Akinori Uemura

Visual field defects after uneventful vitrectomy for epiretinal membrane with indocyanine green–assisted internal limiting membrane peeling

PURPOSE To report visual field defects after vitrectomy for epiretinal membrane with indocyanine green (ICG)-assisted internal limiting membrane (ILM) peeling. DESIGN Interventional consecutive case series. METHODS A retrospective review of 16 eyes of 16 patients who underwent vitrectomy for idiopathic epiretinal membrane. Indocyanine green-assisted ILM peeling was performed in 7 of 16 eyes. The main outcome measure was postoperative visual field. RESULTS Four of seven eyes (57%) with ICG-assisted ILM peeling had visual field defects postoperatively. The field defects identified were nasal in three eyes; in the fourth eye, the visual field was constricted to approximately 30 degrees. None of the nine eyes without ICG-assisted ILM peeling had a visual field defect. CONCLUSIONS Peripheral visual field defects may occur after vitrectomy with ICG-assisted ILM peeling. Although the cause of the defects is unclear, the potential role of ICG toxicity requires further investigation.

Vitrectomy with internal limiting membrane peeling for macular retinoschisis and retinal detachment without macular hole in highly myopic eyes

PURPOSE To report anatomic and visual improvement following vitrectomy with internal limiting membrane (ILM) peeling for two highly myopic patients with retinoschisis and/or retinal detachment without a macular hole. DESIGN Two interventional case reports. METHODS Two highly myopic patients who had retinoschisis and/or retinal detachment without a full-thickness macular hole underwent vitrectomy, internal limiting membrane peeling, and long-acting gas injection. Main outcome measures included best-corrected visual acuity, biomicroscopic appearance, and optical coherent tomography finding. RESULTS Vitrectomy with ILM peeling results in biomicroscopic, functional, and tomographic improvement in both patients, for follow-up periods of 12 months and 8 months, respectively. CONCLUSIONS Vitrectomy with ILM peeling and gas tamponade is an effective method for retinoschisis and/or retinal detachment without a macular hole in highly myopic patients.

Vitreous surgery with and without internal limiting membrane peeling for macular hole repair.

Purpose: To compare surgical results for idiopathic macular holes with and without internal limiting membrane (ILM) peeling in a series of consecutive patients during an 8-year period. Methods: A retrospective, nonrandomized, comparative trial. Four hundred seventeen eyes with macular holes without ILM peeling were compared with 175 eyes with ILM peeling. All eyes underwent pars plana vitrectomy with intravitreous gas, followed by head-down positioning. No adjunctive therapies were used. Comparison of closure and reopening rates and visual acuity with and without ILM peeling was analyzed. Results: Initial success rate significantly improved from 81% to 92% with ILM peeling. ILM peeling significantly improved the initial success rates in all categories of preoperative features. Reopening rates significantly decreased from 7% to 0.6% with ILM peeling. Among successful cases, line improvement was 6.0 in ILM-reserved eyes and 5.8 in ILM-peeled eyes. Among all cases, line improvement was 5.4 in ILM-reserved eyes and 5.7 in ILM-peeled eyes. Initial success rate of holes measuring more than 400 &mgr;m was significantly less than that of holes measuring less than 400 &mgr;m with or without ILM peeling. Initial success rate of holes older than 6 months old was significantly less than that for holes less than 6 months old without ILM peeling. Conclusions: Internal limiting membrane peeling shows high closure and low reopening rates in macular hole surgery. ILM peeling is beneficial in older holes but is limited in larger holes. ILM peeling does not significantly improve visual acuity.

COMPARATIVE STUDY OF CLINICAL FACTORS PREDISPOSING PATIENTS TO PROLIFERATIVE VITREORETINOPATHY

Clinical features of 57 eyes with proliferative vitreoretinopathy (primary PVR) that developed preoperatively were statistically analyzed and compared with a control group of 1353 eyes with non-PVR rhegmatogenous retinal detachment. The statistically significant (P less than 0.05) factors predisposing to PVR were as follows: retinal detachment for more than 1 month; aphakia (47.4% in the PVR group versus 11.1% in the control group); vitreous hemorrhage (26.3% versus 11.0%); giant tear (15.8% versus 0.8%); breaks larger than 3 disc diameters (62.1% versus 27.3%); and horseshoe tear (65.5% versus 44.9%).

