Claus Eckardt

Transconjunctival sutureless 23-gauge vitrectomy.

One of the most innovative vitreoretinal surgery techniques introduced in recent years is transconjunctival sutureless vitrectomy developed by Fujii et al.1,2 In this procedure, three polyamide microcannulas are inserted transconjunctivally through the sclera in the area of the pars plana. The vitreoretinal instruments and infusion line are then introduced through these cannulas into the vitreous cavity. Because a thin 25gauge instrumentarium is used, the incisions left in the sclera after removal of the cannulas are so small that they self-seal without suturing. The procedure has quickly found many advocates. It causes no surgical trauma to the conjunctiva, requires no scleral suture (and thus leaves no postoperative suture-related astigmatism), and entails a distinctly reduced rehabilitation time. Many vitreoretinal surgeons, however, reject the method at all or accept it only for special indications. One of the most frequent objections is that the 25-gauge instruments are too flexible for many of the complicated tasks performed on the retina and vitreous body. A method for transconjunctival sutureless vitrectomy using a 23-gauge instrumentarium that overcomes this flaw is presented.

Macular rotation with and without counter-rotation of the globe in patients with age-related macular degeneration

Abstract · Background: Macular rotation to treat exudative age-related macular degeneration (AMD) involves translocation of the fovea to a site with intact retinal pigment epithelium. To avoid the inevitable postoperative cyclotropia we combined this procedure with torsional muscle surgery. · Patients and methods: In 30 eyes the macula was rotated upward by 30–50° following complete artificial retinal detachment and a 360° retinotomy. Simultaneous torsional muscle surgery was not carried out in the first 8 eyes; in the remaining 22 eyes surgery of the oblique muscles was performed alone or in combination with surgery of two or four rectus muscles. Simultaneously or later, muscle surgery was performed on the fellow eye in 17 of these patients. Three of the eight patients who had no primary muscle surgery were operated on later. They had muscle surgery on the macular-rotated eye and on the fellow eye. · Results: Postoperatively, the silicone oil was removed from all but one eye and an intraocular lens implanted in all but two eyes. Five eyes developed a postoperative retinal detachment, three of them with proliferative vitreoretinopathy. Three other eyes developed a recurrence of the choroidal neovascularization. At last examination, 18 of the 30 eyes (60%) had a near vision of 0.4 or better, sufficient for the reading of normal newsprint. Six of the eight patients who did not undergo muscle surgery reported considerable disorientation caused by the postoperative diplopia and cyclotropia. The muscle operation, which has been performed in a total of 25 patients, conferred complete freedom from complaints in all but one patient. · Conclusion: Macular rotation succeeded in restoring reading vision in about half of cases of exudative AMD, at least in the short term. The most serious complication was the development of a retinal detachment. The extremely disorienting side effects of diplopia and tilted image could be prevented or effectively treated by muscle surgery for counter-rotation of the globe, if need be also in the fellow eye.

Macular hole surgery with air tamponade and optical coherence tomography-based duration of face-down positioning.

Purpose: To evaluate the closure rate after macular hole surgery with air tamponade and face-down positioning whose duration is based on postoperative optical coherence tomography (OCT). Methods: In a prospective study, data were gathered on 33 eyes of 33 consecutive patients undergoing macular hole surgery. Postoperatively, OCT images were obtained in a face-down position to minimize the interfering reflections created by the air bubble. The face-down positioning was ended as soon the OCT revealed closure of the hole. Results: Opacity of the media in 8/33 eyes 24 hours postoperatively precluded OCT. In 18/33 eyes (54.5%), the hole was closed on OCT 24 hours postoperatively and in 25/33 (75.7%), 48 hours postoperatively. In 4/33 eyes (12.1%), the hole was judged to be open on OCT 24 hours postoperatively. Despite continued face-down positioning, the hole had closed on the third day postoperatively in only one of these four eyes. In two of the remaining three eyes, the macular hole could be closed by a second surgery which was performed 5 to 6 days after the first vitrectomy. Using OCT monitoring, more than half (54%) of our patients could quit the face-down position after 24 hours, 21% after 48 hours, and 24% after 3 days. Conclusion: Vitrectomy and air tamponade combined with 1- to 3-day face-down positioning produced an excellent rate of macular hole closure. Already on the first and second day postoperatively OCT on patients in a prone position enabled the monitoring of the progress of the macular hole closure through the air bubble. This method allows effective adjustment of the duration of face-down positioning based on OCT findings.

