Dynamic intraoperative optical coherence tomography for inverted internal limiting membrane flap technique in large macular hole surgery.

BACKGROUND/OBJECTIVES: To assess the efficacy of dynamic intraoperative spectral-domain optical coherence tomography (iSD-OCT) imaging for inverted internal limiting membrane (ILM) flap technique (IILMFT) in large macular hole (MH) surgery. SUBJECTS/METHODS: Prospective, non-randomized, observational study was conducted on 8 eyes of 7 patients with large, chronic and recurrent MHs, which were treated by pars plana vitrectomy (PPV) with IILMFT. All patients underwent standard pre- and postoperative examination. The iSD-OCT imaging was performed using microscope integrated systems before, during, and after ILM peeling. The iSD-OCT data were post-processed using graphic software and reviewed for tissue behavior and instruments position. RESULTS: The real-time iSD-OCT-assisted IILMFT allowed for real-time imaging of the entire surgery with visualization of the MH, vitreoretinal instruments, and all steps of inverted ILM flap formation. In spite of shadowing created by the steel instruments, it was possible to follow and control the distance between the instrument tips and retinal layers. Dynamic imaging of the surgical maneuvers including ILM peeling and mechanical apposition of MH edges revealed the iatrogenic impact on the retina (depression and appearance of hyporeflective zones). iSD-OCT imaging could confirm the proper position of the inverted ILM flap at the very end of the surgery after fluid-air exchange. CONCLUSIONS: iSD-OCT imaging is an effective tool for learning and performing a well-controlled and safe inverted ILM flap technique in patients with large MH. Clinical significance of the structural iSD-OCT findings has to be further studied.

VISION-RELATED QUALITY OF LIFE AND VISUAL FUNCTION AFTER RETINAL DETACHMENT SURGERY.

PURPOSE: To investigate and compare the vision-related quality of life after rhegmatogenous retinal detachment (RRD) surgery with that of normal controls and to evaluate the relationship between the vision-related quality of life and visual function after surgery for RRD. METHODS: In this prospective, consecutive, comparative case series, the 25-Item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) was completed by 100 RRD patients at 6 months after surgery. Among the patients with RRD, 86 underwent pars plana vitrectomy and 14 received scleral buckling. Best-corrected visual acuity was obtained using ETDRS charts and converted to the logarithm of the minimum angle of resolution for statistical calculations. The VFQ-25 also was administered to 107 normal controls. RESULTS: The VFQ-25 composite score and the subscales associated with general vision, mental health, social functioning, driving, and color vision were significantly lower in the RRD group than in the normal controls (P < 0.05). The VFQ-25 composite score significantly correlated with logarithm of the minimum angle of resolution best-corrected visual acuity (P < 0.0001) on both the operated and the fellow eye. CONCLUSION: The vision-related quality of life is significantly impaired in patients after surgery for RRD. Higher age and female gender negatively influences the results of the composite score.

INTRASURGICAL MICROSCOPE-INTEGRATED SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY-ASSISTED MEMBRANE PEELING.

PURPOSE: To evaluate microscope-integrated intrasurgical spectral domain optical coherence tomography during macular surgery in a prospective monocenter study. METHODS: Before pars plana vitrectomy and before, during, and after membrane peeling, 512 × 128 macular cube scans were performed using a Carl Zeiss Meditec Cirrus high-definition OCT system adapted to the optical pathway of a Zeiss OPMI VISU 200 surgical microscope and compared with retinal staining. RESULTS: The study included 51 patients with epiretinal membranes, with 8 of those having additional lamellar macular holes, 11 patients with vitreomacular traction, and 8 patients with full-thickness macular holes. Intraoperative spectral domain optical coherence tomography allowed performing membrane peeling without using retinal dyes in 40% of cases (28 of 70 patients). No residual membranes were found in 94.3% of patients (66 of 70 patients) in intrasurgical spectral domain optical coherence tomography and subsequent (re)staining. In patients with vitreomacular traction, intrasurgical spectral domain optical coherence tomography scans facilitated decisions on the need for an intraocular tamponade after membrane peeling. CONCLUSION: Intraoperative spectral domain optical coherence tomography was comparable with retinal dyes in confirming success after membrane peeling. However, the visualization of flat membranes was better after staining.

