Photocoagulation Up to Ora Serrata in Diabetic Vitrectomy to Prevent Recurrent Vitreous Hemorrhage.

PURPOSE: To evaluate the role of performing photocoagulation up to ora serrata during vitrectomy in preventing recurrent vitreous hemorrhage (VH) in patients undergoing pars plana vitrectomy (PPV) for proliferative diabetic retinopathy (PDR). METHODS: This retrospective, nonrandomized study included 60 eyes from 60 patients who had undergone PPV for VH due to PDR. These patients were divided into two groups: group 1, those who underwent photocoagulation up to ora serrata using the scleral indentation technique during surgery; and group 2, those who did not undergo scleral indentation when photocoagulation and underwent photocoagulation up to vortex veins. Their hospital records were analyzed to investigate the recurrence rate of VH, the time until recurrence of VH after surgery, logarithm of the minimal angle of resolution (logMAR) best-corrected visual acuity (BCVA) measured before surgery and at 1, 2, and 3 years after surgery, and the occurrence of complications such as neovascular glaucoma (NVG) during follow-up. RESULTS: Group 1 exhibited lower recurrence rate of VH (2 of 30 [6.7%] vs. 10 of 30 [33.3%], p = 0.01) and lower occurrence of postoperative NVG (2 of 30 [6.7%] vs. 8 of 30 [26.7%], p = 0.038) compared with group 2. There were no statistically significant differences in logMAR BCVA measured at 1, 2, and 3 years between the two groups (at 1 year: 0.54 ± 0.43 vs. 0.54 ± 0.44, p = 0.954; at 2 years: 0.48 ± 0.47 vs. 0.55 ± 0.64, p = 0.235; at 3 years: 0.51 ± 0.50 vs. 0.61 ± 0.77, p = 0.200). Logistic regression analysis showed that among several factors that could affect recurrence rate of VH, only range of photocoagulation performed was a statistically significant factor (odds ratio, 0.119; 95% confidence interval, 0.022-0.659; p = 0.015). CONCLUSIONS: Photocoagulation treatment over a wider range with scleral indentation could be a beneficial adjunct procedure for preventing postoperative recurrent VH following diabetic vitrectomy.

A pilot study of viscoelastic agent to prevent recurrent vitreous hemorrhage after vitrectomy for proliferative diabetic retinopathy.

BACKGROUND: To evaluate the possibilty of preventing recurrent vitreous hemorrhage (RVH) after vitrectomy in proliferative diabetic retinopathy (PDR) patients with unabsorbed vitreous hemorrhage (VH) by intravitreal injection of viscoelastic agent (VA) at the end of the surgery and compared its effect with triamcinolone acetonide (TA). METHODS: This was a pilot prospective, observational study. PDR patients with VH who underwent vitrectomy were assigned to 3 groups according to the tamponade applicated at the end of the surgery, including VA group (intravitreally injected 1 ml VA if the retina was prone to bleed during the operation), TA group (intravitreally injected 2 mg TA when there was much exudates), or balanced salt solution (BSS) group (no tamponade). Then postoperative follow-up was performed routinely until 6 months after surgery. The primary outcome was the incidence of RVH, secondary outcome were the best-corrected visual acuity (BCVA) and introcular pressure (IOP). Cataract formation and other complication were also assessed. RESULTS: A total of 68 eyes, from 68 patients, were included. 18,18,32 eyes were enrolled in the VA group, TA group and BSS group, respectively. The integral incidence of RVH after vitrectomy was 5.6%, 5.6% and 12.5% respectively (P = 0.602). There was no early RVH in VA or TA group, whereas 3 early RVHs were identified in BSS group, however there was no significant difference (P = 0.171). Every group had one late RVH case. In all groups, final BCVA showed significant improvement compared to baseline. BCVA at any postoperative visit showed no significant differences among 3 groups. Mean IOP was higher 1 week after surgery in VA group compared with the other groups; however, in other times the differences were not significant. No cataract formation and other complication was noted in 3 groups. CONCLUSION: Intravitreal injection of VA or TA at the end of vitrectomy for PDR patients with unabsorbed VH tend to reduce the incidence of early RVH after vitrectomy similarly. As VA was preferred to applicate in the eyes that were prone to bleed, intravitreal injection of VA at the end of vitrectomy might be a promising method for preventing RVH in PDR patients.

Preventing Iatrogenic Retinal Breaks in Cutter-Associated Traction from Chronic Vitreous Hemorrhage (CATCH).

