25-gauge scleral tunnel transconjunctival vitrectomy.

PURPOSE: To compare the intraocular fluid leakage rate between 25-gauge (25G) transconjunctival vitrectomy with scleral tunnels and standard 25G transconjunctival vitrectomy. DESIGN: Single-center, retrospective, interventional case series. METHODS: Transconjunctival vitrectomies were conducted by the use of only 25G instruments with peripheral vitrectomy. Standard 25G vitrectomy was conducted in 542 eyes and 25G vitrectomy with scleral tunnels in 337 eyes. The scleral tunnel was created by inserting trocars at an oblique angle. RESULTS: The intraocular fluid leakage rate was significantly lower (Fisher exact probability test: P < .0001) when scleral tunnels were used in 25G vitrectomy (1%, five of 337 eyes) compared with standard 25G vitrectomy (9%, 50 of 542 eyes). The wound leakage rate was significantly lower when using (rather than not) scleral tunnels in 25G vitrectomy, both without air-gas (P = .0258) and with air exchange (P = .0007). CONCLUSION: The use of scleral tunnels in 25G transconjunctival vitrectomy reduces the frequency of wound leakage even when the peripheral vitreous is removed.

Surgical excision of neovascularization in retinal angiomatous proliferation.

BACKGROUND: We report the postoperative outcomes of surgical neovascularization excision in patients with retinal angiomatous proliferation (RAP). METHODS: Nine eyes of eight patients with RAP who underwent surgical excision of neovascularization were studied. Surgical indications were as follows: RAP diagnosed by fluorescein and indocyanine green angiography, foveal or perifoveal neovascularization, preoperative visual acuity of 0.1 or less, Yannuzzi's stage II with detachment of retinal pigment epithelium (RPE) or stage III, and leakage on late-phase fluorescein angiography. After cataract surgery, vitreous surgery and neovascularization excision were conducted, followed by fluid-air or fluid-gas exchange. RESULTS: Visual acuity was 0.02-0.1 before surgery and 0.03-0.2 after surgery. Macular hole formation was seen in one eye but did not lead to retinal detachment. In two eyes, subretinal bleeding occurred during excision leading to vitreous bleeding after surgery. Although defects of the RPE and choriocapillaries were observed after surgery, the exudation and bleeding were absorbed. CONCLUSIONS: In stage II RAP cases with RPE detachment, surgical excision maintains constant postoperative visual acuity but results in defects of RPE and choriocapillaris; therefore, other treatment options should be examined. Surgical excision of stage III RAP seems to be promising, as postoperative visual acuity remains stable after neovascularization removal in those advanced pathologic situations.

Expanded indications for 25-gauge transconjunctival vitrectomy.

PURPOSE: We conducted 25-gauge (25G) transconjunctival vitrectomy to treat patients with various ocular diseases, and examined the possibility of expanding the indications for this system through combined use with 20G devices when needed. METHODS: The records of 167 patients (169 eyes) who underwent vitrectomy in our hospital between April and June 2004 were studied. Vitrectomy had been conducted using the 20G or 25G transconjunctival vitrectomy system. RESULTS: In 7 of the 169 eyes (4%), the 20G system was initially selected. Vitrectomy could be performed using the 25G system alone in 150 eyes (89%), while 20G devices were used in combination with the 25G system in 12 (7%). None of the 25G scleral wounds were sutured, while all the 20G scleral wounds were sutured at the completion of surgery. Low intraocular tension was noted in 15 of 162 eyes (9%), but all these eyes recovered within 2 to 4 days. In two eyes with macular hole, retinal detachment occurred, but reattachment was achieved after reoperation. No extensive vitreoretinal hemorrhage or postoperative infection was observed. CONCLUSIONS: By combining the use of 20G devices, indications for the 25G system can be expanded. However, postoperative low ocular tension must be addressed by carefully considering surgical indications and prevention measures.