Monitoring of drusen and geographic atrophy area size after cataract surgery using the MD3RI tool for computer-aided contour drawing.

BACKGROUND/AIMS: To monitor possible changes in the cumulated drusen or geographic atrophy area size (CDGAS) of nonexudative age-related macular degeneration (AMD) in patients before and after cataract surgery, using a new tool for computer-aided image quantification. METHODS: Randomized, prospective, clinical trial. 54 patients with cataract and nonexudative AMD were randomly assigned into an early surgery group (ES = 28) and a control group (CO = 26) with a 6-month delay of surgery. CDGAS was determined with the MD3RI tool for contour drawing in a central region of digitized fundus photographs, measuring 3,000 µm in diameter. To evaluate CDGAS progression, differences in pixels and square millimeters were calculated by equivalent tests. RESULTS: Forty-nine patients completed the visits over the 12-month period (ES = 27 and CO = 22). Mean pixel values increased from 201.5 (11.33 × 10(-3) mm(2)) to 202.7 (11.39 × 10(-3) mm(2)) in the ES group and from 191.6 (10.77 × 10(-3) mm(2)) to 194.6 (10.94 × 10(-3) mm(2)) in the CO group. Finally, equivalence of CDGAS differences between ES and CO could be demonstrated. No exudative AMD was recorded during the study period. CONCLUSION: In our cohorts, no significant changes were found in CDGAS 12 months after cataract surgery. The MD3RI software could serve as an efficient, precise and objective tool for AMD quantification and monitoring in future trials.

Feasibility of intrasurgical spectral-domain optical coherence tomography.

PURPOSE: To evaluate the feasibility of intrasurgical spectral-domain optical coherence tomography in a pilot study. METHODS: Using a Carl Zeiss Meditec Cirrus HD-OCT system adapted to the optical pathway of a Zeiss OPMI VISU 200 surgical microscope, 512 × 128 macular cube scans were performed during various steps of microsurgical procedures in 25 cases. The acquired volume data were postprocessed and visualized using a ray-traced three-dimensional display system. RESULTS: The surgical procedures included pars plana vitrectomies for epiretinal membranes (n = 8), macular holes (n = 4), primary rhegmatogenous retinal detachment (n = 1), proliferative diabetic retinopathy (n = 3), silicone oil removal (n = 2), and cataract surgery only (n = 7). It was possible to acquire intraretinal scans with sufficient quality from all patients. Decisions for additional membrane peeling, knowledge about the behavior of the macular hole and the foveal depression during and after membrane removal, information about clinically invisible fluid accumulation under silicone oil or in a clinically diagnosed "macula-on" retinal detachment, and the condition of the fovea immediately after cataract removal could be gained. CONCLUSION: Intrasurgical spectral-domain optical coherence tomography evaluation is feasible using the tested system and may positively influence surgical decisions and techniques resulting in an improved patient outcome.

Reproducibility and comparison of retinal thickness and volume measurements in normal eyes determined with two different Cirrus OCT scanning protocols.

