INTRAVITREAL CHOPPING OF DROPPED NUCLEUS WITH A NITINOL INTRAOCULAR FOREIGN BODY FORCEPS: AN ALTERNATIVE TECHNIQUE FOR THE MANAGEMENT OF RETAINED NUCLEUS FRAGMENTS.

PURPOSE: To evaluate the efficiency and safety of using an intraocular foreign body forceps with two nitinol loops at its tip to capture and chop dropped nucleus (DN) during vitrectomy as an alternative method and to evaluate the outcomes and complications of this surgical technique. METHODS: The eyes that underwent 23-gauge vitrectomy with removal of DN using nitinol forceps with a minimum follow-up time of 1 year are included in this study. The efficiency of surgical technique and anatomical and functional results with complications is recorded. RESULTS: Nine patients with a mean age of 73.11 ± 2.15 years were included in this study. The mean time between DN and vitrectomy was 7.67 ± 3.74 (5-14) days. In all eyes, DN was easily chopped and removed with aspiration. Argon laser photocoagulation was performed in 4 eyes (44.44%) during surgery. All eyes were followed up for a mean time of 21.11 ± 12.36 (12-48) months. The mean preoperative best-corrected visual acuity increased significantly during the postoperative follow-up ( P < 0.001). No complications related to the cataract surgery or DN removal were observed. CONCLUSION: Surgical removal of DN with the help of these forceps with nitinol loops is found to be safe and effective in this study. This method avoids ultrasonographic energy and enables 23-gauge vitrectomy without a fragmatome.

The assessment of autofluorescence of the crystalline lens in diabetic patients and healthy controls: can it be used as a screening test?

BACKGROUND: Our purpose was to demonstrate if measuring lens autofluorescence (AF) with a scanning confocal biomicroscope may be used to identify subjects with undiagnosed type II diabetes mellitus (DM), and hence, for it to be used as a marker for the severity of diabetic retinopathy in diabetic patients. PATIENTS AND METHODS: In this cross-sectional, comparative study, lens AF was measured with scanning confocal lens fluorescence biomicroscope in diabetic and healthy groups. Full ophthalmological examination was performed. Blood tests of fasting plasma glucose, and glycosylated hemoglobin were also analyzed. The correlation between lens AF results and blood tests was evaluated in both groups. The cutoff value for the diagnosis of DM using lens AF was investigated. RESULTS: The study included 191 subjects with a mean age of 52.09±6.75 years. One hundred and seven (56.0%) subjects were female, and 84 (44.0%) were male. Eighty-two (42.9%) patients had type II DM, and 109 (57.1%) subjects self-reported as normal. The fluorescence ratio (FR) values ranged from 0.09 to 0.46 (0.23±0.06) in the total group. Mean FR measurements of diabetic subjects were significantly higher (0.27±0.06) than those without DM (0.20±0.05), (p=0.001). A statistically significant correlation was found between glycosylated hemoglobin, fasting plasma glucose, and FR. The cutoff point for the FR according to the presence of DM was found to be 0.24 and above (p=0.001), with a sensitivity of 71.95% and a specificity of 80.73%. CONCLUSION: Measuring AF of human lens as an indirect evidence of increased advanced glycaton end products may helpful in detecting impaired glucose metabolism. Our results show highly significant correlation between possibility of DM and FR.

Protective effect of pomegranate juice on retinal oxidative stress in streptozotocin-induced diabetic rats.

AIM: To investigate the effect of pomegranate juice (PJ) intake on overall oxidation status in retinas of diabetic rats. METHODS: Twenty-seven rats were divided into four groups as control (CO), diabetic (DM), control treated with PJ (CO-PJ), and diabetic treated with PJ (DM-PJ).The retina tissues were used to determine 8-hydroxy-2'-deoxyguanosine (8OHdG), malondialdehyde (MDA), reduced glutathione (GSH) levels, and the enzyme activities of superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px). RESULTS: The levels of 8OHdG and MDA were significantly increased in the retina of DM group compared to CO group (P=0.001, P<0.001 respectively). Both 8OHdG and MDA levels were decreased in PJ-DM group compared to DM group (P=0.004, P<0.001 respectively). The activities of antioxidant enzymes GSH, SOD, and GDH-Px were significantly decreased in the retina of DM group compared to CO group (P≤0.01). GSH and GSH-Px activities were higher in PJ-DM group compared with DM group (P=0.010, P=0.042, respectively) but SOD activity was not statistically different (P=0.938). CONCLUSION: PJ intake is found to be effective in decreasing oxidative end products, and in increasing the activities of antioxidant enzymes in diabetic retinas of rats, which suggests it may be effective against oxidative stress in diabetic retinas.

