Foveola nonpeeling internal limiting membrane surgery to prevent inner retinal damages in early stage 2 idiopathic macula hole.

PURPOSE: The purpose of this study was to investigate and present the results of a new vitrectomy technique to preserve the foveolar internal limiting membrane (ILM) during ILM peeling in early stage 2 macular holes (MH). METHODS: The medical records of 28 consecutive patients (28 eyes) with early stage 2 MH were retrospectively reviewed and randomly divided into two groups by the extent of ILM peeing. Group 1: foveolar ILM nonpeeling group (14 eyes), and group 2: total peeling of foveal ILM group (14 eyes). A donut-shaped ILM was peeled off, leaving a 400-µm-diameter ILM over foveola in group 1. RESULTS: Smooth and symmetric umbo foveolar contour was restored without inner retinal dimpling in all eyes in group 1, but not in group 2. The final vision was better in group 1 (P = 0.011). All eyes in group 1 (100 %) and seven of 14 eyes in group 2 (50 %)regained the inner segment/outer segment (IS/OS) line. Restoration of the umbo light reflex was found in 12 of 14 eyes in group 1 (86 %) but none in group 2 (0 %). CONCLUSIONS: Nonpeeling of the foveolar ILM in early stage 2 idiopathic MH surgery prevented inner retinal damages, restored umbo light reflex, achieved better foveolar microstructures, and led to better final visual acuity.

Long-term outcome of foveolar internal limiting membrane nonpeeling for myopic traction maculopathy.

PURPOSE: To investigate the long-term results of a novel technique to preserve the foveolar cone without peeling off the foveolar internal limiting membrane (ILM) during myopic traction maculopathy surgery. METHODS: Nineteen patients (19 eyes) were retrospectively studied and divided into 2 groups by the extent of ILM peeled and followed for more than 3 years. Group 1: foveolar ILM nonpeeling group (FN) (12 eyes) and Group 2: total peeling of foveal ILM group (TP) (7 eyes). A donut-shaped ILM was peeled off, leaving a 400-µm diameter ILM over foveola with a sharp margin in FN group. RESULTS: Macular hole was developed in 2 of the 7 eyes (28.6%) in the TP group and none in the FN group. Long-term central fovea thickness thinning and decrease of vision were found in the TP group, but not in the FN group (P < 0.05). Inner segment/outer segment line recovered in 75% of the 12 eyes in the FN group, but in only 14.3% of the 7 eyes in the TP group. CONCLUSION: Preservation of the foveolar cone by foveola nonpeeling surgery correlates with better anatomical and visual results than total peel, prevents long-term foveolar retinal thinning, and successfully saves the fovea from macular hole formation.

Formation of idiopathic macular hole-reappraisal.

PURPOSE: The study is intended to examine the development of macular hole in idiopathic conditions. METHODS: A 2-year case file of optical coherence tomography (OCT) with the initial diagnosis of idiopathic impending hole (IH) or lamellar hole (LH) was reviewed. All cases of IH or LH were sequentially examined for more than 9 months. All cases with IH had vitreo-foveal adhesion, and were separated into type A (foveal detachment +/- inner retinal cysts) and type B (inner retinal cysts only). RESULTS: Eight cases had type A IH, 15 cases had type B IH, and 27 cases had LH. Seven cases of type A IH developed full-thickness macular hole (FTMH) at an average of 5.1 +/- 2.2 months, and the one other case was operated. Five cases of type B IH were operated. For the other ten cases, at an average of 11.4 +/- 3.5 months, none had developed foveal detachment or FTMH, but five had developed LH. Three cases with initial LH subsequently developed FTMH. CONCLUSION: In idiopathic cases, vitreo-foveal traction with foveal detachment may lead to FHMH, while inner cysts only without foveal detachment seem tend to evolve into LH instead of FHMH. Furthermore, LH may develop into FTMH.

Vitreous levels of reactive oxygen species in proliferative diabetic retinopathy.

