Retinal breaks in vitrectomy for retained lens fragments

PURPOSE: To describe the incidence and outcome of retinal breaks in vitrectomy for retained lens fragments. METHODS: This is a retrospective noncomparative interventional case series. Medical records of consecutive cases of vitrectomy for retained lens fragments over a period of 4 years were reviewed. Main outcome measures were incidence of breaks, visual acuity outcome, and occurrence of postoperative complications. RESULTS: We included 89 consecutive cases in 89 patients. The median interval between cataract surgery and vitrectomy was 2 days (range, 0-106 days). Visual acuity at last follow-up was ≥0.5 in 70% of cases. During surgery, retinal breaks were found in 29% of cases. Induction of a posterior vitreous detachment, the use of a fragmatome, or delay between cataract surgery and vitrectomy did not influence retinal break incidence. Postoperative retinal detachment occurred in only 2% of cases. Other complications were intraoperative choroidal hemorrhage in 1 case, postoperative macular pucker in 2, postoperative macular edema in 1, and glaucoma in 2 cases. CONCLUSION: We identified a high number of retinal breaks during vitrectomy for retained lens fragments. Prophylactic treatment of breaks and other areas of retinal traction seem to reduce the risk of postoperative retinal detachmen

Safety of vitrectomy for floaters

Purpose: To assess the risks of vitrectomy for the removal of primary and secondary vitreous opacities. • Design: Retrospective, nonrandomized, interventional case series. • Methods: We reviewed the results of 116 consecutive cases of vitrectomy for vitreous floaters. Eighty-six cases were primary and 30 cases were secondary floaters. Main outcome measures were the incidence of iatrogenic retinal breaks and postoperative rhegmatogenous retinal detachments. • Results: We found iatrogenic retinal breaks in 16.4% of operations. There was no statistically significant difference in risk between cases of primary and secondary floaters. Intraoperative posterior vitreous detachment induction was found to increase significantly the risk of breaks. Retinal detachment occurred in 3 cases (2.5%), all after operations for primary floaters. One case of complicated retinal detachment ended with a low visual acuity of hand movements. Cataract occurred in 50% of phakic cases. Transient postoperative hypotony was found after 5.2% of our operations, and transient postoperative high intraocular pressure was encountered in 7.8%. An intraoperative choroidal hemorrhage occurred in 1 case, which resolved spontaneously. The mean visual acuity improved from 0.20 to 0.13 logarithm of the minimal angle of resolution units. • Conclusions: The risk profile of vitrectomy for floaters is comparable with that of vitrectomy for other elective indications. Retinal breaks are a common finding during surgery and treatment of these breaks is crucial for the prevention of postoperative retinal detachment. Patients considering surgery for floaters should be informed specifically about the risks involved

Primary retinectomy in proliferative vitreoretinopathy

Purpose: To describe the functional and anatomic results of retinectomy without scleral buckling for anterior proliferative vitreoretinopathy in eyes that did not undergo previous buckling surgery. Design: Retrospective, nonrandomized, interventional case series. Methods: We reviewed the results of 123 consecutive cases of retinectomy for rhegmatogenous retinal detachment complicated by anterior proliferative vitreoretinopathy. The primary outcome measure was anatomic success, defined as complete retinal reattachment. Secondary outcome measures were final anatomic success, final visual acuity outcome, number of operations required for retinal reattachment, baseline extent of proliferative vitreoretinopathy, ocular pressure at final follow-up, extent of retinectomy, and occurrence of complications. Results: The anatomic success rate was 77.2%. Final attachment rate was 95.9%, reached after 1 rhegmatogenous retinal detachment reoperation in 21 cases and after 2 rhegmatogenous retinal detachment reoperations in 4 cases. We had a low rate of postoperative hypotony (4.1%). Visual acuity was significantly improved from 2.10 to 1.44 logarithm of the minimal angle of resolution units (P < .001). Improvement was related significantly to retinectomy extent and primary anatomic success. Conclusions: Our results show that primary retinectomy without scleral buckling has good anatomic and functional results

