Ute Eckardt

Macular rotation with and without counter-rotation of the globe in patients with age-related macular degeneration

Abstract · Background: Macular rotation to treat exudative age-related macular degeneration (AMD) involves translocation of the fovea to a site with intact retinal pigment epithelium. To avoid the inevitable postoperative cyclotropia we combined this procedure with torsional muscle surgery. · Patients and methods: In 30 eyes the macula was rotated upward by 30–50° following complete artificial retinal detachment and a 360° retinotomy. Simultaneous torsional muscle surgery was not carried out in the first 8 eyes; in the remaining 22 eyes surgery of the oblique muscles was performed alone or in combination with surgery of two or four rectus muscles. Simultaneously or later, muscle surgery was performed on the fellow eye in 17 of these patients. Three of the eight patients who had no primary muscle surgery were operated on later. They had muscle surgery on the macular-rotated eye and on the fellow eye. · Results: Postoperatively, the silicone oil was removed from all but one eye and an intraocular lens implanted in all but two eyes. Five eyes developed a postoperative retinal detachment, three of them with proliferative vitreoretinopathy. Three other eyes developed a recurrence of the choroidal neovascularization. At last examination, 18 of the 30 eyes (60%) had a near vision of 0.4 or better, sufficient for the reading of normal newsprint. Six of the eight patients who did not undergo muscle surgery reported considerable disorientation caused by the postoperative diplopia and cyclotropia. The muscle operation, which has been performed in a total of 25 patients, conferred complete freedom from complaints in all but one patient. · Conclusion: Macular rotation succeeded in restoring reading vision in about half of cases of exudative AMD, at least in the short term. The most serious complication was the development of a retinal detachment. The extremely disorienting side effects of diplopia and tilted image could be prevented or effectively treated by muscle surgery for counter-rotation of the globe, if need be also in the fellow eye.

Macular hole surgery with air tamponade and optical coherence tomography-based duration of face-down positioning.

Purpose: To evaluate the closure rate after macular hole surgery with air tamponade and face-down positioning whose duration is based on postoperative optical coherence tomography (OCT). Methods: In a prospective study, data were gathered on 33 eyes of 33 consecutive patients undergoing macular hole surgery. Postoperatively, OCT images were obtained in a face-down position to minimize the interfering reflections created by the air bubble. The face-down positioning was ended as soon the OCT revealed closure of the hole. Results: Opacity of the media in 8/33 eyes 24 hours postoperatively precluded OCT. In 18/33 eyes (54.5%), the hole was closed on OCT 24 hours postoperatively and in 25/33 (75.7%), 48 hours postoperatively. In 4/33 eyes (12.1%), the hole was judged to be open on OCT 24 hours postoperatively. Despite continued face-down positioning, the hole had closed on the third day postoperatively in only one of these four eyes. In two of the remaining three eyes, the macular hole could be closed by a second surgery which was performed 5 to 6 days after the first vitrectomy. Using OCT monitoring, more than half (54%) of our patients could quit the face-down position after 24 hours, 21% after 48 hours, and 24% after 3 days. Conclusion: Vitrectomy and air tamponade combined with 1- to 3-day face-down positioning produced an excellent rate of macular hole closure. Already on the first and second day postoperatively OCT on patients in a prone position enabled the monitoring of the progress of the macular hole closure through the air bubble. This method allows effective adjustment of the duration of face-down positioning based on OCT findings.

New Components of ‘Basal Laminar Deposits’ in Age-Related Macular Degeneration

Two new components of basal laminar deposit (BlamD) occurring in samples of submacular neovascular membranes surgically removed from patients with a wet (exudative) form of age-related macular degeneration are described. They are: (1) minute ribbon-like structures which occur singly and/or in a bunch and extend from the inner surface of the BlamD layer into the extracellular matrix (ECM) beneath the retinal pigment epithelium (RPE). The ribbons are composed of polarized molecules, aggregating in parallel, aligned transversally in register, morphologically similar to isolated collagen molecules of the short-chain type. Deeper in the BlamD but always close to its inner surface, aspects suggesting a transition between ribbons and (2) long-spacing collagen (LSC)-like aggregates characterized by periods bordered by a single dense band were observed. This band could arise from the globular domains of the polarized monomers, which assemble in parallel and display all their terminal extensions at the same end of each period resulting in the single dense band. The presence of ribbons and of LSC-like aggregates in the BlamD layer and the concomitant choroidal neovascularization (CNV) suggest that the events might be correlated. The newly formed vessels crossing Bruch’s membrane and invading the BlamD layer could induce physicochemical changes in the ECM of the RPE, providing the required environmental conditions for the polymerization of collagen molecules into aggregates with the LSC-like pattern. With the deposition of new components, the thickness of BlamD increases and further impairs the supply of nutrients and oxygen, thus sustaining CNV.

