Results of different strategies to manage complicated retinal re-detachment.

PURPOSE: Complicated retinal re-detachment with inferior proliferative vitreoretinopathy (PVR) remains a challenge. This study's aim was to compare vitrectomy with conventional silicon oil (CSO) combined with an encircling band (EB) and vitrectomy with heavy silicon oil (HSO) alone to treat retinal re-detachment through inferior PVR, where standard procedures have already failed. METHODS: A retrospective analysis was done on patients with inferior complex re-detachment with secondary PVR after primary surgery, who received pars plana vitrectomy (PPV) with CSO combined with EB (group 1) or PPV alone with HSO (group 2) between December 2006 and August 2017. The primary endpoint was retinal reattachment, and the secondary endpoint was visual acuity (VA) change and complications in both groups. RESULTS: This study included 119 eyes. Total single surgery anatomical success (SSAS) was 64%, with 80% (52/65) achieved in group 1 and 44.5% (24/54) in group 2 (p < 0.0001). The total final anatomical success (FAS) rate was 79% (94/119). In group 1, FAS was 91% (59/65) compared with 65% (35/54) in group 2 (p = 0.003). The pretreatment VA of group 1 had a median of 1.4 logMAR (95% CI 0.3-1.8), and group 2 showed a median of 1.4 logMAR (95% CI 0.2-1.8). The post-treatment decrease in group 1 was a median equal to - 0.6 versus - 0.1 for group 2 (p = 0.0001). Serious complications were similar in both groups. CONCLUSION: For complicated retinal re-detachment through inferior PVR, the combination of PPV with EB may lead to better anatomical (SSAS, FAS) and functional success compared with PPV alone with HSO.

New retinal tack designs: an analysis of retention forces in human scleral tissue.

PURPOSE: The study aimed to construct a new retinal tack design with high retention forces to prevent spontaneous disentanglement in cases of complicated retinal surgery. METHODS: Six new forms for the peak of a retinal tack were developed using computer-aided design (CAD); then a prototype was produced for each model. Finally, standardised design testing was conducted using human (ex vivo) sclera by logging 15 consecutive measurements for each model. RESULTS: Seven different models underwent pull-out testing (six new models and the original tack model), but two tack models (Model 4, Model 5) failed to penetrate the human tissue. The highest pull-out forces (median) were measured for Model 3, followed by Model 6, Model 2 and Model 1. The original Heimann tack (Model H) was found to have the lowest retention forces. CONCLUSION: The different tack designs altered the penetration and holding forces. The retention forces of the proposed peak design led to a significant increase in the retention forces that were more than twice as high as those in the original Heimann Model.

PROSPECTIVE RANDOMIZED TRIAL ASSESSING THE IMPACT OF FEEDBACK MECHANISMS ON PATIENT POSITIONING.

PURPOSE: To investigate the use of a head-fixed feedback sensor to improve good positioning times after macular hole or retinal detachment surgery. The instructional methods, macular hole closure rates, and questionnaire responses were also evaluated. METHODS: After randomization, sensor devices with different feedback types (none/acoustic/vibration) were fixed on the patients' heads. Two positioning recommendations (verbal/illustrated) were used. The posturing data were logged every 500 ms for 24 hours. RESULTS: Forty-eight data sets (24 per group) were evaluated. Using sensory feedback, the median time for face-down positioning after macular hole surgery (Group 1) was significantly boosted from 463 minutes (range: 61-1,168) to 1,257 minutes (range: 1,024-1,327). The side positioning time after retinal detachment surgery (Group 2) increased from a median of 1,032 minutes (range: 520-1,165) to 1,284 minutes (range: 1,231-1,437). The night-time alarm records were reduced; however, the instructional methods exhibited no noteworthy effects. The questionnaires indicated positive acceptance of the sensors. CONCLUSION: Sensory feedback may help in cases where face-down or side positioning is recommended. These constant reminders were superior to verbal or written reminders; however, further studies are required to assess the clinical impact of sensory feedback on patient positioning.

Outcomes of Ahmed Glaucoma Valve Implantation for Glaucoma Secondary to Fuchs Uveitis Syndrome.

PURPOSE: To present the outcomes of Ahmed glaucoma valve implantation (AGV) in glaucoma secondary to Fuchs uveitis syndrome (FUS). METHODS: In this retrospective chart review, two definitions of success were used: 6 mmHg ≤intraocular pressure (IOP) ≤21 mmHg (success 1), and 6 mmHg ≤ IOP ≤21 mmHg and at least 25% reduction from baseline (success 2). Depending on the need of postoperative antiglaucoma medication, success was defined as either complete or qualified. RESULTS: In total, 17 eyes of 17 patients were included. Complete success rates (both definitions) were 23.5% (n = 17) after 1 year and 23% (n = 13) after 3 years. Qualified success rates (both definitions) were 58.3% (n = 17) after 1 and 38.4% (n = 13) after 3 years. Encapsulated bleb formation was the most common complication (47% of eyes). CONCLUSIONS: AGV was moderately successful in the management of glaucoma secondary to FUS. Success rates are improved by medications, needling, and cycloablative procedures.

