William M. Schiff

Persistent indocyanine green fluorescence after vitrectomy for macular hole

PURPOSE To evaluate the persistence of indocyanine green (ICG) autofluorescence after ICG-assisted internal limiting membrane peeling for macular hole surgery. DESIGN Interventional case series. METHODS Retrospective institutional study. Four eyes of four patients who underwent pars plana vitrectomy with ICG-assisted internal limiting membrane peeling for macular hole repair were imaged for ICG autofluorescence at 795 nm with a scanning laser ophthalmoscope. The main outcome measure was persistence of ICG autofluorescence. RESULTS All four patients demonstrated persistent ICG fluorescence in the central macula up to 8 months postsurgery. CONCLUSIONS Persistent ICG signal was noted in the macula months after vitrectomy for macular hole surgery. The persistence of ICG autofluorescence could be responsible for delayed photochemical damage to the retinal pigment epithelium. Further studies must quantify the risk of retinal pigment epithelium injury when ICG-assisted internal limiting membrane peeling is used in macular hole surgery.

Optic Coherence Tomography of Optic Disk Pit Maculopathy

PURPOSE To define the structure of optic disk pit maculopathy. METHODS A patient was examined with optic coherence tomography before and after an intravitreal gas tamponade. RESULTS Before intravitreal gas injection, optic coherence tomography defined a separation between the inner and outer layers of the retina that connected with the optic disk pit. An outer retinal layer detachment that centered on the fovea was also present. After pneumatic displacement of the intraretinal and subretinal fluid, optic coherence tomography disclosed that the two layers were opposed and in contact with the retinal pigment epithelium. CONCLUSIONS Optic coherence tomography confirmed the two-layer structure of optic disk pit maculopathy and demonstrated the positive effect of pneumatic displacement.

Surgical outcomes after massive subretinal hemorrhage secondary to age-related macular degeneration.

Purpose: Massive subretinal hemorrhage (SRH), defined as a thick submacular bleed that extends past the equator in at least two quadrants, is a rare sequela of age-related macular degeneration. This report describes outcomes after surgical intervention for massive SRH. Methods: The study design is a retrospective interventional case series. Records of consecutive patients who underwent surgical intervention for massive SRH were reviewed. Outcomes included change from baseline in postoperative acuity at Months 1, 3, 6, 9, and 12 and postoperative complications. Results: Fifteen consecutive eyes of 13 patients who underwent surgery for massive SRH were included. Procedures performed on initial surgery included subretinal instillation of 25 μg/0.1 mL tissue plasminogen activator (15 of 15), gas tamponade (12 of 15), oil tamponade (3 of 15), 180° or greater retinotomy (4 of 15), and/or cataract extraction (2 of 15). Patients were followed for a median of 20 months (range, 3-66 months). The median visual acuity at baseline and postoperative Month 1 was hand motions but improved to counting fingers at postoperative Months 3 (P = 0.04), 6 (P = 0.04), 9 (P = 0.04), and 12 (P = 0.10). Of the 15 eyes, 9 required at least 1 additional procedure for an indication of hyphema and/or vitreous hemorrhage (n = 6), retinal detachment (n = 2), glaucoma (n = 1), cataract (n = 1), and aphakia (n = 1). At the time of the onset of SRH, 5 of 13 patients were anticoagulated with warfarin (4 patients) or clopidogrel (1 patient), and 1 was diagnosed with a coagulopathy, factor XI deficiency. Conclusion: Massive SRH related to age-related macular degeneration has a grave prognosis. Risk factors may include anticoagulation and coagulopathy. Limitations of the study include its retrospective nature, small sample size, imprecision in acuity measurements below 20/400, and lack of a control group. In this series, surgical intervention was associated with a modest improvement in median visual acuity up to 1 year postoperatively.

Optical Coherence Tomography in Asteroid Hyalosis

Purpose: To demonstrate the clinical utility of optical coherence tomography (OCT) in diagnosing macular structural abnormalities in patients with asteroid hyalosis. Methods: Case series. Results: Seven eyes of seven patients underwent OCT due to inadequate funduscopic visualization secondary to asteroid hyalosis. Fluorescein angiography and B-scan ultrasonography were conducted for two patients but failed to provide diagnostic clarity. OCT provided definitive anatomical diagnoses that included macular epiretinal membrane, macular hole, traction retinal detachment, cystoid macular edema, and drusen. On the basis of OCT-assisted diagnoses, three patients elected to undergo surgical intervention. Conclusion: OCT can be critical to diagnose macular conditions when retinal visualization is limited by asteroid hyalosis.

Ruptured retinal arterial macroaneurysm associated with a stage IV macular hole

PURPOSE To report a case of stage IV macular hole associated with ruptured retinal arterial macroaneurysm. DESIGN Observational case report. METHOD The patients clinical, angiographic, and ophthalmic coherent tomography data were reviewed. RESULTS A stage IV macular hole was observed in association with a ruptured retinal arterial macroaneurysm in a 79-year-old patient. After vitrectomy surgery, the macular hole closed and vision improved from counting fingers to 20/100. CONCLUSIONS Macular hole associated with ruptured retinal macroaneurysm can be closed successfully to result in improved vision.

Rifabutin-associated uveitis in an immunosuppressed pediatric patient without acquired immunodeficiency syndrome

PURPOSE To describe a case of bilateral, symptomatic rifabutin-associated uveitis with hypopyon and vitreal opacities in an immunosuppressed pediatric patient without acquired immunodeficiency syndrome (AIDS). METHOD Case report. An 8-year-old boy presented with bilateral uveitis 24 months after a bilateral lung transplant. RESULTS Our patient, whose medications included rifabutin, clarithromycin, and immunosuppressive agents, responded to discontinuation of the rifabutin and initiation of intensive topical corticosteroid therapy with complete resolution of the uveitis. CONCLUSION Rifabutin-associated uveitis may occur in a non-AIDS pediatric patient.