27-gauge Twinlight chandelier illumination system for bimanual transconjunctival vitrectomy.

27-Gauge Twinlight Chandelier Illumination System for Bimanual Transconjunctival Vitrectomy For many vitreoretinal disorders, chandelier illumination is beneficial because it can provide panoramic illumination ideal for bimanual surgery. Until recently, 25-gauge light fibers were used for this purpose, including the Tornambe Torpedo (Insight Instruments, Stuart, FL), the Awh 25-gauge chandelier (Synergetics, Inc., St. Charles, MO), and the Twinlight (DORC, Zuidland, Holland).1 Newly developed, much brighter xenon light sources, such as the Photon Light Source (Synergetics, Inc.), BrightStar (DORC), and Accurus AHBJ-Illuminator (Alcon, Fort Worth, TX), allow the use of smaller-gauge light probes. More recently, self-retaining 27-gauge chandelier endoillumination was introduced.2 In our experience, successful insertion of such a slim fiber during transconjunctival vitrectomy can be difficult; after sclerotomy using a 27-gauge disposable cannula, it may be difficult or impossible to locate the incision after withdrawal of the cannula because it has been covered by or is no longer in alignment with the conjunctiva. Therefore, we developed a novel method for transconjunctival insertion of a new 27-gauge Twinlight. The tips of the two 27-gauge fibers of the Twinlight are cone shaped to allow panoramic illumination. The fibers can be inserted into the eye up to a silicon cuff located 4 mm from the tip of each fiber (Fig. 1). The two fibers run through in a common sleeve and finally unite at the plug to the light source. A specially designed needle is used for performing the two sclerotomies. It consists of a 27-gauge cannula with a 3.5-mm-long troughlike depression at the tip that serves to guide the light fibers (Fig. 2). The needle is inserted for about one fourth of its length transconjunctivally and vertical to the sclera at a site 3 mm posterior to the limbus. It is then carefully retracted to leave only the tip of the needle in the sclerotomy. To prevent elevation of the conjunctiva during retraction of the needle, which would obstruct the view of the trough, the conjunctiva is held down with the tip of the light-probe forceps especially designed for this purpose (Fig. 3). While grasping the light fiber with these forceps, the conical tip is then placed into the trough of the needle and advanced at a 10° to 20° angle along the trough into the sclerotomy, while at the same time retracting the needle (Fig. 2). Suture fixation of the fiber to the sclera is not required because the fiber is self-retaining. The second fiber is introduced in the same manner. At conclusion of the vitreous surgery, the light fibers are simply removed. Small hemorrhages, which may appear on the conFrom the Department of Ophthalmology, Staedtische Kliniken Frankfurt am Main-Hoechst, Frankfurt, Germany. Claus Eckardt has a proprietary interest in the described instruments. Reprint requests: Claus Eckardt, MD, Augenklinik Staedtische Kliniken Frankfurt am Main-Hoechst, Gotenstrasse 6-8, 65929 Frankfurt, Germany; e-mail: C.Eckardt@em.uni-frankfurt.de Fig. 1. The 27-gauge Twinlight (DORC, Zuidland, Holland). A silicon cuff is located 4 mm from the tip of each fiber.

Macular translocation in a patient with adult-onset foveomacular vitelliform dystrophy with light- and electron-microscopic observations on the surgically removed subfoveal tissue

PurposeTo correlate the functional results of macular translocation (MT) in a patient suffering from an adult-onset foveomacular vitelliform dystrophy (AFVD) with the microscopic findings of the surgically removed subfoveal retinal pigment epithelium (RPE).MethodsA 78-year-old woman with AFVD underwent MT with 360° retinotomy 3–4 months after loss of reading ability. Most of the vitelliform material was lost during surgery; the subfoveal tissue was excised, fixed in aldehydes, postfixed in reduced OsO4 and embedded in epoxy resin. Semithin sections were stained with toluidine blue for light microscopy (LM) and thin sections with uranyl acetate and lead citrate for transmission electron microscopy (TEM).ResultsPostoperatively, the patient developed a retinal detachment complicated by proliferative vitreoretinopathy (PVR) requiring two additional vitreoretinal procedures before finally the silicone oil could be removed. Twenty-two months after MT the distance visual acuity was unchanged at 0.2; the near visual acuity had improved from less than 0.1 before MT to 0.4. The retina was completely attached. LM and TEM revealed serious alterations indicative of a breakdown of the outer layer of the retina.ConclusionThrough the present single case it is not possible to determine whether MT could be a therapeutic approach in patients with AFVD. The most important cause for the limited postoperative visual improvement seems to be a primary injury of the foveal function due to the AFVD. This is supported by the extensive subfoveal degeneration and necrosis affecting not only the RPE cells but also their basement membrane and the interposed basal laminar deposits.

