M. Gilbert Grand

Surgical Management of Subfoveal Choroidal Neovascularization

BACKGROUND Subfoveal choroidal neovascularization (CNV) usually is associated with a poor visual prognosis. Laser photocoagulation of certain subfoveal membranes secondary to age-related macular degeneration (ARMD) appears preferable to observation based on recent Macular Photocoagulation Study (MPS) findings but is associated with decreased vision. The authors explored the use of vitreoretinal surgical techniques as an alternative method of eradicating subfoveal CNV. METHODS After vitrectomy, a small retinotomy technique was used to extract or disconnect from the choroidal circulation subfoveal CNV in 58 eyes. There were 33 eyes with ARMD, 20 eyes with presumed ocular histoplasmosis, and 5 eyes with miscellaneous etiologies. Five eyes also received subfoveal RPE patches. RESULTS With limited follow-up, significant improvement in vision (defined as 2 Snellen lines) was achieved in 7 of 22 eyes with ARMD CNV removal (1 eye 20/20), 0 of 4 eyes with ARMD CNV removal and RPE patches, and 1 of 7 eyes with ARMD CNV disconnection. Significant improvement was achieved in 6 of 16 eyes with presumed ocular histoplasmosis removal and 0 of 4 eyes with presumed ocular histoplasmosis CNV disconnection. In 5 eyes with miscellaneous CNV, 2 improved (20/20 and 20/40). CNV recurred in 29%. CONCLUSIONS Some patients with subfoveal CNV appear to benefit from surgical removal. Only rarely do eyes with ARMD improve. Longer-term follow-up and refined case selection are required before this approach can be widely recommended.

Vitrectomy for Premacular Fibroplasia: Prognostic Factors, Long-term Follow-up, and Time Course of Visual Improvement

Two hundred seventy eyes with premacular fibroplasia consecutively treated by pars plana vitrectomy and membrane peeling were reviewed. This study is among the largest series with long-term follow-up reported to date. Visual improvement of two or more lines was achieved in 43% of eyes at 6 to 12 months, in 54% at 1 to 2 years, in 60% at 2 to 3 years, and in 58% at 3 to 5 years. Overall, complications occurred in 34 eyes (13%). Cataract progression after vitrectomy was noted in 106 (57%) of phakic eyes at 3 to 5 years, and 43 of these eyes underwent subsequent cataract extraction. Mean time to best visual acuity after vitrectomy was slightly less than 1 year for all eyes unless they had cataract worsening with subsequent cataract extraction (1.9 years). Significant factors affecting visual outcome were: preoperative lens status, visual acuity before vitrectomy, duration of preoperative symptoms of distortion and/or blurred vision, and the occurrence of intraoperative complications.

Vitrectomy Without Scleral Buckling for Primary Rhegmatogenous Retinal Detachment

Trans pars plana vitrectomy with air-fluid exchange was performed on 29 selected cases of primary rhegmatogenous retinal detachment in which scleral buckling would be the usual surgical approach. The group contained 20 phakic eyes, two aphakic eyes, and seven pseudophakic eyes; the macula was detached preoperatively in 17 eyes (66%). The reattachment rate after one operation was 79% (23 of 29 eyes); after two operations this increased to 93% (27 of 29 eyes). Visual acuities of 20/50 or better were achieved in 22 of 27 successfully treated cases (81%). Vitrectomy without scleral buckling may allow retinal reattachment with excellent visual results in selected cases of primary rhegmatogenous retinal detachment.

Outcome results in macular hole surgery: An evaluation of internal limiting membrane peeling with and without indocyanine green

