Pars plana vitrectomy combined with internal limiting membrane peeling for recurrent macular edema due to branch retinal vein occlusion after antivascular endothelial growth factor treatments.

PURPOSE: To evaluate the anatomic and functional outcomes of pars plana vitrectomy combined with internal limiting membrane peeling for recurrent macular edema (ME) due to branch retinal vein occlusion (BRVO) after intravitreal injections of antivascular endothelial growth factor (anti-VEGF) agents. METHODS: Twenty-four eyes of 24 patients with treatment-naive ME from BRVO were treated with intravitreal injections of anti-VEGF agents. Recurred ME was treated with pars plana vitrectomy combined with internal limiting membrane peeling. RESULTS: After the surgery, ME was significantly reduced at 1 month (P=0.031) and the reduction increased with time (P=0.007 at the final visit). With the reduction in ME, treated eyes showed a slow improvement in visual acuity (VA). At the final visit, improvement in VA was statistically significant compared with baseline (P=0.048). The initial presence of cystoid spaces, serous retinal detachment, or subretinal hemorrhage under the fovea, as well as retinal perfusion status, showed no association with VA improvement. However, the presence of epiretinal membrane showed a significant association with the visual recovery. Although eyes without epiretinal membrane showed visual improvement (-0.10±0.32 in logarithm of the minimum angle of resolution [logMAR]), eyes with epiretinal membrane showed greater visual improvement (-0.38±0.12 in logMAR, P=0.012). CONCLUSION: For recurrent ME due to BRVO after anti-VEGF treatment, particularly when accompanied by epiretinal membrane, pars plana vitrectomy combined with internal limiting membrane peeling might be a possible treatment option.

Pars Plana Vitrectomy Combined with Internal Limiting Membrane Peeling to Treat Persistent Macular Edema after Anti-Vascular Endothelial Growth Factor Treatment in Cases of Ischemic Central Retinal Vein Occlusion.

OBJECTIVE: To evaluate the efficacy of pars plana vitrectomy (PPV) combined with internal limiting membrane (ILM) peeling in cases of ischemic central retinal vein occlusion (CRVO) where macular edema (ME) persisted after anti-vascular endothelial growth factor (anti-VEGF) treatment. METHODS: Fifteen eyes with ischemic CRVO-related ME were included in the study. Nine were treated with panretinal photocoagulation after initial examination. Anti-VEGF agents were injected intravitreally. Persistent ME was treated with PPV combined with ILM peeling. During surgery, laser photocoagulation was further applied to the non-perfused area. RESULTS: Mean retinal thickness gradually decreased after surgery (p = 0.024 at 6 months), although visual acuity did not improve significantly during the follow-up period (14.7 ± 11.6 months). Neovascular glaucoma subsequently developed in three cases and a trabeculectomy was performed in one case. CONCLUSION: In eyes with ischemic CRVO, PPV combined with ILM peeling contributed to a reduction in persistent ME. However, there was no significant improvement in visual acuity.

Six-month results of intravitreal aflibercept injections for patients with polypoidal choroidal vasculopathy.

BACKGROUND: This study aims to evaluate the therapeutic effect of intravitreal aflibercept injection for polypoidal choroidal vasculopathy (PCV). METHODS: Eighteen eyes of 17 consecutive patients with PCV received three consecutive monthly intravitreal injections of aflibercept and one additional injection 2 months later (four injections totally). All patients underwent eye examinations, which included best-corrected visual acuity (BCVA), fluorescein angiography, indocyanine green angiography, and optical coherence tomography. The primary endpoint of the study was the regression of polypoidal lesions. The secondary endpoints were BCVA, central retinal thickness (CRT) and changes in retinal exudation. RESULTS: Six months after the first aflibercept injection, the polypoidal lesions were completely resolved in 14 eyes (77.7%) and partially resolved in 4 eyes (22.2%). Although branching choroidal vascular networks were still present in all eyes, retinal exudative changes had completely resolved in 17 eyes (94.4%), and the mean CRT decreased significantly from 407.2±100.1 µm to 229.1±57.2 µm (p<0.0001). BCVA (logarithm of the minimal angle of resolution, logMAR) improved significantly from 0.414±0.384 at baseline to 0.297±0.334 after 6 months (p=0.016). CONCLUSIONS: At 6 months, aflibercept monotherapy effectively reduced polyps, retinal exudation and CRT in patients with PCV.

Subretinal injection of recombinant tissue plasminogen activator for submacular hemorrhage associated with ruptured retinal arterial macroaneurysm.