Keratoprosthesis as an aid to learning surgical techniques on cadaver eyes.

Practice on cadaver eyes can be an essential aid for residents and inexperienced surgeons in learning operative techniques. Cadaver eyes, however, have been of only limited utility for teaching highly complicated procedures because of the obscuring of intraocular structures caused by the rapid post mortem onset of corneal swelling. We have overcome this problem by the use of a silicone keratoprosthesis that provides an excellent view of all intraocular tissues. Our model allows the use of donor eyes unsuitable for transplantation and facilitates the learning of even complicated cataract surgery, and vitrectomy techniques on the human eye. It thus can reduce the rate of complications in operations on patients.

Makulalochchirurgie mit Lufttamponade

BACKGROUND AND PURPOSE We used a specially designed optical coherence tomography (OCT) device to investigate the dynamics of early macular hole closure after vitrectomy with air tamponade and to determine the closure rate and the briefest possible prone positioning. METHODS A total of 112 patients with macular holes were examined using a modified spectral-domain OCT on days 1, 2 and 3 after vitrectomy with air tamponade. As soon as closure was complete (group one) or partial (hole closed at inner retinal layers but outer retinal layers still detached from pigment epithelial layer, group two), prone positioning was ended. If neither partial nor complete closure was observed by the third day, renewed vitrectomy was performed on postoperative days 4-8. RESULTS Macular hole closure was achieved in 88 of the 112 eyes (79%). In 35 of the 88 eyes partial closure was noted on the first postoperative day. In 20 of the 24 eyes requiring renewed surgery the hole was finally closed. After a median follow-up of 144 days the macular hole was completely closed in all layers in 108 patients (96%). Mean visual acuity at final follow-up was 0.37 logMAR in group one, 0.29 logMAR in group two and 0.51 logMAR in patients whose holes closed after renewed surgery. Once closed, none of the macular holes reopened. CONCLUSIONS The 79% initial closure rate in the present study is about 10% lower than that reported in other studies employing long-acting gas tamponades. However, renewed surgery with air tamponade achieved a closure rate of 96%. Early partial closure is sufficient for subsequent complete closure, requires no further tamponade or prolonged prone positioning, and has no negative effect on the functional results. Short-term prone positioning is sufficient for most patients.

[Macular hole surgery with air tamponade. Does air suffice for short-term tamponade?].

BACKGROUND AND PURPOSE We used a specially designed optical coherence tomography (OCT) device to investigate the dynamics of early macular hole closure after vitrectomy with air tamponade and to determine the closure rate and the briefest possible prone positioning. METHODS A total of 112 patients with macular holes were examined using a modified spectral-domain OCT on days 1, 2 and 3 after vitrectomy with air tamponade. As soon as closure was complete (group one) or partial (hole closed at inner retinal layers but outer retinal layers still detached from pigment epithelial layer, group two), prone positioning was ended. If neither partial nor complete closure was observed by the third day, renewed vitrectomy was performed on postoperative days 4-8. RESULTS Macular hole closure was achieved in 88 of the 112 eyes (79%). In 35 of the 88 eyes partial closure was noted on the first postoperative day. In 20 of the 24 eyes requiring renewed surgery the hole was finally closed. After a median follow-up of 144 days the macular hole was completely closed in all layers in 108 patients (96%). Mean visual acuity at final follow-up was 0.37 logMAR in group one, 0.29 logMAR in group two and 0.51 logMAR in patients whose holes closed after renewed surgery. Once closed, none of the macular holes reopened. CONCLUSIONS The 79% initial closure rate in the present study is about 10% lower than that reported in other studies employing long-acting gas tamponades. However, renewed surgery with air tamponade achieved a closure rate of 96%. Early partial closure is sufficient for subsequent complete closure, requires no further tamponade or prolonged prone positioning, and has no negative effect on the functional results. Short-term prone positioning is sufficient for most patients.

