CLINICAL CHARACTERISTICS AND SURGICAL OUTCOMES IN STAGE 4 MACULAR HOLE WITH EPIRETINAL PROLIFERATION.

PURPOSE: To investigate the clinical characteristics and surgical outcomes of Stage 4 macular holes (MHs) with epiretinal proliferation (EP) and explore the pathogenesis of MH formation. METHODS: This retrospective study included consecutive patients who underwent pars plana vitrectomy for Stage 4 MH. Patients were divided into two groups based on the presence or absence of EP. Baseline characteristics, optical coherence tomography features of MHs, and surgical outcomes were compared between the groups. RESULTS: EP was detected in 31 of 102 eyes with Stage 4 MH (30%). Patients with EP were older ( P = 0.044), predominantly male ( P = 0.047), had a greater axial length ( P = 0.008), and had better preoperative visual acuity ( P < 0.001) than those without EP. On optical coherence tomography, eyes with EP had more epiretinal membrane and intraretinal splitting ( P = 0.002 and P < 0.001, respectively) than those without EP. The hole closure rate after primary surgery was comparable, and visual acuity at 6 months after surgery was significantly better in eyes with EP than those without EP ( P = 0.036). In 9 eyes with EP, the medical record documented the presence of complete posterior vitreous detachment before MH development. CONCLUSION: Patients of Stage 4 MH with EP were older, predominantly male, and had better preoperative and postoperative visual acuity compared with those without EP. The differences in demographic characteristics and optical coherence tomography findings suggest that the pathogenesis of Stage 4 MH with EP is different from that of Stage 4 MH without EP.

FULL-THICKNESS MACULAR HOLE WITH PERSISTENT BROAD VITREOMACULAR ATTACHMENT: Clinical Characteristics and Surgical Outcomes.

PURPOSE: To describe the characteristics and surgical outcomes of full-thickness macular holes (FTMHs) with persistent broad vitreomacular attachment. METHODS: This was a retrospective, observational case series. Consecutive patients undergoing pars plana vitrectomy for FTMHs with persistent broad vitreomacular attachment (study group) were reviewed. Clinical charts, optical coherence tomography (OCT) features of macular holes, and surgical outcomes were reviewed and compared with those with typical FTMH with focal vitreomacular traction (control group). RESULTS: A total of 15 eyes of 14 consecutive patients (eight males and six females with a mean age of 60.6 years) were included in the study group. OCT showed a zone of at least 1,500 µm all around the circumference of the fovea where the vitreous was attached. On OCT, epiretinal membrane and epiretinal proliferation were observed in 73% and 87% of cases, respectively. Compared with the control group, the study group was younger (P = 0.027) and had better preoperative visual acuity (P = 0.007). All FTMHs closed after one surgery in both groups, and the postoperative visual acuity of the study group was better than that of the control group (P = 0.002). CONCLUSION: Full-thickness macular holes may have developed under the condition that the vitreous cortex was broadly attached around the hole. These FTMHs were associated with younger age, better baseline visual acuity, and a higher incidence of epiretinal membranes and epiretinal proliferations compared with macular hole with focal vitreomacular traction. The surgical outcome was favorable, but the pathogenesis of FTMH development remains unclear.

AIR VERSUS SULFUR HEXAFLUORIDE GAS TAMPONADE IN VITRECTOMY FOR UNCOMPLICATED RETINAL DETACHMENT WITH INFERIOR BREAKS.

PURPOSE: To compare surgical outcomes of filtered air and sulfur hexafluoride (SF6) as an internal tamponade in patients undergoing primary 25-gauge pars plana vitrectomy for uncomplicated rhegmatogenous retinal detachment with inferior breaks. METHODS: Patients with uncomplicated rhegmatogenous retinal detachment associated with inferior breaks (between 4 and 8 o'clock positions) who were undergoing primary pars plana vitrectomy were enrolled. All eyes underwent pars plana vitrectomy and complete drainage of subretinal fluid, followed by filtered air or 20% SF6 tamponade. The main outcome measures included single-surgery anatomical success rates and final visual recovery. RESULTS: Overall, 116 eyes of 116 patients (81 men and 35 women with a mean age of 55.2 years) were assessed. Air was used in 52 eyes (air group) and gas in 64 eyes (gas group). Single-surgery anatomical success was achieved in 50 (96.2%) and 60 (93.8%) eyes in the air and gas groups, respectively (P = 0.69), and final anatomical success was achieved in all eyes. The mean final Snellen visual acuity was similar in the air (20/23) and gas groups (20/21; P = 0.13). CONCLUSION: No significant differences were observed in single-surgery anatomical success rates and final visual recovery when comparing air with SF6 gas tamponade in pars plana vitrectomy for primary uncomplicated rhegmatogenous retinal detachment with inferior breaks.

