Gary W. Abrams

Vitrectomy for Diabetic Macular Traction and Edema Associated with Posterior Hyaloidal Traction

Pars plana vitrectomy with separation of the posterior hyaloid was performed in 10 eyes with diabetic macular edema and traction associated with a thickened and taut premacular posterior hyaloid. Nine of the 10 eyes had previous macular photocoagulation. Preoperative fluorescein angiography showed a deep and diffuse pattern of leakage in the macula. Intraoperatively, the attached and thickened posterior hyaloid was lifted and separated from the retina. Postoperatively, vision improved in nine eyes. The macular traction and edema resolved in eight eyes and decreased in two. Complications included a vitreous hemorrhage, a rhegmatogenous retinal detachment, cataract formation, and a mild epimacular membrane, each occurring in one eye. Vitreous surgery can improve the visual prognosis of some eyes with diabetic macular traction and edema associated with a thickened and taut posterior hyaloid.

Inhibition of Intraocular Proliferations with Intravitreal Corticosteriods

Autotransplantation of one fourth million tissue cultured fibroblasts from rabbit rump skin into the vitreous cavity resulted in intravitreal strand formation and traction retinal detachment (27 of 47 eyes, 57%). A single intravitreal injection of 1 mg of dexamethasone alcohol inhibited fibroblast growth as judged by the significantly reduced number of retinal detachments (11 of 46 eyes, 24%). Retinal neovascularization that was observed when fibrous strands came into contact with vascularized retina (nine of 47 eyes, 19%) was also inhibited after corticosteroid application (two of 46 eyes, 4%).

Results and Prognostic Factors in Penetrating Ocular Injuries with Retained Intraocular Foreign Bodies

Of 105 eyes with ocular injuries involving retained intraocular foreign bodies, 63 (60%) had a final visual acuity of 20/40 or better; 20 (19%) were 20/50 to 5/200; and 15 (14%) were worse than 5/200. Six eyes (6%) were enucleated. The extent of visual recovery was limited in selected cases by the characteristics of the initial injury. Multivariate analysis was used to identify prognostic factors. Predictive of a good visual outcome (greater than or equal to 20/40) were: (1) initial visual acuity better than 20/40 and (2) the need for only one or two operations in the treatment of the injury. Predictive of a poor visual outcome (less than 5/200) were: (1) initial visual acuity worse than 5/200 and (2) a wound 4 mm or longer in length, independent of wound location. The visual outcome in this series of patients was compared with other large series of intraocular foreign bodies reported before the development of vitreous microsurgical techniques. The percentage of patients with a visual outcome of 20/40 or better has remained the same, whereas the incidence of enucleation has diminished.

Postoperative Intraocular Pressure Abnormalities in the Silicone Study: Silicone Study Report 4

BACKGROUND Chronically abnormal intraocular pressure (IOP) may follow surgery for proliferative vitreoretinopathy (PVR), using either long-acting gas or silicone oil tamponade. Its prevalence and clinical significance are unclear. METHODS In the Silicone Study, 241 eyes with severe (> or = C-3) PVR were treated with vitrectomy, randomized to perfluoropropane gas (C3F8) or silicone oil, and followed for 6 months or longer. Chronic IOP abnormalities, based on findings at two consecutive or any three postoperative visits, were defined as (1) low IOP (hypotony), 5 mmHg or less, or (2) elevated IOP, more than 25 mmHg. RESULTS Eleven (5%) eyes had chronically elevated IOP and 58 (24%) had chronic hypotony. Chronically elevated IOP was more prevalent in eyes randomized to silicone oil than in those randomized to C3F8 gas (8% versus 2%; P < 0.05). Chronic hypotony was (1) more prevalent in eyes randomized to C3F8 gas than in those randomized to silicone oil (31% versus 18%; P < 0.05); (2) more prevalent in eyes with anatomic failure (48% versus 16%; P < 0.01); and (3) correlated with poor postoperative vision (P < 0.0001), corneal opacity (P < 0.001), and retinal detachment (P < 0.001). Factors prognostic of chronic hyotony included preoperative hypotony (P < 0.01), diffuse contraction of the retina anterior to the equator (P < 0.01), rubeosis (P = 0.02), and large retinal breaks (P = 0.02). In a multivariate analysis, diffuse contraction of the retina anterior to the equator remained an independent factor prognostic of chronic hypotony (odds ratio = 4.2), regardless of whether the retina was attached postoperatively. CONCLUSION Intraocular pressure abnormalities are a common postoperative complication in eyes with PVR, and may occur with either C3F8 gas or with silicone oil. The presence of diffuse contraction of the retina anterior to the equator should alert the vitrectomy surgeon that the eye is likely to be hypotonus postoperatively.

Surgical Results in Ocular Trauma Involving the Posterior Segment

Of 106 eyes with trauma involving the posterior segment, 12 could not be repaired, 74 were treated with vitrectomy, and 20 without vitrectomy. Fifty-five eyes (52%) achieved functional success (defined as a final visual acuity of 6/30 [20/100] or better or as a postoperative improvement in visual acuity from light perception or worse to 6/240 [5/200] or better), 16 (15%) attained anatomic success (attached retinas and generally clear media) but were functional failures, and 35 (33%) were both anatomic and functional failures. The prognosis was better in cases with intraocular foreign bodies and worse in cases with retinal detachments, marked vitreous hemorrhage, and large scleral lacerations. Traumatic involvements of the lens did not appear to affect the prognosis. Prophylactic scleral buckling appeared to lessen the incidence of postoperative retinal detachment. The eyes that underwent vitrectomy within 14 days of the injury had a better final visual outcome than those that underwent later vitrectomy.