BACKGROUND AND OBJECTIVE: To describe an under-recognized complication in the surgical management of dense, nonclearing vitreous hemorrhage, specifically, the development of iatrogenic retinal breaks as a result of cutter-associated traction. STUDY DESIGN/PATIENTS AND METHODS: Review of surgical cases with cutter-associated traction from chronic vitreous hemorrhage (CATCH). RESULTS: Cutter-associated traction from chronic vitreous hemorrhage is a commonly encountered surgical entity that may result in complications such as iatrogenic retinal breaks, including giant retinal tears. These complications can be minimized or potentially avoided through the use of open sclerotomies or potentially mixed-gauge vitrectomy. CONCLUSION: Careful surgical planning in cases of dense or chronic vitreous hemorrhage is required to prevent cutter-associated tractional retinal breaks. [Ophthalmic Surg Lasers Imaging Retina 2022;53:584-585.].

Effect of prophylactic anti-VEGF injections on the prevention of recurrent vitreous hemorrhage in PDR patients after PRP.

We evaluated the effectiveness of intravitreal anti-vascular endothelial growth factor (anti-VEGF) antibody injection (IVAI) for the prevention of recurrent vitreous hemorrhage (VH) due to neovascularization on disc (NVD) in patients with proliferative diabetic retinopathy (PDR) after panretinal photocoagulation (PRP). This retrospective case series reviewed the medical records of 12 PDR patients with recurrent VH after PRP from NVD. The interval between IVAIs was decided on the basis of the interval between VH recurrences after the initial IVAI, and NVD regression/recurrence during follow-up. We recorded the success rate of VH prevention, and the interval between IVAIs. Fundus examination revealed NVD regression at 1 month after the injection. However, NVD progressed gradually and VH recurred after 3-4 months. Thereafter, IVAIs were administered every 3-4 months; VH did not recur and visual acuity remained stable during the treatment period. In one case, NVD did not recur after 4 years of periodic injections. No systemic or ocular complications of IVAI were observed. In conclusion, proactive and periodic IVAIs (at 3-4-month intervals) may prevent recurrent VH in association with NVD in PDR patients after PRP.

Gas Tamponade for the Prevention of Postoperative Vitreous Hemorrhaging After Diabetic Vitrectomy: A Randomized Clinical Trial.

PURPOSE: To compare vitreous substitution with sulfur hexafluoride (SF6) gas to balanced salt solution (BSS) for the prevention of postoperative vitreous hemorrhage (VH) in proliferative diabetic retinopathy (PDR) patients undergoing pars plana vitrectomy (PPV) for the indication of non-clearing VH. METHODS: One hundred forty-four PDR subjects requiring PPV for the indication of non-clearing VH were enrolled into the trial. Subjects were prospectively randomized into 1 of 2 vitreous substitution groups: Group A subjects underwent 20% to 30% SF6 gas tamponade, whereas Group B subjects underwent vitreous substitution with BSS. The primary outcome was the incidence of postoperative VH during the 6-month trial period. Secondary outcomes were unplanned PPV for VH and best corrected visual acuity (BCVA) at 6-months follow-up. RESULTS: Ninety-six subjects underwent randomization and completed 6-months follow-up. Postoperative VH during the trial period occurred in 6 of 54 subjects in Group A (SF6) (11.1%) and 14 of 42 in Group B (BSS) (33.3%) (P = .008). Unplanned PPV during the trial period for postoperative VH occurred in 2 of 54 in Group A (3.7%) and 6 of 42 in Group B (14.2%) (P = .06). The mean BCVA was not significantly different at 6-months follow-up between groups (P = .58). CONCLUSIONS: This trial indicates that vitreous substitution with SF6 gas lowers the incidence of postoperative VH compared with BSS in PDR subjects undergoing PPV for the indication of non-clearing VH at 6-months follow-up. Specialists may consider SF6 gas tamponade during PPV as a means of helping reduce postoperative VH in this patient population. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Intravitreal conbercept as an adjuvant in vitrectomy for proliferative diabetic retinopathy: a meta-analysis of randomised controlled trials.

