Scott E. Burk

Indocyanine green-assisted peeling of the retinal internal limiting membrane.

OBJECTIVE To determine whether indocyanine green (ICG) stains and facilitates peeling of the retinal internal limiting membrane (ILM). To investigate the different staining properties of the posterior cortical hyaloid, retinal ILM, and the retina after ILM removal. DESIGN Autopsy eye study. MATERIALS Eleven human cadaveric eyes. METHODS Open sky vitrectomy including removal of the posterior cortical vitreous was performed. A 0.5% ICG solution was then injected into the posterior vitreous cavity over the macula. The dye was allowed to settle on the macula for 5 minutes and was then removed by mechanical aspiration. Peeling of the ILM was initiated with a bent needle and completed with intraocular forceps. Specimens were submitted for light and electron microscopy. MAIN OUTCOME MEASURES Staining properties and ease of peeling of retinal ILM were evaluated. Retinal ILM removal was confirmed by histopathologic and electron microscopic examination. RESULTS ICG contact with the retinal surface resulted in bright green staining of the ILM. This stain greatly facilitated ILM peeling by improving direct visualization of the membrane. The underlying retina did not stain, thus providing a clear distinction between the stained ILM and the unstained retina. Continuous circular peeling of the ILM was easily completed with this technique. Light microscopic and ultrastructural studies confirmed removal of the ILM. CONCLUSIONS ICG solution distinctly stains the nearly invisible retinal ILM in human cadaveric eyes. ICG staining greatly facilitates ILM peeling by providing a stark contrast between the stained ILM and the unstained retina.

Indocyanine green–assisted peeling of the retinal internal limiting membrane1

OBJECTIVE To determine whether indocyanine green (ICG) stains and facilitates peeling of the retinal internal limiting membrane (ILM). To investigate the different staining properties of the posterior cortical hyaloid, retinal ILM, and the retina after ILM removal. DESIGN Autopsy eye study. MATERIALS Eleven human cadaveric eyes. METHODS Open sky vitrectomy including removal of the posterior cortical vitreous was performed. A 0.5% ICG solution was then injected into the posterior vitreous cavity over the macula. The dye was allowed to settle on the macula for 5 minutes and was then removed by mechanical aspiration. Peeling of the ILM was initiated with a bent needle and completed with intraocular forceps. Specimens were submitted for light and electron microscopy. MAIN OUTCOME MEASURES Staining properties and ease of peeling of retinal ILM were evaluated. Retinal ILM removal was confirmed by histopathologic and electron microscopic examination. RESULTS ICG contact with the retinal surface resulted in bright green staining of the ILM. This stain greatly facilitated ILM peeling by improving direct visualization of the membrane. The underlying retina did not stain, thus providing a clear distinction between the stained ILM and the unstained retina. Continuous circular peeling of the ILM was easily completed with this technique. Light microscopic and ultrastructural studies confirmed removal of the ILM. CONCLUSIONS ICG solution distinctly stains the nearly invisible retinal ILM in human cadaveric eyes. ICG staining greatly facilitates ILM peeling by providing a stark contrast between the stained ILM and the unstained retina.

Visualizing vitreous using Kenalog suspension.

&NA; We developed and evaluated a method of visualizing vitreous gel in the anterior segment. In this study, 0.2 mL of injectable triamcinolone (Kenalog®) 40 mg/mL was captured in a 5 &mgr;m filter and rinsed with 2 mL of balanced salt solution (BSS®). It was then resuspended in 5 mL of BSS and recaptured to thoroughly remove the preservative. The Kenalog particles were ultimately resuspended in 2 mL of BSS and injected into the anterior chamber through a 27‐gauge cannula. Kenalog particles were trapped on and within the vitreous gel, making it clearly visible. The visualization provided direct observation of vitreous behavior in various experimental settings and assisted surgeons intraoperatively in the identification and removal of vitreous in the anterior segment.

