Paul E. Tornambe

Management of submacular hemorrhage with intravitreous tissue plasminogen activator injection and pneumatic displacement

OBJECTIVE To investigate the efficacy and safety of treating thick submacular hemorrhages with intravitreous tissue plasminogen activator (tPA) and pneumatic displacement. DESIGN Retrospective, noncomparative case series. PARTICIPANTS From 5 participating centers, 15 eligible patients had acute (<3 weeks) thick subretinal hemorrhage involving the center of the macula in eyes with pre-existing good visual acuity. Hemorrhages were secondary to age-related macular degeneration in 13 eyes and macroaneurysm and trauma in 1 eye each. METHODS The authors reviewed the medical records of 15 consecutive patients who received intravitreous injection of commercial tPA solution (25-100 microg in 0.1-0.2 ml) and expansile gas (0.3-0.4 ml of perfluoropropane or sulfur hexafluoride) for thrombolysis and displacement of submacular hemorrhage. After surgery, patients maintained prone positioning for 1 to 5 days (typically, 24 hours). MAIN OUTCOME MEASURES Degree of blood displacement from under the fovea, best postoperative visual acuity, final postoperative visual acuity, and surgical complications. RESULTS In 15 (100%) of 15 eyes, the procedure resulted in complete displacement of thick submacular hemorrhage out of the foveal area. Best postprocedure visual acuity improved by 2 lines or greater in 14 (93%) of 15 eyes. After a mean follow-up of 10.5 months (range, 4-19 months), final visual acuity improved by 2 lines or greater in 10 (67%) of 15 eyes and measured 20/80 or better in 6 (40%) of 15 eyes. Complications included breakthrough vitreous hemorrhage in three eyes and endophthalmitis in one eye. Four eyes developed recurrent hemorrhage 1 to 3 months after treatment, three of which were retreated with the same procedure. CONCLUSIONS Intravitreous injection of tPA and gas followed by brief prone positioning is effective in displacing thick submacular blood and facilitating visual improvement in most patients. The rate of serious complications appears low. Final visual outcomes are limited by progression of the underlying macular disease in many patients.

Macular hole surgery without face-down positioning. A pilot study

Purpose: To investigate whether postoperative face‐down positioning is necessary for successful macular hole repair. Background: Although never proven, face‐down positioning is strongly considered an important maneuver to achieve macular hole closure. Face‐down posturing is inconvenient, and for patients with physical or mental limitations, weeks of face‐down positioning may be an impossible task. A gas bubble that completely fills the vitreous cavity will tamponade a macular hole despite head position and may close a macular hole as effectively as a partial gas fill with face‐down positioning. If face‐down positioning were not necessary, more patients would be eligible to benefit from this surgery. Methods: Thirty‐three consecutive eyes in 31 patients aged 65‐79 years with Stage II, III, or IV full‐thickness macular holes underwent macular hole surgery with a complete 15% C3F8 vitreous fill. Hole duration varied from 1 month to 10 years; in 21% of eyes, (seven of 33) holes had been present for more than 1 year. All phakic eyes (n = 25) had cataract extraction with intraocular lens insertion when macular hole surgery was done. No patients were positioned face down. Results: The follow‐up period was 6‐40 months; 73% of the patients have been observed for more than 1 year. Preoperative hole duration did not affect hole closure rate. The success rate after one surgery was 79% (26 of 33 eyes), and with additional vitrectomy surgery, the total success rate was 85% (28 of 33 eyes). Forty‐eight percent of eyes attained visual acuity of 20/50. Eighty percent of eyes with preoperative acuity of > 20/100 attained > 20/50 acuity. Significant complications included iris incarceration into the cataract wound during a postoperative fluid‐gas exchange (one eye), posterior synechiae (four eyes), intraocular lens capture (two eyes), elevated intraocular pressure (three eyes), and retinal detachment (three eyes). Most of these problems can be avoided or reduced. Conclusion: This pilot study suggests that successful macular hole closure is possible without face‐down positioning. This technique may be an alternative for patients with macular holes in pseudophakic eyes who are unable to assume face‐down posturing. Combining cataract surgery with this technique for macular hole repair is reasonable for phakic patients who cannot maintain prone positioning. Major disadvantages of combined surgery include the morbidity of the second procedure and removal of a visually insignificant cataract. This approach should be considered for those patients unable to tolerate face‐down positioning.

Pneumatic retinopexy. A collaborative report of the first 100 cases.

The preliminary experience of one surgeon, using pneumatic retinopexy for 20 consecutive cases of rhegmatogenous retinal detachment, was previously reported. The collaborative experience of six surgeons using pneumatic retinopexy for 100 cases is now reported. This series includes cases with pseudophakia, aphakia, macular detachment, macular breaks, vitreous hemorrhage, trauma, and old detachments. Initially, 91% were reattached, but seven recurrences yielded a 6-month follow-up cure rate of 84% with pneumatic retinopexy. With subsequent scleral buckling, 98% were reattached. Postoperative complications included proliferative vitreoretinopathy (3%), macular pucker (3%), and new/missed retinal breaks (7%). A review of the literature disclosed postoperative new/missed retinal breaks in nine series: 21, 3, 8, 4, 9, 7, 5, 4, and 13%. There were no cases of glaucoma, cataract, subretinal gas, endophthalmitis, or extension of the detachment into a previously attached macula. Pneumatic retinopexy offers the advantages of reduced tissue trauma, fewer complications, no hospitalization, and less expense. The major disadvantage is the need for postoperative positioning.

