Itsuro Tsukahara

Early postoperative retinal thickness changes and complications after vitrectomy for diabetic macular edema

PURPOSE To determine the early postoperative changes in retinal thickness and complications after pars plana vitrectomy for diabetic macular edema. DESIGN Consecutive interventional case series. METHODS Studied retrospectively, pars plana vitrectomy was performed on 65 consecutive eyes of 63 patients with diabetic macular edema. The follow-up interval ranged from 6 to 36 months (12.6 +/- 7.4 months [mean +/- standard deviation (SD)]). The indications of pars plana vitrectomy in this study were (1) diffuse diabetic macular edema, (2) preoperative visual acuity less than 20/40, and (3) noneffective macular photocoagulation therapy. Preoperative and postoperative examinations by stereoscopic biomicroscopy, color fundus photography of the macula and optical coherence tomography (OCT) were performed on all eyes. Preoperatively, direct photocoagulation to microaneurysms in the macula had been performed in 48 eyes, and focal/grid photocoagulation had been performed in five eyes. Preoperative examination showed that epiretinal membranes were observed in 20 eyes, cystoid macular edema in 40 eyes, and 23 eyes had a complete posterior vitreous detachment (PVD). Epimacular membranes, removed during surgery, were examined histopathologically. RESULTS The postoperative mean best-corrected visual acuity (logarithm of the minimum angle of resolution [logMAR] = 0.696 +/- 0.491 [mean +/- SD]) was significantly better than the preoperative mean best-corrected visual acuity (0.827 +/- 0.361; P <.0001; Wilcoxon signed-rank test). The final visual acuity improved by 2 or more lines in 32 of 65 eyes (45%), remained unchanged in 32 of 65 eyes (49%), and exacerbated after the surgery in 4 of 65 eyes (6%) due to neovascular glaucoma (2 eyes) and residual cystoid macular edema (2 eyes). The postoperative foveal retinal thickness (224.9 +/- 116.9 microm) at the last visit was significantly thinner than the preoperative foveal retinal thickness (463.7 +/- 177.3 microm; P <.0001; Wilcoxon signed-rank test). The foveal retinal thickness did not decrease linearly but fluctuated: The mean postoperative retinal thickness had decreased significantly 7 days after surgery, then remained unchanged for approximately 1 month, and thereafter gradually decreased until 4 months. The intraoperative and postoperative complications included peripheral retinal tear in 3 of 65 (4.6%) eyes, postoperative rhegmatogenous retinal detachment in 1 of 65 (1.5%) eyes, neovascular glaucoma in 3 of 65 (5%) eyes, recurrent vitreous hemorrhage in 1 of 65 (1.5%) eyes, hard exudates in the center of the macula in 3 of 56 (4.6%) eyes, postoperative epiretinal membrane formation in 9 of 65 (13.8%) eyes, and a lamellar macular hole in 1 of 65 (1.5%) eyes. CONCLUSIONS Vitrectomy for diabetic macular edema is an effective procedure for reducing the edema and improving visual acuity. Because the postoperative reduction in retinal thickness is not complete until 4 months, the assessment of vitrectomy on foveal thickness should not be made until this time. In addition, there are severe complications from vitrectomy for diabetic macular edema, and careful preoperative and postoperative examinations and surgical methods are required.

Macular configuration determined by optical coherence tomography after idiopathic macular hole surgery with or without internal limiting membrane peeling.

Aims: To evaluate the effect of pars plana vitrectomy (PPV) with or without internal limiting membrane (ILM) peeling on the closure and configuration of idiopathic macular holes (IMH). Methods: PPV was performed for IMH on 44 eyes with ILM peeling (ILM peeled group) and on 42 eyes without ILM removal (ILM preserved group). Optical coherence tomography (OCT) was performed on 34 ILM peeled eyes and 14 ILM preserved eyes after successful surgery. The repaired macular holes were classified by the OCT images as being of “good shape” (nearly normal foveal contour) or “poor shape” (abnormal foveal contour with flat fovea and steep edge, or with a thick retina without a foveal pit). Results: The anatomical closure rate was significantly higher in the ILM peeled group (93.2%) than in the ILM preserved group (76.2%) (p = 0.028). In the ILM peeled group, 31 eyes had a fovea of good shape and three eyes had a fovea with a poor shape, while in the ILM preserved group, six eyes had a fovea of good shape and eight eyes had a fovea of poor shape. The percentage of eyes with good macular configuration in the ILM peeled group was significantly higher than in the ILM preserved group (p = 0.0003). No significant difference was found in the postoperative visual acuity and the increase of visual acuity between the ILM peeled group and the ILM preserved group (p = 0.26, and p = 0.91 respectively). There was also no significant difference in the postoperative visual acuity and improvement in visual acuity between eyes with a fovea of good shape and those with fovea of poor shape fovea (p = 0.99 and p = 0.66, respectively). Conclusions: ILM peeling may provide better anatomical success and recovery of the macular shape, but the postoperative visual acuity and improvement of visual acuity were not related to the morphological results.

Efficacy of internal limiting membrane removal for retinal detachments resulting from a myopic macular hole.