Prosthetic iris implantation for congenital, traumatic, or functional iris deficiencies

Purpose: To determine the efficacy and safety of surgical implantation of prosthetic iris devices in patients with anatomic or functional iris deficiencies. Setting: Cincinnati Eye Institute, Cincinnati, Ohio, USA. Methods: Twenty‐five patients were enrolled in an interventional prospective noncomparative case series. Twenty‐eight eyes had prosthetic iris diaphragm implantation for traumatic iris defects, congenital aniridia or iris coloboma, herpetic iris atrophy, surgical iris loss, or ocular albinism. Prosthetic iris implantation was performed with phacoemulsification and intraocular lens (IOL) implantation in 20 eyes, secondary IOL implantation in 6 eyes, and IOL exchange in 1 eye. A single pseudophakic eye with disabling glare secondary to traumatic aniridia had secondary prosthetic iris implantation alone. The surgical ease of insertion, intraoperative and postoperative complications, postoperative anatomic results, visual acuity, and subjective glare reduction were evaluated. Results: Patients were followed postoperatively for a mean of 10.2 months (range 1.4 to 25.7 months). All eyes achieved the desired anatomic result. Visual acuity was improved in 22 of 28 eyes (79%), unchanged in 5 eyes, and worsened by a single line in 1 eye. Patients were surveyed postoperatively to determine the change in glare disability. The severity of glare disability was subjectively improved in 23 of 24 patients (96%) who responded to the survey. Intraoperative complications included 3 fractured implants as well as an incomplete or torn capsulorhexis in 3 eyes. Postoperative complications included transient hypotony in 2 eyes, mild persistent inflammation in 1 eye, and macular edema followed by a retinal detachment in 1 eye with recent severe trauma. Conclusions: Implantation of prosthetic iris devices improved postoperative outcomes by reducing glare disability and, in selected cases, by correcting aphakia. Although operating on traumatized, congenitally aniridic, or uveitic eyes presents special challenges, implantation of prosthetic iris devices appears to be a safe and effective method for reducing the ubiquitous glare in patients with iris deficiency.

A Study of Topical Nonsteroidal Anti-inflammatory Drops and No Pressure Patching in the Treatment of Corneal Abrasions

OBJECTIVE To evaluate the effectiveness of an ophthalmic nonsteroidal anti-inflammatory drug (NSAID) in the treatment of noninfected, non-contact lens-related, traumatic corneal abrasions and no pressure patch. DESIGN A single-center, randomized, double-masked, placebo-controlled study. PARTICIPANTS One hundred patients with noninfected, non-contact lens-related, traumatic or foreign body removal-related corneal abrasions less than 36 hours in duration. INTERVENTION All patients received a cycloplegic drop and erythromycin or polymyxin B (Polysporin Ophthalmic Ointment, Burroughs Wellcome, Research Triangle Park, NC). Patients were then randomized to receive either ketorolac tromethamine 0.5% ophthalmic solution or control vehicle drops. MAIN OUTCOME MEASURES The main outcome measures were six subjective symptoms monitored daily, evaluation of corneal abrasion, and determination of adverse events. Long-term complications were determined 3 to 8 months after randomization. RESULTS Twelve patients were excluded from the study. One day after randomization, patients receiving ketorolac tromethamine 0.5% ophthalmic solution noted significantly decreased levels of pain (P < 0.002), photophobia (P < 0.009), and foreign body sensation (P < 0.003) as compared with the control vehicle group. In addition, the time to resumption of normal activities was shorter in the group who received ketorolac tromethamine 0.5% ophthalmic solution (P < 0.001). There was no statistical difference in the amount of tearing, healing time, acuity changes, or complication rates between the two groups. CONCLUSIONS Ketorolac tromethamine 0.5% ophthalmic solution provides increased patient comfort without clinical adverse effects when used as adjunctive therapy in the treatment of noninfected, non-contact lens-related, traumatic corneal abrasions.

