Rate of Postoperative Autofluorescent Macular Shift with Expanding Gas Bubble Tamponade and No Prone Posture Ambulatory Care in Patients with Macula-Involved Retinal Detachment.

PURPOSE: Chronically distorted vision is an important adverse outcome in patients with otherwise successfully treated macula-involved retinal detachment (RD). Symptomatic distortion is associated with macular vessel shift on fundus autofluorescence (FAF) imaging. Immediate prone posture has to date been the only mechanism adopted to reduce postoperative FAF shift. The aim of this study was to establish the rates of primary anatomical success and (FAF) macular shift in 67 eyes with macula-involved RD and superior breaks treated with vitrectomy, retinopexy, 0.7-1 mL 100% gas tamponade, and no prone posture. METHODS: Single-center, retrospective series. RESULTS: Rates of primary anatomical success and fundus autofluorescent imaging macular shift were 89 and 26%, respectively. CONCLUSION: Vitrectomy with a 0.7-1 mL expanding gas bubble tamponade and no prone posture were associated with an acceptable rate of primary anatomical success. We found the lowest yet reported rate of FAF shift in patients with macula-involved RD. If confirmed, this simple technique modification could improve the visual outcome of RD surgery whilst facilitating postoperative ambulatory care.

Does Same-Day Postoperative Increased Intraocular Pressure Affect Endothelial Cell Density After Descemet Membrane Endothelial Keratoplasty?

PURPOSE: High intraocular pressure (IOP) is common in association with intracameral air and gas tamponade after Descemet membrane endothelial keratoplasty (DMEK); yet its influence on endothelial cell survival is unknown. Our aim was to determine the effect of high IOP measured 2 hours after DMEK on 1-month endothelial cell density (ECD). The influence of other potentially relevant factors was also investigated. METHODS: Retrospective, consecutive series. Inclusions: low-to-moderate risk DMEK surgery alone or combined with phacoemulsification. EXCLUSIONS: previous penetrating keratoplasty or glaucoma surgery; grafts with any of the following in the first month: rebubble, rejection, or graft failure. RESULTS: Sixty-two grafts met inclusion with 60 having IOP recorded at 2 hours. Thirty-eight percent (23/60) had IOP >30 mm Hg and 22% (13/60) had IOP >40 mm Hg at 2 hours. All grafts with IOP >30 mm Hg had air released and immediate normalization of pressure. One-month ECD (mean ± standard error of mean) was 1872 ± 58 cells/mm, representing cell loss of 29.8 ± 2.0%. Two-hour IOP was highly insignificant against 1-month ECD when tested as a continuous variable (P = 0.78). Lower 1-month ECD was statistically correlated with lower donor count (P = 0.002) and combined DMEK-phaco surgery (P = 0.01) on univariate and multivariate analysis. Insignificant factors (P > 0.05) against 1-month ECD included patient age, sex and race, surgical indication (Fuchs endothelial dystrophy vs. non-Fuchs endothelial dystrophy), and donor age. CONCLUSIONS: Increased IOP at 2 hours is common after DMEK, but does not seem to influence early endothelial cell survival. One-month ECD was influenced by donor counts and combined cataract surgery.

Descemet's membrane endothelial keratoplasty: surgical outcomes and endothelial cell count modelling from a UK centre.

