[Macular pucker surgery with and without delamination of the internal limiting membrane-a prospective randomized study]. / Macular-Pucker-Chirurgie mit und ohne Delamination der Membrana limitans interna ­ eine prospektive randomisierte Studie.

BACKGROUND: There is evidence that additional internal limiting membrane (ILM) removal reduces the recurrence rate after pucker surgery with a similar functional outcome. On the other hand, morphological changes of the inner retinal layers after ILM peeling have been described. The aim of this study was to compare the long-term data after vitrectomy with and without ILM delamination in order to uncover possible differences in morphological and functional results. METHODS: In a prospective study of 32 patients with idiopathic epiretinal membrane, 16 patients were randomized into each of 2 groups. Both groups underwent pars plana vitrectomy (ppV) with peeling of the epiretinal membrane. In group 1 no forced additional peeling of the ILM was performed and in group 2 the ILM or ILM residues were additionally removed after staining. The investigated parameters were visual acuity, central retinal thickness (CRT) in optical coherence tomography (OCT), metamorphopsia and surgical complications. The time points of the examinations were directly preoperative, after 1, 3 and 6 months and partly 8.4 years postoperatively. RESULTS: In group 1 (n = 15) the preoperative mean visual acuity improved from 0.54 logMAR to 0.38 logMAR after 6 months postoperatively (n = 13). Of this group 6 patients could be examined in the long-term course and the visual acuity improved further to 0.32 logMAR after 8 years. The CRT decreased from 473 µm preoperatively to 235 µm in the long-term interval. In group 2 (n = 15) the mean visual acuity preoperatively was 0.47 logMAR and improved 6 months postoperatively (n = 13) to 0.38 logMAR and in the long-term examination (n = 5) to 0.1 logMAR. The CRT in this group decreased from 417 µm preoperatively to 278 µm in the long-term interval. In group 1 one recurrence occurred in the follow-up period, in group 2 none. CONCLUSION: The study showed that there was no significant difference in visual acuity and CRT between the two groups neither after 6 months nor after 8 years of follow-up. The observed recurrence in the group without ILM delamination underlines the assumption that additional ILM peeling could reduce the recurrence rate.

[Minimally invasive therapy of submacular hemorrhage in exsudative age-related macular degeneration]. / Minimal-invasive Therapie submakulärer Blutungen bei exsudativer altersbedingter Makuladegeneration.

BACKGROUND: The purpose of this prospective observational study was to analyze the efficacy and safety of a minimally invasive approach in patients with subretinal hemorrhage secondary to exsudative age-related macular degeneration (ARMD). METHODS: A total of 34 eyes from 33 patients with submacular hemorrhage due to exsudative ARMD were included in the study and 18 of the 33 patients were under anticoagulant medication. Combined subretinal injection of recombinant tissue plasminogen activator (rTPA) and bevacizumab with subsegment core vitrectomy and gas tamponade with 1.8-2.2 ml pure sulphur hexafluoride gas (SF6) was applied using a single pars plana incision. The follow up period was 1-17 months and median 4.5 months. RESULTS: This approach achieved a sufficient SF6 gas filling in all cases without the requirement of strict face-down positioning. Postoperatively all patients had subjective improvement of central visual field. Visual acuity increased in 16 out of 33 patients and 12 out of 33 patients remained unchanged. As complications seven tears of the retinal pigment epithelium (RPE) and one recurrent subfoveal hemorrhage were observed, two cases of retinal detachment occurred and required buckling surgery. In 14 out of 33 patients further application of intravitreal anti-VEGF (vascular endothelial growth factor) was necessary. CONCLUSION: This minimally invasive approach seems to be a feasible and effective method to displace subretinal hemorrhages with tenable results.

[Autologous translocation of large retinal pigment epithelium choroid patches in age-related macular degeneration]. / Autologe Translokation grosser Pigmentepithel-Aderhaut-Exzisate bei feuchter Altersmakulopathie.

BACKGROUND: The latest development in ARMD surgery is the translocation of an autologeous pigment epithelium choroid patch. The method has technical shortcomings: The transplant is excised including the overlaying retina and inserted through a retinotomy near the posterior pole thus causing iatrogenic field defects. For the same reasons the size of the transplant is limited. MATERIALS AND METHODS: The technique was modified as follows: lens surgery using a special PCL with equal power in water and silicone oil, 180 degrees retinotomy just at the temporal ora serrata, subretinal surgery including patch transplantation with the retina folded over nasally and fixed by PFCL, complete silicone oil tamponade without any water remaining. PATIENTS: 12 consecutive cases, age 79 (70 - 86) years, 4 RPE detachments and rips, 8 subretinal hemorrhages from wet ARMD, follow-up in 10 eyes over 15.3 (3 - 23) months. Time courses for visual acuity, depth of central scotoma, OCT and FAG. RESULTS: The mean diameter of the transplants was 16.5 (9 - 33) degrees . Silicone explantation in 7 / 10. Complications in 3 / 10: 1 macula puckering, 1 peripheral detachment, 1 PVR detachment. According to FAG the transplant vascularises in 4 - 6 weeks. 4 / 10 eyes reached visual acuity > 0.2 with limited reading capability. Central scotoma depth remained constant at -11 dB. Function deteriorated again after 6 - 9 months with cystoid degeneration and retinal thickening. 8 / 11 patients estimated the operated eye to be superior to the untreated partner eye. CONCLUSIONS: Patch transplantation is able to restore limited reading capability in eyes having minor damage of the central retina. The best cases for this type of operation are RPE rips and recent sub-RPE haemorrhages. The functional success lasts 5 to 9 months, then the retina over the transplant begins to degenerate.

