Robert Biowski

Cataract surgery in patients with diabetic retinopathy: Visual outcome, progression of diabetic retinopathy, and incidence of diabetic macular oedema

AbstractBackground. Compared to non-diabetic patients, outcome after cataract surgery was reported to be worse in diabetic patients – especially in those with diabetic retinopathy. This prospective study was planned to evaluate visual outcome, progression of diabetic retinopathy, and incidence of clinically significant macular oedema (CSME) in a homogenous group of patients with non-proliferative diabetic retinopathy (NPDR) without CSME at baseline 1 year after cataract surgery. Methods. Over a period of 18 months, all consecutive patients with mild-to-moderate diabetic retinopathy who had cataract surgery with phacoemulsification and posterior chamber lens implantation were prospectively followed up. Outcomes were assessed 1 year postoperatively and included visual acuity (VA), progression of retinopathy, and incidence of CSME. Progression of retinopathy and incidence of CSME were compared to the non-operated fellow eyes. Results. Of 50 patients included, 42 completed the 1-year follow-up. VA improved in 85% of patients, and was better than 0,5 in 71%. Progression of retinopathy occurred in 12% of eyes after cataract surgery and in 10.8% of non-operated fellow eyes. No patient developed proliferative diabetic retinopathy in the operated eye. CSME occurred in 13 operated eyes (31%), five of them with retinal ischemia, and in five non-operated eyes (13.5%). Patients with ischemic macular oedema had the worst prognosis regarding VA. Conclusion. Modern cataract surgery seems to have no influence on the progression of diabetic retinopathy. A visual improvement is achieved in the majority of patients with NPDR, but poorer visual outcome is observed in patients developing macular oedema.

Primary silicone oil tamponade without retinopexy in highly myopic eyes with central macular hole detachments.

Background: In highly myopic macular hole central retinal detachments, the ideal treatment is still under discussion. In our study, we analyzed anatomic and functional outcomes for eyes undergoing vitrectomy with primary silicone oil filling without central photocoagulation, using the oil as inductor and scaffold for glial closure of the causative macular hole. Methods: Eleven patients with central macular hole detachments and myopia ranging from −10.0 to −23.0 diopters underwent vitrectomy and primary silicone oil filling without laser photocoagulation of the central retina. After at least 3 months (mean ± SD, 5.2 ± 2.0 months), the oil was removed from all eyes. Results: In all eyes, the retina was attached by the first postoperative day and remained attached after silicone oil removal until the end of the follow-up period. No severe intra- or postoperative complications were noted. Visual acuity increased in 7 (63.6%) of 11 eyes, remained unchanged in 3 (27.3%) of 11, and deteriorated in 1 (9.1%) of 11. Conclusion: Vitrectomy plus primary silicone oil tamponade without endophotocoagulation is an effective method to treat central macular hole detachments in highly myopic eyes.

Cataract surgery and silicone oil removal: visual outcome and complications in a combined vs. two step surgical approach.

Purpose To compare visual outcome and complications of two surgical strategies for patients who needed cataract surgery and silicone oil removal. Methods A prospective, nonrandomized study was performed to compare two groups of patients who had cataract surgery and silicone oil removal from April 1998 to January 2002. From April 1998 to November 1999, patients had two surgical sessions with cataract surgery before silicone oil removal (Group 1), and from December 1999 to January 2002, patients underwent combined cataract surgery and silicone oil removal in a single session (Group 2). Results Thirty-five patients were included in each group. The postoperative visual acuity improved by at least two lines of Snellen in 13 patients (37.1%) in Group 1 and 15 (42.8%) patients in Group 2 (P = 0.63). The mean visual improvement was 0.12 lines and 0.13 lines in groups 1 and 2 (P = 0.62). Complications in groups 1 and 2 included transient intraocular pressure rise (25.7% versus 28.5%), retinal detachment (14.2% versus 11.4%), fibrin reaction (5.7% in both groups), and persistent intraocular pressure rise (2.8% in both groups). Conclusion The visual outcome and complication rates were similar in both groups. Combined surgery offers the advantages of a single surgical event and a faster visual rehabilitation. We therefore suggest a surgical approach with combined cataract surgery and silicone oil removal in selected patients with a stable retinal situation.

