VITRECTOMY WITH SUBRETINAL INJECTION OF RECOMBINANT TISSUE PLASMINOGEN ACTIVATOR FOR SUBMACULAR HEMORRHAGE WITH OR WITHOUT VITREOUS HEMORRHAGE.

PURPOSE: To evaluate the outcomes and prognostic factors of pars plana vitrectomy combined with subretinal injection of recombinant tissue plasminogen activator for submacular hemorrhage (SMH) patients with or without vitreous hemorrhage (VH). METHODS: Sixty-four eyes of 64 patients with SMH underwent pars plana vitrectomy with subretinal injection of recombinant tissue plasminogen activator. Best-corrected visual acuity, SMH displacement, and postoperative complications were analyzed. Predictive factors of the final best-corrected visual acuity were determined using multivariant linear regression. RESULTS: There were 26 eyes with VH and 38 eyes without VH best-corrected visual acuity significantly improved in both VH group (from 2.27 ± 0.40 to 1.25 ± 0.70 logarithm of the minimum angle of resolution) and non-VH group (from 1.76 ± 0.55 to 0.85 ± 0.65 logarithm of the minimum angle of resolution). Complete displacement of SMHs was observed in 47 (73.43%) eyes. Postoperative complications included recurrent SMH (4.69%), recurrent VH (10.94%), rhegmatogenous retinal detachment (3.13%), and epiretinal membrane (4.68%). Treatment-naive condition, early surgery, and younger age were significantly associated with better final best-corrected visual acuity ( B = 0.502, 0.303, and 0.021, respectively, with all P < 0.05). CONCLUSION: Pars plana vitrectomy combined with subretinal recombinant tissue plasminogen activator injection is an effective treatment for SMH patients with and without VH.

Preoperative hemoglobin A1c is associated with postoperative bleeding after vitrectomy for vitreous hemorrhage in patients with diabetic retinopathy.

We previously reported that a high HbA1c level 3 months before vitrectomy for vitreous hemorrhage or a large preoperative decrease in the HbA1c level over 3 months tended to increase the risk of rebleeding in diabetic retinopathy patients evaluated between 2010 and 2014. Here, we aimed to confirm these results with an extended study period and an increased number of operated eyes. This study included 121 diabetic patients who were admitted to Osaka University Hospital between 2010 and 2019 and who underwent vitrectomy for vitreous hemorrhage. Binomial logistic regression analysis was performed with the presence of postoperative bleeding as the outcome. The present study showed that the duration of the operation was associated with rebleeding (odds ratio = 1.02, p = 0.0016). A high HbA1c level just before vitrectomy tended to be associated with the bleeding (odds ratio = 1.27, p = 0.05), while preoperative HbA1c changes were not associated with rebleeding. The results of this study suggest that a high preoperative HbA1c level just before vitrectomy, not a decrease in HbA1c levels, in addition to the duration of the operation may increase the risk of postoperative bleeding after vitrectomy in diabetic retinopathy patients.

Traumatic terson syndrome with a peculiar mass lesion and tractional retinal detachment: a case report.

BACKGROUND: To report a case with bilateral Terson syndrome presented with a unique mushroom-like mass lesion on the optic disc along with proliferative vitreoretinopathy and tractional retinal detachment. CASE PRESENTATION: A 33-year-old man was injured during a traffic accident and had diffuse brain swelling and intraocular hemorrhage. Poor vision in both eyes was noted after the patient regained consciousness. B-scan ultrasonography showed extensive vitreous opacity with a posterior vitreous detachment and without obvious retinal detachment. Vitrectomy was performed in both eyes five months after the accident. After clearing up the vitreous opacity, a peculiar pigmented mushroom-like mass lesion was noted in the posterior pole and had severe adhesion to the underneath optic disc. Extensive multilayered peripapillary epiretinal membrane was found covering the posterior pole and led to tractional retinal detachment around the macula. The mass was presumed to be an organized vitreous hemorrhage originated from the optic disc. The extensive and adherent epiretinal membrane together with the mass lesion were removed as much as possible and silicon oil was injected for tamponade. However, in the right eye, the retina redetached under silicon oil, whereas in the left eye, his vision improved to 20/100. CONCLUSIONS: Terson syndrome usually has a favorable prognosis but may be complicated by proliferative vitreoretinopathy and tractional retinal detachment. Careful monitoring is warranted and early vitrectomy should be considered in cases suspecting additional pathologies.

[Terson syndrome and acute myeloid leukemia (case report)]. / Sindrom Tersona na fone ostrogo mieloidnogo leikoza (klinicheskoe nablyudenie).

