Modified Vitrectomy Technique for Phakic Rhegmatogenous Retinal Detachment with Intermediate Break.

PURPOSE: To evaluate the effects of a modification of the traditional 25-gauge pars plana vitrectomy technique in the treatment of uncomplicated macula-on rhegmatogenous retinal detachment (RRD) with intermediate retinal break(s) and marked vitreous traction in the phakic eye. METHODS: Prospective, noncomparative, and interventional case series. All consecutive phakic eyes with primary uncomplicated macula-on RRD with intermediate retinal break(s) and marked vitreous traction, with at least 1 year of postoperative follow-up, were enrolled. In all eyes, "localized 25-gauge vitrectomy" under air infusion with localized removal of the vitreous surrounding the retinal break(s), in association with laser photocoagulation and air tamponade, was performed. The primary end point was the rate of primary retinal attachment. Secondary end points were cataract progression and assessed by digital Scheimpflug lens photography (mean change of nuclear density units) and the rate of complications. RESULTS: Thirty-two phakic eyes were included in the final analysis. At 12 months, the primary outcome of anatomical success was achieved in 94% of eyes. The mean nuclear density units did not change significantly at any time point during the follow-up. After localized vitrectomy, one eye developed an epiretinal membrane, and one eye developed cystoid macular edema; no other significant complications were reported. CONCLUSIONS: "Localized vitrectomy" has a high anatomical success rate in phakic eyes with primary uncomplicated macula-on RRD with intermediate retinal break(s) and marked vitreous traction, without causing progression of cataract.

Mixture of ether and silicone oil for the treatment of inferior complicated retinal detachment.

PURPOSE: To report the efficacy and ocular tolerance of a new tamponade made with ether and silicone oil (HeavySil [HSIL]) for the treatment of retinal detachment (RD) complicated by inferior proliferative vitreous retinopathy (PVR). METHODS: Prospective noncomparative interventional study on 31 consecutive eyes that underwent pars plana vitrectomy and were treated with HSIL as an intraocular tamponade. All patients presented with at least one retinal break and grade B-C PVR located between 4 and 8 o'clock. The main endpoint criteria were retinal reattachment after the removal of HSIL and complications arisen from the use of this tamponade. RESULTS: Primary anatomic success was achieved in 27 out of 31 cases. Mean visual acuity improved from logMAR 1.4 (SD 0.7) to logMAR 1.1 (SD 0.6) (p=0.02). The main complications reported were cataract formation (5 out of 7 phakic eyes cases), clinically visible emulsification (6 cases), and difficulty of oil removal in 3 cases. Severe intraocular inflammation with HSIL in situ was found in only one case. CONCLUSIONS: HeavySil, a saturated solution of ether with silicone oil, is a safe and effective tamponade agent for the treatment of complicated RD. The most common complications are cataract formation and oil emulsification.

The combined use of heavy and light silicone oil in the treatment of complicated retinal detachment with 360º retinal breaks: tamponade effect or filling effect?

INTRODUCTION: This study aims to report the safety and effi cacy of the combined use of 70% Densiron®-68 and 30% polydimethysiloxane as a temporary vitreous substitute after pars plana vitrectomy (PPV) in selected cases of retinal detachment with superior and inferior retinal breaks. MATERIAL AND METHODS: Fifty consecutive eyes of 50 patients affected by complicated retinal detachment with retinal breaks of the superior and inferior quadrants associated with proliferative vitreoretinopathy (PVR) of grade C2 or more, underwent a pars plana vitrectomy and a combination internal tamponade with 70% Densiron®-68 and 30% silicone oil. The main outcome measures were visual acuity, retinal attachment, intraocular pressure (IOP) and incidence of complications. RESULTS: The mean best-corrected visual acuity rose from 1.4 logMAR to 0.7 logMAR (P <0.01). Initial retinal reattachment was achieved in 48 (96%) patients. In 15 patients (30%), IOP increased over 21 mmHg. The main complications were redetachment at the 3 month follow-up in 12/48 cases (25%) and cataract formation in 13/21 phakic eyes (62%). CONCLUSION: This combination tamponade comprised lighter and heavier oil compounds was well tolerated and effective. It may be a useful tool for the treatment of retinal detachment complicated with breaks and PVR involving the upper and lower quadrants.

