S K Gibran

Can a preoperative bevacizumab injection prevent recurrent postvitrectomy diabetic vitreous haemorrhage

AimsTo evaluate the recurrence rate of vitreous haemorrhage (VH) in patients treated with one intravitreal bevacizumab (IVB) injection (2.5 mg/0.1 ml) before planned pars plana vitrectomy for treatment of diabetic non-clearing VH.MethodsProspective pilot study of 32 eyes of 31 consecutive diabetic patients who underwent IVB injection within 1 week before surgery for persistent VH in the presence of active proliferative diabetic retinopathy. Three masked retinal specialists graded the amount of VH from grade 0 to grade 3 with slit-lamp biomicroscopy. Main outcome measures were the rate of recurrence of the VH, improvement in visual acuity, incidence of cataract formation, and postoperative complications through a follow-up of 6 months.ResultsThe percentage of severe recurrent VH with no fundus details (grade 3) was 3% at 1 week follow-up and 3, 6, and 6% respectively at 1-, 3-, and 6-month follow-up. The mean best-corrected visual acuity (BCVA) improved from 1.6 (1/60) to 0.40 (6/15) logMAR (P=0.02) in 29 out of 32 eyes (91%). In all, 12 out of 22 (54%) phakic eyes developed cataract during the follow-up period, and 10 (31%) of them underwent cataract surgery.ConclusionsOur study suggests that IVB injection few days before planned surgery seems to be efficacious and safe as an adjuvant treatment to prevent rebleeding in eyes undergoing pars plana vitrectomy for treatment of diabetic vitreous haemorrhage. IVB facilitates the surgery and reduces the need for extensive delamination and segmentation, decreasing the possibility of significant early active postoperative VH.

Does the Presence of an Epiretinal Membrane Alter the Cleavage Plane during Internal Limiting Membrane Peeling

PURPOSE To determine whether the presence of a clinically and/or microscopically detectable epiretinal membrane (ERM) alters the cleavage plane during internal limiting membrane (ILM) peeling. DESIGN Retrospective, observational, immunohistochemical study of ILM specimens using archival formalin-fixed, paraffin-embedded tissue. PARTICIPANTS Fifty-one patients who had had ILM excision. METHODS Fifty-one ILM specimens peeled during vitrectomy for various etiologies were examined by light microscopy. The removal of ILM was assisted using Trypan blue (n = 30), indocyanine green (n = 7), or brilliant blue G (n = 14). Monoclonal antibodies to glial fibrillary acidic protein and to neurofilament protein were used to detect glial or neuronal cells respectively on the vitreous or retinal surfaces of the ILM. Specimens were divided into 2 groups: ILM peeled for full-thickness macular hole (MH; n = 31) and ILM peeled after removal of clinically detectable ERM (n = 20). MAIN OUTCOME MEASURES Primary outcome measure was the localization of immunohistochemical markers to neuronal or glial cells on the vitreous or retinal surfaces of ILM. The secondary outcome measure was the correlation of the results of the primary measure with the dyes used to facilitate ILM peeling. RESULTS Glial and/or neuronal cells were detected on the retinal surface of the ILM in 10 of 31 (32%) of the MH ILM specimens and in 13 of 20 (65%) of the ILM peeled after ERM excision; the difference was significant (P = 0.02). There was no association between the presence of neuronal and glial cells with the type of dye used (P = 0.2). Of the 23 ILM specimens with cells attached to the retinal surface, 21 (91%) were associated with clinical and/or histologic evidence of ERM and 2 (9%) were not. The correlation between the presence of cells on the vitreous and the retinal surfaces of ILM was high (P<0.0001). CONCLUSIONS The findings suggest that ERM may be associated with sub-ILM changes that alter the plane of separation during ILM peeling. This study does not confirm any influence of dyes on the cleavage plane during surgery.

Peel and peel again

Aim: To determine if the internal limiting membrane (ILM) was present in the epiretinal membrane (ERM) when we deliberately tried to perform a “double peel” for macular pucker. Methods: Pars-plana vitrectomy and a “double peel” were carried out. The ERM and ILM were stained with Trypan Blue and peeled separately over the same area. The amount of ERM present in ILM specimens and the amount of ILM present in ERM specimens were evaluated by histological examination. Results: Seventeen eyes in 17 patients were included. It was possible to double peel in all cases. Five of 17 ERM specimens (29%) contained ILM fragments. When ILM was present on the ERM, it represented less than 50% of the sample. One ILM specimen was lost as result of an administrative error; of the remaining 16 specimens, residual ERM was found in six, and cellular remnants were observed on the vitreous surface in a further six of the ILMs. Clinically, no recurrence of ERM was found. Conclusion: ILM was present in some ERM specimens seemingly over the same area that an intact ILM was subsequently peel. We speculate that the ILM in the ERM represent a secondary basement membrane and that the surgical plane of dissection for most ERM peel is between the ERM and the native ILM, making it feasible to double peel routinely.