Comparison of ab externo trabeculotomy in primary open-angle glaucoma and uveitic glaucoma: long-term outcomes.

BACKGROUND: The aim of this study was to compare the long-term outcomes of ab externo trabeculotomy in primary open-angle glaucoma (POAG) and uveitic glaucoma (UG). DESIGN: This was a retrospective single-center case series study. PARTICIPANTS: Twenty eyes of 17 patients with POAG and 22 eyes of 18 patients with UG were included in this study. PATIENTS AND METHODS: The medical records of all consecutive patients with POAG and UG who underwent ab externo trabeculotomy since 2004 were reviewed. MAIN OUTCOME MEASURE: The main outcome measure was change in median intraocular pressure (IOP). Success was defined as IOP ≤21 mmHg (success 1) and IOP ≤21 mmHg and at least 25% reduction from baseline (success 2). RESULTS: In the POAG group, the median IOP decreased significantly from 22 mmHg (95% CI 21-25 mmHg; n=20) at baseline to 14 mmHg (95% CI 12-16; n=13) after 4 years, P<0.001. In the UG group, the median IOP decreased significantly from 27 mmHg (95% CI 24.5-30.5 mmHg; n=22) at baseline to 12 mmHg (95% CI 9-15 mmHg; n=15) after 4 years, P<0.001. Seven eyes in the UG group failed within the first year after surgery compared to none in the POAG group. Of these, four eyes had Fuchs' uveitis syndrome and two had granulomatous uveitis. No sight-threatening complications occurred in both POAG and UG groups. CONCLUSION: Ab externo trabeculotomy effectively reduced IOP in both UG and POAG groups. However, the success rates in the UG group were significantly lower due to the high failure rate in patients with Fuchs' uveitis syndrome and granulomatous uveitis. The procedure demonstrated a high safety profile in both UG and POAG patients.

Long-term results of ab externo trabeculotomy for glaucoma secondary to chronic uveitis.

PURPOSE: To present the long-term results of ab externo trabeculotomy in the management of glaucoma secondary to chronic uveitis. METHODS: In this retrospective single-centre case series, medical records of patients with glaucoma secondary to chronic uveitis, who underwent ab externo trabeculotomy, were evaluated. Two definitions of success were used: intraocular pressure (IOP) 6 ≤ IOP ≤ 21 mmHg (success 1) or 6 ≤ IOP ≤ 21 mmHg and at least 25 % reduction from baseline (success 2). Success was complete when no additional medication was required or qualified when additional medication or cycloablative procedures were required to achieve the specific IOP definition. RESULTS: Twenty-two eyes of 18 patients were included. After 3 years, median IOP decreased from 27 mmHg [range 17-43 mmHg, mean 27.5 mmHg, 95 % confidence interval of the mean (CI) 24.5-30.5 mmHg] to 15 mmHg (range 9-19 mmHg, mean 14.5 mmHg, CI 13-16.1 mmHg). Complete and qualified success 1 was 23 and 45 % after 3 years, respectively. For success 2, the rates were 23 and 32 %, respectively. Hyphema was the most common complication, which resolved completely within 1 month after surgery without further intervention. CONCLUSION: Trabeculotomy ab externo was moderately successful in glaucoma secondary to chronic uveitis after 3 years. No sight-threatening complications were observed during the follow-up period.

Submacular predominantly hemorrhagic choroidal neovascularization: resolution of bleedings under anti-VEGF therapy.