PURPOSE: To report surgical outcomes and endothelial cell density (ECD) trends up to 2 years post-operatively in the first cohort of eyes undergoing Descemet's membrane endothelial keratoplasty (DMEK) for low-to-moderate risk indications at our UK centre. Tight corneal sutures were used to ensure high intraoperative pressure from intracameral air for 10-min and to maintain a good post-operative air fill. Outcomes were compared to a prior series at our unit of similar eyes having Descemet's stripping endothelial keratoplasty (DSEK). METHODS: Retrospective, interventional series. Inclusions: all DMEKs with a minimum of 1-month follow-up. EXCLUSIONS: prior glaucoma surgery, penetrating keratoplasty or anterior chamber lens. RESULTS: 88 DMEKs met inclusion. Median follow-up: 332 days. Main indication: Fuchs dystrophy (90%). COMPLICATIONS: re-bubbling 2%, primary failure 6%, retinal detachment 2%, rejection 3%. At 3 months, BCVA ≥6/6 and ≥6/9 were 67% and 86%, respectively. Graft survival at both 1 and 2 years was 94 ± 2%. Mean(±SD) cell-loss at 1 month, 3 months, 6 months, 12 months and 24 months: 30 ± 15%, 29 ± 16%, 33 ± 17%, 35 ± 17% and 48 ± 16%, respectively. Compared to a prior series at our unit of 210 low-to-moderate risk DSEKs, cell loss was lower for DMEK at all time-points (p < 0.001) through to 12 months but was not statistically different at 24 months. Mixed-modelling of ECD over time demonstrated the convergence of DMEK and DSEK curves by 2 years. CONCLUSIONS: DMEK using tissue from UK eye-banks resulted in high survival and excellent visual acuity. ECD through 1 year was superior to DSEK in a similar cohort. Our low re-bubble rate (2%) may be attributable to use of intracameral air at temporarily elevated intraocular pressure.

Vitreoretinal surgery on the fellow eye: A retrospective analysis of 18 years of surgical data from a tertiary center in England.

Purpose: To determine the long-term incidence of fellow-eye surgical involvement in patients who have undergone first-eye vitreoretinal (VR) surgery for a variety of indications. This was a single-institution retrospective, consecutive series. Methods: Eighteen years of electronic surgical data were reviewed at our institution. All patients having surgery for the following indications were included: rhegmatogenous retinal detachment (RRD), macular hole (MH), epiretinal membrane (ERM), proliferative diabetic retinopathy (PDR), vitritis, and dropped nucleus. Primary outcome was the cumulative incidence of fellow-eye surgery at 10 years by Kaplan-Meier analysis. Results: Total follow-up was 29,629 patient-years. Cumulative incidence (± standard error) of fellow-eye surgery at 10 years was 7.2% ± 0.6% for RRD, 9.1% ± 1.3% for ERM, 7.5% ± 1.8% for MH, 30.6% ± 1.9% for PDR, 13.7% ± 2.9% for vitritis, and 2.8% ± 1.6% for dropped nuclei. The hazard for second-eye surgery was greatest in the early postoperative period after first-eye surgery for all indications. For RRD, the hazard was 2.7% ± 0.3% at year 1, 1.1% ± 0.2% at year 2, and 0.5% ± 0.2% at year 5. Risk factors for fellow-eye involvement for RRD were younger age (P < 0.001) and male gender (P < 0.01). Conclusion: We report the long-term risk of fellow-eye involvement in various VR pathologies, which is important in counseling patients regarding their risks as well as planning service provision.

INTRAOPERATIVE AND POSTOPERATIVE COMPLICATIONS IN PHACOVITRECTOMY FOR EPIRETINAL MEMBRANE AND MACULAR HOLE: A Clinical Audit of 1,000 Consecutive Eyes.

PURPOSE: The aim of this study was to report the intraoperative and postoperative complications of phacovitrectomy for epiretinal membrane (ERM) and macular hole (MH). METHODS: This was a retrospective audit of 1,052 phacovitrectomy operations (410 for ERM and 642 for MH) by the same surgical team between 1998 and 2017. Outcome measures included rates of intraoperative anterior segment and posterior segment complications such as posterior capsule rupture and retinal breaks. A subgroup analysis of 189 procedures in which postoperative complications were rigorously recorded was also undertaken. RESULTS: The rate of posterior capsule rupture was 2.2%, with no difference between ERM and MH (1.7 vs. 2.5%; P = 0.40). Iatrogenic retinal tears were more common in MH than in ERM surgery (15.6 vs. 6.8%; P < 0.001). The chance of one or more anterior segment or posterior segment intraoperative complications occurring (excluding iatrogenic retinal breaks) was not associated with: indication for surgery, grade of surgeon, gauge of surgery, surgical machine, diabetic status, patient sex, or patient age. Subgroup analysis showed postoperative events as follows: posterior capsular opacification 10.6% (20/189), posterior synechiae 4.2% (8/189), uveitis 2.1% (4/189), angle closure glaucoma 1.6% (3/189), and rhegmatogenous retinal detachment 1.1% (2/189). CONCLUSION: Phacovitrectomy seems to be safe in phakic patients with ERM or MH, performed either by fellows or consultants. It avoids the requirement for repeat surgery and is more cost and resource efficient.

