PERSISTENT SUBRETINAL FLUID AFTER VITRECTOMY FOR MACULAR HOLE-ASSOCIATED RETINAL DETACHMENT.

PURPOSE: To evaluate the incidence, associated factors, and outcome of persistent subretinal fluid (SRF) after vitrectomy for macular hole-associated retinal detachment (MHRD). METHODS: A total of 158 eyes from 156 patients with MHRD who achieved macular hole closure after primary vitrectomy were included in the analysis; persistent SRF was defined as the presence of SRF for more than 1 month after first surgery. Preoperative and postoperative parameters were analyzed for their relationship with SRF development. RESULTS: Persistent SRF was observed in 19 eyes (12.0% of 158) postoperatively. Seven eyes (36.8% of 19) with persistent SRF eventually displayed complete absorption during follow-up. Univariate analysis revealed that eyes with persistent SRF were statistically associated with internal limiting membrane inverted flap, duration of symptoms, tamponade (perfluoropropane/silicone oil: 14/5 vs. 35/104, P < 0.001), and MHRD subtype (Type 1/Type 2/Type 3: 15/4/0 vs. 60/40/39, P = 0.003). In multivariate analysis, only internal limiting membrane inverted flap (odds ratio, 15.778, 95% confidence interval, 3.170-78.523; P = 0.001) was positively associated with persistent SRF. There were no significant differences in best-corrected visual acuity improvement ( P = 0.425) between the SRF involved foveal and without involved foveal groups and no significant differences between the SRF complete absorption and incomplete absorption groups. CONCLUSION: Absorption of persistent SRF may be more difficult in MHRD eyes than in ordinary rhegmatogenous retinal detachment eyes. The internal limiting membrane inverted flap in MHRD was associated with a greater likelihood of persistent SRF. The location and incomplete absorption of persistent SRF did not seem to be associated with the final visual outcome.

Vitrectomy for retinal detachment associated with macular hole: Prognostic factor analysis under different axial length conditions.

PURPOSE: To identify prognostic factors for complete anatomical success (CAS) under different axial length (AL) conditions after vitrectomy plus internal limiting membrane (ILM) peeling for retinal detachment associated with macular hole (MHRD). METHODS: This retrospective study included 243 patients (251 eyes) with MHRD who underwent primary vitrectomy plus ILM peeling. Multivariate logistic regression explored prognostic factors for CAS in AL <30 mm and ≥ 30 mm groups. RESULTS: Overall, 113 eyes (45.0% of 251) exhibited complete CAS after initial surgery. Eyes with CAS had greater best-corrected visual acuity improvement than eyes without CAS (p < 0.001). CAS was more common in eyes with AL < 30 mm (50.3% of 155) than in eyes with AL ≥ 30 mm (36.5%, 35/96; p = 0.032). In the AL < 30 mm group, CAS was associated with ILM insertion (odds ratio [OR], 2.824, 95% confidence interval [CI], 1.189-6.710; p = 0.019), silicone oil (SO)/perfluoropropane (C3F8) tamponade (SO: OR, 0.408, 95% CI, 0.191-0.873; C3F8: OR, 2.448, 95% CI, 1.145-5.234; p = 0.021) and staphyloma (OR, 0.318, 95% CI, 0.143-0.707; p = 0.005). In the AL ≥30 mm group, CAS was associated with ILM insertion (OR, 11.621, 95% CI, 2.557-52.813; p = 0.001), SO /C3F8 tamponade (SO: OR, 5.305, 95% CI, 1.206-23.334; C3F8: OR, 0.188, 95% CI, 0.043-0.829; p = 0.027) and age (OR, 0.928, 95% CI, 0.876-0.983; p = 0.011). CONCLUSION: Vitrectomy plus ILM peeling can effectively treat MHRD but has limited efficacy in eyes with AL ≥ 30 mm. ILM insertion was associated with more frequent CAS at any AL. C3F8 tamponade yielded better outcomes with AL < 30 mm; SO tamponade yielded better outcomes with AL ≥ 30 mm.

Nomogram for predicting non-proliferative vitreoretinopathy probability after vitrectomy in eyes with rhegmatogenous retinal detachment.