PURPOSE To evaluate the anatomic closure rate and visual outcome in patients undergoing pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling with and without indocyanine green (ICG) enhancement. DESIGN Retrospective, noncomparative interventional case series. PARTICIPANTS One hundred ninety-three consecutive patients (204 eyes) seen at the Barnes Retina Institute with the clinical diagnosis of macular hole who underwent PPV between January 1998 and December 2000. INTERVENTION A consecutive series of 97 patients undergoing PPV with or without unilateral epiretinal membrane removal without ILM peeling (group 1), 44 patients with PPV and ILM peeling without ICG (group 2), and 35 patients with ICG-assisted ILM peeling (group 3). RESULTS Overall, 86.4% of the holes closed with one operation, with 75 of 97 (77.3%) eyes in group 1, 43 of 44 (97.7%) eyes in group 2, and 34 of 35 (97.1%) eyes in group 3 (chi(2)= 10.51, P = 0.007). Of the eyes that did not close, 18 patients in group 1 underwent repeat surgery, with 90 of 97 (92.8%) eyes ultimately achieving closure. Visual acuity after surgery was 20/50 or better in 55 of 97 (56.7%) patients, 31 of 44 (70.4%) patients, and 18 of 35 (51.4%) patients in groups 1, 2, and 3, respectively (chi(2) = 3.43, P = 0.18) and increased by 2 or more lines from their preoperative status in 63 of 97 (64.9%) patients, 34 of 44 (77.3%) patients, and 25 of 35 (71.4%) patients, respectively (chi(2)= 2.25, P = 0.32). Multivariate logistic regression demonstrated that use of ILM peeling during vitrectomy increases the chances of developing 20/50 vision or better (odds ratio [OR], 2.4; 95% confidence interval, 1.06-5.45; P = 0.04). No eyes received concurrent cataract extraction with macular hole surgery, but 75 of 166 (45.2%) required cataract extraction postoperatively. Complications included 20 retinal tears, 4 retinal detachments, and 34 patients with postoperative elevations in intraocular pressure (IOP; defined as IOP greater than 30 mmHg). CONCLUSIONS Although this study is limited by the shorter follow-up in patients undergoing ILM peeling with or without ICG relative to the control group, our experience indicates that the use of ILM peeling is associated with a statistically significant improvement in the rate of primary macular hole closure with a single operation.

Vitrectomy for Prevention of Macular Holes: Results of a Randomized Multicenter Clinical Trial

PURPOSE: The purpose of this study is to assess the benefit of vitreous surgery in preventing full-thickness macular holes in patients with impending (stage 1) macular holes. METHODS: A prospective randomized multicenter clinical trial was conducted on patients with full-thickness macular holes in their first eye (stage 3 or 4) and signs and symptoms of stage 1 macular holes in their fellow eye (study eye). The study eye was randomized to vitreous surgery or observation. Outcome was assessed by standardized measurement of visual acuity, detailed clinical examination, fundus photographs, and fluorescein angiography. RESULTS: A full-thickness macular hole developed in 10 (37%) of 27 patients in the vitrectomy group compared with 14 (40%) of 35 patients randomized to observation (P = 0.81). This difference of 3% has a 95% confidence interval of (-21%, 27%). CONCLUSION: The study was terminated because of low recruitment. The authors were unable to prove (or disprove) the benefit of vitreous surgery in patients with stage 1 macular holes. The authors can state, however, that should a beneficial effect from vitrectomy exist, it would probably be minimal. Considering the cost and morbidity of vitreous surgery, a conservative approach for stage 1 macular hole might be appropriate.Purpose: The purpose of this study is to assess the benefit of vitreous surgery in preventing full-thickness macular holes in patients with impending (stage 1) macular holes. Methods: A prospective randomized multicenter clinical trial was conducted on patients with full-thickness macular holes in their first eye (stage 3 or 4) and signs and symptoms of stage 1 macular holes in their fellow eye (study eye). The study eye was randomized to vitreous surgery or observation. Outcome was assessed by standardized measurement of visual acuity, detailed clinical examination, fundus photographs, and fluorescein angiography. Results: A full-thickness macular hole developed in 10 (37%) of 27 patients in the vitrectomy group compared with 14 (40%) of 35 patients randomized to observation ( P = 0.81). This difference of 3% has a 95% confidence interval of (-21%,27%). Conclusion: The study was terminated because of low recruitment. The authors were unable to prove (or disprove) the benefit of vitreous surgery in patients with stage 1 macular holes. The authors can state, however, that should a beneficial effect from vitrectomy exist, it would probably be minimal. Considering the cost and morbidity of vitreous surgery, a conservative approach for stage 1 macular hole might be appropriate.

Traumatic macular hole: observations, pathogenesis, and results of vitrectomy surgery.