Nonarteritic anterior ischemic optic neuropathy as the presenting manifestation of primary antiphospholipid syndrome.

Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by vascular thrombosis or pregnancy morbidity. Ocular involvement in APS includes a broad spectrum of manifestations involving anterior and posterior segment or the presence of neuroophthalmologic features. Nonarteritic anterior ischemic optic neuropathy (NAION) is a very rare finding, and in this report a case having NAION as the prevailing sign of APS is presented. A middle-aged women who presented with visual disturbances in her left eye (LE) and turned out to have the diagnosis of primary APS with the help of rheumatological investigations is discussed. She was treated with oral steroids for NAION in her LE. With systemic and rheumatological work-up, primary APS was diagnosed, and hydroxychloroquine, coumadin, and aspirin were started, after which she remained stable under control. Due to the important diagnostic and therapeutic implications of APS, it should be considered in the differential diagnosis of NAION, particularly when the etiology is uncertain.

The relation between bullying, victimization, and adolescents' level of hopelessness.

In this study, 419 Turkish middle school students (203 girls, 216 boys) were surveyed on their exposure to and engagement in bullying, and their level of hopelessness. Our findings suggest that girls were victims of indirect (e.g. gossiping) bullying more than boys. Boys reported being victims of physical (e.g. damaging property) and verbal (e.g. teasing) bullying more than girls. While the level of hopelessness among victims of physical and verbal bullying was higher than non-victims, no difference was found between the victims of indirect bullying and non-victims. Students who never talked to their teachers and parents about bullying reported higher levels of hopelessness than others. The implications of the study for intervention and prevention programs are discussed.

Outcome of photodynamic therapy in choroidal neovascularization due to pathologic myopia and related factors.

To evaluate the outcome of photodynamic therapy (PDT) and the factors influencing its outcome in patients with subfoveal choroidal neovascularization (CNV) due to pathologic myopia. Twenty-three eyes of 21 consecutive patients who received PDT for subfoveal CNV due to pathologic myopia and who were followed for >12 months were included in the study. The relationship between the factors that might affect the treatment outcome were evaluated. Mean age was 48.7 ± 16.0 years (23-74 years). Mean follow-up was 23.2 ± 7.7 months (15-41 months). Mean logMAR visual acuity was 0.85 ± 0.24 before treatment, 0.89 ± 0.37 at 12 months, and 0.92 ± 0.46 at the final visit. Mean logMAR visual acuity did not change significantly at 12 months or at the final visit (P = 0.47 and 0.36, respectively). The baseline visual acuity strongly correlated with the final visual acuity (P = 0.001). Age showed an inverse correlation with change in logMAR visual acuity at 12 months (P = 0.01). PDT prevented significant visual loss in eyes with subfoveal CNV due to pathologic myopia. Better initial visual acuity resulted in better final visual acuity. Younger age was correlated with better treatment outcome at 12 months.

Incidence of endophthalmitis after 20-gauge vs 23-gauge vs 25-gauge pars plana vitrectomy.

PURPOSE: To compare endophthalmitis rates after 20-gauge versus 23-gauge versus 25-gauge pars plana vitrectomy (PPV) in 2007-2008, and compare the rates with those of 2005-2006. METHODS: Multicenter study including all patients who developed endophthalmitis following PPV performed by any of the authors during 2005-2008, and all patients who developed endophthalmitis following PPV at Penn State College of Medicine and Bascom Palmer Eye Institute during 2005-2008. The endophthalmitis rates after 20-gauge, 23-gauge and 25-gauge PPV during 2007-2008 were compared to those from 2005-2006. RESULTS: The endophthalmitis incidence during 2007-2008 was 1/4,403 (0.02%) for 20-gauge PPV, 1/3,362 (0.03%) for 23-gauge PPV, and 1/789 (0.13%) for 25-gauge PPV. There is no significant difference among these rates between any two of the three groups. Compared with the endophthalmitis rates among the same group of surgeons during 2005-2006, the 2007-2008 endophthalmitis rates following 20-gauge and 23-gauge PPV were stable, and the rate following 25-gauge PPV was marginally lower (p = 0.056; odds ratio = 0.15; 95% CI: (0.003, 1.03)). CONCLUSIONS: There was no significant difference in the 2007-2008 rates of endophthalmitis following 20-gauge versus 23-gauge versus 25-gauge PPV; among the same group of surgeons, the 2007-2008 rate of endophthalmitis following 25-gauge PPV was marginally lower than the 2005-2006 rate.