PURPOSE: To assess reproducibility and compare raster scanning protocols of Cirrus high-definition optical coherence tomography (Carl Zeiss Meditec, Dublin, CA). METHODS: Five hundred and twenty-eight computed tomography scans were performed in 17 healthy subjects. Four sessions were performed at each visit including two 200 × 200 and two 512 × 128 macular cube scans per session. The examined eye, observer, and order of scanning protocols in-between each session were randomly chosen. Reproducibility was described with intraclass correlation coefficients, coefficients of variance, intervisit, interrater, intersession intra-, and intersubject standard deviations. RESULTS: Intraclass correlation coefficients ranged from 80.4% to 97.8% and the coefficients of variance from 0.7% to 2.3% for retinal volume and retinal thickness measurements. Intersubject, intervisit, interrater, intersession, and intrasubject standard deviations ranged from 0 µm to 18.54 µm. Differences in retinal thickness between protocols were small (range 3.55 ± 1.95 µm to 0.81 ± 0.59 µm) but significant for the central (P < 0.0001), the outer superior (P = 0.0036), temporal (P = 0.0026), and nasal subfield (P < 0.0001). Average difference of retinal volume between protocols was 0.05 ± 0.04 mm (P = 0.0001). CONCLUSION: Both raster scanning protocols of the Cirrus optical coherence tomography showed excellent reproducibility of retinal thickness and volume measures. Significant differences between protocols for retinal thickness in four macula thickness map subfields and for retinal volume were found.

Trends in primary retinal detachment surgery: results of a Bicenter study.

PURPOSE: To assess trends and outcomes in retinal detachment (RD) surgery based on a retrospective, interventional, bicenter study. METHODS: Baseline demographic data, surgical procedures, and outcomes from 230 patients with a diagnosis of primary rhegmatogenous RD, who underwent surgery between January 2007 and December 2008 at the Rudolf Foundation Clinic, Vienna (Center 1) and the Weill Cornell Medical College, New York, (Center 2) were analyzed using a regression model. RESULTS: Besides the baseline parameters, lens status (P = 0.01), refraction (P = 0.01), retinal tears (P < 0.02), proliferative vitreoretinopathy (P = 0.02), and previous treatment (P < 0.02), the primary RD procedure (P < 0.0001) was significantly different between the 2 centers. In Center 1, scleral buckling was the most common primary RD procedure (66.19%) compared with vitrectomy (82.42%) in Center 2. Primary retinal reattachment (88.49% Center 1 vs. 84.62% Center 2, P = 0.43) and best-corrected visual acuity at the final follow-up (best-corrected visual acuity ≥ 0.3 logarithm of minimum angle of resolution 48.92% Center 1 vs. 47.25% Center 2, P = 0.78) were not significantly different between the 2 centers. CONCLUSION: Although there is a trend toward primary vitrectomy, scleral buckling was preferred in the center in Vienna and primary vitrectomy in the center in New York. Despite the different primary RD procedures, anatomical and visual outcomes were comparable.

Spectral-domain optical coherence tomography for monitoring epiretinal membrane surgery.

PURPOSE: To assess prognostic factors in epiretinal membrane (ERM) surgery using spectral-domain (SD) optical coherence tomography (OCT). DESIGN: Prospective, interventional case series. PARTICIPANTS: Forty-one patients. METHODS: Patients with a diagnosis of ERM were examined with spectral-domain and time-domain (TD) OCT before and after surgery. MAIN OUTCOME MEASURES: Main outcome measures were functional results and predefined OCT patterns. Cofactors analyzed were the type of ERM, the duration and grading of subjective metamorphopsia, simultaneous cataract surgery, the type of dyes used, the duration of surgery, gender, and age. A multivariate regression analysis was performed. RESULTS: Thirty-nine patients (95%) showed an improved or stable best-corrected distance visual acuity (DVA) at 3 months, whereas 36 patients (88%) showed an improved or stable best-corrected near visual acuity (NVA) at 3 months. Significant correlations (P>0.4) were found between the course of central retinal thickness (CRT) assessed using SD OCT and TD OCT (P<0.02). No clinically relevant correlations (P<0.3) were seen between CRT and VA (P>0.1). Baseline DVA and NVA were found to be significant prognostic values for the postoperative decrease in CRT in both OCT systems (P<0.04) as well as for the visual outcomes (P<0.007) at 3 months. In addition, the integrity of the junction between the photoreceptor inner segment and outer segment (IS/OS) significantly influenced the visual outcomes at 3 months (P<0.038). The baseline profile of the internal limiting membrane (ILM) significantly influenced the NVA at 3 months (P<0.009), whereas the postoperative foveal contour significantly influenced the DVA at 3 months (P<0.025). The type of ERM, subjective metamorphopsia, simultaneous cataract surgery, the type of dyes used, the duration of surgery, gender, or age had no significant influence on patient outcome (P>0.05). Compared with TD OCT, SD OCT allowed for a more precise differentiation between the ERM and the retinal surface and for a better evaluation of the IS/OS line. CONCLUSIONS: Besides the baseline VA, the integrity of the IS/OS line, better visualized by SD OCT, can be used to predict the functional outcomes after surgery. Additionally, analyzing the ILM profile and the foveal contour may help to understand limited visual outcomes after surgery. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Spectral domain high-definition optical coherence tomography in patients undergoing epiretinal membrane surgery.