Effect of bevacizumab on inflammation and proliferation in human choroidal neovascularization.

OBJECTIVE To evaluate the effect of bevacizumab (Avastin; Genentech, Inc, South San Francisco, California) on inflammation and proliferation in human choroidal neovascularization (CNV) secondary to age-related macular degeneration. METHODS Retrospective review of interventional series of 38 patients who underwent choroidal neaovascular membrane (CNVM) extraction. Twenty-four patients received intravitreal bevacizumab 1 to 154 days preoperatively (bevacizumab CNV group). Fourteen patients received no preoperative therapy (control CNV group). The CNVM were stained for cytokeratin 18, CD68, CD45, intercellular adhesion molecule (ICAM)-1, E-selectin, Ki-67, Thy-1, and endostatin. RESULTS No significant difference was detected in ICAM-1 and E-selectin expression between groups. The density of leukocytes in the bevacizumab CNV group (median, 271.61 cells/mm(2)) was higher than in the control CNV group (median, 116.87 cells/mm(2); P = .07), but without significance. Density of macrophages (median, 4661.95 cells/mm(2)), proliferative activity (median, 160.19 cells/mm(2)), and percentage of Thy-1-expressing vessels (median, 100%) were significantly higher in the bevacizumab CNV group than in the control CNV group (median, 882.66 cells/mm(2), P < .001; median, 34.34 cells/mm(2), P < .001; and median, 80%, P < .001, respectively). Endostatin immunoreactivity was considerably stronger in the retina pigment epithelium (RPE)-Bruch membrane complex (median, 3; range, 2-3; P < .001), and stroma (median, 3; range, 1-3; P < .001) of the bevacizumab CNV group than control CNV group (median, 1.5; range, 0-3 and median, 1; range, 0-3, respectively). CONCLUSIONS Unexpectedly, CNVM from patients treated by bevacizumab are characterized by significantly high inflammatory and proliferative activity and enhanced endostatin expression. These characteristics need to be considered when protocols for combination therapies are established.

Twin lights: a new chandelier illumination for bimanual surgery.

Complicated situations encountered during vitreoretinal operations can be better mastered using bimanual techniques than with conventional single-handed methods. It is especially advantageous to have both hands active during removal of enlarged epiretinal membranes in patients with proliferative vitreoretinopathy and diabetic retinopathy, or during macular translocation with 360° retinotomy. Various methods have been devised, including illuminated instruments, the multiport illumination system, 1 external diaphanoscopic illumination, 2 chandelier illumination,3 and Torpedo Mini Lights. 4

HEADS-UP SURGERY FOR VITREORETINAL PROCEDURES: An Experimental and Clinical Study.

Purpose: To investigate the feasibility of performing vitrectomies while viewing a three-dimensional image on a large display in a heads-up position. Methods: Twenty volunteers were compared performing meticulous tasks using the heads-up and the traditional method. Some optical parameters, resolution and depth of field, were measured, and the possibilities of digital image processing were investigated. In addition, routine use of the heads-up method for >400 vitrectomies over 8 months was retrospectively analyzed. Results: Of note, 91.7% of the volunteers preferred the ergonomics of the heads-up technique. The two methods were judged to be similar regarding speed and ease of microscopic manipulations and sharpness of image. Significantly fewer mistakes were made with the heads-up method. The measured resolution of the eyepieces was approximately twice that of the three-dimensional display, whereas depth of the field was about equal. Electronic amplification of the cameras signal resulted in increased image brightness, allowing use of reduced endoillumination levels. In clinical routine, better ergonomics, digital image processing, and use of a large display are found to be major advantages. Conclusion: The heads-up method is well suited for vitreoretinal surgery. With further technical improvements, the procedure should soon find widespread use.

