Tom S. Chang

A new 25-gauge instrument system for transconjunctival sutureless vitrectomy surgery.

OBJECTIVES To introduce and evaluate the infusion and aspiration rates and operative times of the 25-gauge transconjunctival sutureless vitrectomy system (TSV) DESIGN: In vitro experimental and comparative interventional study. PARTICIPANTS AND CONTROLS Twenty eyes of 20 patients underwent a variety of vitreoretinal procedures using the 25-gauge TSV, including idiopathic epiretinal membrane (n = 10), macular hole (n = 4), rhegmatogenous retinal detachment (n = 3), branch retinal vein occlusion (n = 2), diabetic vitreous hemorrhage (n = 1), and 20 cases similar in diagnosis and severity were matched to provide comparison between duration of individual portions of the surgical procedures with the existing 20-gauge vitrectomy system. METHODS Description of the 25-gauge TSV is provided; infusion and aspiration rates of the 25-gauge and standard 20-gauge vitrectomy system were measured in vitro using balanced saline solution and porcine vitreous for several levels of aspirating power and bottle height, and operating times of individual portions of surgical procedures were measured for the 25-gauge and 20-gauge vitrectomy system. MAIN OUTCOME MEASURES Infusion, aspiration rates, and operative times of the 20-gauge and 25-gauge vitrectomy system. RESULTS Infusion and aspiration rates of the 25-gauge TSV system were reduced by an average of 6.9 and 6.6 times, respectively, compared with the 20-gauge system when balanced saline solution was used. The average flow rate of the Storz 25-gauge cutter (at 500 mmHg, 1500 cuts per minute [cpm]) was 40% greater than that of the 20-gauge pneumatic cutter (at 250 mmHg, 750 cpm) but about 2.3 times less than the 20-gauge high-speed cutter (at 250 mmHg, 1500 cpm). Mean total operative time was significantly greater for the 20-gauge high-speed cutter (26 minutes, 7 seconds) than for the 25-gauge vitrectomy system (17 minutes, 17 seconds) (P = 0.011). CONCLUSIONS Although the infusion and aspiration rates of the 25-gauge instruments are lower than those for the 20-gauge high-speed vitrectomy system, the use of 25-gauge TVS may effectively reduce operative times of select cases that do not require the full capability of conventional vitrectomy.

Initial experience using the transconjunctival sutureless vitrectomy system for vitreoretinal surgery

OBJECTIVE To describe the initial experience and to evaluate the safety and feasibility of using the 25-gauge Transconjunctival Sutureless Vitrectomy System (TSV) for a variety of vitreoretinal procedures. DESIGN Retrospective review of a consecutive interventional case series. PARTICIPANTS Thirty-five eyes of 33 patients, including cases of idiopathic epiretinal membrane (12 cases), retinal detachment (6 cases), macular hole (5 cases), branch retinal vein occlusion (4 cases), retinopathy of prematurity (4 cases), persistent diabetic macular edema (1 case), diabetic vitreous hemorrhage (1 case), retained lens material after cataract extraction (1 case), and Norrie disease (1 case). INTERVENTION All patients underwent surgery using the 25-gauge TSV. MAIN OUTCOME MEASURES Intraocular pressure, visual acuity, and postoperative complications. RESULTS The median preoperative intraocular pressure was 16 mmHg (range, 10-21 mmHg), whereas the median intraocular pressure on the first postoperative day was 12 mmHg (range, 6-28 mmHg). The median intraocular pressure at 1 week and 1 month were both 16 mmHg (range, 10-30 mmHg). Overall, the median preoperative visual acuity was 20/100 (range, 20/30 to hand motions), and the median postoperative visual acuity after a mean follow-up of 14 weeks (range, 1-60 weeks) was 20/60 (range, 20/20-20/150). One eye developed a postoperative retinal detachment. CONCLUSIONS The 25-gauge TSV seems to be practical and safe for a variety of vitreoretinal procedures. The concept of transconjunctival surgery has the potential to increase the efficiency of a variety of vitreoretinal surgeries and possibly hasten the postoperative recovery and outcomes in several conditions by simplifying the surgical procedure; minimizing surgically induced trauma; and decreasing the convalescence period, the operating time, and the postoperative inflammatory response.

