Didier Ducournau

Strategy for the Management of Uncomplicated Retinal Detachments: The European Vitreo-Retinal Society Retinal Detachment Study Report 1

OBJECTIVE To study success and failure in the treatment of uncomplicated rhegmatogenous retinal detachments (RRDs). DESIGN Nonrandomized, multicenter retrospective study. PARTICIPANTS One hundred seventy-six surgeons from 48 countries spanning 5 continents provided information on the primary procedures for 7678 cases of RRDs including 4179 patients with uncomplicated RRDs. METHODS Reported data included specific clinical findings, the method of repair, and the outcome after intervention. MAIN OUTCOME MEASURES Final failure of retinal detachment repair (level 1 failure rate), remaining silicone oil at the studys conclusion (level 2 failure rate), and need for additional procedures to repair the detachment (level 3 failure rate). RESULTS Four thousand one hundred seventy-nine uncomplicated cases of RRD were included. Combining phakic, pseudophakic, and aphakic groups, those treated with scleral buckle alone (n = 1341) had a significantly lower final failure rate than those treated with vitrectomy, with or without a supplemental buckle (n = 2723; P = 0.04). In phakic patients, final failure rate was lower in the scleral buckle group compared with those who had vitrectomy, with or without a supplemental buckle (P = 0.028). In pseudophakic patients, the failure rate of the initial procedure was lower in the vitrectomy group compared with the scleral buckle group (P = 3×10(-8)). There was no statistically significant difference in failure rate between segmental (n = 721) and encircling (n = 351) buckles (P = 0.5). Those who underwent vitrectomy with a supplemental scleral buckle (n = 488) had an increased failure rate compared with those who underwent vitrectomy alone (n = 2235; P = 0.048). Pneumatic retinopexy was found to be comparable with scleral buckle when a retinal hole was present (P = 0.65), but not in cases with a flap tear (P = 0.034). CONCLUSIONS In the treatment of uncomplicated phakic retinal detachments, repair using scleral buckle may be a good option. There was no significant difference between segmental versus 360-degree buckle. For pseudophakic uncomplicated retinal detachments, the surgeon should balance the risks and benefits of vitrectomy versus scleral buckle and keep in mind that the single-surgery reattachment rate may be higher with vitrectomy. However, if a vitrectomy is to be performed, these data suggest that a supplemental buckle is not helpful. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Strategy for the Management of Complex Retinal Detachments

OBJECTIVE To study the outcome of the treatment of complex rhegmatogenous retinal detachments (RRDs). DESIGN Nonrandomized, multicenter, retrospective study. PARTICIPANTS One hundred seventy-six surgeons from 48 countries spanning 5 continents reported primary procedures for 7678 RRDs. METHODS Reported data included clinical manifestations, the method of repair, and the outcome. MAIN OUTCOME MEASURES Failure of retinal detachment repair (level 1 failure rate), remaining silicone oil at the studys conclusion (level 2 failure rate), and need for additional procedures to repair the detachments (level 3 failure rate). RESULTS The main categories of complex retinal detachments evaluated in this investigation were: (1) grade B proliferative vitreoretinopathy (PVR; n = 917), (2) grade C-1 PVR (n = 637), (3) choroidal detachment or significant hypotony (n = 578), (4) large or giant retinal tears (n = 1167), and (5) macular holes (n = 153). In grade B PVR, the level 1 failure rate was higher when treated with a scleral buckle alone versus vitrectomy (P = 0.0017). In grade C-1 PVR, there was no statistically significant difference in the level 1 failure rate between those treated with vitrectomy, with or without scleral buckle, and those treated with scleral buckle alone (P = 0.7). Vitrectomy with a supplemental buckle had an increased failure rate compared with those who did not receive a buckle (P = 0.007). There was no statistically significant difference in level 1 failure rate between tamponade with gas versus silicone oil in patients with grade B or C-1 PVR. Cases with choroidal detachment or hypotony treated with vitrectomy had a significantly lower failure rate versus treatment with scleral buckle alone (P = 0.0015). Large or giant retinal tears treated with vitrectomy also had a significantly lower failure rate versus treatment with scleral buckle (P = 7×10(-8)). CONCLUSIONS In patients with retinal detachment, when choroidal detachment, hypotony, a large tear, or a giant tear is present, vitrectomy is the procedure of choice. In retinal detachments with PVR, tamponade with either gas or silicone oil can be considered. If a vitrectomy is to be performed, these data suggest that a supplemental buckle may not be helpful. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Does 23-gauge sutureless vitrectomy modify the risk of postoperative retinal detachment after macular surgery? A comparison with 20-gauge vitrectomy.