Influence of verteporfin photodynamic therapy on inflammation in human choroidal neovascular membranes secondary to age-related macular degeneration.

Purpose: To examine the short- and long-term consequences of verteporfin photodynamic therapy (PDT) on inflammation with regard to infiltration of macrophages and leukocytes and expression of thy-1 in human choroidal neovascularization membranes (CNV) secondary to age-related macular degeneration (AMD). Methods: Retrospective review of an interventional case series of 43 patients who underwent removal of CNV. Twenty patients were treated with PDT 3 to 246 days preoperatively. Twenty-three CNV without previous treatment were used as control. CNV were stained for CD34, CD105, cytokeratin18, Ki-67, thy-1, an endothelial cell glycoprotein known to be upregulated only by inflammatory cytokines, CD68 (macrophages), and CD45 (common leukocyte antigen). Results: Specimens treated by PDT 3 days previously showed significantly reduced endothelial thy-1 expression (P = 0.008), leukocyte (P = 0.04) and macrophage (P = 0.0063) infiltration, and proliferative activity (P = 0.02) compared to control CNV. Specimens at longer intervals after PDT, in contrast, disclosed a significantly increased expression of thy-1 (P = 0.004), infiltration with leukocytes (P = 0.044) and macrophages (P = 0.01), and proliferative activity (P = 0.03) compared to CNV excised 3 days after PDT. Conclusions: The rebound effect after PDT seems to be based on an inflammatory response that contributes to enhanced proliferation. These data support the need for an anti-inflammatory therapy as adjuvant to PDT.

New Components of ‘Basal Laminar Deposits’ in Age-Related Macular Degeneration

Two new components of basal laminar deposit (BlamD) occurring in samples of submacular neovascular membranes surgically removed from patients with a wet (exudative) form of age-related macular degeneration are described. They are: (1) minute ribbon-like structures which occur singly and/or in a bunch and extend from the inner surface of the BlamD layer into the extracellular matrix (ECM) beneath the retinal pigment epithelium (RPE). The ribbons are composed of polarized molecules, aggregating in parallel, aligned transversally in register, morphologically similar to isolated collagen molecules of the short-chain type. Deeper in the BlamD but always close to its inner surface, aspects suggesting a transition between ribbons and (2) long-spacing collagen (LSC)-like aggregates characterized by periods bordered by a single dense band were observed. This band could arise from the globular domains of the polarized monomers, which assemble in parallel and display all their terminal extensions at the same end of each period resulting in the single dense band. The presence of ribbons and of LSC-like aggregates in the BlamD layer and the concomitant choroidal neovascularization (CNV) suggest that the events might be correlated. The newly formed vessels crossing Bruch’s membrane and invading the BlamD layer could induce physicochemical changes in the ECM of the RPE, providing the required environmental conditions for the polymerization of collagen molecules into aggregates with the LSC-like pattern. With the deposition of new components, the thickness of BlamD increases and further impairs the supply of nutrients and oxygen, thus sustaining CNV.

27-gauge Twinlight chandelier illumination system for bimanual transconjunctival vitrectomy.

