Combination of Anti-VEGF and Laser Photocoagulation for Diabetic Macular Edema: A Review.

Diabetic macular edema (DME) is the most common cause of vision loss in diabetic patients. Thirty years ago, the Early Treatment Diabetic Retinopathy Study (ETDRS) demonstrated that focal/grid laser photocoagulation reduces moderate vision loss from DME by 50% or more; thus, macular photocoagulation became the gold standard treatment for DME. However, with the development of anti-VEGF drugs (bevacizumab, ranibizumab, and aflibercept), better outcomes were obtained in terms of visual acuity gain and decrease in macular thickness in some studies when antiangiogenic drugs were administered in monotherapy. Macular laser therapy may still play an important role as an adjuvant treatment because it is able to improve macular thickness outcomes and reduce the number of injections needed. Here, we review some of the clinical trials that have assessed the efficacy of macular laser treatment, either as part of the treatment protocol or as rescue therapy.

Pars Plana Vitrectomy Alone for the Management of Pseudophakic Rhegmatogenous Retinal Detachment with Only Inferior Breaks.

PURPOSE: To report the surgical results of primary pseudophakic rhegmatogenous retinal detachment (RRD) with only inferior retinal breaks (IRBs) repaired by pars plana vitrectomy (PPV) alone and complete drainage of subretinal fluid. DESIGN: Prospective, interventional cohort study. PARTICIPANTS: A total of 147 consecutive pseudophakic eyes of 147 patients with primary RRD with causative inferior breaks. METHODS: All eyes underwent PPV alone and complete drainage of subretinal fluid, with air, 20% sulfur hexafluoride (SF6), or 12% perfluoropropane (C3F8) as tamponade and with no face-down position in the postoperative period. MAIN OUTCOME MEASURES: Postoperative primary and final anatomic outcome, visual acuity, and complications. RESULTS: The patient population consisted of 44 women (30%) and 103 men (70%) with a mean age of 60.8±12.9 years. The mean follow-up period was 24.9±19.4 months. The mean number of quadrants affected was 2.4 (range, 1-4). A single break was present in 90 cases (61.2%), and 2 to 4 breaks were present in 57 cases (38.8%). The macula was found to be detached in 118 cases (80.3%) and attached in 29 cases (19.7%) intraoperatively. Of 152 breaks located between 5 and 7 clock-hours, 124 breaks (81.6%) were located outside the limits of the gas bubble on the first or third day postoperatively. Initial reattachment was achieved in 139 cases (94.5%; 95% confidence interval, 89.5-97.6). Final reattachment was achieved in 147 cases (100%). Two cases (1.3%) redetached because of new or missed retinal breaks. Six cases (4.1%) redetached because of incomplete retinal adhesion of the treated break(s). Mean preoperative best-corrected visual acuity (BCVA) was 1.11±0.59 logarithm of the minimum angle of resolution (logMAR). The mean final postoperative BCVA was 0.42±0.33 logMAR. CONCLUSIONS: Pars plana vitrectomy alone with complete drainage of subretinal fluid achieves a high reattachment rate in the management of primary pseudophakic RRD due to IRBs.

Epiretinal membrane after pars plana vitrectomy for primary pseudophakic or aphakic rhegmatogenous retinal detachment: incidence and outcomes.

PURPOSE: To compare outcomes of eyes that did or did not develop an epiretinal membrane (ERM) after repair of primary pseudophakic or aphakic rhegmatogenous retinal detachment by pars plana vitrectomy alone. METHODS: Interventional, prospective, consecutive case series. Of 312 consecutive eyes that underwent pars plana vitrectomy for primary rhegmatogenous retinal detachment, 28 (8.97%) developed ERM during the postoperative period. Best-corrected visual acuity (BCVA) and fundus examinations were performed 1 month and 3, 6, and 12 months postoperatively. RESULTS: Eyes with an ERM more often had a break at the equator (odds ratio, 3.92; 95% confidence interval, 1.3­11.2; P < 0.011). At ERM diagnosis, BCVA ranged from 20/400 to 20/25 with a mean of 20/100 (0.75 logarithm of the minimum angle of resolution), and BCVA at the final visit ranged from 20/200 to 20/25 with a mean of 20/63 (0.53 logarithm of the minimum angle of resolution). Of the 22 eyes that underwent surgical removal of the ERM, BCVA was ≥ 20/40 in 5 (22.7%) before the surgical procedure and in 13 (59%) at the final follow-up visit. CONCLUSION: The incidence of ERM after pars plana vitrectomy alone for the repair of primary pseudophakic or aphakic rhegmatogenous retinal detachment was similar to reported incidences after scleral buckling. Best-corrected visual acuity improved after surgical removal of ERM, although eyes with the macula detached had lower final BCVA.

