Hidetaka Yamaji

Unintentional Displacement of the Retina after Standard Vitrectomy for Rhegmatogenous Retinal Detachment

OBJECTIVE To study unintentional displacement of the retina after standard vitrectomy for rhegmatogenous retinal detachment (RRD). DESIGN Prospective interventional case series. PARTICIPANTS Forty-three eyes of 43 consecutive patients with cystic RRD involving 1 or more quadrants underwent successful standard vitrectomy with 20% sulfur hexafluoride gas injection. Neither scleral buckling nor retinotomy was performed. METHODS Fundus autofluorescence (FAF) imaging was subsequently recorded to detect displacement of the retina using the Topcon TRC-50DX (Topcon, Tokyo, Japan) at 10 days and 1, 3, and 6 months postoperatively. Fluorescein angiography was also recorded using standard techniques for patients with abnormal FAF findings. Cyclotorsion and vertical deviation were measured postoperatively. MAIN OUTCOME MEASURES The proportion of eyes with postoperative retinal displacement detected by FAF imaging. RESULTS The mean age of these 43 patients was 60 years with a range of 39 to 77 years. Of the 43 eyes, retinal detachment involved 1 quadrant in 2 eyes, 2 quadrants in 31 eyes, 3 quadrants in 8 eyes, and 4 quadrants in 2 eyes. After complete reattachment of the retina, FAF photography demonstrated hyperfluorescent lines superiorly parallel to retinal vessels within the vascular arcade in 27 of the 43 eyes (62.8%). Fluorescein angiography did not demonstrate any abnormalities corresponding to the linear autofluorescence. This autofluorescence was hypothesized to originate from increased metabolic activity of the retinal pigment epithelium that had been preoperatively located under the major retinal vessels and was postoperatively exposed to light because of downward displacement of the retina. Of the 27 eyes with retinal displacement, 1 to 5 degrees of extorsion were seen in 16 eyes (59.3%), and 1 to 4 degrees of vertical deviation were seen in 13 eyes (48.1%). None of the 27 patients had diplopia or slant. The extent of retinal detachment (P = 0.019) and the macular status (on or off) (P = 0.016) were significantly associated with postoperative displacement of the retina. CONCLUSIONS In eyes with RRD treated with standard vitrectomy and gas injection, the retina may move downward after the surgery. If the extent of retinal detachment is large, or macular detachment is present, unintentional postoperative retinal translocation may easily occur. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Multicenter Survey with a Systematic Overview of Acute-Onset Endophthalmitis after Transconjunctival Microincision Vitrectomy Surgery

PURPOSE To explore the incidence and visual outcomes of acute-onset endophthalmitis after transconjunctival microincision vitrectomy surgery (MIVS). DESIGN Retrospective, interventional, multicenter survey with a systematic review. METHODS A clinical database search was performed at 27 institutions involving 43 868 consecutive patients who underwent vitrectomy between November 2003 and October 2008 to identify all patients with endophthalmitis after vitrectomy. A systematic review of studies reporting the endophthalmitis rates after MIVS versus 20-gauge vitrectomy was conducted to assess the pooled incidence rates of postvitrectomy endophthalmitis. RESULTS The endophthalmitis rates from the multicenter survey were 0.034% (10 cases per 29 030 eyes) after 20-gauge vitrectomy and 0.054% (8 cases per 14 838 eyes) after MIVS, with no significant (P = .603) differences between groups. Although the incidence in 25-gauge cases (6 per 8238 eyes; 0.073%) was greater than in 23-gauge cases (2 per 6600 eyes; 0.030%), the difference was not significant (P = 0.451). Of 8 eyes in which endophthalmitis developed after MIVS, 6 eyes (75%) had a final visual acuity of 0.5 or better, and none lost light perception. By combining the results of 7 studies, including the current multicenter survey, meta-analyses from a total of 77 956 cases at the baseline showed that the pooled endophthalmitis rates after MIVS (0.08%; 95% confidence interval, 0.030% to 0.164%) and after 20-gauge vitrectomy (0.030%; 95% confidence interval, 0.012% to 0.048%) did not differ significantly (P = .207, pooled risk difference; 0.0005 [95% confidence interval, -0.0002 to 0.0012]). CONCLUSIONS The incidence of postvitrectomy endophthalmitis was low with no significant differences between MIVS and 20-gauge vitrectomy.

