Pseudophakic retinal detachment

Prophylactic Circumferential Retinal Cryopexy to Prevent Pseudophakic Retinal Detachment after Posterior Capsule Rupture during Phacoemulsification

Purpose. To evaluate whether prophylactic circumferential retinal cryopexy (CRC) can prevent pseudophakic retinal detachment (PRD) development after posterior capsule rupture (PCR) during phacoemulsification. Methods. Retrospective patient chart analysis of eyes experiencing a PCR during phacoemulsification. Comparison of PRD development between eyes receiving CRC (cryo+ group) or not (cryo- group). Results. Overall 106 patients were analyzed, thereof 61 (58%) in the cryo+ and 45 (42%) in the cryo- group. In both clusters a total of 10 PRDs (9.4%) occurred, thereof 3 (30%) in the cryo+ as well as 7 (70%) in the cryo- group (p = 0.087), 79.8 ± 81.58 weeks after PCR. Relative/absolute risk reduction in CRC-treated eyes was calculated to be 68%/11%. Prophylactic CRC reduced PRD development 0.3-fold. Number needed to treat was estimated to be 9.4. Conclusion. Prophylactic CRC might be a useful treatment option in eyes with PCR to hamper PRD development in the further course. Further research is indicated to evaluate this beneficial effect between eyes with and without a rupture of the anterior vitreous cortex and accompanying vitreous loss in an expanding number of eyes.

Retinal Detachment Due to Retinal Dialysis: Surgical Outcome After Scleral Buckling

PURPOSE

The aim of this study was to determine the efficacy and safety of scleral buckling surgery in retinal detachment due to retinal dialysis.

DESIGN

This study was a prospective, interventional case series.

METHODS

A total of 48 eyes of 48 consecutive patients were included after obtaining informed written consent. Besides taking a thorough history, all eyes were examined by a retinal surgeon. The macula status, site, and extent of retinal dialysis and rhegmatogenous retinal detachment (RRD) were particularly noted. Proliferative vitreoretinopathy grading was done. Buckling was performed by a single surgeon. At every follow-up, visual acuity, intraocular pressure, retina status, and buckle position were noted. Any complication found was recorded. Follow-up was done for at least 6 months. SPSS version 16 was used for data analysis.

RESULTS

We included 48 cases of RRD due to retinal dialysis. The mean ± SD age of the patients was 26.85 ± 15.1 years. The macula was detached in 85.4% of the cases, and proliferative vitreoretinopathy grade C was found in 25% of the cases. A surgical reattachment rate of 95.8% was attained after a single primary buckling procedure. Final Snellen best-corrected visual acuity of 6/18 or better was attained in 12.5% of the cases. However, 62.5% of the cases had best-corrected visual acuity in the range of 6/24 to 6/60. Subretinal hemorrhage occurred in 8.3% of cases intraoperatively after subretinal fluid drainage.

CONCLUSIONS

We conclude that scleral buckling has a definite role in the management of RRD due to retinal dialysis.

The clinical effectiveness and cost-effectiveness of second-eye cataract surgery: a systematic review and economic evaluation

BACKGROUND

Elective cataract surgery is the most commonly performed surgical procedure in the NHS. In bilateral cataracts, the eye with greatest vision impairment from cataract is operated on first. First-eye surgery can improve vision and quality of life. However, it is unclear whether or not cataract surgery on the second eye provides enough incremental benefit to be considered clinically effective and cost-effective.

OBJECTIVE

To conduct a systematic review of clinical effectiveness and analysis of cost-effectiveness of second-eye cataract surgery in England and Wales, based on an economic model informed by systematic reviews of cost-effectiveness and quality of life.

DATA SOURCES

Twelve electronic bibliographic databases, including MEDLINE, EMBASE, Web of Science, The Cochrane Library and the Centre for Reviews and Dissemination databases were searched from database inception to April 2013, with searches updated in July 2013. Reference lists of relevant publications were also checked and experts consulted.

REVIEW METHODS

Two reviewers independently screened references, extracted and checked data from the included studies and appraised their risk of bias. Based on the review of cost-effectiveness, a de novo economic model was developed to estimate the cost-effectiveness of second-eye surgery in bilateral cataract patients. The model is based on changes in quality of life following second-eye surgery and includes post-surgical complications.

RESULTS

Three randomised controlled trials (RCTs) of clinical effectiveness, three studies of cost-effectiveness and 10 studies of health-related quality of life (HRQoL) met the inclusion criteria for the systematic reviews and, where possible, were used to inform the economic analysis. Heterogeneity of studies precluded meta-analyses, and instead data were synthesised narratively. The RCTs assessed visual acuity, contrast sensitivity, stereopsis and several measures of HRQoL. Improvements in binocular visual acuity and contrast sensitivity were small and unlikely to be of clinical significance, but stereopsis was improved to a clinically meaningful extent following second-eye surgery. Studies did not provide evidence that second-eye surgery significantly affected HRQoL, apart from an improvement in the mental health component of HRQoL in one RCT. In the model, second-eye surgery generated 0.68 incremental quality-adjusted life-years with an incremental cost-effectiveness ratio of £1964. Model results were most sensitive to changes in the utility gain associated with second-eye surgery, but otherwise robust to changes in parameter values. The probability that second-eye surgery is cost-effective at willingness-to-pay thresholds of £10,000 and £20,000 is 100%.