Purpose: To compare the cumulative risk of retinal detachment (RD) after macular surgery with 23-gauge sutureless vitrectomy and with 20-gauge vitrectomy. Methods: A single-center retrospective comparative study was conducted, comparing eyes operated for epiretinal membrane, macular hole, vitreomacular traction, and internal limiting membrane peeling. The 23-gauge group included 349 eyes operated consecutively between June 2007 and December 2008. The 20-gauge group included 346 eyes operated between October 2003 and September 2007. Results: After a 6-month follow-up, the cumulative probability of RD was 1.1% in the 23-gauge group and 3.5% in the 20-gauge group (P = 0.04). With a median follow-up of 14 months (range, 6-30 months) in the 23-gauge group and 30 months (range, 6-72 months) in the 20-gauge group, the cumulative probability of RD was, respectively, 1.1% and 4.9% (P = 0.04; log-rank test). Overall, RD was observed in 7 of 96 cases after macular hole surgery (7.3%), in 11 of 478 cases after epiretinal membrane surgery (2.3%), and in 3 of 70 cases after vitreomacular traction surgery (4.3%) (P = 0.14; log-rank test). Conclusion: After a short-term follow-up, a lower rate of postoperative RD was observed in the 23-gauge group. Sutureless 23-gauge vitrectomy appears safe when considering the risk of postoperative RD. Prospective and long-term studies are still needed to confirm these results.

Clinical Variables Associated with Failure of Retinal Detachment Repair: The European Vitreo-Retinal Society Retinal Detachment Study Report Number 4

OBJECTIVE To identify risk factors associated with failure of anatomic reattachment in primary rhegmatogenous retinal detachment repair. DESIGN Nonrandomized, multicenter, collaborative study. PARTICIPANTS Primary procedures for 7678 rhegmatogenous retinal detachments reported by 176 surgeons from 48 countries. METHODS We recorded specific preoperative clinical findings, repair method, and outcome after intervention. We performed univariate, bivariate, and multivariate analyses to identify variables associated with surgical failure. MAIN OUTCOME MEASURES Final failure of retinal detachment repair (level 1), remaining silicone oil at study conclusion (level 2), and need for additional procedures to repair the detachment (level 3). RESULTS We analyzed 7678 cases of rhegmatogenous retinal detachment repair. Presence of choroidal detachment or significant hypotony was associated with significantly higher level 1 failure rates when grade 0 or B proliferative vitreoretinopathy (PVR) was present and higher level 2 failure rates, regardless of PVR status (P<0.05). Excluding cases with choroidal detachment or hypotony, increasing PVR was associated with increasing level 1 failure rates. The difference between grade B and C-1 PVR was significant (P = 2 × 10(-6)). No difference was observed in level 1 failure rates when operated eyes were phakic versus pseudophakic. Level 1 failure was significantly higher when all 4 quadrants of retina (4.4%) were detached than when only 1 quadrant (0.8%) had subretinal fluid. With grade B or C-1 PVR, cases with large or giant tears had significantly higher level 1 failure rates. No association was observed between number of retinal breaks and failure rates. Multivariate analysis showed grade C-1 PVR, 4 detached quadrants, and presence of choroidal detachment or significant hypotony were independently linked with a greater level 1 failure rate; the presence of a smaller retinal break was associated with a lesser level 1 failure rate. CONCLUSIONS Choroidal detachment, significant hypotony, grade C-1 PVR, 4 detached quadrants, and large or giant retinal breaks were independent explanatory variables of retinal detachment repair failure. In contrast to earlier studies, the significance of phakic versus pseudophakic status was not confirmed.

Strategy for the Management of Macular Edema in Retinal Vein Occlusion: The European VitreoRetinal Society Macular Edema Study

Objective. To compare the efficacy of different therapies in the treatment of macular edema associated with retinal vein occlusion (RVO). Design. This is a nonrandomized, multicenter collaborative study. Participants. 86 retina specialists from 29 countries provided clinical information, including choice of treatment and outcome, on 2,603 patients with macular edema including 738 cases of RVO. Methods. Reported data included the type and number of treatments performed, visual acuities, and other clinical and diagnostic findings. Main Outcome Measures. The mean increase in visual acuity and mean number of treatments performed. Results. 358 cases of central retinal vein occlusion (CRVO) and 380 cases of branch retinal vein occlusion (BRVO) were included in this investigation. Taking all RVO cases together, pars plana vitrectomy with internal limiting membrane (ILM) peeling alone resulted in an improvement in vision greater than other therapies. Those treated with intravitreal antivascular endothelial growth factor (anti-VEGF) injection alone showed the second greatest improvement in vision. Dexamethasone intravitreal implant alone and intravitreal triamcinolone alone both resulted in modest visual gains. Conclusions. In the treatment of macular edema in RVO, vitrectomy with ILM peeling may achieve visual improvement and may be a good option for certain cases. Anti-VEGF injection is the most effective of the nonsurgical treatments.