PURPOSE: To evaluate the efficacy of intravitreal conbercept (IVC) in pars plana vitrectomy (PPV) for patients with proliferative diabetic retinopathy (PDR). METHODS: A meta-analysis of randomized control trials (RCTs) using online databases was performed. The intraoperative outcome measures were the incidence of intraoperative bleeding and endodiathermy application, and the mean surgical time. The postoperative outcome measures were mean change in best-corrected visual acuity (BCVA) from baseline, postoperative vitreous clear-up time and incidence of recurrent vitreous hemorrhage (VH). RESULTS: Eight RCTs were selected for meta-analysis. They included 409 eyes (215 eyes in IVC group and 194 eyes in no conbercept group). Preoperative IVC application was associated with less intraoperative bleeding and endodiathermy applications (RR = 0.34, 95% CI, 0.23-0.50, P < 0.00001, and RR = 0.26, 95% CI, 0.12-0.56, P = 0.0005) compared to no conbercept. It also shortened surgical time (WMD = -15.87, 95% CI, -22.04 to -9.69, P < 0.00001). In addition, preoperative or intraoperative IVC achieved better BCVA outcome (WMD = -0.37, 95% CI, -0.62 to -0.13, P = 0.003), shorter vitreous clear-up time postoperatively (WMD = -5.44, 95% CI, -6.31 to -4.57, P < 0.00001) and a lower rate of VH recurrence (RR = 0.45, 95% CI, 0.22-0.91, P = 0.03). CONCLUSION: IVC is an effective adjuvant in PPV for PDR, with better intraoperative and postoperative outcomes.

Prophylactic intravitreal injection of aflibercept for preventing postvitrectomy hemorrhage in proliferative diabetic retinopathy: A randomized controlled trial.

Introduction: The aim of this study was to assess the effects of preoperative intravitreal aflibercept (IVA) injection on the incidence of postoperative vitreous hemorrhage (VH) after vitrectomy for proliferative diabetic retinopathy (PDR). Methods: This study involved a prospective, randomized clinical trial. One hundred twenty-eight eyes of 128 patients of PDR who underwent pars plana vitrectomy (PPV) were enrolled. Sixty-four eyes were assigned randomly to either the IVA group (IVA injection 1 to 5 days before PPV) or the control group (no IVA injection). The primary outcome was the incidence of VH at 1 month after PPV. Secondary outcome measures were best-corrected visual acuity (BCVA) changes from baseline to at 1 week, 1 month, 2 months, and 3 months after surgery. Results: The VH incidences in the IVA group and the control group were 14.8 and 39.3% at week 1, 8.6 and 31.7% at month 1, 11.7 and 30.5% at month 2, and 8.6 and 30.5% at month 3, respectively. Intergroup differences showed a significantly decreased VH rate in the IVA group compared with that in the control group at week 1, month 1, and month 3 (p = 0.021, 0.006, and 0.047, respectively). Compared to the baseline, neither the mean BCVA nor the BCVA change in the Logarithm of the Minimum Angle of Resolution (logMAR) scale did differ significantly between the two groups at each visit point. There are a greater number of eyes with BCVA improvement of more than 2 logMAR in the IVA group than in the control group at week 1 (8 vs. 2, p = 0.048). Conclusions: This study found that the adjunctive use of preoperative IVA reduces early and late postoperative VH in vitrectomy for PDR.

The effect of adjunctive intravitreal conbercept at the end of diabetic vitrectomy for the prevention of post-vitrectomy hemorrhage in patients with severe proliferative diabetic retinopathy: a prospective, randomized pilot study.

BACKGROUND: To investigate the effect of intravitreal conbercept (IVC) injections on the incidence of postoperative vitreous hemorrhage (VH) in eyes undergoing surgery for severe proliferative diabetic retinopathy. METHODS: This was a pilot prospective, comparative, and randomized study. Thirty patients, who underwent vitrectomy for severe proliferative diabetic retinopathy, were assigned randomly to either group 1 (intravitreal conbercept [IVC] injection at the end of pars plana vitrectomy) or group 2 (no IVC injection). Postoperative follow-up was performed on the first day, first week, first month, third month, sixth month and first year after surgery. The primary outcome was the incidence of postoperative VH. Secondary outcomes were the initial time of vitreous clearing (ITVC), best-corrected visual acuity (BCVA) and central retinal thickness (CRT) after surgery. RESULTS: A total of 30 eyes, from 30 patients, were included. Fifteen eyes were enrolled in the IVC group and fifteen in the control group. The incidence of early and late postoperative VH was not significantly different between the control and IVC groups. ITVC was shorter in the IVC group than that in the control group, but this was not significant (7.38 ± 10.66 vs 13.23 ± 17.35, P = 0.31). Final BCVA, 1 year after surgery, showed significant improvement compared to baseline in both groups. However, analysis of the BCVA at any postoperative visit after surgery showed no significant differences between the two groups. There were two cases of recurrent VH identified at 3 and 6 months after surgery in each group, requiring a second round of surgery. Foveal thickness was significantly different between the two groups at the 3-month, 6-month and 1-year follow-up visits. CONCLUSIONS: In this pilot study, the effect of IVC injection in reducing the incidence of postoperative VH after diabetic vitrectomy at the end of vitrectomy was not shown. TRIAL REGISTRATION: The study was registered with the Chinese Clinical Trial Registry. (Reference Number: ChiCTR1800015751).

