Ido Didi Fabian

Sutureless vitrectomy: evolution and current practices

This review presents the evolution of sutureless vitrectomy and describes the minimisation of surgical techniques in the posterior segment, as well as their advantages and disadvantages. Shorter operating time, improvement of patient comfort and faster visual recovery are feasible when using small-diameter sutureless vitrectomy technique and equipment. However, a number of associated problems, such as postsurgical hypotony and endophthalmitis, were noticed initially in higher rates compared to 20-gauge vitreoretinal surgery. The purpose of this review is to summarise the available information on transconjunctival sutureless vitrectomy and evaluate its role in modern vitreous surgery.

Comparison of Pars Plana Vitrectomy With and Without Scleral Buckle for the Repair of Primary Rhegmatogenous Retinal Detachment

PURPOSE To compare pars plana vitrectomy (PPV) with combined PPV and scleral buckle (SB) for the repair of noncomplex primary rhegmatogenous retinal detachment (RRD). DESIGN Retrospective, nonrandomized, interventional case series. METHODS We reviewed 181 consecutive cases of vitrectomy for primary RRD at 2 major medical centers in Israel. The follow-up was at least 3 months. There were 96 eyes in the PPV group and 85 eyes in the PPV plus SB group. Main outcome measures were single-surgery anatomic success (SSAS) and final visual acuity (VA). RESULTS SSAS was achieved in 81.3% and 87.1% in the PPV and PPV plus SB groups, respectively (P=.29). Final anatomic success rate was 98.9% and 98.8%, respectively (P=.61). Final VA was 0.41 (20/51) in the PPV group and 0.53 (20/68) in the PPV plus SB group (P=.13). The final VA was significantly better than the preoperative VA in both groups (P<.0001). In detachments caused by inferior tears, SSAS rates were 80.9% and 81.5% in the PPV and PPV plus SB groups, respectively (P=.74). In phakic eyes, SSAS rates were 92% and 87.5%, respectively, and in pseudophakic eyes, SSAS rates were 77.5% and 86.7%, respectively, in the PPV and PPV plus SB groups (P=.29). CONCLUSIONS The reattachment rate and the final VA were similar in both groups. The addition of SB did not improve the results and was associated with slightly lower VA than with PPV alone. Tear location or lens status had no significant effect on success rates. It is likely that in eyes undergoing PPV for primary RRD, addition of a SB is not warranted.

Macular hole after vitrectomy for primary rhegmatogenous retinal detachment.

Purpose: To report a series of full-thickness macular holes (MH) that developed after pars plana vitrectomy for rhegmatogenous retinal detachment (RRD). Methods: A retrospective review of the demographic and medical data, including optical coherence tomography studies of 6 patients (7 eyes) who underwent pars plana vitrectomy for RRD and subsequently developed MH. Results: There were 4 women and 2 men with a mean age of 60 ± 10 years (range, 50–79 years). The mean interval between RRD repair and MH formation was 20 ± 18 months (range, 1–48 years). Five eyes underwent surgery to repair the MHs, four of which were closed at the last follow-up. Two eyes were not operated, one because of unfavorable prognosis, and in the other, which presented with an epiretinal membrane before the development of the MH, the hole closed spontaneously. In all operated cases, the inner limiting membrane was peeled during MH surgery. The mean logarithm of the minimal angle of resolution was 0.73, 0.53, 0.77, and 0.57 at RRD presentation, after surgical repair of RRD and before MH diagnosis, at MH presentation, and at last follow-up, respectively. The study subjects accounted for 1.1% of our 609 patients who underwent pars plana vitrectomy for primary RRD during the study period. Conclusion: Macular hole may develop after pars plana vitrectomy for RRD, and these cases can be surgically repaired. The pathogenesis of the formation of these holes remains unclear.

Congenital ptosis repair-surgical, cosmetic, and functional outcome: a report of 162 cases.

