Raymond R. Margherio

Photocoagulation Treatment of Proliferative Diabetic Retinopathy: The Second Report of Diabetic Retinopathy Study Findings

Data from the Diabetic Retinopathy Study (DRS) show that photocoagulad inhibited the progression of retinopathy. These beneficial effects were noted to some degree in all those stages of diabetic retinopathy which were included in the Study. Some deleterious effects of treatment were also found, including losses of visual acuity and constriction of peripheral visual field. The risk of these harmful effects was considered acceptable in eyes with retinopathy in the moderate or severe retinopathy in the moderate or severe proliferative stage when the risk of severe visual loss without treatment was great. In early proliferative or severe nonproliferative retinopathy, when the risk of severe visual loss without treatment was less, the risks of harmful treatment effects assumed greater importance. In these earlier stages, DRS findings have not led to a clear choice between prompt treatment and deferral of treatment unless and until progression to a more severe stage occurs.

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.

COMPARISON OF RECOMBINANT TRANSFORMING GROWTH FACTOR-BETA-2 AND PLACEBO AS AN ADJUNCTIVE AGENT FOR MACULAR HOLE SURGERY

OBJECTIVE This study aimed to compare the visual and anatomic results of macular hole surgery in eyes treated with recombinant transforming growth factor-beta-2 (TGF-beta2) or placebo. DESIGN The design was a prospective, multicenter, randomized, double-masked, placebo-controlled clinical study. PARTICIPANTS One hundred thirty eyes with idiopathic macular holes of 1 year or less and a refracted Early Treatment Diabetic Retinopathy Study visual acuity of 20/80 or worse were treated with 1.1 microg recombinant TGF-beta2 or placebo to the macular hole after fluid-gas exchange. INTERVENTION The effect of recombinant TGF-beta2 as an adjunctive agent for macular hole surgery was evaluated. MAIN OUTCOME MEASURES Closure of the macular hole and change in visual acuity at 3 months were measured. RESULTS The 3-month visits were completed for 120 eyes. The macular hole was closed at 3 months in 35 (61.4%) of 57 eyes treated with placebo and 49 (77.8%) of 63 eyes treated with recombinant TGF-beta2 (P = 0.08). The mean visual acuity gain was +6.4 letters in eyes receiving placebo and +8.9 letters in eyes treated with recombinant TGF-beta2 (P = 0.27). Visual acuity improved 2 or more lines in 23 (40.4%) of 57 eyes treated with placebo and 30 (47.6%) of 63 eyes treated with recombinant TGF-beta2 (P = 0.42). Intraocular pressure elevation greater than 30 mmHg was more common 2 weeks after surgery in eyes treated with recombinant TGF-beta2 (P < 0.001). CONCLUSIONS Recombinant TGF-beta2 resulted in a similar proportion of successful closure of macular holes as placebo. There was no statistically significant visual acuity benefit with the use of recombinant TGF-beta2 for the treatment of macular holes.

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.

Vitrectomy for chronic pseudophakic cystoid macular edema

PURPOSE We report the results of pars plana vitrectomy for chronic pseudophakic cystoid macular edema unresponsive to medical treatment. METHODS Retrospective analysis of 23 consecutive eyes of 23 patients with chronic pseudophakic cystoid macular edema was performed. Eyes with vitreous incarceration into the cataract wound or vitreous-cornea contact were excluded from the study. Preoperatively, all eyes had cystoid macular edema confirmed on fluorescein angiography and were unresponsive to medical treatment. Pars plana vitrectomy was performed using standard techniques and vitreous adhesions to the iris, intraocular lens, or both were lysed if present. RESULTS The mean interval between cataract surgery and vitrectomy was 32.3+/-30.9 months (median, 20 months; range, 3 to 110 months). The vitreous was adherent to the iris or intraocular lens in 12 eyes (52.2%) and was present in the anterior chamber with no evidence of adhesions in seven eyes (30.4%). In four eyes (17.4%) the vitreous was posterior to the iris plane with no adhesions to anterior segment structures. The median preoperative best-corrected visual acuity was 20/200, and the median final postoperative best-corrected visual acuity was 20/60 (P<.0001) after a mean follow-up of 30.2+/-31.2 months (median, 14 months; range, 2 to 109 months). Final best-corrected visual acuity improved by a mean of 3.3+/-2.6 Snellen lines, with a median percent change of 70% (mean, 57.3%; range, 0% to 99%). In all 23 eyes the cystoid macular edema resolved postoperatively by biomicroscopic examination in a mean period of 3.3 months (median, 2 months; range, 1 to 12 months). CONCLUSIONS In pseudophakic eyes with chronic cystoid macular edema unresponsive to medical treatment, vitrectomy resulted in resolution of the cystoid macular edema with improved visual acuity in some cases. Clinical improvement may occur in eyes with no apparent vitreous disturbance.