The article presents a clinical case of bilateral Terson syndrome caused by the manifestation of acute myeloid leukemia. A 32-year-old man complained of a sharp decrease in vision in both eyes. Spontaneous subarachnoid hemorrhage occurred secondary to acute myeloid leukemia. Uncorrected visual acuity (UCVA) amounted to OD=0.01, OS=0.005. The anterior segment was normal in both eyes, voluminous immobile white-gray mass measuring 7-9 DD that completely covered the macula (intense hyperechoic cell suspension with a volume of about 1/2 of the vitreous cavity, ultrasound B-scan) were visualized in the posterior pole of the vitreous body of both eyes under conditions of maximum drug-induced mydriasis. Diagnosis: vitreous hemorrhage due to subarachnoid hemorrhage in both eyes secondary to acute myeloid leukemia. Vitrectomy was performed in both eyes. UCVA increased to 0.05 in both eyes. Vitrectomy contributed to improvement of visual functions and patient quality of life.

Anti-vascular endothelial growth factor for proliferative diabetic retinopathy.

BACKGROUND: Proliferative diabetic retinopathy (PDR) is an advanced complication of diabetic retinopathy that can cause blindness. It consists of the presence of new vessels in the retina and vitreous haemorrhage. Although panretinal photocoagulation (PRP) is the treatment of choice for PDR, it has secondary effects that can affect vision. Anti-vascular endothelial growth factor (anti-VEGF), which produces an inhibition of vascular proliferation, could improve the vision of people with PDR. OBJECTIVES: To assess the effectiveness and safety of anti-VEGFs for PDR and summarise any relevant economic evaluations of their use. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register; 2022, Issue 6); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov, and the WHO ICTRP. We did not use any date or language restrictions. We last searched the electronic databases on 1 June 2022. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing anti-VEGFs to another active treatment, sham treatment, or no treatment for people with PDR. We also included studies that assessed the combination of anti-VEGFs with other treatments. We excluded studies that used anti-VEGFs in people undergoing vitrectomy. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies for inclusion, extracted data, and assessed the risk of bias (RoB) for all included trials. We calculated the risk ratio (RR) or the mean difference (MD), and 95% confidence intervals (CI). We used GRADE to assess the certainty of evidence. MAIN RESULTS: We included 15 new studies in this update, bringing the total to 23 RCTs with 1755 participants (2334 eyes). Forty-five per cent of participants were women and 55% were men, with a mean age of 56 years (range 48 to 77 years). The mean glycosylated haemoglobin (Hb1Ac) was 8.45% for the PRP group and 8.25% for people receiving anti-VEGFs alone or in combination. Twelve studies included people with PDR, and participants in 11 studies had high-risk PDR (HRPDR). Twelve studies were of bevacizumab, seven of ranibizumab, one of conbercept, two of pegaptanib, and one of aflibercept. The mean number of participants per RCT was 76 (ranging from 15 to 305). Most studies had an unclear or high RoB, mainly in the blinding of interventions and outcome assessors. A few studies had selective reporting and attrition bias. No study reported loss or gain of 3 or more lines of visual acuity (VA) at 12 months. Anti-VEGFs ± PRP probably increase VA compared with PRP alone (mean difference (MD) -0.08 logMAR, 95% CI -0.12 to -0.04; I2 = 28%; 10 RCTS, 1172 eyes; moderate-certainty evidence). Anti-VEGFs ± PRP may increase regression of new vessels (MD -4.14 mm2, 95% CI -6.84 to -1.43; I2 = 75%; 4 RCTS, 189 eyes; low-certainty evidence) and probably increase a complete regression of new vessels (RR 1.63, 95% CI 1.19 to 2.24; I2 = 46%; 5 RCTS, 405 eyes; moderate-certainty evidence). Anti-VEGFs ± PRP probably reduce vitreous haemorrhage (RR 0.72, 95% CI 0.57 to 0.90; I2 = 0%; 6 RCTS, 1008 eyes; moderate-certainty evidence). Anti-VEGFs ± PRP may reduce the need for vitrectomy compared with eyes that received PRP alone (RR 0.67, 95% CI 0.49 to 0.93; I2 = 43%; 8 RCTs, 1248 eyes; low-certainty evidence). Anti-VEGFs ± PRP may result in little to no difference in the quality of life compared with PRP alone (MD 0.62, 95% CI -3.99 to 5.23; I2 = 0%; 2 RCTs, 382 participants; low-certainty evidence). We do not know if anti-VEGFs ± PRP compared with PRP alone had an impact on adverse events (very low-certainty evidence). We did not find differences in visual acuity in subgroup analyses comparing the type of anti-VEGFs, the severity of the disease (PDR versus HRPDR), time to follow-up (< 12 months versus 12 or more months), and treatment with anti-VEGFs + PRP versus anti-VEGFs alone. The main reasons for downgrading the certainty of evidence included a high RoB, imprecision, and inconsistency of effect estimates. AUTHORS' CONCLUSIONS: Anti-VEGFs ± PRP compared with PRP alone probably increase visual acuity, but the degree of improvement is not clinically meaningful. Regarding secondary outcomes, anti-VEGFs ± PRP produce a regression of new vessels, reduce vitreous haemorrhage, and may reduce the need for vitrectomy compared with eyes that received PRP alone. We do not know if anti-VEGFs ± PRP have an impact on the incidence of adverse events and they may have little or no effect on patients' quality of life. Carefully designed and conducted clinical trials are required, assessing the optimal schedule of anti-VEGFs alone compared with PRP, and with a longer follow-up.

