Scott R. Sneed

Pars plana vitrectomy without scleral buckle for pseudophakic retinal detachments

OBJECTIVE To report the anatomic and visual results of primary pars plana vitrectomy (PPV) without scleral buckling to repair primary rhegmatogenous retinal detachments in pseudophakic eyes. DESIGN Nonrandomized, prospective, comparative clinical trial. PARTICIPANTS Two hundred eighty-three consecutive patients (294 eyes) with pseudophakia, peripheral retinal tears, and new rhegmatogenous retinal detachments were treated according to the surgery protocol. INTERVENTION Patients underwent PPV with fluid-gas exchange and endolaser to repair the retinal detachment. Two hundred sixty-four patients (275 eyes) were followed from 6 months to 6 years and 8 months with an average follow-up of 19 months. MAIN OUTCOME MEASURES Reattachment of the retina and visual outcome were compared to previously published studies. RESULTS Of 97 eyes with a macula-attached rhegmatogenous retinal detachment, 88 eyes (91%) were reattached with a single operation, and of the 178 eyes with a macula-detached retinal detachment, 153 (86%) eyes were reattached with a single operation. In 241 (88%) of 275 eyes, the retina was reattached with a single operation, and in 265 (96%) of 275 eyes, the retina was ultimately reattached with subsequent operations. The median initial visual acuity was 20/300, and the median final visual acuity was 20/40. The rate of reattachment with one operation was similar for eyes with an anterior chamber intraocular lens (91%) and for eyes with a posterior chamber intraocular lens (88%). Refractive error measurements obtained in 81 eyes were essentially unchanged. The mean change in refractive error was -0.15 diopter. Seventeen eyes (6%) developed macular puckers requiring surgery, 46 eyes (17%) developed cystoid macular edema, and 6 eyes (2%) developed full-thickness macular holes. CONCLUSION Primary PPV with fluid-gas exchange and laser is a safe, effective method to repair primary pseudophakic retinal detachments. The anatomic reattachment rate and the visual acuity obtained with this technique appear to be at least as good as those reported in the literature for scleral buckling, PPV with scleral buckling, and pneumatic retinopexy.

Macular pucker removal with and without internal limiting membrane peeling: pilot study

OBJECTIVE To investigate results of macular pucker surgery with and without internal limiting membrane (ILM) peeling. DESIGN Retrospective noncomparative interventional case series. PARTICIPANTS Forty-four consecutive patients underwent pars plana vitrectomy to remove an idiopathic macular pucker by two surgeons from June 1999 to July 2000. INTERVENTION During the vitrectomy, one surgeon removed only the macular epiretinal membrane (24 patients), whereas the other surgeon removed the macular epiretinal membrane and then performed an additional ILM peeling (20 patients). MAIN OUTCOME MEASURES Visual acuity and recurrence of macular pucker. RESULTS Twenty-four (55%) patients underwent pars plana vitrectomy without ILM peeling, and 20 patients (45%) underwent pars plana vitrectomy with ILM peeling. Visual acuity improved or was unchanged in 79% of operated eyes without ILM peeling and 100% of operated eyes with ILM peeling (P = 0.01). Visual acuity improved 5 or more lines in 25% of operated eyes without ILM peeling and 30% of operated eyes with ILM peeling. At the final visit, 21% of eyes without ILM peeling at the initial surgery showed postoperative recurrent macular pucker or persistent contraction to the ILM, whereas none of the eyes with ILM peeling had evidence of this. CONCLUSIONS This pilot study provides evidence that peeling of the ILM during macular pucker surgery may not have deleterious effects.

