Amir Alhalel

Refractive results with secondary piggyback implantation to correct pseudophakic refractive errors

PURPOSE: To assess the efficacy and safety of implanting a second intraocular lens (IOL) to correct pseudophakic refractive errors. SETTING: Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel. METHODS: This prospective noncomparative case series included 10 pseudophakic eyes, 5 with a myopic residual refractive error and 5 with a hyperopic residual refractive error. All eyes had secondary piggyback IOL implantation with the IOL placed in the ciliary sulcus. Five types of IOLs were used to correct the residual refractive error. RESULTS: The mean preoperative myopia was −6.6 diopters ± 3.3 (SD), and the refractive outcome was within 0.5 ± 0.7 D of the desired refraction (range –1.5 [undercorrected] and +1.0 D [overcorrected]). The mean preoperative hyperopia was +3.8 ± 0.8 D, and the refractive outcome was within 0.46 ± 0.4 D of the desired refraction (range 0 and 1.0 D overcorrected). All patients showed visual acuity improvement. Best spectacle‐corrected visual acuity improved from 20/44 to 20/30 (P<.05). CONCLUSION: An IOL type that is appropriate for implantation in the ciliary sulcus is a viable option for correcting pseudophakic refractive error using the piggyback technique.

Reduced rate of retinal detachment following silicone oil removal.

Purpose: To investigate the rate of retinal redetachment and other complications after silicone oil removal over a 4‐year period. Methods: Retrospective analysis of charts of patients who underwent vitrectomy and silicone oil injection between January 1994 and June 1998 followed by oil removal. Results: Sixty‐eight eyes of 67 patients were included. The average follow‐up time after oil removal was 15 months. Significant retinal redetachment developed in 6 eyes (8.8%). The redetachment rate was slightly higher in the 32 eyes with proliferative vitreoretinopathy (9.3%) than in the 36 eyes with other pathologies (8.3%). The average time to redetach‐ment was 4.2 months. These eyes were reoperated and reattached, and at the end of the follow‐up, three retained silicone oil. Two other eyes without redetachment were hypotonus after oil removal. Cataract extraction and intraocular lens implantation were performed at the time of oil removal in 18 eyes; 2 (11%) developed redetachment. Visual acuity improved significantly after oil removal (P < 0.001). Conclusion: The rate of retinal redetachment after removal of silicone oil in recent years is low compared with previous series. The authors attribute this reduction to the improved surgical management of complicated retinal detachments; particularly, the introduction of perfluorocarbon liquids and wide‐field viewing systems and the widespread use of endolaser.

Long-term follow up of accidental parafoveal laser burns.

The findings after 12 years of follow-up evaluation of 2 patients who sustained accidental parafoveal and juxtafoveal Nd:YAG laser injuries are reported. In both cases, the fovea was not destroyed by the initial insult and early scar formation. Both cases demonstrated, after more than a decade, minimal visual deficit without significant late complications. In spite of early decrease in visual performance, the long-term prognosis for Q-switched Nd:YAG laser retinal lesions in which the fovea was not directly involved in the injury or its repair mechanisms is relatively benign.

Retrospective Analysis of Vitrectomy With and Without Internal Limiting Membrane Peeling for Stage 3 and 4 Macular Hole

BACKGROUND AND OBJECTIVE To evaluate the efficacy and safety of pars plana vitrectomy with indocyanine green (ICG)-assisted internal limiting membrane (ILM) peeling versus pars plana vitrectomy without ILM peeling for stage 3 and 4 primary idiopathic macular hole. PATIENTS AND METHODS Sixty-two eyes of 60 consecutive patients with idiopathic macular hole underwent vitrectomy with gas (C3F8) injection. The first 46 eyes underwent vitrectomy without ILM peeling; of these, 14 had epiretinal membrane peeling and were excluded, leaving 32 eyes (no ILM group). The remaining 16 eyes underwent vitrectomy with ICG-assisted ILM peeling (ICG-ILM group). Follow-up data at 6 to 48 months postoperatively were recorded and analyzed. RESULTS Macular hole closure was achieved in 13 (81%) of 16 patients in the ICG-ILM group and 16 (50%) of 32 patients in the no ILM group (P = .036). Analysis of the data from eyes with closed holes indicates that the ICG-ILM group achieved a better mean final visual acuity compared with the no ILM group (20/60 vs 20/100, respectively) (P = .017). No complications were attributed to the use of ICG. CONCLUSIONS ICG-assisted ILM peeling significantly increased the rate of hole closure in eyes with stage 3 or 4 idiopathic macular hole. The use of ICG did not adversely affect the visual acuity results, and it appears to be a safe adjunct to macular hole surgery.

