Randomised controlled trial on robot-assisted versus manual surgery for pucker peeling.

BACKGROUND: The aim was to explore the feasibility and safety of performing common surgical steps in epiretinal membrane (ERM) peeling using the Preceyes Surgical System (PSS). METHODS: In a tertiary centre, 15 pseudophakic patients with an idiopathic ERM were randomised to robot-assistance or manual surgery in a 2:1 ratio. In the robot-assisted group, the following steps were performed using PSS: (1) staining the internal limiting membrane (ILM), (2) removal of the dye, (3) creating an ILM flap, (4) completing the peeling, (5) holding a light pipe and (6) fluid-air exchange. Primary outcome measures were feasibility and safety. Secondary outcome measures were duration, best-corrected visual acuity (BCVA) and central retinal thickness (CRT). Moreover, the distance travelled by the instrument during peeling was assessed using motion tracking software. RESULTS: All steps performed with PSS were feasible with no clinical adverse events or complications. The surgical time was longer in the robot-assisted group (mean 56 min, SD = 12 vs. 24 min, SD = 5). During the study, the duration of robot-assisted surgeries decreased from 72 to 46 min. The distance travelled by the forceps was shorter in the robot-assisted group (mean 403 mm, SD = 186 vs. 550 mm, SD = 134). BCVA and CRT improved equally in both groups. CONCLUSIONS: This is the world's first randomised controlled trial on robotic surgery for ERM. Although more time-consuming, we found that several surgical steps were feasible with assistance of the PSS.

Destructive inflammatory reaction after an autologous retinal pigment epithelium and choroid transplantation: no detection of an auto-immune response.

PURPOSE: Five patients who underwent uncomplicated retinal pigment epithelium (RPE)-choroid transplantation for neovascular age-related macular degeneration developed a destructive inflammatory reaction causing subretinal fluid accumulation and extensive RPE atrophy in the graft. We hypothesized that this inflammation could be caused by an auto-immune response against the graft, resulting in circulating auto-antibodies. The aim of our study was to examine a potential autoimmune origin, which would allow a more targeted therapy approach. METHODS: Five above-mentioned patients and four control groups of five patients each were included: 1) after uncomplicated RPE-choroid transplantation, 2) after full macular translocation, 3) treated with anti-vascular endothelial growth factor, and 4) healthy controls. Histopathology of rejected graft tissue was performed using standard procedures. Presence of RPE-choroid autoantibodies in serum was examined by indirect immunofluorescence and Western blot, and human leukocyte antigen (HLA) typing was performed. RESULTS: Histopathological examination of an explanted graft showed infiltration of T-lymphocytes and macrophages in the choroid and RPE, and an increased number of B-cell lymphocytes were found in the choroid. Indirect immunofluorescence showed weak RPE-choroid autoantibody immunoreactivity in three patients of different groups. Western blot did not show specific RPE-choroid autoantibody immunoreactivity and no difference of HLA genotypes between the groups was found. CONCLUSIONS: Although local mononuclear inflammatory cell infiltration and a high number of B-lymphocytes were observed in an explanted graft, we did not detect serological evidence of an autoimmune origin of the postoperative inflammation using direct immunofluorescence and Western Blot. Alternatively, the graft failure may have been caused by local innate inflammation, triggered by breakdown of tolerance. Based on our current findings of this small study group, we have no rationale to pursue therapies targeted towards autoreactive graft failure. More research is needed to confirm our findings.

Surgery for Combined Hamartoma of the Retina and Retinal Pigment Epithelium.

There is no consensus on whether and when surgical treatment is indicated for combined hamartoma of the retina and retinal pigment epithelium (CHRRPE). We aim to discuss the benefits of surgical intervention and techniques that may improve the outcome. A 24-year-old man experienced progressive visual loss for 6 months in his left eye due to CHRRPE. At presentation, visual acuity was 1.3 LogMAR and fundoscopy revealed extensive tractional pre- and epiretinal membranes, subretinal exudation, and a vasoproliferative tumor in the inferior periphery. A complete vitrectomy was performed, while paying special attention to vitreous shaving at the vitreous base and removal of vitreoschisis-induced vitreous cortex remnants (VCR) from the retinal surface posterior to the vitreous base. Tractional membranes and internal limiting membrane were peeled, and the vasoproliferative tumor was excised. Silicone oil tamponade was removed 11 weeks after surgery. No intra- or postoperative complications occurred. Visual acuity improved to 0.8 LogMAR and remained stable for 48-month follow-up. Vitreoretinal surgery can prevent complications that occur with CHRRPE. In addition, visual function may improve even if the initial visual acuity is low. Timely and complete vitrectomy with extensive membranectomy and detection and removal of VCR is recommended to avoid complications in challenging CHRRPE.

Prevalence and Severity of Diabetic Retinopathy in Patients with Macular Telangiectasia Type 2.

