Philip J. Ferrone

Vitrectomy for diffuse diabetic macular edema associated with a taut premacular posterior hyaloid

PURPOSE To evaluate the role of vitrectomy in eyes with diffuse diabetic macular edema associated with a taut posterior hyaloid. METHODS Records of 55 eyes of 50 patients with diabetic retinopathy and diffuse clinically significant diabetic macular edema who underwent vitrectomy with stripping of the premacular posterior hyaloid were reviewed. In all 55 eyes, diffuse diabetic macular edema was present on contact lens examination and confirmed with fluorescein angiography. On fundus examination, the premacular posterior hyaloid was attached and appeared taut. RESULTS The mean preoperative best-corrected visual acuity was 20/160, and the mean final best-corrected visual acuity was 20/80 (P <.0001, Wilcoxon signed rank test), with 27 (49.1%) of the 55 eyes demonstrating improvement in best-corrected visual acuity of 2 or more lines. Fifty-two (94.5%) of the 55 vitrectomized eyes showed improvement in clinically significant macular edema and in 45 eyes (81.8%) the macular edema resolved completely during a mean period of 4.5 months (range, 1 to 13 months). Eyes with macular ischemia and preoperative best-corrected visual acuity of 20/200 or less tended to respond less favorably to vitrectomy than eyes lacking these characteristics. All eyes had at least 6 months of follow-up after surgery, with a mean follow-up of 23.2 months. CONCLUSION In eyes with persistent diffuse diabetic macular edema with a taut premacular posterior hyaloid face unresponsive to laser therapy, vitrectomy with removal of the posterior hyaloid appears to be beneficial in some cases. Careful selection of eyes with favorable preoperative clinical characteristics may improve surgical outcomes.

Telemedical evaluation and management of retinopathy of prematurity using a fiberoptic digital fundus camera

OBJECTIVE We sought to determine whether retinopathy of prematurity (ROP) can be evaluated and managed telemedically. DESIGN Multicenter noncomparative case series. PARTICIPANTS Ten patients (19 eyes) with ROP were evaluated and treated per standard of care and imaged with the RetCam 120 digital fundus camera (Massie Research Laboratories, Inc., Dublin, CA). INTERVENTION Images were transmitted to a remote site for evaluation and management recommendations. MAIN OUTCOME MEASURES Telemedical evaluations and management recommendations were compared with traditional on-site standard of care evaluations and treatments. RESULTS The identification of Plus disease at the remote site was accurately identified in 95% of eyes. Prethreshold, threshold, and stage 4 or 5 ROP were correctly detected in 17 of 19 (89%) eyes. CONCLUSIONS Results indicate ROP can be evaluated and treatment recommendations made at remote sites with telemedicine strategies.

PLASMIN ENZYME-ASSISTED VITRECTOMY IN TRAUMATIC PEDIATRIC MACULAR HOLES

OBJECTIVE This study aimed to evaluate the benefit of plasmin enzyme-assisted macular hole surgery on a consecutive series of pediatric patients with traumatic macular holes. DESIGN Prospective noncomparative case series operated on at William Beaumont Hospital between July 13, 1996, and November 16, 1996, and observed for at least 6 months. PARTICIPANTS During this interval, the authors operated on four eyes from four consecutive patients who were 14 years of age or younger with traumatic macular holes. INTERVENTION The patients underwent plasmin enzyme-assisted pars plana vitrectomy with membrane peeling, fluid-gas exchange, and postoperative positioning. The enzyme used was 0.4 international unit (IU) of autologous plasmin enzyme. MAIN OUTCOME MEASURES Snellen lines of improvement in visual acuity and rate of final visual acuity of 20/40 or greater, and incidence of complications and reoperations were measured. RESULTS All four macular holes were closed successfully. Follow-up was from 6 to 12 months. There were no reoperations. Visual acuity improved from four to eight lines in all eyes. Three eyes (75%) achieved a postoperative visual acuity of 20/40 or better. Three eyes (75%) had transient, posterior, subcapsular cataracts develop: two of the eyes after surgery and one as a result of the initial injury. CONCLUSION The treatment of pediatric traumatic macular holes with plasmin enzyme-assisted vitrectomy, membrane peeling, and gas-fluid exchange resulted in closure of the macular holes with significant visual improvement.