Macular hole after vitrectomy for primary rhegmatogenous retinal detachment.

Purpose: To report a series of full-thickness macular holes (MH) that developed after pars plana vitrectomy for rhegmatogenous retinal detachment (RRD). Methods: A retrospective review of the demographic and medical data, including optical coherence tomography studies of 6 patients (7 eyes) who underwent pars plana vitrectomy for RRD and subsequently developed MH. Results: There were 4 women and 2 men with a mean age of 60 ± 10 years (range, 50–79 years). The mean interval between RRD repair and MH formation was 20 ± 18 months (range, 1–48 years). Five eyes underwent surgery to repair the MHs, four of which were closed at the last follow-up. Two eyes were not operated, one because of unfavorable prognosis, and in the other, which presented with an epiretinal membrane before the development of the MH, the hole closed spontaneously. In all operated cases, the inner limiting membrane was peeled during MH surgery. The mean logarithm of the minimal angle of resolution was 0.73, 0.53, 0.77, and 0.57 at RRD presentation, after surgical repair of RRD and before MH diagnosis, at MH presentation, and at last follow-up, respectively. The study subjects accounted for 1.1% of our 609 patients who underwent pars plana vitrectomy for primary RRD during the study period. Conclusion: Macular hole may develop after pars plana vitrectomy for RRD, and these cases can be surgically repaired. The pathogenesis of the formation of these holes remains unclear.

Management of persistent loculated subretinal fluid after pneumatic retinopexy

AIM To report on the incidence and management of a unique and troublesome complication of pneumatic retinopexy—localised, delayed subretinal fluid absorption (DSRFA). METHODS A retrospective chart review was done for all patients who underwent pneumatic retinopexy for retinal detachment over a 5 year period to identify the patients with DSRFA. RESULTS Seven phakic patients (five females, two males, age range 26–87 years) were identified with the phenomenon of delayed resolution of subretinal fluid after pneumatic retinopexy and cryotherapy. In four patients the subretinal fluid involved the macula. Time taken to complete absorption of the subretinal fluid ranged from 10 to 26 months. In one patient there was still residual fluid inferiorly at 18 months of follow up. During the follow up period additional procedures were performed—scleral buckling (five eyes), pars plana vitrectomy (one eye), and mild laser scatter to extramacular areas of shallow subretinal fluid (four eyes). None of these procedures appeared to influence the rate of fluid absorption. CONCLUSIONS Loculated subretinal fluid following pneumatic retinopexy may persist for very long periods, extending up to more than 2 years. Additional surgical procedures or laser photocoagulation do not affect the rate of subretinal fluid absorption. Spontaneous reattachment eventually occurs in most eyes, and conservative management is indicated.

ICGA-guided laser photocoagulation of feeder vessels of choroidal neovascular membranes in age-related macular degeneration. Indocyanine green angiography.

Purpose: To report the ability of indocyanine green angiography (ICGA) with a confocal scanning laser ophthalmoscope (SLO) to identify feeder vessels of choroidal neovascular membranes (CNVM) secondary to age‐related macular degeneration (ARMD) and to show the feasibility of inducing complete closure of the CNVM by photocoagulation targeted exclusively to the feeder vessels. Methods: Five consecutive patients with exudative ARMD in whom ICGA with the confocal SLO showed extrafoveal feeder vessels supplying choroidal neovascular nets had laser photocoagulation done only to the feeder vessels. In two patients, two separate membranes were seen. Results: Laser photocoagulation resulted in closure of the feeder vessels and the CNVM in four patients. Complete closure was achieved with one treatment in one patient and with two treatments in three patients. In one patient, two treatments failed to close the feeder vessel and the CNVM, but a third, more intense laser treatment resulted in temporary closure of the feeder vessel and CNVM, which recanalized 2 to 4 weeks later with development of a large rip in the retinal pigment epithelium. In one patient, two separate CNVMs grew from the edge of the laser scars, but they were not directly related to the original CNVM and its feeder vessel, and were treated successfully. The same eye later developed subfoveal occult CNVM with gradual deterioration of visual acuity. In the other four patients, visual acuity improved in two and was unchanged in two. Conclusions: Indocyanine green angiography with the confocal SLO can identify choroidal feeder vessels supplying CNVM secondary to ARMD. Laser treatment to such extrafoveal feeder vessels, particularly in membranes that are large or subfoveal, may be effective in closing the feeder vessel and CNVM with preservation of the fovea and central vision. More than one treatment may be required, however, and failures and complications may be expected with this treatment modality.

