Silicone Oil Tamponade for Therapy of Primary Retinal Detachment in Patients Who Live at High Altitudes.

BACKGROUND: Uncomplicated rhegmatogenous retinal detachment (RRD) is mainly treated with vitrectomy and gas tamponade or, alternatively, scleral buckling surgery. However, gas tamponade inflates at high altitudes, causing significant complications. Silicone oil (SO) tamponade volume is unaffected by atmospheric pressure and may be used in patients who live or must undertake travel at high altitudes. PURPOSE: To determine the anatomical and functional outcomes after pars plana vitrectomy (PPV) with SO tamponade in primary uncomplicated RRD. METHODS: Twenty-eight consecutive cases of patients operated between January 2017 and December 2022 in Jules-Gonin University Eye Hospital in Lausanne were included in this retrospective study. All patients had a follow-up of at least 3 months after SO removal. RESULTS: Primary reattachment was achieved in all 28 eyes. Mean follow-up was 17.2 months (range: 3 - 51 months) after SO removal. Mean age at the time of intervention was 60 years (range: 21 - 80 years). Vision was stabilized or improved in 27 eyes (96%). One patient demonstrated a slight visual acuity decrease due to cataract formation at the last follow-up. In all patients, SO was removed 2 to 5 months after primary repair. In 14 of the 21 phakic patients, concomitant cataract surgery was performed. No surgical complications were encountered. Postoperatively, 5 (18%) patients had ocular hypertension, presumably steroid related, that was successfully controlled with topical treatment. CONCLUSION: PPV with SO injection seems to be a safe and efficient surgical approach in the treatment of primary uncomplicated RRD in patients living at high altitudes and was associated with good anatomical and functional outcome in our series. However, the need for a follow-up surgery to remove SO should be weighed in these cases.

INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE FOR MACULAR HOLE COEXISTENT WITH RHEGMATOGENOUS RETINAL DETACHMENT.

PURPOSE: To report the clinical features and treatment outcomes of patients with macular hole coexistent with rhegmatogenous retinal detachment surgically treated with pars plana vitrectomy and inverted internal limiting membrane flap technique. METHODS: Eleven consecutive patients with rhegmatogenous retinal detachment and macular hole who underwent vitrectomy and internal limiting membrane peeling with the inverted flap technique between December 2017 and February 2021 were retrospectively evaluated. The main outcome measures were retinal reattachment rate, macular hole closure rate, and postoperative best-corrected visual acuity. A nonsystematic literature review was performed to compare the study outcomes with those previously reported. RESULTS: The primary retinal reattachment rate was 90% (10/11) with one surgery and 100% with 2 surgical procedures. Macular hole closure was achieved in all patients (11/11). All patients showed an improvement in visual acuity at the final postoperative visit, and the mean postoperative best-corrected visual acuity was 0.60 ± 0.32 logarithm of the minimum angle of resolution (20/80 Snellen equivalent). CONCLUSION: Vitrectomy with the inverted internal limiting membrane flap technique achieved not only favorable anatomical retinal reattachment rates but also an encouraging recovery of central macular anatomy and visual function in patients with macular hole coexistent with rhegmatogenous retinal detachment.

Simultaneous Management of Retinal Detachment and Aphakia with Pars Plana Vitrectomy, Silicone Oil Tamponade and Retropupillary Iris-Claw Intraocular Lens Implantation in These Cases.