Heavy tamponade 2 Densiron 68® in routine clinical practice: anatomical and functional outcomes of a consecutive case series

PurposeTo evaluate the safety and efficacy of Densiron 68® in the clinical management of complex vitreoretinal cases with inferior retinal pathology.MethodsWe present a prospective interventional non-comparative case series of 122 eyes of 121 consecutive patients. The primary end point was anatomical re-attachment of the retina, defined as retinal re-attachment in the absence of any tamponade agent. The secondary end point was to record the visual function and surgical complications. Inclusion criteria were proliferative vitreoretinopathy, posterior or inferior retinal breaks, and the patients inability to posture.ResultsPatients were 59.9 years (±19.6), (m/f=72:49), (R/L=65:57). Seventy-seven (63.1%) had previous unsuccessful retinal surgery and 45 had Densiron 68 at first procedure. The extent of the detachments was 2.21 quadrants (±1.07) with macular involvement in 66 cases (54%). Eighty-seven (71.3%) patients achieved retinal re-attachment with one retinal operation and ultimately no tamponade, 102 (83.6%) achieved retinal re-attachment with more than one operation and ultimately no tamponade, and 112 (91.3%) patients achieved flat retina with tamponade in situ. Visual acuity rose from 1.38 LogMar (±0.87) to 1.06 (±0.83) (P=0.007). Densiron was removed after 135 days (±73.2; range 35–405)ConclusionNo tamponade agent can provide simultaneous support for the superior as well as the inferior retina; therefore, a tamponade agent that ‘sinks’ is a welcome new tool at the surgeons disposal. The sequential use of heavy silicone oil followed by conventional silicone oil may be an acceptable management strategy in recurrent detachment.

A guide to the removal of heavy silicone oil

Aim: Heavy silicone oil removal can be challenging and differs considerably from conventional oil. Traditionally, strong active aspiration had to be applied through a long 18G needle just above the optic disc. We present a novel technique using a much shorter (7.5 mm) and smaller (20G) needle allowing its removal “from a distance.” Method: Active aspiration on a vacuum of 600 mm Hg of the “viscous fluid injector” was applied using the 20G cannula in a polymethylmethacrylate model eye chamber that was surface-modified to mimic the surface properties of the retina. Measurements were taken using still photographs. Results: Under injection the maximum diameter of a silicone oil bubble supported by interfacial tension alone was 5 mm for a steel and 7 mm for a polyurethane cannula. Under suction, the silicone bubble changed shape and became conical, thus further increasing the cannula’s reach. This conical shape illustrated “tubeless siphoning,” which is a physical property of non-Newtonian fluids. Discussion: The use of shorter and smaller gauge cannula for removal of Densiron obviates the need to enlarge the sclerotomy beyond 20G or to apply suction in close proximity to disc and fovea. This potentially reduces the risk of iatrogenic damage such as entry site tears or postoperative hypotony.

Changes in the retinal inner limiting membrane associated with Valsalva retinopathy

Valsalva retinopathy was first described in 1972 by Thomas Duane as “a particular form of retinopathy, pre-retinal and haemorrhagic in nature, secondary to a sudden increase in intrathoracic pressure.” Incompetent or no valves in the venous system of head and neck allow direct transmission of intrathoracic or intra-abdominal pressure into the head and neck. Sudden elevation of venous pressure may cause a decompensation in the retinal capillary bed, with subinternal limiting membrane haemorrhages (Hg) that rarely may break through and become subhyloid or intravitreal 1. We report the histological findings of internal limiting membrane (ILM) peel in a case of Valsalva retinopathy. A 41-year-old Caucasian male was referred to the vitreoretinal services with a spontaneous and sudden loss of vision in left eye for 3 weeks. There was no history of trauma or violent exertion but the patient had hay fever and had frequent episodes of sneezing. On examination his vision was 6/6 and hand movements in right and left eyes, respectively. Anterior segment examination was normal. Dilated fundoscopy revealed a dense vitreous haemorrhage in the left eye and normal fundus appearance in the right eye. Ultrasound echography revealed a posterior vitreous detachment, vitreous …

Fibrous membranes in diabetic retinopathy and bevacizumab.