Ten-year follow-up of epikeratophakia for the correction of high myopia

OBJECTIVE To determine the long-term functional results of epikeratophakia for myopic patients. DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS Twenty-two patients (32 eyes; average age, 43+/-6 years) who underwent epikeratophakia surgery for high myopia. Mean preoperative myopia was -18.74+/-9.16 diopters (D; range, -7 D to -49 D). Follow-up was 12+/-2 years. MAIN OUTCOME MEASURES Uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), change in mean keratometry, visual acuity under glare conditions, BCVA versus potential acuity meter reading, and patient satisfaction with the visual outcome. RESULTS Mean preoperative UCVA increased from 20/800+/-20/400 (range, counting fingers-20/400) to 20/80+/-20/200 (range, 20/250-20/32) in 24 eyes. Mean preoperative BCVA of 20/32+/-20/64 increased only in five eyes, whereas six eyes had no change and 18 eyes had a more than one line loss of Snellen BCVA. Mean preoperative keratometry reading decreased from 43.67+/-0.90 D (range, 41.0-46.25 D) to 37.40+/-2.92 D (range, 29.43-47.68 D). In the presence of glare, mean BCVA decreased to 20/100+/-20/100 (range, counting fingers-20/32). Potential acuity meter (PAM) readings were significantly (P<0.05) higher than BCVA. Mean PAM reading was 20/25+/-20/100 (range, 20/100-20/16). Seven patients (11 eyes) were extremely satisfied with the operative result more than 10 years after the operation, whereas four patients (four eyes) were not satisfied at all. CONCLUSIONS Epikeratophakia for the correction of myopia improved UCVA significantly, but BCVA decreased. The removal of the lenticules in patients who were not satisfied with their visual acuity was uncomplicated, and acceptable vision could be achieved with either contact lenses or intraocular lens implantation.

Laser shaping of corneal transplants in vitro: area ablation with small overlapping laser spots produced by a pulsed scanning laser beam using an optimizing ablation algorithm

Area laser lathing and trephination of donor corneas is used to produce different types of grafts for human transplantation. 193 nm (ArF excimer) laser radiation is used, since this is known to give a non-thermal laser-tissue interaction with a minimal zone of tissue damage. To guarantee the highest degree of flexibility concerning the overall shape of the grafts as well as their thickness profiles, we use a small (compared with the area to be ablated) scanning laser spot. For area lathing of the tissue we have developed a new ablation algorithm (optimized scanning laser ablation, OSLA) that can be applied to lathe and perforate any tissue--with concave (as in this application), convex or plane surface geometry--where surface precision and smoothness are key issues. Using OSLA with the Excimer Laser Corneal Shaping System (a tool for in vitro fabrication of all kinds of corneal transplants like donor buttons for keratoplasty, lamellar grafts for epikeratoplasty and refractive lenticules) enabled us to produce all types of corneal grafts with very high precision. This is considered to be a major improvement towards the production of refractive lenticules.

Corneal Lathing Using the Excimer Laser and a Computer-controlled Positioning System

PURPOSE To present the excimer laser corneal shaping system (ELCS-S), an add-on device to the Keratom, a commercially available 193-nm excimer laser built by Schwind. METHODS The system is designed for the preparation of donor corneas under sterile conditions using the ultraviolet laser to offer greatest possible flexibility. Lenticules for planolamellar grafting and refractive epikeratoplasty, as well as donor buttons for penetrating keratoplasty can be computer-designed by the surgeon or technician and lathed with the system. RESULTS Using the excimer laser corneal shaping system (ELCS-S) on human donor corneas, the central surface of the epikeratoplasty lenticule exhibited only narrow, flat concentric notches corresponding to the single lathing steps. Transmission electron microscopy revealed a damage zone of less than 0.3 microm in close approximation to the treated surface. The final thickness revealed a difference of less than +/-53 microm from the intended, initially programmed value. Ultrastructural studies showed the perpendicular stromal surface of the penetrating keratoplasty buttons to be smooth with minimal protrusion of Descemets membrane. Endothelial injury was observed in a zone averaging between 40 and 100 microm adjacent to the cutting edge only. CONCLUSION The excimer laser corneal shaping system (ELCS-S) allows a computer-controlled, surgeon-designed, sterile preparation of lamellar and penetrating corneal grafts with the use of the excimer laser. This could offer significant advantages in comparison to presently available systems for lamellar dissection and trephination.

Midterm visual outcome and progression of diabetic retinopathy following cataract surgery: Midterm outcome of cataract surgery in diabetes

Objective: To assess the influence of cataract surgery on progression of diabetic retinopathy and visual acuity. Methods: 37 patient eyes with mild to moderate diabetic retinopathy at baseline underwent phacoemulsification and intraocular posterior chamber lens implantation. They were examined 3.3 ± (SD) 0.7 years after surgery. Results: 83.8% of the eyes showed a better final visual acuity, and 67.6% achieved a final visual acuity of 0.5 or better. The retinopathy remained unchanged in 83.8% and progressed in 16.2% of the eyes. No eye progressed to proliferative retinopathy. Conclusion: Phacoemulsification and implantation of a posterior chamber intraocular lens is a safe procedure for patients with mild to moderate diabetic retinopathy.