OBJECTIVE: To investigate vitreous levels of reactive oxygen species (ROS) in patients with proliferative diabetic retinopathy (PDR) and analyze ROS levels among different groups of PDR patients. DESIGN: Retrospective case-control study. PARTICIPANTS: Thirty-nine eyes of 39 patients with PDR and 16 eyes of 16 non-PDR patients (control group) that underwent primary vitrectomy for complications of PDR and other conditions (control group), with a follow-up time > or = 12 months. METHODS: Proliferative diabetic retinopathy patients were classified into 3 groups according to the extent of fibrovascular proliferation: (1) no or focal adhesions at < or =3 sites (n = 17); (2) > or =1 broad adhesions or vitreous-retinal adhesions around disc, macula, and arcade (n = 12); and (3) vitreous-retinal attachment extending to the periphery or no posterior vitreous detachment with or without retinal detachment (RD) (n = 10). The control group (n = 16) contained non-PDR patients. Vitreous samples were obtained during measurement of vitrectomy and vitreous levels of ROS by luminol-enhanced chemiluminescence assay. MAIN OUTCOME MEASURES: Reactive oxygen species levels were recorded as mean (+/- standard deviation) chemiluminescence counts per 10 seconds. Correlations of vitreous levels of ROS among the 3 PDR groups and anatomic prognosis were evaluated. Multiple linear regression analysis of selective potential risk factors was performed to investigate the main determinants of ROS levels. RESULTS: Vitreous ROS levels were significantly higher in patients with PDR (125.76+/-351.72 chemiluminescence counts per 10 seconds) than in control patients (0.37+/-0.72 chemiluminescence counts per 10 seconds; P<0.0001). Reactive oxygen species levels were 1.86+/-1.63 (group 1), 24.47+/-22.68 (group 2), and 457.94+/-597.01 (group 3); the difference among groups was significant (P = 0.001). Regression analysis indicated that only patient grouping (according to the severity of fibrovascular proliferation) had a strong dependent association with ROS levels (P = 0.001). Final anatomic results revealed that recurrent untreatable RD occurred in 3 patients of group 3, who also had the highest ROS levels. CONCLUSIONS: Reactive oxygen species levels were significantly elevated in the vitreous fluid of PDR patients, and patients with a more advanced clinical PDR appearance had higher ROS levels. These findings suggest an association between ROS and the pathogenesis of PDR. Reactive oxygen species might be correlated with PDR severity.

Fractalkine, a CX3C chemokine, as a mediator of ocular angiogenesis.

PURPOSE: Fractalkine (FKN) is a chemoattractant and adhesion molecule for leukocytes. Angiogenic effect of FKN also has been reported. This study was an investigation of FKN-mediated angiogenesis in vitro and in vivo to determine its role in ocular angiogenic disorders. METHODS: FKN effects on cultured human umbilical vein endothelial cells (HUVECs) and bovine retinal capillary endothelial cells (BRECs) were evaluated with chemotaxis assay and a synthetic matrix capillary tube formation assay in vitro. Reverse transcription-polymerase chain reaction (RT-PCR) and Western blot analysis were used to detect mRNA and protein expression of FKN and its receptor, CX3CR1, in HUVECs and BRECs. A rabbit corneal neovascularization assay and an oxygen-induced retinopathy (OIR) model of mice were used to test the angiogenic property of FKN in vivo. FKN levels of vitreous samples from patients with proliferative diabetic retinopathy were measured by enzyme-linked immunosorbent assay (ELISA). Immunodepletion of FKN in PDR vitreous samples by anti-FKN polyclonal antibody was observed in endothelial cell chemotaxis assays. RESULTS: FKN significantly induced migration of HUVECs and BRECs. FKN induced formation of endothelial cell capillary tubes on synthetic matrix. Expression of FKN and CX3CR1 was detected in HUVECs and BRECs by RT-PCR and Western blot analysis. FKN significantly induced more blood vessel growth than did the control in the rabbit corneal pocket neovascularization assay. Intravitreal injection of anti-mouse FKN antibody decreased retinal angiogenesis in the OIR model. The vitreous level of FKN was elevated in patients with PDR compared with control subjects. Immunodepletion of soluble FKN from PDR vitreous samples caused 36.6% less migration of BRECs. CONCLUSIONS: FKN is an angiogenic mediator in vitro and in vivo. The vitreous level of FKN was elevated in patients with PDR. FKN may play an important role in ocular angiogenic disorders such as PDR.

Decreased density of corneal basal epithelium and subbasal corneal nerve bundle changes in patients with diabetic retinopathy.

PURPOSE: To define alterations in the density of corneal basal epithelium in relation to diabetic retinopathic severity and the alteration of corneal innervation using confocal microscopy. DESIGN: Prospective case-control study. METHODS: Forty-two type II diabetic patients stratified into nondiabetic (NDR), nonproliferative diabetic (NPDR), and proliferative diabetic (PDR) retinopathy and 14 age-matched healthy control subjects were studied. Epithelial and stromal cell densities and subbasal nerves were investigated by confocal microscopy. RESULTS: Corneal basal epithelial cell density (P = .0001), nerve fiber density (NFD) (P < .0001), nerve branch density (NBD) (P = .0003), and tortuosity coefficient (Tc) (P < .0001) were significantly different among the four groups. Basal epithelial density was significantly correlated with NFD (r = 0.43, P = .0009), NBD (r = 0.36, P = .007), and TC (r = -0.58, P < .0001). CONCLUSIONS: Patients with diabetes show alterations in corneal innervations and basal epithelial cell density in different retinopathic stages. We demonstrate that reduced density in basal epithelial cell is correlated with changes in innervation.

