravitreal drugs. Release of VMT may improve the clinical course of neovascular AMD, and a few case series suggest that vitrectomy can lead to both a functional and anatomic improvement. A large, randomized, controlled clinical trial is underway, investigating pharmacologic release of VMA in eyes with neovascular AMD.

Black-on-clear piggyback technique for a black occlusive intraocular device in intractable diplopia.

Black occlusive intraocular devices have been used successfully for intractable binocular diplopia. We describe a novel technique of implanting both a black occlusive device and a clear poly(methyl methacrylate) intraocular lens (IOL) in the capsular bag during phacoemulsification surgery. If the need should arise at a later date, this approach will allow safer and easier explantation of the black occlusive device, avoiding the need for IOL exchange.