AIM: To identify the risk factors for postoperative proliferative vitreoretinopathy (PVR) in patients with primary rhegmatogenous retinal detachment (RRD) and develop a nomogram for predicting postoperative PVR-free probability. METHODS: A total of 741 patients (741 eyes) diagnosed with primary RRD who underwent first surgery in the same hospital were retrospectively reviewed and randomly assigned with 521 to the training set and 220 to the validation set. Univariate and multivariate logistic regression analyses were performed in the training cohort to determine risk factors to construct a nomogram for predicting the 3-, 4-, 5-, and 6-month postoperative PVR-free probabilities. Nomogram performance was estimated by the concordance index (C-index), calibration plot, and the area receiver operating characteristic (ROC) curve. RESULTS: A nomogram was constructed based on the preoperative PVR, silicone oil tamponade time (SOTT), photocoagulation energy (PE), retinal tear size (RTS), and hypertension. In the training set, the C-index of the nomogram was 0.896, 0.936, 0.961, and 0.972 at 3, 4, 5, and 6mo, respectively. The C-index values in the validation set were 0.860, 0.936, 0.951, and 0.965 at 3, 4, 5, and 6mo, respectively. Decision-curve analysis indicated that only the 4-, 5-, and 6-month nomograms had significant net benefits over a large threshold probabilities interval. CONCLUSION: Preoperative PVR, SOTT, PE, RTS, and hypertension are significant risk factors for postoperative PVR formation in patients with primary RRD. The proposed nomogram can effectively predict the 4-, 5-, and 6-month PVR-free probabilities after surgery and assist in making clinical decisions during follow-up.

Risk factors for epiretinal membrane in eyes with primary rhegmatogenous retinal detachment that received silicone oil tamponade.

BACKGROUND/AIMS: This study investigated the risk factors for epiretinal membrane (ERM) in eyes with primary rhegmatogenous retinal detachment (RRD) that received silicone oil (SO) tamponade. METHODS: This retrospective analysis included 1140 patients (1140 eyes) with RRD who underwent primary vitrectomy and SO tamponade. The prevalence of ERM was estimated and possible risk factors (eg, type 2 diabetes, proliferative vitreoretinopathy (PVR), SO tamponade time (SOTT), photocoagulation, vitreous haemorrhage, choroidal detachment, cryotherapy and retinal tear size) were analysed via multiple logistic regression. RESULTS: The prevalence of ERM was 12.3% (140/1140), and the accuracy of preoperative ERM diagnosis was 40.5%. Multivariate logistic regression analysis showed that risk factors for ERM in eyes with SO tamponade included preoperative PVR (OR=4.336, 95% CI 2.533 to 7.424, p<0.001), type 2 diabetes (OR=3.996, 95% CI 2.013 to 7.932, p<0.001), photocoagulation energy (OR=1.785, 95% CI 1.306 to 2.439, p<0.001) and SOTT (OR=1.523, 95% CI 1.261 to 1.840, p<0.001). No statistically significant associations were observed between the incidence of ERM and other risk factors. Preoperative PVR showed the strongest association with risk of ERM. The risk of ERM was positively associated with SOTT, photocoagulation energy and preoperative PVR grade. CONCLUSION: In eyes with RRD that received SO tamponade, the prevalence of ERM was 12.3%, while the accuracy of preoperative ERM diagnosis was low. Preoperative PVR, type 2 diabetes, photocoagulation energy and SOTT were the main risk factors for ERM.

Clinical features, surgical outcomes and genetic analysis of ectodermal dysplasia with ocular diseases.

AIM: To report on the clinical features, surgical outcomes and gene mutation analysis of three ectodermal dysplasia probands with ocular diseases. METHODS: A case-note review of three unrelated probands diagnosing with ectodermal dysplasia with ocular diseases was undertaken. Patient clinical features and the outcomes of surgery were analysed. The suspected pathogenic genes were analysed by whole exome sequencing from patients with ectodermal dysplasia and Sanger sequencing from family members. RESULTS: The ocular clinical features of ectodermal dysplasia with ocular diseases mainly include eyelid ectropion, lagophthalmos and absence of lacrimal punctum. All the probands underwent surgeries of full-thickness free skin flap grafting to correct ectropion. They achieved good recovery, and there were no obvious complications during the follow-up. The gene sequencing results did not show any meaningful genetic mutations. CONCLUSION: Lid ectropion is one of the key clinical traits of ectodermal dysplasia with ocular diseases. Ectropion correction with full-thickness free skin flap grafting is an effective procedure to correct ectropion for ectodermal dysplasia patients with ichthyosis-like tissue. The suspected pathogenic genes of ectodermal dysplasia with ectropion should be further verified or confirmed by large samples of the family.