Intraocular Fibrin Glue to Lower the Risk of Postoperative Vitreous Hemorrhage After Diabetic Pars Plana Vitrectomy.

PURPOSE: To investigate the use of intraocular fibrin glue to lower the risk of vitreous hemorrhage (VH) after pars plana vitrectomy (PPV) in eyes with diabetic VH or traction retinal detachment. METHODS: A matched, case-control, single-surgeon, pilot study of patients undergoing PPV for diabetic VH or traction retinal detachment with versus without fibrin glue was performed. RESULTS: Thirty-nine patients (13 glue and 26 control patients) were included. In the glue group, mean (SD) logarithm of the minimum angle of resolution visual acuity (Snellen) significantly improved from 1.53 (0.6) (20/678) to 0.99 (0.9) (20/195) at postoperative month 6 ( P = 0.03). In the control group, mean logarithm of the minimum angle of resolution visual acuity also improved from 1.45 (0.8) (20/564) to 1.17 (0.9) (20/296) at postoperative Month 6 ( P = 0.3). Persistent post-PPV VH was similar between the 2 groups (15.4% in both groups, P > 0.99). However, early recurrent VH (<3 months post-PPV) was seen in 34.6% in the control group and none in the glue group ( P = 0.02). No intraocular inflammatory events were seen in the glue group. CONCLUSION: Intraocular fibrin glue may be a safe adjuvant in diabetic vitrectomy and may reduce the rate of early recurrent postoperative VH.

PHOTORECEPTOR DAMAGE IN TERSON SYNDROME.

PURPOSE: To describe photoreceptor damage in patients with Terson syndrome as a potential cause for inconsistent clinical outcomes. METHODS: Clinical evaluation and retinal imaging in six patients. RESULTS: Four patients were women and two men, with an average age of 46.8 years (SD 8.9). Four patients suffered aneurysmal subarachnoid hemorrhage, one vertebral artery dissection, and one superior sagittal sinus thrombosis. In 11 eyes, a consistent pattern of outer retinal changes within the central retina affecting the ellipsoid zone and the outer nuclear layer was observed, indicating photoreceptor damage. Areas of photoreceptor damage showed poor spatial correlation with intraocular hemorrhage, particularly subinternal limiting membrane hemorrhage. The observed retinal abnormalities demonstrated incomplete recovery over long-term follow-up 3.5 to 8 years posthemorrhage, irrespective of surgical or conservative treatment strategy, and had variable impact on the patients' visual function. CONCLUSION: The observations suggest that photoreceptor damage in Terson syndrome likely represents a distinct manifestation of this condition, which could be caused by transient ischemia of the outer retina secondary to acute rise in intracranial pressure.

SURGICAL OUTCOMES OF PARS PLANA VITRECTOMY FOR INTRAOCULAR COMPLICATIONS RELATED TO VASOPROLIFERATIVE TUMOR OF THE RETINA.

PURPOSE: To investigate the safety and efficacy of vitrectomy pars plana vitrectomy in managing intraocular complications relating to vasoproliferative tumors of the retina (VPL). METHODS: Retrospective study. 17 patients with VPL who underwent vitrectomy at Sheffield Teaching Hospital NHS Trust from 2005 to 2020 were included. Patient demographics, clinical characteristics, intraoperative data, and surgical outcomes were collected and evaluated. RESULTS: The mean age was 52 years. Indications for pars plana vitrectomy included epiretinal membrane (n = 7), vitreous hemorrhage (n = 5), retinal detachment (n = 3), diagnostic (n = 1), and others (n = 1). After pars plana vitrectomy, 14/17 (82.4%) have stabilized vision and 3/17 (17.6%) deteriorated. Subgroup analysis of epiretinal membrane peel had good outcomes with 6/7 (85.7%) noticing improvement or stabilization of symptoms and mean logarithm of minimal angle of resolution visual acuity improved from 0.719 [6/30] ± 0.267 [6/12] to 0.476 [6/19] ± 0.271 [6/12]. Patients undergoing surgery for vitreous hemorrhage also had good outcomes with resolution (and no recurrence) of the hemorrhage in 3/5 (60%) and 5/5 (100%) with one or more surgeries, respectively. Outcomes for retinal detachment surgery were logarithm of minimal angle of resolution 2.126 [HM] ± 0.301 [6/12] preoperatively and 1.185 [6/95] ± 0.522 [6/19] postoperatively, with one recurrence of retinal detachment. In the epiretinal membrane group, three patients had adjunctive treatment for VPL intraoperatively and four patients had none, and no difference found between the two groups in outcome or complications. Tumor with thickness of ≥2 mm exhibited inferior visual outcomes compared with <2 mm ( P < 0.05). CONCLUSION: This is one of the largest data sets in looking at outcomes of vitrectomy for complications of VPL. Pars plana vitrectomy is effective and safe in managing VPL-related intraocular complications with good outcomes and a low rate of complications, especially for patients with epiretinal membrane and vitreous hemorrhage.

