Hee Jin Sohn

Changes in aqueous concentrations of various cytokines after intravitreal triamcinolone versus bevacizumab for diabetic macular edema.

PURPOSE To investigate the changes in aqueous inflammatory and angiogenic cytokine levels after intravitreal injection of triamcinolone or bevacizumab for reducing foveal thickness in diabetic macular edema (DME). DESIGN Prospective, interventional case series. METHODS Twenty-two eyes of 11 patients with bilateral DME and 6 eyes of 6 patients undergoing cataract surgery participated in this study. In each DME patient, 1 eye received an intravitreal injection of 4 mg triamcinolone acetonide and the other eye received 1.25 mg bevacizumab. Aqueous humor samples were obtained before and 4 weeks after the intravitreal injection in the DME group and before the surgery in the control group. Aqueous concentrations of interleukin (IL)-6, IL-8, interferon-induced protein (IP)-10, monocyte chemotactic protein (MCP)-1, platelet-derived growth factor (PDGF)-AA, and vascular endothelial growth factor (VEGF) were measured by multiplex bead assay. RESULTS Before the administration of the drugs, aqueous levels of IL-8, IP-10, MCP-1, and VEGF were significantly higher in the DME group than in the control group. After intravitreal injection, foveal thickness was more decreased in the triamcinolone acetonide (IVTA) group compared with the bevacizumab (IVBe) group. IL-6, IP-10, MCP-1, PDGF-AA, and VEGF were significantly decreased in the IVTA group, but only VEGF in the IVBe group. Aqueous levels of VEGF were more decreased in the IVBe group than in the IVTA group. CONCLUSIONS These findings suggest that the pathogenesis of DME is not only related to VEGF dependency, but also to other mechanisms suppressed by corticosteroids. We suppose that these cytokines would have an important role in both the pathogenesis of DME and the underlying mechanism of intravitreal injections.

Minimal fluid-air exchange in combined 23-gauge sutureless vitrectomy, phacoemulsification, and intraocular lens implantation.

Purpose: The purpose of this study was to compare rates of postoperative hypotony and intraocular lens-related complications between minimal fluid–air exchange and partial fluid–air exchange in combined 23-gauge vitrectomy and cataract surgery. Methods: A prospective, consecutive, interventional case series of 48 eyes that underwent 23-gauge vitrectomy with a minimal fluid–air exchange (minimal F–A group) was compared with a retrospective, consecutive case series of 38 eyes that underwent 23-gauge vitrectomy with a partial fluid–air exchange (partial F–A group). The main outcome measures were postoperative hypotony (<6 mmHg) and intraocular lens-related complications, such as posterior capsule opacification or pupillary capture. Results: Two (5.3%) of 38 eyes in the partial F–A group had hypotony, and only 1 (2.1%) of 48 eyes in the minimal F–A group had hypotony (P > 0.05). Posterior capsule opacification was identified in 11 (28.9%) of 38 eyes in the partial F–A group but only in 4 (8.3%) of 48 eyes in the minimal F–A group (P = 0.013). Pupillary capture was observed in 3 (7.9%) of 38 eyes in the partial F–A group, but it was absent in the minimal F–A group (P = 0.049). No retinal detachment or endophthalmitis was developed in both groups during follow-up. Conclusion: Minimal fluid–air exchange in combined 23-gauge sutureless vitrectomy and cataract surgery may reduce postoperative hypotony and intraocular lens–related complications.

Combined 23-gauge sutureless vitrectomy and clear corneal phacoemulsification in patients with proliferative diabetic retinopathy.

