Christopher D. Riemann

Macular traction detachment and diabetic macular edema associated with posterior hyaloidal traction

PURPOSE To review the clinical, photographic, fluorescein angiographic, and optical coherence tomographic findings in patients with the diabetic macular traction and edema (DMTE) associated with posterior hyaloidal traction (PHT). METHODS We performed a prospective review of nine eyes of nine patients with diabetic macular edema (DME) and PHT on clinical examination. The patients had a comprehensive ophthalmic history and examination, color photographs, fluorescein angiography, and optical coherence tomography (OCT). RESULTS All patients had diabetic retinopathy and DME. Of the nine eyes, eight patients had previous focal or grid photocoagulation. All nine eyes had a thickened, taut, glistening posterior hyaloid on clinical biomicroscopic examination with no posterior vitreous separation. Fluorescein angiography was performed on seven eyes, and all had early hyperfluorescence with deep, diffuse, late leakage in the macular area consistent with DMTE associated with PHT. Optical coherence tomography scans of the macular region revealed retinal thickening in all eyes with a mean retinal thickness of 556.9 +/- 114.7 microns. In addition, eight of the nine eyes had a shallow macular traction detachment associated with PHT. CONCLUSION Eyes with DME associated with PHT may have a shallow, subclinical, macular detachment. Optical coherence tomography may be useful in evaluating patients with DME to see if a macular detachment is present.

Outcomes Of Transconjunctival Sutureless 25-gauge Vitrectomy With Silicone Oil Infusion

Purpose: To evaluate the outcomes and complications of surgical management with 25-gauge pars plana vitrectomy (PPV) and silicone oil (SO) tamponade in complex vitreoretinal diseases. Methods: Retrospective review of a consecutive, interventional case series at a single center. Results: Thirty-five eyes of 35 patients were included in the study. The indications for vitrectomy included tractional retinal detachment (11 eyes), macular hole (6 eyes), proliferative vitreoretinopathy or recurrent retinal detachment (9 eyes), neovascular glaucoma (3 eyes), giant retinal tear (3 eyes), and pathologic myopia with epiretinal membrane or macular hole (3 eyes). All patients underwent 25-gauge PPV with either 1,000-centistoke (n = 31) or 5,000-centistoke (n = 4) SO tamponade infused through a 24-gauge angiocatheter. No intraoperative complications were noted. The median preoperative visual acuity was counting fingers (range, 20/50 to light perception). The median postoperative visual acuity after a median follow-up of 6 months (range, 1–19 months) was 20/200 (range, 20/30 to light perception). A small subconjunctival SO bleb was identified in two patients. Recurrent retinal detachment occurred in three patients. No significant complications relating to the use of SO in the setting of 25-gauge PPV occurred. Conclusions: Advances in 25-gauge PPV instrumentation have enabled expanding indications for 25-gauge PPV. 25-Gauge PPV with SO tamponade is safe and efficient and can be considered in the surgical management of complex vitreoretinal disease.

PRIMARY REPAIR OF RETINAL DETACHMENT WITH 25-GAUGE PARS PLANA VITRECTOMY

Purpose: To evaluate 25-gauge pars plana vitrectomy (PPV) for primary repair of rhegmatogenous retinal detachment (RRD). Study Design and Participants: This retrospective, consecutive case series included 42 eyes of 41 patients who underwent primary repair of RRD utilizing transconjunctival 25-gauge PPV without scleral buckling at the Cincinnati Eye Institute from July 2004 through January 2007. Methods: The medical records were retrospectively reviewed, and the corresponding demographic data, preoperative ophthalmic diagnoses, surgical management, and postoperative course and treatment were recorded. Main outcome measures included single surgery anatomical success, preoperative and postoperative visual acuity, and complications. Results: Most patients had pseudophakic RRD (36 [85.7%] of 42 eyes). The crystalline lens was present in the remaining 6 eyes (14.3%). Of 42 eyes, 28 (66.7%) had macula-on RRD, while 14 (33.3%) had macula-off RRD. Four surgeons contributed to this study, and 25-gauge PPV instrumentation, a wide-angle viewing system, endolaser photocoagulation, and gas tamponade were used in each case. The single surgery anatomical success rate was 92.9% (39 of 42 eyes). For eyes with macula-on RRD, best-corrected visual acuity was 20/50 (0.43 logMAR [logarithm of the minimum angle of resolution]) preoperatively and 20/30 (0.23 logMAR) postoperatively (P = 0.24). For eyes with macula-off RRD, best-corrected visual acuity was 5/200 (1.56 logMAR) preoperatively and 20/30 (0.23 logMAR) postoperatively (P = 0.001). Three eyes required additional surgery for final reattachment. Final reattachment was achieved in 100% of patients (mean follow-up, 8 months). Conclusions: Twenty-five–gauge PPV with laser retinopexy and gas tamponade is effective for primary repair of RRD. The single operation anatomical success rate is comparable with rates reported for primary vitrectomy with 20-gauge instrumentation, scleral buckling, and combined vitrectomy/scleral buckling.

