Retinoschisis associated with optic nerve pits. 1988.

Stereoscopic transparencies studied with magnification and projection suggest that the retinal elevation that communicates with optic pits is frequently a schisislike separation of the internal layers of retina. Thirteen of 15 eyes with optic pits and maculopathy fit the schisis pattern. Separation of the outer layers of the retina is a secondary phenomenon that starts in the macula.

Surgical techniques for repair of primary retinal detachment: Part II. Comparison of present techniques in relation to morbidity.

PURPOSE: To compare present surgical techniques for repair of primary retinal detachment. AIM of each technique is closing the retinal break(s), but the approach is either extraocular (e.o.) with scleral buckling or intraocular (i.o.) with pneumatic retinopexy or vitrectomy. The results are similar ranging between 94% and 99% attachment, however, the difference lies in their morbidity and socioeconomic implications which will be compared. MATERIAL AND METHODS: Literature of cerclage, minimal segmental buckling, pneumatic retinopexy and primary vitrectomy are reviewed for anatomical results, postoperative PVR, new breaks, reoperation and secondary complications jeopardizing regained visual acuity. RESULTS: All 4 surgical approaches for repair of a primary retinal detachment, i.e., e.o. or i.o. procedures, have one common premise for sustained success: To find and close the break(s). This is so whether the surgery is limited to the break or extending over the entire detachment or whether it is performed as an e.o. or i.o. procedure. At present the i.o. procedures still harbour a 6-fold higher risk of postoperative PVR and 2.5-fold of reoperation. The recent SPR Study confirms that in a phakic eye postoperative visual function is statistically significant better after scleral buckling than after primary vitrectomy. CONCLUSION: Since the results after the 4 major techniques for reattaching the retina are similar, therefore, the selected procedure has to fulfill 4 postulates: (1) Retinal attachment with 1 operation, (2) it should harbour a minimum of morbidity, (3) be performed on a small budget and under local anesthesia, (4) it should provide long-term visual function, not jeopardized by secondary complications.

A 50-year review of minimal extraocular surgery for retinal detachment: five hurdles had to be overcome for its acceptance.

The non-drainage segmental buckling procedure by Custodis for repair of a retinal detachment harboured serious postoperative complications. To amend this new technique to a minimal extraocular surgery with practically no intra- nor postoperative complications, four hurdles had to be overcome: diathermy was replaced by cryosurgery, polyviol plombe by the silicone sponge, eight rules were defined to find the break in a primary retinal detachment or in an eye up for reoperation and a subsequent 15-year follow-up of anatomical and functional results confirmed that minimal extraocular surgery for repair of retinal detachment suffices for optimal long-term results without harbouring secondary complications threatening regained visual acuity.

Intravitreal bevacizumab versus triamcinolone acetonide for exudative age-related macular degeneration.

BACKGROUND: To compare an intravitreal high-dose injection of triamcinolone acetonide with an intravitreal injection of bevacizumab for the treatment of progressive exudative age-related macular degeneration (AMD). METHOD: The comparative nonrandomized retrospective clinical interventional study included 305 patients with progressive AMD, divided into a bevacizumab group of 36 patients (1.5 mg bevacizumab) and a triamcinolone group of 269 patients (about 20 mg triamcinolone). All patients were consecutively included, in the first phase of the study for triamcinolone, and in the second phase of the study for bevacizumab. The mean follow-up was 8.5+/-6.8 months (2-35.7 months). RESULTS: In the bevacizumab group, best visual acuity increased significantly (p<0.001) by 3.2+/-3.4 Snellen lines, with 25 (69%) eyes and 21 (58%) eyes, improving by at least 2 and 3 Snellen lines, respectively. In the triamcinolone group, the visual acuity change was not statistically significant for any specific follow-up examination within the first 3 months. The maximal increase in visual acuity, the visual acuity change at 2 months after injection and the percentage of patients with an improvement by at least 2 and 3 Snellen lines were significantly (p<0.001) higher in the bevacizumab group than in the triamcinolone group. Intraocular pressure increased significantly (p<0.001) in the triamcinolone group and did not change significantly (p=0.47) in the bevacizumab group. CONCLUSION: In exudative AMD, intravitreal bevacizumab (1.5 mg) compared with intravitreal triamcinolone acetonide (about 20 mg) results in a higher improvement of visual acuity and does not markedly influence intraocular pressure within 2 months after injection.

