Periklis Brazitikos

Primary pars plana vitrectomy versus scleral buckle surgery for the treatment of pseudophakic retinal detachment: a randomized clinical trial.

Objective: To compare the anatomical and functional outcome of scleral buckle (SB) surgery with that of pars plana vitrectomy (PPV) alone in the treatment of primary rhegmatogenous pseudophakic retinal detachment (RD). Methods: In this prospective, randomized clinical trial, 150 eyes of 150 patients with pseudophakic RD and proliferative vitreoretinopathy (PVR) stage B or less were randomized to SB surgery (75 eyes) or primary PPV (75 eyes). SB surgery involved break localization, cryotherapy, placement of a circumferential 240 style 2.5-mm solid silicone band, combined with a local buckle when indicated, and transscleral drainage of subretinal fluid. PPV included extensive vitreous removal, perfluoro-n-octane injection or endodrainage of subretinal fluid to flatten the retina, cryopexy treatment of breaks, and fluid/air exchange with injection of 20% SF6. Postoperative follow-up was 1 year. Break diagnosis, operating time, intraoperative and postoperative complications, retinal reattachment rate for single as well as multiple surgeries, axial length changes, and best-corrected visual acuity at 1 year after surgery were the main outcome measures. Results: The number of eyes that were diagnosed with additional breaks interoperatively was higher in the PPV group (P = 0.004, &khgr;2 test). Mean operating time was significantly less (P = 0.0001, t-test) in the PPV group. With a single surgery, the retina was reattached in 62 eyes (83%) in the SB surgery group and in 71 eyes (94%) in the PPV group (P = 0.037, Fisher exact test). With subsequent surgeries, final anatomical reattachment was achieved in 71 cases in the SB surgery group and in 74 cases in the PPV group (P = 0.37, Fisher exact test). Mean axial length change at 1 year was 0.95 mm in the SB surgery group and 0.1 mm in the PPV group (P = 0.0001, t-test). Mean final best-corrected visual acuity (logMAR) was 0.40 in the SB surgery group and 0.33 in the PPV group (P = 0.26, t-test). Conclusions: Primary PPV offers potential advantages over SB surgery in the treatment of pseudophakic RD, including less operating time, accurate diagnosis of breaks, higher reattachment rate with a single surgery, and no postoperative axial length changes. Retinal reattachment rate with multiple surgeries and final visual acuity at 1 year were similar for SB surgery and PPV.

Primary vitrectomy with perfluoro-n-octane use in the treatment of pseudophakic retinal detachment with undetected retinal breaks.

PURPOSE This report describes the results of a prospective trial to evaluate the efficacy of pars plana vitrectomy (PPV) in conjunction with perfluoro-n-octane (PFO) as initial treatment of pseudophakic retinal detachment (RD) with no breaks diagnosed preoperatively. METHODS Fourteen consecutive eyes presenting with pseudophakic RD in which retinal breaks could not be identified preoperatively underwent primary PPV, internal microsurgical identification of the retinal breaks with endoillumination and noncontact wide angle viewing system, PFO retinal reattachment, transscleral cryopexy or endolaser treatment of breaks, PFO-air exchange, and final injection of 20% sulfur hexafluoride. In five eyes, a scleral buckle was also used. Mean follow-up period was 18 months. RESULTS In 13 of the 14 eyes in which no breaks had been identified preoperatively, breaks were diagnosed during surgery. Perfluoro-n-octane retinal attachment facilitated accurate microscopic treatment of retinal breaks. The retina was reattached with a single operation in all eyes. Eleven eyes had final visual acuity of 20/60 or better. Complications were minimal. CONCLUSIONS Pars plana vitrectomy in conjunction with PFO expression of subretinal fluid is effective in the initial treatment of pseudophakic RD with no preoperative diagnosis of retinal breaks.

Intravitreal adalimumab for refractory uveitis-related macular edema.