Macular holes following vitrectomy for rhegmatogenous retinal detachment: epiretinal proliferation and spontaneous closure of macular holes.

PURPOSE: To describe the characteristics and management of full-thickness macular holes (MHs) that develop after pars plana vitrectomy for rhegmatogenous retinal detachment (RD). METHODS: Retrospective, interventional, consecutive case series. Patients who developed secondary full-thickness MHs after prior pars plana vitrectomy for RD over a 6-year period were included. The main outcome measures included optical coherence tomography (OCT) findings and the clinical course of full-thickness MHs. RESULTS: A total of 11 eyes of 11 consecutive patients were included in the study. The mean age of the patients was 58.8 years (range, 47-70 years). The median time between RD repair and MH diagnosis was 36 months (range, 1 month-11 years). The fovea was attached to 10 eyes (91%) at the time of RD repair. OCT demonstrated epiretinal proliferation (EP) at the hole margin in 10 eyes (91%). MH spontaneously closed in 7 eyes (63%) but reopened in 5 eyes. A total of 7 eyes (63%) required a vitrectomy to repair the MHs. All MHs were closed at the last follow-up visit. CONCLUSION: Full-thickness MHs after pars plana vitrectomy for RD have features that are distinct from that of typical idiopathic MH. The presence of EPs is common, and MHs are prone to spontaneous closure and reopening. These findings suggest that EP may be associated with spontaneous hole closure and that long-term follow-up is necessary even if the MHs close spontaneously.

SIX MONTHS PRIMARY SUCCESS RATE FOR RETINAL DETACHMENT BETWEEN VITRECTOMY AND SCLERAL BUCKLING.

PURPOSE: To compare clinical outcomes between pars plana vitrectomy (PPV), scleral buckling (SB), and PPV+SB for rhegmatogenous retinal detachment in the Japan-RD Registry. METHODS: This is a nation-wide, multicenter, observational study based on the registry data between 2016 and 2017. The failure levels were defined as Level 1 (a failure of retinal detachment repair), Level 2 (remaining silicone oil), and Level 3 (multiple surgeries to achieve reattachment). We compared cases treated by SB or PPV in the subgroup of simple rhegmatogenous retinal detachment using multivariate Cox proportional hazard models. RESULTS: A total of 2,775 cases were included. Overall, 6 months any levels of failure in total, SB, PPV, and PPV+SB were 9.2% (n = 256), 6.9% (n = 48), 8.2% (n = 157), and 21.3% (n = 51), respectively. Poor visual acuity at baseline in SB and inferior rhegmatogenous retinal detachment and larger retinal tear in PPV were associated with a higher risk of failure. Pars plana vitrectomy was associated with a higher chance of achieving primary success in cases with simple RRD, especially for cases with superior RRD (adjusted hazard ratio 3.61, 95% confidence interval 2.22-5.94, P < 0.001). CONCLUSION: In this nationwide study, surgical anatomic outcomes were equally successful in either SB or PPV. There were different baseline characteristics associated with primary success between SB and PPV.

Preoperative factors to select vitrectomy or scleral buckling for retinal detachment in microincision vitrectomy era.

