Direct Exchange of PerfluoroCarbon Liquid for Silicone Oil: A Surgical Technique to Control Pressure and Avoid Retinal Slippage.

BACKGROUND/PURPOSE: Perfluorocarbon heavy liquid (PFCL) is used in vitreoretinal surgery to flatten the unsupported detached retina before insertion of silicone oil in cases of giant retinal tear or relaxing retinectomy. Direct exchange of PFCL for silicone oil is recommended to reduce retinal slippage when compared with fluid-air exchange, but it is commonly regarded as a difficult procedure. We describe our technique for direct PFCL-silicone oil exchange using a 20-gauge drainage cannula, reliably avoiding the complications of retinal slippage and high intraoperative intraocular pressure. METHODS: We present a consecutive case series of patients undergoing PFCL-oil exchange and explain, using Poiseuille's equation for laminar fluid flow through a cannula, the rationale for using a 20-gauge drainage cannula rather than smaller gauges to avoid high intraocular pressure. RESULTS: Twenty-six patients underwent PFCL-oil exchange from February 1, 2019, to September 30, 2019. There was no intraoperative retinal slippage or pressure-related complications. Postoperatively 20 patients underwent oil removal. Six suffered retinal redetachment, and 14 remained attached. The vision postoil removal ranged from 6/6 to hand movements. CONCLUSION: We are confident that the PFCL-oil exchange technique described here is reliable and safe. The use of a 20-gauge drainage cannula is recommended regardless of vitrectomy gauge.

Contemporary Outcomes and Prognostic Factors of 23-Gauge Vitrectomy for Retained Lens Fragments After Phacoemulsification.

PURPOSE: To provide data on visual acuity (VA) outcomes and prognostic factors of microincision (23-gauge) vitrectomy surgery (MIVS) for retained lens fragments after complicated cataract surgery. DESIGN: Retrospective, interventional case series from 2012 to 2017. METHODS: Precataract surgery and intraoperative (vitrectomy) parameters, postvitrectomy complications, and best-corrected visual acuities (BCVAs) were identified. Vitrectomy was performed as early as corneal clarity permitted. Univariate and multivariate logistic regression were used to characterize factors associated with achieving VA better than 20/40, or worse than 20/200 at 6 months. RESULTS: This study included 291 consecutive eyes (291 patients). LogMAR BCVA improved from 0.73 ± 0.70 before cataract surgery to 0.46 ± 0.63 (P < .001) after vitrectomy. The previtrectomy VA was 1.43 ± 0.79. At 6 months, 183 (62.9%) and 45 patients (15.5%) achieved BCVAs better than 20/40 and worse than 20/200, respectively. Most frequent complications were de novo ocular hypertension (29 eyes, 10%) and transient cystoid macular edema (25 eyes, 8.6%). Postvitrectomy retinal detachment occurred in 9 eyes (3.1%). Final VA of 20/40 or better was independently associated only with better precataract surgery VA, age <75 years, absence of preexisting diabetic macular edema (DME) or postvitrectomy persistent cystoid macular edema (P < .05). Only poorer precataract surgery VA, delaying vitrectomy to later than 2 weeks, and final aphakic status were independently predictive of 20/200 or worse VA (P < .05). CONCLUSION: Contemporary VA outcomes of 23-gauge vitrectomy for retained lens fragments are comparable with that of prior predominantly non-MIVS cohorts, but fall short of benchmarks for uncomplicated cataract surgery. IOL type or timing of placement do not impact final VA.

A 21-Year Study of Vitreoretinal Surgery for Aphakic Retinal Detachment: Long-Term Surgical Outcomes and Complications.

