Ruggero Tartaro

INTERNAL LIMITING MEMBRANE PEELING VERSUS INVERTED FLAP TECHNIQUE FOR TREATMENT OF FULL-THICKNESS MACULAR HOLES: A COMPARATIVE STUDY IN A LARGE SERIES OF PATIENTS

Background: The inverted flap (IF) technique has recently been introduced in macular hole (MH) surgery. The IF technique has shown an increase of the success rate in the case of large MHs and in MHs associated with high myopia. This study reports the anatomical and functional results in a large series of patients affected by MH treated using pars plana vitrectomy and gas tamponade combined with internal limiting membrane (ILM) peeling or IF. Methods: This is a retrospective, consecutive, nonrandomized comparative study of patients affected by idiopathic or myopic MH treated using small-gauge pars plana vitrectomy (25- or 23-gauge) between January 2011 and May 2016. The patients were divided into two groups according to the ILM removal technique (complete removal vs. IF). A subgroup analysis was performed according to the MH diameter (MH < 400 µm and MH ≥ 400 µm), axial length (AL < 26 mm and AL ≥ 26 mm), and the presence of chorioretinal atrophy in the macular area (present or absent). Results: We included 620 eyes of 570 patients affected by an MH, 300 patients underwent pars plana vitrectomy and ILM peeling and 320 patients underwent pars plana vitrectomy and IF. Overall, 84.94% of the patients had complete anatomical success characterized by MH closure after the operation. In particular, among the patients who underwent only ILM peeling the closure rate was 78.75%; among the patients who underwent the IF technique, it was 91.93% (P = 0.001); and among the patients affected by full-thickness MH ≥400 µm, success was achieved in 95.6% of the cases in the IF group and in 78.6% in the ILM peeling group (P = 0.001); among the patients with an axial length ≥26 mm, success was achieved in 88.4% of the cases in the IF group and in 38.9% in the ILM peeling group (P = 0.001). Average preoperative best-corrected visual acuity was 0.77 (SD = 0.32) logarithm of the minimum angle of resolution (20/118 Snellen) in the peeling group and 0.74 (SD = 0.33) logarithm of the minimum angle of resolution (20/110 Snellen) in the IF group (P = 0.31). Mean postoperative best-corrected visual acuity was 0.52 (SD = 0.42) logarithm of the minimum angle of resolution (20/66 Snellen) in the peeling group and 0.43 (SD = 0.31) logarithm of the minimum angle of resolution (20/53 Snellen) in the IF group (P = 0.003). Conclusion: Vitrectomy associated with the inverted ILM flap technique seems to be effective surgery for idiopathic and myopic large MHs, improving both functional and anatomical outcomes.

27-Gauge Via Pars Plana Vitrectomy With Autologous ILM Transplantation for Optic Pit Disc Maculopathy

To report a case of a serous macular detachment associated with optic pit that did not improve after a previous vitrectomy with internal limiting membrane (ILM) peeling, peripapillary laser, and gas tamponade. The authors performed a lens-sparing 27-gauge pars plana vitrectomy with autologous transplantation of ILM inside the optic nerve pit and gas tamponade. The subretinal fluid gradually resolved and visual acuity improved to 20/20 at the tenth month after surgery. The authors did not observe a recurrence of subretinal fluid during the 14 months of follow-up. Autologous transplantation of the ILM may be effective to repair recurring optic disc pit maculopathy. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:712-714.].

Post-Traumatic Giant Retinal Tear Without Posterior Vitreous Detachment: A Case Series

BACKGROUND AND OBJECTIVE To investigate the vitreal condition in retinal detachment (RD) related to giant retinal tears (GRT) after ocular blunt trauma. PATIENTS AND METHODS Retrospective, observational study conducted at Azienda Ospedaliera Universitaria Careggi, Florence, Italy. The institutional review board and ethics committee approved the study. Records of 23 eyes of 23 patients affected by traumatic RD associated with a GRT were evaluated. A total of four eyes had RD related to blunt trauma, in which the authors performed 25-gauge vitrectomy and silicone oil was used as a endotamponade. RESULTS Three out of four eyes did not display a posterior vitreous detachment at the B-scan, and this was confirmed during surgery. The three eyes had a mean visual acuity of 20/32 1 month after silicone oil removal. CONCLUSIONS Posterior vitreous detachment may not be present in RD associated with GRT after blunt trauma. This knowledge could result in modified intraoperative management to improve postoperative outcomes. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:686-690.].

New Vital Dye Injection Technique With Vitrectomy Probe

BACKGROUND AND OBJECTIVE To evaluate a new, safer way to inject vital dye during chromovitrectomy for dye-assisted macular peeling. PATIENTS AND METHODS Prospective consecutive case series. Enrolled patients underwent macular surgery with a new technique of staining the epiretinal membrane and the internal limiting membrane with vital dyes. Twenty eyes of 20 patients (eight men, 12 women) were affected by idiopathic epiretinal membrane and underwent 25-gauge via pars plana vitrectomy for epiretinal membrane removal. Ten eyes were stained with Membrane Blue-Dual (Brilliant Blue G + trypan blue; DORC, Zuidland, The Netherlands) and 10 eyes were stained with Brilliant Peel (Brillant Blue G; Fluoron GmbH, Ulm, Germany). Preoperatively and postoperatively (1, 3, and 6 months) all patients received a complete ophthalmologic examination with best-corrected visual acuity (BCVA) assessment, swept-source optical coherence tomography, and multifocal electroretinography (mfERG). RESULTS The mean age of the patients was 67.0 years ± 8.6 years (range: 55 years to 78 years). No statistically significant difference in BCVA improvement or central foveal thickness decrease was observed in either group (P > .05). The mfERG showed an increase in electrical response densities 3 months after surgery. CONCLUSION The authors describe a new technique to inject vital dye during chromovitrectomy for dye-assisted macular peeling that may help to improve the overall safety of macular surgery. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:528-533.].