PURPOSE To review our experience with vitrectomy surgery techniques for the treatment of traumatic macular holes and the biomicroscopic and surgical findings. DESIGN Retrospective noncomparative, multicenter, case series. PARTICIPANTS AND INTERVENTION Twenty-five patients with traumatic macular hole underwent surgical repair. INTERVENTION Vitrectomy with membrane peeling and gas injection followed by prone positioning for 7 to 14 days. MAIN OUTCOME MEASURES Postoperative evaluation included visual acuity testing, closure of the macular hole, and ocular complications. RESULTS The macular hole was successfully closed in 24 of 25 cases (96%). The visual acuity improved two or more lines in 21 (84%) cases, and 16 (64%) achieved 20/50 or better vision. CONCLUSIONS Vitrectomy surgery can successfully close macular holes associated with trauma and improve vision.

Pseudophakic Retinal Detachments in the Presence of Various IOL Types

A series of 600 pseudophakic retinal detachments in 578 patients undergoing surgical repair between 1974 and 1984 was reviewed. Patients with previous retinal surgery of less than six months follow-up were excluded. The series included 395 iris-fixated (IF) lenses, 130 anterior chamber (AC) lenses, and 75 posterior chamber (PC) lenses. The overall success rate for retinal detachment was 88% but was significantly better in the PC lens group and significantly worse in the AC lens group. Forty-one percent of all cases achieved 20/40 visual acuity or better, although the AC lens group did worse (28%), while the PC lens group did significantly better (48%). Risk factors that were predictive of failure also were identified. Many of these factors occurred more frequently in the AC lens group and probably are related to the overall worse outcome in eyes with AC lens implants. The implications of these results for retinal and cataract surgeons are discussed.

New Retinal Detachment after Pneumatic Retinopexy

Thirteen cases of rhegmatogenous retinal detachment repaired by pneumatic retinopexy were reviewed retrospectively. All patients were followed for a minimum of 6 months after surgery. At the end of follow-up, retinal detachment repair by pneumatic retinopexy succeeded in nine cases (70%) and failed in four (30%). Within 2 days of pneumatic retinopexy, vitreous condensation and traction with new retinal tears and associated detachments in previously uninvolved quadrants developed in two patients. The occurrence of new retinal detachments in the early postoperative period after pneumatic retinopexy has not been previously observed.

Persistent endophthalmitis after intravitreal antimicrobial therapy

PURPOSE To assess the frequency of persistent infection after injection of intravitreal antimicrobials as therapy for endophthalmitis and to determine if persistent infection influences the final visual outcome after treatment. METHODS In a series of 42 eyes with culture-positive endophthalmitis of various types, the authors performed a second vitreous culture and injection of antimicrobial agents in 22 eyes. Repeat cultures were obtained 3 to 8 days after initial therapy in 20 of the 22 eyes. RESULTS Twelve of the 22 eyes were persistently culture-positive. Organisms identified in the persistently culture-positive eyes included staphylococcal species (n = 4), Streptococcus (n = 4), Serratia (n = 1), Propionibacterium acnes (n = 1), and fungi (n = 2). Eyes in which the initial antimicrobial therapy failed to eradicate a bacterial infection had a worse outcome than those that were culture-negative on repeat sampling. Final visual acuity of 20/200 or better after repeat injection was attained in 4 of the 12 culture-positive eyes. CONCLUSION A single injection of intravitreal antimicrobial agents may be insufficient to cure some cases of endophthalmitis, and a second injection should be considered in some circumstances.

Intravitreal Bevacizumab for Choroidal Neovascularization in Ocular Histoplasmosis

PURPOSE To define the role of intravitreal bevacizumab in individuals with choroidal neovascularization (CNV) resulting from Ocular Histoplasmosis syndrome (OHS). DESIGN Retrospective chart review of a surgical therapy. METHODS We reviewed the course of 28 eyes of 28 patients who underwent intravitreal injection of bevacizumab for treatment of CNV secondary to OHS. Outcome was measured by pretreatment and posttreatment visual acuity (VA). RESULTS The average pretreatment logarithm of the minimum angle of resolution (logMAR) VA was 0.65 (Snellen equivalent of 20/88). Mean follow-up was 22.43 weeks with an average of 1.8 intravitreal injections. Average final logMAR VA was 0.43 (Snellen equivalent of 20/54). Twenty eyes (71%) experienced an increase in central VA, whereas four eyes (14%) were unchanged and four eyes (14%) experienced a decrease in vision. CONCLUSIONS Intravitreal bevacizumab may improve or stabilize VA in a significant majority of patients with neovascular complications of OHS (24 eyes [85.7%] in our study population).