EVALUATION OF SURGICAL FACTORS AFFECTING VITREOUS HEMORRHAGE FOLLOWING PORT DELIVERY SYSTEM WITH RANIBIZUMAB IMPLANT INSERTION IN A MINIPIG MODEL.

PURPOSE: To develop an animal model of vitreous hemorrhage (VH) to explore the impact of surgical parameters on VH associated with insertion of the Port Delivery System with ranibizumab (PDS) implant. METHODS: Ninety eyes from 45 treatment-naive male Yucatan minipigs received PDS implant insertion or a sham procedure. The effect of prophylactic pars plana hemostasis, scleral incision length, scleral cauterization, surgical blade type/size, and viscoelastic usage on postsurgical VH was investigated. RESULTS: Postsurgical VH was detected in 60.0% (54/90) of implanted eyes. A systematic effect on VH was only detected for pars plana hemostasis before the pars plana incision. The percentage of eyes with VH was 96.6% (28/29) among eyes that did not receive prophylactic pars plana hemostasis and 42.4% (24/58) among eyes that did. There was no VH in eyes that received laser ablation of the pars plana using overlapping 1,000-ms spots; pars plana cautery or diathermy was less effective. The majority of all VH cases (83.3% [45/54]) were of mild to moderate severity (involving ≤25% of the fundus). CONCLUSION: In this minipig surgical model of VH, scleral dissection followed by pars plana laser ablation before pars plana incision most effectively mitigated VH secondary to PDS implant insertion.

Preoperative Bevacizumab for Tractional Retinal Detachment in Proliferative Diabetic Retinopathy: A Prospective Randomized Clinical Trial.

PURPOSE: To assess the effectiveness and safety of an intravitreal injection of 1.25 mg bevacizumab (IVB) as a preoperative adjunct to small-gauge pars plana vitrectomy (PPV) compared with PPV alone in eyes with tractional retinal detachment secondary to proliferative diabetic retinopathy. METHODS: This prospective, double-masked, randomized, multicenter, active-controlled clinical trial enrolled 224 eyes of 224 patients between November 2013 and July 2015. All eyes underwent a baseline examination including best-corrected visual acuity, color photos, optical coherence tomography, and fluorescein angiography. Data were collected on intraoperative bleeding, total surgical time, early (<1 month) postoperative vitreous hemorrhage, and mean change in best-corrected visual acuity at 12 months. P < .05 was considered statistically significant. RESULTS: A total of 214 patients (214 eyes) were randomized in a 1:1 ratio to PPV plus IVB ([study group] 102 eyes) or PPV plus sham ([control] 112 eyes). Iatrogenic retinal breaks were noted intraoperatively in 35 eyes (34.3%) in the study group, and 66 eyes (58.9%) in the control group (P = .001). Grade 2 intraoperative bleeding was noted in 32 (31.3%) eyes in the study group and 58 (51.7 %) eyes in the control group (P = .001). Endodiathermy was necessary in 28 (27.4 %) eyes in the study group, compared with 75 (66.9%) eyes in the control group (P = .0001). Mean surgical time was 71.3 ± 32.1 minutes in the study group and 83.6 ± 38.7 minutes in the control group (P = .061). CONCLUSION: Preoperative IVB seems to reduce intraoperative bleeding, improving surgical field visualization, and reducing intraoperative and postoperative complications. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Ziv-aflibercept versus bevacizumab administration prior to diabetic vitrectomy: a randomised and controlled trial.

PURPOSE: To compare the effectiveness of intravitreal ziv-aflibercept (IVZ) to intravitreal bevacizumab (IVB) administered preoperatively to patients undergoing pars plana vitrectomy (PPV) for severe manifestations of proliferative diabetic retinopathy (PDR). DESIGN: Randomised clinical trial (RCT). METHODS: Two hundred and six patients with PDR-related complications requiring PPV were randomised into one of two treatment groups: Group A received IVZ (1.25 mg/0.05 mL) 1-10 days before PPV, while Group B received IVB (1.25 mg/0.05 mL) 1-10 days before PPV. The primary outcome was best-corrected visual acuity (BCVA) at 6 months follow-up. Secondary outcome measures were perioperative tractional retinal detachment (TRD) rates, surgical times, intraoperative and postoperative complications and incidence of unplanned PPV during the 6 month study interval. RESULTS: One hundred and seventy three subjects underwent PPV and completed the 6-month follow-up interval. Group A subjects had better BCVA at 6 months (p=0.0035), shorter surgical times (p=0.0013) and were less likely to have a recurrence of vitreous haemorrhaging in the postoperative period (p=0.0101) when compared with subjects in Group B. There were no significant differences among the treatment groups with regards to baseline characteristics, perioperative TRD development, intraoperative complications and incidence of unplanned PPV during the 6 month study interval. CONCLUSIONS: This RCT demonstrated better final visual outcomes, shorter operating times and less vitreous haemorrhage recurrences in the postoperative period when subjects received IVZ compared to IVB prior to PPV for the treatment of PDR-related complications.