Subinternal Limiting Membrane Hemorrhage Related to Laser Exposure in 2 Young Patients

Purpose: Lasers can be sight damaging, because they can produce severe and permanent retinal damage. Methods: This paper reports two cases of subinternal limiting membrane (sub-ILM) hemorrhage related to laser exposure. Results: The first patient was only observed for the reason that the retinal localization was extramacular; for the second patient, we decided to perform ultraspeed (7500 cuts per minute) 27-gauge pars plana vitrectomy (PPV) because of the foveal position of the hemorrhage and because of the nonimprovement of his clinical condition. The first patient recovered 20/20 Snellen after 10 days without intervention, whereas the second patient recovered 15/20 Snellen the day after surgery; 15 days later, his visual acuity was 20/20 Snellen. Conclusions: Sub-ILM hemorrhage after exposure to lasers can be treated using an ultraspeed 27-gauge PPV. This tool can be considered safe and effective on non–self-resolving sub-ILM hemorrhage.

Evaluation of ocular perforation during retrobulbar block using high-resolution spectral domain–optical coherence tomography and optical coherence tomography angiography:

Introduction: This article reports a case of ocular perforation during a retrobulbar block in a patient who underwent scleral buckle for retinal detachment. Methods: Sterile air was immediately injected into the vitreous cavity to restore intraocular pressure and the scleral buckle operation was quickly finished. One week later, a laser retinopexy was performed on the two retinal holes that were outside the foveal area. After 6 months, spectral domain–optical coherence tomography and optical coherence tomography angiography were performed on the perforated wall centered on the exit hole area. Results: The visual acuity was maintained 20/20 and the retina was totally attached. Spectral domain–optical coherence tomography showed a localized interruption of inner retina, retinal pigment epithelium, and choroid, with a higher posterior reflectivity in correspondence with the sclera. Optical coherence tomography angiography was able to detect atrophic alterations in the choroidal slab with a good visualization of large and rarefied choroidal vessels due to lack of retinal pigment epithelium and choriocapillaris. Conclusion: When ocular perforation by a needle is outside the foveal area and when there is an early awareness of the perforation, the complications may be avoided, and we could observe a good final visual acuity result. Furthermore, using spectral domain–optical coherence tomography and optical coherence tomography angiography, we could observe the perforated eyeball wall and study the effects of a 25-gauge needle perforation in the retinal and choroidal blood stream.

Italian real-life experience on the use of ocriplasmin

Objective To evaluate the success of an intravitreal injection of ocriplasmin to release symptomatic vitreomacular traction (VMT) and close a full-thickness macular hole. Methods and analysis An observational retrospective multicentre study conducted in Italy. Patients with symptomatic distortion and loss of vision secondary to VMT were included in the study. The patients received a single injection of ocriplasmin and were followed up for 1, 3 and 6 months. Best-corrected visual acuity (BCVA) and spectral domani OCT (SD-OCT) were performed for patient assessment, and adverse events were recorded and analysed. Results 74 patients (74 eyes) were included in the study. 44 of 74 eyes (59.5%) experienced complete release of the VMT. Macular hole closure was obtained in eight eyes (40%). BCVA improved about three lines after 3 months of follow-up in the patients with VMT resolution in comparison with the patients who did not have VMT resolution (p<0.0001). In 55/74 eyes of 55 patients (74.3%), no adverse events were reported, and most of them were transitory (17/19; 89.5%). The mean time to resolve VMT was 27.4±21.9 days. No cases of retinal tear, retinal detachment or lens destabilisation were observed. Conclusion Ocriplasmin is a potential alternative treatment for patients with symptomatic VMT and has a good safety profile. A more careful selection of patients, in clinical practice, may increase the success rate.

SCLERAL BUCKLING FOR PRIMARY RHEGMATOGENOUS RETINAL DETACHMENT USING A NONCONTACT WIDE-ANGLE VIEWING SYSTEM WITH A CANNULA-BASED 27-G CHANDELIER ENDOILLUMINATOR

PURPOSE To assess the outcome of scleral buckling surgery using a noncontact wide-angle viewing system for fundus visualization in patients with rhegmatogenous retinal detachment. METHODS Twenty-eight eyes of 28 patients underwent a modified scleral buckling surgery using a noncontact wide-angle viewing system combined with a 27-gauge optic fiber inserted into the sclera at the pars plana through a valved 27-gauge trocar. RESULTS The mean age of the patients was 61.5 ± 9.9 years. The mean axial length was 25.16 ± 1.27 mm. The mean extension of the retinal detachment was 5.3 ± 2.5 clock hours. The mean follow-up time was 6.4 months. Retinal reattachment was achieved in 27 of the 28 eyes (96.4%). One eye underwent vitrectomy with a silicone oil injection because of the development of proliferative vitreoretinopathy. CONCLUSION Simultaneous use of a noncontact wide-angle viewing system combined with 27-gauge light fiber illumination for fundus visualization adds the advantages of microsurgery and indirect ophthalmoscopy to scleral buckling surgery. We found a high rate of primal retinal reattachment.