Macular holes after rhegmatogenous retinal detachment repair: surgical management and functional outcome.

PURPOSE: To review the surgical management and functional outcome of macular holes (MHs) developing after rhegmatogenous retinal detachment repair. METHODS: Retrospective, interventional, noncomparative case series. Twenty patients with MH developing after rhegmatogenous retinal detachment repair were included. Pars plana vitrectomy with internal limiting membrane peeling and gas tamponade was performed. Macular attachment status and number of best-corrected visual acuity lines of improvement after MH repair were evaluated. RESULTS: The fovea had been detached in all eyes at the time of rhegmatogenous retinal detachment repair. Six MHs developed after scleral buckling surgery and 14 MHs after vitrectomy with an encircling band. In 5 of the 20 patients, ≥ 2 operations had been required to achieve retinal reapplication. The mean time to MH diagnosis was 38 weeks. Preoperative best-corrected visual acuity was ≤ 20/100 in all but one case. Single-operation MH closure rate was 100%, with a mean of 4 Early Treatment Diabetic Retinopathy Study lines of visual improvement (P < 0.001). Mean postoperative Snellen best-corrected visual acuity was 20/70 (± 0.15) (P < 0.001). CONCLUSION: In this small retrospective study, standard surgical treatment for idiopathic MH was effective in achieving anatomical closure of these secondary MHs, but visual acuity gain was limited by the previous macula-involving rhegmatogenous retinal detachment status.

Pars plana vitrectomy alone with diffuse illumination and vitreous dissection to manage primary retinal detachment with unseen breaks.

OBJECTIVE: To report on pars plana vitrectomy with diffuse illumination, wide-angle viewing, and meticulous vitreous dissection for identifying and managing retinal breaks when no breaks were detected before surgery for primary rhegmatogenous retinal detachment. METHODS: Prospective clinical study of 61 of 800 consecutive eyes (7.6%) (61 of 782 patients) seen at a university hospital during the 48-month study for primary rhegmatogenous retinal detachment in whom no break could be identified preoperatively despite thorough examinations. All of the patients underwent pars plana vitrectomy alone with meticulous peripheral vitreous dissection assisted by diffuse illumination, a wide-angle viewing system, perfluorocarbon liquid, triamcinolone acetonide suspension, and balanced salt solution to identify and manage primary retinal breaks. RESULTS: Retinal breaks were found intraoperatively in 60 eyes (98%). In 51 of 61 eyes (84%), balanced salt solution was left in the vitreous cavity. Best-corrected visual acuity was 20/40 or better in 25 of 61 study eyes (41%). Primary retinal reattachment was attained in 60 study eyes (98%). Final reattachment was achieved in all 61 eyes (100%). CONCLUSIONS: Pars plana vitrectomy alone with diffuse illumination and extensive vitreous dissection led to identification and management of retinal breaks undetectable before surgery, achieving a high primary reattachment rate.

Transconjunctival sutureless 23-gauge vitrectomy for diabetic retinopathy. Review.

This paper reviews the current experience and trends in 23-gauge transconjunctival sutureless vitrectomy for diabetic retinopathy in those patients that need a surgical intervention for either vitreous hemorrhage, fibrovascular proliferation with traction retinal detachment affecting or threatening the macula, traction-rhegmatogenous retinal detachment, or refractory macular edema with taut posterior hyaloid. Since the instruments in 23-gauge vitrectomy are less flexible and perform in a more similar way to 20-gauge instruments, the vitrectomy is more thorough and for more complex manoeuvres can be done. The 23-gauge transconjuntival sutureless vitrectomy avoids some of the shortcomings of the 25-gauge systems.