OBJECTIVE To evaluate the safety and efficacy of intravitreal adalimumab injections on refractory cystoid macular edema (CME) secondary to noninfectious uveitis. DESIGN Prospective, noncomparative, interventional case series. PARTICIPANTS Eight consecutive patients with controlled uveitis and chronic, refractory CME who had failed steroid treatment. INTERVENTION Intravitreal adalimumab injections were given monthly for 3 months. MAIN OUTCOME MEASURES Mean change in central retinal thickness (CRT) on optical coherence tomography (OCT); secondary objective was the mean change in best-corrected visual acuity (BCVA). RESULTS Five of the eight patients completed the 6-month follow-up. For all 5 patients, the changes in BCVA from baseline to 3 months were not statistically significant (P=0.070). Similarly, the change in BCVA from baseline to 6 months was not statistically significant (P=1.0). The mean CRT at baseline was 692 microm. The changes from baseline to 3 months were not statistically significant (P=0.466); the changes from baseline to 6 months were also not statistically significant (P=0.808). We did not observe any ocular or systemic adverse effects. CONCLUSIONS Intravitreal adalimumab showed no efficacy in improving BCVA or reducing CRT in patients with chronic uveitic macular edema.

Angiogenic Growth Factors and their Inhibitors in Diabetic Retinopathy

Diabetic retinopathy is considered one of the vision-threatening diseases among working-age population. The pathogenesis of the disease is regarded multifactorial and complex: capillary basement membrane thickening, loss of pericytes, microaneuryms, loss of endothelial cells, blood retinal barrier breakdown and other anatomic lesions might contribute to macular edema and/or neovascularization the two major and sight threatening complications of diabetic retinopathy. A number of proangiogenic, angiogenic and antiangiogenic factors are involved in the pathogenesis and progression of diabetic retinal disease, Vascular Endothelial Growth Factor (VEGF) being one of the most important. Other growth factors, which are known to participate in the pathogenesis of the disease, are: Platelet Derived Growth Factor (PDGF), Fibroblast Growth Factor (FGF), Hepatocyte Growth Factor (HGF), Transforming Growth Factor (TGF), Placental Endothelial Cell Growth Factor (PlGF), Connective Tissue Growth Factor (CTGF). Other molecules that are involved in the disease mechanisms are: intergrins, angiopoietins, protein kinase C (PKC), ephrins, interleukins, leptin, angiotensin, monocyte chemotactic protein (MCP), vascular cell adhesion molecule (VCAM), tissue plasminogen activator (TPA), and extracellular matrix metalloproteinases (ECM-MMPs). However, the intraocular concentration of angiogenic factors is counterbalanced by the ocular synthesis of several antioangiogenic factors such as pigment epithelial derived factor (PEDF), angiostatin, endostatin, thrombospondin, steroids, atrial natriuretic peptide (ANP), inteferon, aptamer, monoclonal antibodies, VEGF receptor blocker, VEGF gene suppressors, intracellular signal transduction inhibitors, and extracellular matrix antagonists. Growth stimulation or inhibition by these factors depends on the state of development and differentiation of the target tissue. The mechanisms of angiogenesis factor action are very different and most factors are multipotential; they stimulate proliferation or differentiation of endothelial cells. This review attempts to briefly outline the knowledge about peptide growth factor involvement in diabetic retinopathy. Further ongoing research may provide better understanding of molecular mechanisms, disease pathogenesis and therapeutic interactions.

Macular epiretinal membranes.

Epiretinal membranes (ERM) are a common finding in older patients. Although they may be associated with numerous clinical conditions, most epiretinal membranes occur in the absence of ocular pathology. Patients symptoms range from asymptotic to complaints of severe vision loss and metamorphopsia. Epiretinal membranes are commonly classified according to their density, to the seventy of retinal distortion and to associated biomicroscopic changes. Pars plana vitrectomy has been found to be effective in removing ERM from the macula, improving the visual acuity and decreasing metamorphopsia. Both idiopathic and secondary ERMs do well after surgery, although secondary ERMs showed a greater amount of improvement than idiopathic ones. Complications are frequent including accelerated postoperative nuclear sclerosis, retinal breaks and RD, macular edema, RPE and, occasionally, macular hole and hypotony. However only RD involving the macula have a worsening prognosis on final outcome

Lamellar macular holes: tomographic features and surgical outcome.

