Intravitreal anti-VEGF treatment in eyes with combined choroidal neovascularisation and vitreomacular traction syndrome.

PURPOSE: To report the effect of intravitreal anti-vascular endothelial growth factor injections (IVI) on visual acuity in eyes with choroidal neovascularisation (CNVM) and co-existent vitreomacular traction (VMT) or when VMT has developed during the course of treatment. METHODS: Retrospective interventional case series of seven eyes in seven patients. VMT was monitored with serial optical coherence tomography scans. RESULTS: The mean age at presentation was 74 years (range 64-95 years). All patients presented with blurring of central vision, rather than distortion. The aetiology of CNVM was wet age-related macular degeneration in five eyes (72%), angioid streaks in one eye (14%) and pathological myopia in one eye (14%). Ranibizumab was used in four eyes (57%) and bevacizumab in three (43%) for the active CNVM component. The mean follow-up was 11 months (range 2-28 months). None of the eyes in this series required surgery for the VMT component, nor were there any cases of spontaneous resolution of VMT. Visual acuity was stabilised or improved in five of the seven eyes (71%) with IVI. Visual acuity results across the whole group were gain of three or more lines of Snellen visual acuity in two eyes (28%), gain of up to three lines in three eyes (42%), no change in visual acuity in one eye (14%) and loss of up to three lines in one eye (14%). There were no eyes losing more than three lines of Snellen visual acuity. In four eyes with pre-existing VMT, visual acuity improved in three with IVI. In three eyes that developed VMT after IVI, visual acuity improved in two with IVI. Delay from diagnosis of CNVM to treatment with IVI contributed to a poor response. CONCLUSIONS: Most eyes improved visual acuity with IVI for combined CNVM and VMT. Despite the often dramatic features of VMT on optical coherence tomography, treatment of co-existing CNVM should be prompt. Vitreoretinal surgery was not required in this series, but is held in reserve if there is still potential for gain in vision following CNVM resolution.

Hydrophobic acrylic and plate-haptic silicone intraocular lens implantation in diabetic patients: pilot randomized clinical trial.

PURPOSE: To compare the capsular and uveal reaction after implantation of a plate-haptic silicone intraocular lens (IOL) (C11UB, Chiron) and a hydrophobic acrylic (AcrySof MA60, Alcon) IOL in diabetic patients. SETTING: Moorfields Eye Hospital and St. Thomas' Hospital, London, United Kingdom. METHODS: Thirty-five diabetic patients were recruited consecutively and randomly assigned to have implantation of either of the 2 IOLs. The percentage area of posterior capsule opacification (PCO), anterior capsule contraction (ACC), and postoperative inflammatory indices (flare and cells) were assessed objectively at 2 to 3 weeks, 6 months, and 1 year. Between-group and within-group analyses were conducted using the Student t test or Mann-Whitney test and Friedmann test, respectively. RESULTS: Between-group analysis showed the percentage area of PCO was significantly greater in patients with plate-haptic silicone IOLs at 6 and 12 months (P = .002). At 6 months, ACC was significantly greater in the plate-haptic group (P = .04), but the difference was not significant at 12 months. There was higher flare in the hydrophobic acrylic IOL group than in the plate-haptic silicone IOL group at 2 to 3 weeks (P = .08). Within-group analysis showed that over the follow-up period, the plate-haptic silicone group, but not the hydrophobic acrylic group, had a progressive increase in PCO (P = .003). In the hydrophobic acrylic group, but not the plate-haptic silicone group, there was a significant reduction in the mean anterior chamber flare value (P = .01). There was no significant difference in visual acuity or contrast sensitivity at any postoperative visit. CONCLUSION: In diabetic patients, hydrophobic acrylic IOLs can lead to an increased flare in the early postoperative period but they seem to be more favorable than plate-haptic silicone IOLs because the latter lead to more PCO.

Optical coherence tomography of intraocular lens implants and their relationship to the posterior capsule: a pilot study comparing a hydrophobic acrylic to a plate-haptic silicone type.