Purpose: To evaluate the results and complications of combined 23-gauge sutureless vitrectomy, clear corneal phacoemulsification, and intraocular lens implantation in patients with proliferative diabetic retinopathy. Methods: This was a retrospective, consecutive, noncomparative, interventional case series of 136 eyes of 108 patients who underwent combined sutureless vitrectomy and clear corneal cataract surgery for the complications of proliferative diabetic retinopathy. The main outcome measures were visual outcomes and surgical complications. Results: Main indications for the combined surgery were vitreous hemorrhage (78 eyes, 57.4%) and tractional retinal detachment (36 eyes, 28.7%). The logarithm of the minimum angle of resolution visual acuity (mean ± SD) improved from 0.86 ± 0.59 preoperatively to 0.39 ± 0.52 six months postoperatively (P < 0.0001). Intraoperative retinal tear occurred in 7 eyes (5.1%) and postoperative vitreous hemorrhage in 10 eyes (7.5%). Even in the absence of suturing of sclerotomy sites, only 1 eye (0.7%) had postoperative hypotony (<6 mmHg). During the 6 months after surgery, only 1 eye (0.7%) developed neovascular glaucoma and 6 eyes (4.4%) required a repeat vitrectomy (3 for retinal detachment and 3 for vitreous hemorrhage). Conclusion: Combined 23-gauge sutureless vitrectomy and clear corneal phacoemulsification in patients with proliferative diabetic retinopathy was safe and effective. It may have not only the known advantages of conventional combined surgery but also additionally those such as faster visual rehabilitation and less conjunctival fibrosis.

Changes in aqueous cytokines after intravitreal triamcinolone versus bevacizumab for macular oedema in branch retinal vein occlusion

Purpose:  To investigate the changes in the aqueous levels of various cytokines after intravitreal triamcinolone or bevacizumab for branch retinal vein occlusion (BRVO).

Surgeon-controlled–endoillumination-guided irrigation and aspiration during combined 23-gauge sutureless vitrectomy and cataract surgery in eyes with poor fundus reflex

&NA; We describe a surgeon‐controlled−endoillumination‐guided irrigation and aspiration (I/A) technique that can be used to polish the posterior capsule during combined 23‐gauge sutureless vitrectomy and cataract surgery in eyes with a poor red fundus reflex. In a dark room with the microscope light turned off, the surgeon holds and controls a 23‐gauge endoilluminator with the left hand to achieve better retroillumination during I/A. Using surgeon‐controlled endoillumination, it is possible to follow and guide the posterior capsule area undergoing I/A. The excellent visibility of the posterior capsule facilitates posterior capsule polishing with no intraoperative complications. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Early postoperative intraocular pressure stability after combined 23-gauge sutureless vitrectomy and cataract surgery in patients with proliferative diabetic retinopathy.

Purpose: To compare rates of early postoperative hypotony and intraocular pressure (IOP) elevation between 23-gauge sutureless vitrectomies with and without phacoemulsification and intraocular lens implantation in patients with proliferative diabetic retinopathy. Methods: This study reviewed the medical records of 302 eyes of patients who underwent primary 23-gauge sutureless vitrectomy for the complications of proliferative diabetic retinopathy. A case series of 207 eyes that underwent combined vitrectomy and cataract surgery (combined group) was compared with that of 95 eyes that underwent vitrectomy only (vitrectomy group): The eyes that remained phakic after the vitrectomy were excluded from this study. The main outcome measures were postoperative hypotony (IOP < 6 mmHg or IOP < 10 mmHg with choroidal detachment) and IOP elevation (>30 mmHg). Results: Postoperative hypotony was identified in 4 (1.9%) of 207 eyes in combined group, but in 7 (7.4%) of 95 eyes in vitrectomy group (P = 0.048). Rate of IOP elevation was very low and not different between the two groups. The multivariate analysis showed that vitrectomy without cataract surgery was associated with the postoperative hypotony (odds ratio = 4.6, P = 0.045). Conclusion: The incidence of early postoperative hypotony was lower in combined sutureless vitrectomy and cataract surgery than in sutureless vitrectomy alone and that of IOP elevation was very low in both groups. The maintenance of a stable IOP with a low risk of IOP fluctuation may be an additional advantage of sutureless diabetic vitrectomy combined with cataract surgery.