Air-Perfused 23-Gauge Sutureless Diabetic Vitrectomy for Control of Intraoperative Bleeding during Removal of Fibrovascular Membrane.

PURPOSE: To demonstrate the advantages and efficacy of an air-perfused membrane dissection to control intraoperative bleeding in 23-gauge sutureless vitrectomy for proliferative diabetic retinopathy with severe fibrovascular membranes. Meterials and Methods: A prospective, consecutive, interventional case series of 15 eyes that underwent air-perfused diabetic vitrectomy (air vitrectomy group) for removal of the membranes was compared with a retrospective, membrane-matched case series of 10 eyes that underwent conventional diabetic vitrectomy (conventional vitrectomy group). The main outcome measures were real vitrectomy time, intraoperative and postoperative complications, and anatomic and functional successes at the final examination. RESULTS: The incidence of intraoperative retinal tears was 30% (3/10 eyes) in the conventional vitrectomy group and 20% (3/15 eyes) in the air vitrectomy group (p > 0.05). The postoperative complications such as vitreous hemorrhage or tractional retinal detachment were not common in both groups during the 6-month follow-up (p > 0.05). In addition, the final anatomic and functional success rates did not differ significantly between the groups (p > 0.05). However, the vitrectomy time was significantly shorter in the air vitrectomy group (67.0 ± 21.8 min) than in the conventional group (84.6 ± 21.1 min) (p = 0.04). CONCLUSION: Air-perfused vitrectomy showed comparable anatomic and functional success rates and shorter surgical time, compared with conventional vitrectomy in diabetic eyes with severe fibrovascular membranes. We suppose that the shortened surgical time in the air vitrectomy group is related to less intraoperative bleeding and more efficient hemostasis.

Argon Laser Photocoagulation For Macular Edema In Branch Vein Occlusion.

The Branch Vein Occlusion Study is a multi-center, randomized, controlled clinical trial designed to answer several questions regarding the management of complications of branch vein occlusion. This report discusses the question, "Is argon laser photocoagulation useful in improving visual acuity in eyes with branch vein occlusion and macular edema reducing vision to 20/40 or worse?" One hundred thirty-nine eligible eyes were assigned randomly to either a treated or an untreated control group. Comparing treated patients to control patients (mean follow-up 3.1 years for all study eyes), the gain of at least two lines of visual acuity from baseline maintained for two consecutive visits was significantly greater in treated eyes (P = .00049, logrank test). Because of this improvement in visual acuity with argon laser photocoagulation of macular edema from branch vein occlusion, we recommend laser photocoagulation for patients with macular edema associated with branch vein occlusion who meet the eligibility criteria of this study.

A comparative study to determine the optimal intravitreal injection angle to the eye: A computational fluid-structure interaction model.

This study was aimed at investigating the role of IVI angle on the induced stresses and deformations among the components of the eye. Thereafter, the most optimal angle of IVI to minimize the complications of post IVI at the injection site on a basis of the computed stresses via a Fluid-Structure Interaction (FSI) computational model was proposed. IntraVitreal Injection (IVI) is broadly employed as a principal treatment of vascular vitro-retinal diseases. So far, there have been reports regarding the complications of post IVI and determine them as severe uveitis, tractional retinal detachment, IntraOcular Pressure (IOP) elevation as well as ocular haemorrhage. However, there is a lack of knowledge on how to reduce the subsequent ocular tissue damage and patient symptoms in the injection site. Seven different IVI angles were simulated, including 0∘, 15∘, 30∘, 45∘, 60∘, 75∘, and 90∘, through the Finite Element (FE) code; and the term, 'post IVI complication' or 'injury', in the results was interpreted as the level of maximal principal stress in the eye components. The results revealed the lowest amount of stresses at the angle of 45∘ in respect to the horizontal line (acute to the surface of the sclera) for the lens, iris, vitreous body, aqueous body, ciliary body, sclera, retina, and choroid. The cornea illustrated the same amount of stress at the angles of 45∘, 60∘, 75∘, and 90∘ with the highest one at the IVI angle of 30∘. The lowest and the highest stresses among the eye components regardless of IVI angle were observed in the choroid and retina/sclera, respectively, which imply the importance of the IVI angle on the stresses of these eye components. The findings of the contemporary research revealed that the IVI angle of 45∘ would trigger less post IVI complications and, as a result, a more effective surgery outcome compared to the other angles, i.e., 0∘, 15∘, 30∘, 60∘, 75∘, and 90∘.