Direct orbital manometry in patients with thyroid-associated orbitopathy

PURPOSE To determine orbital tissue tension and orbital compartment compliance in patients with and without thyroid-associated orbitopathy (TAO). DESIGN Prospective case series. PARTICIPANTS Orbits of patients with TAO (18 orbits) and control patients without TAO (35 orbits) were studied. METHODS An orbital manometer was designed to directly measure orbital tissue tension in patients undergoing ocular or orbital surgery. MAIN OUTCOME MEASURES Tissue tension was recorded before, during, and for 5 minutes after a 5-ml retrobulbar injection of anesthetic. Orbital compliance was calculated as change in volume divided by change in tissue tension. RESULTS Resting orbital tissue tension was 4.4 +/- 2.2 mmHg (mean +/- SD) in normal orbits and 9.7 +/- 4.8 mmHg in orbits of TAO patients (P = 0.0005) Following retrobulbar injection, orbital tissue tension rose to 12.0 +/- 3.6 mmHg (P = 0.0000000000000006 compared with baseline) in the control group and to 36.3 +/- 15.2 mmHg in the TAO group (P = 0.0000007 compared with baseline, and P = 0.000008 TAO group versus control group). Orbital compartment compliance was 0.80 +/- 0.50 ml/mmHg in the control group and 0.27 +/- 0.21 ml/mmHg in the TAO group (P = 0.00001). Resting orbital tissue tension in 8 TAO orbits with compressive optic neuropathy was 12.4 +/- 4.9 mmHg, and was 7.8 +/- 3.5 mmHg in 10 orbits of TAO patients without compressive optic neuropathy (P < 0.05). No adverse events occurred. CONCLUSIONS Retrobulbar injection causes consistent measurable changes in orbital tissue tension. Orbital manometry safely demonstrated higher orbital tissue tension and lower orbital compartment compliance in the orbits of TAO patients versus those of normal subjects. Resting orbital tissue tension was higher in the orbits of TAO patients with compressive optic neuropathy than in those orbits without. Compressive optic neuropathy may partially result from an orbital compartment syndrome in some patients with TAO. Directly assessing orbital dynamics in vivo may prove useful as an adjunct in the clinical evaluation of patients with TAO and other orbital disorders.

Ionic contrast agent-mediated endothelial injury causes increased platelet deposition to vascular surfaces☆☆☆

Contrast agent-mediated endothelial injury may be clinically relevant to the development of acute thrombosis after coronary interventions. We sought to investigate the extent to which contrast agents increase platelet deposition by measuring deposition of indium-111 radiolabeled platelets in an isolated perfused rabbit carotid artery model. Carotid artery segments were perfused at physiologic temperature, pressure, and shear. Vessels were subjected to angioplasty or no angioplasty before exposure to either buffer, diatrizoate (high osmolal/ionic), ioxaglate (low osmolal/ionic), or ioversol (low osmolal/nonionic). Subsequent deposition of indium-111 radiolabeled platelets was quantified. In vessels without balloon angioplasty, platelet deposition (platelets/cm2) was 110,000 +/- 95,000 for buffer perfused vessels, 280,000 +/- 210,000 for vessels perfused with diatrizoate, 290,000 +/- 160,000 for vessels perfused with ioxaglate, and 130,000 +/- 98,000 for vessels perfused with ioversol. After balloon angioplasty, platelet deposition was 1,300,000 +/- 590,000 for buffer controls, 1,800,000 +/- 320,000 for diatrizoate-perfused vessels, 1,500,000 +/- 450,000 for ioxaglate-perfused vessels, and 1,000,000 +/- 180,000 for ioversol-perfused vessels. In vessels without balloon angioplasty, diatrizoate and ioxaglate increased platelet deposition 2.5-fold and 2.6-fold, respectively, relative to buffer-perfused vessels (p < 0.05 and p < 0.01), whereas no increase was seen with ioversol. After balloon angioplasty, diatrizoate increased platelet deposition 1.4-fold over control (p < 0.05), whereas ioxaglate and ioversol showed no statistically significant increase. We conclude that ionic contrast media may cause more endothelial injury and associated localized platelet deposition than nonionic contrast media. These findings may be relevant to coronary interventions, specifically with regard to acute closure and chronic restenosis.

Boston type 1 keratoprosthesis combined with silicone oil for treatment of hypotony in prephthisical eyes.