BACKGROUND: Marfan Syndrome is an autosomal dominant disease with multiple ocular abnormalities including ectopia lentis and a high incidence of rhegmatogenous retinal detachment (RRD). The management of RRD may be challenging in cases of aphakic patients with Marfan. PURPOSE: To report on the management of four cases of simultaneous RRD and aphakia with vitrectomy, silicone oil tamponade, and retropupillary iris-claw intraocular lens (IOL) implantation in patients with Marfan that have been operated at the Jules-Gonin Eye Hospital between 2019 and 2020. HISTORY AND SIGNS: Ages at presentation were 20, 30, 32, and 31 years, respectively. All patients had a history of extraction of a dislocated lens. None of the patients had a previous posterior vitrectomy. Two patients had records of previous measurements for IOL calculation by optical biometry (IOL Master, Carl Zeiss Meditec AG, Jena, Germany) about 1 year prior to the RRD development. In two cases, measurements for IOL calculation by optical biometry were based on the contralateral eye. THERAPY AND OUTCOME: All patients underwent 23 G vitrectomy, peripheral iridotomy, and retropupillary iris-claw IOL. No intraoperative complications were encountered. All patients had silicone oil tamponade, one of which required heavy silicone oil. Silicone oil was removed 3 months following primary surgery. Minimum follow-up was 1 year. The single surgery anatomic success rate was 100%. All patients had visual acuity of at least 0.8 at the last follow-up (1.25, 1.0, 0.8, and 0.8 respectively). The targeted refractive results were accurately achieved in all four cases postoperatively. One patient presented ocular hypertension 2 weeks after surgery due to presumed steroid response and was managed conservatively. None of the patients had silicone oil migration into the anterior chamber. CONCLUSION: Retropupillary iris-claw IOL implantation in cases of RRD and aphakia creates a barrier to tamponades from the posterior segment, effectively preventing them from entering the anterior segment of the eye. Therefore, the management of aphakia and retinal detachment with simultaneous vitrectomy and a retropupillary iris-claw IOL may be a successful strategy in reducing postoperative complications in patients with Marfan syndrome.

OCRIPLASMIN FOR VITREOMACULAR TRACTION IN CLINICAL PRACTICE: The INJECT Study.

PURPOSE: Randomized clinical trials have demonstrated the safety and efficacy of ocriplasmin in patients with vitreomacular traction (VMT), including those with macular hole (MH). The INJECT study prospectively evaluated ocriplasmin in the setting of clinical practice. METHODS: INJECT was a Phase 4, multicenter, prospective observational study. Patients were followed up for 12 months. Assessments included nonsurgical VMT resolution, nonsurgical MH closure, best-corrected visual acuity, occurrence of vitrectomy, and adverse events. RESULTS: The efficacy population (N = 395) received an ocriplasmin injection and had optical coherence tomography-confirmed VMT at baseline. At Day 28, the rate of nonsurgical VMT resolution was 40.7% in the overall group, and the rate of nonsurgical MH closure was 36.0% in the VMT with MH group. At Month 12, the rate of ≥2-line best-corrected visual acuity gain (irrespective of vitrectomy) was 36.8% in the overall group and 59.6% in the VMT with MH group. The percentage of patients who underwent vitrectomy in the study eye was 29.1% in the overall group and 55.6% in the VMT with MH group. Photopsia (9.8%) and vitreous floaters (6.8%) were the most frequent adverse events. CONCLUSION: The INJECT study showed that ocriplasmin is effective in a clinical setting in patients with VMT, with or without MH. No new safety signals were identified from this large and surgeon-selected patient group, although the significant limitations of the study design without an image reading center and scheduled study visit timings should be noted.

Rupture of the Globe: What to Do, What not to Do. / Bulbusberstung: Vorgehen und Ergebnisse.

Due to their complexity, globe ruptures are highly compromising traumas for the patient. This is due on the one hand to the eye injury itself with the accompanying loss of vision and on the other hand due to the need for extended treatment with uncertain prognosis and the resulting psychological stress. Globe ruptures are among the prognostically most unfavorable injuries due to the force and peak pressure impacting the eye. Furthermore, contusional retinal necrosis may be of significance prognostically. In the present review, we discuss treatment of globe ruptures involving retinal surgery. We discuss the primary sugery, its chronological planning and extent as well as the necessity for follow-up interventions. We also discuss the origin of traumatic retinal detachment with differential diagnosis of giant retinal tear versus oradialysis as well as secondary sequelae of traumas such as formation of macular holes and their treatment. On this basis, the use of buckling surgery versus pars-plana vitrectomy is discussed. Further focus is set on the role of the iris lens diaphragm in surgery of globe ruptures.