PURPOSE: To evaluate the surgical outcomes of small-gauge vitrectomy with subretinal injection of recombinant tissue plasminogen activator (rt-PA) for a submacular hemorrhage caused by a ruptured retinal arterial macroaneurysm (RAM). METHODS: Non-comparative, consecutive case-series performed at two ophthalmological institutions. We examined 22 eyes of 22 patients with a submacular hemorrhage associated with a RAM but without a preretinal or sub-internal limiting membrane hemorrhage at the fovea. During 25-gauge vitrectomy, approximately 4000-8000 IU of rt-PA was injected subretinally, followed by the injection of air or 10 % sulfur hexafluoride as a tamponade. The patients maintained an upright position for 1 hour, then turned to a facedown position for 1 to 3 days. The best-corrected visual acuity (BCVA) and postoperative complications were evaluated. RESULTS: The average interval from the onset of symptoms to surgery was 8.4 ± 7.6 days, and the average size of the subretinal hemorrhage was 3.4 ± 1.0 disc diameters. The submacular hemorrhage was displaced from the foveal area in all eyes after 1 week. The mean baseline BCVA was 1.41 ± 0.41 logMAR units, and it improved to 0.91 ± 0.43 at 1 month and to 0.64 ± 0.45 at the final visit (P = 0.0001, P < 0.0001 respectively). A macular hole was detected intraoperatively in two eyes and postoperatively in two eyes, and both were closed by internal limiting membrane peeling or a second vitrectomy. CONCLUSIONS: Small-gauge vitrectomy with subretinal rt-PA injection and gas tamponade were effective in displacing a submacular hemorrhage associated with a RAM.

Autologous transplantation of the internal limiting membrane for refractory macular holes.

PURPOSE: To determine the effectiveness of autologous transplantation of the internal limiting membrane (ILM) for refractory macular holes. DESIGN: Prospective, interventional case series. PATIENT AND METHODS: Ten eyes of 10 consecutive patients who underwent autologous transplantation of the ILM for the treatment of refractory macular holes were studied. The primary diseases in these patients were large idiopathic macular holes that had existed for more than 1 year (4 eyes), a traumatic macular hole (1 eye), myopic foveoschisis (2 eyes), foveoschisis resulting from pit-macular syndrome (2 eyes), and proliferative diabetic retinopathy (1 eye). Apart from the 5 eyes with idiopathic or traumatic macular holes, macular holes developed in the other 5 eyes after initial vitrectomies with ILM removal. In all eyes, regular macular hole surgery failed to achieve closure. The main outcome measures used in this study were macular hole closure and best-corrected visual acuity (BCVA). RESULTS: Macular holes were closed successfully in 9 eyes (90%) after autologous transplantation of the ILM. The postoperative BCVAs were significantly better than the preoperative BCVAs (P = .007, paired t test). Postoperative BCVAs improved by more than 0.2 logarithm of the minimal angle of resolution units in 8 eyes (80%) and were unchanged in 2 eyes (20%). CONCLUSIONS: Although this is a pilot study, the results suggest that autologous transplantation of the ILM may contribute to improved anatomic and visual outcomes in the treatment of refractory macular holes and may warrant further investigation.

Two-year results of reduced-fluence photodynamic therapy for polypoidal choroidal vasculopathy.

PURPOSE: To report the results of a 2-year follow-up study of Japanese polypoidal choroidal vasculopathy (PCV) patients treated with reduced-fluence photodynamic therapy (PDT) monotherapy. DESIGN: Prospective interventional case series. METHODS: In the present study, 38 eyes of 38 consecutive patients underwent PDT with a reduced laser fluence of 25 J/cm(2). During the 2-year follow-up, visual acuity (VA) and optical coherence tomography measurements were performed every 3 months after the PDT procedure and then compared with baseline values. PCV vascular lesions were evaluated by indocyanine green and fluorescein angiography. RESULTS: At baseline, the mean logarithm of the minimal angle of resolution (logMAR) best-corrected VA (BCVA) was 0.43. There was a significant improvement of the mean logMAR BCVA to 0.28 and 0.29 at 12 and 24 months, respectively (P < .0001, P = .001). The logMAR BCVA was stable or improved by ≥0.3 in 36 (95%) of the eyes at the 2-year follow-up. In 13 eyes in which the baseline VA was better than 20/40, there was a significant improvement of the mean logMAR BCVA at 12 months, with the acuities continuing to be stable at 24 months. The mean number of treatment sessions during the 24-month study period was 1.9. CONCLUSIONS: Reduced-fluence PDT monotherapy for PCV effectively improved and maintained the VA over a 24-month period, even in eyes with a baseline VA better than 20/40. In addition, the number of treatments could be much smaller as compared with intravitreal injection of anti-vascular endothelial growth factor agents.