Surgical techniques for repair of primary retinal detachment: part I. Review of their development during the last 80 years.

OBJECTIVE: To analyse the evolution of surgical approaches to repairing primary rhegmatogenous retinal detachment and the issues which had determined the changes starting from 1929 to the present. MATERIAL AND METHODS: Literature of retinal detachment surgery during the past 80 years is reviewed. There was a change from surgery of the entire retinal detachment to surgery limited to the retinal break and a change from extraocular (e.o.) to intraocular (i.o.) surgery to achieve retinal reattachment. RESULTS: All four surgical approaches to the repair of a primary retinal detachment have still one common premise for sustained success: finding and closing the retinal break which caused the retinal detachment and which would cause a redetachment, if not sealed off sufficiently. This is regardless of whether the surgery is limited to the area of the break or extends over the entire detachment, as well as whether it is performed as an e.o. or i.o. procedure. CONCLUSION: Finding and closing the leaking retinal break in a primary detachment once and for all have accompanied the efforts of retinal detachment surgeons like a red thread over the past 80 years and are still the premises for sustained reattachment. However, four postulates will have to be fulfilled: (1) Retinal reattachment should be achieved with only a single operation, (2) the surgery should have a minimum of morbidity, (3) it should not cause secondary complications jeopardizing regained visual acuity during subsequent years, and (4) the surgery should be performed on a small budget and under local anesthesia.

Intravitreal triamcinolone acetonide for treatment of intraocular proliferative, exudative, and neovascular diseases.

Within the last three years, triamcinolone acetonide has increasingly been applied intravitreally as treatment option for various intraocular neovascular edematous and proliferative disorders. The best response in terms of gain in visual acuity after the intravitreal injection of triamcinolone acetonide was found in eyes with intraretinal edematous diseases such as diffuse diabetic macular edema, branch retinal vein occlusion, central retinal vein occlusion, and pseudophakic cystoid macular edema. Visual acuity increased and degree of intraocular inflammation decreased in eyes with various types of non-infectious uveitis including acute or chronic sympathetic ophthalmia and Adamantiadis-Behcet's disease. Intravitreal triamcinolone may be useful as angiostatic therapy in eyes with iris neovascularization and proliferative ischemic retinopathies. Possibly, intravitreal triamcinolone may be helpful as adjunct therapy for exudative age-related macular degeneration, possibly in combination with photodynamic therapy. In eyes with chronic, therapy resistant, ocular hypotony, intravitreal triamcinolone can induce an increase in intraocular pressure and may stabilize the eye. The complications of intravitreal triamcinolone therapy include secondary ocular hypertension in about 40% of the eyes injected, cataractogenesis, postoperative infectious and non-infectious endophthalmitis, and pseudo-endophthalmitis. Intravitreal triamcinolone injection can be combined with other intraocular surgeries including cataract surgery. Cataract surgery performed some months after the injection does not show a markedly elevated rate of complications. If vision increases and eventually decreases again after an intravitreal triamcinolone acetonide injection, the injection can be repeated. The duration of the effect of a single intravitreal injection of triamcinolone depended on the dosage given. Given in a dosage of about 20mg to non-vitrectomized eyes, the duration of the effect and of the side-effects was 6-9 months. Intravitreal triamcinolone acetonide may offer a possibility for adjunctive treatment of intraocular edematous and neovascular disorders. One has to take into account the side-effects and the lack of long-term follow-up observations.

Infectious and noninfectious endophthalmitis after intravitreal high-dosage triamcinolone acetonide.

PURPOSE: To evaluate the rate of infectious and noninfectious endophthalmitis after intravitreal injection of a high-dosage of triamcinolone acetonide. DESIGN: Clinical interventional case-series study. METHODS: The study included 1135 intravitreal injections of approximately 20 mg triamcinolone performed for 915 eyes with diabetic macular edema (n = 257), exudative age-related macular degeneration (n = 561), retinal vein occlusions (n = 82), and other reasons. Among the injections were 220 reinjections. Triamcinolone was filtered to remove the solvent agent. Mean follow-up was 8.1 +/- 7.4 months. RESULTS: In none of the eyes, signs of an infectious or noninfectious endophthalmitis were observed such as noncrystalline hypopyon, cellular infiltration, or amorphous opacification of the vitreous, retinal infiltration, or pain. One patient developed infectious endophthalmitis 2 days after a traumatic rupture of a previous corneoscleral cataract incision. CONCLUSIONS: The rate of infectious or noninfectious endophthalmitis after an intravitreal high-dosage triamcinolone injection may be approximately 1:1000, if the solvent agent was removed.