Pars plana vitrectomy with and without triamcinolone acetonide assistance in pseudophakic retinal detachment complicated with proliferative vitreoretinopathy.

PURPOSE: To evaluate the anatomical and functional outcomes of pars plana vitrectomy (PPV) in pseudophakic retinal detachment (RD) complicated with proliferative vitreoretinopathy (PVR) without previous scleral buckling (SB) or vitrectomy, both with and without triamcinolone acetonide (TA) assistance. METHODS: In this retrospective, interventional, comparative case series, 72 pseudophakic eyes with RD with PVR grade C1 or greater underwent PPV either with (group 1, n = 40) or without (group 2, n = 32) TA assistance. Eyes with a minimum of 6 months of follow-up were evaluated. Main outcome measures were reattachment, redetachment, complication rate, and changes in visual acuity (VA). RESULTS: The mean follow-up period was 14.57 +/- 8.55 months. Single-surgery and final reattachment rates were 87.50% and 95% in group 1, and 78.12 % and 96.87% in group 2, (P = 0.349, P = 1.000). Redetachment rates were 12.50% in group 1 and 21.87% group 2 (P = 0.349). In both groups the mean VA increased significantly in postoperative week 1 and in all control visits (P< 0.001) with no difference in complication rate (P > 0.05). CONCLUSIONS: In this study PPV with TA assistance resulted in a lower, albeit statistically insignificant, redetachment rate in the treatment of RD complicated with PVR compared to PPV without TA assistance in eyes without previous SB or PPV. Visual acuity improved in 72% of eyes in both groups. Intraoperative and postoperative complication rates were also similar.

Secondary iris claw intraocular lens implantation for the correction of aphakia after pars plana vitrectomy.

PURPOSE: The purpose of this study was to evaluate the safety and efficacy of iris claw intraocular lens implantation for correction of aphakia in vitrectomized eyes without capsular support. METHODS: This was a prospective interventional case series. Twelve aphakic vitrectomized eyes without capsular support underwent iris claw intraocular lens implantation. The main outcome measures were changes in uncorrected visual acuity, best-corrected visual acuity, spheric equivalent, corneal endothelial cell density, corneal thickness, central macular thickness, and complications. RESULTS: Mean follow-up was 15.58 +/- 3.80 months with no intraoperative complications. Postoperatively, uncorrected visual acuity increased significantly at all follow-up visits (P < 0.05). Mean best-corrected visual acuity increased 10 letters/2 lines at the final follow-up visit (P = 0.023). Mean postoperative spheric equivalent at the last visit was -1.68 +/- 063 D, and the spheric equivalent was within +/-2.00 D of emmetropia in 9 (75%) eyes. Mean central macular thickness increased only at postoperative Month 3 (P = 0.043). Mean endothelial cell density loss was 23.87% at the last visit. Mean corneal thickness did not change during follow-up (P > 0.05). No corneal edema was observed. Complications were transient intraocular pressure increase (n = 1), cystoid macular edema (n = 1), and haptic dislocation replaced by surgery (n = 1). Retinas remained attached in all eyes. CONCLUSION: Secondary iris claw intraocular lens implantation is clinically safe and effective to correct aphakia in vitrectomized eyes without capsular support. Larger studies with longer follow-up are warranted.

Comparative outcomes of pars plana vitrectomy in acute postoperative endophthalmitis with 25-gauge and 20-gauge techniques.