VITRECTOMY FOR VITREOUS HEMORRHAGE ASSOCIATED WITH RETINAL VEIN OCCLUSION: Visual Outcomes, Prognostic Factors, and Sequelae.

PURPOSE: To report the outcomes of pars plana vitrectomy for vitreous hemorrhage (VH) associated with retinal vein occlusion and to identify prognostic indicators. METHODS: Interventional, retrospective consecutive case series between 2015 and 2021. RESULTS: The study included 138 eyes of 138 patients (64 female and 74 male); 81 patients had branch retinal vein occlusion and 57 had central retinal vein occlusion. The mean age was 69.8 years. The mean duration between the diagnosis of VH and surgery was 79.6 ± 115.3 (range, 1-572) days. The mean follow-up was 27.2 months. The logarithm of the minimum angle of resolution visual acuity significantly improved from 1.95 ± 0.72 (Snellen equivalent, 20/1782) to 0.99 ± 0.87 (20/195) at 6 months and to 1.06 ± 0.96 (20/230) at the final visit (both P < 0.001). The visual acuity at 6 months improved by three or more lines in 103 eyes (75%). Postoperative complications during follow-up included recurrent VH in 16 eyes (12%) (of which 8 eyes underwent reoperations), rhegmatogenous retinal detachment in six eyes (4%), and new neovascular glaucoma in three eyes (2%). Worse final visual acuity was significantly associated with older age ( P = 0.007), concurrent neovascular glaucoma ( P < 0.001), central retinal vein occlusion ( P < 0.001), worse preoperative visual acuity ( P < 0.001), postoperative new neovascular glaucoma ( P = 0.021), and postoperative retinal detachment ( P < 0.001). The duration of VH was not associated with visual outcomes ( P = 0.684). Preoperative antivascular endothelial growth factor injections and tamponade did not prevent postoperative recurrent VH. CONCLUSION: Pars plana vitrectomy is effective for VH associated with retinal vein occlusion, regardless of the duration of hemorrhage. However, pre-existing risk factors and postoperative sequelae may limit visual recovery.

Factors related to postoperative vitreous hemorrhage after small-gauge vitrectomy in proliferative diabetic retinopathy patients.

BACKGROUND: The role of anticoagulation or antiplatelet on post-vitrectomy vitreous hemorrhage (POVH) in patients with proliferative diabetic retinopathy (PDR) is rarely investigated in the small-gauge vitrectomy era. We investigate the relationship between the long-term use of those medications and POVH in a group of PDR patients. METHODS: A retrospective cohort study was carried out in a group of PDR patients who underwent small-gauge vitrectomy in our center. The baseline data on diabetes, diabetic complications, long-term use of anticoagulants and antiplatelet agents, ocular findings, and vitrectomy details were collected. The occurrence of POVH was recorded during at least three-month follow-up. Factors related to POVH were analyzed using logistic analysis. RESULTS: During a median follow-up of 16 weeks, 5% (11/220) of patients had POVH, and 75 had received antiplatelet or anticoagulation agents before the operation. Factors related to persistent POVH were the use of antiplatelet or anticoagulation agents (5.98, 1.75-20.45, p = 0.004), the presence of myocardial revascularization (130.65, 3.53-4834.50, p = 0.008), the presence of coronary artery disease (CAD) treated with medicine (56.52, 1.99-1604.06, p = 0.018), and younger age (0.86, 0.77-0.96, p = 0.012). For those receiving preoperative antiplatelet or anticoagulation agents, the probability of developing POVH was higher in the patients whose previous therapy was adjusted compared to those with continued therapy (p = 0.02 by Log-rank test). CONCLUSIONS: We identified long-term use of anticoagulation or antiplatelet medication, the presence of CAD, and younger age as three independent factors related to POVH. In PDR patients on long-term antiplatelet or anticoagulation medications, particular attention should be given to controlling intraoperative bleeding, and follow-up for POVH should be scheduled.