Strategy for the management of diabetic macular edema: the European Vitreo-Retinal Society macular edema study

Objective. To compare the efficacy of different therapies in the treatment of diabetic macular edema (DME). Design. Nonrandomized, multicenter clinical study. Participants. 86 retina specialists from 29 countries provided clinical information on 2,603 patients with macular edema including 870 patients with DME. Methods. Reported data included the type and number of treatment(s) performed, the pre- and posttreatment visual acuities, and other clinical findings. The results were analyzed by the French INSEE (National Institute of Statistics and Economic Studies). Main Outcome Measures. Mean change of visual acuity and mean number of treatments performed. Results. The change in visual acuity over time in response to each treatment was plotted in second order polynomial regression trend lines. Intravitreal triamcinolone monotherapy resulted in some improvement in vision. Treatment with threshold or subthreshold grid laser also resulted in minimal vision gain. Anti-VEGF therapy resulted in more significant visual improvement. Treatment with pars plana vitrectomy and internal limiting membrane (ILM) peeling alone resulted in an improvement in vision greater than that observed with anti-VEGF injection alone. In our DME study, treatment with vitrectomy and ILM peeling alone resulted in the better visual improvement compared to other therapies.

Juxtapapillary subretinal pigment epithelial polypoid pseudocysts associated with unilateral tilted optic disc: Case report with clinicopathologic correlation

OBJECTIVE To describe the unique preoperative appearance, successful postoperative clinical course, and histopathologic features of a cluster of progressively enlarging pseudocysts that arose at the temporal margin of a unilateral tilted optic disc. STUDY DESIGN Case report. METHODS Clinical observation, color fundus photography, fluorescein angiography, and optical coherence tomography, as well as routine histologic and immunohistochemical studies of tissue removed by subretinal surgery. RESULTS Subretinal surgical excision of the lesions resulted in retinal reattachment with improved postoperative visual acuity. Histologic examination disclosed a cluster of fluid-filled polypoid pseudocysts lined by small vessels of choroidal origin lying beneath the basement membrane of the overlying retinal pigment epithelium (RPE). CONCLUSIONS We postulate that buds of small vessels of choroidal origin grew through or around the edge of Bruchs membrane at the temporal margin of the tilted optic disc and then passed under the juxtapapillary RPE. Ensuing leakage of proteinaceous fluid from these vessels eventuated in formation of a cluster of polypoid pseudocysts and subsequent localized papillomacular retinal separation with visual loss. The lesions were amenable to subretinal surgical removal with restoration of visual acuity.

Proliferation of the ciliary epithelium with retinal neuronal and photoreceptor cell differentiation in human eyes with retinal detachment and proliferative vitreoretinopathy

BackgroundThere is some in vitro evidence that the adult ciliary body might harbor an inactive population of stem/retinal progenitor cells (RPC), or that ciliary epithelial (CE) cells might have the capacity to trans-differentiate, which may result in a balance between neural and epithelial properties. We have reported alterations in the ciliary body (CB) and adjacent vitreous in vivo by endoscopic evaluation of human eyes with a history of retinal detachment (RD) and anterior proliferative vitreoretinopathy (PVR).MethodsThe present study examined with light microscopy three paraffin–embedded phthisic human eyes with RD and anterior PVR. One normal eye, exenterated for an orbital tumor, served as the control. All specimens were stained with hematoxilin and eosin safran (HES), and serial sections were immunostained with antibodies against EGFR, Ki67, CD133, NSE, rhodopsin, and GFAP.ResultsWe observed: (1) an intense proliferation and displacement of clusters of CE cells into the vitreous base in a “neurosphere-like” fashion; (2) differentiation of CE cells towards early and late neuronal [photoreceptor (PR)] lineages; and (3) strong staining of EGF and EGFR in the CE. Such proliferation, migration, and differentiation were not present in the CE of the control eye. GFAP staining was intensely positive in the three detached retinae, and was negative in the CE of eyes with RD, as well as in the retina of the control eye.ConclusionsOur observations suggest that EGFR-positive CE cells in the adult human eye in vivo with RD and PVR form “neurosphere-like” structures; their differentiation seems to be directed towards the neural and photoreceptor lineage, and not towards glial formation. In the adult human eye, the CE in a pathological retinal environment such as RD might provide a spontaneous source of donor cells for retinal transplantation.