LIMITATIONS

Clinical effectiveness studies were all conducted more than 9 years ago. Patients had good vision pre surgery which may not represent all patients eligible for second-eye surgery. For some vision-related patient-reported outcomes and HRQoL measures, thresholds for determining important clinical effects are either unclear or have not been determined.

CONCLUSIONS

Second-eye cataract surgery is generally cost-effective based on the best available data and under most assumptions. However, more up-to-date data are needed. A well-conducted RCT that reflects current populations and enables the estimation of health state utility values would be appropriate. Guidance is required on which vision-related, patient-reported outcomes are suitable for assessing effects of cataract surgery in the NHS and how these measures should be interpreted clinically.

STUDY REGISTRATION

This project is registered as PROSPERO CRD42013004211.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme.

Incidence, Progression, and Associated Risk Factors of Posterior Vitreous Detachment in Type 2 Diabetes Mellitus: Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetic Study (SN-DREAMS II, Report No. 7)

PURPOSE

To report the incidence and progression of posterior vitreous detachment (PVD) and factors influencing the same in a cohort of patients with type 2 diabetes in a South Indian population.

METHODS

A subset of 615 subjects from Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetics Study II were included in this study. All of the subjects underwent detailed ophthalmic evaluation including stereo fundus photography. The status of PVD was assessed using B-scan ultrasonography. A p value of <0.05 was considered statistically significant.

RESULTS

The incidence of either incomplete PVD (IPVD) or complete PVD (CPVD) from no PVD at baseline visit was 80.8%. Of them, 32.63% converted to CPVD from IPVD at baseline. High prevalence of emmetropia was observed in subjects with stable No PVD. Risk factors associated with the conversion of CPVD from no PVD and IPVD at baseline were age (OR: 1.04, p = 0.002), myopia (OR: 2.14, p = 0.009), and increase in axial length (OR: 1.35, p = 0.004). Subjects undergoing cataract surgery were at 2.32 times higher risk of converting to CPVD (p = 0.038).

CONCLUSION

Independent risk factors for the progression of PVD were increase in age, myopia, increased axial length, and cataract surgery.

Macula-On Versus Macula-Off Pseudophakic Rhegmatogenous Retinal Detachment Following Primary 23-Gauge Vitrectomy Plus Endotamponade

AIM

To evaluate anatomical and functional outcomes of macula-on and macula-off rhegmatogenous retinal detachment (RRD) after 23-gauge vitrectomy and gas endotamponade, in eyes after successful cataract surgery.

METHODS

Forty-six pseudophakic eyes of 46 consecutive patients who underwent surgery for RRD repair were included. Based on the severity degree and extension of the RRD, diluted C3F8, SF6 or C2F6 gases were used for endotamponade. Patients were followed 1 month, 3 months, 6 months and 12 months after surgery. Main outcome variables were functional and anatomic outcomes till 12 months after surgery.

RESULTS

Proliferative vitreoretinopathy of grade B or C was observed in 43%. C3F8 was used in 59%, SF6 in 28% and C2F6 in 13%. Reattachment after the first intervention was achieved in 89%. Preoperatively, 63% of patients presented with fovea-off retinal detachment. No intraoperative complications were registered. Preoperatively, eyes with macula-on RRD had a logMar BCVA of 0.3 ± 0.6 compared with 1.2 ± 0.7 in the macula-off group (p = 0.01). The mean visual acuity significantly improved to 0.06 ± 0.1 logMar in macula-on eyes and to 0.2 ± 0.3 logMar in macula-off eyes at 12 months (p = 0.01 compared to baseline and p = 0.04 between both the groups). The mean final postoperative CRT was 318 ± 48 µm in the macula-on group compared with 305 ± 71 µm in the macula-off group (p = 0.5).

CONCLUSIONS

Even morphological improvement after 23-gauge vitrectomy and gas endotamponade was comparable between macula-on and macula-off eyes, macula-off RRDs showed delayed visual rehabilitation. Both groups showed significant visual acuity improvement until 12 months, however, macula-on RRDs showed significantly more improvement than macula-off RRDs.

Quality assessment of cataract surgery in Denmark - risk of retinal detachment and postoperative endophthalmitis