Acute retinal detachment induced by the Valsalva manoeuvre in morning glory disc anomaly.

We present a case in which a large, bullous, predominantly inferior, serous retinal detachment developed acutely after the Valsalva manoeuvre (from a coughing fit) in an eye with morning glory disc anomaly. We postulate that a rapid alteration in intracranial pressure was transmitted through the cavitary disc defect. This allowed a sudden influx of cerebrospinal fluid and/or liquefied vitreous into the subretinal space. This previously unreported case provides important evidence for the role of intracranial pressure fluctuations in the pathogenesis of macular schisis and neurosensory detachment secondary to optic disc cavitations.

Modeling Endothelial Cell Loss After Descemet Stripping Endothelial Keratoplasty: Data From 5 Years of Follow-up.

PURPOSE: To report 5-year outcomes for graft survival and endothelial cell survival after Descemet stripping endothelial keratoplasty (DSEK) including regression modeling for cell survival over time. METHODS: This is a single-institution, retrospective, consecutive interventional series of 210 primary DSEK grafts operated for low-to-moderate risk indications, specifically Fuchs dystrophy and bullous keratopathy. Primary outcomes were cumulative graft survival and % endothelial cell loss from 3 months through 5 years; the secondary outcome was to trend endothelial cell density over time by least-squares and mixed nonlinear modeling. RESULTS: Cumulative graft survival was high at 99%, 98%, and 94% at 1, 3, and 5 years, respectively. Mean endothelial cell loss was (mean ± SD) 44% ± 16%, 56% ± 17%, and 67% ± 13% at 1, 3, and 5 years. The trend in mean endothelial cell density over time by least square regression was accurately and parsimoniously described by a straight line taking earliest values (3 mo) through to 5 years, with a rate of cell loss of 148 ± 13 cells·mm·yr. Higher-order polynomial and exponential models did not provide a closer regression fit. Mixed nonlinear modeling using exponential decay equations confirmed a relatively stable rate of cell loss for DSEK from 3 months through to 5 years, in contrast to penetrating keratoplasty models using similar techniques in previous studies. CONCLUSIONS: DSEK graft survival is high in our series through 5 years. Endothelial cell loss occurs at a relatively constant albeit low-grade rate from the earliest postoperative measurements through 5 years.

Descemet Stripping Endothelial Keratoplasty in Iridocorneal Endothelial Syndrome: Postoperative Complications and Long-Term Outcomes.

PURPOSE: To determine the long-term outcomes of Descemet stripping endothelial keratoplasty (DSEK) in iridocorneal endothelial (ICE) syndrome. METHODS: Retrospective review of a consecutive series of 4 eyes of 4 patients with ICE syndrome treated by DSEK surgery at a single institution with follow-up between 2 and 7 years. RESULTS: Mean follow-up after initial DSEK surgery was 55 months (range, 24-95 months). One eye required 1 repeat DSEK, and 2 eyes required 2 repeat DSEKs for a total of 9 DSEK operations across the 4 eyes. There were no graft dislocations and no primary graft failures. Seven of 9 grafts achieved a visual acuity of 6/12 or better by 6 months. Mean endothelial cell loss at 3, 6, 12, and 24 months was 55 ± 14%, 78 ± 5%, 80 ± 6%, and 83 ± 9%, respectively. Long-term graft survival was poor with 7 of 9 grafts suffering late endothelial failure by a mean of 18 ± 7 months (range, 12-28 months). Mean graft survival on Kaplan-Meier analysis was 19 months (95% confidence interval, 14-24 months). CONCLUSIONS: DSEK has the potential to provide good short-term visual outcomes in eyes with ICE syndrome. However, long-term graft survival beyond 2 years is poor because of late endothelial failure. Patients with ICE considering DSEK surgery should be warned about the high probability of repeat surgery.