PURPOSE: To report the visual and morphological outcomes following intravitreal bevacizumab in neovascular age-related macular degeneration (nAMD) with submacular, predominantly hemorrhagic, lesions. METHODS: Retrospective study of patients with a follow-up after 1 year. All eyes with submacular hemorrhages larger than 50% of the total lesion size and received only anti-VEGF (vascular endothelial growth factor) monotherapy (intravitreous administration of 1.25 mg bevacizumab, PRN). The primary endpoint was the change in hemorrhage size and time to resolution, in association with the mean best-corrected visual acuity (BCVA). The eyes were grouped based on the size of the hemorrhage: group A (≥1 to <4 disc area [DA]), group B (≥4 to <9 DA), and group C (≥9 DA). RESULTS: Forty-six consecutive eyes were included. The mean area of the hemorrhage was 6 DA at baseline. Eyes with smaller bleeding (group A) had better chances of stabilized or improved vision. Complete resolution of the hemorrhage was seen in 96% of the eyes within 1 year. The mean BCVA increased from 0.81 logarithm of the minimum angle of resolution (logMAR) (95% confidence interval [CI]: 0.70-0.92) (Snellen 20/125) at baseline to 0.75 logMAR (95% CI: 0.62-0.88) (20/125) after 1 year (P=0.11). BCVA improved (one or more ETDRS [Early Treatment of Diabetic Retinopathy Study] lines) in 57% of the eyes (13/23) in group A; 53% (8/15) in group B; and 38% (3/8) in group C. CONCLUSION: Many of the eyes with hemorrhagic lesions showed stabilization or improvement of the mean BCVA after treatment within 1 year. Anti-VEGF treatment can be considered as a useful treatment option in eyes with hemorrhages secondary to nAMD.

Exit strategies in canaloplasty: intraoperative conversion into 180-degree trabeculotomy or 360-degree trabeculotomy in cases of unsuccessful catheterisation of Schlemm's canal: influence of degree of canal cleavage.

PURPOSE: To investigate the safety and efficacy of intraoperative conversion of unsuccessful canaloplasty technique into 180-degree metal or 360-degree suture trabeculotomy. METHODS: In this retrospective observational case series, 35 eyes of 35 patients with open-angle glaucoma (OAG) who had undergone unsuccessful canaloplasty technique and underwent intraoperative conversion were studied. In 17 eyes (group A), the procedure was converted into 180-degree metal trabeculotomy because of unsuccessful circumferential Schlemm's canal (SC) catheterisation. Group B included 18 eyes that were converted into 360-degree trabeculotomy because of cheese wiring of tension suture through the trabecular meshwork (TM) after successful complete catheterisation of SC. RESULTS: Median preoperative IOP was 22.0 mmHg (range 16-34) in group A, and 22.0 mmHg (range 15-48) in group B. Median IOP was significantly reduced in both groups postoperatively, at the 12-month examination to 15.0 mmHg (range 9-21) representing a reduction of 36 % in group A, and to 14.5 mmHg (range 8-21) representing a reduction of 34 % in group B. Median glaucoma medication number decreased significantly from 4 (range 2-4) and 3 (range 1-4) preoperatively to 2 (range 0-4) and 1 (range 0-3) at 12 months in groups A and B respectively. Hyphema was the commonest complication, with an incidence of 76 % in group A and 78 % in group B. CONCLUSION: 180-degree metal or 360-degree suture/catheter trabeculotomy are safe and effective surgical backup methods to control IOP in cases of unsuccessful intracanalicular placement of tension suture during canaloplasty surgery.

Switching intravitreal anti-VEGF treatment in neovascular age-related macular degeneration.

PURPOSE: To compare the outcomes after switching between bevacizumab and ranibizumab therapy due to poor treatment effect in neovascular age-related macular degeneration (AMD). METHODS: This is a retrospective review of patients with neovascular AMD with first treatment using intravitreal bevacizumab (group 1) or ranibizumab (group 2) who switched to the other drug due to poor treatment effect. Primary outcome measures were change in mean best-corrected visual acuity (BCVA) and mean central retinal thickness (CRT) at 1 year and last visit. RESULTS: Eighty-seven eyes met the inclusion criteria. In group 1 (43 eyes), the mean BCVA decreased from 20/94 to 20/100 at 1 year after being switched (p = 0.573) and to 20/150 (p = 0.015) at final visit (mean 29.2 months, range 12-53). In group 2 (44 eyes), mean BCVA decreased from 20/72 to 20/90 (p = 0.401) and 20/100 (p = 0.081) at 1 year after switch and at final visit (mean 20.1 months, range 10-40), respectively. The mean CRT at switch, 1 year after switch, and at final visit were 344.4 ± 140 µm (mean ± SD), 286.26 ± 155 µm (p = 0.019), and 290.58 ± 196 µm (p = 0.009) in group 1 and 329.36 ± 144 µm, 302.0 ± 179 µm (p = 0.215), and 309.5 ± 220 µm (p = 0.154) in group 2, respectively. CONCLUSIONS: The mean BCVA decreased over time in both groups; however, nearly 30% of the eyes in each group showed vision improvement after switching. Mean CRT decreased in both groups, which was more pronounced after being switched from bevacizumab to ranibizumab. In neovascular AMD, a switch between ranibizumab and bevacizumab can be considered as a further therapy option if poor treatment effect is seen with the initial therapy.

Using a slit lamp-mounted digital high-speed camera for dynamic observation of phakic lenses during eye movements: a pilot study.