PURPOSE: To determine the characteristics and outcomes of primary retinal detachment (RD) surgery in aphakic patients. DESIGN: Retrospective case series. PARTICIPANTS: Sixty eyes with primary aphakic RD (ARD) in 51 patients. METHODS: A consecutive series of patients who underwent vitreoretinal surgery for primary rhegmatogenous ARD was analyzed retrospectively between 1997 and 2018 at Moorfields Eye Hospital. MAIN OUTCOME MEASURES: Best-corrected visual acuity (BCVA), surgical outcomes, and complications. RESULTS: Mean BCVA improved from 1.31 to 1.08 logarithm of the minimum angle of resolution (logMAR; P = 0.081) over a mean follow-up period of 8.2 years. Macula-off retinal detachments showed significantly improved BCVA from 1.72 to 1.1 logMAR (P = 0.007). Mean age was 38.8 years, and the most common cause of aphakia was congenital cataract surgery (55%). The macula was attached in 45% eyes, and grade C proliferative vitreoretinopathy (PVR) was present in 12%. Operations performed were vitrectomy (88%), combined vitrectomy and scleral buckle (8%), and encirclement (3%). The final anatomic success rate was 88%, and PVR was a significant predictor of redetachment (P = 0.03; odds ratio, 20.7; 95% confidence interval, 2.8-152.2). Raised intraocular pressure was the most common postoperative complication at 30%, with a rate of de novo postoperative glaucoma of 6.7% at final follow-up. CONCLUSIONS: We report high rates of primary and overall anatomic success for surgery in ARD surgery. Grade C PVR was a positive predictor for surgical failure. Final visual outcomes were limited by ocular comorbidity, and we report significant improved visual outcomes for macula-off ARD.

A Study of the Natural History of Vitreomacular Traction Syndrome by OCT.

PURPOSE: To examine the natural history of vitreomacular traction syndrome (VMTS) in the absence of other ocular comorbidities. DESIGN: Retrospective clinical case series. PARTICIPANTS: A total of 183 eyes of 159 patients diagnosed with VMTS with no other ocular comorbidity. METHODS: Patients with VMTS were identified from an OCT database at Moorfields Eye Hospital, London. Sequential OCT scans and patient notes were reviewed over a minimum period of 6 months. Data collected included patient demographics, best-corrected visual acuity, and OCT features of vitreomacular adhesion. Contingency tests and binary logistic modeling were used to identify baseline predictors of stability and progression. MAIN OUTCOME MEASURES: The rates of spontaneous resolution (defined by release of traction), progression to full-thickness macular hole, and surgical intervention were analyzed. RESULTS: Presenting visual acuity was 0.3±0.3 logMAR units. The mean length of follow-up was 17.4±12.1 months. During this period, VMTS persisted in 60% and resolved in 20% (occurring on average at 15 months). Of the remainder, 12% developed a macular hole and 8% elected to proceed with surgery for symptoms. Focal adhesion <1500 µm was present in 87%. A premacular membrane with macular pucker (PMM) was present in 20%. With persistent VMTS, vision and central foveal thickness remained unchanged. The relative risk of resolution increased in those cases with better presenting visual acuities, lesser foveal thicknesses, and no associated PMMs; vision significantly improved in those cases with resolution. CONCLUSIONS: VMTS persists in the majority of patients but despite this, visual acuities did not deteriorate significantly over the study period unless patients developed a full-thickness macular hole or required surgical intervention for symptoms. Resolution spontaneously occurred in 20%, with an improvement in vision.

Vitrectomy, Inner Limiting Membrane Peel, and Gas Tamponade in the Management of Traumatic Paediatric Macular Holes: A Case Series of 13 Patients.

PURPOSE: To review the outcomes of pars plana vitrectomy, internal limiting membrane (ILM) peel, and gas tamponade in the management of traumatic paediatric macular holes. METHODS: Retrospective case series of children undergoing vitrectomy, ILM peel, and gas tamponade for traumatic macular hole between March 2007 and July 2014. Main outcome measures were postoperative visual acuity at 3 and 12 months, anatomic closure rate, and surgical complications. RESULTS: Anatomic macular hole closure was achieved in 12 (92.3%) of 13 cases. Mean preoperative logMAR visual acuity was 0.91 (95% CI 0.65-1.17) with improvement postoperatively to 0.54 (95% CI 0.43-0.64) at 3 months (p = 0.002) and 0.50 (95% CI 0.39-0.60) at 12 months (p = 0.002). There were no perioperative complications. CONCLUSION: Pars plana vitrectomy and ILM peel is an effective management option for paediatric macular holes.