Ocular tolerance and efficacy of short-term tamponade with double filling of polydimethyloxane and perfluoro-n-octane.

OBJECTIVE: The aim of the study was to evaluate the ocular tolerance and efficacy of double filling with perfluoro-n-octane (n-C8F18) (PFO) and polydimethyloxane (PDMS) as a temporary vitreous substitute in patients with retinal detachment complicated by proliferative vitreoretinopathy (PVR). MATERIAL AND METHODS: Tamponade was performed in 30 eyes of 30 patients by double filling with 30% PFO and 70% PDMS for an average of 23 (standard deviation 2.2) days. The follow-up visits were scheduled 1 week, 1 month, and 3 months after surgery. The main outcome measures were visual acuity, intraocular pressure (IOP), PVR reproliferation, and electrophysiological parameters. RESULTS: The primary success rate was 80% (24/30). Fourteen patients (46.7%) had a postoperative improvement in visual acuity, 12 patients (40.0%) maintained their preoperative visual acuity, and four patients (13.3%) experienced a reduction in visual acuity. The mean postoperative IOP was 19.7 mm Hg (11-32 mm Hg); nine cases (30.0%) developed an IOP increase that was treated with topical drops and/or systemic carbonic anhydrase inhibitors. The electroretinogram (ERG) and the bright flash electroretinogram (bf ERG) parameters showed a statistically significant difference of means between 4- and 8-week follow-up visits. CONCLUSION: Our experience with double filling in selected cases of retinal detachment has been positive. No electroretinographic signs of retinal toxicity and a low incidence of PVR reproliferation were observed.

Individualised treatment of proliferative diabetic retinopathy: optimal surgical timing improves long-term outcomes.

Ocular treatment of progressing proliferative diabetic retinopathy is based on retinal laser photocoagulation and pars plana vitrectomy. Improvements in instrumentation and advances in techniques and procedures have increased indications for vitrectomy. These include vitreous haemorrhage preventing laser photocoagulation, severe nonclearing vitreous haemorrhage, subhyaloid and premacular haemorrhage, tractional retinal detachment involving or threatening the macula, combined tractional and rhegmatogenous retinal detachment, progressive fibrovascular proliferation, clinically significant macular oedema and rubeosis iridis. Together with the increasing number of indications, timing for vitrectomy has also changed. The beneficial effect of early vitrectomy for these indications has been clinically shown and supported by several studies. The benefit is evident in case of type I diabetes and when the duration of the diabetes is less than 20 years. Long-term outcomes can therefore be improved when individualised treatment algorithms are applied.

The IOL-Vip System: a double intraocular lens implant for visual rehabilitation of patients with macular disease.

PURPOSE: To investigate the efficacy of a new surgical and rehabilitative procedure designed to improve vision in patients with central scotoma due to macular diseases. DESIGN: Case series of 40 consecutive surgical and rehabilitative procedures. PARTICIPANTS: Forty eyes of 35 consecutive patients with a stable central scotoma due to macular disease underwent phacoemulsification cataract surgery with the implant of the IOL-Vip System. METHODS: The IOL-Vip System consists of a biconcave high minus-power intraocular lens (IOL) in the capsular bag and a biconvex high plus-power IOL in the anterior chamber, reproducing an intraocular Galilean telescope with x1.3 magnification for distance. Selection of the candidate patients was carried out by means of a low-vision diagnostic and rehabilitative program (IOL-Vip software) that evaluates the residual visual function of patients and prognosis for visual improvement based on simulation of the postoperative condition. The software also designs the rehabilitation strategies based on preoperative and postoperative training of the preferred retinal locus. MAIN OUTCOME MEASURES: Best-corrected visual acuity (BCVA), evaluated by means of the Early Treatment Diabetic Retinopathy Study charts and procedure; reading magnification; and reading distance. RESULTS: All patients showed an improvement of visual acuity (VA) due to the surgical and rehabilitative procedure, confirming or exceeding the preoperative expected results. Mean postoperative BCVA was 0.77 (logarithm of the minimum angle of resolution), compared with 1.28 preoperatively. The mean postoperative best reading magnification gain was x6.2, and the mean postoperative reading distance gain was 7.66 cm. No cases of intraoperative or postoperative complications were detected, and the implant was subjectively well tolerated in both monocular and binocular procedures. CONCLUSION: In this pilot study, the IOL-Vip System was shown to be effective and apparently well tolerated in improving the vision of patients with macular disease. Best-corrected VA, reading magnification, and reading distance improved in all cases of this low-vision patient series.

