Does the presence of an epiretinal membrane alter the cleavage plane during internal limiting membrane peeling?

PURPOSE: To determine whether the presence of a clinically and/or microscopically detectable epiretinal membrane (ERM) alters the cleavage plane during internal limiting membrane (ILM) peeling. DESIGN: Retrospective, observational, immunohistochemical study of ILM specimens using archival formalin-fixed, paraffin-embedded tissue. PARTICIPANTS: Fifty-one patients who had had ILM excision. METHODS: Fifty-one ILM specimens peeled during vitrectomy for various etiologies were examined by light microscopy. The removal of ILM was assisted using Trypan blue (n = 30), indocyanine green (n = 7), or brilliant blue G (n = 14). Monoclonal antibodies to glial fibrillary acidic protein and to neurofilament protein were used to detect glial or neuronal cells respectively on the vitreous or retinal surfaces of the ILM. Specimens were divided into 2 groups: ILM peeled for full-thickness macular hole (MH; n = 31) and ILM peeled after removal of clinically detectable ERM (n = 20). MAIN OUTCOME MEASURES: Primary outcome measure was the localization of immunohistochemical markers to neuronal or glial cells on the vitreous or retinal surfaces of ILM. The secondary outcome measure was the correlation of the results of the primary measure with the dyes used to facilitate ILM peeling. RESULTS: Glial and/or neuronal cells were detected on the retinal surface of the ILM in 10 of 31 (32%) of the MH ILM specimens and in 13 of 20 (65%) of the ILM peeled after ERM excision; the difference was significant (P = 0.02). There was no association between the presence of neuronal and glial cells with the type of dye used (P = 0.2). Of the 23 ILM specimens with cells attached to the retinal surface, 21 (91%) were associated with clinical and/or histologic evidence of ERM and 2 (9%) were not. The correlation between the presence of cells on the vitreous and the retinal surfaces of ILM was high (P<0.0001). CONCLUSIONS: The findings suggest that ERM may be associated with sub-ILM changes that alter the plane of separation during ILM peeling. This study does not confirm any influence of dyes on the cleavage plane during surgery.

Fibrous membranes in diabetic retinopathy and bevacizumab.

PURPOSE: The purpose of this study was to determine the histopathologic characteristics of bevacizumab-treated human proliferative diabetic retinopathy (PDR) membranes with particular regard to membrane vasculature as a step toward addressing the effects of the drug on PDR membranes. Intravitreous injection of bevacizumab, an antivascular endothelial growth factor monoclonal antibody, has recently been advocated as an adjunct in surgery for PDR. In this context, a clinically observed decrease in PDR epiretinal membrane vascularity (vascular regression) occurs from 24 hours to 48 hours after injection, but the exact mechanisms of drug action are unknown. METHODS: A consecutive series of seven PDR membrane specimens that had been removed sequentially from seven bevacizumab-treated patients were studied retrospectively. The membrane specimens were examined using light microscopic methods, including immunohistochemistry. RESULTS: Five of the seven membranes were clinically avascular (one contained "ghost" vessels) and did not hemorrhage during excision. Of these 5 specimens, which included 1 removed 7 days after a total of 6 intravitreous injections of 1.25 mg bevacizumab, 4 contained histologically detectable capillaries (1 did not). These blood vessels were lined by endothelial cells as determined by immunohistochemistry for the endothelial markers CD31 and CD34. The two remaining membranes were clinically and histologically still vascularized despite bevacizumab treatment. All the specimens also contained smooth muscle actin-containing fibroblastic cells within the collagenous stroma. CONCLUSION: The findings do not support the concept that the clinical phenomenon of vascular regression in PDR membranes after bevacizumab injection in the vitreous is resulting from obliteration of the membrane blood vessels. Another mechanism appears to be involved in at least some patients, possibly a vasoconstrictive response. Such a mechanism might explain reversal of the effects of bevacizumab that has been reported after this treatment.

Visual loss associated with tacrolimus: case report and review of the literature.