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

Vitrectomy for chronic macular holes.

Purpose: To address the efficacy of surgical intervention for chronic macular holes. Methods: The cases of 22 patients (23 eyes) who underwent pars plana vitrectomy with or without internal limiting membrane (ILM) peeling and use of 10% to 16% C3F8 gas for macular holes of duration of >1 year (mean, 4.2 years; range, 1.2–15 years) were retrospectively reviewed. Preoperative visual acuity ranged from 20/60 to 5/200 (mean, 20/278). Thirteen eyes (56.5%) had stage 3 macular holes, and 10 eyes (43.5%) had stage 4 macular holes. The mean age of the patients was 70.2 years (range, 47–78 years), and 20 (87%) were female. Results: Nineteen (83%) of 23 macular holes were closed at final follow-ups at ≥9 months (mean, 4.67 years; range, 0.9–10.8 years). With one operation that included ILM peeling, 13 (81%) of 16 eyes had holes that closed. Seven eyes on which initial surgery without ILM peeling failed underwent reoperation with ILM peeling, and all but one had closed holes. ILM peeling was significant for surgical success of one operation (Fisher exact test, P = 0.0005). Postoperative visual acuity ranged from 20/30 to 20/800 (mean, 20/166). Improved vision with halving of the visual angle occurred in 16 eyes (70%). Nine eyes (39%) achieved visual acuity of 20/70 or better, and two eyes (8.7%) achieved visual acuity of 20/40 or better. One eye (4%) had worse visual acuity, and three eyes (13%) remained unchanged. Cataract was a possible cause of decreased vision in six eyes (26%) at the end of follow-up. Conclusion: Chronic macular holes can be surgically closed with visual improvement in most patients. ILM peeling is an important surgical factor for closure of the macular hole with one operation.

Preoperative fluorescein angiographic features of surgically removed idiopathic epiretinal membranes.

Purpose To determine whether preoperative fluorescein angiograms can be used to predict visual prognosis in eyes undergoing surgical removal of idiopathic epiretinal membranes. Methods A retrospective study of preoperative fluorescein angiographic findings in cases of idiopathic epimacular membrane removal during vitreous surgery was conducted. Of 422 consecutive cases, 229 met the criteria for minimum follow-up period of 6 months. Angiograms from these 229 cases were analyzed in a standardized, masked fashion for macular edema, retinal vascular distortion, and contraction of the foveal avascular zone. Results Visual improvement was greatest in 7 eyes (3%) with the most severe degree of macular edema (P = 0.0215). No difference in visual outcome was noted between eyes with less severe macular edema or no macular edema. Change in visual acuity was not associated with the extent of retinal vascular distortion (P = 0.477) or contraction of the foveal avascular zone (P = 0.248) Conclusion The presence of macular edema on preoperative fluorescein angiography is not predictive of a poor visual outcome in eyes undergoing surgery for idiopathic epiretinal membranes. In general, preoperative fluorescein angiography is not useful in predicting visual prognosis in these cases.

Surgical Management of Vitreomacular Traction Syndromes

A series of 106 consecutive symptomatic eyes considered to be at high risk for idiopathic macular holes developing underwent pars plana vitrectomy with membrane peeling. One of three types of vitreomacular traction was noted intraoperatively in all the eyes. The elimination of the vitreomacular traction resulted in improved vision in 89% of the eyes, no change in 7%, and decreased vision in 4%. A total of 62% of the patients were women (median age, 67 years). Follow-up ranged from 6 months to 118 months (average, 35 months). Complications included accelerated nuclear sclerosis in 16% and a 2% incidence of retinal detachment, macular pucker, and macular holes.