Prospective clinical trial evaluating the efficacy of photodynamic therapy for symptomatic circumscribed choroidal hemangioma.

PURPOSE: To evaluate photodynamic therapy (PDT) for symptomatic circumscribed choroidal hemangioma (CCH). DESIGN: Prospective, multicenter, nonrandomized clinical trial. PARTICIPANTS: Thirty-one eyes of 31 patients with posterior pole CCH and symptoms caused by exudation into the macular area. INTERVENTION: Photodynamic therapy was applied by Zeiss laser. Intravenous verteporfin at 6 mg/m(2) body surface was administered before treatment, and light emitted at 689 nm for photosensitization. The treatment spot diameter was calculated on early-phase frames of pretreatment indocyanine green angiography. Fifteen minutes after starting the verteporfin infusion, the laser beam was applied to the retina at radiant exposure 50 J/cm(2) and exposure time 83 seconds. One to 4 treatments were applied at 12-week intervals over 1 year. Standardized evaluation was performed before and at 4-week intervals after each treatment, and at 3, 6, 9, and 12 months. All patients were followed for >or=12 months. MAIN OUTCOME MEASURES: The primary outcome measure was the absence of exudative retinal detachment at the 12-month follow-up visit on ophthalmoscopy, fluorescein angiography, and optical coherence tomography. Secondary measures were the visual acuity outcome, with best-corrected visual acuity determined by the Early Treatment for Diabetic Retinopathy Study chart, tumor thickness decrease on B-scan ultrasonography, and adverse events. RESULTS: Among the total, 82.8% of patients required 1, 13.8% 2, and 3.4% 3 PDTs to eliminate exudative retinal detachment. Visual acuity increased from a mean of 20/60 to 20/35 (P<0.001). Sixty-nine percent of patients demonstrated visual recovery (P<0.001). Cystoid macular edema regressed in all cases and exudative macular detachment disappeared in all but 2 cases. The CCH thickness decreased in all cases from a mean of 3.0 to 1.7 mm, with the most intense effect seen after 4 weeks of treatment (P<0.001). Visual fields showed resolution of central scotomas. There were no severe adverse events. CONCLUSIONS: Combining PDT with the standard age-related macular degeneration protocol is an effective treatment for CCH in terms of resolution of exudative subretinal fluid and recovery of VA. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.

Topical anesthesia: possible risk factor for endophthalmitis after cataract extraction.

PURPOSE: To assess the relationship between the risk for acute endophthalmitis after cataract extraction and whether certain factors, such as surgeon qualification, numerical order, duration of surgery, operating theater, and type of anesthesia (topical or retrobulbar), could be modified to decrease the risk. SETTING: Single-center academic practice. METHODS: Two epidemiological studies were performed: a case-control study and a retrospective cohort study. The surgical records of all patients with clinically diagnosed endophthalmitis within 30 days after cataract surgery performed between February 2002 and September 2003 were reviewed. The endophthalmitis cases were compared with 108 randomly selected controls (4 controls per case). The global incidence of endophthalmitis and the incidence according to type of anesthesia were calculated. RESULTS: Of 5011 cataract extractions performed, 27 cases of endophthalmitis occurred. The incidence was 5.39 per 1000 procedures. An independent statistically significant relationship was found between endophthalmitis and the use of topical anesthesia (odds ratio [OR], 11.8; 95% confidence interval [CI], 2.4-58.7) and surgery longer than 45 minutes (OR, 7.2; 95% CI, 1.7-29.7) but not between the other variables. The incidence of endophthalmitis was 1.8 per 1000 cataract extractions with retrobulbar anesthesia and 6.76 per 1000 with topical anesthesia (relative risk [RR], 3.76; 95% CI, 0.89-15.85). After the start of the study period was extended to May 2001, the incidence of endophthalmitis was 1.3 per 1000 cataract extractions with retrobulbar anesthesia and 8.7 per 1000 with topical anesthesia (RR, 6.72; 95% CI, 1.63-27.63). CONCLUSION: Results suggest that there may be an association between topical anesthesia and endophthalmitis after cataract extraction.

Pars plana vitrectomy, laser retinopexy, and aqueous tamponade for pseudophakic rhegmatogenous retinal detachment.