Duration of the effect of intravitreal triamcinolone acetonide in eyes with exudative age-related macular degeneration.

OBJECTIVE: The aim of this study was to evaluate the duration of the effect of an intravitreal injection of approximately 20 mg of triamcinolone acetonide (TA) on visual acuity and intraocular pressure (IOP) in patients with exudative age-related macular degeneration (AMD) with subfoveal choroidal neovascularization. PARTICIPANTS: The prospective, clinical, interventional, case series study included 69 patients (71 eyes) with exudative AMD who showed an increase in visual acuity by at least 2 Snellen lines after an intravitreal injection of approximately 20 mg TA. Mean follow-up was 11.5 +/- 7.4 months (3.3-35.7 months). The main outcome measure was visual acuity. RESULTS: Within the first week after the injection, visual acuity and IOP started to increase significantly (P < 0.001) by reaching a plateau-like maximum at 1-6 months after the injection. Visual acuity and IOP returned to baseline values 7-9 months after the injection. Increase of IOP was statistically (P = 0.72) independent of the change in visual acuity. CONCLUSIONS: In patients with exudative AMD, who have shown an increase of at least 2 Snellen lines in visual acuity, the effect of intravitreal TA (dosage approximately 20 mg) lasts 7-9 months with respect to an increase in visual acuity and IOP.

Primary retinal detachment: A review of the development of techniques for repair in the past 80 years.

BACKGROUND/PURPOSE: The evolution of present surgical techniques for reattaching a primary retinal detachment will be reviewed starting from 1929, and the present techniques analyzed in regard to their morbidity, reoperation, and long-term visual function. METHODS: Literature of retinal detachment operations during the past 80 years is reviewed, of which the author has first-hand experience during the past 40 years. There had been a change from surgery of the entire detachment to a surgery limited to the retinal break and a change from extraocular to intraocular surgery. RESULTS: The four major operations for repair of a primary retinal detachment in use at the beginning of the 21st century, have still one thing in common for sustained reattachment: to find and close the break that caused the primary retinal detachment and that would cause a redetachment, if not sealed completely. This is independent of whether the surgery is limited to the break or extends over the entire detachment and the same is true whether the surgery is performed as an extraocular or intraocular procedure. CONCLUSION: To find and close sufficiently the break in a primary retinal detachment has accompanied the efforts of retinal detachment surgeons during the past 80 years. This is still the premise for sustained reattachment. However, today four postulates have to be fulfilled: (1) retinal reattachment with the first operation; (2) the procedure should have a minimum of morbidity; (3) the procedure should not harbor secondary complications jeopardizing regained visual acuity; and (4) the procedure should be performed on a small budget with local anesthesia.

Intraocular pressure elevation after intravitreal triamcinolone acetonide injection.

PURPOSE: To report on intraocular pressure (IOP) after intravitreal injections of triamcinolone acetonide. DESIGN: Meta-analysis of previously reported data and case series studies. PARTICIPANTS: The study included 272 patients (305 eyes) receiving an intravitreal injection of approximately 20 mg triamcinolone acetonide as treatment for diffuse diabetic macular edema (n = 84 patients), exudative age-related macular degeneration (n = 181 patients), retinal vein occlusions (n = 20 patients), uveitis (n = 9), pseudophakic cystoid macular edema (n = 6), and other reasons (n = 5). Mean follow-up was 10.4+/-6.7 months (median, 7.9 months; range, 3.0-35.7 months). INTERVENTION: Intravitreal injection of approximately 20 mg triamcinolone acetonide. MAIN OUTCOME MEASURE: Intraocular pressure. RESULTS: Intraocular pressure readings higher than 21 mmHg, 30 mmHg, 35 mmHg, and 40 mmHg, respectively, were measured in 112 (41.2%) patients, 31 (11.4%) patients, 15 (5.5%) patients, and 5 (1.8%) patients, respectively. Triamcinolone-induced IOP elevation was treated by antiglaucoma medication in all but 3 (1.0%) eyes, for which filtering surgery was performed. Mean IOP started to rise 1 week after injection and returned to baseline values approximately 8 to 9 months after injection. Younger age (P = 0.029) was significantly associated with triamcinolone-induced ocular hypertension. Triamcinolone responders and triamcinolone nonresponders did not vary significantly in gender (P = 0.42), refractive error (P = 0.86), diabetes mellitus status (P = 0.74), and reason for treatment. CONCLUSIONS: These findings may be useful for comparing risks and benefits of intravitreal triamcinolone acetonide therapy.

