Surgical Innovations in the Treatment of Diabetic Macular Edema and Diabetic Retinopathy.

PURPOSE OF REVIEW: Diabetic macular edema (DME) and complications of proliferative diabetic retinopathy (PDR) are the primary causes of vision loss in patients with diabetic retinopathy. As the incidence of diabetes increases worldwide, new, cost-effective treatments for DME and PDR will become paramount. Currently, anti-vascular endothelial growth factor (anti-VEGF) medications are considered first-line treatment. However, multiple visits for injections and the economic and time burden they entail make this treatment modality less than ideal. Early vitrectomy as well as depot delivery systems for medications could potentially reduce the treatment burden of patients with diabetes, prevent visual loss, and provide long-term stabilization of retinopathy in patients with diabetes. Newer port delivery systems for anti-VEGF medications could one day make this treatment modality better suited for patients across the globe. RECENT FINDINGS: Real-world data shows poor compliance with treatment among patients with diabetes. Recent publications show catastrophic results when anti-VEGF treatments are stopped abruptly. The port delivery system for ranibizumab shows maintenance of adequate anti-VEGF levels in the vitreous cavity for many months. Early vitrectomy can provide cost-effective long-term stabilization in eyes with diabetic retinopathy. Microincisional vitrectomy as a treatment for DME and PDR remains controversial and larger trials are needed to definitively prove its superiority over other modalities; however, small-scale data point towards its usefulness in specific populations. Newer port delivery systems of anti-VEGF show promise in decreasing the number of office visits in patients with diabetic retinopathy.

Management of Giant Retinal Tear Detachments.

Giant retinal tears (GRTs) are full-thickness circumferential tears of more than 90 degrees of the retina that are associated with vitreous detachment. They are related to ocular trauma, high myopia, aphakia, pseudophakia, genetic mutations involving collagen and young age. GRTs comprise 1.5% of all rhegmatogenous retinal detachments and the average age of incidence is 42 years. GRTs are more common in males, as 72% of all cases occur in males. The incidence of GRTs in the general population is estimated to be 0.05 per 100,000 individuals. Common techniques used in the management of GRTs include fluid-air exchange, pneumatic retinopexy, scleral buckling, primary vitrectomy with gas or silicone oil tamponade, and combined scleral buckle-vitrectomies. However, management of GRTs poses a great challenge to physicians due to the high risk of intra- and post-operative complications and the many technical difficulties involved. The advent of perfluorocarbon liquids (PFCL) and the use of micro-incisional surgery for the treatment of GRTs has provided new opportunities for the management of GTRs. Today, retinal reattachment can be achieved in 94-100% of cases.

Terson's Syndrome in a Patient with von Hippel-Lindau Disease.

PURPOSE: Terson's syndrome is a condition where a preretinal hemorrhage forms as a result of increased intracranial pressure. The elevated intracranial pressure is thought to be transmitted through the veins and the optic nerve sheath to the optic disc and retina, causing the thin capillary walls to rupture. The authors present a unique case of Terson's syndrome in a patient who underwent recent surgical management for cerebellar hemangioblastomas related to von Hippel-Lindau disease. CASE REPORT: A 17-year-old African American female patient with a history of von Hippel-Lindau disease presented with pain in her right eye. She had recently undergone surgery to remove cerebellar hemangioblastomas. Preliminary fundus imaging was performed, but before formal ophthalmic testing could be conducted, the patient seized and was taken directly to the emergency room. When the patient returned for a formal evaluation 3 weeks later, a new preretinal "boat-shaped" hemorrhage was now present. Additionally, reports from the emergency room suggested that she had bled into the cavity where the previous cerebellar resection had taken place. This hemorrhage likely led to an increase in intracranial pressure, causing a Terson's-like event. CONCLUSIONS: A Terson's event may be caused by high intracranial pressure secondary to the surgical removal of von Hippel-Lindau syndrome-associated cerebellar tumors and should be included as a possible complication of surgical management.