Surgical excision of type 2 choroidal neovascularization in age-related macular degeneration.

PURPOSE: To evaluate the visual acuity outcome and the influence of various factors on visual outcome in patients undergoing surgical removal of type 2 choroidal neovascular neovascularization (CNV) caused by age-related macular degeneration (AMD). METHODS: We studied the records of 92 patients (92 eyes) who were followed for at least 1 year after surgical excision of CNV associated with AMD. RESULTS: The final visual acuity was 0.4 or better in 21%, 0.1 to 0.3 in 66%, and worse than 0.1 in 13% of the patients. Final visual acuity was improved in 62%, stable in 29%, and worse in 9%. Stepwise regression identified CNV size as a significant factor influencing final visual acuity (R = 0.287, P = 0.0045). CONCLUSIONS: Surgical excision of CNV for AMD is indicated for patients with subfoveal active type 2 CNV with a visual acuity of 0.3 or worse. To achieve better postoperative visual acuity it is important to operate on AMD patients in the early stage of CNV.

Surgical excision of type 1 + 2 choroidal neovascularization in age-related macular degeneration.

PURPOSE: To evaluate the visual acuity outcome and the various factors influencing visual outcome in patients undergoing surgical removal of type 1 + 2 choroidal neovascularization (CNV) caused by age-related macular degeneration (AMD). METHODS: We studied the records of 54 patients (54 eyes) followed for at least 1 year after surgical excision of CNV associated with AMD. RESULTS: The final visual acuity was 0.4 or better in 4%, 0.1 to 0.3 in 46%, and worse than 0.1 in 50% of the patients. Final visual acuity was improved in 39%, stable in 37%, and worse in 24%. Stepwise regression showed that the distance between the center of the foveal avascular zone and the CNV margin had the greatest effect on final visual acuity. CONCLUSIONS: Surgical excision of type1 + 2 CNV due to AMD may be indicated for preserving preoperative visual acuity. The distance between the center of the foveal avascular zone and the CNV margin is the most important factor affecting final visual acuity.

Twenty-gauge Transconjunctival Vitrectomy.

PURPOSE: To describe a new 20-gauge transconjunctival vitrectomy procedure that we designed, to evaluate its usefulness, and to compare two different methods of use. METHODS: The records of 431 patients (433 eyes) who underwent 20-gauge transconjunctival vitrectomy at the Surugadai Hospital of Nihon University between March 2003 and January 2004 were studied retrospectively. In surgical method 1, 20-gauge wounds were made through the conjunctiva and sclera together. In surgical method 2, 20-gauge conjunctival openings were made 2 mm posterior to the sclerotomies. Absorbable sutures were used to stitch the scleral and conjunctival openings simultaneously in both methods. RESULTS: A 20-gauge transconjunctival vitrectomy has various benefits and is indicated for nearly all ocular diseases. Moreover, it is not limited by the intraocular instruments required. However, since cannulas were not placed in all ports, conjunctival edema occurred more easily with surgical method 2 owing to the leakage of perfusion fluid. CONCLUSIONS: This new 20-gauge transconjunctival vitrectomy procedure has various benefits and is indicated for nearly all ocular diseases. It is not limited by the intraocular instruments required.

A study of laser photocoagulation for polypoidal choroidal vasculopathy.