The main purpose of this thesis was to examine whether the Danish National Patient Registry (NPR) could be used to monitor and assess the quality of cataract surgery in Denmark by studying the risks of two serious postoperative complications following cataract surgery - retinal detachment (RD) and postoperative endophthalmitis (PE). The thesis consists of four retrospective studies. In the first study (paper I), we used data from the NPR in the calendar period 2000-2010 to investigate the risk of pseudophakic retinal detachment (PRD) using the fellow non-operated eyes of the patients as reference. The study showed that over a 10-year study period, the risk of PRD was increased by a factor of 4.2 irrespective of sex and age. The risk of PRD was highest in the first part of the postoperative period and then gradually decreased but remained statistically significantly higher than the risk of RD in non-operated fellow eyes up to 10 years after cataract surgery. The epidemiology of RD in the non-operated fellow eyes was different from the epidemiology of RD in the background population as young men had the highest risk of RD in the non-operated fellow eyes. This means that the absolute risk of PRD was highest for young men because they had a higher risk of RD before they underwent cataract surgery. In the second study (paper II), we used data from the NPR and reviewed patient charts to assess the risk of PE after cataract surgery performed in public eye departments and private hospitals/clinics in the study period 2002-2010. The overall risk of PE among the seven public eye departments was 0.36 per 1000 registered cataract operations, and the PE risk among the departments was homogeneous. The overall risk of PE among the 28 private hospitals/clinics was 0.73 per 1000 registered cataract operations, and the risk among the private hospitals/clinics was heterogeneous. Most private hospitals/clinics had a risk of PE that was lower than or similar to the risk of PE after registered cataract surgery in public eye departments, but six private hospitals/clinics had a statistically significantly higher risk of PE compared to the public eye departments. We used PE as a proxy measure of the registration of cataract surgery and found that 98% of the cataract operations performed in public eye departments were registered in the NPR while only 38% of the cataract operations performed in private hospitals/clinics were registered in the NPR. In general, the coding of the PE cases was not uniform and the lack of registration by the private hospitals/clinics meant that the NPR could not be used to monitor the true risk of PE. NPR data were also used in the third study (paper III) to examine whether patients who had surgical intervention for PE following cataract surgery with either a pars plana vitrectomy (PPV) or a vitreous tap (VT) had a higher risk of subsequent surgical complications. There was no statistically significant difference in the overall risk of complications among the two groups, but the risk of surgery for vitreous opacities was statistically significantly higher for patients who underwent a VT. A surgical complication occurred in 27.3% of the patients and 9.9% of the patients developed more than one surgical complication. Ninety-seven per cent of the primary surgical complications occurred within the first 5 months. The risk of surgical complications in this study was similar to or higher than the risk of complications in the landmark Endophthalmitis Vitrectomy Study from the early 1990s. In the fourth study (paper IV), we used data from all three Danish cataract registries to describe the epidemiology of cataract operations performed in public hospitals and private hospitals/clinics in the study period 2004-2012. Again, PE was used as a proxy measure of the registration of cataract surgery. There were several noticeable differences in the epidemiology of the cataract operations performed in public hospitals and private hospitals/clinics. Patients who had cataract surgery in public hospitals had a statistically significantly higher mortality compared to patients who had cataract surgery in private hospitals/clinics during the entire period. The decrease in the mean age at first eye cataract surgery in private hospitals/clinics was statistically significantly greater compared to public hospitals during the study period. There was a statistically significantly shorter median time interval between first and second eye cataract surgery at private hospitals/clinics compared to public hospitals during the entire study period. The study showed that only 54% of the cataract operations performed in private hospitals/clinics that led to PE were registered. The lack of registration of cataract surgery is the main reason why the NPR has limitations when used as a tool to monitor and assess the quality of cataract surgery in Denmark.

Retina evaluation with nonmydriatic ultrawide-field color imaging after cataract extraction surgeries in asymptomatic patients

BACKGROUND AND OBJECTIVE

To evaluate the role of nonmydriatic ultrawide-field (UWF) color retinal imaging as a screening tool in the follow-up of asymptomatic patients after cataract extraction surgeries.

PATIENTS AND METHODS

A retrospective, observational case series. A review of electronic medical records identified patients after cataract extraction followed with UWF retinal imaging (Optos 200Tx; Optos, Dunfermline, Scotland). Images were graded and reviewed by a retina specialist. Outcome measures included image quality, the detection of peripheral lesions, and association with perioperative risk factors.

RESULTS

Seventy-six eyes of 58 consecutive patients were enrolled. A good visualization of the peripheral retina was accomplished in more than 90% of patients. Peripheral lesions were identified in 40 eyes (52.6%) with no surgery-related retinal breaks and/or detachments. Additional pathologies were found in 35 eyes (46.1%).

CONCLUSION

Nonmydriatic UWF color retinal imaging was found to be a useful screening tool in the follow-up of asymptomatic patients after cataract extraction in this series.

A nationwide study on the incidence of rhegmatogenous retinal detachment in Denmark, with emphasis on the risk of the fellow eye

PURPOSE

To estimate the risk of developing rhegmatogenous retinal detachment (RRD) in the fellow eye in patients with RRD in the first eye and to identify potential risk factors.

METHODS

We used the Danish National Patient Registry to identify all surgeries performed for RRD in Denmark in the period from January 2000 to July 2011.

RESULTS

In 11,451 cases of RRD in the study period, 8,553 cases in 8,081 patients were identified as primary RRD with an annual incidence of 13.7 per 100,000 citizens. There was a significant increase in the number of cases with RRD during the study period that was mainly explained by an increase of cataract surgeries. Four hundred and seventy-one of 7,941 patients with primary RRD on one eye and no other previous eye disease developed an additional RRD in the fellow eye with an overall incidence of 1% per year. Cox analysis revealed male gender, surgery on the lens, and young age as significant risk factors (P < 0.0001).

CONCLUSION

Patients with RRD on the first eye have a 100 times greater risk of developing RRD on the second eye, and the risk increases with male gender and surgery on the lens but decreases with age.

Evaluation of early results of quick-chop phacoemulsification in the patients with high myopic cataract

AIM

To assess the early surgical outcomes of quick-chop phacoemulsification technique in patients with high myopia.