BACKGROUND AND OBJECTIVE: To evaluate possible advantages of spectral domain optical coherence tomography (SD-OCT) in epiretinal membranes. PATIENTS AND METHODS: Patients with idiopathic epiretinal membranes (ERMs) were examined before and after vitreoretinal surgery. Cirrus SD high-definition (HD)-OCT was compared with Stratus time domain OCT to find correlations with visual acuity (VA) and metamorphopsia. RESULTS: Five consecutive patients were enrolled. With Cirrus HD-OCT, it was possible to differentiate between the ERM and the retinal surface in all patients. In areas where the ERM was adherent, this differentiation was severely limited with Stratus OCT. We found no significant correlations between Cirrus OCT and Stratus OCT for retinal thickness and VA. However, we found a relationship between metamorphopsia and topographic maps of the internal limiting membrane. CONCLUSION: Cirrus HD-OCT improved the preoperative evaluation of ERMs, offered a topographic reconstruction of the vitreomacular interface, and improved identification of retinal structures.

Blue light-filter intraocular lenses in vitrectomy combined with cataract surgery: results of a randomized controlled clinical trial.

PURPOSE: To evaluate the effect of the blue light-filter intraocular lenses (IOLs) in vitrectomy combined with cataract surgery, focusing on the surgeon's ability to perform specific vitreoretinal procedures and on the patients' outcome. DESIGN: Randomized clinical trial. METHODS: Sixty patients, recruited from our outpatient department, were assigned randomly to receive an ultraviolet-filter IOL (clear IOL group) or a blue light-filter IOL (yellow IOL group) combined with a vitreoretinal procedure. Main outcome measures were intraoperative conditions for the surgeon and the functional outcome. Second outcome measures were complication rates and vitreoretinal diagnoses. RESULTS: The questionnaire responses showed that the blue light-filter IOLs did not represent an impediment to vitreoretinal surgery (P>.05). No intraoperative complications were encountered in either group. Patients in both IOL groups showed comparable functional results with respect to visual acuity, contrast sensitivity, color vision, and glare effect (P>.05). The functional outcome was influenced significantly by the vitreoretinal diagnosis (P<.01). CONCLUSIONS: With the possible advantage of macular protection and no intraoperative or functional disadvantage, the routine use of the blue light-filter IOL in combined surgery can be recommended.

Accuracy of preoperative biometry in vitrectomy combined with cataract surgery for patients with epiretinal membranes and macular holes: results of a prospective controlled clinical trial.

PURPOSE: To evaluate how adding vitrectomy to cataract surgery affects the accuracy of preoperative biometry and postoperative refractive outcomes. SETTING: Department of Ophthalmology, Ludwig Boltzmann Institute of Retinology and Biomicroscopic Lasersurgery, Rudolf Foundation Clinic, Vienna, Austria. METHODS: This study comprised 40 patients with vitreoretinal pathology and coexisting significant cataract (study group) and 40 patients with significant cataract only (control group). The main outcome measure was intraocular lens (IOL) power prediction error. Secondary outcome measures were spherical equivalent, anterior chamber depth, axial length, keratometry values, and intraocular pressure. A multivariate regression analysis was performed. RESULTS: There was a significant difference in prediction error between the study group and control group (P< .05). The addition of vitrectomy was associated with induced myopia of approximately -0.4 diopter, more so in patients who had epiretinal membrane removal than in patients with macular hole surgery (P= .04). There was no significant difference in prediction error between the 3 IOLs used (P= .2). CONCLUSION: The myopic shift was strongly dependent on the diagnosis and the need for intraocular tamponade, indicating that a slightly hyperopic IOL should be used in patients having combined surgery.

