Jeroni Nadal

Treatment Of Retinal Detachment Secondary To Macular Hole In High Myopia: Vitrectomy With Dissection of the Inner Limiting Membrane to the Edge of the Staphyloma and Long-term Tamponade

Purpose: To evaluate the rates of retinal reattachment and the closure of myopic macular hole because of posterior pole retinal detachment after treatment with pars plana vitrectomy and subsequent dissection of the inner limiting membrane. Methods: Prospective noncomparative study of 27 eyes from 27 phakic patients diagnosed with posterior pole retinal detachment as a result of myopic macular hole. All underwent pars plana vitrectomy with dissection of the inner limiting membrane and intravitreal silicone oil tamponade performed by the same surgeon. The main variables assessed were visual acuity, retinal reattachment, and macular hole closure determined by optical coherence tomography. Results: Of the 27 eyes, 16 (59.3%) were right eyes and 11 (40.7%) were left eyes. Mean age was 50.5 years. Myopia ranged from −9 diopters (D) to −27 diopters (mean, −18 diopters), and axial length ranged from 28.5 mm to 35.6 mm (mean, 32.05 mm). After a mean postoperative period of 12 months, retinal reattachment was found in 85.1% of the patients and anatomical closure of the macular hole in 51.9%. Conclusion: This technique offers good rates of retinal reattachment and macular hole closure, although seldom increases the final visual acuity. It showed limited effectiveness in eyes with an axial length >30 mm.

Vitrectomy without face-down posturing for idiopathic macular holes

Purpose: To report the results of vitrectomy with internal limiting membrane peeling and C3F8 tamponade for macular hole without postoperative face-down posturing in 208 eyes. Methods: The study included 208 eyes on an uncontrolled retrospective review, undergoing pars plana vitrectomy with trypan blue–assisted internal limiting membrane peeling and C3F8 tamponade, without subsequent face-down posturing. All patients were followed-up at 1 day, 1 week, 3 months, and 12 months postoperatively. Biomicroscopy and optical coherence tomography were used to assess macular hole closure at 1 day, 1 week, 3 months, and 12 months postoperatively. Pre- and postoperative visual acuity by Snellen chart was compared. Results: In 208 eyes with idiopathic macular hole, preoperative mean visual acuity was 20/200 and final visual acuity was 20/40 (P = 0.00017). Anatomic macular hole closure rate was 81.3%. Conclusion: In agreement with published studies, combined phacovitrectomy without face-down posturing after macular hole surgery seems effective and safe, showing anatomical improvement and favorable best-corrected visual acuity. Isolating the macula from vitreous fluid with a large long-lasting gas-fill may render postoperative posturing unnecessary. Eliminating face-down posturing may increase patient acceptance and compliance.

Pronóstico visual y complicaciones posquirúrgicas en queratoprótesis de Boston tipo 1

OBJECTIVE To describe the visual outcome of patients who underwent Boston type 1 keratoprosthesis (KPro1) implantation, and describe serious sight-threatening post-operative complications. METHODS We performed an analysis of the clinical records of all patients who underwent Boston keratoprosthesis implantation (BKI)in our institution from May 2006 to February 2011. RESULTS A total of 41 eyes of 37 patients were included in the final analysis, of whom 22 (59.45%) were male and 15 were (40.54%) female. The mean age was 56.44 years (range 2-90). The most frequent diagnoses were bullous keratopathy, autoimmune diseases, such as Stevens-Johnson syndrome (SJS)/Lyell syndrome (LS), and aniridic keratopathy. The mean number of previous keratoplasties (PK) was 2.36 (range 0-8), the mean number of previous non-PK surgeries was 1.58 (range 0-9). The mean follow-up time was 22.17 months (range 3-46). The mean best corrected visual acuity (BCVA) logMAR before surgery was 2.05 (range 1.10-2.52), and the mean best corrected visual acuity achieved after surgery was 1.16 (range 0.08- 2.70). The most frequent complication was the formation of retroprosthetic membrane (RPM) which appeared in 22 (53.65%) eyes. Of these, 6 (27.27%) appeared after another surgery. Fourteen (63.63%) RPM required treatment, an average of 1.71 (range 1-4) laser YAG applications were performed, and surgical membranectomy was performed in 3 patients. Eleven (26.82%) eyes showed chorioretinal adhesion problems, 6 (14.63%) of which occurred after follow-up of BKI surgery. Infectious complications occurred in 7 (17.07%) cases; 2 (4.87%) patients had infectious keratitis and 5 (12.19%) endophthalmitis. CONCLUSIONS Visual function improved in most patients. Those with prior multiple ocular surgeries and alterations of systemic immunity such as SJS, LS, and diabetes mellitus are at increased risk for serious sight-threatening complications, such as RPM, chorioretinal detachment and infection. Nevertheless, we consider KPro as an effective alternative in patients with multiple ocular pathology and imminent risk of rejection of a new KP.