METHODS

The data of patients with high myopia who underwent quick-chop phacoemulsification were reviewed retrospectively. There were 42 eyes of 31 patients. The axial length was more than 26 mm in all eyes. All eyes underwent quick-chop phacoemulsification surgery with the placement of an intraocular lens (IOL) in the capsular bag. Postoperative visits were performed at 1, 3d; 2wk, 1mo. Early postoperative best corrected visual acuity (BCVA), preoperative and postoperative corneal endothelial cell density (ECD), central corneal thickness (CCT) and postoperative complications were assessed. Paired sample t-test or Wilcoxon tests were used to compare data between preoperative and postoperative data.

RESULTS

There was no statistically significant difference between preoperative and postoperative ECD and CCT. Retinal detachment was developed in one eye at postoperative first day. There was an iris prolapsus from side port insicion.

CONCLUSION

Quick-chop phacoemulsification technique is a safe surgical technique. However we can encounter some complications in high myopic eyes due to histopathological differences. Both side port and clear corneal tunnel insicion size is crucial for preventing postoperative complications. If any persistent leakage is noticed, suture should be placed.

A Retrospective Clinical Study of the Etiology and Post-operative Visual Outcome of Rhegmatogenous Retinal Detachment

AIM

To study the etiology of rhegmatogenous retinal detachment and visual outcome after retinal detachment surgery.

MATERIALS AND METHODS

Retrospective study conducted at the tertiary eye care hospital over a period of one year. Thirty eyes of 30 patients were included after fulfilling the inclusion criteria. Complete ocular examination details of each patient such as visual acuity for distant vision (checked with Snellen's acuity chart),slit lamp examination, fundus examination (done with +90D lens) and binocular indirect ophthalmoscopy. In addition the following were noted: extent of the detachment present, position and number of breaks, status of the macula, presence of PVR, mobility of retina and presence of any peripheral retinal degenerations, and fundus photographs of the patient (before and after surgery).

RESULTS

Risk factors for retinal detachment included myopia in 7 eyes (23.3%), prior cataract surgery in 10 eyes (33.3%), peripheral retinal degeneration in 3 eyes (10%) and traction with new vessels in 1 eye (3.3%). Eighteen eyes (60%) presented with macula off while 12 eyes (40%) presented with macula partly or completely attached. Visual acuity at presentation was <3/60 in 16 eyes. Following surgery, retina was attached in 28 eyes (93.3%) and remained detached in 2 eyes (6.7%). Visual acuity after surgery was <3/60 in 12 eyes.Visual acuity improved in 13 eyes (43.3%), remained the same in 16 eyes (53.3%) and worsened in 1 eye (3.3%).

CONCLUSION

Myopia and prior cataract surgery are important risk factors for Rhegmatogenous Retinal Detachment. Majority of patients in this setting presented late with Rhegmatogenous Retinal Detachment and this was responsible for relatively poor visual outcomes despite good anatomical results after surgery. Proper screening of eyes at risk and education of patients is important for preventing visual loss due to retinal detachment.

Giant retinal tears

A giant retinal tear (GRT) is a full-thickness neurosensory retinal break that extends circumferentially around the retina for three or more clock hours in the presence of a posteriorly detached vitreous. Its incidence in large population-based studies has been estimated as 1.5% of rhegmatogenous retinal detachments, with a significant male preponderance, and bilaterality in 12.8%. Most GRTs are idiopathic, with trauma, hereditary vitreoretinopathies and high myopia each being causative in decreasing frequency. The vast majority of GRTs are currently managed with a pars plana vitrectomy; the use of adjunctive circumferential scleral buckling is debated, but no studies have shown a clear anatomical or visual advantage with its use. Similarly, silicone oil tamponade does not influence long-term outcomes when compared with gas. Primary and final retinal reattachment rates are achieved in 88% and 95% of patients, respectively. Even when the retina remains attached, however, visual recovery may be limited. Furthermore, fellow eyes of patients with a GRT are at higher risk of developing retinal tears and retinal detachment. Prophylactic treatment under these circumstances may be considered but there is no firm evidence of its efficacy at the present time.

Giant retinal tears after prior pars plana vitrectomy: management strategies and outcomes

Purpose

To evaluate management strategies and outcomes for patients with giant retinal tear (GRT)-associated retinal detachment (RD) that had undergone previous pars plana vitrectomy (PPV).

Methods

A noncomparative consecutive case series between January 2005 and July 2010. Patients with a preceding history of PPV undergoing retinal reattachment surgery for GRTs were identified.

Results

Using International Classification of Diseases 9 codes for GRTs, 227 cases were identified. A total of eight eyes in eight patients were identified as having had preceding PPV for non-RD-related pathology. The mean age was 45.5 (range of 10–79) years. The mean time between PPV and diagnosis of GRT was 2.4 months. The mean follow-up after RD surgery was 24.3 months. Presenting visual acuity was 20/400 or better in four of eight patients (50%). All patients underwent repeat PPV with either gas or oil tamponade. A scleral buckling procedure was performed in seven patients (88%). Perfluorocarbon liquid was used during reattachment surgery in four patients (50%). Although anatomic success was achieved in all patients, visual acuity at last follow-up was 20/400 or better in 6 patients (75%).