Heavy trypan blue staining of epiretinal membranes: an alternative to Infracyanine green

Background: By using dyes, it is easier to identify the extent of an epiretinal membrane (ERM) or the inner limiting membrane (ILM) during surgery. Trypan blue (TB) stains ERM and ILM weakly, but with less apparent toxicity than other intraocular dyes. Its main drawback in vitreoretinal surgery is the requirement of an air-fluid exchange (AFX) before its use. Aim: To propose a modified form of TB denser than water, thus obviating the need for an AFX. Design: A prospective, consecutive trial with heavy trypan blue in vitreoretinal surgery. Methods: A consecutive group of patients with ERMs was recruited prospectively. Patients were operated on using conventional methods. Heavy TB was prepared by mixing glucose 10% with Membrane blue (Dorc, Zuidland, The Netherlands) isovolumetrically. Patients were preoperatively and postoperatively assessed at 3 and 6 months (vision and ocular coherence tomography (OCT)). Ease of surgery was also assessed. Results: 29 eyes were included in the study. Reapplication of dye was necessary in 25% of the cases, leading to improved contrast further facilitating the peeling process. In no case was an AFX necessary to obtain sufficient staining. All patients with ERM had an improvement in vision (from median 0.30 to 0.55) and macular volume and foveal thickness (from median 450 to 238 mm) on OCT. No retinal detachment or other complications developed as a result of surgery. Conclusion: Heavy TB can be delivered efficiently to the retinal surface without an AFX. Staining was sufficient to allow a safe and efficient peeling of ERM. Repeat applications were easily performed. Its use was associated with vision improvement and decreased in foveal thickness, and the absence of adverse events in this small case series

Enhanced internal search for iatrogenic retinal breaks in 20-gauge macular surgery

Purpose: To evaluate the incidence and characteristics of iatrogenic retinal breaks in 20-gauge macular surgery with an intensified search strategy. Design: Retrospective, non-comparative interventional case series. Participants: 218 consecutive operations in 209 patients who underwent 20-gauge vitrectomy vitrectomy for idiopathic macular pucker or idiopathic macular hole. Methods: Retrospective review of patient records undergoing 20-gauge vitrectomy with intensified peripheral search for retinal defects. Main outcome measures: Incidence of breaks related to the sclerotomies, the incidence of breaks occurring elsewhere, the incidence of lesions suspicious for traction, the location of identified breaks and intraoperative induction of posterior vitreous detachment. Results: Retinal breaks occurred in 24.3% of operations. In 17.4% breaks were related to the sclerotomies and in 9.6% of breaks were found elsewhere. In 6.4% of eyes, only lesions suspicious for traction were detected. Retinal detachment occurred in 1.8% of cases. The occurrence of breaks was significantly related to induction of PVD. Conclusions: With intensified intraoperative search, a much higher incidence of retinal breaks was found than previously reported in the literature. Despite the high incidence of breaks, the incidence of postoperative rhegmatogenous retinal detachment was low. These findings support the rationale that intensive intraoperative search for iatrogenic breaks is crucial for the prevention of postoperative retinal detachments in macular surgery

Early simultaneous fundus autofluorescence and optical coherence tomography features after pars plana vitrectomy for primary rhegmatogenous retinal detachment

PURPOSE: To describe fundus autofluorescence and optical coherence tomography (OCT) features of the macula after pars plana vitrectomy for rhegmatogenous retinal detachment. METHODS: Thirty-three eyes of 33 consecutive patients with repaired rhegmatogenous retinal detachment with or without the involvement of the macula were prospectively investigated with simultaneous fundus autofluorescence and OCT imaging using the Spectralis HRA+OCT (Heidelberg Engineering, Heidelberg, Germany) within a few weeks after the operation. RESULTS: Fundus autofluorescence imaging of the macula showed lines of increased and decreased autofluorescence in 19 cases (57.6%). On OCT, these lines corresponded to the following abnormalities: outer retinal folds, inner retinal folds, and skip reflectivity abnormalities of the photoreceptor inner segment/outer segment band. Other OCT findings, not related to abnormal lines on fundus autofluorescence, consisted of disruption of photoreceptor inner segment/outer segment band and collection of intraretinal or subretinal fluid. The presence of outer retinal folds significantly related to metamorphopsia but did not relate to poor postoperative visual acuity. CONCLUSION: Partial-thickness retinal folds occur commonly after vitrectomy for rhegmatogenous retinal detachment repair and may represent an important anatomical substrate for postoperative metamorphopsia. Fundus autofluorescence and OCT are both sensitive techniques for the detection of these abnormalities