Long-term vitreous replacement with perfluorohexyloctane and silicone oil: preliminary reports of a multicentric study.

AIM: To report on the use of a combined intra-ocular tamponade with silicone oil and perfluorohexyloctane (F(6)H(8)) in the treatment of complex retinal detachment. DESIGN: A prospective consecutive interventional case series from seven study centres. PARTICIPANTS: 69 patients presenting a retinal detachment with proliferative vitreoretinopathy (PVR) and retinal breaks of the inferior two quadrants of the fundus. METHOD: Patients were divided into two groups: (1) 28 eyes which had not been operated on before; (2) 41 eyes affected by recurrent retinal detachment that had had unsuccessful previous surgery with silicone oil or gas tamponade. A pars plana vitrectomy, membrane peeling and -- when necessary -- a retinotomy were performed; the vitreous cavity was filled with two thirds of F(6)H(8) and one third of silicone oil 1,000 mPas (double filling, DF). The endotamponade was removed after 30-45 days (median 38) and replaced by balanced salt solution or silicone oil according to the condition of the retina. RESULTS: Retinal reattachment was achieved in 52 out of 69 cases (75%) 6 months after removal of the DF without any endotamponade. CONCLUSION: The DF with F(6)H(8) and silicone oil allows a good endotamponading to the inferior retina and the posterior pole. The DF appeared to be well tolerated. Further studies are necessary to evaluate whether a DF is advantageous in respect to silicone oil filling alone in case of retinal breaks and PVR of the inferior retina.

Staining of the internal limiting membrane with intravitreal triamcinolone acetonide.

PURPOSE: To evaluate the use of triamcinolone acetonide to stain the internal limiting membrane (ILM) during vitreoretinal surgery. METHODS: A prospective clinical interventional case series study was performed, including 16 patients who underwent pars plana vitrectomy. Seven patients had proliferative diabetic retinopathy with macular edema. Seven patients had epiretinal membranes. One patient had a retinal detachment with a cystoid macular edema and proliferative vitreoretinopathy. One patient had a pseudophakic cystoid macular edema. After vitrectomy, 2 mL triamcinolone acetonide suspension was injected into the vitreous cavity. The ILM was peeled, as it was evidenced by the particles of triamcinolone that adhered to its surface. The ultrastructure of tissue harvested during surgery was analyzed using transmission electron microscopy in selected cases to confirm the presence or absence of ILM. RESULTS: After the injection of triamcinolone, the visualization of the vitreous base and hyaloid was excellent in all patients. The particles of triamcinolone deposited on the retinal surface enabled the ILM to be stained. Once removed, the ILM was clearly distinguishable, floating in the vitreous cavity with particles of triamcinolone adhering to its surface. Ultrastructural analysis of tissue collected during vitrectomy confirmed that the removed tissue represented ILM. CONCLUSION: We observed that triamcinolone acetonide can be useful in staining the internal limiting membrane, thus greatly facilitating the retinal ILM peeling. The absence of particles of triamcinolone on the underlying retina enables the area where the ILM has already been removed to be identified.