G. William Aylward

Is prophylactic 360° laser retinopexy protective?: Risk factors for retinal redetachment after removal of silicone oil

OBJECTIVES To identify risk factors for retinal redetachment after removal of silicone oil. To determine the effectiveness of prophylactic laser in preventing retinal redetachment after removal of silicone oil. DESIGN A nonrandomized retrospective comparative interventional trial. PARTICIPANTS Three hundred seventy-six patients undergoing vitrectomy with silicone oil tamponade for rhegmatogenous retinal detachment at one institution over a 4-year period. Two hundred eighty-seven patients with fully attached retinas subsequently underwent removal of silicone oil. One hundred thirty-eight cases had undergone prophylactic 360 degrees laser retinopexy before removal of silicone oil, either at the time of their final retinal reattachment procedure (n = 36) or as a separate supplementary procedure (n = 102). METHODS A retrospective case note review was performed to identify clinical and demographic factors associated with increased or reduced odds of retinal redetachment after removal of silicone oil. Both univariate and multiple variable analysis were used to identify significant risk factors. MAIN OUTCOME MEASURES Incidence of retinal redetachment after removal of silicone oil. RESULTS Median follow-up after removal of silicone oil was 272 days. Three hundred sixty-degree prophylactic laser retinopexy was associated with a reduction from 26% to 14% in the incidence of redetachment after removal of silicone oil (adjusted odds ratio, 0.42; 95% confidence interval, 0.22-0.78; P = 0.006). Patients requiring further retinal reattachment surgery after their first oil procedure were at twice the odds of re-detachment after oil removal (adjusted odds ratio, 2.10; 95% confidence interval, 1.03-4.26; P = 0.04). CONCLUSIONS The need for retinal reattachment surgery subsequent to a first silicone oil procedure was associated with twice the odds of retinal redetachment after removal of silicone oil. Prophylactic laser retinopexy may halve the incidence of retinal redetachment after removal of silicone oil.

Intraretinal and periretinal pathology in anterior proliferative vitreoretinopathy

ObjectivesTo determine the intraretinal and periretinal pathological changes in early anterior proliferative vitreoretinopathy (APVR).DesignObservational case series.ParticipantsEighteen patients undergoing retinectomy for APVR.MethodsRetinectomy specimens removed at vitrectomy surgery were analysed by (a) semithin light microscopy, (b) immunohistochemistry and (c) electron microscopy.ResultsThe specimens showed consistent outer retinal degenerative changes, marked Muller cell hypertrophy and glial continuity to epiretinal membranes. Photoreceptor outer and inner segments were markedly disrupted and occasional photoreceptor nuclear had pyknosis and chromatin clumping consistent with apoptosis. Muller cells expressed upregulated levels of glial fibrillary acid protein (GFAP) and extended through glial bridges to complex epiretinal membranes which in some areas had a bilaminar structure with a glial-negative inner lamina.ConclusionRetinal degeneration and photoreceptor apoptosis occur in retinal detachment complicated by proliferative vitreoretinopathy (PVR), although during the early stages of the process neural retinal cells remain present, suggesting potential for recovery. The intraretinal glial response appears to be centrally involved in the formation of contractile epiretinal membranes. The retina retains the capacity for a degree of functional recovery following surgery for PVR. Surgical separation of anterior epiretinal membranes in PVR may be difficult and incomplete and alternative surgical strategies may be necessary to prevent recurrence.

Long-term visual and microperimetry outcomes following autologous retinal pigment epithelium choroid graft for neovascular age-related macular degeneration.

Background:  To describe the 2‐ to 4‐year visual and microperimetry outcomes of autologous retinal pigment epithelium (RPE)‐choroid graft in patients with neovascular age‐related macular degeneration (AMD).

Prophylactic 360° cryotherapy in fellow eyes of patients with spontaneous giant retinal tears

Abstract Purpose To assess the effect of prophylactic 360° peripheral retinal cryotherapy in fellow eyes of patients with spontaneous giant retinal tears (GRTs) on the incidence of retinal detachment. Design Retrospective, noncomparative case series. Participants Forty-eight consecutive patients (31 male, 17 female) with spontaneous GRTs were included. The average age was 41 ± 2 years. The average refraction of the fellow eye was −4.0 ± 0.8 diopters (D). Intervention Patients underwent vitrectomy and silicone oil tamponade in the affected eye and 360° peripheral cryotherapy in the unaffected fellow eye during the same anesthetic. Main outcome measure Attachment of the retina in the fellow eye was determined clinically by indirect ophthalmoscopy. Results During a mean follow-up of 84 ± 10 months after cryotherapy, one patient (2%) experienced a retinal tear without retinal detachment, and three patients (6%) experienced a retinal detachment in the fellow eye. These occurred 18 ± 9 months after prophylactic treatment and were the result of a small retinal break in two cases and a GRT posterior to the treated area in one case. Conclusions Prophylaxis of fellow eyes with 360° cryotherapy appears to be associated with a lower incidence of retinal detachment than that reported in natural history studies. A prospective, randomized clinical trial of such prophylaxis is desirable but would require a sample size of at least 645 patients in each arm of the study, as well as long-term follow-up of at least 5 years to show an unequivocal difference in outcome.