Histopathological Changes and Clinical Outcomes following Intervention for Sub-Internal Limiting Membrane Haemorrhage.

INTRODUCTION: Haemorrhage confined to the sub-internal limiting membrane (ILM) space can be associated with good visual recovery. There is controversy as to the best management of purely sub-ILM haemorrhage, which ranges from observation to immediate surgical intervention. METHODS: We studied a retrospective case series of patients with sub-ILM haemorrhage who underwent vitrectomy with subsequent histological analysis of the removed ILM. RESULTS: Sixteen patients underwent vitrectomy for sub-ILM haemorrhage. Five patients had underlying Terson syndrome, 6 had ruptured macro-aneurysms, and 5 had Valsalva retinopathy. Seven patients demonstrated cellular proliferation on the retinal surface of the ILM with staining for glial fibrillary acidic protein and cytokeratin 7, as well as CD68pg and Prussian blue. All but 1 of these cases were isolated from patients undergoing surgery >4 weeks following initial symptoms, the other presented at >2 weeks. Serial optical coherence tomography (OCT) was available in 8 patients; serial OCT in patients with delayed intervention demonstrated persistent inner retinal layer hyper-reflectance. Fourteen of 15 patients demonstrated symptomatic recovery and showed visual improvement with acuity ranging from -0.1 to 1.8 (mean 0.43) within 3 months of intervention (1 was lost to follow-up). The post-operative vision was 0.11 logMAR (mean; range -0.1 to 0.4) at 3 months in the group with intervention within 2 weeks of symptoms, and 0.9 logMAR (mean; range 0.0 to HM) in the group with delayed surgery. CONCLUSIONS: Early surgical intervention for sub-ILM haemorrhage resulted in good visual outcomes; delayed surgery may lead to proliferative vitreoretinopathy-like changes on the inner retinal surface of the ILM, and untreated cases may demonstrate persistent inner retinal changes potentially limiting visual prognosis despite subsequent surgical intervention.

Polydimethyl Siloxane as an Internal Tamponade for Vitreoretinal Surgery.

PURPOSE: To report the efficacy and safety of polydimethyl siloxane (Siluron Xtra®) as an internal tamponade. DESIGN: Audit and adverse event screening of procedures (March 2014-2015). METHODS: Patients who had undergone vitreoretinal procedures with Siluron Xtra® tamponade were retrospectively analysed with respect to anatomical outcome, visual outcomes, and perioperative complications, in particular intraocular pressure. INCLUSION CRITERIA: all patients who had undergone Siluron Xtra® tamponade. EXCLUSION CRITERIA: No cases were excluded; however, there were no paediatric or pregnant patients within this cohort. All vitreoretinal cases were included, including retinal detachments, but also trauma, endophthalmitis, and intraocular foreign bodies. RESULTS: Twenty-eight patients had polydimethyl siloxane as an intraocular tamponade; 24 retinal detachments (83% complicated by proliferative vitreoretinopathy ≥grade C), 12 had previous failed surgery, and 4 had procedures for intraocular lymphoma, endophthalmitis, or trauma. Follow-up was 14-20 months, and mean duration of tamponade was 6.8 months (3-12 months). Anatomical success was 79% after polydimethyl siloxane injection, 58% 3 months following removal (14/24), 5 remain with long-term tamponade, and 5 with redetachment under tamponade required further intervention. Five required topical anti-glaucomatous agents, and 1 following trauma required glaucoma surgery. Cataract developed in 3/6 phakic patients, and visible emulsification occurred in a single patient. CONCLUSION: Polydimethyl siloxane seems to be an acceptable alternative tamponade agent for the management of complex retinal detachments with comparable anatomical success and comparable rates of raised intraocular pressure to other low-viscosity silicone oil agents, but more importantly, with a lower rate of emulsified oil-related complications, which is important particularly for cases requiring long-term tamponade.

Novel heavy tamponade for vitreoretinal surgery.