Tacrolimus is an immunosuppressive medication in the class of calcineurin inhibitors that acts by inhibiting T-cell and interleukin-2 activity, and is commonly used after allogeneic organ transplant. We present a patient who used tacrolimus after cadaveric kidney transplant and experienced blurry vision. Ocular examination and patient's course subsequently revealed aqueous tear deficiency as a dose-dependent adverse effect of oral tacrolimus.

Management of exudative retinal detachment in choroidal melanoma.

Exudative retinal detachment is the most common source of visual loss associated with malignant melanoma of the uveal tract. Management has historically been conservative, leading to irreversible visual loss from photoreceptor damage during the several months needed for post-radiation resolution. The purpose of this paper is to describe timely vitreoretinal surgical intervention for exudative retinal detachments associated with choroidal melanomas. This was an interventional case series including six consecutive patients with malignant melanoma who experienced VA reduction secondary to associated exudative retinal detachment. Patients underwent complete ophthalmic evaluation and B-scan ultrasound. Treatment included proton-beam radiation or brachytherapy, prognostic transretinal tumour biopsy with 25-gauge vitrector and surgical treatment of exudative retinal detachment, including vitrectomy and drainage of subretinal fluid at the time of irradiation. Successful management of exudative retinal detachments associated with choroidal melanomas was observed in all cases, with significant restoration of vision. Steady regression of tumour thickness was noted clinically and ultrasonographically, without extrascleral extension or metastasis, and with no recurrence of exudative retinal detachment found over follow up. In the present study, the investigators have showed effective surgical treatment of exudative retinal detachment associated with malignant melanoma. These patients had significant restoration of vision, confirming that timely intervention of exudative retinal detachment associated with malignant melanoma can reverse visual loss in these patients. These findings are in contrast to previous reports of irreversible visual loss after exudative retinal detachments, and suggest that photoreceptor atrophy might play a role in visual loss associated with chronic exudative retinal detachments.

Trans-vitreal endoresection for vasoproliferative retinal tumours.

We present an interventional consecutive case series to describe our experience of transvitreal endoresection (TVE) for vasoproliferative retinal tumours (VPRTs). Three patients with VPRTs refractory to conventional treatment modalities of cryotherapy, plaque radiotherapy and anti-VEGF presented with macular exudative changes and were offered TVE. Complete ophthalmic examination with colour fundal photographs was performed before and during the follow-up period. All patients were followed up for 6 months following silicone oil removal. At the last follow up, resolution of macular and retinal exudative changes with parallel improvement in vision was observed. No recurrences were detected during the follow-up period. Two of three patients had simultaneous cataract surgery and developed fibrinous uveitis, requiring management with intensive topical steroids. After 3 months, these patients had a fibrotic pupillary membrane enveloping the intraocular lens (IOL) with posterior synechiae. These two patients underwent SO removal, IOL explantation and artisan IOL (iris clipped) insertion, resulting in visual improvement. We did not observe any PVR complications in our cases. TVE represents an effective and safe option for the treatment of VPRTs refractory to other treatment modalities. Further studies with a larger sample size and long-term follow up are indicated to evaluate the role of TVE in the management of VPRTs.

Efficacy of combined intravitreal bevacizumab and triamcinolone for branch retinal vein occlusion.

PURPOSE: To evaluate the efficacy of combined treatment with intravitreal bevacizumab (IVB) and triamcinolone acetate (IVT) for patients with macular edema secondary to branch retinal vein occlusion (BRVO). MATERIALS AND METHODS: Retrospective analysis of 20 eyes injected with 1.25 mg IVB and 2 mg IVT for clinically identified BRVO within 8 weeks of onset. All patients lacked concomitant ocular pathology and completed 6 months' follow-up. Clinical examination including LogMAR visual acuity (VA) and central macular thickness (CMT) by spectralis optical coherence tomography (OCT) was performed preoperatively and at 1, 3 and 6 months post-operatively. RESULTS: Mean patient age was 61.3 years with a mean BRVO diagnosis time of 3 weeks at presentation. VA improved from logMAR 1.08 preoperatively to Mean logMAR VA of 0.55 ± 0.17 at 1 month (P < 0.001), 0.56 ± 0.21 at 3 months (P < 0.001), and 0.38 ± 0.1 at 6 months (P < 0.001) Mean CMT improved from 482 ± 107 µm preoperatively to 319 ± 53 µm at 1 month (P < 0.001), 344 ± 89 µm at 3 months (P < 0.001), and 241 ± 29 µm at 6 months (P < 0.001). Mean IOP preoperatively was 16.5 mmHg, 21 mmHg at 1 month, and 15 mmHg at 6 months. Six out of 20 patients (30%) were re-injected with IVB and IVT at 3 months. CONCLUSIONS: Early combined treatment with IVB and IVT is effective in improving anatomic and functional outcomes in patients with macular edema secondary to BRVO.

