Travis A. Meredith

Submacular surgery trials randomized pilot trial of laser photocoagulation versus surgery for recurrent choroidal neovascularization secondary to age-related macular degeneration: I. Ophthalmic outcomes. Submacular Surgery Trials Pilot Study report number 1

PURPOSE To report complications and changes in vision during 2 years of follow-up of patients with age-related macular degeneration assigned randomly to surgical removal or to laser photocoagulation of subfoveal recurrent neovascular lesions in a pilot trial designed to test methods, to refine estimates of outcome rates, and to project patient accrual rates for a larger multicenter randomized trial to evaluate submacular surgery. PATIENTS AND METHODS Eligible patients with previous laser photocoagulation of extrafoveal or juxtafoveal choroidal neovascularization secondary to age-related macular degeneration were enrolled at 15 collaborating clinical centers. Assignments to treatment arm were made by personnel at a central coordinating center. Adherence to eligibility criteria and treatment assignment was assessed centrally at a photograph reading center. Patients were examined at 3, 6, 12, and 24 months after treatment for data collection purposes. Outcome measures reported include treatment complications, adverse events, requirements for additional treatment, and 2-year changes in visual acuity from baseline. RESULTS Of 70 patients enrolled, 36 were assigned to laser photocoagulation and 34 to submacular surgery; all were treated as assigned. One patient in each group died before the 2-year examination. Visual acuity was measured at the 2-year examination for 31 of the surviving patients (89%) in the laser arm and for 28 of the surviving patients (85%) in the surgery arm. The 2-year measurements for 36 of the 59 patients (61%) were made by an examiner masked to treatment assignment and to the identity of the study eye. Improvements and losses of visual acuity were observed in both treatment arms; 20 of 31 study eyes (65%) in the laser arm and 14 of 28 study eyes (50%) in the surgery arm had visual acuity 2 years after enrollment that was better than or no more than 1 line worse than the baseline level. Changes in visual acuity and the size of the central macular lesions from baseline to the 2-year examination were similar in the treatment arms. Few serious complications were observed in either arm at the time of initial treatment; serious adverse events were rare. During follow-up, 11 laser-treated eyes and 18 surgically treated eyes had additional intraocular procedures. CONCLUSIONS The data from this pilot trial suggest no reason to prefer submacular surgery over laser photocoagulation for treatment of patients with age-related macular degeneration who have lesions similar to those studied in this pilot trial. Any clinical trial designed to compare submacular surgery with laser photocoagulation in eyes with age-related macular degeneration and subfoveal recurrent neovascular lesions must enroll several hundred patients in order to reach a statistically valid conclusion regarding differences between these two methods of treatment with respect to either changes in visual acuity or complication rates.

Pars Plana Vitrectomy for Severe Penetrating Injury with Posterior Segment Involvement

We studied 50 consecutive cases of severe penetrating ocular trauma with posterior segment involvement for which vitreous surgery and scleral buckling were performed as secondary reparative procedures. Eyes with a better prognosis, such as those with anterior segment injuries alone and intraocular foreign bodies, were excluded. Of 50 eyes, 31 (62%) had a successful outcome. There was a significant difference in visual outcome between those eyes that had received blunt and sharp penetrating trauma. Visual acuity of 20/50 or better was more frequently attained in eyes with sharp penetrating trauma (P = .002). Thirty-three eyes had initial retinal detachment; 17 (52%) were successfully repaired. Blunt penetrating trauma produced retinal detachment more frequently than sharp penetrating trauma (22 of 29 vs 11 of 21). Retinal detachment was more often successfully repaired after sharp penetrating trauma (8 of 11 vs 9 of 22). Contusive damage to the choroid and retina limited final visual and anatomic results after blunt rupture of the globe.

Cystoid Macular Edema after Retinal Detachment Surgery

One hundred eyes in 98 patients were studied by fluorescein angiography and stereo color photography six weeks after successful scleral buckling surgery. Twenty-five percent of 67 phakic eyes and 40% of 33 aphakic eyes demonstrated cystoid macular edema. Older phakic patients were at significantly greater risk to develop cystoid macular edema than younger phakic patients. Seventeen percent of successfully repaired eyes demonstrated distortion of the macula by preretinal membranes; 16 of these 17 eyes showed leakage of fluorescein dye into the surrounding retina sometimes also causing cystoid edema. Either cystoid macular edema or macular distortion was present in 38% of the phakic eyes and 64% of the phakic eyes after successful retinal detachment surgery.

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.

Classification of Proliferative Vitreoretinopathy Used in the Silicone Study

The Silicone Study is a multicenter randomized clinical trial that compares a long-acting gas with silicone oil for the surgical treatment of proliferative vitreoretinopathy (PVR). As part of the study, a topographic classification of PVR has been developed that is based on the characteristic patterns of retinal distortion produced by the contraction of proliferative membranes on the retina or within the vitreous base. This classification is used to document the extent and anatomic distribution of PVR present preoperatively and to help standardize the surgical treatment. Experience has shown that this classification facilitates the identification of these membranes and their systematic dissection, and the authors therefore suggest that it be used to augment the Retina Society classification of PVR.