PURPOSE: To evaluate the safety and outcomes of 25-gauge pars plana vitrectomy (PPV) in the treatment of postoperative endophthalmitis and compare it with 20-gauge PPV. METHODS: The medical records of all patients diagnosed with acute endophthalmitis following cataract surgery who underwent PPV between December 2000 and December 2007 were reviewed. Main outcome measures included final visual acuity (VA), additional interventions, and both intraoperative and postoperative complications. RESULTS: Records of 70 eyes of 70 patients with a condition diagnosed as postoperative endophthalmitis were evaluated. Fifty-eight eyes underwent 20-gauge PPV (group 1), and 12 eyes underwent 25-gauge PPV (group 2). Mean follow-up time for group 1 was 9.6 +/- 8.8 months, and for group 2, 7.9 +/- 12.7 months (P = 0.57). Median VA at presentation was hand motion in both groups. The differences between the two groups in frequencies of visual outcome levels of 20/800 and 20/100 were significant in favor of group 2 (20/800, P = 0.006; 20/100, P = 0.01). In group 2, fewer additional interventions were required, and postoperative complications tended to be less frequent. CONCLUSIONS: Twenty-five-gauge PPV seems to be safe and effective in the management of postoperative endophthalmitis. This sutureless technique may have some advantages over 20-gauge surgery, but controlled studies are needed to confirm the results.

25-Gauge sutureless vitrectomy with oblique sclerotomies for the management of retinal detachment in pseudophakic and phakic eyes.

PURPOSE: To evaluate the anatomic and functional outcomes of 25-gauge sutureless vitrectomy in primary treatment of noncomplex retinal detachments (RD) in pseudophakic and phakic eyes. METHODS: In this interventional clinical case series, 23 pseudophakic and 13 phakic eyes with total RDs with proliferative vitreoretinopathy grade A/B underwent primary 25-gauge sutureless vitrectomy with oblique sclerotomies and gas endotamponade. Eyes with minimum follow-up of 6 months were evaluated. Main outcome measures were single surgery and final reattachment rates, complications, and changes in visual acuity (VA). RESULTS: Mean duration of visual loss was 14.65+/-12.57 and 22.46+/-18.95 days in pseudophakic and phakic eyes, respectively. Eighteen (78.26%) pseudophakic eyes and 12 (92.30%) phakic eyes had macular detachment. In all eyes, 25-gauge sutureless vitrectomy was completed without complication. Mean follow-up period was 11.00+/-6.63 months. Single surgery and final retinal attachment rates were 91.30% and 95.65% in pseudophakic eyes and 61.53% and 84.61% in phakic eyes, respectively (p=0.073, p=0.539). In both groups, mean VA increased significantly at postoperative month 1 (p<0.05) and at the last visit (p<0.001). Transient hypotony was detected in 2 pseudophakic and 3 phakic eyes with spontaneous resolution. Two (15.38%) phakic eyes had cataractous changes. CONCLUSIONS: In this study, 25-gauge sutureless vitrectomy resulted in higher single surgery and final anatomic success rates in primary treatment of noncomplex RDs in pseudophakic versus phakic eyes, with commensurate increase in VA.

Prognostic factors in severely traumatized eyes with posterior segment involvement.

BACKGROUND: To determine the prognostic indicators of functional outcome in eyes with severe posterior segment trauma managed with pars plana vitrectomy. METHODS: One hundred and six eyes of 101 patients were retrospectively reviewed to determine the accuracy of a number of factors in predicting functional outcome after surgery. These potential prognostic indicators included initial visual acuity (VA), retinal detachment (RD), type of trauma, presence of intraocular foreign body (IOFB), type of IOFB, posttraumatic endophthalmitis, hyphema, choroidal detachment, initial hypotonia, accompanying lens subluxation/dislocation, and severe vitreous hemorrhage. In our study, functional success was defined as VA > or =5/200. Fisher's exact and chi-square tests were used for statistical analysis. RESULTS: The mean follow-up time was 12.8+/-0.52 (8-18) months. Thirty-three eyes (31.13%) had functional success. Forty-four (68.7%) of 64 eyes with preoperative RD had anatomical success (total retinal reattachment). Predictors of poor visual outcome (VA < or =5/200) were found to be poor initial VA (p<0.0001), presence of RD (p<0.001), and presence of endophthalmitis (p<0.05). No statistically significant correlation was found between the other predictors surveyed and visual outcome (p>0.05). CONCLUSION: Vitreoretinal surgery can improve anatomical and functional success in eyes with severe posterior segment trauma. Poor initial VA, RD, and posttraumatic endophthalmitis are poor predictors of visual outcome.