A comparison of two-way text versus conventional paging systems in an academic ophthalmology department.

Alphanumeric paging systems are unidirectional without prioritization capabilities. Newer electronic communication devices such as two-way text paging systems are capable of bidirectional paging and prioritization. While previous studies have evaluated alphanumeric paging systems in academic hospital settings, bidirectional two-way text paging systems have not been investigated. The goal of this study was to evaluate efficiency and impact on patient care delivery of a two-way text paging system compared to conventional one-way alphanumeric pagers. This unmasked, crossover prospective study was divided into three phases. In phase one, surveys were distributed to all ophthalmology attending physicians, residents, clinical technicians, and secretaries to assess the conventional alphanumeric paging system. In phase two, these participants used two-way text pagers without instruction (unstructured format) that they subsequently compared to the alphanumeric system with devised surveys assessing (on a scale of 0 to 100) time saved, increased daily efficiency, facilitation in patient care, and overall impression (helpfulness).In phase three, participants used a specific communication prioritization protocol (structured format) with the two-way text pagers with subsequent comparison and assessment with the same surveys. Compared to traditional alphanumeric pagers, new digital two-way text pagers were found to be statistically (p < 0.0001) more helpful by participants in all categories: as a time saver (80.33 vs. 56.95) p < 0.0001, increased daily efficiency (78.15 vs. 57.13) p < 0.0001, facilitation in patient care (78.79 vs. 56.95) p < 0.0001, and overall impression (helpfulness) (61.82 vs. 84.33) p < 0.0001. When compared to the alphanumeric pager, the two-way text pager was found to decrease subjectively call backs (73.6% to 45.6%, p < 0.0001), reduce interruptions of learning activities (43.63% to 26.6%, p < 0.0001) and enabled better patient care (59.8% to 42.2%, p < 0.0001). No significant statistical difference was found between the structured and unstructured system. Two-way text paging (structured versus unstructured guidance) was preferred over the conventional one-way alphanumeric paging system in every participant category. Two-way text paging is an effective alternative to alphanumeric paging, demonstrating saved time, increased daily efficiency, reduced call backs and interruptions of educational activities, and facilitation in patient care.

Surgical management of massive submacular hemorrhage associated with age-related macular degeneration.

PURPOSE: To investigate the safety and efficacy of surgical drainage of massive and elevated submacular hemorrhage associated with age-related macular degeneration through circumferential peripheral 180° temporal retinotomy. METHODS: Prospective interventional case series of first eyes of six consecutive patients with large elevated submacular hemorrhage. The surgical approach consisted of combined cataract surgery, three-port pars plana vitrectomy, induction of retinal detachment, and circumferential peripheral temporal 180° retinotomy. The temporal retina was reflected and the solid blood clot was removed with a vitreous cutter along with the choroidal neovascular complex. Silicone oil was used as an internal temponade in all patients. Complete clinical examination was performed in all cases preoperatively and postoperatively at 1 and 3 months. After removal of silicone oil, the patients were observed for 12 months. RESULTS: Submacular hemorrhage was completely removed in all cases the next day after the surgery. All patients experienced improvement of central scotoma. Twelve months after silicone oil removal, visual acuity was defined as improvement in 5 eyes (83%) and stable in 1 eye (17%). No recurrence or complications were observed during the period of follow-up. CONCLUSION: Our surgical approach could be efficacious to remove a large elevated submacular hemorrhage that is not feasible for any other treatment. It may help to improve the central scotoma and results in limited visual improvement in selected patients.