Optical coherence tomography predictors of retinal pigment epithelial tear following intravitreal bevacizumab injection.

BACKGROUND AND OBJECTIVE To evaluate the ability of optical coherence tomography (OCT) to predict the risk of retinal pigment epithelium (RPE) tear in patients with choroidal neovascular membrane associated with pigment epithelium detachment treated with bevacizumab. PATIENTS AND METHODS Retrospective observational case series of 24 consecutive patients treated with bevacizumab. All patients had sequential OCT scans performed before treatment and during follow-up. Six patients developed an RPE tear. Eighteen patients served as the non-tear group. RESULTS Wavy RPE indentations or small interruptions and breaks in the elevated RPE were evident in all six patients who developed an RPE tear, whereas only two of the remaining 18 patients had such findings (P < .001). CONCLUSION Indentations or minute interruptions and breaks in the RPE layer seen on OCT were correlated with increased risk of developing an RPE tear in patients with pigment epithelium detachment following treatment with bevacizumab.

Pneumatic Retinopexy for the Repair of Primary Rhegmatogenous Retinal Detachment A 10-Year Retrospective Analysis

OBJECTIVE To assess the outcome and risk factors for failure of pneumatic retinopexy (PR) in eyes with primary rhegmatogenous retinal detachment (RRD). METHODS Data of patients who underwent PR for the repair of primary RRD, from January 1, 2000, through June 30, 2011, were retrieved from medical records and retrospectively analyzed. Patients with a follow-up time of less than 4 months were contacted and invited for examination. Patients with less than 2 months of follow-up were excluded. Successful cases (attached retina at 2 months after the PR) were compared with failures. A subgroup analysis was performed comparing successful and failed cases of RRD that were reattached with only 1 additional operation. RESULTS Two hundred seventy-six eyes (271 patients) underwent PR during the study period, of which 258 eyes (93.5%) were included in the study. Mean (SD) follow-up time was 36.1 (39.4) months; only 23 eyes (8.9%) had a follow-up of less than 4 months. Successful reattachment at 2 months was achieved in 171 eyes (66.3%). Sixty-seven eyes (77.0% of the failed cases) were reattached with only 1 additional operation and final anatomical success was achieved in 256 eyes (99.2%). Successful cases had significantly better final vision (P= .002) and fewer postoperative complications (P ≤ .026). However, nonsignificant differences were found between the primary failure PR cases that underwent only 1 additional operation and the successful cases (P ≥ .073). CONCLUSIONS Pneumatic retinopexy is a good surgical option for primary RRD. Most cases of primary failure are reattached with 1 additional procedure and have excellent final vision.

The protective effect of early intraoperative injection of viscoelastic material in trabeculectomy.

In a prospective study, we evaluated the effect of intracameral injection of sodium hyaluronate (HA) in trabeculectomy on short- and long-term results, including the effect on the corneal endothelium. Twenty-two patients were randomly assigned into two groups: group A, consisting of 11 patients, underwent standard trabeculectomy; in group B (11 patients), additionally, HA was injected into the anterior chamber immediately following paracentesis in an attempt to minimize shallowing of the chamber after the subsequent trabeculectomy. Both groups had comparable age distributions, preoperative intraocular pressures (IOPs), preoperative endothelial cell counts, postoperative IOPs after 3 months, and glaucoma medication indices. The reduction in the number of endothelial cells after 1 month was significantly greater in group A than in group B (16.1% vs 6.7%). Also, significantly more shallow anterior chambers occurred in group A (three eyes vs one eye). However, 1 day postoperatively, the average IOP was 16.4 mm Hg in group A, as compared with 25 mm Hg in group B. Thus, although HA, injected early in trabeculectomy, appeared to protect against corneal endothelial loss and flat anterior chamber, it also seemed to be associated with early IOP spikes.