Conclusion

GRTs are an uncommon complication of PPV. The majority of patients underwent repeat PPV, scleral buckling procedure, perfluorocarbon liquid use and silicone-oil tamponade. Patients presenting with GRT-associated RD after PPV undergoing additional surgery achieved high rates of anatomic success, but visual outcomes were variable.

[Risk factors for failure of scleral buckling in rhegmatogenous retinal detachment. A Moroccan series]

PURPOSE

To evaluate risk factors for failure of scleral buckling in rhegmatogenous retinal detachment (RRD) in an adult Moroccan population.

METHODS

A retrospective study of 432 eyes of 422 patients undergoing scleral buckling (SB) for primary RRD between 2001 and 2009 was carried out. Statistical analysis of risk factors for failure was performed using binary logistic regression.

RESULTS

Mean patient age was 43 ± 15 years, and 45.4% were myopic. The median recurrence was at 10 months. The final failure rate was 22.5%. Univariate analysis shows that significant risk factors for failure were extent of RRD ≥ 3 quadrants (P<0.001), advanced PVR (P<0.001) and worsening PVR postoperatively (P<0.001). In the multivariate model, the only significant risk factor for failure was the worsening postoperative PVR (P<0.001).

CONCLUSIONS

Our findings suggest that worsening of PVR after surgery is the major risk factor for failure of SB in RRD. Thus, it is necessary to recognize the risk factors contributing to PVR and to plan the most appropriate, earliest and least traumatic surgical treatment of RRD.

Surgical management of rhegmatogenous retinal detachment: a meta-analysis of randomized controlled trials

PURPOSE

To examine possible differences in clinical outcomes between pars plana vitrectomy (PPV) and scleral buckling (SB) for uncomplicated rhegmatogenous retinal detachment (RRD).

DESIGN

Meta-analysis.

PARTICIPANTS

Adult patients with uncomplicated RRD from previously reported randomized controlled trials of PPV and SB.

METHODS

A comprehensive literature search using the Cochrane Collaboration methodology to identify randomized controlled trials comparing PPV with SB for uncomplicated RRD.

MAIN OUTCOME MEASURES

Analysis was divided into phakic and pseudophakic/aphakic patients. Primary outcome parameters included proportion of primary reattachment and difference of means of best-corrected visual acuity (BCVA) at 6 months or more between the PPV and SB groups. Secondary outcome parameters included the proportion of secondary reattachment and complications between the PPV and SB groups.

RESULTS

Seven studies were identified and analyzed for comparing PPV (636 eyes) with SB (670 eyes) for uncomplicated RRD. In the phakic group, there were no significant differences in the proportion of primary reattachments (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.69-1.46) or secondary reattachments (OR, 0.99; 95% CI, 0.34-2.87) between the PPV and SB groups. Meta-analysis showed a statistically significant difference in the logarithm of the minimum angle of resolution (logMAR) BCVA at 6 months between the PPV-treated and SB-treated phakic eyes (mean deviation, 0.14; 95% CI, 0.06-0.21; P<0.0004). In the pseudophakic/aphakic group, there were no significant differences in the proportion of primary reattachments (OR, 1.46; 95% CI, 0.79-2.71) or logMAR BCVA at 6 months between the PPV and SB groups (mean deviation, -0.03; 95% CI, -0.10 to 0.04). A statistically significant difference was noted in the proportion of secondary reattachments (OR, 2.08; 95% CI, 1.08-4.03; P = 0.03) between the PPV and SB groups in pseudophakic/aphakic eyes. Meta-analysis showed a statistically significant rate of cataract progression in the PPV group (OR, 4.11; 95% CI, 2.70-6.25; P<0.00001).

CONCLUSIONS

There were no significant differences in the proportions of primary reattachment in the PPV and SB groups in phakic eyes. The SB-treated phakic eyes had better postoperative BCVA at 6 months or more. This is most likely related to higher rates of cataract progression in PPV-treated phakic eyes. There were no significant differences in proportions of primary reattachment and postoperative BCVA at 6 months or more in pseudophakic/aphakic eyes.

Blepharoptosis repair outcomes from trainee versus experienced staff as the primary surgeon

PURPOSE

To compare outcomes of conjunctival Müllerectomy with or without tarsectomy versus external levator advancement for correction of upper blepharoptosis when performed by trainee versus staff surgeons.

DESIGN

Retrospective, nonrandomized, interventional, consecutive case series.

METHODS

Charts of patients undergoing conjunctival Müllerectomy with or without tarsectomy and external levator advancement blepharoptosis repair from January 2006 through December 2009 were reviewed. Main outcome measures included age, gender, preoperative and postoperative use of artificial tears, preoperative and postoperative marginal reflex distance, surgical complications, surgeon (trainee or staff surgeon), and anesthesia time. The Student t test was used for statistical analysis.