Outcomes of a novel bubble ultra-wide field viewing system for vitreoretinal surgery.

PURPOSE: To report the clinical outcomes and evaluate the efficacy of a novel bubble ultra-wide field viewing system for vitreoretinal surgery. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: One hundred and fifty-one eyes of 146 consecutive patients with proliferative diabetic retinopathy (PDR), vitreous haemorrhage originating from retinal vein occlusion (VH-RVO), epiretinal membrane (EM), macular hole (MH) or retinal detachment (RD) who underwent vitreoretinal surgery using the bubble ultra-wide field viewing system were included. METHODS: A standard phacoemulsification was performed on each patient. Core humour and mid-peripheral vitreous humour were removed using a planoconcave lens. A suitably sized bubble was infused to attach to the posterior capsule or the anterior chamber depending on the integrity of the posterior capsule. The planoconcave lens and the air bubble formed the wide-angle viewing system, through which peripheral vitrectomy was performed. MAIN OUTCOME MEASURES: Range of applications, field of view, model validation and complications were recorded. RESULTS: The new ultra-wide field viewing system was successfully applied in all eyes, including 34 with PDR, 28 VH-RVO, 28 EM, 25 MH and 36 RD. Peripheral vitrectomy, local or panretinal laser photocoagulation, and removal of the peripheral proliferative membrane were successfully performed while viewing through this system. Maximum peripheral retinal area observable during the procedure was positively correlated with pupil diameter. Model analysis results showed that when the pupil diameter was 6 mm, the maximum field of view was approximately 128.1- 148.0 degrees with this system. Of 142 eyes, the main intraoperative complication was iatrogenic retinal breaks (IRBs) in 8 eyes (5.3%) and posterior capsule injury by vitreous cutter during bubble removal in 6 eyes (4.2%). The postsurgery mean best-corrected visual acuity (BCVA) (0.48 ± 0.39 logMAR) was significantly improved compared with the preoperative mean BCVA (1.60 ± 1.08 logMAR, p < 0.001). No incidents of postoperative choroidal detachment, secondary glaucoma or endophthalmitis were recorded. CONCLUSIONS: For patients with lens excision or absence, vitreoretinal surgery can be successfully performed using the novel viewing system described here. The system is a safe, convenient and economical ultra-wide field viewing system with a wide range of applications.

Removal of sticky silicone oil adhered to the retinal surface: comparison of methodological safety and effectiveness.

PURPOSE: To compare safety and effectiveness among methods to remove sticky silicone oil bubbles adhered to the retinal surface. METHODS: This retrospective nonrandomised case series included 14 eyes of 14 patients who had sticky silicone oil residue during silicone oil removal surgery. For small sticky silicone oil bubbles (< 2-disc diameter), aspiration was performed with a 23-gauge vitreous cutter. Residual tiny oil bubbles were then removed with a silicone-tipped flute needle or internal limiting membrane (ILM) peeling. For large sticky silicone oil bubbles (≥ 2-disc diameter) that could not be removed with a 23-gauge vitreous cutter, we devised a more efficient active removal method involving a modified 22-gauge venous indwelling cannula device. RESULTS: The mean preoperative best-corrected visual acuity (BCVA; logarithm of the minimum angle of resolution [logMAR]) significantly improved from 1.28 ± 0.63 logMAR to 0.77 ± 0.58 logMAR (p = 0.014). The postoperative BCVA and improvement in BCVA were significantly better in the ILM peeling group than in the non-ILM peeling group (p = 0.004 and p = 0.045, respectively). Postoperative complications included residual sticky silicone oil bubbles in seven eyes without ILM peeling (50.0%), retinal neuroepithelial layer damage in two eyes (14.3%), and temporary hypotony in five eyes (35.7%). CONCLUSION: Various methods can safely and efficiently remove sticky silicone oil bubbles adhered to the retinal surface. A 22-gauge venous indwelling cannula enabled simple and safe removal of large sticky silicone oil bubbles, while small residual sticky silicone oil bubbles could be completely removed by ILM peeling.