Visual fields after removal of subretinal hemorrhages and neovascular membranes in age-related macular degeneration.

BACKGROUND: Surgical removal of subretinal hemorrhaging and membranes in eyes with age-related macular degeneration is feasible from a technical point of view, but no advantage over the spontaneous course of the disease has been proven. Visual acuity usually does not improve much. A realistic aim of surgical intervention may be diminution of the central scotoma size, which has not been studied. METHOD: In a prospective study visual fields were measured preoperatively and 6 weeks and 6 months postoperatively in eyes operated on for subretinal hemorrhages and membranes in exudative age-related macular degeneration. The OCTOPUS 1-2-3 program glx, which tests the visual field of 60 degrees diameter at 59 points, was used. Changes in the total size of areas with sensitivity loss of 10-20 dB (= relative scotoma) and > 20 dB (= absolute scotoma) were interpreted as surgical effect. Patients with postoperative retinal detachment or neovascular recurrence were excluded. 30 eyes of 29 patients were enrolled (mean age 75.3 years, 11 male, 18 female) and divided into 3 groups: 14 eyes with massive subretinal hemorrhage of diameters > 30 degrees; 12 eyes with hemorrhages of 10 degrees-30 degrees; 4 eyes with mere neovascular membranes < 10 degrees. RESULTS: (1) The visible area of damage is diminished by surgery (P < 0.01). The reduction for lesions > 30 degrees is 80%; for lesions between 10 degrees and 30 degrees the improvement is 43%. For lesions < 10 degrees there is no significant change. (2) The absolute scotoma size diminishes in all three groups (P = 0.05). The reductions are 63%, 57% and 21%, respectively. (3) Areas of absolute scotoma do not regain full function but are converted to relative scotoma depth, at best. Therefore, in the > 30 degrees group an overall increase (P < 0.01) of the relative scotoma size is observed. (4) The mean sensitivity in the 60 degrees field enhances by 1.6 dB (average over 30 eyes, P = 0.04). (5) Mean preoperative visual acuities were 0.03, 0.12 and 0.17, respectively, with no significant change after surgery. The power of testing is sufficient (0.93) to reject an increase of acuity from 0.12 to 0.2 in group 2. CONCLUSIONS: For hemorrhagic subretinal lesions of diameter > 10 degrees a relevant reduction of central scotoma size is achieved by surgery. The final benefit for the patients depends on the frequency of surgical complications and neovascular recurrence.

[Fluorosilicone oil heavier than water: a new aid in vitreoretinal surgery]. / Fluor-Silikonöl schwerer als Wasser: ein neues Hilfsmittel der vitreo-retinalen Chirurgie.

The specific gravity of fluorosilicone oil (trifluoropropylmethyl siloxane) is greater than that of water, and because of this it opens up new possibilities in vitreoretinal surgery: In cases of PVR detachment, retinal defects at the inferior margin or the posterior pole can be reliably tamponaded. If there is a peripheral retinal hole, the retina is reattached solely by injection of the oil - drainage is unnecessary, since the subretinal fluid is forced back into the vitreous cavity through the retinal defect. Retinal folds resulting from a giant tear will flatten out of their own accord. The present paper communicates initial clinical experience with fluorosilicone oil in 21 eyes (trauma and PVR detachment cases, some of which were considered hopeless). Even though the cases selected for surgery were extreme, reattachment was accomplished intraoperatively in all but one of them. Redetachment occurred in 4 out of 10 eyes following removal of the oil; this was rectified with low-density silicone oil. An immediate side-effect of the new oil was a transient iritis, seen in 5 out of 21 cases. A suspected side-effect after longer-term observation (mean 19 weeks) was that the oil promoted PVR. Out of 4 histologically studied membranes which proliferated under the oil, phagocytosis and foreign body reaction to the oil were found in one of the specimens. No retinal damage due to the oil could be detected by electroretinography. As an intraoperative aid, fluorosilicone oil is thoroughly to be recommended. If a long-term tamponade is essential, the fluorosilicone oil should be replaced with low-density silicone oil (dimethylsiloxane) after a few weeks.