Pneumatic retinopexy : a two-year follow-up study of the multicenter clinical trial comparing pneumatic retinopexy with scleral buckling

The authors report 2-year follow-up information on 179 of 198 eyes (90%) enrolled in a previously published multicenter, randomized, controlled clinical trial comparing pneumatic retinopexy (PR) with scleral buckling (SB) for the management of selected retinal detachments. Scleral buckling was compared with PR with regard to redetachment after the initial 6-month follow-up period (1% versus 1%), overall attachment (98% versus 99%), subsequent cataract surgery (18% versus 4%; P less than 0.05), preoperative visual acuity (no significant difference), and final visual acuity of 20/50 or better in eyes with macular detachment for a period of 14 days or less (67% versus 89%; P less than or equal to 0.05). Reoperations after a failed PR attempt did not adversely affect visual outcome. After 2 years, PR continues to compare favorably with SB.

Retinal Pigment Epitheliopathy after Macular Hole Surgery

BACKGROUND Full-thickness idiopathic macular holes were previously considered untreatable, but surgical intervention has been proposed to collapse the hole and improve vision. This study evaluates the fluorescein angiographic changes that occur after macular hole surgery. METHODS Sixteen patients with stage III idiopathic macular holes underwent pars plana vitrectomy, removal of the posterior hyaloid, peeling of fine epiretinal sheets along the edges of the holes, and fluid-gas exchange. Preoperative fluorescein angiograms were performed, and best-corrected preoperative visual acuity was 20/200 or less in all eyes. RESULTS Postoperatively, the macular hole disappeared in 12 eyes (75%). In all 12 eyes, retinal pigment epithelial swelling was present, with a unique fluorescein angiographic appearance. This pattern slowly resolved over months, with gradual visual improvement but residual retinal pigment epithelial mottling. Systemic and periocular steroids had no significant impact on the process. CONCLUSION The combination of prolonged intraocular gas contact and light exposure exceeding threshold for an already compromised macula appears to be responsible for this pigmentary pattern. Depending on the severity of the pigment epithelial alteration, this unique pattern may portend a guarded visual prognosis in affected patients undergoing successful macular hole repair.

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.

Macular hole genesis: the hydration theory.

&NA; Optical coherence tomography 3 images and a simple model suggest macular hole formation may be due to a defect in the inner retina with secondary vitreous fluid accumulation into the middle and outer retinal tissue.

PNEUMATIC RETINOPEXY: An Analysis of Intraoperative and Postoperative Complications

There have been 26 series (1,274 eyes) published on the use of pneumatic retinopexy for selected retinal detachments. Eighty percent were reattached with a single procedure and 98% with reoperations. New retinal breaks occurred in 13% and proliferative vitreoretinopathy in 4%. The three complications reported with pneumatic retinopexy but not with scleral buckling are subretinal gas, gas entrapment at the pars plana, and subconjunctival gas. Twenty-six complications of pneumatic retinopexy, most of which may also occur with scleral buckling, are discussed as to incidence, cause, prevention, and management.

Expanded Indications for Pneumatic Retinopexy

The Collaborative Pneumatic Retinopexy Study evaluated retinal detachments (RDs) secondary to one break or group of breaks no larger than 1 clock hour located within the superior 8 clock hours of the fundus. Eyes with prominent proliferative vitreoretinopathy (PVR) were excluded. Forty eyes which exceed these criteria and were treated with pneumatic retinopexy have been retrospectively evaluated to determine what preoperative conditions limit the application of pneumatic retinopexy. Multiple breaks in multiple quadrants, large tears up to 2.5 clock hours in size, and RDs associated with a moderate degree of PVR were successfully managed with pneumatic retinopexy. The greatest number of failures were due to inferior breaks. The overall success rate for pneumatic retinopexy was 75%. New breaks occurred in 12.5% of eyes, but all of these were successfully managed.

Interferon Alpha-2a for Subfoveal Neovascularization in Age-related Macular Degeneration

BACKGROUND The current study is a prospective randomized clinical trial to determine the effect of interferon alpha-2a on eyes with subfoveal subretinal neovascularization secondary to age-related macular degeneration (AMD). METHODS Twenty eyes of 19 patients with subfoveal neovascularization secondary to AMD were prospectively evaluated. Ten eyes were randomized to subcutaneous interferon alpha-2a (3 million units/m2) every other day for 8 weeks, whereas 10 eyes were randomized to observation alone as controls. Fluorescein angiography, best-corrected visual acuity tests, and macular visual field assessments were performed, and all eyes were followed for a minimum of 6 months. RESULTS At the 2-month follow-up visit, the interferon group manifested somewhat slower neovascular growth than controls, but the results were not statistically significant. At the 6-month follow-up visit, there was no difference in visual acuity, average macular sensitivities, or extent of neovascularization. The rate of neovascular progression was significantly related to the extent of previous macular photocoagulation in both groups. CONCLUSION Though the rate of neovascular progression was slowed during the second month of interferon treatment, the effect did not persist once interferon was discontinued. No long-term benefit appeared to be present. Unfortunately, lengthening the time of administration, increasing the dosage, or increasing the frequency of administration would likely give rise to unacceptable side effects.