The role of day one postoperative review of intraocular pressure in modern vitrectomy surgery.

BACKGROUND: With the introduction of sutureless 23-gauge (23G) vitrectomy, the risks for elevated intraocular pressure (IOP) and the need for day 1 review of IOP are less certain. AIMS: To assess current practice for postoperative review in the vitreoretinal service at a large tertiary referral centre; to assess whether day 1 review detected complications altering patient management; to identify risk factors for IOP spikes postvitrectomy. METHODS: Retrospective, consecutive case note review of all patients undergoing 23G vitrectomy at the study institution between April and June 2013. Patients had assessment at either day 1, week 2 and month 2 or week 2 and month 2. Linear regression analysis was performed to identify risk factors for IOP elevation. RESULTS: 200 (89%) cases met inclusion criteria. Of these, 176 (89.3%) had day 1 review, 24 (12%) were seen at week 2. Mean follow-up was 120 days (range 20-360). Two cases (1%) required urgent surgical intervention due to early IOP complications. Combined laser was the only risk factor for a day 1 IOP spike (p=0.005). In total, 44 patients (22%) were treated for elevated IOP within 2 weeks following vitrectomy. No long-term complications were detected in these patients. CONCLUSIONS: Day 1 review detected adverse events in 0.5% of study patients. No long-term complications were reported in the 22% of patients who received treatment for early postoperative IOP elevation. This observation has led to the removal of routine day 1 review from the surgical care pathway following routine uncomplicated vitrectomy at the study institution.

Incidence, mechanism and outcomes of schisis retinal detachments revealed through a prospective population-based study.

AIM: To determine the incidence, presentation and outcomes of progressive sight-threatening retinal detachment (RD) complicating degenerative retinoschisis. METHODS: We conducted the first prospective population-based epidemiological study of progressive schisis detachment over a 1-year period (2014-2015) in the UK. Case ascertainment was via monthly British Ophthalmological Surveillance Unit reporting cards sent to all ophthalmologists in the UK. For each reported case, data were collected using incident and 6 months follow-up questionnaires gathering information including demographic, presenting symptoms, retinal findings, primary management, primary outcome, secondary management and secondary outcome. RESULTS: Fifty-five cases of progressive schisis RD were identified with similar age distribution to conventional rhegmatogenous RD (mean age 64.0 years, range 20-88), and male-to-female ratio of 2.3:1. The locations of schisis detachments were predominantly supratemporal (46.7%) and infratemporal (35.6%). At least 70% of schisis RD were associated with posterior vitreous detachment (PVD) at presentation and 21% with grade B-C proliferative vitreoretinopathy. Primary management consisted of pars plana vitrectomy (82%), scleral buckle (9%), observation (4%), laser (2%) and combined vitrectomy-buckle (2%). Primary reattachment rate was 70%. Final reattachment rate was 87% with mean best-corrected visual acuity of 0.49 Decimal (SD 0.34) for fovea-on and 0.42 Decimal (SD 0.29) for fovea-off schisis detachments at mean follow-up of 8.7 months (SE 1.0). CONCLUSIONS: The estimated annual incidence of progressive schisis RD was 0.85 per million population (95% CI 0.64 to 1.11), equivalent to around 0.66% of all rhegmatogenous RD. PVD may play a key pathogenic role in the development of progressive schisis detachments. Surgical outcomes are inferior to those of conventional rhegmatogenous RD.

PRIMARY SCLERAL BUCKLING FOR PEDIATRIC RHEGMATOGENOUS RETINAL DETACHMENT.