Cryotherapy of the anterior retina and sclerotomy sites in diabetic vitrectomy to prevent recurrent vitreous hemorrhage: an ultrasound biomicroscopy study.

OBJECTIVE: To evaluate the role of cryotherapy of the anterior retina and sclerotomy sites in the prevention of fibrovascular ingrowth (FVIG) at sclerotomy sites and postoperative recurrent vitreous hemorrhage in patients undergoing pars plana vitrectomy (PPV) for proliferative diabetic retinopathy (PDR). DESIGN: Retrospective, nonrandomized, observational case series. PARTICIPANTS: Eighty-one eyes in 71 patients who had undergone PPV for complications of PDR in the previous 2 years, with postoperative retinal reattachment for at least 3 months. METHODS: Cases were divided into 3 groups: (1) having panretinal or supplementary endophotocoagulation; (2) having anterior peripheral retinal cryotherapy (ARC) in addition to panretinal endolaser treatment; and (3) having endophotocoagulation, ARC, and cryotherapy on the 3 sclerotomy sites added. Ultrasound biomicroscopy (UBM) examination of the 3 sclerotomy sites was performed > or =2 months after surgery. The UBM findings were separated into 4 categories: well-healed, gap, vitreous incarceration, and FVIG. History and management of recurrent vitreous hemorrhage were recorded. MAIN OUTCOME MEASURES: Ultrasound biomicroscopy findings and the percentage of recurrent vitreous hemorrhage in the 3 groups were compared to determine the effectiveness of the adjunct cryotherapy in inhibiting FVIG and preventing recurrent vitreous hemorrhage. RESULTS: The recurrent vitreous hemorrhage rates in groups 1, 2, and 3 were 12 of 32 (37.5%), 3 of 26 (11.5%), and 1 of 23 (4.3%), respectively (P = 0.0004). In each group, different sclerotomy sites had similar distributions of the 4 UBM categories. Among the 3 groups, gap was found in 9.4%, 20.5%, and 52.2% of eyes, respectively (P<0.001), whereas FVIG was found in 36.5%, 15.4%, and 0% of eyes (P<0.001). Fibrovascular ingrowth was noted in 87.5% (14/16) of all eyes experiencing recurrent vitreous hemorrhage. Of those with rebleeding but no FVIG (2 eyes), 1 had vitreous lavage combined with additional cryotherapy, and 1 had no treatment. Of those with FVIG (14 eyes), 5 needed > or =2 operations. CONCLUSIONS: The presence of FVIG had good correlation with the development of recurrent postoperative vitreous hemorrhage. Anterior peripheral retinal cryotherapy combined with cryotherapy of sclerotomy sites might be helpful adjunct procedures in diabetic vitrectomy for inhibition of FVIG and prevention of recurrent vitreous hemorrhage.

Metastatic choroidal tumors in Taiwan: an 11-year experience.

PURPOSE: To report the clinical features, the primary sites, and overall prognosis of choroidal metastasis. DESIGN: Observational case series. METHODS: Included were all cases of choroidal metastases evaluated at National Taiwan University Hospital over an 11-year period. Patients with blood or lymphoproliferative diseases were excluded. Clinical features were correlated with disease entity and prognosis. RESULTS: A total of 36 patients with choroidal metastases were identified. The mean age was 53.9 +/- 12.8 years. The mean follow-up period was 5.1 +/- 4.2 months. The primary sites of tumors were lung in 18 (50%), breast in eight (22.2%), gastrointestinal tract in three (8.3%), pancreas in two (5.6%), ovary in two (5.6%), kidney in one (2.8%), liver in one (2.8%), and unknown in one (2.8%). Twenty-two patients (61%) died during follow-up. Mean life span after diagnosis was 4.3 months in these 22 patients. CONCLUSIONS: Lung and breast cancers represent more than two thirds of primary tumor sites. Choroidal metastases may indicate terminal status of the underlying malignancy and short survival time.

Clinical characteristics and surgical outcomes of pediatric rhegmatogenous retinal detachment in Taiwan.

