Michael A. Kapusta

Outcomes of dropped nucleus during phacoemulsification.

PURPOSE To evaluate the clinical outcome of vitrectomy in the management of dropped nucleus during phacoemulsification. METHOD Twenty-five consecutive patients who underwent pars plana vitrectomy for the management of dropped nucleus from phacoemulsification, over a 36-month period, were studied. Twenty-two patients underwent vitrectomy within 15 days of cataract surgery. Most of the patients were followed for more than 6 months. RESULTS Final visual acuity was 20/40 or better in 71% (17/24) of eyes and 20/50 in 8% (2/24). Visual acuity was 20/70 or worse in 21% (5/24) of patients. Complications included persistent cystoid macular edema in three eyes, epimacular proliferation in two eyes, and a choroidal detachment in one eye. CONCLUSION Poor visual outcome after dropped nucleus at phacoemulsification cataract extraction can be avoided if managed by prompt pars plana vitrectomy.

Ultrasound biomicroscopy of sclerotomy sites: the effect of vitreous shaving around sclerotomy sites during pars plana vitrectomy.

Purpose To study the difference in the amount of vitreous incarceration between conventional pars plana vitrectomy (PPV) and PPV with vitreous shaving around sclerotomy sites. Methods A dynamic in vivo examination using ultrasound biomicroscopy (UBM) was performed on the sclerotomy sites of 22 eyes after PPV. Patients were divided into two groups. In the study group (n = 11), the vitreous was completely shaved from the internal initial sclerotomy by cotton-tip depressed vitrectomy under coaxial illumination. In the control group (n = 11), no vitreous shaving was performed. Results Vitreous incarceration into sclerotomy sites was significantly less in the study group compared with the control group (P <0.001). No difference was seen among the three sclerotomy sites regarding vitreous incarceration within individual eyes. No difference was seen between eyes operated by right- and left-handed surgeons. Conclusions Vitreous shaving of sclerotomy sites using depressed vitrectomy significantly reduces vitreous incarceration. This may reduce the rate of sclerotomy-related complications following PPV in selected cases.

Management of optic disk pit-associated macular detachment with tisseel fibrin sealant.

BACKGROUND Optic disk pit-associated macular detachment is a challenging condition to treat. Many surgical methods have been used to treat this condition with varying degrees of success. METHODS We managed optic disk pit-associated macular detachment in three cases with pars plana vitrectomy, fluid-air exchange, drainage of subretinal fluid through the optic disk pit, application of Tisseel fibrin sealant (Baxter Healthcare Corporation, CA) to the optic disk pit, C3F8 gas injection, and postoperative prone positioning. RESULTS All three patients maintained flat maculae and had improved vision. Patient 3 had postoperative macular hole formation. This was managed successfully with pars plana vitrectomy, internal limiting membrane peeling, fluid-air exchange, and C3F8 gas injection. CONCLUSION Our case series suggest that Tisseel fibrin sealant in conjunction with pars plana vitrectomy can be used successfully for management of optic pit disk-associated macular detachments.

Visual function assessment and metamorphopsia after macular hole surgery

The purpose of this study was to develop a new resolution acuity measure for patients after macular hole surgery. Fifty eyes of 44 patients who had undergone successful treatment were tested. Visual acuity was measured with the Snellen, Early Treatment of Diabetic Retinopathy Study and Landolt‐C charts. A Line Resolution Test was performed as part of their follow‐up exam where a vertical line was presented. Participants were categorized by their perception of the line as solid, bent or broken. The line could be distorted into a sine‐wave pattern in order to determine the participants’ detection threshold for the distortion. Chart acuities did not differ among the three groups, as categorized by their line perception. Only the distortion measure was sensitive enough to differentiate the solid‐ from the broken‐line group. The distortion measure assesses resolution power of the macula in smaller increments than acuity charts. This hyperacuity approach is more appropriate in the assessment of functional outcome after microsurgery.

Preoperative B-scan ultrasonography of the vitreoretinal interface in phakic patients undergoing rhegmatogenous retinal detachment repair and its prognostic significance

PurposeTo perform ultrasonographic evaluation of the preoperative status of the posterior vitreoretinal interface in phakic patients undergoing surgery for retinal detachment (RD) with flap tear(s) and to investigate its relationship with postoperative anatomic and visual acuity outcomes.MethodsA prospective, consecutive case series including 50 phakic eyes of 49 patients with retinal detachment and flap tear(s) undergoing retinal detachment surgery by a single vitreoretinal surgeon, who was unaware of the patient’s preoperative B-scan ultrasonographic findings. Main outcome measures were comparisons between patients with partial versus complete posterior vitreous detachment (PVD) of primary retinal reattachment rates (retinal reattachment with a single surgical procedure), rates of retinal reattachment at month 12, and visual acuity outcomes at month 12.ResultsPartial PVD was observed in 22 (44%) eyes and complete PVD in 28 (56%) eyes. Eighteen eyes underwent pneumatic retinopexy, 15 underwent scleral buckling, and 17 underwent pars plana vitrectomy. Retinal reattachment with a single surgical procedure was achieved in 76% (38/50) of eyes, including 54.5% (12/22) of eyes with partial PVD at baseline and 92.9% (26/28) of eyes with complete PVD at baseline (P < 0.01). Stratification by type of surgical intervention demonstrated a significantly higher rate of primary anatomic success for pneumatic retinopexy among patients with complete PVD compared to partial PVD (P = 0.02). Retinal reattachment at month 12 was achieved in 100% (50/50) of eyes. At last follow-up, the mean (±SD) number of interventions was 1.70 (±1.10) for patients with partial PVD at baseline and 1.10 (±0.30) for patients with complete PVD (P < 0.01). There was no significant difference among the groups in mean change in visual acuity from baseline to month 12, nor in the distribution of visual acuities at month 12.ConclusionsIn phakic patients with retinal detachment and flap tear(s), a higher primary anatomic success rate may be associated with the presence of a complete PVD compared to a partial PVD. Subgroup analysis suggests that the presence of partial PVD at baseline might influence negatively the primary anatomic success rate, particularly for eyes undergoing pneumatic retinopexy.