OBJECTIVE: To evaluate a novel pars plana vitrectomy (PPV) approach with aqueous tamponade for repair of primary pseudophakic rhegmatogenous retinal detachment (RRD). DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Sixty nonconsecutive patients (60 eyes) with primary pseudophakic RRD. INTERVENTION: Patients underwent PPV alone with injection of perfluoro-n-octane followed by fluid-air exchange and transscleral diode laser retinopexy and then balanced salt solution (BSS) tamponade. All patients were observed for at least 1 year. MAIN OUTCOME MEASURES: Anatomic outcome, visual acuity (VA), and complications. RESULTS: The mean follow-up period was 16.4 months (range, 12.1-21.5). Preoperatively, 32 patients (53.3%) had 1 break and 28 patients (46.7%) had 2 to 4 breaks (mean, 2.7). Intraoperatively, 108 retinal breaks were identified, 82 (75.9%) superior and 26 (24%) inferior. Eight breaks in 8 patients that were not seen preoperatively or intraoperatively were diagnosed after air-BSS exchange. Mean preoperative best-corrected VA (BCVA) was 20/700 (range, hand movements [HM]-20/20). Final BCVA was a mean of 20/59 (range, 20/200-20/20). For the 13 eyes with macula-attached RRD, BCVA was the same preoperatively and postoperatively (mean, 20/27; range, 20/50-20/20). For the 47 eyes with macula-detached RRD, the mean BCVA was 20/888 preoperatively (range, HM-20/50) and 20/68 postoperatively (range, 20/200-20/20). Final VA was > or =20/40 in 34 of 60 eyes (56.6%). Primary retinal reattachment (attachment at 1 month postoperatively) was attained in 59 of the 60 patients (98.3%). The single failure was due to a new break postoperatively; this break was treated by pneumatic retinopexy and photocoagulation of the break. At the 12-month follow-up visit, reattachment had been attained in all 60 eyes (100%). Postoperatively, 1 patient (1.6%) had hypotony at the 1-day postoperative visit, but intraocular pressure was 14 mm at the 4-day visit, and 2 patients (3.3%) had mild vitreous hemorrhage during the first 48 hours that resolved spontaneously during the following 10 days. CONCLUSION: Pars plana vitrectomy with laser retinopexy followed by BSS tamponade is effective for intraoperative sealing of retinal breaks causing pseudophakic RRD. We did not identify safety concerns in this 60-patient series.

Radial optic neurotomy in central retinal vein occlusion: comparison of outcome in younger vs older patients.

PURPOSE: To evaluate the effectiveness of radial optic neurotomy (RON) for central retinal vein occlusion (CRVO) in patients < or =50 years of age (group 1) vs those >50 (group 2). DESIGN: Prospective, interventional, comparative case series. METHODS: The study included 43 consecutive patients with CRVO and preoperative visual acuity (VA) < or =0.70 logarithm of minimal angle of resolution (logMAR). All patients underwent pars plana vitrectomy and RON at the nasal border of the optic disk. VA and optical coherence tomography (OCT) findings were recorded preoperatively and at one, six, and 12 months postoperatively. RESULTS: Systemic hypertension, diabetes, and open-angle glaucoma were statistically significantly more prevalent in group 2 (P < .05). One patient in group 1 had hyperhomocysteinemia, and had another antiphospholipid syndrome. Fifty percent of patients in group 1 gained > or =3 lines of Early Treatment Diabetic Retinopathy Study (ETDRS) vision, vs 33% in group 2. Mean final VA was 0.5 logMAR VA in group 1 vs 0.8 in group 2 (P = .04). Foveal thickness decreased significantly in both groups (P < .001). Ten patients (55.6%) in group 1 and 13 (54.2%) in group 2 developed retinochoroidal collaterals. CONCLUSIONS: Underlying systemic disease does not seem to be an important factor in the pathogenesis of CRVO in younger patients, and thrombophilia was present in only 11% of patients in this age group. RON yielded better functional results in younger patients, although functional improvement remained limited in those with low baseline VA.

Radial optic neurotomy for management of hemicentral retinal vein occlusion.