RESULTS

A total of 170 patients underwent 248 surgeries (154 conjunctival Müllerectomies with or without tarsectomy and 94 external levator advancements). There were 108 female and 62 male patients. Mean patient age was 62 years (range, 3 to 94 years). Forty-one (24%) patients (26 conjunctival Müllerectomies with or without tarsectomy and 15 external levator advancements) underwent concurrent eyelid surgery, such as blepharoplasty. Trainees performed surgery on a total of 88 (35%) eyelids in 60 patients (35%). There was no significant difference in the percentage of cases undergoing concomitant surgery between trainee and staff surgeons (P = .18). The mean postoperative marginal reflex distance difference was 0.53 and 0.59 for trainee and staff surgeons, respectively. Mean overall anesthesia time was 26.8 minutes and 30.3 minutes for trainee and staff surgeons, respectively. Complications, including increase in dry eye or irritative symptoms and reoperation, occurred in 8 (13%) of 60 patients undergoing surgery by a trainee surgeon and in 22 (20%) of 110 patients undergoing surgery by staff surgeon. There was no significant difference in eyelid symmetry (P = .55), mean anesthesia time (P = .14), complication rate (P = .26), or reoperation rate (P = .17) when surgery was performed by a trainee versus a staff surgeon.

CONCLUSIONS

There is no significant difference in mean postoperative marginal reflex distance, mean anesthesia time, complication rate, or reoperation rate between either conjunctival Müllerectomy with or without tarsectomy or external levator advancement blepharoptosis repair performed by trainee versus staff surgeons.

Outcomes of pseudophakic retinal detachment

PURPOSE

 To provide data on the outcome of pseudophakic retinal detachment (PRD).

METHODS

In a retrospective case-control study, we identified a consecutive series of 63 298 cataract extractions (45 520 patients) performed in a single institution between 1994 and 2003. We included 249 cases with PRD and 845 controls that had cataract surgery on the same day as cases but without PRD. Outcome measures were the risk of impaired vision (6/18-6/60) or blindness (<6/60). A multinomial logistic regression model evaluated risk factors for impaired vision or blindness, while multivariable regression models measured the relative risk of poor visual outcome for posterior capsule tear (PCT) and PRD.

RESULTS

Primary pars plana vitrectomy was performed on 207 (84.5%) of the 245 cases treated with surgery, of which 175 (71.4%) needed one procedure. The final acuity was <6/60 in 62 cases (24.9%) and 34 controls (4.0%). After PRD, the relative risk for a final visual outcome <6/60 was 6.8 [95% confidence interval (CI) 4.3-10.6; p < 0.001], and we estimated that the proportion of blindness attributable to PRD was 1.1% (CI 0.7-1.9%). A PCT prior to a PRD was not associated with an increased risk of macular detachment (p = 0.165), but it did carry an increased risk of blindness [odds ratio 4.8 (CI 2.2-10.2; p < 0.001].

CONCLUSION

 Although a PCT has an adverse effect on visual outcome after cataract surgery, a PRD is the foremost surgery-related risk for a poor visual outcome. Patient education of symptoms and prompt treatment may limit the visual consequences.

Rhegmatogenous retinal detachment treatment guidelines

This paper outlines general guidelines following the initial diagnosis of rhegmatogenous retinal detachment. These include preoperative evaluation, treatment, possible intra- and post-operative complications, retinal re-detachment, and all therapeutic options available for each case. Treatment of the traumatic retinal detachment is also described, due to its importance and peculiarities. Treatment or prophylactic guidelines are suggested for the different types of retinal detachment described. These are based on both the experience of the ophthalmologists that have participated in preparing the guidelines, and also on evidence-based grading linked to bibliographical sources. However, these guidelines should not be interpreted as being mandatory. Given that there is a wide spectrum of options for treatment of retinal detachment, the surgeons' experience with one or other surgical technique will be of utmost importance in obtaining the best surgical result. As guidelines, they are intended as an additional aid to the surgeon during the decision-making process, with the expectation that the final choice will still be left to the surgeon's judgment and past experience.

The incidence of retinal detachment after cataract surgery

Purpose:

To estimate the cumulative risk of retinal detachment (RD) after routine cataract surgery by phacoemulsification.

Setting:

Department of Ophthalmology, Aarhus University Hospital, Denmark

Methods:

Retrospective cohort study based on 12.222 consecutive cataract surgeries in 7.856 patients using phacoemulsification over a 6 year period from 2000 to 2005. Cases with a diagnosis of RD were identified through the procedure-coding database at the Medical Registry of Aarhus University Hospital, which is based on Diagnosis Related Groups (DRG) and used to report to the Danish Patients Registry (LPR). For each case the age of the patient, gender, axial length, surgical complications, postoperative Nd:YAG capsulotomy and time interval between cataract surgery and RD were recorded.

Results:

The mean follow-up time was 64.8 months (range 26.2–97.6 months). Forty-eight (48) cases of RD were identified making an overall cumulative risk of 0.39%. As compared to the normal incidence of RD reported in the Scandinavian literature, the relative risk of RD following cataract surgery was about 2.3 times that of the natural incidence. As compared to the average cataract group, the group of RD following cataract surgery was characterized by a younger mean age (60.5 vs. 73.7 years), male gender (58.3% vs 34.8%), longer axial lengths (24.56 vs 23.25 mm) and a higher frequency of surgical complications (10.4% vs 1.8%) (p<0.001) but not a higher frequency of Nd:YAG capsulotomy (p>0.05),

Conclusions:

The cumulative risk of RD after lens surgery was about 2.3 times the natural incidence but seems to be lower than that of older reports.

Synopsis:

Retinal detachment following cataract surgery is associated with young age, male gender, long axial lengths and surgical complications. The cumulative risk of RD after lens surgery was about 2.3 times the natural.