Purpose: To evaluate the efficacy of internal limiting membrane (ILM) or epiretinal membrane removal during pars plana vitrectomy for a retinal detachment resulting from a macular hole in myopic eyes. Methods: A retrospective study was conducted in a single institution. Twenty-six highly myopic eyes with a retinal detachment resulting from a macular hole were studied. During pars plana vitrectomy, ILM peeling (ILM-peeled group) was performed on 13 eyes, and the ILM was not removed (ILM-preserved group) in 12 eyes. Main outcome measures were anatomic reattachment, optical coherence tomography-determined macular hole closure, and visual acuity. Follow-up periods were longer than 12 months in all cases. Results: The anatomic reattachment rate after the initial surgery was significantly higher in the ILM-peeled group (92.3%) than in the ILM-preserved group (50%). The macular holes of 8 (72.7%) of the 11 ILM-peeled and reattached eyes and 2 (50%) of the 4 ILM-preserved and reattached eyes were successfully closed by the initial surgery. No significant difference was found in the postoperative visual acuity and the improvement of visual acuity between the ILM-peeled group and the ILM-preserved group. There was also no significant difference of the postoperative visual acuity and improvement of the visual acuity between the two groups in cases with an initial anatomic success. Conclusion: These results indicate that removal of the ILM contributes to a successful reattachment and is an effective treatment for macular hole and retinal detachment in highly myopic eyes. The authors suggest that the higher success rate after ILM peeling resulted from the release of the traction of the prefoveal vitreous and the epiretinal membrane over the detached retina.

Surgical Outcomes in Juvenile Retinal Detachment

PURPOSE To evaluate retrospectively clinical features and surgical outcomes of rhegmatogenous retinal detachment in juvenile patients. METHODS Between 1991 and 1996, 28 patients younger than 15 years of age with rhegmatogenous retinal detachment (32 eyes) underwent the first surgical procedure, scleral buckling and/or pars plana vitrectomy, at our hospital. RESULTS The major types of juvenile detachment, in order of frequency, were idiopathic, familial exudative vitreoretinopathy, trauma, and high myopia. Proliferative vitreoretinopathy (PVR) of grade C or D was involved in 12 cases (37.5%). Among the 12 eyes with PVR, 7 attained retinal reattachment after the first surgery with scleral buckling. The overall reattachment rate was 28/32 (87.5%) after the first operation and 30/32 (93.8%) after the second operation. CONCLUSION These findings indicate that the reattachment rate and visual prognosis can be as good in juvenile retinal detachment as in adult cases, when appropriate surgical procedures are used.

Monocyte chemotactic protein-1 levels in the Vitreous of patients with proliferative vitreoretinopathy

PURPOSE To assess the potential role of monocyte chemotactic protein-1 (MCP-1) in the pathogenesis of proliferative vitreoretinopathy (PVR) and to investigate its possible interaction with the macrophage migration inhibitory factor (MIF). METHODS We assayed MCP-1 and MIF levels in the vitreous samples of 85 consecutive patients with PVR (29 eyes), rhegmatogenous retinal detachment (RRD; 22 eyes), and macular hole or idiopathic epimacular membrane (controls; 34 eyes), by enzyme-linked immunosorbent assay. RESULTS Vitreous levels of MCP-1 were 1760.7 +/- 471.3 pg/mL (mean +/- SD) in PVR patients, 1200.4 +/- 579.8 pg/mL in RRD patients, and 436.3 +/- 286.1 pg/mL in the controls. Vitreous MCP-1 levels in PVR patients were significantly higher than those in RRD patients and in the controls (P <.0001, respectively). MCP-1 levels in grade C of PVR (1883.7 +/- 479.5 pg/mL) were significantly greater than those in grade D (1437.8 +/- 258.8 pg/mL) (P =.0112). Vitreous concentrations of MCP-1 had no correlation with those of MIF. CONCLUSIONS The results indicate the possibility that MCP-1 may have a role mainly in the early stage of PVR and that the role of MCP-1 in PVR may differ from that of MIF.

S-cone electroretinograms in multiple evanescent white dot syndrome

Cone electroretinograms (ERGs), elicited by different color flashes under Ganzfeld conditions, were recorded from 6 patients with multiple evanescent white dot syndrome (MEWDS). All of the patients had normal color vision as determined by the Farnsworth Panel D-15 except for one who showed non-specific errors. The b-waves elicited from short wavelength sensitive (S-) cones were reduced more than the mixed long (L-) and middle (M-) wavelength sensitive cones in the affected eyes. The ratio of the S-cone b-wave amplitude of the affected eyes to that of the normal fellow eyes was significantly lower than the comparable ratio for the L- and M-cone ERG b-waves (p= 0.012). The S-cone ERGs recorded from 2 patients recovered to normal levels after their symptoms abated. These ERG results indicate that the S-cone system is more impaired than the L- and M-cone systems in the acute stage of MEWDS, and the changes in the S-cones may be reversible.

Selective reduction of S-cone response and on-response in the cone electroretinograms of patients with X-linked retinoschisis.

AbstractPurpose. To examine the electroretinograms (ERGs) of the short-wavelength-sensitive (S-) and the mixed long- and middle-wavelength-sensitive (L,M-) cones, and the ON- and OFF-responses of the cone ERGs in three patients with X-linked juvenile retinoschisis (XLRS). Methods. Cone ERGs elicited by different color flashes and those elicited by long duration stimuli under Ganzfeld conditions were recorded from three patients with XLRS. Results. The S-cone b-waves were undetectable to short-wavelength stimuli in all three XLRS patients, while the L,M-cone ERG b-waves were within the normal range. To long-duration white stimuli, the ON-response (b-wave) was reduced and delayed in all patients compared with that of the normal subjects, while the d-wave or OFF-response appeared normal in amplitude and implicit time. Conclusions. These results support the hypothesis that the normal S-cone ERG arises primarily from the ON-pathway of the cone ERGs and the hypothesis that ON-bipolar cells are predominant in the S-cone system.