Spatial judgments in patients with retinitis pigmentosa

Previous investigations into cortical plasticity in the presence of ocular disease have focused on central retinal damage. Perceptually, patients often report distortions of visual space which can be partially explained by perceptual filling-in. The mechanisms involved could also apply to peripheral field loss. Spatial interval discrimination was tested in 28 retinitis pigmentosa (RP) patients and a control group. When stimuli were presented to both hemispheres, bias did not differ whereas threshold was poorer in RP patients. When presenting the task to only one hemifield, bias was related to field asymmetry, but only in the left visual field, r(2)=.59. Brain laterality may be an important factor when examining changes in cortical function in response to peripheral system damage.

Hierarchical Linear Modeling of Visual Acuity Change Over Time: Rate of Functional Recovery After Macular Hole Surgery

Purpose. To examine acuity recovery rate after Macular Hole (MH) surgery, using Hierarchical Linear Modeling (HLM) with linear and curvilinear regression analysis. Methods. Preoperative MH diameter (OCT) and acuity (ETDRS) were recorded in 20 eyes. Acuities were tested during follow-up (6 to 23 months), with three to eight measurements per eye. The resulting 95 acuities were analyzed using HLM. Variability at the level of the person was explained by change over time, using a natural logarithm conversion. Across patients, MH diameter was used to predict slopes and intercepts at the level of the individual. Results. MH diameter was able to account for significant amounts of variability in preoperative acuity (intercept) and significantly influenced rate of functional recovery (slope). A nonlinear approach to the data accounted for the largest amount of variance. Conclusions. Participants with larger MHs recovered relatively more acuity sooner while eyes with smaller MHs had better absolute acuity outcome. HLM provides important insight into the recovery process after MH surgery and is more flexible with follow-up data. In the context of MH treatment, most recuperation occurred during the initial 6 months.

Vision Impairment by Choice: Why Do Patients Decline Macular Hole Surgery?

Introduction: Vision care providers generally assume that patients who are affected with treatable vision impairment are interested in appropriate medical options. It has been our clinical experience, however, that approximately 10% of macular hole (MH) patients opt to decline surgery, even though its beneficial effects have been well established. They, thereby, choose to remain visually impaired in the affected eye. The present study investigated visual acuity in the unaffected eye, living distance from the hospital, and the presence of other age-related medical conditions as possible factors in the decision-making process of seniors affected with MH. Method: Thirty patients (aged 59–81 years) who declined treatment between 1998 and 2003 were matched on age and gender with a group of patients who chose the surgical intervention during the same time period. Information from their medical files was used for statistical comparison. Results: The groups did not differ statistically with regard to acuity in th...

Preretinal hemorrhages as the presenting sign of subacute bacterial endocarditis.

Subacute bacterial endocarditis classically presents with systemic features, such as fever, anemia and a heart murmur. 1 We describe a patient with subacute bacterial endocarditis who presented with decreased vision and multiple preretinal hemorrhages. Investigations showed a congenital bicuspid aortic valve with perivalvular abscess and aortic insufficiency requiring urgent surgical intervention.

Ocriplasmin versus vitrectomy for the treatment of macular holes

OBJECTIVE To compare the anatomical and visual outcomes of patients with bilateral macular holes (MH) who have been treated with pars plana vitrectomy in one eye and intravitreal ocriplasmin in the fellow eye. DESIGN Multicentre, retrospective case series. PARTICIPANTS Twenty-two eyes of 11 patients with bilateral MH treated with vitrectomy in one eye and ocriplasmin in the other were included. Patients were followed-up by 5 vitreoretinal surgeons from 3 retinal practices in Canada. METHODS All charts were reviewed for data collection, and optical coherence tomography (OCT) scans pre- and posttreatment were evaluated. RESULTS MH closed primarily in 36.4% (n = 4) of the ocriplasmin-treated eyes and in 90.9% (n = 10) of the vitrectomy-treated eyes (p = 0.031). The 4 successfully treated ocriplasmin MH were preceded by a vitreomacular traction (VMT) release. Three additional ocriplasmin-treated eyes achieved a VMT release without MH closure. All persistent MH (100%) closed with subsequent vitrectomy, with no significant difference in final best-corrected visual acuity (BCVA) between those who achieved MH closure with primary or secondary interventions (p = 0.073). Final BCVA improved from logMAR 0.85 ± 0.34 to 0.37 ± 0.22 (p = 0.005) in the vitrectomy eyes and from 0.56 ± 0.28 to 0.28 ± 0.16 (p = 0.009) in the ocriplasmin eyes, with no significant difference in final BCVA between treatments (p = 0.306). Postoperative ellipsoid zone disruption persisted more frequently in vitrectomy-treated eyes. CONCLUSION Both procedures were associated with improved visual outcomes, but eyes initially treated with vitrectomy had a higher primary MH closure rate. On OCT, patients had more outer structural changes in vitrectomy eyes than in ocriplasmin eyes.