Gewinnung von Spenderhornhäuten ohne Bulbusentnahme

Untersuchungsziel war ein Qualitätsvergleich direkt an der Leiche gewonnener 7-mm-Hornhautscheibchen mit herkömmlich gewonnenen Spenderhornhäuten nach Lagerung in einem Nährmedium. An Schweineaugen wurden Dicke und Endothelquali-tät mit 16-mm-Hornhautsklerapräparaten nach 3- und 7tägiger Lagerung in Optisol-nährmedium verglichen. Ultraschallpachy-metrisch zeigte sich in Serien von je 20 Hornhäuten eine Abnahme der ursprünglichen Dicke auf 73% (7-mm-Hornhautscheiben) bzw. 83% (16-mm-Hornhautsklerapräparate) und nach 7 Tagen eine erneute Zunahme auf 91% des Ausgangswerts. Lichtmikroskopisch wiesen beide Gruppen vergleichbare Endothelzellbilder mit nur wenigen avitalen Zellen und geringeren Descemet-Falten bei den 7-mm-Präparaten auf. Menschliche 7-mm-Hornhautscheibchen wurden teils sofort am Leichnam gewonnen und anschließend 3 Tage in Optisol aufbewahrt, teils erst nach 3-tägiger Lagerung in Optisol aus einer 16-mm-Hornhautsklerascheibe trepaniert. Die Rasterelektronenmikroskopie zeigte jeweils glatt konturierte Schnittränder. Das Endothel wies keine Unterschiede auf. Nach den Ergebnissen ist die Qualität eines direkt am Leichnam ohne Bulbusentnahme gewonnenen und mehrtägig in Nährmedium gelagerten 7-mm-Hornhautscheibchens vergleichbar mit der eines in herkömmlicher Technik gewonnenen.The goal of the present study was to compare the quality of 7-mm corneal buttons taken directly from donor eyes with commonly obtained transplants. Seven-mm porcine corneal specimens and 16-mm corno-scleral specimens were immersed for 3 and 7 days in Optisol culture medium. After 3 days, ultrasonic pachometry revealed a decline to 73% of the original thickness in the 7-mm and to 83% in the 16-mm specimens. After 8 days, the thickness in both groups had returned to 91% of the original values. Light microscopy revealed a homogeneous endothelial layer in both groups. Staining with 0.25% Trypan blue revealed only a few dead cells. The 7-mm specimens exhibited fewer wrinkles in Descemets membrane than the 16-mm specimens. Scanning electron microscopy of human 7-mm corneal specimens, some obtained directly from donor eyes and stored in Optisol and some trephined from 16-mm corneoscleral specimens after immersion, detected uniformly smooth cutting edges in both groups. Even the endothelia displayed no marked differences. Our results show that the quality of donor specimens removed at the desired size in situ and stored in Optisol equals that of commonly obtained specimens. Further investigations must show the feasibility of this procedure in practice.

Makulalochchirurgie mit Lufttamponade@@@Macular hole surgery with air tamponade: Ist Luft als kurzzeitige Tamponade ausreichend?@@@Does air suffice for short-term tamponade?

BACKGROUND AND PURPOSE We used a specially designed optical coherence tomography (OCT) device to investigate the dynamics of early macular hole closure after vitrectomy with air tamponade and to determine the closure rate and the briefest possible prone positioning. METHODS A total of 112 patients with macular holes were examined using a modified spectral-domain OCT on days 1, 2 and 3 after vitrectomy with air tamponade. As soon as closure was complete (group one) or partial (hole closed at inner retinal layers but outer retinal layers still detached from pigment epithelial layer, group two), prone positioning was ended. If neither partial nor complete closure was observed by the third day, renewed vitrectomy was performed on postoperative days 4-8. RESULTS Macular hole closure was achieved in 88 of the 112 eyes (79%). In 35 of the 88 eyes partial closure was noted on the first postoperative day. In 20 of the 24 eyes requiring renewed surgery the hole was finally closed. After a median follow-up of 144 days the macular hole was completely closed in all layers in 108 patients (96%). Mean visual acuity at final follow-up was 0.37 logMAR in group one, 0.29 logMAR in group two and 0.51 logMAR in patients whose holes closed after renewed surgery. Once closed, none of the macular holes reopened. CONCLUSIONS The 79% initial closure rate in the present study is about 10% lower than that reported in other studies employing long-acting gas tamponades. However, renewed surgery with air tamponade achieved a closure rate of 96%. Early partial closure is sufficient for subsequent complete closure, requires no further tamponade or prolonged prone positioning, and has no negative effect on the functional results. Short-term prone positioning is sufficient for most patients.