Patient selection for macular translocation surgery using the scanning laser ophthalmoscope

OBJECTIVES To evaluate the use of the scanning laser ophthalmoscope (SLO) as a predictor for potential visual improvement in eyes with subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD) undergoing limited macular translocation. DESIGN Retrospective noncomparative case series. PARTICIPANTS Consecutive series of 71 eyes of 70 patients with subfoveal CNV secondary to AMD that underwent effective and uncomplicated limited macular translocation at the Wilmer Ophthalmological Institute. METHODS Evaluation of the fundus microperimetry and fixation pattern was conducted on all patients using the Rodenstock scanning laser ophthalmoscope (G. Rodenstock Instrument GmbH, Munich, Germany) within 72 hours before surgery. MAIN OUTCOME MEASURES Sensitivity and specificity in addition to positive and negative predictive values of SLO findings for visual outcome after macular translocation. RESULTS Stable fixation presented the highest positive predictive value for visual acuity equal to or better than 20/100 (30 of 33 = 0.91), and predominantly eccentric fixation had the highest negative predictive value for visual acuity worse than 20/100 (7 of 9 = 0.78). Sensitivity was higher for the presence of predominantly central fixation (42 of 48 = 0.87), and specificity was higher for relatively unstable/unstable fixation (20 of 23 = 0.87). CONCLUSIONS Eyes with stable and central fixation (without dense central scotoma) good preoperative visual acuity, and short length of symptoms are those with the greatest chance to achieve good vision after macular translocation. The knowledge of the fixation and microperimetry pattern enables better understanding of the macular function in eyes with AMD and may be useful for evaluation of baseline retinal cell viability. Incorporation of these testing modalities may help to optimize patient selection for macular translocation or other future techniques aimed at rescuing photoreceptors.

Idiopathic retinal vasculitis, aneurysms, and neuro-retinitis

Purpose: The authors describe the clinical feature of ten patients with a new syndrome characterized by the presence of retinal vasculitis, multiple macroaneurysms, neuro-retinitis, and peripheral capillary nonperfusion. Methods: The authors evaluated ten patients identified to have clinical features compatible with the syndrome of idiopathic retinal vasculitis, aneurysms and neuroretinitis (IRVAN). Clinical examination findings, sequential fundus photographs (when available), fluorescein angiograms, systemic investigations, response to therapy, and visual outcomes were reviewed. Results: Seven eyes of four patients sustained a marked decrease in visual acuity of 20/200 or worse. Visual loss was due to a combination of an exudative maculopathy and sequelae of retinal ischemia. Capillary nonperfusion was seen in all ten patients and was severe enough to warrant panretinal laser photocoagulation in six patients. Systemic investigations were uniformly noncontributory. Oral prednisone appears to have little beneficial effects on patients with this disorder. Conclusions: Patients with IRVAN have characteristic retinal features that readily identify this syndrome. An increased awareness of this rare syndrome may help to identify sight-threatening complications at an earlier stage. The authors caution against extensive medical investigations. Ophthalmology 1995;102:1089-1097

Vision-Related Function after Ranibizumab Treatment by Better- or Worse-Seeing Eye: Clinical Trial Results from MARINA and ANCHOR

OBJECTIVE To examine the effects of ranibizumab on the National Eye Institute Visual Function Questionnaire-25 (NEI VFQ-25) scores in neovascular age-related macular degeneration (AMD) according to whether the study eye was the better- or worse-seeing eye at baseline. DESIGN Within 2 randomized, double-masked clinical trials (MARINA and ANCHOR), the NEI VFQ-25 was administered at 0, 1, 2, 3, 6, 9, 12, 18, and 24 months. PARTICIPANTS We included 646 MARINA and 379 ANCHOR patients. INTERVENTION Patients were randomized 1:1:1 to monthly intravitreal ranibizumab (0.3 or 0.5 mg) or control (sham injections for MARINA; photodynamic therapy [PDT] with verteporfin for ANCHOR). MAIN OUTCOME MEASURES Mean change from baseline in NEI VFQ-25 scores at 12 and 24 months. RESULTS Across all treatment arms, 21% to 38% of enrolled eyes were the better-seeing eye. At the 24-month follow-up visit, mean change in composite scores with ranibizumab seemed to be better than control for both better-seeing eyes (8.4 [95% confidence interval (CI), 5.2-11.6], 7.5 [95% CI, 3.7-11.4], and -9.4 [95% CI, -12.5 to -6.3] for the 0.3-mg, 0.5-mg, and sham groups, respectively) and worse-seeing eyes (1.7 [95% CI, -1.1 to 4.4], 1.7 [95% CI, -0.7 to 4.1], and -5.4 [95% CI, -7.9 to -2.8] for the 0.3-mg, 0.5-mg, and sham groups, respectively) in MARINA, as well as the better-seeing eye in ANCHOR (11.3 [95% CI, 5.3-17.3], 13.3 [95% CI, 7.7-19.0], and -2.7 [95% CI, -9.0 to 3.7] for the 0.3-mg, 0.5-mg, and PDT groups, respectively). When the worse-seeing eye was treated in ANCHOR, such differences could not be detected at 24 months (1.3 [95% CI, -1.7 to 4.2], 2.6 [95% CI, -1.1 to 6.3], and 0.1 [95% CI, -3.5 to 3.7] for the 0.3-mg, 0.5-mg, and PDT groups, respectively). CONCLUSIONS Analysis of patient perception of vision-related function in phase III trials evaluating ranibizumab for neovascular AMD demonstrates improved patient-reported outcomes regardless of whether the treated eye is the better- or worse-seeing eye at onset of treatment, and supports treatment of such lesions with ranibizumab, even those in the worse-seeing eye. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Improved Vision-Related Function After Ranibizumab vs Photodynamic Therapy: A Randomized Clinical Trial