BACKGROUND: Optical coherence tomography (OCT) has been used to examine the anterior as well as the posterior segment and can be used to examine the intraocular lens (IOL) and their relationship to the posterior capsule in vivo. OBJECTIVES: To use OCT to examine two of the IOLs and some of the features related to the development of posterior capsular opacification (PCO). METHODS: This is a pilot study of a prospective (n = 12) and a retrospective (n = 14) series of patients who had uneventful phacoemulsification and IOL implantation of either hydrophobic acrylic (Acrysof; Alcon) or plate-haptic (PH) silicone (C11UB; Chiron, Bausch & Lomb) IOLs. The outcome of interest was the ability of OCT to clearly delineate the outline of the IOL optics and their appositional relationship to the posterior capsule. RESULTS: OCT showed that hydrophobic acrylic IOLs had a better defined outline than PH silicone IOLs. It also showed close apposition between hydrophobic acrylic optics and the mid-peripheral part of the posterior capsule and the absence thereof with PH silicone IOLs. CONCLUSIONS: Hydrophobic acrylic implants have better definition on the OCT scans than PH silicone and they develop close apposition to the posterior capsule. The latter feature is consistent with the 'no space, no cell, no PCO' concept and what is known about the effect of the implant material and design on the rate of PCO.

Cataract surgery in diabetes.

Recent studies of cataract surgery in diabetes confirm retinopathy severity and macular edema as the principal determinants of postoperative visual acuity, and link improved visual outcomes to the shift from conservative management toward earlier surgical intervention.

Phacoemulsification versus extracapsular cataract extraction in patients with diabetes.

OBJECTIVE: To compare phacoemulsification with extracapsular cataract surgery in patients with diabetes and to identify determinants of postoperative visual acuity. DESIGN: Prospective, randomized, paired-eye trial. PARTICIPANTS: Forty-six patients with diabetes and bilateral cataract. INTERVENTION: Patients were allocated to phacoemulsification surgery with silicone intraocular lens to one randomly determined eye, and extracapsular cataract surgery with 7-mm polymethylmethacrylate intraocular lens to the other. MAIN OUTCOME MEASURES: Logarithm of minimum angle of resolution visual acuity (logMAR VA), incidence of clinically significant macular edema (CSME), retinopathy progression, indices of anterior segment inflammation, and incidence of capsulotomy. RESULTS: Compared with eyes undergoing phacoemulsification, eyes managed with extracapsular surgery had more anterior chamber cells (P = 0.0004) and flare (P = 0.007) 1 week after surgery and a higher incidence of posterior synechiae (P = 0.04) and intraocular lens deposits (P < 0.0005) in the first postoperative year. The need for posterior capsulotomy was greater in eyes undergoing extracapsular surgery (16 of 46 vs. 5 of 46, P = 0.01). No difference in incidence of postoperative CSME, progression of retinopathy, or development of high-risk proliferative retinopathy was identified between techniques (P = 1.0, 0.8, and 0.2). Median 1-year logMAR VA was worse in eyes undergoing extracapsular surgery (0.08 vs. 0.06, P = 0.02), especially in those with retinopathy (0.14 vs. 0.08, respectively; P = 0.01). The presence or absence of CSME at the time of surgery was the most significant determinant of 1-year logMAR VA in regression models for both extracapsular (P = 0.0004, R2 = 0.45) and phacoemulsification groups (P < 0.00005, R2 = 0.46). CONCLUSIONS: Phacoemulsification is associated with better postoperative VA, less postoperative inflammation, and less need for capsulotomy than extracapsular cataract surgery in patients with diabetes. However, with both techniques, the principal determinant of postoperative VA appears to be the presence or absence of CSME at the time of surgery. Early intervention, reducing the risk that unrecognized CSME is present at the time of surgery, may be more critical to outcome than choice of surgical technique.

Panretinal photocoagulation during cataract extraction in eyes with active proliferative diabetic eye disease.