A Comparison of Retrobulbar versus Sub-Tenon's Corticosteroid Therapy for Cystoid Macular Edema Refractory to Topical Medications

OBJECTIVE The objective is to compare the effectiveness of retrobulbar and posterior sub-Tenons injection of corticosteroids for treatment of post-cataract cystoid macular edema that was refractory to topical medications. DESIGN A retrospective study was performed. PARTICIPANTS A total of 48 patients (49 eyes) with post-cataract cystoid macular edema refractory to topical medications was studied. INTERVENTION Patients received either a single retrobulbar injection (18 eyes) or 3 biweekly posterior sub-Tenons injections (31 eyes) of corticosteroids. MAIN OUTCOME MEASURES Patients were observed for clinical resolution of the cystoid macular edema, visual acuity, and intraocular pressure. RESULTS Both treatment methods resulted in significant improvement in visual acuity. The posterior sub-Tenons group had a visual improvement from 20/92 pretreatment to 20/50 post-treatment (P = 0.0001) with a median follow-up of 12 months. The retrobulbar group had a visual improvement from 20/97 pretreatment to 20/58 post-treatment (P = 0.035) with a median follow-up of 10 months. The visual improvement was not significantly different between the two groups. The average intraocular pressure increased from a pretreatment level of 14.1 mmHg to a high of 17.7 mmHg (P < 0.00005) in the sub-Tenons group. The average intraocular pressure increased from 15.1 mmHg to a high of 17.6 mmHg (P = 0.04) in the retrobulbar group. CONCLUSIONS Cystoid macular edema that persists after treatment with topical medications may improve after retrobulbar or posterior sub-Tenons corticosteroid injections. There was no significant difference in outcome between the two treatment groups.

Vitrectomy For Vitreomacular Traction Syndrome With Macular Detachment

Purpose: To describe the clinical characteristics of the vitreomacular traction syndrome with macular detachment and to report our surgical experience with this condition. Methods: A retrospective chart and photographic review was performed on nine patients (nine eyes) who had a symptomatic decrease in visual acuity from a macular traction retinal detachment caused by vitreomacular traction syndrome. Vitrectomy was performed in each eye to reattach the retina. Results: Intraoperative observation confirmed partial posterior vitreous separation with adherence of the posterior hyaloid to the detached retina and separation of the posterior hyaloid from the attached retina. After surgery the macula was reattached in seven eyes (78%). Visual acuity was improved in four eyes, stable in four eyes, and worse in one eye. Conclusion: Macular detachment may occur secondary to vitreomacular traction syndrome. Although the retina may be reattached surgically in these cases, visual improvement may be limited by chronic detachment, premacular fibrosis, cystoid macular edema, or macular schisis.

Early Retinal Adhesion from Laser Photocoagulation

Histopathologic examination of eight cynomolgus monkey eyes and one human eye revealed that both argon and krypton laser photocoagulation cause adhesion between the neurosensory retina and the retinal pigment epithelium (RPE) within 24 hours of treatment. The neurosensory retina remained attached at the sites of laser burns despite surrounding retinal detachment in untreated areas. This early adhesion with the laser is useful for the treatment of eyes in which the retina has been recently reattached such as at the end of a vitrectomy for a retinal detachment with proliferative vitreoretinopathy (PVR) or after a pneumatic retinopexy. It is also useful for the treatment of retinal breaks without detachment.

Outcome of sulcus fixation of dislocated posterior chamber intraocular lenses using temporary externalization of the haptics33

OBJECTIVE This study evaluated the visual outcome and complications of repositioning and sulcus fixation of a dislocated posterior chamber intraocular lens (PC IOL) using a technique in which the haptics of the IOL are temporarily externalized for suture placement. DESIGN Retrospective, noncomparative case series. PARTICIPANTS Seventy-eight patients with a dislocated PC IOL. INTERVENTION All patients underwent surgery to fixate the PC IOL using this technique. MAIN OUTCOME MEASURES Patients were evaluated for visual acuity, refractive error, and surgical complications associated with the procedure. RESULTS The average visual acuity before surgery was 20/205 (range, 20/20 to light perception), with a median refractive error of -1.00 diopters (D; range, -7.25-+15.00 D). After surgery, the average visual acuity improved to 20/72 (range, 20/20 to no light perception), with a median refractive error of -0.75 D (range, -5.50-+3.50 D). Patients were observed for a median of 15.5 months (range, 6-57 months). Twenty patients had postoperative cystoid macular edema (26%), 7 patients had an epiretinal membrane (ERM) (9%), and 5 patients had a retinal detachment (6%). Eight patients (10%) experienced iris capture of the sutured IOL, and in three patients (4%) the PC IOL dislocated again after surgery. CONCLUSIONS This technique is an effective method for securing a dislocated PC IOL.