Subretinal versus intravitreal injection of recombinant tissue plasminogen activator in post-traumatic submacular hemorrhages

Considering the administration of rtPA, our experience agrees with the actual trends of treatment. The first case treated with subretinal rtPA shows quick blood reabsorption with good anatomical and functional outcome since 1 month after treatment. Three months later, the visual acuity (VA) was completely restored. The second case instead, treated with intravitreal rtPA, showed persistence of subretinal blood and low VA 1 month after treatment. Five months later, the central retina showed focal gaps in the photoreceptor layers, VA did not improved and patient complained for central scotomas. The blood lasting in the retina may have caused focal death of the photoreceptors, resulting in the gaps which can be seen on OCT B-scan 5 months after treatment. This poor outcome could also depend on the localization of the haemorrhage: indeed the blood was not only subretinal but also intraretinal, so the anatomical architecture in this patient was more affected than in the other one, interfering with a complete restauration. Maybe the rtPA administered subretinally would have allowed a fast recovery and a better outcome

Evolution of outer retinal folds occurring after vitrectomy for retinal detachment repair

Purpose.: To assess the evolution of outer retinal folds (ORFs) occurring after repair of rhegmatogenous retinal detachment (RRD) using spectral domain-optical coherence tomography (sd-OCT) and fundus autofluorescence (FAF), and to discuss their pathogenesis. Methods.: Twenty patients were operated on with 25-gauge pars plana vitrectomy and 20% sulfur hexafluoride gas injection for primary macula-off RRD repair and were followed prospectively. Sd-OCT and FAF images were recorded at 1, 3 and 6 months postoperatively. Results.: ORFs appeared on sd-OCT as hyperreflective lesions consisting of folded inner segment/outer segment of photoreceptors band and external limiting membrane band. Corresponding lines of increased or decreased autofluorescence were observed on FAF. Over the follow-up, the thick hypoautofluorescent lines progressively evolved to thick hyperautofluorescent lines and to thin hyperautofluorescent lines and eventually disappeared. Concomitantly, OCT scans revealed that the corresponding hyperreflective lesions decreased in number, height, and size. In six cases FAF assessment at month 6 was precluded by cataract development. Conclusions.: ORFs tend to resolve spontaneously within a few months from operation leaving no or subtle abnormalities at the level of the outer retinal layers. OCT is superior to FAF to follow the evolution of ORFs in phakic eyes. The following factors might be involved in ORFs pathogenesis: structural changes occurring in the detached retina, residual pockets of subretinal fluid after retinal reattachment, intravitreal gas, unintentional retinal translocation, and intraoperative or perioperative hypotony

A shift in the balance of vascular endothelial growth factor and connective tissue growth factor by bevacizumab causes the angiofibrotic switch in proliferative diabetic retinopathy