PURPOSE: To evaluate the anatomical outcomes of primary scleral buckling (SB) procedures for pediatric rhegmatogenous retinal detachments. METHODS: Retrospective consecutive case series. One hundred and four eyes of 99 consecutive nonselected pediatric patients undergoing primary SB were identified. Baseline factors recorded were demographics, presenting clinical examination findings, previous ocular surgery, predisposing factors. Intraoperative factors recorded were the type of buckle, number and distribution of retinal breaks, number of retinal quadrants detached, macular status (involved vs. uninvolved), the use of subretinal fluid drainage, and surgical complications. Anatomical reattachment rate at last follow-up. Subgroup analysis was carried out to identify any predisposing factors for failure of primary surgery, effect of age on outcome, intraoperative pathology, effect of posterior versus anterior SB, and redetachment and secondary-procedure complications specific to SB. RESULTS: The initial surgery was segmental SB alone in 87 eyes (83.6%). Retinal reattachment was achieved with 1 operation in 73% (76 of 104 eyes). Of the 28 cases that redetached, 14 eyes underwent a repeat SB procedure (success rate of this second operation: 85.7% [12 of 14 eyes]), 13 eyes underwent vitrectomy (success rate of this second operation: 38.4% [5 of 13 eyes]), and 1 case was not reoperated. Overall, the final success rate was 94% (98 of 104 eyes). Factors associated with a statistically significant increased risk of failure included more than one break; three or more quadrants of detachment; horseshoe tears; no breaks seen on preoperative examination; Stickler syndrome. CONCLUSION: In selected cases, primary SB is an effective treatment for pediatric, rhegmatogenous retinal detachment.

Using spectral-domain optical coherence tomography imaging to identify the presence of retinal silicone oil emulsification after silicone oil tamponade.

PURPOSE: To describe small hyperreflective areas using spectral-domain optical coherence tomography (SD-OCT) imaging in eyes that have had silicone oil tamponade. METHODS: Retrospective case series of 11 eyes of 11 patients. The authors retrospectively identified patients who underwent vitrectomy and silicone oil tamponade secondary to a rhegmatogenous retinal detachment (nine patients), panuveitis with retinal necrosis (one patient), or recurrent full-thickness macular hole surgery (one patient) who had manifestations of silicone oil emulsion on SD-OCT imaging. Patients were monitored during the postoperative period by clinical examination and using SD-OCT. A model eye in which emulsified silicone oil had been injected in the anterior chamber was used to obtain anterior segment SD-OCT images for comparison. RESULTS: The mean age of our patients was 50 years (range, 39-76 years). In eight eyes, the SD-OCT examination was carried out after silicone oil removal, and in three eyes, the SD-OCT examination was carried out with the oil in situ. Of the nine eyes treated for rhegmatogenous retinal detachment, five had a relieving retinectomy for advanced anterior proliferative vitreoretinopathy or for traumatic retinal incarceration (one eye). The eye treated for full-thickness macular hole had a vitrectomy, internal limiting membrane peel, and silicone oil injection for recurrent macular hole. Ten eyes showed hyperreflective, spherical, tiny droplets using SD-OCT imaging. These were thought to represent silicone oil droplets intraretinally or underneath epiretinal membranes, and one eye showed hyperreflective areas subretinally (retina detached). One additional patient was found to have tiny intravitreal silicone oil droplets after silicone oil removal. Similarly, the silicone oil appeared as multiple hyperreflective spherical droplets as detected by SD-OCT. Anterior segment studies of silicone oil emulsification in the experimental model revealed a similar appearance to that seen with in vivo SD-OCT imaging. CONCLUSION: The authors have found small hyperreflective areas intraretinally, subretinally, and underneath epiretinal membranes on SD-OCT in eyes that have had silicone oil tamponade for a variety of indications. The authors have seen a similar appearance when silicone oil emulsification is examined in vivo. The authors conclude that the hyperreflective areas are likely (but not certain) to be very small bubbles of emulsified silicone. Further studies are required to determine the incidence, clinicopathologic, and functional significance of probable silicone oil emulsification and deposition within the retinal layers.

Cataract progression in macular hole cases: results with vitrectomy or with observation.