A comparison of dense versus less dense diode laser photocoagulation patterns for threshold retinopathy of prematurity

OBJECTIVE To determine if the density of diode laser photocoagulation for the treatment of zone 1 or zone 2 threshold retinopathy of prematurity (ROP) affects the rate of progression of the disease. DESIGN Retrospective, nonrandomized, comparative trial (n = 12) and prospective, randomized, clinical trial (n = 46). PARTICIPANTS Two surgeons treated a total of 107 eyes from 58 patients with zone 1 or zone 2 threshold ROP within 72 hours of diagnosis. The two consecutive groups of patients were treated with two different diode laser photocoagulation patterns between May 1995 and October 1997 and were observed for at least 3 months. INTERVENTION All patients underwent diode laser photocoagulation of the peripheral avascular retina extending from the ridge of extraretinal proliferation to the ora serrata. One cohort received a near confluent laser pattern, whereas the second cohort received a pattern of laser spots placed 1 to 1.5 burn widths apart. MAIN OUTCOME MEASURES Anatomic outcome, rate of progression to stage 4 or 5 retinopathy of prematurity, postoperative complications, and timing and frequency of retreatment. RESULTS For analysis, the retrospective and randomized outcome data were grouped. The rate of progression in the near confluent laser treatment group was 3.6% overall, 0% of zone 1 eyes, and 3.8% of zone 2 eyes. The rate of progression in the less dense treatment group was 29% overall, 44% of zone 1 eyes, and 21 % of zone 2 eyes. Mean time to retreatment was 16 days in cohort 1 and 24 days in cohort 2. CONCLUSIONS A dense pattern of diode laser treatment for threshold ROP and prompt retreatment for residual plus disease significantly reduce the rate of progression in eyes with zone 2 disease (P = 0.02) and may be beneficial in eyes with zone 1 disease.

Successful closure of traumatic macular holes.

PURPOSE To establish the efficacy of vitreoretinal surgery without the use of transforming growth factor-beta or autologous platelet concentrate in the repair of traumatic macular holes. METHODS This retrospective review consisted of 16 eyes from 16 consecutive patients treated by five vitreoretinal surgeons at a single institution between 1993 and 1997. Intervention included pars plana vitrectomy with creation of posterior vitreous detachment, placement of 14% to 16% C3F8 gas, and postoperative face-down positioning. Ten eyes received intraoperative autologous plasmin to facilitate formation of posterior vitreous detachment. Main outcome measures were anatomic closure rate and visual outcome. RESULTS Anatomic closure of the macular holes was achieved in 15 (94%) of 16 eyes, with an average follow-up of 7 months. Six (38%) eyes achieved visual acuity of 20/40 or better. Visual acuity improved by 2 or more lines in 11 (69%) of 16 eyes. The average preoperative logMAR-converted visual acuity of 20/175 improved to 20/60 postoperatively. CONCLUSION Traumatic macular holes can be closed successfully with substantial visual recovery without the use of transforming growth factor-beta or platelet concentrate.

External versus internal approach to the removal of metallic intraocular foreign bodies.

Objective: To review the management of metallic intraocular foreign bodies (IOFB) at a single institution and to compare the use of internal and external approaches for their removal. Subjects and Methods: A retrospective review was conducted on 70 eyes from 70 patients who underwent surgical removal of a metallic IOFB with either an internal (vitrectomy followed by forceps or internal magnet use) or external approach (large electromagnet) by seven vitreoretinal surgeons at a single institution between 1973 and 1996. Visual acuity and complications occurring with the two approaches were the main outcome measures studied. Results: Overall, patients showed significant improvement in visual acuity following surgical intervention (P < 0.001) despite widely varying surgical techniques. When the authors compared patients treated with an external versus an internal approach they found no statistically significant difference with regard to visual outcome and a trend toward a higher rate of postoperative endophthalmitis in the external approach group. Conclusion: Surgical removal of metallic IOFB results in significant visual improvement. The external approach to the removal of magnetic metallic IOFB remains a viable treatment option in select cases. RETINA 20:364‐369, 2000

Management of macular holes that develop after retinal detachment repair.

PURPOSE To study the characteristics and management of macular holes that develop after prior rhegmatogenous retinal detachment (RD) repair. DESIGN Retrospective, interventional, consecutive case series. METHODS The setting was a clinical practice. The case records of all of our patients (n = 12) who developed a new full-thickness macular hole after prior RD repair over an 8-year period were examined. Patients who developed a macular hole after prior RD repair were offered either surgical repair of the macular hole or continued observation. For eyes that underwent macular hole repair, main outcome measures included macular attachment status and postoperative visual acuity. RESULTS Twelve full-thickness macular holes were detected in a series of 2,380 eyes (0.5% prevalence), which had undergone surgery for prior primary RD. Ten macular holes developed after scleral buckling surgery, two after pneumatic retinopexy, and none were seen after primary vitrectomy. The fovea had been detached in 11 of the 12 eyes at the time of RD. The median time to macular hole diagnosis after RD repair was 3.4 months (range, 0.3-161 months). Eight of the eight eyes (100%) undergoing surgical repair achieved macular reattachment with a median of 3.5 lines of visual improvement at a median of 14.8 months of follow-up. Seven of these eight eyes had an improvement in visual acuity of at least 3 Snellen lines, and four of the eight had at least 20/40 visual acuity postoperatively. Four eyes with macular holes were observed. CONCLUSIONS Macular holes developed in less than 1% of eyes that had previously undergone repair of rhegmatogenous RD. In our series, these atypical holes were seen predominantly after macula-off detachments, most commonly occurring after scleral buckling procedures. They were effectively repaired using conventional pars plana vitrectomy with long-acting gas tamponade and a variety of adjuvant therapies. A good visual outcome is possible with this approach.