PURPOSE: Cataract surgery in the presence of active proliferative diabetic eye disease carries a high risk of progression of retinopathy and neovascular glaucoma. Lens opacities may prevent panretinal photocoagulation (PRP) before surgery, and applying PRP in the immediate post-operative period can be difficult. The purpose of this study is to report results of cataract extraction combined with per-operative indirect laser PRP in a group of these patients. METHODS: Nine eyes of 9 diabetic patients with active retinal or iris neovascularisation in which lens opacities prevented adequate pre-operative PRP underwent cataract surgery combined with indirect laser PRP after cortex aspiration and before intraocular lens implantation. RESULTS: Regression of neovascularisation with this combined procedure alone was achieved in 5 eyes, 3 responded to further PRP, and 1 developed neovascular glaucoma. Visual acuity improved in all eyes, 4 achieving > or = 6/12. Four patients developed increased post-operative uveitis. One developed clinically significant macular oedema. CONCLUSIONS: The method described has definite practical advantages over PRP attempted in the immediate post-operative period, when many factors can prevent its application or reduce its effectiveness, and when neovascularisation may be progressing rapidly. In addition, adjunctive per-operative indirect laser PRP appears to improve the outcome of cataract surgery in eyes with active proliferative diabetic eye disease.

The natural history of macular edema after cataract surgery in diabetes.

OBJECTIVE: To determine the natural history of macular edema after cataract surgery in diabetes to provide a rational basis for laser therapy. DESIGN: Prospective clinical and angiographic trial. PARTICIPANTS: Thirty-two patients with diabetes undergoing cataract surgery. INTERVENTION: Phacoemulsification surgery with intraoperative fluorescein angiography, and postoperative clinical and angiographic assessment without macular laser therapy for 1 year after surgery. MAIN OUTCOME MEASURES: Clinically significant macular edema, postoperative macular and optic disc hyperfluorescence relative to the intraoperative angiogram, and logarithm of the minimum angle of resolution (LogMAR) visual acuity. RESULTS: In the first postoperative year, macular fluorescence remained at its intraoperative level in 2 (6%) of 32 eyes and increased in 30 (94%) of 32 eyes, returning to its intraoperative level within 1 year of surgery in 13 (43%) of 30 eyes. Optic disc fluorescence remained at its intraoperative level in 2 (6%) of 32 eyes, was not graded in 3 (9%) of 32 eyes, and increased in 27 (84%) of 32 eyes, returning to its intraoperative level within 1 year of surgery in 19 (70%) of 27 eyes. Clinically significant macular edema was identified in the first postoperative year in 18 (56%) of 32 eyes, being present at the time of surgery in 5 eyes and arising de novo within 1 year of surgery in 13 eyes. It resolved spontaneously within 1 year of surgery in 0 of 5 eyes in which it had been present at the time of surgery and in 9 (69%) of 13 eyes in which it arose in the first 6 months after surgery (P = 0.05). Angiographic and clinical resolutions of macular edema were less likely in eyes with more severe retinopathy at the time of surgery (P = 0.03, 0.005). One-year LogMAR acuity of 0.3 or less (> or = 20/40) was achieved in 27 (84%) of 32 eyes. Clinically significant macular edema at the time of surgery was associated with poorer 1-year visual acuity in multivariate analysis (P = 0.005, r2 = 0.5). CONCLUSIONS: Clinically significant macular edema present in diabetic eyes at the time of cataract surgery is unlikely to resolve spontaneously, but clinically significant macular edema arising after surgery commonly resolves, particularly if retinopathy is mild. These findings have implications for the timing of cataract surgery in diabetes and postoperative macular laser therapy. Ophthalmology 1999;106:663-668

Identifying maculopathy after neodymium: YAG membranotomy for dense diabetic premacular hemorrhage.

PURPOSE: To assess the value of neodymium:YAG membranotomy in achieving rapid intravitreal dispersion of dense diabetic premacular hemorrhage and allowing the identification and treatment of maculopathy before panretinal photocoagulation (PRP). METHODS: A pilot study, in which nine eyes with dense diabetic premacular hemorrhages were treated with neodymium:YAG membranotomy, is described. After intravitreal dispersion of premacular blood, fundus examination and fluorescein angiography were performed to identify neovascularization and macular edema. Macular photocoagulation was performed before PRP in eyes with co-existing maculopathy and neovascularization. RESULTS: Complete intravitreal dispersion was achieved in all eyes within 1 week. Clinically significant macular edema was identified and treated, before PRP, in three eyes. No exacerbation of macular edema occurred after PRP, and visual acuity was stabilized at pre-hemorrhage levels in seven eyes and to within one line in the remaining two eyes. No traction retinal detachments or rebleeding occurred, and vitrectomy was not required in any eye. CONCLUSIONS: Early neodymium:YAG membranotomy may obviate the need for early vitrectomy for dense diabetic premacular hemorrhage, and allows early identification and treatment of maculopathy, before PRP, thus reducing the risk of exacerbation after PRP. Further studies to evaluate this treatment modality, particularly with respect to long-term visual prognosis, appear warranted.