Surgical management of late-onset retinal detachments associated with regressed retinopathy of prematurity.

The authors report their experience in managing 16 cases of late-onset retinal detachments (RDs) associated with regressed retinopathy of prematurity (ROP). Fourteen (88%) of the 16 eyes were successfully reattached. An initial scleral buckling procedure was successful in 6 of 12 eyes. A pars plana vitrectomy was necessary in a total of eight eyes that either initially presented with proliferative vitreoretinopathy (1 case), posterior retinal breaks (1 case), subretinal fibrosis (1 case), vitreoretinal traction bands (1 case), or had persistent vitreoretinal traction after failed scleral buckling procedures (4 cases). Visual acuity stabilized or improved in 13 of the 14 eyes with successful retinal reattachment. Because these cases often have significant vitreoretinal traction and/or posterior retinal breaks, pars plana vitrectomy in conjunction with scleral buckling may be necessary in order to achieve long-term retinal reattachment.

Fenestrated sheen macular dystrophy.

We examined a family with fenestrated sheen macular dystrophy. The red macular lesions were strikingly apparent in the propositus and more subtle in one affected cousin. Pronounced macular retinal pigment epithelial disruption or mottling was present in the father of the propositus, who also had markedly reduced electroretinogram rod and cone responses. The extent of electroretinogram amplitude reduction indicates abnormal function of the peripheral retina in addition to the clinically evident macular changes. Affected family members showed peripheral retinal pigment epithelial granularity. Central visual acuity remained normal despite the presence of macular lesions.

Systemic therapeutic agents and retinal toxicity

With the thousands of systemic therapeutic agents available, only a limited number of medications have been associated with retinal and retinal pigment epithelial toxicity. The intent of this report is to review these medications and discuss the mechanisms of toxicity when known. Emphasis will be placed on agents producing toxicity to the mature retina

DIDANOSINE RETINAL TOXICITY.

Purpose: To report nine new cases of retinal degeneration secondary to didanosine toxicity and to summarize the previously reported cases in the literature. Methods: This was a multicenter, retrospective, observational case study from seven institutions. Medical records of patients who demonstrated well-demarcated severe midperipheral chorioretinal degeneration and who were previously treated with didanosine therapy were collected and the following information was reviewed: age, gender, medical history, detailed medication history including current and previous antiretroviral use, ocular and retinal examination findings, and multimodal imaging findings with optical coherence tomography, fundus photography, wide-field fundus autofluorescence, and wide-field fluorescein angiography. When available, findings with electrophysiology testing and automated perimetry were also collected and reviewed. A literature review was also performed to collect all reported cases of chorioretinal degeneration secondary to didanosine toxicity. Results: Nine patients were identified who had findings consistent with peripheral retinal toxicity secondary to didanosine use. Eight of the 9 patients were men, and the median age was 54 years at the time of presentation (mean: 55 years, range, 42–71 years). Snellen distance acuity ranged from 20/20 to 20/32. At least three of the cases in the series demonstrated progression of the peripheral retinal pigment epithelium and photoreceptor atrophy despite didanosine cessation. A review of the literature revealed 10 additional cases of didanosine toxicity. Seven of the 10 cases were in men (70%), and the average age was 26 years with a wide range (2–54 years). Chorioretinal findings were very similar to this cohort. Conclusion: Herein, we report the largest series of nine cases of peripheral chorioretinal degeneration secondary to didanosine toxicity in adults. When combined with the cases in the literature, 19 cases of didanosine toxicity, 4 of which occurred in children, were collected and analyzed. Three of the new cases presented showed clear progression of degeneration despite didanosine cessation. Newer nucleoside reverse transcriptase inhibitors may potentiate mitochondrial DNA damage and lead to continued chorioretinal degeneration.