Cataract surgery combined with implantation of an artificial iris

We describe 6 patients who presented with cataract or aphakia and absent or nonfunctional irides. The etiologies included congenital aniridia, traumatic iris loss, and chronic mydriasis secondary to recurrent herpetic uveitis. In 5 eyes, a prosthetic iris was successfully implanted in combination with small incision cataract surgery. In 2 eyes, a single-piece iris diaphragm and optical lens was implanted. Artificial irides offer a safe alternative for patients who previously had no viable options for iris reconstruction.

Thinning of the anterior capsule associated with congenital aniridia.

Purpose: To report the unusual finding of intraoperative fragility of the anterior capsule in some patients with congenital aniridia and determine the histopathologic etiology of this finding. Setting: Cincinnati Eye Institute, Cincinnati, Ohio, USA. Methods: Anterior lens capsule specimens were obtained from aniridic and nonaniridic patients during cataract surgery. The intraoperative behavior of each capsule was noted, after which the specimens were submitted for histopathologic evaluation. Results: All anterior capsule specimens from the nonaniridic patients were of normal thickness. Some, but not all, anterior capsule specimens from the aniridic patients were remarkably thin. Thin capsules were associated with extreme intraoperative fragility. Conclusion: Greater awareness of anterior capsule fragility in some aniridic patients may reduce the risk of capsule complications and lead to safer surgical outcomes.

Outcomes of prosthetic iris implantation in patients with albinism

PURPOSE: To assess the safety and efficacy of implantation of prosthetic iris devices in patients with albinism. SETTING: Private practice, Cincinnati, Ohio, USA. METHODS: This retrospective noncomparative case series comprised 13 eyes of 8 patients with diminished pigment epithelium of the iris secondary to albinism. All eyes had anterior segment surgery with intraocular lens (IOL) and prosthetic iris device implantation. Eleven eyes received an endocapsular‐type iris reconstruction implant (Morcher aniridia interdigitating rings), and 2 eyes (1 patient) received a combined iris–IOL device (Ophtec model 311). The visual acuity, subjective glare reduction, postoperative anatomical outcomes, and intraoperative or postoperative complications were reviewed. RESULTS: All eyes achieved the desired anatomic result. The best corrected visual acuity improved in 8 of 13 eyes, remained stable in 3 eyes, and decreased in 2 eyes. Glare and photophobia improved subjectively in 6 of 8 patients, remained unchanged in 1 patient, and increased in 1 patient after implantation of an artificial iris diaphragm. There were no intraoperative or postoperative complications. CONCLUSIONS: Implantation of prosthetic iris devices appears to be useful in the management of patients with iris deficiency secondary to albinism. The procedure was safe and particularly effective in reducing glare and photophobia in most patients.

Indocyanine green-assisted internal limiting membrane peeling for macular holes to stain or not to stain?