Terson Syndrome in Patients with Aneurysmal Subarachnoid Hemorrhage: A 10-Year Single-Center Experience.

BACKGROUND: Terson syndrome (TS), an intraocular hemorrhage associated with aneurysmal subarachnoid hemorrhage (aSAH), occurs in up to 46% of all patients with subarachnoid hemorrhage. Despite its high incidence, TS is underrepresented in the literature, and patients with aSAH are sometimes not systematically evaluated for the presence of TS in clinical practice. This work aims to raise awareness of TS, reevaluate previous scientific findings, describe risk factors associated with the occurrence of TS, and present our local diagnostic and treatment concept. METHODS: All patients with aSAH treated at our institution between October 2010 and May 2020 were included in this retrospective study. The frequency of ophthalmological screening by indirect funduscopy, as well as the results, was investigated. In addition, the collection and statistical analysis of epidemiological and clinical data was performed using χ2, Kruskal-Wallis, and analysis of variance testing; multivariate regression; and receiver operating characteristic analysis. The significance level was set at p < 0.05. RESULTS: A total of 617 patients were treated for aSAH in our institution. Of these, 367 patients (59.5%) were ophthalmologically examined for the presence of TS. The rate of TS in the examined patients was 21.3% (n = 78). Patients with TS had significantly higher Fisher and World Federation of Neurosurgical Societies (WFNS) scores (p < 0.0001). Regression analyses showed WFNS grade (p = 0.003) and the occurrence of seizures (p = 0.002) as independent predictors of TS, as did receiver operating characteristic analyses, which had a significant area under the curve of 0.66 for the combination of WFNS grade and seizures. For 12 (15.4%) patients, the TS had to be surgically treated by pars plana vitrectomy in a total of 14 eyes, which resulted in significant improvement of visual function in all patients: mean preoperative best-corrected visual acuity was 0.03 (± 0.08) versus 0.76 (± 0.21) postoperatively (p < 0.001). CONCLUSIONS: TS is a common complication in patients with aSAH, affecting approximately one in five patients. A higher WFNS grade and the occurrence of seizures are associated with TS; therefore, screening for TS should be performed in these patients.

Complications of Acute Posterior Vitreous Detachment.

PURPOSE: To evaluate the risk factors for retinal tear (RT) or rhegmatogenous retinal detachment (RRD) associated with acute, symptomatic posterior vitreous detachment (PVD) in a large comprehensive eye care setting. DESIGN: Retrospective cohort study. PARTICIPANTS: A total of 8305 adult patients in the Kaiser Permanente Northern California Healthcare System (KPNC) during calendar year 2018 who met inclusion criteria. METHODS: The KPNC electronic medical record was queried to capture acute, symptomatic PVD events. Each chart was reviewed to confirm diagnoses and capture specific data elements from the patient history and ophthalmic examination. MAIN OUTCOME MEASURES: Presence of RT or RRD at initial presentation or within 1 year thereafter. RESULTS: Of 8305 patients who presented with acute PVD symptoms, 448 (5.4%) were diagnosed with RT and 335 (4.0%) were diagnosed with RRD. When considering variables available before examination, blurred vision (odds ratio [OR], 2.7; confidence interval [CI], 2.2-3.3), male sex (OR, 2.1; CI, 1.8-2.5), age < 60 years (OR, 1.8; CI, 1.5-2.1), prior keratorefractive surgery (OR, 1.6; CI, 1.3-2.0), and prior cataract surgery (OR, 1.4; CI, 1.2-1.8) were associated with higher risk of RT or RRD, whereas symptoms of flashes were mildly protective (OR, 0.8; CI, 0.7-0.9). Examination variables associated with a high risk of RT or RRD included vitreous pigment (OR, 57.0; CI, 39.7-81.7), vitreous hemorrhage (OR, 5.9; CI, 4.6-7.5), lattice degeneration (OR, 6.0; CI, 4.7-7.7), and visual acuity worse than 20/40 (OR, 3.0; CI, 2.5-3.7). Late RTs or RRDs occurred in 12.4% of patients who had vitreous hemorrhage, lattice degeneration, or a history of RT or RRD in the fellow eye at initial presentation but only 0.7% of patients without any of these 3 risk factors. Refractive error had an approximately linear relationship with age at presentation of PVD, with myopic patients presenting at a younger age (r = 0.4). CONCLUSIONS: This study, based in a comprehensive eye care setting, found the rate of RT and RRD associated with acute PVD to be lower than rates previously reported by retina subspecialty practices. Several patient features strongly predicted the presence of initial and late complications of acute PVD.