BACKGROUND: To determine the preoperative factors associated with selecting scleral buckling (SB) or pars plana vitrectomy (PPV) to treat rhegmatogenous retinal detachments (RRDs) in the era of microincision vitrectomy surgery. METHODS: A nationwide, multicenter, observational study in the Japan Retinal Detachment Registry was done. From February 2016 to March 2017, 3446 cases were registered, and 3219 among them were analyzed. The factors related to the patient or surgeon were selected; the surgeon's factor included years of experience, number of cases registered, and current activity. The odds ratio (OR) for factors associated with SB or PPV was estimated by a mixed logistic regression model. RESULTS: SB was selected in 24.2% (779/3219), PPV was in 71.5% (2238/3219), and PPV+SB was in 6.3% (202/3219). Multivariate analysis showed that age [< 70 years old, OR 4.27, 95% confidence interval (CI) 2.34-7.79, P < 0.001], visual acuity [1.0+ (OR 7.41, 95% CI 3.47-15.82, P < 0.001)], pseudo-phakia (OR 4.83, 95%CI 2.11-10.56, P < 0.001), retinal tear (OR 6.92, 95% CI 4.83-9.92, P < 0.001), breaks at/near the vitreous base (OR 8.07, 95% CI 3.50-18.62, P < 0.001), 90+° retinal tear (OR 108.24, 95% CI 7.44-1574.34, P < 0.001), and number of breaks 4+ (OR 3.15, 95% CI 1.95-5.09, P < 0.001), were significantly associated with selecting PPV over SB. The surgeons' activity defined as the number of cases experienced during the registry period was related to the selection of PPV (OR 3.83, 95% CI 2.11-6.93, P < 0.001). CONCLUSIONS: The choice of PPV for the RRD was associated not only with patients' preoperative factors but also the surgeon's activity. Active surgeons selected PPV more than SB.

Soft shell technique during vitrectomy for proliferative vitreoretinopathy.

PURPOSE: To determine whether ophthalmic viscoelastic devices (OVDs) can be used during vitrectomy to prevent perflorocarbon liquid (PFCL) from leaking into the subretinal space through retinal tears in eyes with proliferative vitreoretinopathy (PVR). The OVDs are adhesive materials that can temporally close retinal breaks. We introduce a "soft shell technique", which allows the unfolding of the retina by PFCL. METHODS: We studied five eyes of five patients with proliferative vitreoretinopathy that underwent vitrectomy using the soft shell technique. After removing the core vitreous, the OVDs were carefully injected over the area where confluent retinal folds were formed with possible retinal breaks. This created a soft shell shield on the retina that can prevent the intravitreal PFCL from leaking into the subretinal space. RESULTS: The soft shell technique still allowed the PFCL to unfold the retina even if iatrogenic breaks are present. The high viscosity of OVDs sealed the iatrogenic retinal breaks and thus prevented the PFCL from leaking into the subretinal space during the vitrectomy. All patients had an improvement of the visual acuity, and four eyes had a reattachment of the retina. CONCLUSIONS: Although only five eyes were examined, the success of the soft shell technique indicates that it can be used with PFCL, which facilitates the unfolding of the contracted retina.

AMOUNT OF RESIDUAL SILICONE OIL IN VITREOUS CAVITY IS SIGNIFICANTLY CORRELATED WITH AXIAL LENGTH.

PURPOSE: To determine the parameters of the eye that are significantly correlated with the amount of residual silicone oil remaining after most of it is removed by vitrectomy. METHODS: Nineteen eyes of 19 patients who had silicone oil removed were studied. The day after the surgery for silicone oil removal, B-scan ultrasonography was performed, and the residual silicone oil droplets were observed as hyperechoic particles in the ultrasonographic images. The images of the vitreous cavity were binarized, and the ratio of area of hyperechoic particles to the total vitreous area was quantified and named the silicone oil index (SOI). The correlations between SOI and clinical findings were determined. RESULTS: The SOI was significantly and positively correlated with the axial length (AL) and the preoperative intraocular pressure (AL, R = 0.676, P = 0.002; preoperative intraocular pressure, R = 0.771, P < 0.001). Partial correlation analysis showed that the AL remained significantly correlated with the SOI but the preoperative intraocular pressure was not (AL, R = 0.734, P = 0.001; preoperative intraocular pressure, R = 0.417, P = 0.096). None of the other clinical factors was significantly correlated with the SOI. CONCLUSION: Considering the significant correlation between the amount of residual silicone oil and the AL of the eye, myopic eyes should be carefully scrutinized for residual silicone oil.