PURPOSE To categorize tomographically the distinct entity of lamellar macular holes (MH) and present the surgical outcomes in our patient cohort. DESIGN Prospective observational and interventional study. METHODS All cases were clinically diagnosed initially with slit-lamp biomicroscopy and confirmed with the use of optical coherence tomography (OCT)-3. Cases either were observed or underwent surgical intervention with a 25-gauge pars-plana vitrectomy (PPV) technique. Follow-up was at least 12 months for all cases and ranged from 12 to 46 months. Main outcome measures included closure of the lamellar MH following surgical intervention; best-corrected visual acuity (BCVA) preoperatively and postoperatively for the cases that underwent surgery. RESULTS We identified 32 eyes of 30 patients with lamellar MH diagnosed by OCT-3. Lamellar MHs were classified into 3 different categories: 1) associated with macular epiretinal membrane (ERM) (20 eyes), 2) secondary to cystoid macular edema (8 eyes), and 3) attributable to partial-thickness macular avulsion after acute posterior vitreous detachment (PVD) (4 eyes). Visual acuity was less affected in cases with an associated ERM. Surgery included PPV and ERM removal (when present), followed by internal limiting membrane (ILM) removal and 16% C(3)F(8) injection. Postoperatively, BCVA improved in 17 out of the 20 cases (85%) operated from the first group of patients; 3 cases retained the same BCVA preoperatively and postoperatively. Mean BCVA improvement in the first group was 2.6 Snellen lines, which was statistically significant (P = .002, paired t test). CONCLUSIONS Surgical treatment of lamellar MH associated with an ERM may result in preservation or improvement of visual acuity, by relieving the tangential traction caused by the ERM.

The Expanding Role of Primary Pars Plana Vitrectomy in the Treatment of Rhegmatogenous Noncomplicated Retinal Detachment

The surgical management of rhegmatogenous retinal detachment has evolved dramatically during the past 2 decades. Investigators have introduced and refined alternative techniques to scleral buckling surgery including pneumatic retinopexy and primary pars plana vitrectomy (PPV). Rapid parallel developments in instrumentation, including wide-angle viewing systems, perfluorocarbon liquids, novel vitrectomy machines, intraocular tamponades, and endolaser photocoagulators have led to increasing sophistication in primary PPV surgical techniques for the treatment of rhegmatogenous uncomplicated retinal detachment. However, the precise role of primary PPV in new uncomplicated retinal detachment remains debatable owing to the lack of controlled randomized trials. This article examines primary vitrectomy treatment for rhegmatogenous uncomplicated retinal detachment and presents the specific types of retinal detachments for which primary PPV may be optimal, according to personal and reported results, the surgical instrumentation and technique, as well as the complications and limitations of this surgical method

Acute Posterior Multifocal Placoid Pigment Epitheliopathy: Outcome and Visual Prognosis

Objectives: To examine the clinical outcomes and the effect of treatment in patients with acute posterior multifocal placoid pigment epitheliopathy. Methods: Cases of acute posterior multifocal placoid pigment epitheliopathy treated at the Massachusetts Eye and Ear Infirmary from 1990 to 2002 and cases from the literature were identified. Data on visual acuity, ocular symptoms, bilateral involvement, foveal involvement at presentation, and treatment regimens were recorded. Results: Visual acuity was 20/25 or worse in 226 (76.6%) eyes and 20/40 or worse in 172 (58.3%) eyes at presentation. At the last follow-up visit, visual acuity was 20/25 or less in 125 (42.3%) eyes and 20/40 or less in 70 (23.7%) eyes. Topical or systemic therapy was given in nearly half of the cases (54.4%). Overall, 87 (71.9%) eyes were symptomatic at last follow-up visit. Finally, measured visual acuity was more than 20/25 in 20 (87.5%) eyes without foveal involvement at presentation and in 28 (39.2%) eyes with foveal involvement. Conclusions: Although acute posterior multifocal placoid pigment epitheliopathy shows a relatively benign prognosis, especially when compared with some of the other white dot syndromes, there are patients who experience incomplete visual recovery.