Thymic Stromal Lymphopoietin-Related Allergic Pathway in Patients With Vernal Keratoconjunctivitis.

PURPOSE: To investigate the expression of thymic stromal lymphopoietin (TSLP) and the relevant signaling pathways in the giant papillae obtained from patients with vernal keratoconjunctivitis (VKC) and to study the potential functional role and molecular mechanism of TSLP. METHODS: Giant papillae from VKC patients and control samples were used to perform immunohistochemical staining and analyze the mRNA expression of TSLP and related pathway by real-time polymerase chain reaction. RESULTS: TSLP was markedly expressed in the epithelial cells and some inflammatory cells of giant papillae, but not in the control conjunctival tissue. TSLP mRNA expression in the giant papillae of VKC was increased by 9.63 ± 0.99 (mean ± SD) fold compared with controls (P < 0.01). CD11c and OX40L immunoreactive cells largely infiltrated the giant papillae as observed by immunohistochemical staining. CD4Th2 cell infiltration was observed through high immunoreactivity of CD4. Th2 cytokines (IL-4, IL-5 and IL-13) and OX40 in the VKC specimens showed increased expression. Augmented gene expression levels of CD4 (6.88 ± 1.84), OX40L (7.60 ± 1.79), OX40 (7.25 ± 1.38), IL-4 (6.89 ± 1.46), IL-5 (8.42 ± 1.55), and IL-13 (9.69 ± 1.94) were significantly different from controls (P < 0.05). CONCLUSIONS: Our observations provide strong evidence that TSLP may be a crucial factor that contributes to the development and progression of allergic conjunctivitis. The results also demonstrated that TSLP activates dendritic cells to prime CD4T cells to differentiate into Th2 type and triggers Th2-dominant allergic inflammation through the TSLP/OX40L/OX40 signaling as part of immunopathogenesis of VKC.

Foveal microstructure and visual outcomes of myopic macular hole surgery with or without the inverted internal limiting membrane flap technique.

PURPOSE: The aim of this study was to determine the effect of the inverted internal limiting membrane (ILM) flap technique on the macular hole (MH) closure and foveal microstructure recovery of patients with highly myopic MH. METHODS: Pars plana vitrectomy and gas tamponade with the inverted ILM flap technique (19 eyes) or with the ILM peeling technique (21 eyes) were performed in patients with highly myopic MH with or without retinal detachment. The rate of MH closure and retinal reattachment, the reconstructive anatomical change of the foveal microstructure and the best-corrected visual acuities (BCVA) of the two groups were compared. RESULTS: The anatomic closure rate was statistically significantly higher in the inverted group (100%) than in the peeling group (66.7%; p=0.009). All eyes with MH retinal detachment had successful retinal reattachment in these two groups. However, the rate of the external limiting membrane (ELM) and ellipsoid zone (EZ) (p=0.020), as well as gliosis (p=0.049) in macular area, detected by OCT, was significantly greater in the inverted group than in the peeling group. The postoperative BCVA was significantly better in the eyes with ELM, EZ (p=0.031) and gliosis (p=0.008), but without hyperreflective foci (p=0.001). CONCLUSIONS: These findings demonstrate that the inverted ILM flap technique has better efficacy than the ILM peeling technique for patients with myopic MH in closure rate, foveal microstructure and postoperative BCVA.

Conjunctival myxoid stromal tumour: a distinctive clinicopathological and immunohistochemical study.