PURPOSE: To quantify the difference in progression of nuclear sclerotic cataract using Scheimpflug image analysis in patients with idiopathic full-thickness macular hole who were randomized to have vitrectomy and gas tamponade or to be observed. SETTING: Moorfields Eye Hospital, London, United Kingdom. DESIGN: Prospective randomized placebo-controlled masked clinical trial. METHODS: As part of the Moorfields Macular Hole Study, patients with full-thickness macular hole who were randomized to have vitrectomy and gas tamponade or who were observed were compared. Patients had Scheimpflug image analysis of the crystalline lens to evaluate nuclear sclerosis progression by the single-masked observer at baseline and 3, 6, 9, and 12 months postoperatively. RESULTS: Ninety-eight patients had sufficient baseline data for analysis. At 3 months and 6 months, vitrectomy patients had significant increases in nuclear density compared with baseline (16.6% and 33.9%, respectively) (both P<.0001). In the observation group, nuclear density increased by 1.4% between baseline and 6 months (P = .92). At 6 months, the increase in nuclear density from baseline was 24 times greater in the surgical group than in the observation group (P<.0001). No correlation between the rate of nuclear sclerosis progression and age or baseline nuclear density was found. CONCLUSIONS: Rapid nuclear sclerosis progression was quantifiable by Scheimpflug image analysis in patients having surgery for idiopathic full-thickness macular hole.There was no [corrected] evidence of a correlation between age groups and the rate of cataract progression. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Retinal pigment epithelium detachment associated with vitreomacular traction syndrome-case report.

PURPOSE: To report the unusual association of vitreomacular traction syndrome (VMT) with retinal pigment epithelium (RPE) detachment and describe the outcomes of successful surgery. METHODS: An 84-year-old man was referred with 6-month history of blurred vision in his RE. Best-corrected visual acuity (BCVA) was "counting fingers." Slit-lamp examination revealed VMT overlying a RPE detachment. The above findings were confirmed by optical coherence tomography (OCT). Pars plana vitrectomy and internal limiting membrane (ILM) peeling were performed. OCT was carried out at 3, 6, 9, and 11 months postoperatively. RESULTS: Eight weeks postoperatively BCVA improved to 6/60. Slit-lamp examination and OCT showed relief of the vitreomacular traction, however the underlying RPE detachment remained unchanged and progressively regressed during the following 11 months. Visual acuity did not improve above 6/36 at the last follow-up visit. CONCLUSION: Retinal pigment epithelium detachment could be associated with VMT. Although the incidence is rare, it may compromise the outcomes of successful surgery.

Proton beam irradiation for neovascular age-related macular degeneration.

OBJECTIVE: To evaluate safety and visual outcomes after proton therapy for subfoveal neovascular age-related macular degeneration (AMD). DESIGN: Randomized dose-ranging clinical trial. PARTICIPANTS: One hundred sixty-six patients with angiographic evidence of classic choroidal neovascularization resulting from AMD and best-corrected visual acuity of 20/320 or better. METHODS: Patients were assigned randomly (1:1) to receive 16-cobalt gray equivalent (CGE) or 24-CGE proton radiation in 2 equal fractions. Visual acuity was measured using standardized protocol refraction. Complete ophthalmological examinations, color fundus photography, and fluorescein angiography were performed before and 3, 6, 12, 18, and 24 months after treatment. MAIN OUTCOME MEASURE: Proportion of eyes losing 3 or more lines of vision from baseline. Kaplan-Meier statistics were used to compare cumulative rates of vision loss between the 2 treatment groups. RESULTS: At 12 months after treatment, 36 eyes (42%) and 27 eyes (35%) lost 3 or more lines of vision in the 16-CGE and 24-CGE groups, respectively. Rates increased to 62% in the 16-CGE group and 53% in the 24-CGE group by 24 months after treatment (P = 0.40). Radiation complications developed in 15.7% of patients receiving 16 CGE and 14.8% of patients receiving 24 CGE. CONCLUSIONS: No significant differences in rates of visual loss were found between the 2 dose groups. Proton radiation may be useful as an adjuvant therapy or as an alternative for patients who decline or are not appropriate for approved therapies.