Sensitivity of spiral computed tomography scanning for detecting intraocular foreign bodies.

OBJECTIVE The purpose of this study is to determine whether 3-mm computed tomography (CT) cuts are equivalent to 1-mm CT cuts for detecting small intraocular foreign bodies (IOFBs). DESIGN Experimental instrument validation study. PARTICIPANTS Seventy-two porcine eyes were divided into three groups. Each group had 0.5 ml of human blood injected into the vitreous cavity and were surgically implanted with IOFBs. INTERVENTION Each eye was surgically implanted with 0.5-mm metallic, 0.5-mm glass, or 0.5-mm stone IOFBs. Two additional eyes were left without IOFBs to serve as negative controls. MAIN OUTCOME MEASURES Axial CT images of both 3-mm and 1-mm thickness were obtained and analyzed in masked fashion by two separate neuroradiologists. RESULTS The sensitivity for detecting 0.5-mm metallic, 0.5-mm glass, and 0.5-mm stone IOFBs with 3-mm CT images was 100%. The sensitivity for detecting 0.5-mm metallic, 0.5-mm glass, and 0.5-mm stone IOFBs with 1-mm CT images was also 100% (confidence interval, 95%; range, 0.88-1.00). Two negative control eyes without IOFBs were also correctly evaluated by the neuroradiologists. CONCLUSIONS With modern spiral CT scanning, 3-mm cuts are as sensitive as 1-mm cuts for detecting small metallic, glass, and stone IOFBs.

Retinal tears and retinal detachment as factors affecting visual outcome after cataract extraction complicated by posteriorly dislocated lens material.

Purpose: To evaluate the incidence and effect on visual acuity of complicating factors such as retinal tears (RTs) and rhegmatogenous retinal detachment (RRD) in eyes with posteriorly dislocated lens fragments after cataract extraction. Methods: Retrospective consecutive series of patients presenting at a referral vitreoretinal practice with posteriorly dislocated lens material after cataract extraction over a period of 8 years. The presence of RT, RRD, endophthalmitis, and choroidal hemorrhage was noted, and their effect on visual outcome was studied. Results: A total of 307 eyes with posteriorly dislocated lens material after cataract extraction were identified. Fifty-eight eyes (19%) were managed medically (Group I), whereas the other 249 eyes (81%) underwent pars plana vitrectomy for removal of the lens material (Group II). Indications for surgical management included uncontrolled inflammation, elevated intraocular pressure, and large lens fragments. No eyes in Group I developed RT or RRD. Of the 249 Group II eyes, 13 (5%) were found to have RT, and 25 (10%) developed RRD. In Group II, choroidal hemorrhage and endophthalmitis were noted in 12 (5%) and 4 (2%) eyes, respectively. Fifty-one (88%) of 58 eyes in Group I and 138 (55%) of 249 eyes in Group II achieved a final visual acuity of 20/40 or better. Seven (54%) of the 13 eyes with RT and 9 (36%) of the 25 eyes with RRD achieved a final visual acuity of 20/40 or better. In the RRD group, 9 (56%) of the 16 macula-on eyes achieved a final visual acuity of 20/40 or better, whereas none of the 9 macula-off eyes had a final visual acuity of 20/40 or better. None of the 4 eyes with endophthalmitis and only 1 (8%) of the 12 eyes with choroidal hemorrhage had a final visual acuity of 20/40 or better. Five (62%) of eight eyes with retinal detachment treated with pneumatic retinopexy needed further treatment with scleral buckle to achieve anatomical reattachment. Conclusion: A good visual outcome (20/40 or better) is possible in eyes with posteriorly dislocated lens fragments after cataract extraction, even when retinal tears or macula-on retinal detachment is present. The presence of a macula-off retinal detachment, however, has a significant adverse effect on the visual outcome. Pneumatic retinopexy is not associated with retinal reattachment in many cases and is not preferred.

Management of complications in eyes containing two intraocular lenses

OBJECTIVE To describe the management of complications in eyes containing two intraocular lenses (IOLs). DESIGN A retrospective noncomparative case series. PARTICIPANTS Eight patients having a dislocated posterior chamber intraocular lens (PC IOL) and a secondary anterior chamber intraocular lens (AC IOL) participated. INTERVENTION Surgical treatment of complications, including mobile dislocated PC IOLs in five eyes and retinal detachment in three eyes, was performed. MAIN OUTCOME MEASURES Visual acuity and anatomic status were evaluated. RESULTS Dislocated PC IOLs were removed through a pars plana incision in five eyes and a limbal incision in three eyes. Retinal detachments were repaired in three eyes. With follow-up from 7 months to 6.5 years, visual acuities ranged from 20/25 to 20/40 in five eyes and 20/60 to 20/400 in the three eyes undergoing retinal detachment repair. CONCLUSION Eyes in which dislocation of a PC IOL occurs during or after cataract surgery may have significant complications develop. Successful surgical repair is more complex in the presence of a secondary AC IOL.