PURPOSE: To evaluate a digital high-speed camera combined with digital morphometry software for dynamic measurements of phakic intraocular lens movements to observe kinetic influences, particularly in fast direction changes and at lateral end points. MATERIALS AND METHODS: A high-speed camera taking 300 frames per second observed movements of eight iris-claw intraocular lenses and two angle-supported intraocular lenses. Standardized saccades were performed by the patients to trigger mass inertia with lens position changes. Freeze images with maximum deviation were used for digital software-based morphometry analysis with ImageJ. RESULTS: Two eyes from each of five patients (median age 32 years, range 28-45 years) without findings other than refractive errors were included. The high-speed images showed sufficient usability for further morphometric processing. In the primary eye position, the median decentrations downward and in a lateral direction were -0.32 mm (range -0.69 to 0.024) and 0.175 mm (range -0.37 to 0.45), respectively. Despite the small sample size of asymptomatic patients, we found a considerable amount of lens dislocation. The median distance amplitude during eye movements was 0.158 mm (range 0.02-0.84). There was a slight positive correlation (r=0.39, P<0.001) between the grade of deviation in the primary position and the distance increase triggered by movements. CONCLUSION: With the use of a slit lamp-mounted high-speed camera system and morphometry software, observation and objective measurements of iris-claw intraocular lenses and angle-supported intraocular lenses movements seem to be possible. Slight decentration in the primary position might be an indicator of increased lens mobility during kinetic stress during eye movements. Long-term assessment by high-speed analysis with higher case numbers has to clarify the relationship between progressing motility and endothelial cell damage.

Is cyclophotocoagulation an option in the management of glaucoma secondary to Fuchs' uveitis syndrome?

BACKGROUND: Glaucoma is one of the sight-threatening complications of Fuchs' uveitis syndrome (FUS) and the most difficult to manage. The goal of this study was to assess the efficacy and safety of cyclophotocoagulation (CPC) in the management of glaucoma secondary to FUS. METHODS: In a retrospective analysis, the charts of all patients with FUS referred to our clinic from January 2002 to December 2012 were reviewed. In patients with glaucoma or ocular hypertension, controlled eye pressure was defined using two alternative upper limits of 6 ≤ IOP ≤ 21 mmHg and 6 ≤ IOP ≤ 18 mmHg at 1 year follow-up. RESULTS: One hundred and seventy-six patients with FUS were included in this study. Of those, 28 had ocular hypertension (OHT) or glaucoma. Mean maximal intraocular pressure (IOP) of patients with glaucoma/OHT was 40.8 mmHg. Twenty-three patients (82.1 %) had maximal IOP levels of 35 mmHg or higher. Sixteen patients with glaucoma/OHT underwent CPC alone (ten patients) or in combination with other surgical procedures (six patients). After 1 year, control of IOP for both upper limits (6 ≤ IOP ≤ 18 mmHg) and (6 ≤ IOP ≤ 21 mmHg) was achieved in six of ten patients (60 %) who received CPC alone, and in five of six patients (83.3 %) who required additional surgery after CPC. The mean number of cycloablative procedures was 1.3 (range 1-2) in the CPC alone group and 1.2 (range 1-2) in patients for whom CPC was used as adjunct therapy. There was no exacerbation of intraocular inflammation, no postoperative hypotony and no phthisis bulbi in the 16 patients who underwent CPC. CONCLUSIONS: CPC is a safe and effective procedure that should be considered if medical treatment has failed to control glaucoma in FUS.

Usability of a gravity- and tilt-compensated sensor with data logging function to measure posturing compliance in patients after macular hole surgery: a pilot study.

BACKGROUND: To investigate the use of a small gravity- and tilt-compensated, head-fixed sensor with data-logging function to measure compliance and head posture of patients after macular hole surgery based on the recommendation of a face-down position. Main outcome measures were the median inclination, the times with correct or incorrect head position and the acceptance/annoyance of a data-logging device. METHODS: A small battery-driven electronic sensor device with gravity and tilt compensations was placed within a plastic box and fixed on a patient's head with a headband. Face-down position data were logged every half second for 24 h after macular hole surgery and were stored on a memory card. RESULTS: Thirteen patients were involved (seven females, six males, median age, 68 years, range, 50-75 years), two cases with early dropout. Ten of 11 datasets could be evaluated showing a complete data record file. The average percentage for face-down >45° was 18% within 24 h and 17% in the daytime. The median inclination was -6.7° (min: -89.7° max: 90°). The sensor system was well tolerated and disturbance was rated low by all ten patients. CONCLUSIONS: While the patients' face-down posture considerably varied over time in extent and continuity, the assessment might lead to optimizing the patients' compliance with the optimal position. Results showed an excellent acceptance of the motion sensor.