Characteristics of rhegmatogenous retinal detachment in pseudophakic and phakic eyes

AIMS

To investigate whether pseudophakic and phakic rhegmatogenous retinal detachment (RRD) patterns differ.

METHODS

Retrospective review of electronic database of patients, aged 50 years or over, presenting to our vitreoretinal service. Data included baseline characteristics, digital drawings, and outcomes. Retinal drawings were analysed in a masked fashion for site, size, and number of retinal breaks. Comparisons were made between the following groups and subgroups: pseudophakic eyes, phakic eyes, phakic eyes with cataract, and phakic eyes without cataract.

RESULTS

Of 500 eyes included, 146 were pseudophakic; 177 of the phakic eyes had cataract. The following were significant by univariate analysis: pseudophakic patients were older than phakic patients in general, but the same age as patients with cataract; in the pseudophakic group, there were lower proportions of females and of patients presenting with vitreous haemorrhage or with large or superotemporal breaks; higher proportions of pseudophakic eyes had small breaks and inferonasal breaks. Some differences remained significant when comparing pseudophakia eyes with cataract. Multivariate analysis comparing pseudophakia with phakia confirmed a lower chance in pseudophakia of large breaks, vitreous haemorrhage and superotemporal breaks, but higher chance of detached inferior breaks. Some variables were age dependent.

CONCLUSION

Differences were found between pseudophakic and phakic RRD patterns. These suggest special pathogenetic mechanisms in pseudophakic retinal detachment, which could help explain increased incidences of RRD after cataract surgery.

Familial retinal detachment associated with COL2A1 exon 2 and FZD4 mutations

BACKGROUND

  To characterize the clinical and genetic abnormalities within two Australian pedigrees with high incidences of retinal detachment and visual disability.

DESIGN

  Prospective review of two extended Australian pedigrees with high rates of retinal detachment.

PARTICIPANTS

  Twenty-two family members from two extended Australian pedigrees with high rates of retinal detachment were examined.

METHODS

  A full ophthalmic history and examination were performed, and DNA was analysed by linkage analysis and mutation screening.

MAIN OUTCOME MEASURES

  Characterization of a causative hereditary gene mutation in each family.

RESULTS

  All affected family members of one pedigree carried a C192A COL2A1 exon 2 mutation. None of the affected family members had early-onset arthritis, hearing abnormalities, abnormal clefting or facial features characteristic of classical Stickler syndrome. All affected members of the familial exudative vitreoretinopathy pedigree carried a 957delG FZD4 mutation.

CONCLUSIONS

  Patients with retinal detachment and a positive family history should be investigated for heritable conditions associated with retinal detachment such as Stickler syndrome and familial exudative vitreoretinopathy. The absence of non-ocular features of Stickler syndrome should raise the possibility of mutations in exon 2 of COL2A1. Similarly, late-onset familial exudative vitreoretinopathy may appear more like a rhegmatogenous detachment and not be correctly diagnosed. When a causative gene mutation is identified, cascade genetic screening of the family will facilitate genetic counselling and screening of high-risk relatives, allowing targeted management of the pre-detachment changes in affected patients.

Analysis of factors correlated with the development of pseudophakic retinal detachment--a long-term study in a single medical center

BACKGROUND

To analyze the possible factors correlated with the development of retinal detachment (RD) after cataract extraction and intraocular lens (IOL) implantation in a single medical center.

METHODS

We performed a retrospective chart review of patients receiving cataract extraction and posterior chamber IOL implantation from January 2000 to June 2010 at one medical center. We analyzed demographic characteristics, medical history, axial length (AL), operation method, intraoperative and postoperative complications, Nd-YAG posterior capsulotomy and records for RD.

RESULTS

The 9,184 patients analyzed included 6,464 males and 2,720 females, mean age 71.8 ± 9.1 years. The cumulative 7-year RD rate was 0.84 %. Young age, long axial length and intraoperative complications were significantly associated with the risk of pseudophakic RD. Although not a statistically significant factor for the whole group, Nd-YAG posterior capsulotomy represented a significant risk in those with high myopia stratified by axial length. In moderate myopic group, both intra-operative complication and Nd-YAG posterior capsulotomy showed more tendencies to increase risk of RD, but only intra-operative complication had significant difference.

CONCLUSIONS

Young age, myopia and intra-operative complications were significant risk factors for the development of RD after cataract extraction and IOL implantation. Post-operative Nd-YAG posterior capsulotomy led to more risk for pseudophakic RD in myopic eyes, especially high myopia. The risk of pseudophakic RD should be considered before deciding to perform cataract extraction and the following capsulotomy in myopic eyes, particularly those for refractive indication in young patients.

Evolution of early changes at the vitreoretinal interface after cataract surgery determined by optical coherence tomography and ultrasonography

PURPOSE

To evaluate the onset of posterior vitreous detachment (PVD) including early changes at the vitreoretinal interface after uneventful phacoemulsification in nonmyopic eyes using optical coherence tomography (OCT) and ultrasound.

DESIGN

Prospective consecutive study.