27-Gauge Twinlight Chandelier Illumination System for Bimanual Transconjunctival Vitrectomy For many vitreoretinal disorders, chandelier illumination is beneficial because it can provide panoramic illumination ideal for bimanual surgery. Until recently, 25-gauge light fibers were used for this purpose, including the Tornambe Torpedo (Insight Instruments, Stuart, FL), the Awh 25-gauge chandelier (Synergetics, Inc., St. Charles, MO), and the Twinlight (DORC, Zuidland, Holland).1 Newly developed, much brighter xenon light sources, such as the Photon Light Source (Synergetics, Inc.), BrightStar (DORC), and Accurus AHBJ-Illuminator (Alcon, Fort Worth, TX), allow the use of smaller-gauge light probes. More recently, self-retaining 27-gauge chandelier endoillumination was introduced.2 In our experience, successful insertion of such a slim fiber during transconjunctival vitrectomy can be difficult; after sclerotomy using a 27-gauge disposable cannula, it may be difficult or impossible to locate the incision after withdrawal of the cannula because it has been covered by or is no longer in alignment with the conjunctiva. Therefore, we developed a novel method for transconjunctival insertion of a new 27-gauge Twinlight. The tips of the two 27-gauge fibers of the Twinlight are cone shaped to allow panoramic illumination. The fibers can be inserted into the eye up to a silicon cuff located 4 mm from the tip of each fiber (Fig. 1). The two fibers run through in a common sleeve and finally unite at the plug to the light source. A specially designed needle is used for performing the two sclerotomies. It consists of a 27-gauge cannula with a 3.5-mm-long troughlike depression at the tip that serves to guide the light fibers (Fig. 2). The needle is inserted for about one fourth of its length transconjunctivally and vertical to the sclera at a site 3 mm posterior to the limbus. It is then carefully retracted to leave only the tip of the needle in the sclerotomy. To prevent elevation of the conjunctiva during retraction of the needle, which would obstruct the view of the trough, the conjunctiva is held down with the tip of the light-probe forceps especially designed for this purpose (Fig. 3). While grasping the light fiber with these forceps, the conical tip is then placed into the trough of the needle and advanced at a 10° to 20° angle along the trough into the sclerotomy, while at the same time retracting the needle (Fig. 2). Suture fixation of the fiber to the sclera is not required because the fiber is self-retaining. The second fiber is introduced in the same manner. At conclusion of the vitreous surgery, the light fibers are simply removed. Small hemorrhages, which may appear on the conFrom the Department of Ophthalmology, Staedtische Kliniken Frankfurt am Main-Hoechst, Frankfurt, Germany. Claus Eckardt has a proprietary interest in the described instruments. Reprint requests: Claus Eckardt, MD, Augenklinik Staedtische Kliniken Frankfurt am Main-Hoechst, Gotenstrasse 6-8, 65929 Frankfurt, Germany; e-mail: C.Eckardt@em.uni-frankfurt.de Fig. 1. The 27-gauge Twinlight (DORC, Zuidland, Holland). A silicon cuff is located 4 mm from the tip of each fiber.

Early Effects of Triamcinolone on Vascular Endothelial Growth Factor and Endostatin in Human Choroidal Neovascularization

OBJECTIVE To evaluate the early effects of triamcinolone acetonide as monotherapy or as an adjuvant to ocular verteporfin photodynamic therapy (PDT) on angiogenesis in human choroidal neovascularization (CNV) secondary to age-related macular degeneration. METHODS Retrospective review of an interventional series of 55 patients who underwent CNV extraction. Eleven patients were treated with intravitreal triamcinolone acetonide (4 mg) monotherapy (triamcinolone-treated CNV group [n = 5]) or with PDT-triamcinolone combination therapy (PDT-triamcinolone-treated CNV group [n = 6]) 3 to 9 days before surgery. Forty patients who underwent CNV extraction without previous therapy (control CNV group) and 4 patients who underwent CNV extraction 3 days after PDT (PDT CNV group) served as control subjects. The CNV samples were stained for CD34, endostatin, cytokeratin 18, and vascular endothelial growth factor (VEGF). RESULTS Vascular endothelial growth factor expression was stronger in the PDT CNV samples (P < .001), triamcinolone CNV samples (P = .01), and PDT-triamcinolone CNV samples (P = .007) compared with the control CNV samples. There were no statistically significant differences in VEGF expression among the PDT CNV samples, triamcinolone CNV samples, and PDT-triamcinolone CNV samples. Endostatin expression was weaker in the PDT CNV samples than in the control CNV samples (P = .008). Endostatin expression was stronger in the triamcinolone CNV samples and the PDT-triamcinolone CNV samples compared with the control CNV samples (P = .001 and P < .001, respectively) and the PDT CNV samples (P < .001 for both). CONCLUSION To some extent, triamcinolone monotherapy seems to exert its angiogenesis inhibitory effects on CNV by enhancing endostatin expression rather than by suppressing VEGF expression.