PURPOSE: To evaluate the efficacy of laser photocoagulation for polypoidal choroidal vasculopathy (PCV) involving the macula. METHODS: The records of 38 patients (47 eyes) undergoing laser photocoagulation for PCV causing serosanguineous detachment involving the fovea were reviewed and the results were evaluated. Ten eyes underwent photocoagulation to induce a fusion scar covering whole lesions consisting of both abnormal vessels and polypoidal lesions. Thirty-seven eyes underwent photocoagulation for only polypoidal lesions. When serosanguineous detachment recurred, additional photocoagulation was performed, targeting the causative lesions. Photocoagulation was performed with an argon dye laser or multicolor krypton laser. Final visual acuity, macular changes at the final visit, and the number of photocoagulations were evaluated. Follow-up period after the first photocoagulation was at least 1 year. RESULTS: Of the 10 eyes undergoing photocoagulation of whole lesions, 9 showed absorption of exudate and/or blood after one photocoagulation, and maintained or improved visual acuity. Of the 37 eyes undergoing laser photocoagulation of only polypoidal lesions, 20 (54%) showed decreased visual acuity because of recurrent or persistent exudation and/or classic choroidal neovascularization or, alternatively, because of atrophy at the fovea; 32 of the 37 eyes had undergone photocoagulation at least twice or more. CONCLUSION: Photocoagulation is recommended only for whole lesions.

[Surgical removal of juxtafoveal and extrafoveal choroidal neovascularization in age-related macular degeneration].

PURPOSE: In the treatment of age-related macular degeneration (AMD), the effect on the fovea of photocoagulation of juxtafoveal choroidal neovascularization(CNV) and extrafoveal CNV near the fovea has been of concern, and so usefulness of surgical excision of CNV was evaluated. SUBJECTS AND METHODS: Fifteen eyes with AMD that underwent removal of juxtafoveal CNV and extrafoveal CNV near the fovea and had been followed for over one year were included in this study. Eligibility criteria were preoperative visual acuity of 0.3 or less and evidence of CNV activity by fundus angiography. RESULTS: Visual acuity of 0.4 or more was obtained in 60% of the eyes with best visual acuity and 47% with final visual acuity. The mean best visual acuity was 0.51 in cases with Gass type 2, 0.51 in type 1 + 2 CNV, and 0.21 in type 1 CNV. Good post-operative visual acuity was obtained in type 2 and 1 + 2 cases with type 2 CNV at the foveal side accompanied by preoperative foveal retinal sensitivity of 25 dB or more. There was little improvement of visual acuity in type 1 CNV because the retinal pigmented epithelium defect occurred at the fovea. CONCLUSION: For juxtafoveal CNV and extrafoveal CNV near the fovea in AMD, type 2 and 1 + 2 cases with type 2 CNV at the foveal side are thought to be candidates for surgery. Especially, relatively good postoperative visual acuity was obtained in cases with preoperative foveal retinal sensitivity of 25 dB or above. Active surgical removal is thought to be indicated for these cases.

Clinicopathological findings of retinal angiomatous proliferation.

BACKGROUND: Neovascular membranes obtained from surgical excision of neovascularization for retinal angiomatous proliferation (RAP) were examined histopathologically in an attempt to elucidate the pathogenic mechanism of RAP. METHODS: Nine eyes of eight patients (mean age, 79 +/- 6 years) who underwent neovascularization excision were studied. Three eyes had stage II with RPE detachment, six had stage III. Immunohistochemical studies were performed to identify von Willebrand factor, vascular endothelial factor (VEGF), CD68 and hypoxia inducible factors (HIF-1 alpha and HIF-2 alpha). RESULTS: Multiple soft drusen were present in the macular area in all patients. In one stage II eye, we observed intraretinal neovascularization as a VEGF-positive mass, CD68-positive macrophage migration and HIF expression. In another stage II eye, neovascularization had extended above the RPE, while VEGF-positive fibroblasts were observed below the RPE. Therefore, in stage II, neither angiographic nor histopathological examinations identified choroidal neovascularization. In one phase III eye, angiography demonstrated choroidal neovascularization and chorioretinal anastomosis. Histopathologically, chorio-retinal communication was observed in the region where the RPE was destroyed, and VEGF-positive neovascularization was also seen below the RPE. CONCLUSIONS: The findings of multiple drusen in elderly patients together with macrophage migration and HIF expression surrounding VEGF-positive retinal neovascularization suggest ischemic and inflammatory factors to be associated with the development and progression of RAP.