OBJECTIVE To evaluate the surgical and functional outcome of congenital ptosis repair and the anisometropic changes after surgical repair of ptosis to determine the potential contribution of anisometropia to the development of refractive amblyopia. METHODS The clinical records of 162 children with congenital ptosis that had been surgically repaired between 1995 and 2006 at the Goldschleger Eye Institute were reviewed and analyzed for functional and cosmetic outcome, visual acuity status, and presence of amblyopia. RESULTS A total of 162 patients (mean age, 10 months) underwent surgical ptosis repair, of whom 120 (74%) had unilateral and 42 (26%) had bilateral ptosis. The surgeries were levator resection (47.5%), frontalis suspension (46.3%), and Fasanella-Servat (7.4%). Good functional and cosmetic outcomes were achieved in 130 (80.2%) patients, with unilateral cases showing more postoperative asymmetry. The reoperation rate was 10.4% (8/77) for levator resection, 29.3% (22/75) for frontalis suspension, and 20% (2/10) for Fasanella-Servat. There were no significant differences in visual acuity, spherical equivalent, or mean cylinder at 90° between the ptotic eyes before and after surgery (P = 0.33, P = 0.83, and P = 0.65, respectively), and compared with the sound eyes (P = 0.66, P = 0.78, and P = 0.08, respectively). The mean astigmatism correction by vector analysis after ptosis surgery was 1.1±0.68 D. CONCLUSIONS Congenital ptosis repair yields good functional and cosmetic outcome, although the reoperation rate is relatively high (19.8%). Congenital unilateral ptosis was not associated with any differences in anisometropia or astigmatism between the ptotic and sound eye.

Pneumatic Retinopexy for the Repair of Primary Rhegmatogenous Retinal Detachment A 10-Year Retrospective Analysis

OBJECTIVE To assess the outcome and risk factors for failure of pneumatic retinopexy (PR) in eyes with primary rhegmatogenous retinal detachment (RRD). METHODS Data of patients who underwent PR for the repair of primary RRD, from January 1, 2000, through June 30, 2011, were retrieved from medical records and retrospectively analyzed. Patients with a follow-up time of less than 4 months were contacted and invited for examination. Patients with less than 2 months of follow-up were excluded. Successful cases (attached retina at 2 months after the PR) were compared with failures. A subgroup analysis was performed comparing successful and failed cases of RRD that were reattached with only 1 additional operation. RESULTS Two hundred seventy-six eyes (271 patients) underwent PR during the study period, of which 258 eyes (93.5%) were included in the study. Mean (SD) follow-up time was 36.1 (39.4) months; only 23 eyes (8.9%) had a follow-up of less than 4 months. Successful reattachment at 2 months was achieved in 171 eyes (66.3%). Sixty-seven eyes (77.0% of the failed cases) were reattached with only 1 additional operation and final anatomical success was achieved in 256 eyes (99.2%). Successful cases had significantly better final vision (P= .002) and fewer postoperative complications (P ≤ .026). However, nonsignificant differences were found between the primary failure PR cases that underwent only 1 additional operation and the successful cases (P ≥ .073). CONCLUSIONS Pneumatic retinopexy is a good surgical option for primary RRD. Most cases of primary failure are reattached with 1 additional procedure and have excellent final vision.

Intraocular Pressure Measurements and Biomechanical Properties of the Cornea in Eyes After Penetrating Keratoplasty

PURPOSE To compare intraocular pressure (IOP) measurements obtained using the Goldmann applanation tonometer (GAT; Haag-Streit), the Tono-Pen XL (Reichert, Inc), and the ocular response analyzer (ORA; Reichert Ophthalmic Instruments), and to determine the influence of corneal factors on IOP measurements in eyes that had undergone penetrating keratoplasty (PK). DESIGN Consecutive, prospective study. METHODS Study population. Sixty-one eyes that underwent PK were enrolled in this study. Intervention. IOP was measured using the GAT, Tono-Pen, and ORA. Corneal hysteresis and corneal resistance factor as provided by the ORA were recorded. Central corneal thickness was measured using an ultrasound pachymeter. Main outcome measures. IOP and corneal biomechanical factors. RESULTS IOP measurements were obtained in an average of 65 months (range, 6 to 209 months) after PK surgery. ORA-derived IOP measurements (corneal-compensated IOP and Goldmann-correlated IOP) and Tono-Pen XL IOP all correlated in a significant manner to GAT IOP measurements. Corneal-compensated IOP and Tono-Pen XL IOP values were higher than GAT IOP (P < .001 and P = .001, respectively), whereas Goldmann-correlated IOP readings did not differ from GAT IOP readings (P = .054). Central corneal thickness did not correlate to any tonometry technique. In a regression analysis, corneal hysteresis and corneal resistance factor were found to play a role in IOP prediction. CONCLUSIONS Central corneal thickness may be of less importance than corneal hysteresis and corneal resistance factor in IOP determination in eyes that have undergone PK, perhaps because of the lower modulus of elasticity in these eyes. GAT IOP seems to be lower than other tonometry techniques in eyes that have undergone PK.

Chiasmal stroke following open-heart surgery.

A 62-year-old man awoke from aortic valve replacement surgery with a total loss of vision in his right eye and a temporal visual field defect in his left eye. Automated visual field examination confirmed a right-sided anterior junction syndrome, and a right-sided chiasmal infarct was demonstrated by MRI. Although rare, chiasmal stroke is a potential complication of open-heart surgery.

