Brooks W. McCuen

The Lack of Toxicity of Intravitreally Administered Triamcinolone Acetonide

We gave one eye of each 21 rabbits an intravitreal injection of 1 mg of triamcinolone acetonide; the other eye received an injection of an equal volume of saline solution as a control. Results of slit-lamp examinations, ophthalmoscopy, intraocular pressure, electroretinography, and light electron microscopy all remained normal throughout the three-month course of the experiment, demonstrating the lack of ocular toxicity of triamcinolone acetonide in the rabbit.

Pars plana vitrectomy, subretinal injection of tissue plasminogen activator, and fluid–gas exchange for displacement of thick submacular hemorrhage in age-related macular degeneration☆

PURPOSE To evaluate a new procedure for displacement of large, thick submacular hemorrhage in patients with age-related macular degeneration. METHODS Retrospective review of 11 eyes of 11 patients with age-related macular degeneration and thick submacular hemorrhage (defined as causing retinal elevation detectable on stereo fundus photographs) treated with vitrectomy, subretinal injection of tissue plasminogen activator (25 or 50 microg), and fluid-gas exchange with postoperative prone positioning. Outcome measures included displacement of hemorrhage from the fovea, best postoperative visual acuity, and final postoperative visual acuity. RESULTS In the 11 affected eyes of 11 patients (seven men and four women; mean age, 76 years), preoperative visual acuity ranged from 20/200 to hand motions. With surgery, subretinal hemorrhage was displaced from the fovea in all 11 cases. Mean postoperative follow-up was 6.5 months (range, 1 to 15 months). Best postoperative visual acuity varied from 20/30 to 5/200, with improvement in nine (82%) cases and no change in two cases. Eight eyes (73%) measured 20/200 or better, with four of these eyes (36%) 20/80 or better. Final postoperative visual acuity ranged from 20/70 to light perception, with improvement in eight (73%) cases, no change in one case, and worsening in two cases. A statistically significant difference was found between preoperative and best postoperative visual acuity (P =.004) but not between preoperative and final visual acuity (P =.16). Hemorrhage recurred in three (27%) eyes, causing severe visual loss in one eye. CONCLUSIONS This technique displaces submacular hemorrhage from the fovea and can improve vision in patients with age-related macular degeneration. However, recurrence of hemorrhage occurred in 27% of eyes and caused severe visual loss in one eye. A randomized, prospective clinical trial is necessary to determine the efficacy of this technique in comparison with other proposed treatments.

The Use of Silicone Oil Following Failed Vitrectomy for Retinal Detachment with Advanced Proliferative Vitreoretinopathy

We have used silicone-oil injection in a consecutive series of 44 patients with retinal detachment and advanced proliferative vitreoretinopathy, all of whom had previously failed to reattach with vitrectomy, membrane peeling, and scleral buckling. After a minimal follow-up period of 6 months, complete anatomic retinal reattachment posterior to the encircling scleral buckle was obtained in 64% of these eyes. Ambulatory visual acuity (5/200 or better) was achieved in 57% of the anatomically successful cases. Silicone-oil removal was performed in 69% of the anatomically and visually successful eyes without recurrent retinal detachment. Because of the frequent and severe complications associated with the use of silicone oil, we recommend that silicone-oil injection be considered only when conventional vitreoretinal techniques have failed to achieve retinal reattachment.

Vision-threatening Complications of Surgery for Full-thickness Macular Holes

OBJECTIVE To study complications of vitrectomy surgery for full-thickness macular holes. DESIGN A multicentered, randomized, controlled clinical trial. PARTICIPANTS Community and university-based ophthalmology clinics. INTERVENTION Standardized macular hole surgery versus observation. MAIN OUTCOME MEASURES Assessment of anatomic and visual outcomes and determination of postoperative complications at 12 months after randomization. RESULTS Posterior segment complications were noted in 39 eyes (41%). The incidence of retinal pigment epithelium (RPE) alteration and retinal detachment (RD) were 33% and 11%, respectively. One RD due to a giant retinal tear resulted in a visual acuity of light perception. Other complications included a reopening of the macular hole in 2 eyes (2%), cystoid macular edema in 1 eye (1%), a choroidal neovascular membrane in 1 eye (1%) and endophthalmitis in 1 eye (1%). Eyes with complications had significantly worse visual acuity outcomes as determined by the Early Treatment Diabetic Retinopathy Study, Word Reading, and Potential Acuity Meter charts (P < 0.01 for all comparisons). Eyes with macular holes greater than 475 microns were more than twice as likely to have complications than eyes with holes less than 475 microns (odds ratio [OR] = 2.2, P = 0.07). Before surgery, the stage of the hole was related to postoperative RPE changes (P < 0.0001) and the occurrence of postoperative RD (P = 0.0002). Intraoperative trauma was related to the occurrence of these complications (P < 0.0001 for RPE changes, P = 0.02 for RDs). Epiretinal membrane removal was related to RPE changes (P = 0.02) but not RDs. CONCLUSIONS The RPE alterations and RDs are common after macular hole surgery and result in significantly reduced postoperative visual acuity. The RPE changes may be related to surgical trauma or light toxicity. Further efforts to reduce complications associated with macular hole surgery are indicated.

Retinal oxygenation and laser treatment in patients with diabetic retinopathy.