Long-term outcomes of internal limiting membrane peeling with and without indocyanine green in macular hole surgery.

Purpose: To compare the long-term anatomic closure rate and visual outcome in patients who underwent internal limiting membrane (ILM) peeling with and without indocyanine green (ICG) dye staining for idiopathic macular hole repair. Design: Retrospective, nonrandomized, comparative study of consecutive case series. Methods: A total of 190 eyes of 182 patients with idiopathic macular holes underwent macular hole repair between March 1998 and June 2003. Surgery consisted of pars plana vitrectomy, lensectomy if phakic, ILM peeling, intravitreal gas tamponade, and 1 week’s face-down positioning. In the initial 94 consecutive eyes, ILM peeling was performed without adjuvants (non-ICG group). The subsequent 96 eyes underwent surgery with ICG-stained ILM peeling (ICG group), in which the ILM was stained with intravitreal application of 0.1 to 0.2 mL of 0.1% ICG solution. Results: Two groups of patients had comparable clinical backgrounds preoperatively. Mean follow-up time was 30.7 months in non-ICG group and 26.2 months in ICG group. Anatomic closure of the macular hole was achieved in 99% of the cases in both groups, with both groups showing statistically significant visual improvement. There was no statistically significant difference in visual acuity between the two groups at each follow-up visit. There were also no intraoperative or postoperative complications attributed to the use of ICG. Conclusions: Long-term follow-up of patients undergoing ILM peeling for idiopathic macular hole repair shows equivalent anatomic and visual outcomes with and without the use of ICG.

Vitreomacular adhesion and the defect in posterior vitreous cortex visualized by triamcinolone-assisted vitrectomy

Purpose: To study the vitreomacular adhesion and the contractile force of posterior hyaloid, which are shown in triamcinolone acetonide (TA)-assisted pars plana vitrectomy (PPV). Design: Interventional case series. Methods: Twenty-eight eyes with diabetic macular edema (DME) without posterior vitreous detachment (PVD) received TA-assisted PPV. Surgical PVD was performed by an aspiration of vitrectomy probe, and the dynamic changes of posterior vitreous cortex and residual vitreous cortex were evaluated. Results: A premacular defect was formed in the detached posterior vitreous cortex during surgical PVD in 27 of 28 eyes. Immediately thereafter, the small defect expanded into a large hole in the detached posterior vitreous cortex in all cases. A residual vitreous cortex was left on the macula in 22 eyes. Conclusions: These observations demonstrate a firm vitreoretinal adhesion in the central macula and suggest that the enlargement of the defect of posterior vitreous cortex may be extrusion of vitreous out through the premacular dehiscence into the preretinal space, or a tangentially contractile force may exist in the posterior vitreous cortex. Both macular adhesion and the traction of vitreous cortex might contribute to the pathogenesis of DME and other vitreomacular disease.

Intraoperative characteristics of the posterior vitreous cortex in patients with epiretinal membrane

BackgroundThe aim of the study was to investigate the intraoperative characteristics of the posterior vitreous cortex in patients with epiretinal membranes.MethodFifteen eyes of 15 patients with an idiopathic epiretinal membrane that had no posterior vitreous detachment (PVD) on both slit-lamp biomicroscopy and B-scan ultrasound examination were enrolled in this study. During vitrectomy, the relationship between the posterior vitreous cortex and the epiretinal membrane was observed when PVD was created using triamcinolone acetonide.ResultsThree patterns were observed: (A) seven eyes (47%) showed a round defect in the posterior vitreous cortex after surgical PVD, leaving an epiretinal membrane on the macula, (B) three eyes (20%) showed a complete detachment of the vitreous cortex along with the epiretinal membrane, and (C) five eyes (33%) showed a detachment of the posterior vitreous cortex without a round defect, leaving an epiretinal membrane on the macula. Four of five eyes in group C had a discrete linear signal over the macular area on optical coherence tomography before surgery.ConclusionThe finding that during surgery the posterior vitreous cortex can split into lamellae supports the hypothesis that epiretinal membranes are the result of anomalous PVD with vitreoschisis, leaving the outermost layer of posterior vitreous cortex attached to the macula.