Introduction: In proliferative diabetic retinopathy (PDR), vascular endothelial growth factor (VEGF) and connective tissue growth factor (CTGF) may cause blindness by neovascularisation followed by fibrosis of the retina. It has previously been shown that a shift in the balance between levels of CTGF and VEGF in the eye is associated with this angiofibrotic switch. This study investigated whether anti-VEGF agents induce accelerated fibrosis in patients with PDR, as predicted by this model. Methods: CTGF and VEGF levels were measured by ELISA in 52 vitreous samples of PDR patients, of which 24 patients had received intravitreal bevacizumab 1 week to 3 months before vitrectomy, and were correlated with the degree of vitreoretinal fibrosis as determined clinically and intra-operatively. Results: CTGF correlated positively, and VEGF correlated negatively with the degree of fibrosis. The CTGF/VEGF ratio was the strongest predictor of fibrosis. Clinically, increased fibrosis was observed after intravitreal bevacizumab. Conclusions: These results confirm that the CTGF/VEGF ratio is a strong predictor of vitreoretinal fibrosis in PDR, and show that intravitreal anti-VEGF treatment causes increased fibrosis in PDR patients. These findings provide strong support for the model that the balance of CTGF and VEGF determines the angiofibrotic switch, and identify CTGF as a possible therapeutic target in the clinical management of PDR.Introduction In proliferative diabetic retinopathy (PDR), vascular endothelial growth factor (VEGF) and connective tissue growth factor (CTGF) may cause blindness by neovascularisation followed by fibrosis of the retina. It has previously been shown that a shift in the balance between levels of CTGF and VEGF in the eye is associated with this angiofibrotic switch. This study investigated whether anti-VEGF agents induce accelerated fibrosis in patients with PDR, as predicted by this model.Methods CTGF and VEGF levels were measured by ELISA in 52 vitreous samples of PDR patients, of which 24 patients had received intravitreal bevacizumab 1 week to 3 months before vitrectomy, and were correlated with the degree of vitreoretinal fibrosis as determined clinically and intra-operatively.Results CTGF correlated positively, and VEGF correlated negatively with the degree of fibrosis. The CTGF/VEGF ratio was the strongest predictor of fibrosis. Clinically, increased fibrosis was observed after intravitreal bevacizumab.Conclusions These results confirm that the CTGF/VEGF ratio is a strong predictor of vitreoretinal fibrosis in PDR, and show that intravitreal anti-VEGF treatment causes increased fibrosis in PDR patients. These findings provide strong support for the model that the balance of CTGF and VEGF determines the angiofibrotic switch, and identify CTGF as a possible therapeutic target in the clinical management of PDR

Vitreous TIMP-1 levels associate with neovascularization and TGF-B2 levels but not with fibrosis in the clinical course of proliferative diabetic retinopathy

In proliferative diabetic retinopathy (PDR), vascular endothelial growth factor (VEGF) and CCN2 (connective tissue growth factor; CTGF) cause blindness by neovascularization and subsequent fibrosis. This angio-fibrotic switch is associated with a shift in the balance between vitreous levels of CCN2 and VEGF in the eye. Here, we investigated the possible involvement of other important mediators of fibrosis, tissue inhibitor of metalloproteinases (TIMP)-1 and transforming growth factor (TGF)-β2, and of the matrix metalloproteinases (MMP)-2 and MMP-9, in the natural course of PDR. TIMP-1, activated TGF-β2, CCN2 and VEGF levels were measured by ELISA in 78 vitreous samples of patients with PDR (n = 28), diabetic patients without PDR (n = 24), and patients with the diabetes-unrelated retinal conditions macular hole (n = 10) or macular pucker (n = 16), and were related to MMP-2 and MMP-9 activity on zymograms and to clinical data, including degree of intra-ocular neovascularization and fibrosis. TIMP-1, CCN2 and VEGF levels, but not activated TGF-β2 levels, were significantly increased in the vitreous of diabetic patients, with the highest levels in PDR patients. CCN2 and the CCN2/VEGF ratio were the strongest predictors of degree of fibrosis. In diabetic patients with or without PDR, activated TGF-β2 levels correlated with TIMP-1 levels, whereas in PDR patients, TIMP-1 levels, MMP-2 and proMMP-9 were associated with degree of neovascularization, like VEGF levels, but not with fibrosis. We confirm here our previous findings that retinal fibrosis in PDR patients is significantly correlated with vitreous CCN2 levels and the CCN2/VEGF ratio. In contrast, TIMP-1, MMP-2 and MMP-9 appear to have a role in the angiogenic phase rather than in the fibrotic phase of PDR