The learning curve for primary vitrectomy without scleral buckling for pseudophakic retinal detachment.

BACKGROUND: To assess the functional and anatomical outcome of primary vitrectomy without scleral buckling for rhegmatogenous retinal detachment (RRD) in pseudophakic patients and to present the learning curve for this surgery in less experienced surgeons. METHODS: We reviewed the charts of pseudophakic patients treated with primary vitrectomy without scleral buckling for a rhegmatogenous retinal detachment with PVR

Eubacterial PCR for bacterial detection and identification in 100 acute postcataract surgery endophthalmitis.

PURPOSE: To evaluate eubacterial PCR compared with conventional cultures for detection and identification of bacterial agents in ocular samples from patients with acute postcataract endophthalmitis. METHODS: Broad-range eubacterial PCR amplification was used, followed by direct DNA sequencing in ocular samples (aqueous humor, vitreous samples from tap or vitrectomy) from 100 consecutive patients presenting with acute postcataract endophthalmitis. Bacterial cultures were performed on the same ocular samples by using traditional methods (brain-heart infusion broth). RESULTS: At the time of admission, the detection rate was not significantly different between cultures and PCR (38.2% for cultures versus 34.6% for PCR in aqueous humor samples; 54% versus 57% in vitreous from a vitreous tap). In contrast, in the vitreous obtained from vitrectomy, after intravitreous injection of antibiotics, PCR detected bacteria in 70% of the cases, compared with 9% in cultures. By combining PCR and cultures, bacterial identification was obtained in 47% of aqueous humor samples at admission, in 68% of vitreous samples from a vitreous tap at admission, and in 72% of vitreous samples from pars plana vitrectomy. Gram-positive bacteria predominated (94.3%). The concordance between cultures and PCR was 100%. The contamination rate was 2%. CONCLUSIONS: Cultures and eubacterial PCR are complementary techniques for bacterial identification in eyes with acute postcataract endophthalmitis. PCR technique was needed for identification of the involved microbial pathogen in 25% of all the cases. Eubacterial PCR is more effective than cultures in detecting bacteria in vitreous samples from patients with previous intravitreous administration of antibiotics.

Comparison of face-down and seated position after idiopathic macular hole surgery: a randomized clinical trial.

PURPOSE: To compare two therapeutic modalities on anatomic and functional results after idiopathic macular hole (MH) surgery: seated vs face-down position. DESIGN: Multicenter, prospective, randomized trial. SETTING: University Hospital Dijon and University Hospital Nancy. PATIENTS: One hundred and forty-four patients (150 eyes) were enrolled and randomly separated into two groups for postoperative position: for the 72 eyes in the P0 group and the 78 eyes in the P1 group, the patients were asked to keep the seated (P0 group) and the face-down position (P1 group) after the idiopathic MH surgery. INTERVENTION: All patients underwent a complete vitrectomy with a fluid-air exchange and an intraocular gas tamponade. After the surgery, patients were asked to keep one of the two randomly chosen positions for five days. MAIN OUTCOME MEASURES: Best-corrected visual acuity (VA), fundus examination, and macular optical coherence tomography were performed before and six months after surgery. RESULTS: The overall anatomic success rate was 92.7%. The idiopathic MH sealed in 63 of 72 P0 eyes (87.5%) and 76 of 78 P1 eyes (97.4%) (P = .027). The mean VA increased from 0.86 to 0.61 logMAR (0.88 to 0.61 in P0 and 0.84 to 0.60 in P1). However, in a post hoc analysis based on the size of the idiopathic MH, the success rate in idiopathic MHs smaller than 400 microm was not influenced by the postoperative position (P = .47). CONCLUSIONS: A face-down postoperative position is highly recommended in holes larger than 400 microm. The size of the idiopathic MH seems to be an important factor affecting outcome.

Incidence of retinal detachment after macular surgery: a retrospective study of 634 cases.

AIMS: To evaluate the rate of retinal detachment after macular surgery. METHODS: A retrospective non-randomised study of 634 macular surgery procedures was undertaken in two academic centres. Idiopathic macular hole (IMH) surgery (n = 272) and epiretinal membrane (ERM) surgery (n = 362) were performed between 2000 and 2003. We noted the anatomical and functional results of these procedures and we studied serious complications excluding cataract. RESULTS: Minimum follow up was 1 year. No retinal detachment (RD) occurred in patients presenting with an intraoperative or preoperative successfully treated retinal break (RB). The rate of RD occurring after IMH surgery was higher than after the ERM surgical procedure (6.6% vs 2.5%, p = 0.02). The rate of RD was higher in patients presenting with stage 2 and 3 IMH than with stage 4 IMH. However, lens status as well as preoperatively treated RD did not influence the rate of RD after macular surgery. CONCLUSION: Retinal detachment remains the most common serious complication of macular surgery. Surgical detachment of the posterior vitreous face and associated peripheral retina anomaly seem to increase the rate of this complication. Careful examination of the peripheral retina is a key issue in preventing retinal detachment occurring after macular surgery.

Corneal endothelial cell changes after trabeculectomy and deep sclerectomy.