Perimetric and angiographic effects of retinotomy.

AIM: We sought to characterise the morphological and functional effects of drainage retinotomy on the vascular, neural, subretinal and epiretinal components of the affected retina. PATIENTS AND METHODS: Following successful retinal reattachment surgery involving drainage retinotomy in 15 cases (retinotomy group) and no retinotomy in 14 cases (control group), the existence, nature and quadrantic area of visual field loss to a white III4e target was determined using kinetic Goldmann perimetry. Vascular alterations were characterised using fluorescein angiography with peripheral sequences. RESULTS: Visual field defects within 30 degrees of fixation were present in 12 of 14 (86%) of the retinotomy group (including all eyes in which the retinotomy was sited within five disc diameters of fixation) and none of the control group (Fisher exact test, P = 0.00005). Following superonasal retinotomy, inferotemporal field area (median area 82 units, range 44 to 128) was approximately half that following superotemporal retinotomy (median area 167 units, range 119 to 192) (Wilcoxon's ranksum P = 0.003). No vascular abnormalities distal to the retinotomy were identified, although subretinal neovascularization (two eyes) and epiretinal membrane formation (one eye) occurred at the retinotomy site. CONCLUSION: We recommended that where possible subretinal fluid be drained via existing breaks, and if retinotomy is necessary, that it should be sited more than five disc diameters from fixation in the supertemporal quadrant to minimise visual field loss.

Extraconal bupivacaine in scleral buckling procedures.

BACKGROUND: Intraoperative retrobulbar bupivacaine injection provides effective analgesia after scleral buckling procedures performed under general anesthesia, but is associated with significant risks. METHODS: The safety and analgesic efficacy of an extraconal technique using a blunt cannula was evaluated. Forty patients undergoing scleral buckling procedures with general anesthesia were randomized to intraoperative extraconal bupivacaine injection (bupivacaine group. n = 21) or to no such treatment (control group, n = 19). General anesthetic and postoperative analgesia regimens were standardized. Analgesia requirements, pain, nausea, and sedation levels were graded at four intervals the first 24 hours after surgery. Chemosis was assessed 1 day after surgery, and ocular motility was assessed at 1 day, 1 week, and subsequent review. RESULTS: Maximum, 0 to 2-hour, and 4 to 6-hour pain levels were lower in the bupivacaine group than the control group (Wilcoxon rank sum, P < 0.005, < 0.005, < 0.01, respectively). Postoperative analgesia was required within the first 24 hours of surgery by all patients in the control group, but by only 12 of 21 patients (57%) in the bupivacaine group (Fisher's exact test, P = 0.001). Ptosis with minimal supraduction defect was noted at first postoperative examination in two patients who had undergone extraconal bupivacaine injection but resolved within 1 week. No other complication was encountered. CONCLUSION: Intraoperative extraconal bupivacaine injection appears to be a safe and effective method for reducing pain and analgesia requirements after scleral buckling procedures performed under general anesthesia.

Diode laser contact transscleral retinal photocoagulation: a clinical study.

AIM: To examine the clinical efficacy of contact transscleral retinal photocoagulation with a diode laser. METHODS: Transscleral retinal photocoagulation was performed on 36 eyes. The conditions treated included peripheral retinal breaks associated with retinal detachments (30 eyes) and giant retinal tears (six eyes). Of the 30 eyes with retinal detachments, 28 underwent transscleral photocoagulation to the site of drainage of subretinal fluid in an attempt to reduce the risk of hemorrhage. RESULTS: Threshold lesions were obtained with irradiances of between 95.4 W/cm2 and 191 W/cm2. Satisfactory chorioretinal adhesion was achieved in all eyes with retinal breaks and giant retinal tears. The only significant complications of treatment encountered were punctate choroidal haemorrhages (three eyes). Drainage related choroidal haemorrhage following earlier photocoagulation occurred in two of 28 eyes. CONCLUSIONS: This study confirms the clinical potential of transscleral diode laser photocoagulation in the therapy of surgical retinal conditions.