Predictive factors for visual acuity after intravitreal triamcinolone treatment for diabetic macular edema.

OBJECTIVE: To evaluate which factors influence maximum gain in best-corrected visual acuity after intravitreal injection of triamcinolone acetonide as treatment for diffuse diabetic macular edema. METHODS: This prospective clinical interventional study included 53 eyes with diffuse diabetic macular edema receiving an intravitreal injection of about 20 mg of triamcinolone. The mean +/- SD follow-up was 10.2 +/- 7.6 months. RESULTS: In a multiple linear regression analysis, maximum gain in best-corrected visual acuity after the intravitreal injection of triamcinolone was significantly (P < .001) and negatively correlated with an increased degree of macular ischemia and a higher preoperative visual acuity. Improvement in best-corrected visual acuity was significantly and positively correlated with increased degree of macular edema (P = .001). Change in best-corrected visual acuity after the intravitreal triamcinolone injection was statistically independent (P > .15) of age, sex, pseudophakia, and macula grid laser treatment before inclusion into the study. The results were comparable for gain in visual acuity at 6 months after the injection. CONCLUSION: Pronounced macular edema may have a positive impact, and marked macular ischemia and a high preoperative best-corrected visual acuity may have a negative impact, on an increase in best-corrected visual acuity after intravitreal triamcinolone injection in patients with diabetic macular edema.

Intravitreal injection of triamcinolone for diffuse diabetic macular edema.

OBJECTIVE: To evaluate the clinical outcome of an intravitreal injection of triamcinolone acetonide as treatment of diffuse diabetic macular edema. PARTICIPANTS: This prospective, interventional, clinical case series study included 20 patients (26 eyes) who received an intravitreal injection of 25 mg of triamcinolone acetonide for treatment of diffuse diabetic macular edema. Mean +/- SD follow-up time was 6.64 +/- 6.10 months. The study group was compared with a control group of 16 patients who underwent macular grid laser coagulation. MAIN OUTCOME MEASURES: Visual acuity and intraocular pressure. RESULTS: In the study group, visual acuity improved significantly (P<.001), from 0.12 +/- 0.08 at baseline to a maximum of 0.19 +/- 0.14 during follow-up. Seventeen (81%) of 21 eyes with a follow-up period of more than 1 month had improved visual acuity. In the control group, visual acuity did not change significantly. In the study group, intraocular pressure increased significantly (P<.001), from 16.9 +/- 2.5 mm Hg to a mean maximal value of 21.3 +/- 4.7 mm Hg, and decreased significantly (P =.03) to 17.7 +/- 4.7 mm Hg at the study's end. CONCLUSION: Intravitreal injection of 25 mg of triamcinolone acetonide may be beneficial for improving visual acuity in patients with clinically significant diffuse diabetic macular edema.

Intravitreal reinjection of triamcinolone for exudative age-related macular degeneration.

OBJECTIVE: To evaluate the outcome of repeated intravitreal injections of triamcinolone acetonide for the treatment of exudative age-related macular degeneration. METHODS: This prospective, comparative nonrandomized clinical interventional study included 13 patients with progressive exudative age-related macular degeneration with occult, or predominantly occult, subfoveal neovascularization. All patients had shown an increase or stabilization of visual acuity after a first intravitreal injection of 25 mg of triamcinolone acetonide. They received a second intravitreal injection of 25 mg of triamcinolone acetonide 3.1 to 18 months after the first injection. Mean +/- SD follow-up time after the second injection was 5.2 +/- 3.6 months (median, 5.3 months). A control group included 24 patients with exudative age-related macular degeneration who did not receive treatment for their maculopathy. The main outcome measures were visual acuity and intraocular pressure. RESULTS: In the study group, mean +/- SD visual acuity increased significantly (P =.005 and P =.003, respectively) from 0.17 +/- 0.11 to 0.32 +/- 0.26 and from 0.15 +/- 0.14 to 0.23 +/- 0.19, respectively, after the first and second injections. An increase in visual acuity was found for 10 patients (77%) after the first and second injections. In the control group, visual acuity did not vary significantly during follow-up (P =.81). The difference in change in visual acuity between the study group and control group was significant (P =.01 [Snellen lines] and P =.05 [logMAR units]). The peak in visual acuity and, in a chronologically parallel manner, the peak in intraocular pressure elevation occurred 2 to 5 months after each injection. CONCLUSIONS: Repeated intravitreal injection of 25 mg of triamcinolone acetonide may lead to an increase in visual acuity in patients with exudative age-related macular degeneration, with the peak in visual acuity and intraocular pressure elevation occurring about 2 to 5 months after each injection.