Evaluation of intraocular lens position during phacoemulsification using intraoperative spectral-domain optical coherence tomography.

PURPOSE: To assess the position of intraocular lenses (IOLs) at the end of standard phacoemulsification with intraoperative spectral-domain optical coherence tomography (SD-OCT). SETTINGS: Department of Ophthalmology, Rudolf Foundation Hospital, Vienna, Austria. DESIGN: Prospective case series. METHODS: Standard phacoemulsification with IOL implantation was performed. The Rescan 700 SD-OCT system was used for intraoperative imaging. The anterior segment of the eye was scanned using SD-OCT at the end of the surgery. The distance from the IOL optic center and the IOL optic edge to the posterior capsule was measured postoperatively using graphic software. RESULTS: The study comprised 74 patients (101 eyes). The mean axial length was 23.97 mm (range 21.43 to 28.61 mm). The mean IOL power was 20.39 diopters (D) (range 6.5 to 27.5 D). Contact between the IOL and posterior capsule was absent in 88 cases (87.13%), and partial or full contact was present in 13 cases (12.87%). The mean distance between the IOL central optic and posterior capsule was 0.71 pixel (range 0.06 to 1.38 pixels) in 99 cases (98.02%). In 42 cases (57.53%), partial contact between the IOL edges and the posterior capsule was noticed. The mean distance between the IOL edge and posterior capsule was 0.21 pixel (range 0.04 to 0.92 pixel). CONCLUSIONS: Intraoperative SD-OCT facilitated the imaging of IOL position during standard phacoemulsification. Contact between the IOL central optic and posterior capsule at the end of the surgery occurred rarely. Improved IOL design should be considered. FINANCIAL DISCLOSURE: Drs. Binder and Glittenberg are consultants to Carl Zeiss Meditech AG. None of the other authors has a financial or proprietary interest in any material or method mentioned.

Vitrectomy combined with endolaser or an encircling scleral buckle in primary retinal detachment surgery: a pilot study.

PURPOSE: To compare pars plana vitrectomy and 360° endolaser therapy with pars plana vitrectomy and an encircling scleral buckle for the treatment of primary rhegmatogenous retinal detachments in a randomized pilot study including 60 patients. METHODS: Main outcome measures were single-surgery anatomic success rate and final best-corrected visual acuity at 6 months follow-up. Cofactors analysed were complication rates, patients' comfort, refractive outcome and macula status assessed using a spectral-domain optical coherence tomography. RESULTS: With differences between both treatment groups regarding type of the retinal detachment, localization of retinal tears (p = 0.0085) and the choice of the intraocular tamponade (p < 0.0202), there were no significant differences between the single-surgery anatomic success rate (93.33% both groups, p = 1.0) and the visual acuity at final follow-up (≤0.3 logMAR [logarithm of minimum angle of resolution] in 66.67% in the endolaser group versus 40.0% in the scleral buckle group, p = 0.0514). Questionnaire responses showed lower levels of patients' discomfort in the endolaser group. A significant difference between both groups was found in the refractive error change after surgery (-0.20 ± 0.51 dioptres in the endolaser group versus -0.88 ± 0.88 dioptres in the scleral buckle group, p = 0.0003). CONCLUSION: Primary vitrectomy combined with 360° endolaser therapy seems to be as effective as vitrectomy combined with an encircling scleral buckle in patients with rhegmatogenous retinal detachment, with possible benefits of an improved patients' comfort and a more stable refractive status after surgery.