Tyrosine phosphorylation of vitreous inflammatory and angiogenic peptides and proteins in diabetic retinopathy.

PURPOSE To evaluate the degree of phosphorylation of vitreous proteins in patients with type 2 diabetes mellitus and diabetic retinopathy compared with a group of control subjects without diabetes and of similar age and sex. METHODS In samples obtained after vitrectomy for diabetic retinopathy in patients and for macular hole in control subjects, immunoblot techniques were applied to a mini-array system for quantification of a wide range of chemokines and vasoactive peptides and proteins. Antiphosphotyrosine antibody was used for tyrosine phosphorylation evaluation and results were expressed as the percentage of variation compared with that in control subjects. RESULTS Samples from eight patients with type 2 diabetes and from eight control subjects were analyzed. The total quantity of proteins analyzed was similar in both patients and control subjects. Tyrosine phosphorylation was very significantly decreased (<20%, P < 0.05) in diabetic patients with respect to the control group in growth-related oncogene, human cytokine I-309, interleukin-13, monocyte colony-stimulating factor, macrophage-derived chemokine, stem cell factor, transforming growth factor-beta1, angiogenin, and oncostatin M. A significant decrease in phosphorylation (between 20% and 40%, P < 0.05) was observed in epithelial neutrophil-activating peptide 78; granulocyte colony-stimulating factor; granulocyte-monocyte-stimulating colony factor; IL-5, -6, -7, -8, -10, and -12p40p70; monokine induced by interferon-gamma; macrophage inflammatory protein 1-gamma; and normal T expressed and secreted cytokine (RANTES) in comparison with that in the control subjects. The greatest decrease in phosphorylation status was found in IL-1-alpha and -1beta. CONCLUSIONS Diabetic retinopathy is associated with a decrease in tyrosine phosphorylation of many vitreous proteins which may indicate an alteration in protein functionality or action even before significant quantitative variations.

Anterior segment changes following intravitreal bevacizumab injection for treatment of neovascular glaucoma

Background: The purpose of this study was to describe anterior segment changes in a prospective, interventional, noncomparative case series of patients with neovascular glaucoma secondary to proliferative diabetic retinopathy treated with intravitreal bevacizumab. Methods: Five consecutive patients with neovascular glaucoma and a refractory, symptomatic elevation of intraocular pressure and pronounced anterior segment congestion received intravitreal bevacizumab 1.25 mg/0.05 mL. Follow-up examinations were performed at 4–16 weeks by the same specialists, with testing performed at hour 48, week 1, and months 1, 3, and 6 after intravitreal bevacizumab. Results: We observed a significant difference (P = 0.021) between initial and mean neovascularization at three months in all the quadrants. At three months, median intraocular pressure was 19 ± 5.38 (range 12–26) mmHg. In three of the five cases, diode laser cyclophotocoagulation was required, and in one case a trabeculectomy was performed. One patient showed complete synechial angle closure 48 hours after treatment which required cyclodestructive procedures to normalize intraocular pressure. Conclusion: Intravitreal bevacizumab achieves complete regression of neovascularization in neovascular glaucoma secondary to proliferative diabetic retinopathy, and this regression is stable when associated with treatment of the underlying disease and should be investigated more thoroughly as an adjunct in the management of neovascular glaucoma.

Scleral Fixation of Posteriorly Dislocated Intraocular Lenses by 23-Gauge Vitrectomy without Anterior Segment Approach

Background. To evaluate visual outcomes, corneal changes, intraocular lens (IOL) stability, and complications after repositioning posteriorly dislocated IOLs and sulcus fixation with polyester sutures. Design. Prospective consecutive case series. Setting. Institut Universitari Barraquer. Participants. 25 eyes of 25 patients with posteriorly dislocated IOL. Methods. The patients underwent 23-gauge vitrectomy via the sulcus to rescue dislocated IOLs and fix them to the scleral wall with a previously looped nonabsorbable polyester suture. Main Outcome Measures. Best corrected visual acuity (BCVA) LogMAR, corneal astigmatism, endothelial cell count, IOL stability, and postoperative complications. Results. Mean follow-up time was 18.8 ± 10.9 months. Mean surgery time was 33 ± 2 minutes. Mean BCVA improved from 0.30 ± 0.48 before surgery to 0.18 ± 0.60 (p = 0.015) at 1 month, which persisted to 12 months (0.18 ± 0.60). Neither corneal astigmatism nor endothelial cell count showed alterations 1 year after surgery. Complications included IOL subluxation in 1 eye (4%), vitreous hemorrhage in 2 eyes (8%), transient hypotony in 2 eyes (8%), and cystic macular edema in 1 eye (4%). No patients presented retinal detachment. Conclusion. This surgical technique proved successful in the management of dislocated IOL. Functional results were good and the complications were easily resolved.

Intraretinal cyst secondary to longstanding retinal detachment.