PURPOSE: The aim of this study was to produce a heavy tamponade with a specific gravity greater than 1.06 g/mL that was optically transparent, could be manufactured using simple processing, could be injected using standard clinical equipment, and would have appropriate biocompatibility. METHODS: Aerosil silica was added to a phenyl trimethicone and mixed via a roller, overhead stirring, and ultrasonics. The refractive index, visible absorbance, and shear viscosity were measured. The injectability of the solutions was evaluated using the Accurus Viscous Fluid Injection system. The tamponade efficiency was assessed using a model eye chamber and compared with that of Densiron 68, Oxane HD, and F6H8. The biocompatibility was evaluated in vitro and in vivo in rabbits. RESULTS: Tamponade agents were produced with specific gravities of 1.10, 1.11, 1.13, and 1.16 g/mL that had good optical clarity. Mixing using overhead stirring was sufficient to produce tamponade agents with shear viscosities in the range 1000 to 5000 mPa·s that were reproducible and stable during storage. The solutions were easier to inject using the Accurus Viscous Fluid Injection system than silicone oil 1000 mPa·s. The 11% silica solution had greater tamponade efficiency than Densiron 68 or Oxane HD. There was no evidence of cytotoxicity in vitro. Silica solution 11% induced cataract earlier than Polydimethylsiloxane 1000 (PDMS 1000). Silica solution 11% and phenyl trimethicone reduced the a-wave value at 1 week after vitrectomy, but recovery was observed at later time points. Silica solution 11% caused inner nuclear layer (INL) nuclei dropdown in inferior retina from 4 weeks postoperation. Polydimethylsiloxane 1000 induced a similar phenomenon in superior retina 12 weeks postoperation. CONCLUSIONS: We have produced a heavy tamponade with good clarity that has appropriate shear viscosity, injectibility, enhanced tamponade efficiency, and biocompatibility similar to that of PDMS 1000.

Endophthalmitis following intravitreal injections.

BACKGROUND: To report the clinical features, culture results, management and visual outcome of patients with endophthalmitis following intravitreal injections. METHODS: Retrospective review of all patients with suspected endophthalmitis after intravitreal injections treated with intravitreal antibiotics (teicoplanin and ciprofloxacin) at a referral centre between January 2003 and December 2010. RESULTS: Nineteen cases that had aqueous or vitreous biopsy were identified. Nine had negative culture. Ten had positive culture; Staphylococcus species in 4/10, Streptococcus species in 4/10, E. coli in 1/10 and gram-negative bacilli in 1/10. Symptoms developed within the first 48 hours in all. One of ten culture-positive cases had no pain on presentation, while 5/9 patients with negative culture reported pain. Initial treatment consisted of intravitreal antibiotics in all cases, 6/19 cases required a second intravitreal antibiotic injection, 4/19 underwent vitrectomy as secondary therapy. At the last follow up, 7/19 patients had visual acuity of 6/18 or better, 9/19 had visual acuity of 6/60 or worse. CONCLUSION: The overall numbers of patients with endophthalmitis following intravitreal injections has risen dramatically over the past years. In contrast to earlier reports of multicentre studies, outcome of patients is relatively poor in the current treatment settings. We did not find clinical features useful in identifying cases with negative culture.

Retrospective review of 50 eyes with long-term silicone oil tamponade for more than 12 months.

BACKGROUND: Silicone oil (SO) is an established tamponade in treating complex vitreoretinal diseases. Although SO is intended to be removed after several weeks to months, permanent SO might be unavoidable in a small subgroup of patients with an extremely complicated clinical course. The aim of this study is to describe the long-term effects of intraocular SO tamponade. METHODS: This retrospective study included 50 patients with intraocular SO (Oxane 5700 Bausch & Lomb, Kingston-upon-Thames, UK) for at least 12 months. The most common reasons for long-term SO tamponade were: retinal re-detachment (re-RD), proliferative diabetic retinopathy (PDR), ocular trauma, and persistent hypotony. RESULTS: Mean age was 59.2 ± 18.4 years, and mean duration of silicone oil in the eye was 54.5 ± 58.6 months (median, 30 months). The average number of previous surgeries were 2.2 ± 1.5. Anatomic success was achieved in 37/50 (74%) of patients. Visual acuities (logMAR) were 1.8 ± 0.6, 1.6 ± 0.6, 2 ± 0.7 and intraocular pressures (mmHg) were 15.6 ± 7, 15.7 ± 5.5, 16.5 ± 7.1 at 3 months, 1 year and at last follow-up respectively. The main long-term silicone-oil-related complications observed were: band keratopathy (8%), corneal decompensation (12%), iris rubeosis (14%), and optic neuropathy (28%). Forty percent of patients achieved ambulatory vision in the SO-filled eye at final follow-up. CONCLUSION: Long-term silicone oil can be a last-resort option in selected patients with severe vitreoretinal disease. Anterior and posterior segment complications did occur at significant rates. Forty percent of our patients maintained ambulatory vision. The actual number of patients that achieved satisfactory stereopsis and benefited functionally from long-term SO was much less [7/50 (14%)].