Individualized, spectral domain-optical coherence tomography-guided facedown posturing after macular hole surgery: minimizing treatment burden and maximizing outcome.

PURPOSE: To evaluate the individualized, optical coherence tomography-guided facedown posturing after macular hole (MH) surgery in minimizing the burden and maximizing outcome. METHODS: A retrospective comparative study. One hundred and seven consecutive eyes with an MH (<500 µm) received vitrectomy and gas tamponade. After surgery, optical coherence tomography examination was performed from 6 hours to postoperative Day 2. In Group A, with a pro re nata posturing protocol, the duration of facedown posturing was determined from the optical coherence tomography findings. Group A was subdivided as follows: Group A1, facedown posturing required postoperatively and Group A2, no posturing required. When MH closure was confirmed, facedown posturing (if any) was discontinued. If the MH did not close, additional posturing was advised. Group B was the control group, consisted of 42 consecutive eyes with traditional 7 days of posturing. RESULTS: After a single surgery, Group A had the MH closure rate of 96.2%, 95.8% in Group A1 and 97.1% in Group A2, whereas Group B had the MH closure rate of 95.2%. The average posturing period was 42 hours for Group A, 57 hours for Group A1 and 10 hours for Group A2 (P < 0.001). The MH size was correlated significantly with the closure time (R = 0.47, P = 0.005, Spearman correlation coefficient). CONCLUSION: A pro re nata posturing protocol achieves a high MH closure rate with a significant reduction of posturing time especially for pseudophakic eyes.

Early imaging of macular hole closure: a diagnostic technique and its quality for gas-filled eyes with spectral domain optical coherence tomography.

BACKGROUND/AIMS: This study was conducted to establish a reliable method to determine macular hole (MH) closure of gas-filled eyes. METHOD: 21 consecutive eyes with MH underwent vitrectomy with gas tamponade, and spectral domain optical coherence tomography (SD-OCT) was performed using our diagnostic technique. The quality of OCT images was rated as signal strength (SS) and evaluated by masked observers. RESULTS: The quality to determine MH closure (SS ≥4) was sufficient in all eyes. In addition, SD-OCT images (SS ≥6) obtained from 16/21 eyes showed detailed retinal structures including the inner segment/outer segment line. The next day after surgery, MH closure was confirmed in 12/21 eyes, and residual MH was observed in 9/21 eyes. Among these 9 eyes, 7 eyes were closed within 2 weeks. CONCLUSION: The present method provided clear SD-OCT images from gas-filled eyes, which is not only essential for the diagnosis of MH closure but also for establishing proper protocols and for studying the pathology of gas-filled eyes.

DEVELOPMENT OF FOCAL CHOROIDAL EXCAVATION AFTER ANTIVASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY FOR POLYPOIDAL CHOROIDAL VASCULOPATHY.

PURPOSE: The purpose of this study was to describe a case of polypoidal choroidal vasculopathy, showing a newly developed focal choroidal excavation during a 4-year follow-up period with multiple intravitreal antivascular endothelial growth factor injections. METHODS: This study was a case report. RESULTS: A 64-year-old man was referred for treatment of age-related macular degeneration in his left eye. His corrected visual acuity at initial presentation was 20/20 in both the right and left eye. Optical coherence tomography of the left eye revealed a steep retinal pigment epithelial detachment and subretinal fluid, and indocyanine green angiography confirmed a polypoidal lesion, leading to the diagnosis of polypoidal choroidal vasculopathy with pachychoroid features. Thereafter, antivascular endothelial growth factor intravitreal injections were continued on a pro re nata basis. Two years after the initial presentation, the sharp pigment epithelial detachment began to shrink, and a novel focal choroidal excavation gradually emerged surrounding the pigment epithelial detachment with an inner choroidal layer attenuation. CONCLUSION: Multiple antivascular endothelial growth factor injections for polypoidal choroidal vasculopathy resulted in atrophy of the polypoidal lesion and a decrease in the blood flow in the adjacent inner choroidal vasculature, leading to the formation of a novel focal choroidal excavation.