Macular hole surgery with triamcinolone acetonide-assisted internal limiting membrane peeling: One-year results

Purpose: To report the 1-year results of macular hole surgery with triamcinolone acetonide (TA)–assisted internal limiting membrane (ILM) peeling and to compare those with results of indocyanine green (ICG)–assisted ILM peeling. Methods: In a nonrandomized, retrospective, interventional case series, 40 eyes of 39 consecutive patients with idiopathic full-thickness macular holes underwent macular hole surgery with TA-assisted ILM peeling. Surgical results 1 year after surgery, including changes in best-corrected visual acuity (BCVA) and macular hole closure, were evaluated. Moreover, we compared the results for these 40 eyes (TA group) with those for 27 eyes of 27 consecutive patients who had undergone macular hole surgery with 0.25% ICG-assisted ILM peeling (ICG group). Results: In the TA group, macular holes were closed in 39 (98%) of 40 eyes. Mean BCVA ± SD significantly improved from 0.78 ± 0.31 logarithm of the minimal angle of resolution (logMAR) preoperatively to 0.20 ± 0.30 logMAR (P < 0.001). BCVA improved by ≥0.2 logMAR in 37 eyes (93%). BCVA was 20/40 or better in 33 (83%) of 30 eyes. In the ICG group, macular holes were closed in all 27 eyes (100%), and mean BCVA ± SD significantly improved from 0.81 ± 0.4 logMAR preoperatively to 0.34 ± 0.2 logMAR 1 year postoperatively (P < 0.001). BCVA improved by ≥0.2 logMAR in 22 eyes (81%). BCVA was 20/40 or better in 16 (59%) of 27 eyes. Significant differences between groups were seen in mean BCVA 1 year after surgery (P = 0.049) but not in BCVA of 20/40 or better (P = 0.17) or change in BCVA by ≥0.2 logMAR (P = 0.05). Conclusion: TA is useful as an adjuvant for ILM peeling in macular hole surgery, and BCVA 1 year after surgery might be more favorable when compared with ICG-assisted ILM peeling.

Morphologic and functional advantages of macular hole surgery with brilliant blue G-assisted internal limiting membrane peeling.

Morphologic and Functional Advantages of Macular Hole Surgery with Brilliant Blue G–Assisted Internal Limiting Membrane Peeling Removal of the internal limiting membrane (ILM) is an effective additional treatment in macular hole (MH) surgery. The transparency of the ILM requires high skill to peel the membrane. In 2000, a technique using indocyanine green (ICG) to stain and peel the ILM was reported. However, some investigators have reported retinal toxicity of the residual ICG. Other investigators have shown the toxicity of ICG to the retinal pigment epithelium in vitro and in vivo. These reports indicate that surgeons have to be very careful not to allow ICG to remain subretinally at the end of MH surgery because it can cause postoperative complications such as retinal pigment epithelial changes and subsequent visual field loss. In 2006, Enaida et al initially reported that brilliant blue G (BBG) stains the ILM while having low retinal toxicity in their morphologic study using electron microscopy. In rapid succession, they also reported the clinical possibility of using BBG for ILM staining and peeling in MH and epiretinal membrane cases with no adverse events. Compared with ICG, the toxicity of BBG to cultured retinal ganglion cells was significantly lower based on evaluation of retinal ganglion cell apoptosis. Ueno et al injected ICG and BBG in clinical concentrations into the subretinal space of rats. They found that ICG caused retinal degeneration and retinal pigment epithelium cell atrophy, while BBG had no detectable toxic effects. After confirmation of the safety of BBG, Cervera et al reported their experience with ILM peeling using BBG and concluded that dyeing with BBG appeared to be an interesting alternative to ICG. Much improvement in the resolution of optical coherence tomography has enabled us to observe microstructure of the macula in MHs before and after surgery. Recent studies have revealed the correlation between visual recovery and the presence of the inner and outer segments of the photoreceptor (IS/OS) junction after MH surgery. The IS/OS junction can be observed in the normal eye as the continuous line located in the outer retina. Another investigator has reported the importance of the external limiting membrane (ELM) compared with the IS/OS in visual recovery after MH surgery. Thus, continuity of the IS/OS junction and the ELM has been well known as an important factor for postoperative recovery of visual acuity. In the present study, the results, including macular microstructure and visual acuity, of MH surgery using BBG and ICG were compared.