Terson syndrome in reverse: intraventricular haemorrhage following primary intraocular haemorrhage.

Terson syndrome (TS) describes the presence of intraocular haemorrhage in patients with intracranial haemorrhage or traumatic brain injury. The aetiology of TS is controversial as an anatomical conduit between the vitreous humour and subarachnoid space remains contested. We herewith present a case of primary vitreous haemorrhage with secondary intracranial extension into the ventricles. Cranial CT demonstrates blood within the left optic nerve and chiasm but not within the subarachnoid space. This unusual phenomenon, which has not been reported before, may be described as 'Terson syndrome in reverse'. We explore mechanisms by which blood within the globe may track into the ventricular system, contextualising recent advances in the understanding of ocular-intracranial fluid transport.

CLINICAL CHARACTERISTICS OF EALES DISEASE AND THE EFFICACY OF DIFFERENT INTERVENTIONS FOR NEOVASCULAR COMPLICATIONS.

PURPOSE: To evaluate clinical features and manifestations of Eales disease and the efficacy of different interventions. METHODS: The databases PubMed, EMBASE, and Ovid from inception until February 2021 were searched. Pooled analyses included 1) presenting features, 2) symptoms and signs, and 3) postoperative vision outcomes and complications. Statistical analyses were conducted with R software version 3.6.3. RESULTS: Forty-seven studies involving 3,557 patients and 4,959 eyes were included. The pooling results showed that Eales disease was male dominated (94%), bilateral involvement (64%), and mainly occurred in adolescents. Approximately 83% of patients were positive in Mantoux test, and 31% of patients have vitreous tap polymerase chain reaction positive for tuberculosis genome. More than half of the patients had decreased vision at the first clinic visit. The common signs of Eales disease included sclerotic vessels (83%), neovascularization of retina elsewhere (64%) and periphlebitis (51%). Macular changes could be detected in 24% of patients. The most common complication was vitreous hemorrhage, followed by cataracts and retinal detachment. Photocoagulation was directed at nonperfusion or neovascularization areas, with a decrease in the incidence of later pars plana vitrectomy (19%). Anti-vascular endothelial growth factor treatment was suggested for vitreous hemorrhage, which could achieve high visual acuity improvement rate (82%) while increasing the possibility of retinal detachment (18%). Pars plana vitrectomy was indicated in cases with persistent vitreous hemorrhage or retinal detachment, with 56% of patients obtaining visual improvement. Still, 17% of patients needed a second pars plana vitrectomy, mainly because of recurrent vitreous hemorrhage or retinal detachment. CONCLUSION: Eales disease most commonly affects young men. It has diverse clinical features, and management should be based on the progression of the disease.

USING RETeval SYSTEM FLICKER ELECTRORETINOGRAPHY FOR EVALUATION OF DENSE VITREOUS HEMORRHAGE.

PURPOSE: To determine whether the RETeval electroretinography (ERG) system can be used to evaluate eyes with dense vitreous hemorrhage (VH). METHODS: This retrospective case series study included 69 eyes of 69 patients with acute dense VH. Flicker ERGs were recorded by the RETeval system, an ERG device with adhesive skin electrodes. We evaluated the flicker ERG amplitudes in eyes with VH and the ratio of the VH eye amplitudes compared with the fellow eye amplitudes for each VH cause. RESULTS: In patients with rhegmatogenous retinal detachment, the amplitude ratios were extremely low (0.08 ± 0.03). To detect rhegmatogenous retinal detachment, the area under the receiver operating characteristic curve was 0.977 (95% confidence interval, 0.943-1.000) (best rhegmatogenous retinal detachment cutoff value, 0.14; sensitivity, 100.0%; and specificity, 95.4%). The flicker ERG amplitude was not significantly correlated with the initial visual acuity (ρ = -0.189, P = 0.120) but was positively correlated with the postoperative visual acuity in eyes with VH (ρ = -0.328, P = 0.006). CONCLUSION: The RETeval ERG system was found to be a useful diagnostic option in situations where dense VH precluded fundus examination or posterior vitreous detachment was indistinguishable from rhegmatogenous retinal detachment.

POSTERIOR VITREOUS DETACHMENT STATUS AS A PREDICTIVE FACTOR FOR OUTCOMES OF VITRECTOMY FOR DIABETIC VITREOUS HEMORRHAGE.