PURPOSE: To study the prevalence and severity of diabetic retinopathy (DR) in patients with macular telangiectasia type 2 (MacTel 2). DESIGN: Retrospective case series. PARTICIPANTS: Patients with a diagnosis of MacTel 2 treated at the Rotterdam Eye Hospital or Erasmus Medical Center between 2014 and 2018 were included. METHODS: The following information was retrieved from patient files: demographics, history of diabetes mellitus and hypertension, presence of DR, and severity of DR, that is, mild, moderate, severe, or proliferative. Presence of diabetic macular edema (DME) was assessed using OCT. MAIN OUTCOME MEASURES: Presence and severity of DR. RESULTS: Two hundred six eyes of 103 patients were included. At the onset of MacTel 2, the mean age was 61 years (standard deviation [SD], 9.8 years) and 64 (62%) were women. Mean follow-up was 71 months (SD, 60 months). Diabetes mellitus type 2 was present in 50 patients (49%) and hypertension was present in 47 patients (46%). Mild DR was present in 22 eyes (11%), of which 14 eyes (7%) showed signs at baseline and 8 eyes (4%) showed signs at a later time during follow-up. Ten eyes (5%) demonstrated remission of mild DR during follow-up. Both eyes (1%) in 1 patient progressed to moderate DR. Severe DR, proliferative DR, and DME did not occur. CONCLUSIONS: Although diabetes mellitus was highly prevalent among MacTel 2 patients, no patients showed severe or proliferative DR or DME. These findings suggest that MacTel 2 could have a protective effect on the progression of DR. We hypothesize that our results may be explained by the role of Müller cells in the development of MacTel 2 and DR, and therefore a link between both diseases warrants additional studies.

Clinical Evaluation of an Instrument-Integrated OCT-Based Distance Sensor for Robotic Vitreoretinal Surgery.

Purpose: To assess the efficacy of an instrument-integrated OCT (iiOCT)-based distance sensor during robotic vitreoretinal surgery using the Preceyes Surgical System (PSS; Preceyes B.V.). Design: Single-center interventional study. Participants: Patients requiring vitreoretinal surgery. Methods: Five patients were enrolled. Standard preoperative OCT images were obtained. After vitrectomy, a predefined set of actions was performed using the iiOCT-based sensor. Images then were processed to assess the signal-to-noise ratio (SNR) at various angles to the retina and at different distances between the instrument tip and the retinal surface. Preoperative and intraoperative OCT images were compared qualitatively and quantitatively. Main Outcomes Measures: The feasibility in performing surgical tasks using the iiOCT-based sensor during vitreoretinal surgery, the SNR when imaging the retina, differences among intraoperative and preoperative OCT images, and characteristics of intraoperative retinal movements detected with the iiOCT-based probe. Results: Surgeons were able to perform all the tasks but one. The PSS was able to maintain a fixed distance. The SNR of the iiOCT-based sensor signal was adequate to determine the distance to the retina and to control the PSS. Analysis of iiOCT-based sensor A-scans identified 3 clearly distinguishable retinal layers, including the inner retinal boundary and the interface at the retinal pigment epithelium-Bruch's membrane. Thickness values differed by less than 5% from that measured by preoperative OCT, indicating its accuracy. The Fourier analysis of iiOCT-based sensor recordings identified anteroposterior retinal movements attributed to heartbeat and respiration. Conclusions: This iiOCT-based sensor was tested successfully and promises reliable use during robot-assisted surgery. An iiOCT-based sensor is a promising step toward OCT-guided robotic retinal surgery.

RETINAL PIGMENT EPITHELIUM-CHOROID GRAFT WITH A PERIPHERAL RETINOTOMY FOR EXUDATIVE AGE-RELATED MACULAR DEGENERATION: Long-Term Outcome.

PURPOSE: To investigate the long-term outcome of autologous retinal pigment epithelium -choroid transplantation with a peripheral retinotomy for exudative age-related macular degeneration. METHODS: In a retrospective study, we selected all patients who underwent a retinal pigment epithelium-choroid transplantation from 2007 through 2013. Exclusion criteria were age <60 years, <12 months of follow-up, and retinal pigment epithelium-choroid graft for other diseases than age-related macular degeneration. The main outcome measure was best-corrected visual acuity converted into logarithm of the minimum angle of resolution. RESULTS: In this study, 81 patients were included with a mean follow-up of 38 months (SD = 19). Median best-corrected visual acuity improved from 1.30 logarithm of the minimum angle of resolution (20/400 Snellen) to 0.90 logarithm of the minimum angle of resolution (20/160 Snellen) 1 year after surgery (P < 0.001). A ≥3-line gain was achieved in 43 patients (53%) 1 year postoperatively and 37 patients (46%) preserved their visual gain until last visit. Of 4 patients with an 8-year follow-up, 3 patients had a ≥6-line gain at last visit. Severe complications were submacular hemorrhage (n = 8, 10%), macular hole (n = 6, 7%), and proliferative vitreoretinopathy (n = 3, 4%). CONCLUSION: Best-corrected visual acuity improved significantly after retinal pigment epithelium-choroid transplantation in patients with age-related macular degeneration and preservation of visual gain was possible in the long term.

Morphological changes in the diseased retina on a healthy choroid-retinal pigment epithelial complex after full macular translocation for exudative age-related macular degeneration.