One-year results of bevacizumab intravitreal and posterior sub-Tenon injection of triamcinolone acetonide with reduced laser fluence photodynamic therapy for retinal angiomatous proliferation.

PURPOSE: Our aim was to study the efficacy of combined triple therapy with intravitreal bevacizumab injections (IVB), posterior sub-Tenon injection of triamcinolone acetonide (STTA), and reduced laser fluence photodynamic therapy (RFPDT) in Japanese patients with retinal angiomatous proliferation (RAP). DESIGN: This was a retrospective, observational, consecutive case series. METHODS: Fifteen consecutive RAP treatment-naïve eyes were treated with triple therapy of IVB, STTA, and RFPDT (25 J/cm(2) of laser fluence). Whenever there was a recurrence of retinal-retinal anastomosis (RRA) or retinal-choroidal anastomosis (RCA) and marked leakage from subretinal neovascularization, the triple therapy was reapplied. When there were only intraretinal exudative and/or hemorrhagic changes without distinct RRA or RCA, IVB alone was applied. RESULTS: The mean logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA) at baseline improved significantly (from 0.489 to 0.294 12 months) (paired t test, p = 0.043). LogMAR BCVA at 12 months was stable or improved by ≥ 0.2 in 14 eyes (93.3 %). Mean number of triple therapy instituted during the 12-month study period was 1.2, and mean number of IVB treatments was 1.4. CONCLUSION: Combined IVB, STTA, and RFPDT for RAP was effective in maintaining or improving VA at 1 year. In addition, the number of treatments could be markedly reduced.

Enhanced depth imaging spectral-domain optical coherence tomography of subfoveal choroidal thickness in normal Japanese eyes.

PURPOSE: To investigate the subfoveal choroidal thickness of healthy Japanese subjects using enhanced depth imaging optical coherence tomography and to evaluate the association between subfoveal choroidal thickness and age in a group of subjects with a wide age range. SUBJECTS AND METHODS: A total of 145 eyes of 145 healthy volunteers (85 women, 60 men, age range 5-88 years, mean age 45.7 years) with no ophthalmic or systemic symptoms were evaluated; 23 subjects were under the age of 20 years. Exclusion criteria included high myopia (greater than -6 D) of spherical equivalent refractive error. RESULTS: The mean subfoveal choroidal thickness was 265.5 ± 82.4 µm. Although the subfoveal choroidal thickness showed a negative correlation with age (p < 0.05), subfoveal choroidal thickness in those subjects younger than 10 years old was significantly thicker than that in each of the other age groups. The subfoveal choroidal thickness remained unchanged from the age groups in the 10s to 20s, and it gradually decreased after the 30s. The subfoveal choroidal thickness tended to have a negative correlation with refractive error. Age and refractive error were statistically significant factors associated with subfoveal choroidal thickness (p < 0.01). The multiple regression formula was subfoveal choroidal thickness = 365.1 - 2.0 × age + 7.9 × refractive error. CONCLUSION: The subfoveal choroidal thickness in healthy Japanese subjects decreased in thickness by 20 µm every 10 years. The subfoveal choroidal thickness in subjects younger than 10 years was significantly thicker than in other age groups. The subfoveal choroidal thickness also depended on the refractive error.

[Changes in subfoveal choroidal thickness of epiretinal membrane and macular hole before and after microincision vitrectomy surgery].

PURPOSE: To evaluate the subfoveal choroidal thickness (SCT) of the epiretinal membrane (ERM) and macular hole (MH) both before and after microincision vitrectomy surgery. SUBJECTS AND METHODS: A total of 104 eyes of 104 subjects (64 ERM, 40 MH, mean age 68.9 years) were evaluated. All subjects underwent vitrectomy with internal limiting membrane peeling. SCT was measured before vitrectomy and 1 week, 1 month and 3 months postoperatively. SCT was measured by enhanced depth imaging OCT (EDI-OCT) using a Heiderberg Spectralis. RESULTS: The SCT of ERM was 202.6 microm before vitrectomy, and 201.8 microm at 1 week, 198.8 microm at 1 month, and 196.4 microm at 3 months postoperatively. There were no significant differences between the times of measurement. MH was 182.5 microm before vitrectomy, and 186.7 microm at 1 week, 189.4 microm at 1 month, and 187.4 microm at 3 months. There were also no significant differences between any other factors. The SCT between the ERM and MH was not significantly different at any time. We examined the correlation between the changes in SCT and the changes in age, refractive error and intraocular pressure (IOP), but found no significant correlation. CONCLUSION: The SCT hat not changed either before or after microincision vitrectomy surgery, and there was no siginificant correlation between SCT and any other factor.