Ocular trauma score in open-globe injuries.

BACKGROUND: To determine the value of calculating an ocular trauma score (OTS) for patients with open-globe injuries. OTS evaluating system can provide valuable prognostic information, and its use may be an asset in counseling patients with open-globe injuries. METHODS: This study was conducted as a retrospective review of 114 eyes of 114 patients who presented with open-globe injuries between January 2001 and July 2006. OTS variables (visual acuity, rupture, endophthalmitis, perforating injury, retinal detachment, and afferent pupillary defect) were determined and OTS was calculated in 114 eyes of 114 patients at the time of initial examination. In this study, presenting and final visual acuity were grouped (1 through 5) as > or = 20/40, 20/200 to 20/50, 1/200 to 19/200, light perception (LP)/hand motion (HM), and no light perception (NLP), similar to the OTS study group. Numerical values to the OTS variables were converted into OTS categories. Similarity of final visual acuities by groups was compared with those in the OTS study. Patients under the age of two and the ones with incomplete data for OTS variables were excluded. RESULTS: When comparing the distribution of final visual acuity in all OTS categories, no statistically significant difference was found (p = 0.35) between the results of our study and the OTS study group. NLP ratio in category 1 and > or = 20/40 ratio in category 5 were statistically higher than in our study (p = 0.01). However, in our study, category 2 of LP/HM ratio (p < 0.0001) was statistically higher than in the OTS study. The likelihood of the final visual acuities (NLP, LP/HM, 1/200 to 19/200, 20/200 to 20/50, and > or = 20/40) in the other OTS categories in this group was similar to those in the OTS study group. The OTS showed positive correlation with final visual acuity (p < 0.001). CONCLUSION: In open-globe injuries, a commonly accepted system for calculating ocular trauma score (OTS) can provide reliable prognostic information.

Acute-onset endophthalmitis after cataract surgery: success of initial therapy, visual outcomes, and related factors.

PURPOSE: To evaluate the success of initial treatment and the factors influencing the outcome in acute-onset endophthalmitis after cataract surgery. METHODS: We retrospectively reviewed the medical records of all patients with acute postoperative endophthalmitis between 2000 and 2007. We performed pars plana vitrectomy (PPV) to all eyes with initial visual acuity of light perception. Eyes with visual acuity of hand motions or better underwent either intraocular antibiotic injection (IOAI) or PPV. Eyes that did not give a good clinical response to initial therapy within 60 hours underwent a second procedure. The main outcome measure was the rate of early reintervention after PPV and IOAI. RESULTS: We evaluated 88 eyes of 88 patients. Thirty-seven patients underwent PPV and 51 patients underwent IOAI alone. Six of 37 (16.2%) patients required 1 or more procedures within 60 hours of the initial procedure in the PPV group. Twenty-eight of 51 eyes (54.9%) in the IOAI group underwent PPV within 60 hours. The rate of response to primary PPV was significantly higher than to primary IOAI (P < 0.001). Gram-negative organisms composed 35.1% of the isolates. CONCLUSION: Pars plana vitrectomy may be preferable to IOAI in postoperative endophthalmitis since the rate of early reintervention is lower with initial PPV.

25-gauge sutureless vitrectomy in osteogenesis imperfecta type I.

PURPOSE: To report a case with type I osteogenesis imperfecta (OI) with intravitreal opacities who underwent 25-gauge sutureless vitrectomy. METHODS: A 2.5-year-old girl with OI type I who presented with intravitreal opacities underwent 25-gauge sutureless vitrectomy. RESULTS: The 25-gauge sutureless vitrectomy system, which is less traumatic, was performed in a patient with OI type I. Nine months postoperatively, funduscopic examination under general anesthesia showed a healthy optic nerve and retina without detachment. Intraocular pressure by Tonopen was 10 mmHg. CONCLUSION: The use of 25-gauge sutureless vitrectomy to avoid scleral suturing and minimize surgical trauma is an option in pediatric patients with associated thin sclera.

Removal of large subretinal foreign bodies with bimanual vitrectomy and use of a suture loop.