Transpupillary thermotherapy versus plaque radiotherapy for suspected choroidal melanomas

PURPOSE To examine the outcomes and complications of transpupillary thermotherapy for treatment of small choroidal melanomas. DESIGN Retrospective case-matched comparative study and retrospective observational study. PARTICIPANTS The case-matched study consisted of 36 patients treated with either transpupillary thermotherapy or plaque radiotherapy (18 patients per group). The observational study consisted of 21 patients treated with transpupillary thermotherapy alone (primary transpupillary thermotherapy) and 9 patients treated with transpupillary thermotherapy plus plaque radiotherapy (adjuvant transpupillary thermotherapy). MAIN OUTCOME MEASURES Visual acuity, local tumor control, and metastasis. RESULTS The case-matched groups did not differ significantly with respect to age, gender, initial visual acuity, tumor location, or length of follow-up (mean, 33 months for transpupillary thermotherapy vs. 40 months for plaque radiotherapy). There was no significant difference in final visual acuity (P = 0.810) or postoperative visual acuity change (P = 0.919) between the 2 groups. In the observational study, the mean follow-up was 32 months (range, 4-58 months). Indications for primary transpupillary thermotherapy included documented growth (10 patients) and the presence of >/=3 risk factors for growth (11 patients). Retinal complications occurred in 16 patients (76%). The mean posttreatment visual acuity change was minus 2 lines (range, minus 9 to plus 7 lines). Local failure occurred in 6 patients (29%). Local failure was associated with an increased number of transpupillary thermotherapy spots per session (P = 0.023) and decreased tumor pigmentation (P = 0.001). Indications for adjuvant transpupillary thermotherapy included tumor radioresistance (6 patients) and the presence of risk factors for local failure (3 patients). All 9 tumors that received adjuvant transpupillary thermotherapy regressed rapidly, with no local failures. The mean postoperative visual acuity change was -1.9 lines (range, -9 to +5 lines). No patient in either study developed metastasis. CONCLUSIONS The recent interest in transpupillary thermotherapy as primary therapy for choroidal melanoma is based largely on the assumption that transpupillary thermotherapy may provide better visual outcomes than plaque radiotherapy. However, this study found no significant difference in visual outcomes between transpupillary thermotherapy and plaque radiotherapy. Further, the local failure rate with transpupillary thermotherapy was substantially higher than with plaque radiotherapy. The most promising role for transpupillary thermotherapy seems to be as an adjunct to plaque radiotherapy. The appropriate indications for transpupillary thermotherapy in the management of choroidal melanoma need to be re-evaluated.

Natural History of Serous Detachments of the Retinal Pigment Epithelium

Fifty eyes of 40 patients with serous (avascular) detachments of the retinal pigment epithelium were followed up for an average of 22 months. Of the 50 eyes, 14 (28%) developed bleeding beneath the retinal pigment epithelium and retina or subretinal neovascularization detected on fluorescein angiography. These changes did not occur in eyes of patients younger than age 56 years at diagnosis or in detachments less than 1 disk diameter in size, whereas 35.9% (14) of eyes in patients older than age 56 years developed vascular complications. Vascular complications were uncommon when the initial detachment did not involve the fovea. Visual acuity declined in only one (9.1%) of eyes in patients younger than age 56 years but in 20 (51.3%) of eyes in patients age 56 years or greater.

Pars Plana Vitrectomy Techniques for Relief of Epiretinal Traction by Membrane Segmentation

We used a technique for surgical management of fibrovascular membranes to relieve epiretinal tangential traction when present in proliferative diabetic retinopathy. Sharp dissection with intraocular scissors was used to segment fibrovascular and cortical vitreous membranes together with cauterization of large vessels with intraocular bipolar diathermy. The objective of membrane segmentation was to relieve all epiretinal traction, thereby reducing retinal surface distortion and allowing the retina to flatten and reattach. Complete relief of traction prevented further late contraction of membranes and subsequent distortion and redetachment.

Chronic bacterial endophthalmitis.

We studied a specific syndrome of uveitis secondary to intraocular bacterial pathogens of low virulence after extracapsular cataract extraction and intraocular lens implantation in three eyes. The onset of photophobia, visual impairment, conjunctival redness, and uveitis was delayed for four days to 12 weeks after surgery. Chronic inflammation persisted for five weeks to 16 months before a definitive diagnosis was made. Signs and symptoms were suppressed by administration of topical and systemic corticosteroids. Intraocular biopsy and antibiotic injection both established the cause as bacterial endophthalmitis and resulted in resolution of signs and symptoms. Staphylococcus epidermidis was cultured in two eyes and Achromobacter was cultured in one.

Rhegmatogenous Retinal Detachment Complicating Cytomegalovirus Retinitis

Six eyes in four patients with cytomegalovirus retinitis developed retinal holes and retinal detachment. Holes appeared in areas of necrosis and were typically large and round with shaggy edges. Differentiation from exudative detachment was sometimes difficult because of obscuration of the fundus by vitreous haze. Cryotherapy was successful in closing open breaks without detachment; cryotherapy and exoplant surgery were used effectively to treat the initial detachments. The occurrence of massive periretinal proliferation and late development of new areas of hole formation or retinitis complicated therapy for these detachments.