BACKGROUND/AIMS: To describe the clinicopathological and immunohistochemical characteristics of 10 patients representing a new entity of benign conjunctival myxoid stromal tumours. METHODS: Retrospective review of clinical findings, histopathological and immunohistochemical studies identified 10 cases of low-grade conjunctival myxoid stromal tumours. Specimens were routinely processed and stained with H&E. Immunohistochemical stains for CD34, CD68, vimentin, S100, smooth muscle actin (SMA), myosin, desmin, actin, Bcl-2 and Ki-67 were performed. Specific stains for Alcian-blue periodic acid-Schiff (AB-PAS) and aldehyde fuchsin stains were also performed. RESULTS: Ten patients with an average age of 45.6±11.1 years had a tender white or faint yellow to red mass on the bulbar conjunctiva. All the lesions were completely removed, and none of the patients relapsed. Histologically, all neoplasms consisted of spindle-shaped cells that showed signs of pseudonuclear inclusions, multinuclear cells and had no atypia. The stroma consisted of a large amount of mucus and was infiltrated with delicate to ropey collagens, a few mast cells and new vessels. Immunohistochemical stains were positive for CD34, vimentin and Bcl-2; partial positive for CD68; very low for Ki-67; and negative for S100, SMA, myosin, desmin and actin. AB-PAS suggested that the stroma was mucinous. CONCLUSIONS: These rare benign mesenchymal conjunctival tumours are mostly unilateral and occur in the bulbar conjunctiva. Complete resection is the radical treatment. These lesions are characterised by multiple spindle cells, a large amount of mucus, and sharing similar basic histopathological features with conjunctival myxoma and conjunctival stromal tumour. We suggest naming these lesions 'conjunctival myxoid stromal tumours'.

Cauterization technique for suture erosion in transscleral fixation of intraocular lenses.

Transscleral suturing is a commonly applied technique to fix intraocular implants in the sulcus. A major problem after transscleral implantation is suture erosion that normally happens in the late post-surgery period and may result in an increased incidence of endophthalmitis. Here we describe an original cauterization method by using a glass rod to melt the exposed suture end without damaging the suture knot in the sclera to avoid suture exposure in sclera-fixed IOL implantation. This is a simple, quick and effective technique that can be performed without conjunctiva incisions and will help to reduce suture erosion related complications.

Clinicopathological features and surgical treatment of intratarsal keratinous cysts.

PURPOSE: To explore the clinical and histopathologic features and surgical outcome of intratarsal keratinous cyst (IKC). METHODS: The clinical findings, histopathologic evaluations, and immunohistochemical studies in 15 cases of IKC were investigated, retrospectively. RESULTS: Fifteen patients with an average age of 44.7 years had noninflamed eyelid cysts sized 1-6 mm in diameter. The cysts appeared as solid, whitish opalescent or yellow-white, mildly elevated lesions beneath the palpebral conjunctiva. The cysts embedded in the tarsus were completely excised with a portion of the adjacent tarsus by a surgical procedure through palpebral conjunctival approach. Histopathologic evaluations revealed stratified squamous epithelium linings and keratin contents, which were not identical to the common epidermal or epidermoid cysts. The results were negative for Alcian blue and periodic acid-Schiff staining and showed positive correlation to the immunoreaction for epithelial membrane antigen. No recurrence occurred in all patients who had their lesions removed completely. CONCLUSIONS: Our study revealed the clinical and pathological characteristics of IKC, including the absence of inflammatory sign, lesion partially embedded in the tarsus and protruding beneath the conjunctiva with the intracystic keratinous contents, stratified squamous epithelium linings, string-like keratin contents from the histopathology sections, and strongly immunoreactivity to antibodies against epithelial membrane antigen. A complete excision of cysts with adjacent tarsectomy by transconjunctival approach was proved to be an effective treatment for prevention of recurrence.

Surgical management of silicone oil migrated into suprachoroidal space after vitrectomy.

AIM: To report a successful surgical management of silicone oil migrated into suprachoroidal space after the repair of the retinal detachment with hemorrhagic choroidal detachment. METHODS: Retrospective observational case report. A 30-year-old man with retinal detachment and hemorrhagic choroidal detachment due to severe corneal penetrating injury, underwent a pars plana lensectomy and vitrectomy, endolaser, and silicone oil tamponade followed by transscleral suprachoroidal hemorrhage drainage in the right eye. One week later, a localised temporal choroid elevation was noted. This persistent elevation was confirmed by operation research to be silicone oil migration into suprachoroidal space. RESULTS: The migrated silicone oil was drained via trans-scleral cut down, and the intravitreal silicone oil was removed and replaced by 16% C2F6. Over the next 2 weeks, the elevation vanished and the choroid became completely flat. CONCLUSION: The migration of silicone oil into suprachoroidal space is a rare complication of vitrectomy. The pathway of the migration is most likely through internal orifice of sclerotomy sites. Trans-scleral drainage surgery is an effective method to remove the migrated silicone oil from suprachoroidal space.