OBJECTIVE To compare patient-reported visual function in those with neovascular age-related macular degeneration treated with ranibizumab or verteporfin photodynamic therapy (PDT). DESIGN Multicenter, double-masked, phase 3 trial (ANCHOR). Participants were randomized in a 1:1:1 ratio to receive 0.3 or 0.5 mg of intravitreal ranibizumab plus sham verteporfin or sham injections plus active verteporfin monthly. The National Eye Institute Visual Function Questionnaire-25 (NEI VFQ-25) was administered at baseline and 1, 2, 3, 6, 9, 12, 18, and 24 months. MAIN OUTCOME MEASURE Mean change from baseline in NEI VFQ-25 scores at 12 months. RESULTS At 12 months, patients treated with ranibizumab (0.3 mg [n = 137] or 0.5 mg [n = 139]) had mean improvements in NEI VFQ-25 composite scores of 5.9 (95% confidence interval [CI], 3.6 to 8.3) and 8.1 (95% CI, 5.3 to 10.8) points, respectively; patients treated with PDT (n = 142) had a mean improvement of 2.2 points (95% CI, -0.3 to 4.7; vs 0.5 mg of ranibizumab, P < .001; vs 0.3 mg of ranibizumab, P = .003). At each dose through 24 months, patients treated with ranibizumab were more likely to improve in most subscales, including the prespecified subscales (near activities, distance activities, and vision-specific dependency). CONCLUSIONS Patients treated with ranibizumab were more likely to report clinically meaningful improvements in visual function through 24 months compared with those treated with verteporfin PDT. Application to Clinical Practice Ranibizumab treatment in neovascular age-related macular degeneration can improve patient-reported visual function. Trial Registration clinicaltrials.gov Identifier: NCT00061594.

Characteristics of visual loss by scanning laser ophthalmoscope microperimetry in eyes with subfoveal choroidal neovascularization secondary to age-related macular degeneration.

PURPOSE To evaluate the effects of subfoveal choroidal neovascularization secondary to age-related macular degeneration on functional parameters obtained by scanning laser ophthalmoscope microperimetry. DESIGN Retrospective observational case series and cross-sectional study. METHODS At the Doheny Retina Institute and Wilmer Eye Institute a consecutive series of 179 eyes of 175 patients with subfoveal choroidal neovascularization secondary to age-related macular degeneration was studied. The onset of visual symptoms, best-corrected visual acuity, fluorescein angiography, evaluation of fundus microperimetry and fixation pattern using the Rodenstock scanning laser ophthalmoscope were obtained for each patient. The main outcome measures were central retinal sensitivity and fixation pattern (fixation location and fixation stability) in eyes with subfoveal choroidal neovascularization and their relationship to the length of disease, type and characteristics of choroidal neovascularization, and visual acuity. RESULTS Of 179 eyes, 135 (75%) had central fixation, 27 (15%) had poor central fixation, and 17 (9%) had predominantly eccentric fixation. Seventy-six eyes (42%) had stable fixation, 70 eyes (39%) had relatively unstable fixation, and 33 eyes (18%) had unstable fixation. In 50 eyes (28%) a dense central scotoma was noted. Eighty-nine of 100 eyes (89%) with length of symptoms of less than 3 months had predominantly central fixation and 58 (58%) had stable fixation; 14 of 34 eyes (41%) with length of symptoms of more than 6 months had predominantly central fixation, and 5 eyes (15%) had stable fixation. In 15 eyes of patients who elected not to receive treatment, successive scanning laser ophthalmoscope microperimetry were obtained over time (follow-up of 18 months after onset of symptoms). Three months or less after the onset of symptoms, 13 eyes (87.7%) had predominantly central fixation and 9 eyes (60%) had stable fixation. More than 3 months and 6 months or less after the onset of symptoms, 10 eyes (66.7%) had predominantly central fixation and 7 eyes (46.7%) had stable fixation. This trend was further demonstrated in eyes more than 6 months after the onset of symptoms. CONCLUSIONS We conclude that the sequence of events leading to visual function deterioration appears to involve an initial mild decrease in central retinal sensitivity and visual acuity followed by progressive fixation instability and, ultimately, development of an absolute central scotoma with totally eccentric fixation. Increased length of disease is associated with worse fixation pattern and retinal sensitivity deterioration as assessed by scanning laser ophthalmoscope microperimetry. A better understanding of the characteristics of visual loss assessed by fixation pattern evaluation and microperimetry in age-related macular degeneration may help optimize timing, patient selection, and treatment options in eyes with this condition.