Ultrasonographic classification and phacoemulsification of white senile cataracts

OBJECTIVE To classify the white senile cataracts and report the results of phacoemulsification of white cataracts. DESIGN Prospective, noncomparative case series. PARTICIPANTS One hundred eyes were included. INTERVENTION White cataracts were examined biomicroscopically before surgery, and their acoustic structure was analyzed with standardized A-scan echography. White cataract surgery was performed with phacoemulsification via a superior temporal near-limbus corneal approach using a bimanual divide-and-conquer or stop-and-chop technique. Patients were followed after surgery for a period of 9 months. MAIN OUTCOMES MEASURES The A-scan acoustic structure of white cataracts; successful accomplishment of capsulorrhexis; mean phacoemulsification time, power, and energy; intraoperative and postoperative complications of phacoemulsification; and visual acuity at 9 months after surgery. RESULTS White senile cataracts were categorized into three different types. Type I included intumescent, white cataracts with cortex liquefaction and high internal acoustic reflections (44 eyes), type II included white cataracts with voluminous nuclei, little amount of whitish solid cortex, and low internal acoustic reflections (49 eyes), and type III included white cataracts with fibrosed anterior capsule and low internal echospikes (7 eyes). Circular capsulorrhexis was completed in 79 eyes and was significantly less successful in eyes with type I intumescent, white cataracts compared with type II white cataracts (P = 0.0034). Mean phacoemulsification time and energy were higher in type II and type III white cataracts. Posterior capsule rupture occurred in ten eyes, and three of these eyes were complicated by vitreous loss. In 95 eyes, the posterior chamber lens was implanted in the capsular bag and in five eyes in the sulcus. After surgery, a transient corneal edema developed in 31 eyes. At the final 6-month examination, the mean postoperative visual acuity was 20/30. CONCLUSION Current phacoemulsification techniques can safely manage eyes with senile white cataracts. The increased risk of difficulty with continuous capsulorrhexis in type-I and type-III white cataracts and the substantial nuclear hardness in type-II and mainly type-III white cataracts would suggest that current phacoemulsification techniques might not be as successful in these patients as they are in ordinary earlier cataracts.

Perfluorocarbon liquid utilization in primary vitrectomy repair of retinal detachment with multiple breaks.

Purpose To evaluate the efficacy of pars plana vitrectomy in conjunction with intraoperative perfluoro-n-octane (PFO) use as initial treatment of retinal detachment (RD) with multiple breaks located at various distances from the ora serrata. Methods Twenty-two consecutive eyes (15 phakic, 2 aphakic, and 5 pseudophakic) presenting with RD with multiple breaks and tears underwent primary pars plana vitrectomy, PFO retinal reattachment, transcleral cryopexy or endolaser treatment of breaks, PFO/air exchange, and final injection of 18% perfluoropropane (C3F8). Scleral buckles were not used. The mean follow-up period was 29 months. Results Temporary PFO utilization attached the posterior retina and facilitated the safe removal of vitreous at its base and around the retinal tears. Intraoperative complications included new breaks (3 eyes), enlargement of breaks (2 eyes), and a small bubble of subretinal PFO (1 eye). Postoperatively, the retina remained attached during follow-up in 19 eyes. Cataract developed or progressed in 13 phakic eyes. Conclusions Pars plana vitrectomy in conjunction with intraoperative PFO utilization is effective as initial treatment of RDs with multiple breaks. The main limitation of this technique is the postoperative progressive cataract formation in phakic eyes.