Optic disk pit morphology and retinal detachment: optical coherence tomography with intraoperative correlation.

Background: The pathogenesis of optic nerve head pits and associated retinal detachment, and the most effective surgical intervention when visual loss develops, remains unclear. Methods: The morphology of the optic disk in patients with pits was investigated with optical coherence tomography. For those who underwent surgical treatment for pit-associated retinal detachment, the efficacy of treatment by vitrectomy and separation of the posterior hyaloid, with and without additional peeling of peripapillary tissue, was assessed. Results: On optical coherence tomography imaging, 14 of 18 pits (78%) demonstrated a localized pit-like invagination, whereas 3 (17%) had disks with a generally excavated structure. For 16 of 18 pits (89%), there was evidence of condensed vitreous or glial tissue seen extending from the pit or inside the optic disk. Nine eyes with retinal detachment underwent vitrectomy, posterior hyaloid separation, and endolaser. The retinal detachment completely resolved in 6 of 6 cases where the surgeon additionally peeled the fibrous tissue from the pit and 2 of 3 cases where this was not performed. Conclusion: Spectral domain optical coherence tomography demonstrates the varying morphology of optic pit anatomy. Condensed vitreous strands or glial tissue in the optic nerve pit may also contribute to retinal detachment development.

Diabetic vitrectomy: the influence of lens status upon surgical outcomes.

Purpose of review Management of the lens in diabetic eyes undergoing vitrectomy has long been a source of controversy. Initially, the lens was removed during diabetic vitrectomy because of intraoperative changes. It was noted, however, that anterior segment neovascular complications were greater in aphakic eyes after diabetic vitrectomy, and subsequently the vitreoretinal surgeon attempted to spare the lens. Lens management in this regard continues to attract discussion. This report reviews recent trends in the management of the native lens in the diabetic eye undergoing vitrectomy. Recent findings The rate of cataract formation after diabetic vitrectomy is high in eyes left phakic. The rates of anterior segment neovascularization and retinal detachment after diabetic vitrectomy are similar in phakic and nonphakic eyes. The rate of subsequent reoperation after diabetic vitrectomy may be greater in eyes left phakic. Summary Although the management of the lens in an eye undergoing diabetic vitrectomy should be individualized, cataract extraction performed either before or in combination with vitrectomy may reduce the rate of subsequent reoperation. The vitreoretinal surgeon may consider rendering an eye nonphakic before or during diabetic vitrectomy to optimize outcomes.

Pascal dynamic contour tonometry versus goldmann applanation tonometry in gas and air-filled eyes after vitrectomy surgery.

Purpose: To compare Pascal Dynamic Contour Tonometry with Goldmann Applanation Tonometry in eyes after vitrectomy surgery with intraocular tamponade of air, silicone oil or perfluorocarbon gas. Methods: Prospective clinical comparative study. Eighty-two consecutive patients undergoing vitrectomy surgery with postoperative air, gas or oil tamponade were recruited. Intraocular pressure was measured with both devices. Results: Mean Goldmann intraocular pressure was 16.6 mmHg (range, 1.0–46.0; SD = 8.80) and the mean Pascal intraocular pressure was 21.70 (range, 4.7–58.5; SD = 9.8) The mean difference between the Pascal and Goldmann readings was 5.09 mmHg (range, −14.7 to +12.9; 95% CI = 4.2–6.0; SD, 4.0; P < 0.001). Mean differences for the different tamponades were 5.09 mmHg for silicone oil, 4.02 mmHg for air, and 5.38 mmHg for perfluorocarbon gas. Conclusion: Pascal dynamic contour tonometry gives readings that are highly correlated with Goldmann applanation tonometry, but on average 5 mmHg higher in eyes after vitrectomy surgery with air, gas or silicone oil tamponades. The difference between Goldmann and Pascal readings does not appear to be altered by the presence of a scleral buckle, or the size of the intraocular gas bubble.

PROPHYLACTIC PREOPERATIVE LASER RETINOPEXY DOES NOT REDUCE THE OCCURRENCE OF RHEGMATOGENOUS RETINAL COMPLICATIONS IN MACULAR SURGERY.

Purpose: Knowledge on the utility of prophylactic 360° laser retinopexy before pars plana vitrectomy in the absence of peripheral retinal pathology is limited. This study compares the occurrence of rhegmatogenous events in the setting of small-gauge pars plana vitrectomy with and without prophylactic preoperative laser. Methods: Our multicenter, retrospective case–control analysis reviewed patients who underwent epiretinal membrane removal or macular hole repair through 23- or 25-gauge pars plana vitrectomy: 205 controls who did not receive prophylactic laser and 176 cases who received preoperative prophylactic laser retinopexy anterior to the equator. Main outcome measures were the rate and characteristics of postoperative retinal tears and detachments. Patients with previous pars plana vitrectomy or significant retinal disease were excluded. Results: Of those patients with prophylactic laser and those without, there was no significant difference in the number of retinal breaks (1.7% vs. 0.49%, respectively; P = 0.339) or retinal detachments (0% vs. 0.49%, respectively; P = 1.00). Of the lasered group, there was one sclerotomy-related retinal break and two non–sclerotomy-related retinal breaks. Of the nonlasered group, there was one non–sclerotomy-related retinal break and one sclerotomy-related retinal detachment. Conclusion: Preoperative prophylactic peripheral laser retinopexy does not seem to offer an added benefit in the prevention of intraoperative and postoperative rhegmatogenous events.