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.

Causes of failure after initial vitreoretinal surgery for severe proliferative vitreoretinopathy.

We performed initial vitreoretinal surgery on 81 eyes with rhegmatogenous retinal detachments complicated by severe proliferative vitreoretinopathy. Of 81 eyes, 68 (84%) had undergone previous scleral buckling. We performed vitreous base dissection on all 18 eyes (22%) that had anterior proliferative vitreoretinopathy. With one vitreoretinal operation, 66 of 81 eyes (81%) remained totally reattached. The main cause of initial anatomic failure and reoperation was either new or recurrent proliferation at the vitreous base. With additional vitreoretinal surgery and after a mean follow-up period of 19 months, 73 of 81 retinas (90%) were totally reattached. The final causes of anatomic failure were anterior proliferative vitreoretinopathy and proliferation from relaxing retinotomies. Of the 73 successfully reattached eyes, 62 (85%) had postoperative visual acuity of 5/200 or better.

Cystoid macular edema associated with latanoprost therapy in a case series of patients with glaucoma and ocular hypertension.

OBJECTIVE To identify coexisting ocular diagnoses in a case series of eyes that developed cystoid macular edema (CME) associated with latanoprost therapy. DESIGN Retrospective observational case series. PARTICIPANTS Seven eyes of seven patients who developed CME possibly associated with latanoprost treatment were studied. INTERVENTION When these patients, all of whom were treated with latanoprost in addition to other glaucoma medications, described blurred vision or eye irritation, ocular examination revealed CME, which was confirmed by fluorescein angiography. Latanoprost was discontinued, and in three cases topical corticosteroids and nonsteroidal anti-inflammatory agents were used to treat the CME. MAIN OUTCOME MEASURES Visual acuity and intraocular pressure were determined before latanoprost use began, during therapy, and after latanoprost use ceased. In these cases, resolution of CME was documented clinically after discontinuing latanoprost. RESULTS Clinically significant CME developed after 1 to 11 months of latanoprost treatment, with an average decrease of 3 lines in Snellen visual acuity. Intraocular pressure decreased an average of 27.9% during treatment. Cystoid macular edema was confirmed in all cases by fluorescein angiography. In these seven patients, the following coexisting ocular conditions may have placed these eyes at risk for prostaglandin-mediated blood-retinal barrier vascular insufficiency: history of dipivefrin-associated CME, epiretinal membrane, complicated cataract surgery, history of macular edema associated with branch retinal vein occlusion, history of anterior uveitis, and diabetes mellitus. In all cases, the macular edema resolved following discontinuation of latanoprost, in some instances with concomitant use of steroidal and nonsteroidal anti-inflammatory agents. CONCLUSIONS In this case series of pseudophakic, aphakic, or phakic eyes, the temporal relationships between the use of latanoprost and developing CME, and the resolution of CME following cessation of the drug, suggest an association between latanoprost and CME. In all cases, coexisting ocular conditions associated with an altered blood-retinal barrier were present.

COMPARISON OF RECOMBINANT TRANSFORMING GROWTH FACTOR-BETA-2 AND PLACEBO AS AN ADJUNCTIVE AGENT FOR MACULAR HOLE SURGERY

OBJECTIVE This study aimed to compare the visual and anatomic results of macular hole surgery in eyes treated with recombinant transforming growth factor-beta-2 (TGF-beta2) or placebo. DESIGN The design was a prospective, multicenter, randomized, double-masked, placebo-controlled clinical study. PARTICIPANTS One hundred thirty eyes with idiopathic macular holes of 1 year or less and a refracted Early Treatment Diabetic Retinopathy Study visual acuity of 20/80 or worse were treated with 1.1 microg recombinant TGF-beta2 or placebo to the macular hole after fluid-gas exchange. INTERVENTION The effect of recombinant TGF-beta2 as an adjunctive agent for macular hole surgery was evaluated. MAIN OUTCOME MEASURES Closure of the macular hole and change in visual acuity at 3 months were measured. RESULTS The 3-month visits were completed for 120 eyes. The macular hole was closed at 3 months in 35 (61.4%) of 57 eyes treated with placebo and 49 (77.8%) of 63 eyes treated with recombinant TGF-beta2 (P = 0.08). The mean visual acuity gain was +6.4 letters in eyes receiving placebo and +8.9 letters in eyes treated with recombinant TGF-beta2 (P = 0.27). Visual acuity improved 2 or more lines in 23 (40.4%) of 57 eyes treated with placebo and 30 (47.6%) of 63 eyes treated with recombinant TGF-beta2 (P = 0.42). Intraocular pressure elevation greater than 30 mmHg was more common 2 weeks after surgery in eyes treated with recombinant TGF-beta2 (P < 0.001). CONCLUSIONS Recombinant TGF-beta2 resulted in a similar proportion of successful closure of macular holes as placebo. There was no statistically significant visual acuity benefit with the use of recombinant TGF-beta2 for the treatment of macular holes.

The Role of Glia, Mitochondria, and the Immune System in Glaucoma

Author(s): Tezel, Gulgun; Fourth ARVO/Pfizer Ophthalmics Research Institute Conference Working Group