Comparison of foveal microstructure imaging with different spectral domain optical coherence tomography machines.

PURPOSE: To investigate the reproducibility of imaging the foveal microstructures of healthy eyes with 3 spectral domain optical coherence tomography (SD-OCT) machines: Cirrus (Carl Zeiss Meditec Inc.), Spectralis (Heidelberg Engineering), and Topcon (Topcon 3D OCT-1000 Mark II). DESIGN: Cross-sectional, prospective, noninterventional study. PARTICIPANTS: Images were obtained for 50 eyes of 50 healthy undilated volunteers without ocular pathology in a clinical setting. METHODS: The fovea of all subjects was imaged using Cirrus, Spectralis, and Topcon. MAIN OUTCOME MEASURES: Among the 4 hyperreflective bands in the outer subfovea on SD-OCT imaging, the innermost band (external limiting membrane [ELM] band), the second innermost band (second band), and the third innermost band (third band) were classified as "continuous," "disrupted," or "none" by 2 independent raters. Weighted κ-coefficient analysis and/or Fisher exact test were used to compare interrater, intermachine, and intramachine agreement measurements. The sensitivity of each machine was also evaluated. RESULTS: The group of 50 subjects consisted of 22 men and 28 women, with an average age of 31.4 years (range, 21-52 years). Interrater agreement for 3 bands was high (κ = 0.876, 0.738, and 0.774) with Cirrus, Spectralis, and Topcon, respectively. The sensitivity of each machine was high for the ELM band (0.92, 0.98, and 0.96), the second band (all 1.00), and the third band (0.96, 0.94, and 0.88) with Cirrus, Spectralis, and Topcon, respectively. The sensitivity of the third band was significantly lower than the second band with Topcon (Fisher exact test, P = 0.027), but the difference was not significant with the other machines. Intermachine agreement was fair to moderate for the third band (κ = 0.65, 0.512, and 0.464) and for all bands (κ = 0.531, 0.369, and 0.362) between Cirrus-Spectralis, Spectralis-Topcon, and Topcon-Cirrus, respectively; however, it was not significant for ELM band (κ = -0.027) between Spectralis-Topcon. CONCLUSIONS: In healthy adults with normal vision, there was almost perfect reproducibility between raters for foveal microstructural images acquired with the Cirrus, Spectralis, and Topcon devices. The machines have good sensitivity to image foveal microstructures, and the sensitivity does not differ significantly among machines; however, they are not necessarily identical or interchangeable for imaging certain structures.

Early diagnosis of macular hole closure of a gas-filled eye with Watzke-Allen slit beam test and spectral domain optical coherence tomography.

PURPOSE: The purpose of this study was to evaluate the usefulness of the Watzke-Allen slit beam test (W/A test) and spectral domain optical coherence tomography (SD-OCT) for diagnosing macular hole closure in gas-filled eyes during the early postoperative period. METHODS: A retrospective comparative study was performed on 40 consecutive eyes of 40 patients with macular hole treated with vitrectomy. Macular hole closure was initially judged within 2 days after surgery with both the W/A test and SD-OCT. Final diagnosis was confirmed with SD-OCT after the gas disappeared. The concordance rate of initial diagnosis and final diagnosis using each method was evaluated. RESULTS: The W/A test could be done for the gas-filled eyes of all patients next day, whereas a diagnosable SD-OCT image could be obtained in 77.5% of patients. The concordance rate was 85% (34of 40 examined eyes) with the W/A test and 77.5% (31 of 40 examined eyes) with SD-OCT (P = 0.39, chi-square test). If a diagnosable result (image or response) could be obtained within 2 days after surgery, the accuracy of SD-OCT (31 of 31 eyes) was significantly better than that of the W/A test (31 of 40 eyes) (P = 0.026, chi-square test). CONCLUSION: The W/A test is more useful for diagnosing macular hole closure of a gas-filled eye than SD-OCT; however, SD-OCT gives more accurate information when diagnosable. Combining both methods could improve the accuracy and applicability.

Effect of surgeon-related factors on outcome of retinal detachment surgery: analyses of data in Japan-retinal detachment registry.