OBJECTIVE: To evaluate the effect of radial optic neurotomy on visual acuity (VA) and foveal thickness in patients with hemicentral retinal vein occlusion. METHODS: A prospective noncomparative case series of 13 eyes in 13 patients with hemicentral retinal vein occlusion and a preoperative VA of 20/60 or less from a total of 232 retinal vein occlusions diagnosed. All patients underwent pars plana vitrectomy, posterior hyaloid dissection, and radial optic neurotomy at the nasal border of the optic disc. RESULTS: Visual acuity and macular thickness were measured with optical coherence tomography. Nine patients (69.2%) gained 2 or more Snellen lines of vision, and in 4 patients (30.8%) VA improved by 4 or more Snellen lines (median visual acuity, 20/50; mean VA, 20/45; P<.01) (average gain, 2.7 Snellen lines). The decrease in foveal thickness was statistically significant (P<.01) (median decrease, 297 microm). Final VA was statistically related to decreased macular thickness at optical coherence tomography (P = .03; rho = -0.62). Retinochoroidal shunts developed in 6 patients (46.1%) at the radial optic neurotomy site. No surgical complications were observed. CONCLUSIONS: Radial optic neurotomy seems to be a potential treatment in selected patients with hemicentral retinal vein occlusion, probably because of the more rapid appearance of retinochorioretinal collateral vessels, which promote faster resolution of macular edema.

Reopening of 2 macular holes after neodymium:YAG capsulotomy.

We report 2 cases of reopening of macular holes after successful neodymium:YAG (Nd:YAG) posterior capsulotomy. Both patients had surgery for closure of macular holes with recovery of visual acuity. To our knowledge, this is the first report of recurrent macular holes after Nd:YAG laser posterior capsulotomy treated successfully with surgery.

Management of inferior breaks in pseudophakic rhegmatogenous retinal detachment with pars plana vitrectomy and air.

OBJECTIVE: To determine the role of pars plana vitrectomy without scleral buckling and air as a tamponade with 24 hours of prone positioning in the management of inferior breaks in primary pseudophakic rhegmatogenous retinal detachment. METHODS: Prospective, noncomparative, interventional case series. Fifteen consecutive eyes (15 patients) with primary pseudophakic rhegmatogenous retinal detachment with causative breaks located between the 4-o'clock and 8-o'clock positions underwent pars plana vitrectomy with air tamponade. The prone position was maintained for 24 hours. Anatomic and functional results are presented. RESULTS: The anatomic reattachment rate was 93.3% after 1 procedure and 100% at the 6-month visit. Mean preoperative best-corrected visual acuity was 20/60 (range, 20/400 to 20/25) and mean postoperative best-corrected visual acuity was 20/30 (range, 20/100 to 20/20). In 1 case the retina redetached at the second week because of an undetected break. Postoperative epiretinal membrane was observed in 1 case. CONCLUSION: Pars plana vitrectomy and air tamponade with only 24 hours of prone positioning postoperatively is effective in the management of primary pseudophakic rhegmatogenous retinal detachment with causative breaks between the 4-o'clock and 8-o'clock positions.

Pars plana vitrectomy alone for the management of inferior breaks in pseudophakic retinal detachment without facedown position.

OBJECTIVE: To introduce a new approach with pars plana vitrectomy (PPV) alone and no facedown positioning in the management of pseudophakic retinal detachments (RDs) with inferior breaks. DESIGN: Prospective noncomparative interventional case series. PARTICIPANTS: Forty consecutive pseudophakic eyes of 40 patients with rhegmatogenous RD with causative inferior breaks. INTERVENTION OR METHODS: All eyes underwent PPV alone, with air as tamponade and with no facedown position in the postoperative period. The supine position was used in some cases for 30 minutes. MAIN OUTCOME MEASURES: Postoperative primary and final anatomical outcome, visual acuity (VA), and complications. RESULTS: Patients were observed for a minimum of 7 months (mean, 11.7). Primary retinal reattachment was obtained in 36 of 40 patients (90%). Final reattachment was obtained in 40 of 40 patients (100%). One patient (2.5%) developed proliferative vitreoretinopathy at the sixth week after surgery. Three patients (7.5%) redetached, presumably due to untreated breaks. Two patients (5%) developed a macular epiretinal membrane that required surgery. Mean preoperative best-corrected VA (BCVA) was 20/63 (range, hand movements [HM] to 20/20). Mean final BCVA was 20/33 (range, 20/200-20/20). Of the 16 eyes with a macula-attached rhegmatogenous RD, mean preoperative BCVA was 20/29 (range, 20/100-20/20). Mean postoperative BCVA was 20/30 (range, 20/60-20/20). Of the 24 eyes with macula-detached RDs, mean preoperative BCVA was 20/300 (range, HM to 20/40). Mean postoperative BCVA was 20/36 (range, 20/200-20/20). Visual acuity of 20/40 or better was seen in 17 of 24 eyes (70.8%). CONCLUSIONS: This pilot study provides evidence that the facedown posture after PPV is not necessary to achieve retinal reattachment in pseudophakic RD with inferior breaks.