Modulation of amblyopia therapy following early surgery for unilateral congenital cataracts.

BACKGROUND: Stimulus deprivation amblyopia is the principal cause of visual impairment in infants with unilateral congenital cataract. Even if lensectomy is undertaken at an early age, intensive postoperative occlusion of the phakic eye is essential for the development of useful vision in the aphakic eye. Despite this, the optimum method of regulating occlusion therapy is uncertain. METHODS: Interocular acuity differences identified using clinical preferential looking techniques (Keeler cards) were used to regulate target levels of phakic eye occlusion in a prospective evaluation of 10 systemically, metabolically, and neurologically normal infants in whom dense unilateral cataract was diagnosed before 8 weeks of age, and operated upon by 10 weeks. Actual occlusion levels were recorded each day by parents in a diary. The development of preferential looking acuity in the phakic and aphakic eye were compared with prediction intervals derived from observations on 43 normal children. RESULTS: Aphakic eye preferential looking acuities were within the normal range at last review in all but one infant. Interocular acuity differences were < or = 0.5 octave in all children older than 1 year of age at last review, and > or = 1 octave in three of four children less than 1 year old at last review (Fisher exact p = 0.033). Phakic eye acuities were within the normal range in all infants at all visits. CONCLUSION: Within the first 2 years of life, normal preferential looking acuity may be achieved in both eyes of infants undergoing early surgery for unilateral congenital cataract if occlusion therapy is modulated according to interocular acuity differences quantified by clinical preferential looking techniques.

Retinal detachment and herpesvirus retinitis in patients with AIDS.

BACKGROUND: The prolongation of survival of patients with herpesvirus retinitis and AIDS has been associated with a rise in the incidence of retinal detachment. In such cases, however, retinal reattachment may be difficult to achieve, and postoperative visual acuity may be poor despite anatomically successful surgery. METHODS: In order to examine factors affecting the visual outcome of surgery, a retrospective review of 29 patients with retinal detachment, herpesvirus retinitis, and AIDS was performed. Retinal reattachment surgery (32 procedures) or prophylactic laser demarcation (five procedures) was performed in 28 eyes of 23 patients. RESULTS: The macula was attached in 23/28 (82%) eyes at the last outpatient visit. Best postoperative visual acuity (median 6/18, range 6/6-hand movements) was significantly greater than final postoperative acuity (median counting fingers, range 6/6-no perception of light) (Wilcoxon sign rank test, p = 0.003), and was retained for a median of 3 months (1-91 weeks) after surgery. Poor visual outcome as evidenced by submedian final visual acuity was invariably associated with persistence of macular detachment, and significantly associated with the occurrence of optic atrophy (odds ratio = 5, p = 0.02). CONCLUSION: Retinal reattachment surgery appears justified in patients with herpesvirus retinitis and AIDS, but postoperative visual deterioration may occur in association with optic atrophy.

Motion detection threshold and field progression in normal tension glaucoma.

Psychophysical tests may demonstrate abnormalities of visual function before the appearance of conventional visual field loss in glaucoma. Motion detection thresholds (MDT) were measured in the normal fellow eye of 51 patients with confirmed normal tension glaucoma and initially unilateral field loss. Humphrey visual fields from the initially normal eye covering a mean follow up of 3.4 years were assessed using pointwise linear regression analysis. In 22 of the 51 eyes with normal visual fields at presentation, field deterioration occurred at one or more Humphrey locations within a mean of 1.7 (SD 1.6) years. An initially abnormal MDT test showed a sensitivity of 73% and a specificity of 90% in predicting field deterioration within the cluster of four Humphrey locations closest to the original MDT test site. Sensitivity was lower (40%) in predicting progression at retinal locations distant from the MDT test site, though specificity remained high (90%).