PURPOSE: To describe the change in the retinal morphology after full macular translocation (FMT) for exudative age-related macular degeneration (AMD) and identify predictive factors for the visual outcome. METHODS: All patients who underwent FMT from December 2008 through July 2013 were selected. Exclusion criteria were FMT for other disease than AMD, age <60 years, <12 months of follow-up or no available images. Spectral domain optical coherence tomography, fundus autofluorescence, fluorangiography and indocyanine green angiography were evaluated. RESULTS: In total, 51 patients were included with a mean follow-up of 30 months. The presence of the external limiting membrane (ELM) was a significant predictor for a favourable visual outcome 1 year after FMT (OR = -0.30). Other significant predictive factors were the absence of intraretinal fluid (OR = 0.28) and the mixed choroidal neovascularization type (OR = -0.47), whereas nonresponders (OR = 0.41) and fibrotic lesions (OR = 0.35) were less likely to have a good visual function after surgery. CONCLUSION: Full macular translocation (FMT), that permits to relocate the diseased macula onto an area of unaffected retinal pigment epithelial and choroid, can restore the anatomy and visual function in some patients with AMD when the outer retina layers are not irreversibly damaged. The presence of the ELM seems to be the most reliable factor in predicting the functional outcome.

Long-Term Results of Full Macular Translocation for Choroidal Neovascularization in Age-Related Macular Degeneration.

PURPOSE: To investigate the long-term outcome of full macular translocation (FMT) for neovascular age-related macular degeneration (AMD) and to identify predictive factors. DESIGN: Retrospective, uncontrolled case series. PARTICIPANTS: Patients were considered for FMT if they had low vision in the fellow eye and choroidal neovascularization (CNV) along with (1) no response to vascular endothelial growth factor (VEGF) inhibitors, (2) retinal pigment epithelium (RPE) tear, (3) subretinal hemorrhage, (4) foveal scar tissue of recent onset, or (5) CNV before the availability of VEGF inhibitors. From 2004 through 2012, a total of 255 patients underwent FMT. Exclusion criteria were patients younger than 60 years, FMT for disease other than AMD, and a follow-up of less than 12 months. METHODS: Preoperative, annual, and last distance best-corrected visual acuity (BCVA) were obtained retrospectively from patient files. Complications were recorded using funduscopy, optical coherence tomography, autofluorescence, and angiography. MAIN OUTCOME MEASURES: Distance BCVA at 1 year and 5 years after surgery and at last visit compared with preoperative BCVA. RESULTS: One hundred fifty-eight patients (mean follow-up, 45 months) were included. Median BCVA improved from 0.90 logarithm of the minimum angle of resolution (logMAR) before surgery to 0.70 logMAR 1 year after FMT (2 lines gained; P = 0.000). In a subgroup of 56 patients followed up for 5 years or more, median BCVA improved from 0.95 logMAR before surgery to 0.70 logMAR 1 year after surgery, and remained improved 5 years after FMT with a median BCVA of 0.80 logMAR (1.5 lines gained compared with preoperative BCVA; P = 0.000). The main complications were foveal RPE atrophy (n = 73; 47%) and CNV recurrence (n = 47; 30%). Foveal RPE atrophy (odds ratio [OR], 7.0), CNV recurrence (OR, 2.6), and proliferative vitreoretinopathy (PVR; OR, 17.6) were statistically significant predictors (P < 0.05) for losing 1 line or more at last visit. CONCLUSIONS: In this study, BCVA was improved up to 5 years after FMT. Foveal RPE atrophy, CNV recurrence, and PVR carried a worse prognosis. In patients who are unlikely to benefit from VEGF inhibitors, FMT can be considered for second eyes with neovascular AMD.

Is Hyperopia an Important Risk Factor for PACG in the Dutch Population?-A Case Control Study.

Objectives. To determine if hyperopia is a risk factor for primary angle-closure glaucoma (PACG) in the Dutch population and to identify other biometrical parameters as risk factors for PACG including axial length (AL), anterior chamber depth (ACD), and k values. Methods. The study population consisted of PACG patients that had undergone a laser peripheral iridotomy (LPI). The control group consisted of age- and gender-matched cataract patients. The main outcome was hyperopia (spherical equivalent ≥+0.5 dioptres) measured with IOL Master or autorefractor. Refractive error, ACD, AL, and k values were tested with a Mann-Whitney U test and by logistic regression. Results. 117 PACG patients and 234 controls were included (mean age = 80 years ± 3.6). The prevalence of hyperopia in patients and controls was 69.6% and 61.1%, respectively (Fisher's test P = 0.076). Mann-Whitney U test showed no statistically significant relation with refractive error (P = 0.068) or k values (P = 0.607). In contrast, ACD and AL were statistically significant (P < 0.001). Tested with logistic regression, only ACD was a significant predictor of PACG (P < 0.001). Conclusion. There was no statistically significant correlation between refractive error and PACG. ACD was strongly correlated, though, with PACG, whereas AL turned out to be a less significant risk factor.