Predictors of postoperative bleeding after vitrectomy for vitreous hemorrhage in patients with diabetic retinopathy.

AIMS/INTRODUCTION: To clarify the association between perioperative variables and postoperative bleeding in pars plana vitrectomy for vitreous hemorrhage in diabetic retinopathy. MATERIALS AND METHODS: The present retrospective study enrolled 72 eyes of 64 patients who were admitted to Osaka University Hospital between April 2010 and March 2014, and underwent vitrectomy for vitreous hemorrhage as a result of diabetic retinopathy. RESULTS: Postoperative bleeding developed in 12 eyes. Using binomial logistic regression analysis, we found that the duration of operation was the only significant variable associated with postoperative bleeding within 12 weeks after vitrectomy. Furthermore, Poisson regression analysis identified fasting blood glucose just before vitrectomy, no treatment with antiplatelet drugs and treatment with antihypertensive drugs, as well as duration of operation, to be significantly associated with the frequency of bleeding within 52 weeks after vitrectomy. CONCLUSIONS: Long duration of operation can be used to predict bleeding within both 12 and 52 weeks after vitrectomy. In addition, fasting blood glucose just before vitrectomy, no treatment with antiplatelet drugs and treatment with antihypertensive drugs might be risk factors for postoperative bleeding up to 1 year after vitrectomy.

[Analysis of the Cochrane Review: Anti-vascular Endothelial Growth Factor for Prevention of Postoperative Vitreous Cavity Hemorrhage after Vitrectomy for Proliferative Diabetic Retinopathy. Cochrane Database Syst Rev. 2015;8:CD008214.] / Análise da Revisão Cochrane: Anti-fator de Crescimento Vascular Endotelial na Prevenção da Hemorragia Vítrea Pós-Operatória após Vitrectomia por Retinopatia Diabética Proliferativa. Cochrane Database Syst Rev. 2015;8:CD008214.

Postoperative vitreous hemorrhage is a complication following vitrectomy for proliferative diabetic retinopathy, delaying visual recovery and making fundus examination and disease follow-up more difficult. Anti-vascular endothelial growth factor drugs such as bevacizumab, when injected in the vitreous cavity, reduce vascular proliferation and their use has been proposed to reduce the incidence of postoperative vitreous hemorrhage. The authors of this Cochrane systematic review evaluated all randomized controlled trials on the pre- or intraoperative use of anti-vascular endothelial growth factor to reduce postoperative vitreous hemorrhage occurrence after vitrectomy in patients with proliferative diabetic retinopathy. The results suggested that the use of intravitreal bevacizumab was effective in reducing early postoperative vitreous hemorrhage (i.e. at four weeks) occurrence, with a good safety profile. This work aims to summarize and discuss the findings and clinical implications of this Cochrane systematic review.

A hemorragia vítrea pós-operatória é uma complicação da cirurgia de vitrectomia por retinopatia diabética proliferativa, que atrasa a melhoria da acuidade visual e dificulta a visualização do fundo ocular e o seguimento da doença. Quando injetados na cavidade vítrea, os fármacos anti-factor de crescimento do endotélio vascular, como o bevacizumab, diminuem a proliferação vascular e o seu uso tem sido proposto na redução da incidência de hemorragia vítrea pós-operatória. Os autores desta revisão sistemática Cochrane reviram os ensaios clínicos aleatorizados sobre o uso pré- ou intraoperatório de anti-factor de crescimento do endotélio vascular na redução da incidência de hemorragia vítrea pós-operatória após vitrectomia em doentes com retinopatia diabética proliferativa. Dos resultados, destaca-se o efeito benéfico da utilização de bevacizumab na diminuição da hemorragia vítrea pós-operatória precoce (i.e. às quatro semanas), com um bom perfil de segurança. Neste trabalho, sumarizam-se e discutem-se os principais achados e implicações práticas desta revisão sistemática Cochrane.

Ranibizumab pretreatment in diabetic vitrectomy: a pilot randomised controlled trial (the RaDiVit study).