Purpose: The purpose of this study was to determine the histopathologic characteristics of bevacizumab-treated human proliferative diabetic retinopathy (PDR) membranes with particular regard to membrane vasculature as a step toward addressing the effects of the drug on PDR membranes. Intravitreous injection of bevacizumab, an antivascular endothelial growth factor monoclonal antibody, has recently been advocated as an adjunct in surgery for PDR. In this context, a clinically observed decrease in PDR epiretinal membrane vascularity (vascular regression) occurs from 24 hours to 48 hours after injection, but the exact mechanisms of drug action are unknown. Methods: A consecutive series of seven PDR membrane specimens that had been removed sequentially from seven bevacizumab-treated patients were studied retrospectively. The membrane specimens were examined using light microscopic methods, including immunohistochemistry. Results: Five of the seven membranes were clinically avascular (one contained “ghost” vessels) and did not hemorrhage during excision. Of these 5 specimens, which included 1 removed 7 days after a total of 6 intravitreous injections of 1.25 mg bevacizumab, 4 contained histologically detectable capillaries (1 did not). These blood vessels were lined by endothelial cells as determined by immunohistochemistry for the endothelial markers CD31 and CD34. The two remaining membranes were clinically and histologically still vascularized despite bevacizumab treatment. All the specimens also contained smooth muscle actin-containing fibroblastic cells within the collagenous stroma. Conclusion: The findings do not support the concept that the clinical phenomenon of vascular regression in PDR membranes after bevacizumab injection in the vitreous is resulting from obliteration of the membrane blood vessels. Another mechanism appears to be involved in at least some patients, possibly a vasoconstrictive response. Such a mechanism might explain reversal of the effects of bevacizumab that has been reported after this treatment.

Spontaneous progressive supra-choroidal haemorrhage in a patient undergoing haemodialysis

We present a case of spontaneous and progressive suprachoroidal haemorrhage in a patient undergoing haemodialysis. A 27-year-old female patient with insulin-dependent diabetes presented to eye casualty complaining of sudden onset of pain in her only eye, starting 45 min after haemodialysis with first time use of tissue plasminogen activator (tPA); 8 mg of tPA in 80 ml of saline had been administered over 4 h in order to overcome a thrombosed port. The left eye had a history of laser treatment (panretinal photocoagulation, PRP), cataract extraction with lens implant, vitrectomy and delamination with visual acuity of 6/9. Her right eye was enucleated secondary to rubeotic glaucoma. At presentation visual acuity dropped from 6/9 to CF with raised intraocular pressure (IOP) at 48 mmHg. Ophthalmoscopy revealed peripheral 360° choroidal haemorrhages. The IOP settled initially for 2 days on maximum medical treatment. A computed tomography (CT) scan ruled out orbital haemorrhages and showed choroidal detachments (Fig. 1). On the 3rd day, after another session of haemodialysis (with minimal heparin), the patient developed secondary angle-closure glaucoma with shallow anterior chamber and IOPs of 56 mmHg. The choroidal haemorrhages were observed to have increased. The visual acuity dropped to PL. A B scan showed dome-shaped choroidal haemorrhages with liquefied blood. Progression of the supra-choroidal haemorrhage induced angle-closure glaucoma and threatened the macular architecture. Surgical intervention involved emergency vitrectomy with perfluorocarbon liquid (PFCL)assisted external drainage of the haemorrhage. Silicone oil was used as internal tamponade. Post-operatively, systemic blood pressure was uncontrolled at 230/130 mmHg requiring appropriate anti-hypertensive therapy. Post-operatively the IOP settled to 14 mmHg but rose again to 56 mmHg 24 h later. The supra-choroidal haemorrhages were observed to have increased again. Repeat drainage of choroidal blood was performed through large radial sclerostomies, which were left open underneath the conjunctiva. On a haematologist’s advice, the patient received transfusion of platelets. She continued to have daily dialysis with minimal heparin. Vision recovered 1 month after discharge to 6/12 (aided) (Fig. 2). To the best of our knowledge, only one case of spontaneous supra-choroidal haemorrhage secondary to tPA has been reported in the literature [1]. In contrast to the case by Khawley et al., our case showed progression, threatening the posterior pole along with raised IOP. Spontaneous supra-choroidal haemorrhages have also been reported following thrombolysis with heparin and low molecular weight (LMW) derivatives for myocardial infarction [2, 3]. Choroidal haemorrhages are usually associated with intraocular surgery, mostly with cataract or glaucoma surgery [4]. If necessary, drainage surgery is advised 7–25 days later in order to allow the blood to Graefe’s Arch Clin Exp Ophthalmol (2007) 245:1741–1742 DOI 10.1007/s00417-007-0653-y