Vitrectomy, Laser Photocoagulation, and Intravitreal Triamcinolone for Combined Hamartoma of the Retina and Retinal Pigment Epithelium

Combined hamartoma of the retina and retinal pigment epithelium (CHRRPE) is a rare, benign tumor, but there are no established managements for CHRRPE. A patient with CHRRPE who is treated successfully by the new combination therapy was described. A 32-year-old man was diagnosed as having CHRRPE after evaluation with ophthalmoscopy, fluorescein angiography (FA), and optical coherence tomography (OCT). First performed intravitreal triamcinolone acetonide (IVTA) (4 mg/0.1 mL) and laser photocoagulation to treat the vascular component. There was a rapid and good response after that therapy, but a recurrence 3 months later. To relieve the glial component, we simultaneously combined vitrectomy with IVTA and laser photocoagulation. After the combination therapy, there were no recurrences or complications. A combination therapy of vitrectomy, laser photocoagulation, and intravitreal triamcinolone could be considered as a possible management for CHRRPE with the vascular and glial components.

Jamming of 23-gauge instruments in the microcannula during vitrectomy for severe vitreous haemorrhage.

Editor, T ransconjunctival sutureless vitrectomy has gained popularity in recent years. The use of 25or 23-gauge instruments has many advantages over conventional 20gauge vitrectomy, and there have been many reports on the safety and efficacy of 25or 23-gauge vitrectomy in a variety of vitreoretinal diseases (Fujii et al. 2002; Eckardt 2005). However, complications associated with such small-gauge instruments remain problematic (Inoue et al. 2004; Ooto et al. 2008). Shinoda et al. (2008) reported on the jamming of 25gauge instruments in the cannula during vitrectomy for vitreous haemorrhage. We experienced the jamming of a 23-gauge endo-illuminator or vitreous cutter in the microcannula during 23-gauge vitrectomy in a patient with severe vitreous opacity. A 47-year-old man was diagnosed with severe vitreous opacity and haemorrhage associated with central retinal vein occlusion. Best corrected visual acuity was 20 ⁄20 in the right eye and light perception in the left. Two years previously, the patient had undergone Ahmed valve implantation for neovascular glaucoma in the left eye. A 23-gauge surgical procedure was performed using the DORC twostep system (Dutch Ophthalmic Research Center [DORC] International BV, Zuidland, the Netherlands). Vitreous surgery was carried out using a 23-gauge endo-illuminator and vitreous cutter (DORC International BV) driven by a vitrectomy unit (Associate 2500; DORC International BV). After conventional cataract surgery and subsequent core vitrectomy, peripheral vitrectomy was performed (Fig. 1A). When we attempted to remove the endo-illuminator ⁄ vitreous cutter from the microcannula during the peripheral vitrectomy, we found that the instrument was lodged firmly within the microcannula and its removal was likely to pull the cannula out of the sclerotomy site (Fig. 1B). We found that if we stabilized the collar of the microcannula by holding it firmly with a forceps, it was possible to remove the illuminator ⁄vitreous cutter from the microcannula. Thereafter, we identified organized vitreous membranes trapped in the inner tube of the microcannula (Fig. 1C). We removed the entrapped vitreous with a cutter to clear the inside of the cannula and were able to reinsert or remove 23-gauge instruments freely into and out of the microcannula (Fig. 1D). All other procedures were then completed in the usual manner. Intraoperatively and postoperatively, gross and microscopic examinations revealed no specific deformities of or damage to the microcannula or the 23-gauge instruments. Whereas Shinoda et al. (2008) experienced the jamming of 25-gauge instruments in three (7%) of 45 eyes with vitreous haemorrhage, we experienced jamming in only one of about 50 eyes with vitreous haemorrhage following 23-gauge vitrectomy. By contrast with 25-gauge instruments that are jammed in the microcannula, the jammed 23-gauge cutter or light pipe could be withdrawn from the 23-gauge cannula by the aid of a forceps. Moreover, we did not find any damage to the microcannula or 23-gauge instruments. There are possible explanations for the differences between 25and 23gauge instruments in terms of incidence of jamming and recovery of instruments. One explanation may relate to the material of the microcannula. This is made of polyamide in the 25-gauge system, but stainless steel in the 23-gauge system. Therefore, although the 25-gauge plastic cannula is easily damaged, the 23-gauge metal cannula remains firmly intact. Another (A) (B)