PurposeOur aim was to evaluate the impact of intravitreal ranibizumab pretreatment on the outcome of vitrectomy surgery for advanced proliferative diabetic retinopathy. The objective was to determine the feasibility of a subsequent definitive trial and estimate the effect size and variability of the outcome measure.Patients and methodsWe performed a pilot randomised double-masked single-centre clinical trial in 30 participants with tractional retinal detachment associated with proliferative diabetic retinopathy. Seven days prior to vitrectomy surgery, participants were randomly allocated to receive either intravitreal ranibizumab (Lucentis, Novartis Pharmaceuticals UK Ltd, Frimley, UK) or subconjunctival saline (control). The primary outcome was best-corrected visual acuity 12 weeks following surgery.ResultsAt 12 weeks, the mean (SD) visual acuity was 46.7 (25) ETDRS letters in the control group and 52.6 (21) letters in the ranibizumab group. Mean visual acuity improved by 14 (31) letters in the control group and by 24 (27) letters in the ranibizumab group. We found no difference in the progression of tractional retinal detachment prior to surgery, the duration of surgery, or its technical difficulty. Vitreous cavity haemorrhage persisted at 12 weeks in two of the control group but none of the ranibizumab group.ConclusionRanibizumab pretreatment may improve the outcome of vitrectomy surgery for advanced proliferative diabetic retinopathy by reducing the extent of post-operative vitreous cavity haemorrhage. However, the effect size appears to be modest; we calculate that a definitive study to establish a minimally important difference of 5.9 letters at a significance level of P<0.05 would require 348 subjects in each arm.

Anti-vascular endothelial growth factor for prevention of postoperative vitreous cavity haemorrhage after vitrectomy for proliferative diabetic retinopathy.

BACKGROUND: Postoperative vitreous cavity haemorrhage (POVCH) is a significant complication following vitrectomy for proliferative diabetic retinopathy (PDR). It delays visual recovery and can make further treatment difficult if the view of the fundus is significantly obscured. A number of interventions to reduce the incidence of POVCH have been proposed, including the perioperative use of anti-vascular endothelial growth factor (anti-VEGF). Anti-VEGFs reduce vascular proliferation and the vascularity of neovascular tissue, which is often the source of bleeding following vitrectomy. OBJECTIVES: This updated review aimed to summarise the effects of anti-VEGF use to reduce the occurrence of POVCH after vitrectomy surgery for PDR. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 4), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to May 2015), PubMed (January 1966 to May 2015), EMBASE (January 1980 to May 2015), Latin American and Caribbean Health Sciences (LILACS) (January 1982 to May 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 26 May 2015. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) and quasi-RCTs that looked at the use of anti-VEGFs and the incidence of POVCH in people undergoing vitrectomy for PDR. DATA COLLECTION AND ANALYSIS: Both review authors independently assessed and extracted the data. We used standard methodological procedures expected by Cochrane.The primary outcomes of the review were the incidence of early and late POVCH following perioperative anti-VEGF administration. Secondary outcomes included best-corrected visual acuity at six months following surgery, the incidence of vitreous cavity washout or revision vitrectomy at six months, adverse effects of intervention (cataract, iris rubeosis and rubeotic glaucoma, retinal detachment, increased inflammation and systemic side effects), quality of life measures performed at least six months following vitrectomy, and density of POVCH. MAIN RESULTS: The current review included 12 RCTs that looked at the pre- or intraoperative use of intravitreal bevacizumab to prevent postoperative vitreous haemorrhage during pars plana vitrectomy for complications of PDR. The studies were conducted in a variety of countries (three from Iran, two from Italy, two from Egypt, and the remaining from South Korea, USA, Mexico, Pakistan, and Japan). The inclusion criteria for entry into the studies were standard complications of proliferative retinopathy: non-clearing vitreous haemorrhage, tractional retinal detachment involving the macula, or combined tractional rhegmatogenous detachment. The included studies randomised a total of 654 eyes. The average age of the participants was 54 years.We identified methodological issues in all included studies. Risk of bias was highest for masking of participants and investigators (four studies were an 'open label' design), and a number of studies were unclear when describing randomisation methods and sequence allocation.Participants receiving intravitreal bevacizumab in addition to pars plana vitrectomy were less likely to experience early POVCH (grade 2) compared to people undergoing pars plana vitrectomy alone (risk ratio (RR) 0.28, 95% confidence interval (CI) 0.08 to 0.96, 2 studies, 144 eyes, high-quality evidence). This corresponds to an absolute effect of 130 fewer people (95% CI 167 fewer to 7 fewer) with early POVCH per 1000 people when treated with intravitreal bevacizumab. We saw similar results for all grades of POVCH (RR 0.35, 95% CI 0.23 to 0.53, 9 studies, 512 eyes) and when excluding cases where assessment of outcome was impossible due to presence of silicone oil (RR 0.34, 95% CI 0.19 to 0.60, 6 studies, 302 eyes).The effect of pre- or intraoperative intravitreal bevacizumab on the incidence of late postoperative haemorrhage was uncertain (RR 0.72, 95% CI 0.30 to 1.72, 3 studies, 196 eyes, low-quality evidence). The absolute effect was 55 fewer people (95% CI 138 fewer to 143 more) with late POVCH per 1000 people when treated with intravitreal bevacizumab. This outcome was rarer and was only reported in a few studies. We are currently unable to provide an estimate of the effect of intravitreal bevacizumab on postoperative visual acuity due to significant study heterogeneity.No local or systemic complications of intravitreal bevacizumab were reported by the RCTs. The risk of postoperative retinal detachment was lower in the participants treated with pre- or intraoperative bevacizumab (RR 0.46, 95% CI 0.19 to 1.08, 7 studies, 372 participants, low-quality evidence); the absolute effect was 49 fewer people (95% CI:73 fewer to 8 more) with postoperative retinal detachment per 1000 people when treated with intravitreal bevacizumab. AUTHORS' CONCLUSIONS: The use of pre- or intraoperative bevacizumab lowers the incidence of early POVCH. The reported complications from its use appear to be low. Futher randomised studies that look at other anti-VEGF medications are ongoing and will strengthen the current review findings, giving both surgeons and patients evidence to guide treatment choices in the management of proliferative retinopathy.