COMPARATIVE STUDY OF CLINICAL FACTORS THAT PREDISPOSE PATIENTS TO PROLIFERATIVE VITREORETINOPATHY IN APHAKIA

To clarify the risk factors of proliferative vitreoretinopathy (PVR) in aphakia, the clinical features of 25 aphakic eyes with PVR were statistically analyzed and compared with a control group of 157 aphakic eyes with non-PVR rhegmatogenous retinal detachment. The statistically significant (P < 0.05) factors that predisposed patients to PVR in aphakia were as follows: a history of vitreous loss on cataract surgery, retinal detachment developing within 3 months after cataract extraction, duration of retinal detachment longer than 3 months, break larger than three disc diameters, and choroidal detachment. Vitreous loss is believed to play the most important role in the development of PVR in aphakia.

Long-term visual outcomes after vitrectomy for macular edema with foveal hemorrhage in branch retinal vein occlusion.

Purpose: To determine the long-term visual outcomes after vitreous surgery for macular edema with foveal hemorrhage associated with branch retinal vein occlusion (BRVO). Methods: One hundred twenty eyes of 120 patients underwent pars plana vitrectomy with or without internal limiting membrane (ILM) peeling for macular edema with foveal hemorrhage due to BRVO with a minimum 12 months of follow-up. Simultaneous cataract extraction with intraocular lens implantation was performed on 117 phakic eyes. Results: Follow-up after surgery ranged from 12 months to 129 months (average, 48 months). Visual acuity improved in 71% of cases at the 1-year visit. Mean visual acuity significantly increased from 0.24 (median, 0.3) before surgery to 0.57 (median, 0.7) 1 year after surgery (P < 0.0001) and 0.66 (median, 0.9) at the final visit (P < 0.0001). There was a significant difference between visual acuity at 1 year after surgery and visual acuity at the final visit (P < 0.0001). Of 120 patients, 95 (79%) had final visual acuity of ≥0.5, and 55 (46%) had final visual acuity of ≥1.0. ILM removal did not seem to have significant beneficial effects on visual outcomes in this series. No serious complications occurred during the follow-up period. Conclusion: After vitreous surgery for macular edema with foveal hemorrhage associated with BRVO, visual acuity continued to improve beyond 1 year after surgery. A randomized, multicenter clinical trial is warranted to determine the efficacy of this procedure.

Long-term Outcomes Of Macular Hole Surgery With Triamcinolone Acetonide–assisted Internal Limiting Membrane Peeling

Purpose: To report long-term anatomical and functional results after pars plana vitrectomy with internal limiting membrane (ILM) peeling using triamcinolone acetonide (TA) for idiopathic macular holes. Design: Prospective, consecutive, interventional case series. Methods: Ninety-six eyes of 94 patients who underwent macular hole surgery with TA-assisted ILM peeling were included in the study. Patients with <12 months of follow-up were excluded. On 82 phakic eyes, simultaneous phacoemulsification with intraocular lens implantation was performed. Follow-up examinations included clinical examination, determination of best-corrected visual acuity, intraocular pressure measurement, optical coherence tomography, Goldmann perimetry, and static perimetry using the Humphrey visual field analyzer. The main outcome measures were postoperative visual acuity, macular hole status, and postoperative complications. Results: The mean follow-up period was 17 months (range, 12–30 months). TA improved visualization of the ILM, and the peeled area was seen as an area lacking white specks. All macular holes successfully closed after primary surgery. Mean visual acuity improved from 0.26 to 1.0 at the final visit (P < 0.0001), with 90 eyes (94%) having improvement of visual acuity. Postoperative complications included retinal detachment in one patient and transient intraocular pressure elevation in five patients. Conclusions: Although transient intraocular pressure elevation was observed in a few patients, the use of TA in macular hole surgery may be an effective and safe technique to facilitate visualization of the ILM and can lead to good long-term anatomical and functional results.