Reply to Smith et al

We have read with interest the comments provided by Smith relating to our study. We appreciate his remarks and his interest in our article. As required by the author, we will explain the reason why our results differ from previous literature on the rate of postoperative vitreous cavity haemorrhage (POVCH). In the quoted paper by Yang et al, preoperative bevacizumab (1.25 mg/0.05 ml) was combined with C3F8 10%. This gas is a long-acting gas with haemostatic effect, which could explain the absence of early POVCH. In our series, we did not use any gas at the end of the surgery. Our results also differ from those reported by Yeoh et al by way of substantial differences in the study settings. First, our inclusion criteria were presence of vitreous haemorrhage (VH) with active proliferative diabetic retinopathy, whereas their inclusion criteria were tractional retinal detachment (TRD) involving the macula with active neovascularization, rubeosis with VH and high-risk features for developing rubeosis. Second, all 31 eyes in our study were filled with air, in contrast with only 1 of the 10 eyes in their study (the other nine being filled with SF6 or water). In our study, the amount of VH was graded using slitlamp biomicroscopy from grade 0 to grade 3. This allows a better understanding of the severity of POVCH. Looking carefully at our results, it may be inferred that we reported the presence of a low grade of VH (grade 1: mild VH, fundal details possible/hazy view) only within the first week after the surgery, whereas grade 3 VH (severe recurrent VH with no fundus details) was present only in 3, 3, 6, and 6% of the eyes at 7 days, 1-, 3-, and 6-month follow-up, respectively. The author has asked for clarification on the surgical technique. The fluid–air exchange was performed at the end of the surgical procedure, whereas gas tamponade or silicon oil was never used. In our series, 28 out of 31 patients (90%) had already undergone panretinal photocoagulation earlier. The endolaser photocoagulation was carefully completed in all eyes during the surgery. We did not find any toxic effect of IVB (2.5 mg/0.1 ml). The only adverse event was one single case of TRD that developed during the follow-up period. In our opinion, the IVB injected at the end of the surgery does not have any effect on late re-bleeding, the main reasons for recurrent VH being intraoperative surgical manoeuvres, insufficient haemostasis, and persistent retinal neovascularizations. Our hypothesis is that preoperative bevacizumab injection facilitates surgery by enabling a complete endolaser photocoagulation treatment, reducing intraoperative haemorrhage, and avoiding the need for a complicated manoeuvre to achieve total delamination of the fibrovascular tissue, thereby minimizing the risk of recurrent vitreous haemorrhage.

Surgical management of massive submacular hemorrhage associated with age-related macular degeneration.

PURPOSE To investigate the safety and efficacy of surgical drainage of massive and elevated submacular hemorrhage associated with age-related macular degeneration through circumferential peripheral 180° temporal retinotomy. METHODS Prospective interventional case series of first eyes of six consecutive patients with large elevated submacular hemorrhage. The surgical approach consisted of combined cataract surgery, three-port pars plana vitrectomy, induction of retinal detachment, and circumferential peripheral temporal 180° retinotomy. The temporal retina was reflected and the solid blood clot was removed with a vitreous cutter along with the choroidal neovascular complex. Silicone oil was used as an internal temponade in all patients. Complete clinical examination was performed in all cases preoperatively and postoperatively at 1 and 3 months. After removal of silicone oil, the patients were observed for 12 months. RESULTS Submacular hemorrhage was completely removed in all cases the next day after the surgery. All patients experienced improvement of central scotoma. Twelve months after silicone oil removal, visual acuity was defined as improvement in 5 eyes (83%) and stable in 1 eye (17%). No recurrence or complications were observed during the period of follow-up. CONCLUSION Our surgical approach could be efficacious to remove a large elevated submacular hemorrhage that is not feasible for any other treatment. It may help to improve the central scotoma and results in limited visual improvement in selected patients.