PURPOSE: The purpose of this study was to evaluate the prognostic utility of the degree of vitreous attachment for predicting outcomes of vitrectomy for nonclearing vitreous hemorrhage associated with proliferative diabetic retinopathy. METHODS: Medical records of patients who underwent primary vitrectomy for dense nonclearing vitreous hemorrhage secondary to proliferative diabetic retinopathy were examined retrospectively. Eyes were divided into four groups based on the intraoperatively assessed stage of posterior vitreous detachment (PVD), ranging from Stage 0/1 (complete or near-complete vitreoretinal adhesion) to Stage 4 (complete PVD). RESULTS: Overall, 136 eyes (117 patients) were included. In comparison with eyes with a partial or complete PVD (Stages 2-4), eyes with no PVD (Stage 0/1) had a higher incidence of postoperative hypotony (8%, P = 0.03) and traction retinal detachment (27%, P = 0.002), an increased rate of repeat vitrectomy (49%, P = 0.04), and poorer best-corrected visual acuity at 6 months and 1 year postoperatively (P = 0.04 and P = 0.01, respectively). Presence of a complete PVD at baseline was independently associated with improved postoperative vision at 6 months (P = 0.04). CONCLUSION: More extensive vitreoretinal adhesion is associated with higher rates of reoperation and poorer visual outcomes after vitrectomy for dense nonclearing vitreous hemorrhage associated with proliferative diabetic retinopathy. Preoperative determination of PVD status using B-scan ultrasonography may be useful for predicting anatomical and functional outcomes after vitrectomy in these patients.

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.

Vitreous Hemorrhage, Aetiology and Visual Outcome of Vitrectomy in a Black African Population.

BACKGROUND: Information on the causes and outcome of treatment of vitreous hemorrhage (VH) in sub-Saharan Africa is limited. OBJECTIVES: To determine the causes and postoperative vision after vitrectomy for VH. DESIGN: A retrospective review of records from consecutive eyes, with VH greater than one-month duration, who had vitrectomy and adjunctive treatment in a retina unit in Nigeria. METHODS: We assessed the change between preoperative and postoperative visual acuity, bio data, cause of VH, duration of follow up, and additional treatment. Data was analyzed using SPSS statistical package 17.0 to determine the significance of the change in visual acuity for each cause of VH. A p value <0.05 was considered statistically significant. RESULTS: Of the 221 eyes of 219 patients, the common causes of VH were trauma 43 eyes, (19.7%), proliferative diabetic retinopathy, 37 eyes (17.0%) and proliferative sickle cell retinopathy, 30 eyes (13.8%). There was no association between cause and the presenting preoperative visual acuity. There was a statistically significant association between cause of VH and postoperative visual outcome. Postoperative visual improvement was significant for branch retinal vein occlusion, central retinal vein occlusion, proliferative diabetic retinopathy with VH only, proliferative sickle cell retinopathy, and trauma with VH only, p value = 0.000, 0.002, 0.001, 0.039, and 0.000 respectively. Postoperative visual change was not significant in age-related macular degeneration and polypoidal choroidal vasculopathy (p value = 0.155, 0.428 respectively). CONCLUSION: Significant improvements in visual acuity can be achieved with active treatment of VH in the majority of cases in Nigeria. This information is useful for discussions on prognosis and agrees with previous studies.

CONTEXTE: Les informations sur les causes et les résultats du traitement de l'hémorragie vitréenne (HV) en Afrique subsaharienne sont limitées. OBJECTIFS: Déterminer les causes et la vision postopératoire après une vitrectomie pour une HV. CONCEPTION: Une revue rétrospective des dossiers d'yeux consécutifs, avec une HV de plus d'un mois, qui ont subi une vitrectomie et un traitement d'appoint dans une unité de rétine au Nigeria. MÉTHODES: Nous avons évalué la variation entre l'acuité visuelle préopératoire et postopératoire, les données biologiques, la cause de l'HV, la durée du suivi et le traitement complémentaire. Les données ont été analysées à l'aide du progiciel statistique SPSS 17.0 afin de déterminer la signification du changement d'acuité visuelle pour chaque cause de HV. Une valeur p <0,05 a été considérée comme statistiquement significative. RÉSULTATS: Sur les 221 yeux de 219 patients, les causes les plus fréquentes de l'HV étaient les suivantes : traumatisme, 43 yeux (19,7%), rétinopathie diabétique proliférante, 37 yeux (17,0 %) et rétinopathie drépanocytaire proliférante, 30 yeux (13,8 %). Il n'y avait pas d'association entre la cause et l'acuité visuelle préopératoire. Il y avait une association statistiquement significative entre la cause de l'HV et le résultat visuel postopératoire. L'amélioration visuelle postopératoire était significative pour l'occlusion de la veine rétinienne de branche, l'occlusion de la veine rétinienne centrale, la rétinopathie diabétique proliférante avec HV uniquement, la rétinopathie drépanocytaire proliférante et le traumatisme avec HV uniquement, valeur p = 0,000, 0,002, 0,001, 0,039 et 0,000 respectivement. Le changement visuel postopératoire n'était pas significatif dans la dégénérescence maculaire liée à l'âge et la vasculopathie choroïdienne polypoïde (valeur p = 0,155,0,428 respectivement). CONCLUSION: Des améliorations significatives de l'acuité visuelle peuvent être obtenues avec un traitement actif de l'HV dans la majorité des cas au Nigeria. Cette information est utile pour les discussions sur le pronostic et concorde avec les études précédentes. Mots clés: Rétinopathie diabétique, traumatisme oculaire, rétinopathie diabétique proliférante, rétinopathie drépanocytaire, Afrique subsaharienne, hémorragie vitrée, vitrectomie, acuité visuelle.