The oxygen tension in the preretinal vitreous cavity was measured in human patients undergoing vitreous operations for proliferative diabetic retinopathy. The oxygen tension was significantly higher (P = .004) over areas of retina that had been treated with panretinal photocoagulation than it was over untreated areas in the same retina. This confirmed previous results in animals that showed that panretinal photocoagulation increases the inner retinal oxygen tension. We concluded that panretinal photocoagulation improves the oxygen supply to the inner retina and thereby minimizes the influence of retinal ischemia in diabetic retinopathy.

Silicone oil tamponade to seal macular holes without position restrictions

OBJECTIVE The authors performed a study to determine the effectiveness and safety of silicone oil as a substitute for gas to fill the vitreous cavity to treat macular holes. DESIGN Multicenter, nonrandomized, interventional trial. PARTICIPANTS Thirty-seven consecutive patients chose vitrectomy with silicone tamponade instead of gas to treat 40 eyes with stage-2 to stage-4 idiopathic age-related macular holes. Stage-2 holes constituted 40% of the holes, and stage-3 and stage-4 holes made up 60%. INTERVENTION All eyes were treated with vitrectomy, manual detachment of the posterior vitreous face (not done for stage-4 holes), autologous serum instillation, and silicone fill of the vitreous cavity. After insertion of the oil, the patients resumed normal activity with no restriction of head or eye position except to avoid faceup position. The oil was removed after approximately 6 weeks. MAIN OUTCOME MEASURES The authors considered the seal of the macular hole and the preoperative and postoperative logarithm of the minimum angle of resolution (logMAR) visions the most significant measures for comparison to other studies. RESULTS Eighty percent of all holes and 86% of holes not treated previously were sealed with a single silicone tamponade of the vitreous cavity. The logMAR value of visual acuity improved an average of 0.26 (2.6 lines) to 0.61 (20/81) for all eyes and 0.34 (3.4 lines) to 0.52 (20/66) when the macular hole sealed. Completeness of fill of the vitreous cavity with silicone affected seal of the macular hole. Three of eight eyes in which open holes developed after oil removal had less than 90% fill of the vitreous cavity by silicone. Sixty-nine percent of lenses increased opacity one grade or were removed after silicone tamponade. There were no significant adverse effects arising from silicone tamponade. CONCLUSIONS Silicone oil tamponade of macular holes is effective and safe. Silicone may be optimal for the treatment of macular holes in persons who must travel, who cannot maintain facedown positioning, or who have monocular vision. The most important factor in the successful closure of the macular hole was the completeness of fill of the vitreous cavity with silicone oil.

Long-Term Results of Successful Vitrectomy With Silicone Oil for Advanced Proliferative Vitreoretinopathy

We have analyzed the six-month, one-year, and two-year follow-up examinations in 47 patients who had silicone oil injection in combination with revision of vitrectomy for intractable retinal detachment and advanced proliferative vitreoretinopathy. A visual acuity of 5/200 or better was attained in 22 eyes at six months (47%), 17 eyes at one year (36%), and 14 eyes at two years (30%). Of eyes that were completely attached posterior to the buckle at six months, 77% remained attached at two years. In those eyes that were attached at six months, corneal decompensation was the most frequent cause of a loss of vision between six months and two years. Silicone oil was removed in 22 eyes (47%).

Silicone oil in vitreoretinal surgery part 2: Results and complications

The surgical results and postoperative complications associated with silicone oil injection in the treatment of complicated retinal detachment were evaluated in a series of 164 eyes followed for a minimum of 6 months. The incidence of recurrent retinal detachment, corneal decompensation, cataract, glaucoma, and hypotony were noted to be high, and the final visual results were often disappointing. The avoidance and treatment of these complications are discussed, and removal of the silicone oil after sustained anatomic retinal reattachment has been attained is recommended. RETINA 5:198-205, 1985

Visual Field Loss after Macular Hole Surgery

BACKGROUND Vitrectomy has been successfully used for treating idiopathic macular holes. Although macular hole surgery has been successful and is generally regarded as a safe procedure, various complications have been reported. The authors report eight patients with symptomatic peripheral visual field loss occurring after vitrectomy for macular holes. METHODS Over a 3-year period, vitrectomy with removal of the posterior cortical vitreous and fluid-gas exchange was performed on 50 eyes of 47 patients with idiopathic macular holes. Eight patients reported visual field loss postoperatively, and Goldmann visual fields were obtained. The clinical characteristics and outcomes of the group of patients with visual field loss were compared with the group of patients without visual field loss. RESULTS Postoperatively, significant peripheral visual field loss was documented in eight patients. The macular holes were anatomically closed in seven eyes (87.5%) of these patients compared with 37 (88.1%) of 42 eyes in the group of patients with no symptomatic visual field loss. The visual field loss was not associated with age, sex, macular hole stage, postoperative intraocular pressure, or history of hypertension or coronary artery disease. The etiology of visual field loss was unclear in six patients. CONCLUSION Vitrectomy for idiopathic macular holes can result in significant peripheral visual field loss. The etiology of this complication usually is unknown.

Relaxing Retinotomies and Retinectomies

Relaxing retinotomies and retinectomies are helpful surgical techniques in the treatment of severe cases of retinal detachment with incarcerated retinas, retinal shrinkage caused by proliferative vitreoretinopathy, proliferative vasculopathies, or injury after failure of membrane removal and scleral buckling to reattach the retina. They should be considered as a last resort. The retina is reattached with an intraocular tamponade and then treated with transvitreal laser or cryotherapy. Temporary retinal tacking at the posterior retinal edge before intraocular tamponade is helpful. The retina was attached in 18 of 45 eyes with at least six months of follow-up. Visual acuity was counting fingers or better in 11 eyes and 5/200 or better in three.