Purpose: To present the outcomes of Boston type I keratoprosthesis (KPro) implantation in combination with pars plana vitrectomy (PPV) and silicone oil for the treatment of hypotony in prephthisical eyes. Methods: Interventional case series. Thirteen eyes of 13 patients underwent Boston type I KPro implantation, pars plana vitrectomy, and silicone oil placement. Concurrent retinal detachment repair, membrane peel, or intraocular lens explantation were performed if necessary. Inclusion criteria for surgery were eyes with visual acuity worse than 20/400, previous failed penetrating keratoplasty, corneal opacification, visually significant or worsening hypotony, and visual acuity 20/200 or worse in the fellow eye. Outcome measures included Snellen best-corrected visual acuity, anatomic retinal attachment, and complications. Results: At the final follow-up (mean, 24 months; range, 5-66 months), visual acuity was improved in 10 of 13 eyes (77%), stable in 2 of 13 eyes (15%), and decreased in 1 of 13 eyes (8%). All eyes had attached retina with no progression to phthisis bulbi. No intraoperative complications occurred. Postoperative complications included retroprosthetic membrane (7 of 13), KPro melt (1 of 13), KPro leak (1 of 13), KPro infection (1 of 13), vitreous hemorrhage (1 of 13), and retinal detachment (1 of 13). Conclusions: Boston type I KPro implantation in combination with pars plana vitrectomy and intraocular silicone oil fill can improve vision in most prephthisical eyes with hypotony. Structural findings can also improve.

Indocyanine green-assisted internal limiting membrane peeling for macular holes to stain or not to stain?

Indocyanine Green–Assisted Internal Limiting Membrane Peeling for Macular Holes To Stain or Not To Stain? The retinal internal limiting membrane (ILM) forms the structural boundary between the retina and the vitreous. It is derived primarily from, and rests upon, a sea of Müller cell footplates that separates it from the nerve fiber layer.1 As a basement membrane, the ILM can act as a scaffold that may permit cellular proliferation and transmit tractional forces directly to the inner retina. The ILM is frequently involved in disorders that affect the vitreomacular interface, including epiretinal membranes, vitreomacular traction, and macular holes.2–8 Although to our knowledge there have been no randomized, prospective, controlled clinical trials, most evidence suggests that retinal ILM peeling improves anatomical and visual outcomes after macular hole repair.9–24 Indeed, a meta-analysis of data for 1,654 eyes demonstrated that ILM peeling significantly increased the anatomical and functional success rates of macular hole surgery (P 0.0001).13 Surgical peeling of the ILM can be technically challenging even for experienced vitreoretinal surgeons primarily due to its inherent transparency. Indocyanine green (ICG) was first introduced for intraocular use in 1998 to facilitate visualization of the anterior capsule of the crystalline lens.25 Shortly thereafter, ICG-assisted ILM peeling was described in human cadaveric eyes, as well as intraoperatively for macular hole repair.26–28 ICG enhances visualization of the ILM, and most clinical studies have reported visual and anatomical success with the use of this technique.17,27–45 Indeed, the largest clinical series of ICG-assisted ILM peeling for primary macular hole closure reported an anatomical success rate of 98% and an improvement of 2 lines of Snellen visual acuity in 96% of 121 eyes. No eyes lost visual acuity, and no complications were identified as a result of ICG use.39 This study, however, was noncomparative and retrospective and did not formally evaluate visual fields. In addition, power calculations suggested that a sample size of 300 would be required to have a reasonable chance of detecting a significant adverse event if the rate of that event were 1%.39 ICG-assisted ILM peeling has become routine practice for a large number of vitreoretinal surgeons, with 42% of these surgeons using ICG for 90% of their primary macular hole operations.46,47 ICG staining has been promoted as useful for surgeons learning to peel the ILM. According to the 2003 survey of the American Society of Retinal Specialists, 52% of vitreoretinal surgeons now using ICG-assisted ILM peeling had not routinely attempted ILM peeling before the introduction of ICG.47 Furthermore, several studies have demonstrated that ICG-assisted ILM peeling is helpful in challenging cases such as traumatic, recurrent, and long-standing macular holes as well as macular hole surgery in severely myopic eyes even in the presence of retinal detachment.27,28,30,32,37,48,49 Despite widespread use of ICG-assisted ILM peeling and many favorable reports, it is important to note that some clinical studies have reported unfavorable functional outcomes and complications, such as visual field defects or retinal pigment epithelium (RPE) changes.50–55 Investigators have generally attributed complications and unfavorable outcomes to the use of ICG. They may be correct. Nevertheless, it is important to recall that unfavorable results and these same complications have been previously described as surgeons began to peel the ILM even before the introThe authors received no public or private financial support pertaining to the information reported in this article. Reprint requests: Andrea P. Da Mata, MD, Cincinnati Eye Institute, 10494 Montgomery Road, Cincinnati, OH 45242; e-mail: andreadamata@hotmail.com

Comparison of 20-, 23-, and 25-Gauge Pars Plana Vitrectomy in Pseudophakic Rhegmatogenous Retinal Detachment Repair