The effect of scleral exoplant removal on strabismus following retinal detachment repair.

PURPOSE: Scleral buckling for retinal detachment is a well-reported cause of secondary strabismus. We analyzed the effects on motility of removal of the exoplant alone to determine whether this is warranted as a separate step in the surgical management of these patients. METHODS: A retrospective case series of patients who underwent scleral exoplant removal due to symptomatic strabismus development following retinal detachment repair from 2007 to 2009 was conducted. Manifest horizontal and vertical deviations were treated as vectors of a single combined deviation (|dev|). Pre- and postoperative manifest |dev| in the primary position (|dev|(pp)) and in the gaze position of maximal deviation (|dev|(max)) were analyzed. RESULTS: Five patients were identified, all with symptomatic, binocular diplopia in the primary position prior to exoplant removal. Median |dev|(pp) prior to exoplant removal was 21(Δ) and following removal was 21(Δ) (P = 0.81). The median |dev|(max) prior to exoplant removal was 33(Δ) and following removal, 22(Δ) (P = 0.82). Median follow-up was 8 months. There were no cases of retinal redetachment following the exoplant removal. No patient reported any subjective improvement of their diplopia. All 5 patients went on to have strabismus surgery as a separate procedure. CONCLUSIONS: Median primary position deviation was unchanged by scleral buckle removal, and Exoplant removal has minimal long-term benefit on the strabismus following scleral buckling procedures.

Is there a role for long-term silicone oil tamponade for more than twelve months in vitreoretinal surgery?

Despite modern and sophisticated vitreoretinal techniques, the authors are convinced that an underreported patient group exists, for whom long-term silicone oil tamponade is unavoidable. We conducted a literature review of the current evidence base in order to provide guidance on the ocular tolerance and side effects of long-term silicone oil, weighing up benefits against complications as well as providing an outlook on future silicone oils with improved physical properties. We advocate the removal of silicone oil in all cases; however, one has to recognise that long-term silicone oil tamponade may have to be considered as a measure of last resort for selected patients. There is a clinical need to develop novel, emulsification-resistant tamponades.

Outcomes of delayed vitrectomy in open-globe injuries in young patients.

PURPOSE: The timing of vitrectomy for severe penetrating eye injury to the posterior segment remains controversial; this is particularly pertinent if patients are children and young adults. We present our results of the surgical procedure in young patients after penetrating eye injury using a delayed approach. METHODS: Noncomparative interventional study of patients up to 29 years of age who had vitreoretinal surgery for penetrating eye injury. Surgical procedure was performed in seven eyes of six patients. Posterior vitrectomy was performed because of hemophthalmos after waiting for a mean of 49 days (range, 17-90 days) after posterior vitreous detachment was confirmed on ultrasound examination. RESULTS: The mean postoperative follow-up period was 22 months (range, 9-35 months). Of the 7 patients, 6 (85.7%) achieved visual acuity (Snellen acuity) of 6/12 or better and 4 eyes (57.1%) reached 6/6. At the last follow-up, all patients were pseudophakic, 2 required secondary lens implants, and retinal detachment developed in 1 patient. CONCLUSION: This consecutive case series underlines the fact that a delayed approach is compatible with good visual prognosis in relatively young patients.