PURPOSE: To describe removal of large subretinal foreign bodies with bimanual pars plana vitrectomy and use of a suture loop. METHODS: In a retrospective interventional case series, 2 eyes of 2 patients referred 1 month after primary wound suturation, both with posttraumatic retinal detachment and 1 with endophthalmitis, underwent pars plana vitrectomy. Intraocular foreign bodies (IOFBs) were grasped using a 6-0 polypropylene suture loop. The loop was placed around the IOFBs using an intraocular forceps, and the foreign bodies were extracted from the eyes. RESULTS: A suture loop was placed around the IOFB bimanually, and removal was performed as described. Two large subretinal IOFBs, one metallic and one nonmetallic, were removed successfully without slippage, the first through a limbal incision and the second through an enlarged sclerotomy. The patients were observed for 3 months. One eye had retinal attachment, but the other eye had redetachment that was considered inoperable. CONCLUSION: Large metallic and nonmetallic subretinal IOFBs of different shapes and sizes can be removed with a suture loop, but in complicated cases, bimanual placement of the loop may provide better control for IOFB removal and the ability to surround the IOFB at its desired axis, thereby decreasing the size of the incision for extraction.

Primary 25-gauge sutureless vitrectomy with oblique sclerotomies in pseudophakic retinal detachment.

PURPOSE: To evaluate the anatomic and functional outcomes of 25-gauge sutureless vitrectomy in primary treatment of noncomplex pseudophakic rhegmatogenous retinal detachments (RRD). METHODS: Prospective interventional institutional case series. Twenty-two eyes with pseudophakic RRD with proliferative vitreoretinopathy grade A or B underwent primary 25-gauge vitrectomy with oblique sclerotomies and gas endotamponade. Eyes with minimum follow-up of 6 months were evaluated. Main outcome measures were reattachment rate with single surgery, reoperation, complication rates, and changes in visual acuity (VA). RESULTS: Mean duration of visual loss was 14.68 +/- 12.87 days. Seventeen (77.27%) eyes had macular detachment. In all eyes 25-gauge sutureless vitrectomy was completed without complications. The mean follow-up period was 10.40 +/- 5.77 months. Retinal attachment was achieved in 21 (95.45%) eyes with single surgery and in all (100%) eyes with second vitrectomy. Mean preoperative VA of 1.61 +/- 1.18 improved to 0.50 +/- 0.53 at the last visit (P < 0.001). Transient hypotony was detected in 2 (9.09%) eyes with spontaneous resolution. No other postoperative complication was observed. CONCLUSIONS: Twenty-five-gauge sutureless vitrectomy with oblique sclerotomies in primary treatment of noncomplex pseudophakic RRDs resulted in reattachment in 95.45% with single surgery, and in 100% with reoperation in one eye, accompanied by an increase in visual acuity in 86% of eyes.

Transconjunctival 25-gauge sutureless vitrectomy and silicone oil injection in diabetic tractional retinal detachment.

PURPOSE: The purpose of this article was to evaluate the outcomes and complications of transconjunctival sutureless 25-gauge vitrectomy using silicone oil tamponade in diabetic tractional retinal detachment. MATERIALS AND METHODS: Patients were retrospectively evaluated. Main outcome measure was the feasibility of pars plana vitrectomy and silicone oil injection with 25-gauge system in eyes with diabetic tractional retinal detachment. RESULTS: Fourteen eyes of 14 patients were included in the study. Tractional retinal detachment was accompanied by vitreous hemorrhage in 9 eyes and combined traction/rhegmatogenous retinal detachment was present in 1 eye. All patients underwent transconjunctival sutureless 25-gauge vitrectomy and 1,000 centistokes silicone oil injection. Angled insertion of the trocars was made in all eyes. Bimanual surgery was performed in 6 (42.8%) eyes. The median preoperative best-corrected visual acuities were 3.00 logarithm of the minimum angle of resolution; it increased to 1.60 logarithm of the minimum angle of resolution at last visit. Retinal tear formation occurred in 4 (28.5%) eyes. Retinal detachment developed in 2 (14.2%) eyes. Intraocular pressure of 5 mmHg or less was detected in 3 (21.4%) eyes. One patient lost light perception due to anterior hyaloidal fibrovascular proliferation. CONCLUSION: Pars plana vitrectomy and 1,000 centistokes silicone oil injection with 25-gauge system is feasible in diabetic tractional retinal detachment even in complex cases. Indications of 25-gauge surgery may be expanded toward this area.