Persistencia bilateral de la arteria hialoidea. Reporte de un caso / Bilateral persistent hyaloid artery. A case report

CASO CLÍNICO: Varón de 5 años de edad con mala visión bilateral, endotropía y diagnóstico previo de catarata desde el año de edad. En la exploración, se observa en ambos ojos opacidad capsular posterior paracentral, cavidad vítrea con arteria hialoidea permeable, ocupada por sangre y con pulso. Se dejó en vigilancia. DISCUSIÓN: La persistencia de la arteria hialoidea es infrecuente y es una falla en la involución del vítreo primario. Comúnmente es unilateral (aunque hay casos bilaterales), esporádico y asociado a microftalmos. Puede complicarse con glaucoma y pthisis bulbi. Vitrectomía más lensectomía u observación son opciones de tratamiento según el caso

CASE REPORT: A 5-year-old male presented with bilateral poor vision, esotropia and a previous diagnosis of cataract since he was 1 year old. The physical examination revealed bilateral posterior paracentric capsule opacification, vitreous cavity with a permeable pulsatile blood filled hyaloid artery in both eyes. He was kept under observation. Discussion: Persistent hyaloid artery is an uncommon faulty primary vitreous regression, often unilateral (although it may be bilateral) and sporadic, associated with microphthalmos. It may be complicated with glaucoma and phthisis bulbi. Vitrectomy plus lensectomy or simple observation are the accepted treatment options

The role of intraoperative bevacizumab for prevention of postoperative vitreous hemorrhage in diabetic vitreous hemorrhage.

PURPOSE: To assess the effect of intravitreal bevacizumab (IVB) on the incidence of postoperative recurrent vitreous hemorrhage (VH) in eyes operated for diabetic VH when injected at the end of the surgery. METHODS: A prospective, comparative clinical trial was conducted on a consecutive series of patients requiring vitrectomy for diabetic nonclearing VH. Intravitreal bevacizumab (2.5 mg/0.1 mL) was injected at the completion of surgery. Patients underwent best-corrected visual acuity (VA), applanation tonometry, and biomicroscopic anterior and posterior segment evaluation for VH grading. Postoperative visits were performed at the first day, first week, first month, third month, and sixth month. The VH was graded at each visit, and the rate of postoperative VH and VA improvement and potential complications were evaluated and compared between the groups. RESULTS: A total of 72 eyes of 66 patients were included. Thirty-four eyes were enrolled in the IVB group and 38 eyes were enrolled in the control group. The rate of postoperative VH did not differ significantly between the groups at any postoperative visit (p>0.05). Three eyes (8.8%) in the IVB group and 5 eyes (13.1%) in the control group had postoperative VH throughout the follow-up period and only one eye from each group underwent a second surgery. Postoperative VA significantly increased in both groups but did not differ significantly between the groups at any postoperative visit (p>0.05). CONCLUSIONS: Intravitreal bevacizumab does not seem to have any beneficial effect on the incidence of postoperative VH in eyes operated for diabetic VH when injected at the end of surgery.