INTERNAL LIMITING MEMBRANE PEELING DURING VITRECTOMY FOR DIABETIC VITREOUS HEMORRHAGE: A Randomized Clinical Trial.

PURPOSE: To evaluate the benefits of internal limiting membrane peeling in proliferative diabetic retinopathy subjects undergoing pars plana vitrectomy for the treatment of vitreous hemorrhage. METHODS: Two hundred and fifty-eight proliferative diabetic retinopathy subjects undergoing pars plana vitrectomy for vitreous hemorrhage were enrolled into the trial. Patients were randomized into one of two cohorts: Group A patients underwent internal limiting membrane peeling, whereas Group B patients did not undergo internal limiting membrane peeling. The main outcome was best-corrected visual acuity at 6 months. Secondary outcomes were optical coherence tomography central macular thickness at 6 months, incidence of diabetic macular edema treatment during the postoperative trial period, and incidence of epiretinal membrane at 6 months. RESULTS: Two hundred and seven patients were randomized and completed 6 months follow-up. Group A had better best-corrected visual acuity at 6 months than Group B (P < 0.01). Group A had a lower incidence of diabetic macular edema treatment during the postoperative trial period and a lower incidence of epiretinal membrane at 6 months than Group B (P = 0.02 and P < 0.001, respectively). There was a trend toward lower central macular thickness on optical coherence tomography in Group A than Group B (P = 0.09). There were no significant differences in baseline details or complications intraoperatively or postoperatively between cohorts. CONCLUSION: This trial demonstrated better vision, fewer postoperative diabetic macular edema treatments, and a lower incidence of epiretinal membrane at 6 months when internal limiting membrane peeling was performed. Internal limiting membrane peeling may be considered a vital maneuver to perform in proliferative diabetic retinopathy subjects undergoing pars plana vitrectomy for vitreous hemorrhage.

THE INCIDENCE, CHARACTERISTICS, MANAGEMENT, PROGNOSIS, AND CLASSIFICATION OF BREAKTHROUGH VITREOUS HEMORRHAGE SECONDARY TO POLYPOIDAL CHOROIDAL VASCULOPATHY.

PURPOSE: To describe breakthrough vitreous hemorrhage secondary to polypoidal choroidal vasculopathy (PCV). METHODS: Patients with the diagnosis of PCV from January 2005 to March 2020 at Peking Union Medical College Hospital were retrospectively reviewed, cases with breakthrough vitreous hemorrhage were analyzed. Subgroup analysis was conducted regarding pachychoroid PCV and nonpachychoroid PCV. RESULTS: Among 722 PCV patients (834 eyes), 103 eyes with breakthrough vitreous hemorrhage (12.4%) were included. Pars plana vitrectomy and proper further interventions could significantly improve the best-corrected visual acuity from logMAR 2.15 ± 0.48 (Snellen 20/2825) to 1.65 ± 0.67 (20/893). Hemorrhagic retinal detachment, baseline central macular thickness, and best-corrected visual acuity were factors associated with final best-corrected visual acuity (P < 0.05). In the pachychoroid PCV group, patients were younger, all had hemorrhagic pigment epithelial detachment, with a higher prevalence of choroidal vascular hyperpermeability and hemorrhagic retinal detachment, thicker subfoveal choroidal thickness, and thinner central macular thickness; besides, the initial pars plana vitrectomy were more complicated, more additional surgeries had to be performed. More eyes in the nonpachychoroid PCV group had received anti-vascular endothelial growth factor or photodynamic therapy, mostly fibrovascular pigment epithelial detachment, the best-corrected visual acuity and the status of the fellow eye were significantly worse. For the final ocular status, more eyes in nonpachychoroid PCV group were taking anti-vascular endothelial growth factor monotherapy, whereas more eyes in pachychoroid PCV group were stable. The choroidal parameters of these two groups were all significantly different. CONCLUSION: Breakthrough vitreous hemorrhage is a troublesome complication of PCV. Pars plana vitrectomy and additional interventions are required for better prognosis. Vitreous hemorrhage secondary to pachychoroid PCV or nonpachychoroid PCV have different characteristics and prognosis.