Primary photodynamic therapy with verteporfin for small pigmented posterior pole choroidal melanoma

PurposeThe purpose of the study was to investigate the outcomes of primary photodynamic therapy (PDT) for small pigmented posterior pole choroidal melanoma.Patients and methodsProspective interventional consecutive case series of 15 patients with small pigmented posterior pole choroidal melanoma, who were treated with three sessions of PDT and followed-up thereafter. Risk factors for failure were assessed and outcome measures at presentation were compared to those at last follow-up visit.ResultsTumor control was achieved in 12 (80%) patients in a median follow-up time of 15 months (mean 14, range 8–18). Three patients failed treatment, diagnosed in a median time of 5 months (mean 4, range 3–6), after first PDT. In all failed cases, lesions were 100% pigmented; de novo melanoma rather than transformed nevi and showed a radial growth pattern rather than increased thickness. All failed cases were subsequently successfully treated with radiotherapy. In this cohort, subretinal fluid (SRF) was significantly reduced (P<0.001), vision did not deteriorate (P=0.11) and even improved in patients with subfoveal SRF at presentation (P=0.018), tumor height significantly decreased (P=0.037) and no complications were recorded.ConclusionPrimary PDT was found to be a safe and efficient treatment modality for small pigmented posterior pole choroidal melanoma, achieving short-term tumor control in 80% of patients. PDT offers patients the opportunity to preserve vision by avoiding the retinopathy associated with conventional radiation treatments for choroidal melanoma. However, the long-term local control of these tumors remains uncertain.

The possible association of attention deficit hyperactivity disorder with undiagnosed refractive errors

PURPOSE To evaluate whether attention deficit disorder (ADD) or attention deficit with hyperactivity disorder (ADHD) is associated with undiagnosed refractive errors or binocular function difficulties. METHODS In this case-control study, ADD/ADHD children diagnosed according to criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR), along with age-matched controls, were examined at the ADD clinic at the Sheba Medical Center. For children in both groups the following data were recorded: uncorrected visual acuity for distance and near, cycloplegic refraction, ocular motility, and binocular function. RESULTS A total of 56 children (12 girls; mean subject age, 9.5 years) were included in the ADD/ADHD group. The control group comprised 66 patients (29 girls; mean subject age, 9 years). Mean uncorrected visual acuity was nearly 20/20 for distance and J1 for near in both groups. Cycloplegic spherical equivalent was +0.89 ± 1.1 D for the control group and +0.63 ± 0.89 D for the ADD/ADHD group (P = 0.16). Binocular function and accommodation were similar in both groups, except for a significant difference between the near point of convergence of the controls versus the ADD/ADHD group (5.3 ± 2.3 cm versus 4.1 ± 1.8 cm, respectively; P = 0.002). CONCLUSIONS ADD/ADHD children had similar visual acuity at distance and near and refractive errors as normal subjects. Binocular function and accommodation were also found to be similar in both groups and thus might not contribute to ADD/ADHD.

Strabismus After Inferior-Medial Wall Orbital Decompression in Thyroid-Related Orbitopathy

Purpose: To evaluate the rate and pattern of new-onset diplopia after inferior-medial wall orbital decompression in thyroid-related orbitopathy (TRO) patients. Methods: Medical records of TRO patients who underwent orbital floor and medial wall decompression at the Goldschleger Eye Institute, Sheba Medical Center between 1/1986 and 12/2007 were reviewed and analyzed. Main outcome measures: primary- and down-gaze diplopia, strabismus (prism diopter [PD]). Results: Fifty-one TRO patients (30 females, mean age of 51 years) underwent 102 bilateral inferior-medial wall orbital decompressions. Preoperatively, 29 patients (57%) reported primary gaze diplopia. Of these, 13 patients (45%) had persistent or worsened diplopia postoperatively, all of which required strabismus surgery. Fifteen patients had no primary gaze diplopia preoperatively. Of these, five patients (33%) had new-onset diplopia postoperatively, and only one patient (7%) required strabismus surgery. No data regarding pre-existing diplopia were available in seven patients. Orbital decompression had a significant effect on horizontal ocular deviations with increasing esotropic shift. Primary position esotropia increased from 11.1 (± 22.5) PD preoperatively to 23.8 (± 20.5) PD after surgery (p = 0.01, paired samples t-test). No severe complications were encountered in this group of patients. Conclusions: Inferior-medial wall orbital decompression is associated with a relatively high rate of new-onset diplopia of up to 33%. Patients with pre-existing primary and/or downgaze diplopia are more likely to have persistent symptoms postoperatively that may require strabismus surgery.