Validity of the SF-12 quality of life instrument in patients with retinal diseases

OBJECTIVE To investigate the construct validity and reliability of the SF-12 with the SF-36 composite scores in patients with retinal diseases. DESIGN Cross-sectional study. PARTICIPANTS One thousand eighty-one patients with retinal disease presenting for care at a tertiary referral university-based retina practice. METHODS Each patient completed the SF-36 before his or her initial ocular examination. The SF-12 is based on a subset of 12 items from the SF-36. MAIN OUTCOME MEASURES Physical Composite Score (PCS) and Mental Composite Score (MCS) as determined by the SF-36 and SF-12. RESULTS Eight hundred thirty-nine (78%) of the participants had scorable PCS and MCS scores on the SF-12. No significant differences were found between the SF-36 and SF-12 for the PCS and MCS overall and stratified by the four most frequently occurring disease categories (all P > 0.20). There were statistically significant differences across the disease categories in the mean PCS scores (P < 0.001) on the SF-36 and SF-12 and the MCS score on the SF-36 (P = 0.04). The SF-12 PCS and MCS scores were highly correlated with similar indicators (composite scores and subscales) on the SF-36. CONCLUSIONS The SF-12 is a valid measure of general health status for ophthalmic research, as long as differences in mental composite scores do not need to be demonstrated between different ocular disease groups. The benefit of reduced administration time makes the SF-12 a recommended general quality-of-life outcomes tool.

Inverted pneumatic retinopexy: A method of treating retinal detachments associated with inferior retinal breaks☆

PURPOSE To introduce the new approach of inverted pneumatic retinopexy for the management of rhegmatogenous retinal detachments with inferior retinal breaks. DESIGN Retrospective, noncomparative case series. PARTICIPANTS Eleven patients presenting with rhegmatogenous retinal detachments with causative inferior retinal breaks. INTERVENTION Sterile gas/air injection, cryopexy/laser retinopexy, with inverted positioning. MAIN OUTCOME MEASURES Postoperative primary and final anatomical outcome, visual acuity, and complications. RESULTS Patients were followed for a minimum of 3 months (mean, 5.1 months). Primary retinal reattachment was obtained in 10 of 11(91%) patients. One patient sustained a redetachment secondary to proliferative vitreoretinopathy, resulting in a single operation reattachment rate of 82%. Final reattachment was obtained in 11 of 11 (100%) patients. Mean visual acuity improved about 3 lines from 20/60 to 20/30, with 11 of 11 patients experiencing improvement in their visual acuity. Two patients required an additional surgical procedure to achieve final anatomic success. No new breaks were identified in the postoperative period, and no complications resulted from the pneumatical procedure. CONCLUSIONS Inverted pneumatic retinopexy can successfully repair retinal detachments with inferior retinal breaks under appropriate conditions.

Short-term effectiveness of intravitreal bevacizumab versus ranibizumab injections for patients with neovascular age-related macular degeneration.

Purpose: To compare the effectiveness of three consecutive intravitreal injections of bevacizumab (Avastin) and ranibizumab (Lucentis) in patients with treatment-naïve neovascular age-related macular degeneration. Methods: This is a retrospective comparative study of qualifying consecutively treated patients (n = 176) with new-onset subfoveal choroidal neovascularization presenting at 6 retina referral centers. Patients were treated with 3 consecutive monthly injections of ranibizumab (0.5 mg) or 3 injections of bevacizumab every 6 weeks (1.25 mg) as determined by physician and patient preference. Ophthalmologic evaluations included monthly visual acuity measurements, ocular examinations, and optical coherence tomography imaging at each visit. Results: A 29.2% reduction in the mean central foveal thickness measurement through optical coherence tomography was found in the ranibizumab-treated patients versus a 20.9% reduction in the bevacizumab-treated patients (P ≤ 0.02). Fifty-three percent of ranibizumab-treated patients had returned to a central foveal thickness of <200 μm by the completion of 3 injections compared with 35% of patients treated with bevacizumab (P ≤ 0.07). No ocular or systemic adverse events were reported in either group. Conclusion: Short-term effectiveness of ranibizumab treatment, as measured by incremental improvement in optical coherence tomography parameters, was significantly greater than bevacizumab treatment, suggesting that there is a difference in the biologic activities of ranibizumab and bevacizumab.