Rhegmatogenous retinal detachment in phakic eyes after posterior chamber phakic intraocular lens implantation for severe myopia.

OBJECTIVE: To report the clinical presentation, surgical management, and outcomes of rhegmatogenous retinal detachment (RRD) in patients with severe myopia corrected by posterior chamber phakic (PCP) intraocular lens (IOL) implantation. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: Sixteen eyes of 15 patients in whom retinal detachment developed after PCP IOL implantation. METHODS: The 16 eyes with retinal detachment after PCP IOL implantation underwent scleral buckling and pars plana vitrectomy. MAIN OUTCOME MEASURES: Uncorrected visual acuity, refraction, best spectacle-corrected visual acuity (BSCVA), time between refractive procedure and RRD, vitreoretinal findings, and anatomic reattachment rate. RESULTS: The incidence of RRD after PCP IOL implantation was 2.07%. Mean patient age was 32.9 years (range, 23-46). Nine patients underwent bilateral PCP IOL implantation (60%). Primary RRD developed in 16 eyes of 15 patients. Prophylactic laser photocoagulation was performed in 3 eyes of 3 patients (18.75%). Mean preoperative spherical equivalent (SE) was -17.3+/-2.47 diopters (D) (range, -13.75 D to -22 D). Rhegmatogenous retinal detachment occurred from 1 to 70 months after PCP IOL implantation (mean, 29.12 months). Each of 11 RRDs (68.75%) had 1 causative break. Fourteen breaks (60.86%) were horseshoe tears and 9 (39.14%) were atrophic holes. Scleral buckling was performed in 10 eyes (62.5%). Pars plana vitrectomy alone was performed in 5 cases (31.25%) with posterior breaks. Initial reattachment rate was 90.9%. Final retinal reattachment was 100%. Mean postoperative BSCVA was 20/28 (decimal fraction, 0.72+/-0.25). Mean follow-up after retinal detachment surgery was 35.25+/-17.29 months (range, 12-67 months). CONCLUSIONS: Rhegmatogenous retinal detachment after PCP IOL implantation is rare. Case-control studies are warranted to determine whether this surgical procedure increases the risk of retinal detachment in these patients. The characteristics of RRD do not differ from the natural history of retinal detachment. Surgical management of RRD was successful in restoring vision in our patients. This article contains additional online-only material available at .

Silicone posterior chamber phakic intraocular lens dislocated into the vitreous cavity.

PURPOSE: To report two highly myopic patients with silicone posterior chamber phakic intraocular lenses (Phakic Refractive Lens; CIBA Vision, Duluth, Ga) that luxated into the vitreous cavity without history of ocular trauma. METHODS: Two patients with posterior chamber phakic intraocular lenses (PIOLs) that luxated into the vitreous cavity of the right eye were examined. Each eye underwent pars plana vitrectomy and removal of the posterior chamber PIOL under retrobulbar anesthesia. RESULTS: Both patients were treated successfully. In the first patient, the posterior chamber PIOL luxated into the anterior vitreous cavity whereas in the second patient, the posterior chamber PIOL lay on the posterior pole. No ocular complications developed postoperatively. CONCLUSION: Luxation into the vitreous cavity is a rare, but potentially severe complication of posterior chamber PIOL refractive surgery in highly myopic eyes. Successful management includes pars plana vitrectomy and removal of the posterior chamber PIOL.