The purpose of this study was to investigate the effects of surgeon-related factors on the surgical outcome of pars plana vitrectomy (PPV) and scleral buckling (SB) surgery on eyes with a rhegmatogenous retinal detachment (RRD). This was a nationwide, multicenter, observational study of the data in the Japan-RD Registry. Registered cases that had undergone surgery for a RRD by 128 accredited surgeons in 26 institutions were studied. The surgeon-related factors that significantly affected surgical success and visual outcomes of simple RRD treated by PPV or SB at 6 months postoperatively were analyzed and compared. Among 3446 registered cases, 2533 cases met the inclusion criteria with 1896 in the PPV group and 637 cases in the SB group. The median total number of lifetime cases was 150 and the rate of surgeries/year was 22. Multivariate regression analyses showed that the number and rate of surgeries/year were not significantly associated with the surgical outcome in the PPV group. However, surgeons with a higher average annual number of surgeries had significantly better surgical outcomes in the SB group (P = 0.038). Analyses of a nationwide registry showed that SB but not PPV surgeries require sufficient experience and case numbers to acquire and maintain skills to treat RRDs successfully.

Visual outcomes after surgery for primary rhegmatogenous retinal detachment in era of microincision vitrectomy: Japan-Retinal Detachment Registry Report IV.

BACKGROUND/AIM: To determine the preoperative ocular factors and surgical methods that led to best-corrected visual acuity (BCVA) after pars plana vitrectomy (PPV) or scleral buckling (SB) for rhegmatogenous retinal detachment (RRD). METHODS: This was a prospective, nationwide, multicentre, observational study. Data from the Japanese Retina and Vitreous Society registry from 2016 to 2017 were used to determine the association between preoperative clinical factors, surgical procedures and postoperative BCVA at 6 months. Japanese individuals >40 years of age were included. Eyes with proliferative vitreoretinopathy were included. The primary outcome was the percentage of eyes that achieved 20/25 vision. RESULTS: Of the 3219 registered cases, 2192 met the inclusion criteria (344 SB, 1738 PPV, 110 PPV+SB). Cases with preoperative BCVA (≤0 logarithm of the minimum angle of resolution (logMAR) units) had good postoperative BCVA (OR=3.97, CI 2.87 to 5.51). Older age (>70 years), low intraocular pressure (<10 mm Hg), high myopia (<-5 dioptres), multiple retinal breaks (>4), giant retinal tear (>90°), wide retinal detachment (>3 quadrants) and macula-off detachment were associated with less probability of postoperative 20/25 vision (OR=0.39, 0.64, 0.62, 0.60, 0.12, 0.51 and 0.36, respectively). Postoperative BCVA was 0.03±0.23 and 0.10±0.32 logMAR units after SB and PPV, respectively. The percentage of cases that achieved 20/25 vision was not significantly different after PPV or SB if cases that had concurrent cataract surgery were excluded (p=0.251). CONCLUSIONS: Better BCVA in patients with RRD who had undergone PPV was observed. However, if concurrent cataract surgery is not performed, BCVA will be comparable with either PPV or SB.

Intraocular expression and release of high-mobility group box 1 protein in retinal detachment.

High-mobility group box 1 (HMGB1) protein is a multifunctional protein, which is mainly present in the nucleus and is released extracellularly by dying cells and/or activated immune cells. Although extracellular HMGB1 is thought to be a typical danger signal of tissue damage and is implicated in diverse diseases, its relevance to ocular diseases is mostly unknown. To determine whether HMGB1 contributes to the pathogenesis of retinal detachment (RD), which involves photoreceptor degeneration, we investigated the expression and release of HMGB1 both in a retinal cell death induced by excessive oxidative stress in vitro and in a rat model of RD-induced photoreceptor degeneration in vivo. In addition, we assessed the vitreous concentrations of HMGB1 and monocyte chemoattractant protein 1 (MCP-1) in human eyes with RD. We also explored the chemotactic activity of recombinant HMGB1 in a human retinal pigment epithelial (RPE) cell line. The results show that the nuclear HMGB1 in the retinal cell is augmented by death stress and upregulation appears to be required for cell survival, whereas extracellular release of HMGB1 is evident not only in retinal cell death in vitro but also in the rat model of RD in vivo. Furthermore, the vitreous level of HMGB1 is significantly increased and is correlated with that of MCP-1 in human eyes with RD. Recombinant HMGB1 induced RPE cell migration through an extracellular signal-regulated kinase-dependent mechanism in vitro. Our findings suggest that HMGB1 is a crucial nuclear protein and is released as a danger signal of retinal tissue damage. Extracellular HMGB1 might be an important mediator in RD, potentially acting as a chemotactic factor for RPE cell migration that would lead to an ocular pathological wound-healing response.