A modified laser test for the identification of retinoschisis.

PURPOSE: To describe a modified laser technique for identification of bullous retinoschisis. DESIGN: Retrospective interventional case series collected over 10 years. METHODS: Forty-one eyes with presumed bullous retinoschisis and breaks in the inner layers underwent a low-energy argon green laser application at the same energy as a control spot in adjacent retina. A gray response in the outer layers equal to the control spot was diagnostic of retinoschisis. RESULTS: The laser test was positive for retinoschisis in 40 of 41 eyes. In none of the 40 eyes did the elevation progress. CONCLUSIONS: A low-energy argon green laser application through a break in the inner layers of presumed retinoschisis eliminates the attenuation of the beam and can confirm retinoschisis.

Intravitreal triamcinolone acetonide for pseudophakic cystoid macular edema.

PURPOSE: To report the clinical outcome of patients undergoing intravitreal injection of triamcinolone acetonide as treatment of long-standing cystoid macular edema after phacoemulsification. DESIGN: Prospective clinical interventional cases series studies. METHODS: The study included five patients suffering from cystoid macular edema after cataract surgery. They received an intravitreal injection of 25-mg crystalline triamcinolone acetonide transconjunctivally with topical anesthesia. RESULTS: In the follow-up period of 6.6 +/- 4.1 months, visual acuity increased from 0.26 +/- 0.13 to a mean maximal visual acuity of 0.60 +/- 0.19. For all patients, visual acuity improved during the follow-up by at least 0.20. Two (40%) patients developed intraocular pressure values higher than 21 mm Hg, which could be controlled by topical antiglaucomatous treatment. CONCLUSIONS: Intravitreal triamcinolone acetonide may be a therapeutic option for long-standing cystoid macular edema after cataract surgery.

Safety of intravitreal high-dose reinjections of triamcinolone acetonide.

PURPOSE: To report side effects after intravitreal high-dose reinjections of triamcinolone acetonide. DESIGN: Clinical interventional case series. METHODS: Forty-six patients (47 eyes) received at least two intravitreal injections of approximately 20 to 25 mg triamcinolone acetonide for treatment of diabetic macular edema (n = 6 eyes), exudative age-related macular degeneration (n = 23), and other diseases. Intervals between injections were 6.7 +/- 3.4 months, 8.0 +/- 4.6 months, and 10.2 months, respectively, before the second (n = 47 eyes), third (n = 9), and fourth (n = 2) injection. Mean follow-up was 20.7 +/- 8.9 months. RESULTS: After no reinjection were complications detected, other than those known to occur after a single intravitreal injection. After the first, second, and third injection, respectively, intraocular pressure remained normal in 24 (51%), 25 (53%), and 5 (56%) eyes. CONCLUSIONS: Intravitreal high-dosage reinjections of triamcinolone acetonide may be tolerated within a mean follow-up of approximately 21 months.

Duration of the effect of intravitreal triamcinolone acetonide as treatment for diffuse diabetic macular edema.

PURPOSE: To evaluate the duration of the effect of intravitreal triamcinolone acetonide on visual acuity in patients with diffuse diabetic macular edema. DESIGN: Clinical interventional case series. METHODS: Subjects were 31 patients (38 eyes) with diffuse diabetic macular edema who received an intravitreal injection of 20- to 25-mg triamcinolone acetonide. Mean follow-up time was 13.2 +/- 6.0 months (6.03-25.2 months). RESULTS: Visual acuity and intraocular pressure began to increase significantly (P =.003) within the first week, reaching a plateaulike maximum at 1 to 7 months postinjection, returning to baseline values 8 to 9 months postinjection. CONCLUSIONS: The effect of an intravitreal injection of approximately 20- to 25-mg triamcinolone acetonide in patients with diffuse diabetic macular edema lasts approximately 7 to 8 months. This information may be helpful in determining the optimal dosage of intravitreal triamcinolone acetonide for the treatment of diffuse diabetic macular edema.