Correlation of increased fundus autofluorescence signals at closed macula with visual prognosis after successful macular hole surgery

Purpose To study the significance of the increased fundus autofluorescence (FAF) signals at closed macula with spectral-domain optical coherence tomography and visual prognosis after successful surgery in eyes with idiopathic full-thickness macular holes (MHs). Methods Seventy-eight eyes of 78 consecutive patients with full-thickness MHs underwent successful standard vitrectomy, with internal limiting membrane peeling and followed by 10% sulfur hexafluoride gas injection. Simultaneous FAF and optical coherence tomography images were recorded at 10 days, and 1, 3, and 6 months postoperatively, using a combined spectral-domain optical coherence tomography–fluorescein angiography device (Spectralis™/HRA Heidelberg Retina Angiograph 2). The appearance of increased FAF in the macula postoperatively and the relationship of FAF and optical coherence tomography findings to best-corrected visual acuity were examined. Results Stage 2, 3, and 4 MHs were present in 31, 29, and 18 eyes, respectively. The median patient age was 66 years, with a range of 54 to 79 years. In all patients, the MHs were successfully closed, and the preoperative increased FAF corresponding to MH disappeared 10 days after surgery. In 36 eyes (46.2%), however, hyperautofluorescence again appeared in the macular area 1 month postoperatively. This hyperautofluorescence was significantly associated with the recovery of the external limiting membrane lines at the fovea 1 month after surgery (P = 0.001, multiple logistic regression analysis). Also, this recovery of the external limiting membrane lines 1 month postoperatively was significantly associated with the recovery of photoreceptor inner and outer segment junction line 3 months postoperatively at the fovea (P < 0.001, Fisher exact test). Moreover, a good best-corrected visual acuity of 20/28 or better at 6 months after surgery was significantly associated with hyperautofluorescence in the macula 1 month postoperatively, the recovery of the photoreceptor inner and outer segment lines at the fovea 3 months postoperatively, and preoperative good visual acuity (P < 0.05, multiple logistic regression analysis). Conclusion In full-thickness MHs, 46.2% of our patients showed increased FAF in the macula 1 month after successful MH surgery. This hyperautofluorescence could be a sign of good visual prognosis postoperatively.

A method to decrease the frequency of unintentional slippage after vitrectomy for rhegmatogenous retinal detachment.

Purpose: To investigate a method for preventing retinal slippage after standard vitrectomy for rhegmatogenous retinal detachment. Methods: Eighty six eyes with bullous rhegmatogenous retinal detachment underwent successful standard vitrectomy. Patients were divided into 2 groups. In Group 1, 44 patients started face-down positioning at approximately 10 minutes after the end of the surgery. In Group 2, 42 patients started face-down positioning immediately at the end of the surgery. Postoperative retinal slippage was determined by fundus autofluorescence at 1 month postoperatively. Statistical analysis examined several factors to determine the association between the start time of the face-down positioning and retinal slippage. Results: Retinal slippage occurred in 63.6% of Group 1 and in 24.0% of Group 2 patients. This difference was statistically significant (P = 0.004, Fishers exact probability test). Both the extent of retinal slippage (P = 0.029) and the face-down position (P < 0.001) were significantly associated with the retinal slippage. Conclusion: Earlier implementation of face-down positioning may prevent retinal slippage after surgery in eyes with rhegmatogenous retinal detachment treated by standard vitrectomy.