Purpose To describe the diagnosis and management of an intraretinal cyst. Case Report A 34-year-old man with a history of retinal detachment presented sudden loss of vision in the left eye. Visual acuity was hand movement. Examination revealed hematic vitreous haze and ultrasound showed a rounded mobile object in the vitreous cavity. Results After differential diagnosis ruled out cysticercosis, pars plana vitrectomy revealed a neovascularized intraretinal macrocyst attached to a posterior flap of a 13-year-old retinal tear. Retinotomy and retinectomy were performed, removing this cyst located in the upper retina together with a portion of detached retina. At 1 year, the retina had adapted and the vitreous cavity was clear. Final visual acuity was 18/20. Conclusions Intraretinal cysts are usually asymptomatic and associated with long-standing retinal detachment, as seen in our clinical case. Periodic fundus examination is essential for their detection. Surgical treatment of the underlying condition usually leads to complete resolution.

Diabetic Retinopathy Is Associated with Decreased Tyrosine Nitrosylation of Vitreous Interleukins IL-1α, IL-1β, and IL-7

Objective: To simultaneously evaluate tyrosine nitrosylation and phosphorylation levels of vitreous interleukins of patients with diabetic retinopathy, in which abnormal tyrosine phosphorylation has been previously described. Research Design and Methods: Specific immunoprecipitation of interleukins IL-1α, IL-1β, IL-2 and IL-7 was carried out in samples obtained during vitrectomy performed for proliferative diabetic retinopathy in patients (n = 12) and for macular hole in controls (n = 12). Tyrosine nitrosylation and phosphorylation levels of the immunoprecipitated interleukins were analysed by Western blot with the respective specific antibodies and correlated. The results were also correlated with the total amount of immunoprecipitated interleukin protein. The mean phosphorylation/nitrosylation ratios of these proteins in vitreous humour of both the control group and diabetic patients were determined. Results: Diabetes was associated with decreased tyrosine nitrosylation of IL-1α, IL-1β and IL-7 and an increased tyrosine phosphorylation/nitrosylation ratio with respect to controls in IL-1α (1.58 ± 0.22 vs. 2.74 ± 0.39, respectively; p < 0.05) and IL-7 (2.15 ± 0.01 vs. 3.26 ± 0.57, respectively; p < 0.05). No significant changes were observed in nitrotyrosine or in the tyrosine phosphorylation/nitrosylation ratio of IL-2. Conclusions:Proliferative diabetic retinopathy is associated with concomitant and simultaneous changes in both tyrosine phosphorylation and tyrosine nitrosylation status of specific pro-inflammatory interleukins present in the vitreous fluid such as IL-1α, IL-1β and IL-7. These changes could be related to the increase in pro-inflammatory activity detected in diabetes-induced retinopathy.

Autologous platelet concentrate in surgery for macular detachment associated with congenital optic disc pit.

Purpose To evaluate the anatomical and functional results obtained with pars plana vitrectomy (PPV) plus autologous platelet concentrate (APC) as a treatment for macular detachment associated with optic disc pit (ODP). Methods We performed a prospective interventional study of 19 eyes of 19 consecutive patients with posterior macular detachment due to ODP. All patients underwent PPV, posterior hyaloid peeling, fluid–air exchange, injection of 0.05 mL of APC over the ODP and 15% perfluoropropane (C3F8) endotamponade. Postoperative measures included face-up positioning for 2 hours and then avoidance of the face-up position during the ensuing 10 days. All patients underwent complete ophthalmologic examination and optical coherence tomography preoperatively at 1 month, 3 months, 6 months, 9 months, and 12 months postoperatively and then annually. Outcome measures were best corrected visual acuity (BCVA) by logMAR, improvement of quality of vision, macular attachment, and resolution of intraretinal schisis-like separation. Results Preoperatively, the median BCVA was 0.70 (range: 0.30–1.70) and all patients showed improved visual acuity after surgery; BCVA was 0.22 (range: 0.07–0.52) at 12 months follow-up. All patients showed complete reabsorption of intraretinal fluid (median time: 3.5 months [range: 2–8 months]) and macular attachment at the end of follow-up (median: 60 months [range: 12–144 months]), with stable or improved visual acuity. No reoperations were needed and no major adverse events were recorded. Conclusion For macular detachment associated with ODP, the combination of PPV, posterior hyaloid peeling, APC, and C3F8 tamponade is a highly effective alternative technique with stable anatomical and functional results.

Neovascular Glaucoma Treatment With Extraction of Anterior Chamber FibrovascularTissue

The use of antibody to vascular endothelial growth factor to treat neovascular glaucoma yields good anatomic results in most cases. However, this type of glaucoma can cause angle closure with decompensation of intraocular pressure secondary to fibrovascular tissue contraction in the anterior chamber. Our surgical technique treats the cause by removing the anterior chamber fibrous complex after administration of antibody to vascular endothelial growth factor, thus restoring the chamber angle.