Dye extrusion technique (DE-TECH): occult retinal break detection with subretinal dye extrusion during vitrectomy for retinal detachment repair.

Objective: To investigate the effectiveness of a new technique for the identification of occult retinal breaks in vitrectomy retinal detachment repair. Dye Extrusion Technique involves injection of sub retinal dye and extrusion through the unidentified breaks using perfluorocarbon liquid. Method: Retrospective case note analysis. Main outcome measures: rate of break detection, rate of use of local retinopexy, and short-term gas tamponade alone; Secondary outcomes: anatomical success at 3 months with no long-term tamponade, final visual acuity, progression of proliferative vitreoretinopathy. Results: Thirty-eight percent of eyes had proliferative vitreoretinopathy of grade C1 or worse. Twenty-five percent underwent primary retinal detachment repair surgery. The remainder underwent repeat operations for previously failed surgery. Breaks were found in 89% of eyes and 81% underwent only local retinopexy and gas tamponade. The overall anatomical success rate was 85% (40/47) which included four cases in which the retina was fully attached awaiting removal of silicone oil. No cases had unexplained loss of vision. No progression of proliferative vitreoretinopathy was noted. Conclusions: Results suggest that Dye Extrusion Technique may be an effective technique for the identification of occult retinal breaks and may facilitate simple techniques of detachment repair. No evidence of retino-toxicity from the use of trypan blue was found but the study had limited power to detect adverse effects.

Prophylaxis for retinal detachment: evidence or eminence based?

Purpose: Prophylactic laser treatment of peripheral retinal lesions to prevent retinal detachment enjoys widespread use. However, clinical and scientific evidence for such treatment only exists for a few particular clinical situations. The aim of the present study was to delineate the current practice patterns for such prophylaxis among some European retinal specialists. Methods: A postal survey was conducted among all members of BEAVRS (British and Eire Association of Vitreoretinal Surgeons; n = 236), all members of the German Retinological Society (n = 396), and Swiss retinal surgeons (n = 12) using a questionnaire with 6 case scenarios. The retinal specialists were asked to choose between three different options for each case: treat retinal lesion prophylactically, clinical follow-up, and other options. Results: The return rates of the questionnaire were 36% in the United Kingdom, 42% in Germany, and 83% in Switzerland. There was a general tendency to apply laser prophylaxis to peripheral retinal lesions despite the absence of evidence in the medical literature. Conclusions: Nonevidence-based prophylactic laser treatment of peripheral retinal lesions remains a clinical and economic issue that must be addressed, and more evidence-based data are needed to establish clear clinical guidelines. Swiss retinal specialists are particularly conscientious in sending back a medical questionnaire.

A vascular anomaly seen in suprachoroidal haemorrhage

cification are very typical, but intraocular tumours with calcification are mostly retinoblastomas and choroidal osteomas. This is reflected by the fact that in the literature we found only six cases of calcification in intraocular melanomas. Kellner et al. (1993) reported three cases (from 1300 treated cases) of small choroidal melanomas with calcification-like echographic patterns after brachytherapy. Kiratli & Bilgic (2001) described ultrasonic sign of intratumoural calcification in a juxtapapillary melanoma after fractional transpupillary thermotherapy. These two reports suggest that calcification of intraocular melanomas is mostly related to destructive therapeutic interventions. Additionally, calcification in a choroidal melanoma was reported by Jensen & Andersen (1974). They described spontaneous regression of a choroidal melanoma with dot-like multiple calcifications close to the surface of the tumour. Our case is somewhat similar to that reported by Chan et al. (1995), who described a choroidal melanoma case with Bruch’s membrane-related calcification. In contrast to that report, however, we did not find osteocytes related to the calcium deposit; in our case it was a pure calcification, not bone formation. Our case shows that intratumoural calcification can occur spontaneously, without influence from previous therapeutic interventions. Furthermore, by histopathological examination the tumour showed neither signs of regression nor evidence of necrosis. The cause of calcium deposition is unknown. Histopathology did not reveal ischaemic changes or necrosis in or around the area of calcification. Although secondary drusen of the overlying pigment epithelium can show calcification (Yanoff & Fine 1982), this explanation seems improbable because of the intratumoural localization of the calcium deposit. A preexisting calcification (e.g. idiopathic sclerochoroidal calcification) at the level of the Bruch’s membrane is also a possibility. It is worth noting also that this feature occurred in the tumour of an unusually young patient. We conclude that although it is true that intratumoural calcification is rare in choroidal malignant melanoma, ultrasonic signs of a calcified area within a tumour do not contradict or exclude a diagnosis of malignant melanoma. Because echography is the most informative imaging method for blind eyes with opaque media, this finding may be of value in avoiding diagnostic errors.