Vitreous mediators after intravitreal bevacizumab or triamcinolone acetonide in eyes with proliferative diabetic retinopathy.

PURPOSE: To evaluate vitreous vascular endothelial growth factor (VEGF), stromal cell-derived factor 1alpha (SDF-1alpha), interleukins (ILs), and tumor necrosis factor-alpha (TNF-alpha) after intravitreal bevacizumab or triamcinolone acetonide (TA) in eyes with proliferative diabetic retinopathy (PDR). DESIGN: Interventional, consecutive, retrospective, comparative study with a historical control. PARTICIPANTS: Forty-seven eyes of 47 patients affected by active PDR were investigated. Bevacizumab (1.25 mg; 19 eyes; bevacizumab group) or TA (4 mg; 10 eyes; TA group) was injected into the vitreous cavity as preoperative adjunctive therapy 7 days before vitrectomy. Eighteen eyes without injection served as controls (control group). METHODS: The vitreous samples were obtained at vitrectomy and were analyzed for concentrations of total protein, VEGF, SDF-1alpha, IL-1beta, IL-6, IL-8, IL-10, IL-12p70, and TNF-alpha. MAIN OUTCOME MEASURES: Vitreous concentrations of VEGF, SDF-1alpha, ILs, and TNF-alpha were compared among bevacizumab, TA, and control groups. RESULTS: Vitreous concentrations of VEGF and SDF-1alpha were lower in bevacizumab and TA groups compared with the control group. The median VEGF level was 0 pg/ml (range, 0-79.2 pg/ml) in the bevacizumab group, 343.5 pg/ml (range, 0-1683.3 pg/ml) in the TA group, and 1202.5 pg/ml (range, 76-4213.9 pg/ml) in the control group. The median SDF-1alpha level was 149.2 pg/ml (range, 0-519.4 pg/ml) in the bevacizumab group, 87.5 pg/ml (range, 0-252.5 pg/ml) in the TA group, and 245.7 pg/ml (range, 0-856.8 pg/ml) in the control group. The differences in both vitreous VEGF and SDF-1alpha concentrations among 3 groups were statistically significant (P<0.001 and P = 0.010, respectively). The eyes with intravitreal bevacizumab demonstrated the lowest vitreous level of VEGF, and the level was statistically significant compared with the eyes with intravitreal TA and control eyes (P<0.001 and P<0.001, respectively). The control eyes had the highest vitreous level of SDF-1alpha, and the level was statistically significant compared with the eyes with intravitreal bevacizumab and TA (P = 0.015 and P = 0.009, respectively). There was no significant difference regarding ILs and TNF-alpha. CONCLUSIONS: Intravitreal injection of bevacizumab potentially diminishes not only VEGF but also SDF-1alpha. These findings suggest that intravitreal bevacizumab may influence intraocular mediators beyond VEGF. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Polylactic acid for visualizing the vitreous body during vitrectomy.