Reduction in Dose of Intravitreous Bevacizumab Before Vitrectomy for Proliferative Diabetic Retinopathy

B evacizumab (Avastin) is a full-length recombinant humanized monoclonal antibody directed against vascular endothelial growth factor (VEGF). It has been approved by the US Food and Drug Administration for the treatment of metastatic colorectal cancer. Intravitreous (IV) injection of bevacizumab, 1.25 mg/0.05 mL, has been studied in patients with age-related macular degeneration, macular edema associated with retinal vein occlusion, and diabetic macular edema. Recently, bevacizumab administered prior to vitrectomy for proliferative diabetic retinopathy (PDR) was reported to reduce intraoperative bleeding. Sawada et al showed that IV bevacizumab blocked all free VEGF in the aqueous humor. However, IV bevacizumab may cause systemic adverse effects such as thromboembolic diseases or increases in systolic blood pressure. Moreover, the rapid progression of traction retinal detachment after IV injection of bevacizumab was reported. Therefore, we need to consider an appropriate dose of bevacizumab to be injected intravitreally. The purpose of this study is to elucidate whether a reduced dose (0.25 mg) of IV bevacizumab has an effect equally strong as the widely administered dose (1.25 mg) when IV bevacizumab is used as a surgical adjunct to treat PDR.

Pars plana vitrectomy combined with internal limiting membrane peeling for recurrent macular edema due to branch retinal vein occlusion after antivascular endothelial growth factor treatments.

Purpose To evaluate the anatomic and functional outcomes of pars plana vitrectomy combined with internal limiting membrane peeling for recurrent macular edema (ME) due to branch retinal vein occlusion (BRVO) after intravitreal injections of antivascular endothelial growth factor (anti-VEGF) agents. Methods Twenty-four eyes of 24 patients with treatment-naive ME from BRVO were treated with intravitreal injections of anti-VEGF agents. Recurred ME was treated with pars plana vitrectomy combined with internal limiting membrane peeling. Results After the surgery, ME was significantly reduced at 1 month (P=0.031) and the reduction increased with time (P=0.007 at the final visit). With the reduction in ME, treated eyes showed a slow improvement in visual acuity (VA). At the final visit, improvement in VA was statistically significant compared with baseline (P=0.048). The initial presence of cystoid spaces, serous retinal detachment, or subretinal hemorrhage under the fovea, as well as retinal perfusion status, showed no association with VA improvement. However, the presence of epiretinal membrane showed a significant association with the visual recovery. Although eyes without epiretinal membrane showed visual improvement (−0.10±0.32 in logarithm of the minimum angle of resolution [logMAR]), eyes with epiretinal membrane showed greater visual improvement (−0.38±0.12 in logMAR, P=0.012). Conclusion For recurrent ME due to BRVO after anti-VEGF treatment, particularly when accompanied by epiretinal membrane, pars plana vitrectomy combined with internal limiting membrane peeling might be a possible treatment option.

Combined 25-gauge vitrectomy and cataract surgery with toric intraocular lens with idiopathic epiretinal membrane

Purpose To evaluate the stability of axis rotation, astigmatism correction, and improvement in uncorrected distance visual acuity (UDVA) up to 6 months postoperatively using an astigmatism‐correcting intraocular lens (IOL) in a 25‐gauge transconjunctival sutureless vitrectomy combined with cataract surgery. Setting Department of Ophthalmology, Kagawa University Faculty of Medicine, Kagawa, Japan. Design Prospective nonrandomized interventional study. Method Eyes with a preoperative corneal cylinder of more than 0.75 diopter (D) had a triple procedure for idiopathic epiretinal membrane (ERM) using an Acrysof IQ toric IOL. Outcome measures were the amount of IOL axis rotation up to 3 months postoperatively, UDVA, corrected distance visual acuity, and corneal and refractive astigmatism up to 6 months postoperatively. A comparison was performed between patients with a target postoperative spherical refraction of emmetropia (toric emmetropic group) and patients who previously had a triple procedure for idiopathic ERM using a nontoric IOL (control group). Results The mean IOL axis rotation from the end of surgery until 3 months postoperatively was 3.67 degrees ± 3.13 (SD). Six months postoperatively, the mean corneal and refractive cylinders were 1.32 ± 0.61 D and 0.51 ± 0.31 D, respectively, showing a significant difference (P<.0001, paired t test). In addition, the mean UDVA was significantly improved 6 months postoperatively in the control and toric emmetropic group (0.57 logMAR versus 0.35 logMAR) (P=.028), although the toric group was more improved than the control group. Conclusion In vitrectomy (triple procedure) for idiopathic ERM with a toric IOL, postoperative IOL axis stability was similar to that reported for cataract surgery alone. Furthermore, the UDVA was better than with implantation of a spherical IOL. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.