PURPOSE: To compare the effect of trabeculectomy and deep sclerectomy on the corneal endothelium. METHODS: This prospective comparative study investigated 62 eyes of 62 patients scheduled for a single trabeculectomy (n=18), a single deep sclerectomy (n=14), a combined trabeculectomy and phacoemulsification (n=11), or a combined deep sclerectomy and phacoemulsification (n=19). Exclusion criteria were history of corneal disease, ocular trauma, inflammation, or previous glaucoma or cataract surgery. Preoperative, 3-month and 1-year postoperative noncontact specular microscopies were performed on central and superior corneas. Endothelial cells were counted with a computer-assisted analyzer. RESULTS: In central cornea, a statistically significant postoperative endothelial cell loss was found after trabeculectomy and deep sclerectomy (alone and combined with cataract extraction) at 3 and 12 months. Cell loss was 7% after penetrating surgery and 2.6% after nonpenetrating surgery (noncombined surgeries). This difference in cell loss was statistically significant. Cell loss increased significantly over the course of the study at 12 months (9.6% and 4.5%, respectively). Cell loss was also significantly higher after trabeculectomy than sclerectomy in upper cornea only in noncombined surgeries. No statistically significant difference in coefficient of variation of cell size (CV) and percentage of cell hexagonality (Hex %) was noted. CONCLUSIONS: Endothelial cell loss was moderate 3 and 12 months after glaucoma surgery. However, it was greater after trabeculectomy, suggesting less corneal damage after deep sclerectomy. This observation deserves further clinical study.

Differential mechanisms of conjunctival cell death induction by ultraviolet irradiation and benzalkonium chloride.

PURPOSE: To determine the molecular mechanisms of conjunctival cell death on exposure to the quaternary ammonium preservative benzalkonium chloride (BAC) and ultraviolet (UV) irradiation. METHODS: Chang conjunctival cells, either wild-type or stably transfected with various constructs encoding antiapoptotic molecules or transiently transfected with siRNA targeting the beclin-1 gene, were exposed to BAC or UV radiation Cell death was analyzed morphologically with fluorescence and electron microscopy, and molecular mechanisms of death were studied by using immunofluorescence, cell fractionation, caspase substrates, and immunoblot analysis, with or without immunoprecipitation. The main results were controlled in IOBA-NHC cells. RESULTS: Both agents induced cytochrome c release from the mitochondria, caspase activation, and nuclear chromatin condensation, suggesting caspase-dependent apoptosis. These events are prevented by stable expression of Bcl-2 protein. Both agents also induced a redistribution of Fas in plasma membrane rafts and the Fas-ligand-independent formation of a death-inducing complex leading to caspase-8 activation. Stable expression of either a dominant negative construct of Fas-associated death domain (FADD) or the long or short isoform of FADD-like interleukin-1-beta-converting enzyme inhibitory protein (FLIP) inhibited caspase-8 activation in response to both UV radiation and BAC. However, these proteins, as well as permeant peptides and baculovirus p35 caspase-inhibitors, delayed more efficiently the UV irradiation-induced than the BAC-induced nuclear chromatin condensation. BAC specifically activated a caspase-independent pathway by inducing the mitochondrial release of apoptosis-inducing factor. BAC-treated cells contain autophagosomes/autolysosomes, a characteristic feature of autophagy, and siRNA-mediated downregulation of the beclin-1 gene, whose product is crucial for autophagy, increases BAC toxicity. CONCLUSIONS: UV irradiation induces typical, caspase-dependent cell death, whereas death induced by BAC associates features of caspase-dependent and -independent apoptosis counteracted by an autophagic process.

Trefoil factor family mRNA and protein expression in pterygium.

Trefoil factor family (TFF) of proteins are involved in mucosal protection and healing and are induced in inflammatory diseases and neoplastic progression. The purpose of this investigation was to determine if expression of the trefoil factor family (TFF) proteins is altered in human pterygium compared to in normal conjunctiva. Fourteen pterygia (P) and 21 biopsies from normal human conjunctiva (NC) were studied. TFF1, TFF2 and TFF3 mRNA levels were measured by semi-quantitative reverse-transcription polymerase chain reaction (RT-PCR), and TFF1 mRNA levels in addition by real-time PCR. The cellular expression of TFF1 (pS2), TFF3 (intestinal trefoil factor) and M1/MUC5AC mucin in ten pterygia and ten normal human conjunctiva specimens was analyzed by immunohistochemistry using specific monoclonal antibodies. TFF1 mRNA levels were higher in P than in NC (p=0.02). Accordingly, intensity of TFF1 and mucin MUC5AC immunostaining was higher in P than in NC. Mucus-secreting goblet cells (GC) were more densely packed in P than in NC. In both cases, TFF1 protein was detected in GC only, but was not systematically expressed in all GC. In addition, TFF3 mRNA levels were similar (p=0.89) in NC and P, while TFF2 (spasmolytic polypeptide) mRNA were not detected. Both TFF3 and MUC5AC proteins were clearly detected in all GC identified in NC and P. Increased expression of TFF1 mRNA and protein is observed in pterygium GC, suggesting that this trefoil protein might exert protective and beneficial roles during the pathogenesis of this benign and inflammatory conjunctival tumor.