Safety and efficacy of intravitreal injection of ranibizumab in combination with verteporfin PDT on experimental choroidal neovascularization in the monkey.

OBJECTIVE: To study the safety and efficacy of intravitreal injections of anti-vascular endothelial growth factor antibody fragment (ranibizumab [formerly known as rhuFabV2], Lucentis; Genentech, South San Francisco, Calif) in combination with intravenous verteporfin (Visudyne; Novartis, East Hanover, NJ) photodynamic therapy (PDT) on experimental choroidal neovascularization in the monkey eye. METHODS: Choroidal neovascularization was induced by laser injury in both eyes of cynomolgus monkeys and followed with weekly fundus photography and fluorescein angiography. Two weeks after induction, weekly treatments were initiated. These treatments included using either an intravitreal injection of ranibizumab (previously known as rhuFabV2) in combination with verteporfin PDT or a ranibizumab vehicle (placebo) in combination with verteporfin PDT (PDT only). Six animals (group 1) initially received intravitreal injections followed 1 week later by PDT. Four animals (group 2) initially received PDT followed 1 week later by intravitreal injection. Two animals (group 3) received injections and PDT on the same day at 2-week intervals. Photodynamic therapy was applied in all 3 groups every 2 weeks for 3 treatments with follow-up through 2 weeks after the last PDT treatment. Fluorescein angiograms were graded using a masked standardized protocol. The data were analyzed using the McNemar chi(2) test for matched pairs. RESULTS: No choroidal neovascularization leakage was observed in the eyes of animals treated with ranibizumab and PDT at day 21 or 42 after the start of the first treatment. Leakage persisted in eyes treated with PDT alone at 21 days (3 of 12 eyes) and 42 days (2 of 12 eyes). At all time points studied, the ranibizumab and PDT-treated eyes experienced better angiographic outcomes than the eyes receiving PDT alone. CONCLUSION: These preliminary data indicate that an intravitreal ranibizumab injection in combination with verteporfin PDT (ranibizumab and PDT) causes a greater reduction in angiographic leakage than PDT and intravitreal vehicle injection (PDT only) in experimental choroidal neovascularization. CLINICAL RELEVANCE: This combination therapy can potentially offer a new treatment modality for choroidal neovascularization in patients with macular degeneration and other diseases.

Surgery for idiopathic full-thickness macular hole: two-year results of a randomized clinical trial comparing natural history, vitrectomy, and vitrectomy plus autologous serum: Morfields Macular Hole Study Group RAeport no. 1.

OBJECTIVES: To determine the benefits of idiopathic full-thickness macular hole (FTMH) surgery compared with observation and to evaluate the use of autologous serum as an intraoperative adjunct. METHODS: A randomized clinical trial was performed to evaluate the anatomic and visual benefits of FTMH surgery for lesions of 9 months or less symptom duration and visual acuity of 20/60 or less. We compared surgery with natural history and determined whether use of intraoperative adjunctive autologous serum improves the surgical outcome. Eyes were randomized to (1). observation, (2). vitrectomy, or (3). vitrectomy plus serum and were followed for 24 months to assess anatomic status and visual function. RESULTS: In total, 185 eyes of 174 patients were enrolled. In the observation group, spontaneous closure of the FTMH occurred in 7 (11.5%) of 61 patients, with little or no change in overall acuity levels in 24 months. In contrast, the surgical groups had an overall closure rate of 80.6% (100/124) at 24 months, with 45% of eyes achieving Snellen acuity of 20/40 or greater. Surgical eyes had better median near acuity than observation eyes by 6 lines (N5 vs N14). Use of autologous serum did not seem to affect anatomic or visual results. At 24 months, 72 (58.1%) of 124 surgical eyes had undergone cataract extraction. CONCLUSIONS: Surgery for FTMH is safe and effective and is associated with significant visual improvement compared with the natural history. Autologous serum application does not enhance the results of surgery.