How do vitrectomy parameters influence the results of rhegmatogenous retinal detachments repair? EVRS RD Study No. 3

glaucoma (OAG). We conducted a cross-over, singlecentre masked three-month study with patients at the Eye Clinic of Lithuanian University of Health Sciences, Kaunas, Lithuania, with the Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, USA, serving as the doubleblind reading centre. All patients signed an informed consent after explanation in accordance with the Declaration of Helsinki, and the study protocol was approved by both the clinical and reading centre Institutional Review Boards. This study prospectively examined 35 OAG patients (30 females, 5 males, age 63.3 8.9). We initially estimated our sample size on n = 30 individuals to allow for potential dropouts from recruitment phase (actual Flow cytometric analysis in Lagenaria siceraria (Cucurbitaceae) indicates correlation of genome size with usage types and growing elevation 35) to provide >82% power detect differences of 12% or larger in mean IOP among study groups. All patients had been taking Xalatan for at least 4 weeks prior to the first study visit. IOP (both eyes, Goldmann Applanation Tonometer) was measured during office hours every four hours starting at 8 am for a total of four measurements in a single day. After this first day of measurement trials, all patients continued treatment with Xalatan for another 4 weeks. They were then switched to the generic latanoprost (Latalux , manufactured by Sanitas, AB in Lithuania) without a wash-out phase. After 4 weeks, all patients returned for IOP measurements at the same four time-points in a single day. There were no significant differences between the IOP values measured for the two drugs at their respective four time-points (p > 0.05 at 8 am, 12 noon, 4 pm and 8 pm comparisons). However, as seen in Table 1, Xalatan induced a statistically significant difference in IOP decline between subsequent measurement times twice, compared to once for generic latanoprost. Additionally, Xalatan induced a significantly greater number of IOP reductions below 14 mmHg than generic latanoprost (p = 0.013). Drug tolerability, assessed at each visit, was equally good for Xalatan and generic latanoprost. In a similar 12-week study, Narayanaswamy et al. found that Xalatan lowers IOP significantly more often than generic latanoprost does. Their results showed that 9 of 11 patients on Xalatan had a > 30% decrease in their IOP levels after 12 weeks of treatment, whereas only 3 of 18 subjects receiving generic latanoprost treatment had their IOP lowered by >30% (Narayanaswamy et al. 2007). Our study was limited in that it was not randomized, because all patients received the same regimen. Another limitation was the lack of a wash-out period between treatments; however, we believe this study still holds value, as switching from branded to generic drugs without a wash-out period often mimics clinical practice. Because IOP did not increase or significantly change 1 month after switching to the generic drug, these results are useful in illustrating the relative efficacies of branded versus generic latanoprost. Our study’s findings suggest that both Xalatan and generic latanoprost may be equally effective at lowering IOP over the diurnal period after 4 weeks of treatment. However, a significantly greater number of IOP reductions below 14 mmHg occurred for patients treated with Xalatan as compared to generic latanoprost. This finding may be clinically significant, as achieving a target IOP < 14 mmHg can help prevent progression in moderate to advanced glaucoma (Advanced Glaucoma Intervention Study 2000). Yet, only longitudinal studies performed over greater periods of time and with larger numbers of participants may provide insight into glaucoma progression differences in patients treated with brand name medications versus generic equivalents.

Vitrectomie assistée par triamcinolone dans le traitement des récidives de décollement de rétine par trou maculaire du myope fort

But Decrire les avantages de la vitrectomie assistee par triamcinolone pour identifier les causes d’echec de la vitrectomie de premiere intention dans le traitement du decollement de retine par trou maculaire du myope fort. Observations Nous rapportons les cas de trois patients myopes forts ayant presente une recidive de decollement de retine par trou maculaire apres avoir ete traites initialement par vitrectomie avec creation du decollement posterieur du vitre, pelage de la surface retinienne et injection de SF6. Lors de la recidive, aucune traction residuelle ni dehiscence autre que le trou maculaire n’etait visualisee. La reprise chirurgicale avec injection de triamcinolone au cours de la vitrectomie a mis en evidence la persistance de reliquat de hyaloide posterieure ou de membrane friable et fortement adherente a la retine qui ont pu etre disseques dans tous les cas. Ces trois reinterventions ont conduit a un succes anatomique. Conclusion L’injection de triamcinolone ameliore la qualite de la vitrectomie dans le traitement des decollements de retine chez les myopes forts. La vitrectomie assistee par triamcinolone permet la visualisation de reliquats de hyaloide ou de membrane epiretinienne pouvant etre source de traction sur la retine et expliquer les echecs de la vitrectomie. Le pelage de ces structures transparentes a permis le succes de l’intervention.