Spontaneous closure of an idiopathic macular hole 9 months after unsuccessful vitreoretinal surgery.

PURPOSE: To report spontaneous closure of a persistent idiopathic macular hole (MH) 9 months after cataract and vitreoretinal surgery, and subsequent gas reinjection. METHODS: Baseline and follow-up examinations after surgery included slit-lamp biomicroscopy, best-corrected distance visual acuity and near visual acuity, spectral domain optical coherence tomography, and microperimetry. RESULTS: Spectral domain optical coherence tomography scans showed a persistent MH after surgery until 5 months of follow-up, with an increasing base diameter of the MH and decreasing best-corrected visual acuity. Nine months after surgery, spontaneous closure of the MH with an improvement in best-corrected visual acuity was observed. These findings remained stable at 15 months of follow-up, with an additional increase in retinal sensitivity. CONCLUSION: Spontaneous closure of a persistent Stage 3 full-thickness MH after primary surgery is possible. We recommend follow-up examinations including spectral domain optical coherence tomography for several months before scheduling a reoperation.

Outcome after silicone oil removal and simultaneous 360° endolaser treatment.

PURPOSE: To evaluate the outcome after silicone oil removal combined with a 360° endolaser treatment in complex retinal detachment (RD) cases and to assess prognostic factors. METHODS: This is a retrospective, consecutive interventional study in Vienna, Austria with data from 111 patients following silicone oil removal and simultaneous 360° endolaser treatment for at least 6 months. Stepwise regression analysis between anatomic and visual outcome, baseline demographics, and type and number of RD procedures was performed. RESULTS: One hundred and one patients (91%) showed a retinal reattachment after silicone oil removal, which was associated with a low overall number of RD procedures (p = 0.01) and male gender (p < 0.03). Sixty-five patients (59%) showed an improvement (two or more lines) of best-corrected visual acuity (BCVA) at the final follow-up visit. Improvement of BCVA and a better BCVA after silicone oil removal were associated with a better BCVA before silicone oil removal (p < 0.01) and a low overall number of RD procedures (p < 0.01). CONCLUSION: The overall number of RD procedures can be used to predict the anatomic and visual outcome after silicone oil removal. Adding a simultaneous 360° endolaser therapy to silicone oil removal is associated with a high anatomic success rate and an excellent visual outcome.

Human retinal pigment epithelium (RPE) transplantation: outcome after autologous RPE-choroid sheet and RPE cell-suspension in a randomised clinical study.

AIMS: To evaluate the outcome after two types of retinal pigment epithelium (RPE) transplantation techniques. METHODS: Fourteen consecutive patients with advanced exudative age-related macular degeneration (AMD) were randomly assigned to RPE-choroid sheet transplantation (group 1) or RPE cell-suspension transplantation (group 2). Outcome measures included best corrected distance and near visual acuity (BCVA), complication and recurrence rates, autofluorescence (AF), angiography, and time-domain and spectral-domain optical coherence tomography (TD- and SD-OCT). RESULTS: A gain of three or more lines in BCVA at 24 months was found in two patients in group 1 and in one patient in group 2, whereas a loss of vision of three or more lines occurred in one patient in each group. Revision surgery for proliferative vitreoretinopathy was required in one patient in group 1. Epiretinal membranes developed in two patients in group 1 and in one patient in group 2. No recurrence occurred in this series. AF showed hyperfluorescence coincident with the graft in group 1, and hyper- and hypofluorescence in irregular patterns in group 2. Revascularisation of the graft was present in all patients in group 1, and a normal choroidal vasculature in the area of RPE atrophy in all patients in group 2. OCT showed a decrease in retinal thickness in all patients, with an improved visualisation of inter- and intralaminar structures with SD-OCT. CONCLUSION: The anatomical and functional outcome after both RPE transplantation techniques was comparable. Intrastructural irregularities of the sheet assessed using SD-OCT might explain the rather limited visual gain in otherwise successful sheet transplants. Clinical Trial Registration NCT00401713.