Idiopathic epiretinal macular membrane and cataract extraction: combined versus consecutive surgery.

PURPOSE: To assess the functional and anatomic outcomes of cataract and idiopathic epiretinal macular membrane extraction in combined and consecutive surgeries. DESIGN: Multicenter, retrospective, comparative case series. METHODS: One hundred seventy-four patients (174 eyes) with an epiretinal macular membrane (ERM) and cataract were operated on in 1 or 2 sessions in 2 academic centers, Dijon University Hospital and Nancy University Hospital. Combined surgery (n = 109) and consecutive surgery (n = 65) were performed between 2005 and 2006. All patients underwent ERM and internal limiting membrane removal. Cataract extraction was performed with phacoemulsification followed by a posterior chamber intraocular lens implantation. The main outcome measures were near and far visual acuity and central macular thickness evaluated with optical coherence tomography. RESULTS: After a 12-month follow-up, the postoperative best-corrected visual acuities significantly improved in both the combined and the consecutive surgery groups (near and far vision in both groups, P < .0001). Similarly, the postoperative macular thickness significantly decreased in both groups (P < .0001). We noted no statistical differences between the visual acuity improvement in both groups (near vision, P= .54; far vision, P = .38). However, visual acuity recovery was quicker in the combined surgery group. CONCLUSIONS: Combined and consecutive surgeries are effective procedures to treat idiopathic ERM. The functional and anatomic results are equivalent in both procedures.

Trefoil factor TFF1-induced protection of conjunctival cells from apoptosis at premitochondrial and postmitochondrial levels.

PURPOSE: Goblet cells of the conjunctival epithelium synthesize and secrete TFF1 (Trefoil factor 1), a small protease-resistant peptide that, together with mucins, is responsible for the rheologic properties of the tear film. This study aimed to determine whether TFF1, whose synthesis increases in inflammatory conditions such as pterygium, could protect conjunctival cells from apoptosis. METHODS: Chang conjunctival cells, either wild-type or expressing TFF1 through stable transfection, were exposed to benzalkonium chloride (BAK) and ultraviolet (UV) irradiation to trigger apoptosis. The authors used cell fractionation to detect lipid raft-associated proteins, coimmunoprecipitation to explore the formation of a death-inducing signaling complex (DISC), and a combination of immunofluorescence, immunoblotting, flow cytometry, siRNA-mediated decrease in gene expression, and electrophoretic mobility shift assay to explore the mechanisms of TFF1-protective effects. RESULTS: TFF1 protects Chang conjunctival cells from apoptosis induced by UV irradiation and BAK at two levels. First, TFF1 prevents caspase-8 activation at the level of the DISC that involves Fas receptor in plasma membrane rafts, which in turn decreases the mitochondrial release of cytochrome c. Second, TFF1 interferes with caspase-9 and caspase-3 activation through an NF-kappaB-induced increase in the expression of XIAP (X-linked inhibitor of apoptosis protein). CONCLUSIONS: TFF1 upregulation on inflammatory conditions may be a protective mechanism that limits conjunctival cell loss by inhibiting apoptosis upstream and downstream of the mitochondrial events. These observations suggest a potential interest of TFF1 or related peptides to prevent cell death in ocular surface disorders.

Microbiologic identification of bleb-related delayed-onset endophthalmitis caused by moraxella species.

PURPOSE: To report the clinical presentation and outcome of delayed-onset endophthalmitis caused by Moraxella species and to evaluate the eubacterial polymerase chain reaction (PCR) in aqueous humor samples for the microbiologic diagnosis. PATIENTS AND METHODS: Seven patients with bleb-related delayed onset-endophthalmitis caused by Moraxella were included in a prospective multicenter study (FRIENDS group, 2004 to 2005). Eubacterial PCR followed by direct sequencing and conventional cultures were carried out on aqueous humor samples taken before the first intravitreal antibiotic injection and on vitreous samples taken during pars plana vitrectomy. RESULTS: All cases were postoperative (5 after filtering surgery and 2 inadvertent filtering blebs). The mean delay of onset of endophthalmitis was 41.3 months+/-30.4 (SD) (range, 2.4 to 84.8) after surgery. Initial visual acuity was limited to light perception for 3 patients, hand motions for 2 patients, count fingers for 1 patient, and 20/125 for 1 patient. Functional recovery was variable with final visual acuity ranging from no light perception to 20/25. The eubacterial PCR carried out on aqueous humor provided microbiologic identification in all cases, whereas the cultures were negative in 6 of 7 cases. The eubacterial PCR performed on vitreous samples of 3 vitrectomized patients, after 2 intravitreal injections of antibiotics, identified Moraxella in 2 patients, whereas cultures were negative in all cases. CONCLUSIONS: Delayed-onset endophthalmitis caused by Moraxella occurs predominantly after a bleb-related infection. PCR is a more sensitive technique for the microbiologic diagnosis in this context than conventional culture.