PURPOSE: To evaluate the clinical features and surgical and visual outcomes of rhegmatogenous retinal detachment (RRD) in the pediatric population. DESIGN: Retrospective, noncomparative, interventional case series. METHODS: A review of patients under 18 years who underwent primary retinal detachment surgery at National Taiwan University Hospital from 1989 to 2003 was conducted. RESULTS: Included in the study were 152 eyes of 146 patients (mean age of 13.1 years). Male patients comprised 69.9% of the sample. Bilateral RRD was present in 4.1%. Etiologies included myopia >4 diopters (37.5%), trauma (32.9%), developmental anomaly (11.8%), previous surgery (5.9%), previous uveitis (3.9%), atopic dermatitis (2.6%), and unknown (5.3%). Macular detachment was found in 73.0%. The most common primary treatment was scleral buckling (61.2%). Single-operation reattachment was accomplished in 58.5% of patients and eventual reattachment in 78.3% of patients occurring in a mean of 1.5 (SD = 0.9) operations. Average postoperative follow-up time was 48.3 months. Visual improvement occurred in 42.8%, remained the same in 32.2%, and worsened in 19.1%. In the logistic regression model, statistically significant risk factors for poor surgical outcome were nonmyopic RRD (P = .026), macular involvement (P = .01), and presence of proliferative vitreoretinopathy (P = .07). CONCLUSIONS: Myopia >4 diopters was the most common etiology in retinal detachment in our sample, followed by trauma. Myopia (> -4.0 diopters) may be more common than previously reported. Most eyes (78.3%) were anatomically reattached after multiple surgeries. Retinal detachment not associated with myopia is a newly identified predictor for poor surgical outcomes.

Severe ocular complications following facial calcium hydroxylapatite injections: Two case reports.

Dermal soft-tissue augmentation using a filler is a technique widely used for facial cosmetic enhancement. However, potential complications following facial cosmetic injections have heightened the possibility of iatrogenic visual loss. We report two cases of severe ocular complications after nasal cosmetic enhancement. Both cases had poor visual outcomes in spite of emergency management. The second patient is a rare case with bilateral anterior ischemic optic neuropathy after dermal soft-tissue augmentation. The visual outcome was correlated with the location and the extent of the arterial embolization. Unfortunately, there is still no standard treatment protocol for vision-threatening complications. Clinicians should always keep in mind that embolic arterial occlusion may occur after augmentation.

Central retinal artery occlusion caused by expansion of intraocular gas at high altitude.

PURPOSE: To report a case of central retinal artery occlusion caused by expansion of intraocular gas during mountain travel at high altitude. DESIGN: Interventional case report. METHODS: A 46-year-old man underwent vitrectomy with intraocular gas tamponade for rhegmatogenous retinal detachment, right eye. During his trip to Mountain Ali with an altitude of 6,210 feet, he felt a sensation of fullness and noted loss of vision in his right eye. When he came down to sea level, an intraocular pressure of 54 mm Hg was present in the right eye. He visited our clinics 2 weeks after the episode, and the right eye had best-corrected visual acuity of counting fingers, intraocular pressure of 14 mm Hg, attenuated retinal arteries, and a pale optic disk. RESULTS: Because of irreversible damage to the retina of the right eye, he did not receive any treatment. CONCLUSIONS: We should not neglect the possibility of hazard for patients with intraocular gas under low atmospheric pressure circumstances, such as mountain travel.

Visual outcome in primary macula-off rhegmatogenous retinal detachment treated with scleral buckling.

BACKGROUND AND PURPOSE: To evaluate the visual outcome of primary macula-off rhegmatogenous retinal detachment after successful scleral buckling. METHODS: A retrospective, non-controlled case series study was conducted in 93 patients (93 eyes) who underwent primary successful scleral buckling procedure for retinal detachment. Factors including duration of macular detachment, patient age, preoperative best-corrected visual acuity (VA), surgical management of subretinal fluid, and refractive error were analyzed statistically to determine their association with final visual outcome. RESULTS: Postoperative VA of 20/50 or better was found in 53.6% of eyes with duration of macular detachment within 7 days, and 29.7% of eyes with macular detachment for more than 7 days (Fisher's exact test, p = 0.019). VA better than 20/50 was found in 61% of eyes with preoperative VA better than 20/400 and in 33.9% with preoperative VA worse than 20/400 (Fisher's exact test, p = 0.008). Patients aged 30 years or less achieved better mean postoperative VA than those aged 31 to 50 and those aged 50 years and older (ANOVA, p = 0.003). Patients with low-grade myopia (< -6D) regained significantly better mean postoperative VA as compared with high myopia (> -6D) and emmetropic eyes (0 to +3D) (ANOVA, p < 0.001). Subretinal fluid drainage procedure did not affect postoperative visual result. Multivariate logistic regression analysis revealed that the duration of macular detachment was the only variable affecting the visual result. CONCLUSION: Scleral buckle surgery performed within the first week, preoperative vision more than 20/400, age younger than 30 years old, and low-grade myopia were associated with significantly better visual recovery from macular-off rhegmatogenous retinal detachment.