Indocyanine Green–Assisted Internal Limiting Membrane Peeling for Macular Holes To Stain or Not To Stain? The retinal internal limiting membrane (ILM) forms the structural boundary between the retina and the vitreous. It is derived primarily from, and rests upon, a sea of Müller cell footplates that separates it from the nerve fiber layer.1 As a basement membrane, the ILM can act as a scaffold that may permit cellular proliferation and transmit tractional forces directly to the inner retina. The ILM is frequently involved in disorders that affect the vitreomacular interface, including epiretinal membranes, vitreomacular traction, and macular holes.2–8 Although to our knowledge there have been no randomized, prospective, controlled clinical trials, most evidence suggests that retinal ILM peeling improves anatomical and visual outcomes after macular hole repair.9–24 Indeed, a meta-analysis of data for 1,654 eyes demonstrated that ILM peeling significantly increased the anatomical and functional success rates of macular hole surgery (P 0.0001).13 Surgical peeling of the ILM can be technically challenging even for experienced vitreoretinal surgeons primarily due to its inherent transparency. Indocyanine green (ICG) was first introduced for intraocular use in 1998 to facilitate visualization of the anterior capsule of the crystalline lens.25 Shortly thereafter, ICG-assisted ILM peeling was described in human cadaveric eyes, as well as intraoperatively for macular hole repair.26–28 ICG enhances visualization of the ILM, and most clinical studies have reported visual and anatomical success with the use of this technique.17,27–45 Indeed, the largest clinical series of ICG-assisted ILM peeling for primary macular hole closure reported an anatomical success rate of 98% and an improvement of 2 lines of Snellen visual acuity in 96% of 121 eyes. No eyes lost visual acuity, and no complications were identified as a result of ICG use.39 This study, however, was noncomparative and retrospective and did not formally evaluate visual fields. In addition, power calculations suggested that a sample size of 300 would be required to have a reasonable chance of detecting a significant adverse event if the rate of that event were 1%.39 ICG-assisted ILM peeling has become routine practice for a large number of vitreoretinal surgeons, with 42% of these surgeons using ICG for 90% of their primary macular hole operations.46,47 ICG staining has been promoted as useful for surgeons learning to peel the ILM. According to the 2003 survey of the American Society of Retinal Specialists, 52% of vitreoretinal surgeons now using ICG-assisted ILM peeling had not routinely attempted ILM peeling before the introduction of ICG.47 Furthermore, several studies have demonstrated that ICG-assisted ILM peeling is helpful in challenging cases such as traumatic, recurrent, and long-standing macular holes as well as macular hole surgery in severely myopic eyes even in the presence of retinal detachment.27,28,30,32,37,48,49 Despite widespread use of ICG-assisted ILM peeling and many favorable reports, it is important to note that some clinical studies have reported unfavorable functional outcomes and complications, such as visual field defects or retinal pigment epithelium (RPE) changes.50–55 Investigators have generally attributed complications and unfavorable outcomes to the use of ICG. They may be correct. Nevertheless, it is important to recall that unfavorable results and these same complications have been previously described as surgeons began to peel the ILM even before the introThe authors received no public or private financial support pertaining to the information reported in this article. Reprint requests: Andrea P. Da Mata, MD, Cincinnati Eye Institute, 10494 Montgomery Road, Cincinnati, OH 45242; e-mail: andreadamata@hotmail.com

Indocyanine green–assisted peeling of the retinal internal limiting membrane13The authors have no financial interest in products mentioned in this article.

OBJECTIVE To determine whether indocyanine green (ICG) stains and facilitates peeling of the retinal internal limiting membrane (ILM). To investigate the different staining properties of the posterior cortical hyaloid, retinal ILM, and the retina after ILM removal. DESIGN Autopsy eye study. MATERIALS Eleven human cadaveric eyes. METHODS Open sky vitrectomy including removal of the posterior cortical vitreous was performed. A 0.5% ICG solution was then injected into the posterior vitreous cavity over the macula. The dye was allowed to settle on the macula for 5 minutes and was then removed by mechanical aspiration. Peeling of the ILM was initiated with a bent needle and completed with intraocular forceps. Specimens were submitted for light and electron microscopy. MAIN OUTCOME MEASURES Staining properties and ease of peeling of retinal ILM were evaluated. Retinal ILM removal was confirmed by histopathologic and electron microscopic examination. RESULTS ICG contact with the retinal surface resulted in bright green staining of the ILM. This stain greatly facilitated ILM peeling by improving direct visualization of the membrane. The underlying retina did not stain, thus providing a clear distinction between the stained ILM and the unstained retina. Continuous circular peeling of the ILM was easily completed with this technique. Light microscopic and ultrastructural studies confirmed removal of the ILM. CONCLUSIONS ICG solution distinctly stains the nearly invisible retinal ILM in human cadaveric eyes. ICG staining greatly facilitates ILM peeling by providing a stark contrast between the stained ILM and the unstained retina.