PURPOSE: To investigate the possibility of using polylactic acid (PLA) as a surgical adjuvant for visualizing the vitreous body during vitrectomy. METHODS: After a core vitrectomy, 1 mL of PLA suspension was injected into the rabbit vitreous in two groups: group A, 2.5% PLA (n = 5), and group B, 1% PLA (n = 9). Vehicle injection instead of PLA was used as a control (group C, n = 5). The clinical signs and electroretinogram (ERG) were evaluated for 28 days, and histologic findings were evaluated on day 28. Next, intraocular pressure (IOP) after intracameral injection of a PLA suspension was evaluated in the rabbits (n = 6). Last, the visualization of the vitreous body by PLA suspension was evaluated during vitrectomy in monkey eyes (n = 4). RESULTS: The white granules of PLA disappeared from the vitreous cavity in 10 eyes within 3 weeks; however, a small amount of PLA remained in four eyes for 4 weeks. Mild inflammation of the anterior chamber was observed in one eye in group B and 1 eye in group C. No cataract or retinal hemorrhage was found in any eyes. The amplitude of ERG on each time point did not differ between the groups. IOP remained within normal range except for the initial spike. Retinal structure was well preserved histologically. During vitrectomy in monkey eyes, the vitreous body was well visualized, and the posterior vitreous separation was performed easily and safely. CONCLUSIONS: PLA can be a new surgical adjuvant to visualize the vitreous body during vitrectomy.

Reduced incidence of intraoperative complications in a multicenter controlled clinical trial of triamcinolone in vitrectomy.

PURPOSE: To evaluate the benefits and potential complications of using triamcinolone acetonide (TA) in pars plana vitrectomy (PPV). DESIGN: Multicenter, prospective, controlled clinical trial. PARTICIPANTS: In total, 774 patients from 8 Japanese hospitals were enrolled, with 391 patients undergoing TA-assisted PPV and 383 control patients undergoing conventional PPV. INTERVENTION: Intraoperative use of TA to aid visualization of the vitreous. MAIN OUTCOME MEASURES: The incidence of intraoperative complications, including retinal breaks, was evaluated. Early postoperative complications, intraocular pressure (IOP), and adverse events occurring within 3 months of the operation were also monitored. RESULTS: The incidence of both retinal breaks and intraoperative retinal detachment was significantly lower in TA-assisted PPV than in conventional PPV. Retinal breaks were seen in 34 eyes (8.7%) undergoing TA-assisted PPV compared with 54 eyes (14.1%) undergoing conventional PPV (odds ratio [OR], 0.603; 95% confidence interval [CI], 0.381-0.955; P = 0.031). Retinal detachment was seen in only 3 eyes (0.8%) in which TA was used compared with 14 eyes (3.7%) in which TA was not used (OR, 0.204; 95% CI, 0.057-0.727; P = 0.014). In total, 388 eyes in the TA-assisted PPV group (99.2%) and 374 eyes in the conventional PPV group (97.6%) were followed up for 3 months after the operation. Although the mean postoperative IOPs were comparable in both groups, antiglaucoma eye drops were used more frequently by patients in the TA-assisted group than by those in the conventional PPV group (OR, 1.673; 95% CI, 1.126-2.484; P = 0.011). No serious adverse events, such as endophthalmitis or retinal degeneration, were observed in either group. CONCLUSIONS: Intraoperative use of TA reduced the incidence of retinal breaks and retinal detachments in eyes undergoing PPV. There were no serious adverse events related to the intraoperative use of TA. Although antiglaucoma eye drops were required more frequently after TA-assisted PPV than after conventional PPV, IOP was well-controlled in both groups.

Stromal-derived factor-1 and inflammatory cytokines in retinal vein occlusion.

PURPOSE: To identify the roles of stromal-derived factor (SDF-1) and inflammatory cytokines in retinal vein occlusion (RVO). METHODS: Samples were collected by vitrectomy and the levels of SDF-1, vascular endothelial growth factor, and inflammatory cytokines (interleukins [IL-1beta, IL-6, IL-8, IL-10, IL-12p70]; tumor necrosis factor-alpha) were measured in 20 eyes with RVO, and 9 eyes with epiretinal membrane served as negative controls. Four eyes with inflammatory diseases were also investigated. RESULTS: SDF-1 levels in active RVO (A-RVO; 4 eyes with iris neovascularization) were significantly higher than those in quiescent RVO (Q-RVO; 16 eyes without iris neovascularization) and the negative controls (p < .01), whereas there were no significant difference between the Q-RVO and the negative controls. There were no significant correlations between the concentrations of SDF-1 and other cytokines. CONCLUSIONS: Elevation of intravitreous SDF-1 levels in A-RVO but not Q-RVO suggested a pivotal role of SDF-1 in angiogenic changes during RVO.