Refractive outcome of premature infants with or without retinopathy of prematurity at 2 years of age: a prospective controlled cohort study.

This study evaluated the extent to which refractive morbidity is correlated to preterm birth or retinopathy of prematurity (ROP) itself, or both, and examined the risk factors associated with refractive errors in a cohort of preterm infants with and without ROP compared with full-term infants. This longitudinal, prospective, controlled cohort study enrolled 109 infants, including 74 preterm and 35 full-term infants. Infants were divided into the following groups: no ROP, regressed ROP, laser-treated threshold ROP, and full-term. Cycloplegic refraction was determined at 6 and 24 months' corrected age. Multiple regression models, analysis of variance (ANOVA) with post hoc comparisons, paired t test, and the χ(2) test were used for data analysis. ROP status was highly predictive of significant refractive errors in preterm infants. Eyes with laser-treated threshold ROP had significant myopia at both ages (mean spherical equivalent [MSE] in right eye at both refractions -0.72, -1.21 diopters [D]), astigmatism (MSE -1.62, -1.80 D), and anisometropia (MSE 0.82, 1.02 D; ANOVA p < 0.05), and increased refractive errors across ages (paired t test p < 0.05). Eyes with regressed ROP (MSE + 0.35 D) and eyes without ROP (MSE + 0.78 D) were less hyperopic than the controls (MSE + 1.60 D) before 1 year (post hoc comparisons p < 0.05). After 1 year, however, hyperopic status, astigmatism, and anisometropia were similar to eyes with regressed ROP (MSE + 0.38 D, astigmatism -0.94 D, anisometropia 0.32 D), eyes without ROP (MSE + 0.35 D, astigmatism -0.51 D, anisometropia 0.31 D) and the controls (MSE + 0.72 D, astigmatism -0.59 D, anisometropia 0.50 D) by post hoc comparisons (p > 0.05). Thus, the persistent hyperopic status across ages in patients with regressed ROP and in patients without ROP differed significantly (paired t test p > 0.05) from that in the full-term infants, with a reduction in hypermetropia noted for the first 2 years of life (paired t test p < 0.05). The incidence and magnitude of significant refractive errors increased with severe ROP and with age. Although the emmetropization process of preterm birth, including regressed ROP and no ROP, differed from full-term birth in early infancy, we found no differences in the refractive status after 1 year in patients with regressed ROP and in patients without ROP, who were at risk of developing ametropia similar to that of full-term patients. Therefore, apart from laser-treated ROP, children with regressed ROP and without ROP can likely be observed with a verbal vision screening at 3-4 years of age.

Ciliary detachment after pars plana vitrectomy: an ultrasound biomicroscopic study.

PURPOSE: To determine the incidence, duration, risk factors, and clinical outcomes for ciliary detachment after pars plana vitrectomy (PPV). METHODS: A total of 109 eyes of 103 patients who underwent PPV for various disease entities were included. Ultrasound biomicroscopy was applied to determine the tomographic features of the ciliary body before and 1, 3, and 7 days after the surgery. All eyes were then examined once weekly for 2 months. Demographic, preoperative, intraoperative, and postoperative parameters were evaluated to assess their predictive value in the formation of postvitrectomy ciliary detachment. RESULTS: Ciliary detachment was observed in 46 eyes (42%) after surgery and persisted for less than 3 weeks in 40 of 46 eyes. It most frequently occurred in eyes of patients with proliferative diabetic retinopathy (PDR) (64%) or retinal vascular obstructive diseases (RVO) (47%). Extensive retinal photocoagulation and retinal cryopexy positively predisposed to its formation whereas fluid-gas exchange had a protective effect. No clinical complications were observed in eyes with postoperative ciliary detachment. CONCLUSION: Ciliary detachment occurred frequently after PPV. A diagnosis of PDR or RVO and surgical procedures with extensive retinal photocoagulation and retinal cryopexy may have a higher incidence of its occurrence.