BACKGROUND AND OBJECTIVE To compare 20-, 23-, and 25-gauge pars plana vitrectomy (PPV) for repair of primary pseudophakic rhegmatogenous retinal detachment. PATIENTS AND METHODS One hundred eyes of 94 pseudophakic patients who underwent primary rhegmatogenous retinal detachment repair with 20-, 23-, or 25-gauge transconjunctival PPV without scleral buckling were included. The medical records were retrospectively reviewed and the corresponding demographic information, preoperative ophthalmic diagnoses, surgical management, and postoperative course and treatment were recorded. RESULTS Retinal detachment repair was performed by one of four surgeons. All eyes underwent primary vitrectomy using either 20-, 23-, or 25-gauge vitrectomy instruments, a wide-angle viewing system, endolaser photocoagulation, and gas or silicone oil tamponade. Single surgery anatomical success was 25 of 28 eyes (89.3%) for 20-gauge, 24 of 27 eyes (88.9%) for 23-gauge, and 42 of 45 eyes (93.3%) for 25-gauge PPV. There was no statistical difference in single operation success or final visual acuity results between the groups and 100% of patients achieved final reattachment. CONCLUSION Twenty-, 23-, and 25-gauge instruments are equally effective options for primary repair of pseudophakic rhegmatogenous retinal detachment.

Outcomes of 25-gauge pars plana vitrectomy in the surgical management of proliferative diabetic retinopathy.

BACKGROUND AND OBJECTIVE To report outcomes and complications of 25-gauge pars plana vitrectomy (PPV) for patients with complications of proliferative diabetic retinopathy (PDR). PATIENTS AND METHODS Retrospective, interventional, consecutive case series of 174 eyes undergoing primary 25-gauge PPV for PDR from 2006 to 2009. Primary outcomes were visual acuity changes and rates of postoperative complications. RESULTS Visual acuity improved from 20/187 before to 20/69 after surgery (P < .0001). Postoperative vitreous hemorrhage occurred in 38.7% of eyes and 10.4% of all eyes required another PPV for non-clearing vitreous hemorrhage. Complications included limited choroidal effusion (5.2%), rhegmatogenous retinal detachment (4.6%), hypotony, rubeosis, and ocular hypertension (4.1%), neovascular glaucoma (2.3%), hyphema (1.2%), and phthisis bulbi (0.6%). CONCLUSION The authors found 25-gauge PPV to be effective for vitreous removal and membrane dissection. The spectrum and frequency of complications were similar to those reported for 20-gauge PPV for PDR. In the surgical management of PDR, 25-gauge PPV is an alternative.

Analysis of Outcomes for Intravitreal Bevacizumab in the Treatment of Choroidal Neovascularization Secondary to Ocular Histoplasmosis

PURPOSE To assess the long-term outcomes of intravitreal bevacizumab (IVB) in the treatment of choroidal neovascularization (CNV) secondary to presumed ocular histoplasmosis syndrome (POHS). DESIGN Retrospective, comparative case series. PARTICIPANTS Interventional series of 150 eyes in 140 patients treated for subfoveal or juxtafoveal CNV secondary to POHS from January 2006 to January 2010. INTERVENTION Intravitreal bevacizumab monotherapy or combination IVB and verteporfin photodynamic therapy (IVB/PDT). MAIN OUTCOME MEASURES Visual acuity (VA) at 12 and 24 months was analyzed. Secondary outcome measures included the number of injections per year and treatment-free intervals. RESULTS A total of 117 eyes received IVB monotherapy, and 34 eyes underwent combination IVB/PDT treatment. For all patients, the average pretreatment logarithm of minimum angle of resolution (logMAR) was 0.63 (Snellen equivalent 20/86) with a 12-month logMAR VA of 0.45 (Snellen equivalent 20/56) and a 24-month logMAR VA of 0.44 (Snellen equivalent 20/55). The mean follow-up was 21.1 months with an average of 4.24 IVB injections per year. There was no significant difference in initial VA, VA at 12 months, VA at 24 months, or number of eyes with a 3-line gain between the IVB monotherapy and IVB/PDT groups. Thirty-eight percent (39/104) of eyes gained 3 lines or more, and 81.2% (84/104) of subjects had maintained or improved their starting VA at 1 year. The proportion of subjects maintaining a 3-line gain in VA was relatively preserved at 2 years (29.8%, 17/57) and 3 years (30.3%, 10/32) follow-up. There was no increase in the proportion of subjects losing 3 lines or more over 3 years of follow-up. CONCLUSIONS There is no significant difference in VA outcomes between IVB monotherapy versus IVB/PDT combination therapy. The use of IVB alone or in combination with PDT results in significant visual stabilization in the majority of patients with CNV secondary to POHS.