METHODS

Patients undergoing cataract surgery at our unit between January and October 2010 were recruited and examined with OCT and ultrasound preoperatively. Inclusion criteria were complete vitreoretinal attachment, no ocular pathology other than cataract, and no previous ocular surgery. All patients underwent phacoemulsification with intraocular lens implantation. Postoperatively, OCT and ultrasound were performed 1 month and 3 months after surgery. Exclusion criteria were axial length≥25 mm, lattice degeneration, intraoperative complications, and incomplete follow-up.

RESULTS

Forty-nine eyes of 49 patients could be enrolled in the study. Some degree of PVD was noted in 29 eyes (59.2%) 1 month after surgery and in 35 eyes (71.4%) 3 months after surgery. Moreover, a significant decrease in prevalence of initial PVD and a corresponding increase of more advanced PVD stages throughout the duration of the study was observed. In patients older than 70 years some degree of PVD was diagnosed in 92.3% compared to 47.8% in patients younger than 70 years (P=.002).

CONCLUSION

OCT facilitates the detection of early vitreoretinal separation that indicates initial PVD. After phacoemulsification the prevalence of some degree of PVD is consequently more frequent when supplementary OCT is used. Furthermore, OCT discloses a significant progression of PVD in the postoperative course. Patients older than 70 years are more likely to develop pseudophakic PVD.

Clinical outcomes of cataract surgery after bag-in-the-lens intraocular lens implantation following ISO standard 11979-7:2006

PURPOSE

To assess the clinical outcomes of bag-in-the-lens intraocular lens (BIL IOL) implantation following the International Organization for Standardization (ISO) 11979-7:2006 in pediatric eyes and eyes with ocular comorbidities.

SETTING

Antwerp University Hospital, Department of Ophthalmology, Antwerp, Belgium.

DESIGN

Cohort study.

METHODS

This cohort included the first series of patients having IOL implantation using the bag-in-the-lens technique. Surgeries were performed between December 1999 and September 2006. In addition to IOL implantation, the technique comprised creation of a primary posterior continuous curvilinear capsulorhexis (PCCC) equal in size to the anterior capsulorhexis.

RESULTS

The study enrolled 807 eyes of 547 patients; 326 of the eyes (40.40%) had ocular comorbidity. In the 481 eyes without ocular comorbidity, the mean decimal corrected distance visual acuity was 0.52 ± 0.24 (SD) (0.276 ± 0.206 logMAR) preoperatively and 0.94 ± 0.18 (-0.012 ± 0.053 logMAR) postoperatively. The mean postoperative achieved spherical equivalent was 0.48 ± 0.83 diopter (D) and the mean targeted refraction, -0.24 ± 0.71 D. The A-constant was modified from 118.4 to 118.04. Posterior capsule opacification (PCO) did not occur in any adult eye during the follow-up. Retinal detachment after IOL implantation occurred in 10 eyes (1.24%). In 19 eyes, the iris was captured by the IOL haptics postoperatively. Hypopyon occurred in 3 patients and toxic anterior segment syndrome in 1 patient.

CONCLUSION

The BIL IOL met the ISO criteria; that is, primary PCCC was safe in healthy eyes and in eyes with ocular comorbidities and no eye developed PCO over a mean follow-up of 26.1 ± 21.3 months.

Risk factors for retinal detachment following cataract surgery

PURPOSE OF REVIEW

To review and evaluate the current literature on the incidence and risk factors for rhegmatogenous retinal detachment (RRD) following cataract surgery.

RECENT FINDINGS

RRD is a serious complication of cataract surgery that can occur in the early or late postoperative periods. Identifying factors that increase the risk of pseudophakic retinal detachment can aid in management. Recent studies support long established risk factors for retinal detachment including intraoperative complications such as posterior capsular rupture (PCR). In addition, the current literature further defines the risk for pseudophakic retinal detachment associated with younger age at time of surgery, high myopia, and male sex in several large retrospective studies. Two recent articles also examine the state of the vitreous before and after cataract surgery and find that patients are more likely to develop posterior vitreous detachment postoperatively, possibly contributing to the increased risk of RRD.

SUMMARY

Younger age, high myopia, and male sex continue to be associated with higher risk of pseudophakic retinal detachment. Intraoperative complications such as PCR also increase the retinal detachment risk. Given the high volume of cataract surgeries performed each year, pseudophakic retinal detachment contributes significantly to visual morbidity in the United States and Europe.

Surgical outcomes for primary rhegmatogenous retinal detachments in patients with pseudophakia after phacoemulsification

PURPOSE

To evaluate the clinical features and surgical outcomes for primary rhegmatogenous retinal detachments (RDs) in patients with pseudophakia after phacoemulsification.

METHODS

The medical records of patients with pseudophakia after phacoemulsification and intraocular lens implantation who had undergone surgery for primary rhegmatogenous RDs with a minimum duration of follow-up of 12 months were reviewed retrospectively.

RESULTS

A total of 104 patients were enrolled in this study and 106 eyes were analyzed. Post-operative retinal attachment was achieved in 87 of the eyes (82.1%) and the final visual acuities (logarithm of the minimum angle of resolution) were improved to 0.65 ± 0.49 from the baseline measurement of 1.51 ± 1.14 (p < 0.001). Re-operations were performed in 24 of the eyes (22.6%) and there were no visible retinal breaks in 30 of the eyes (28.3%). The failure to identify a retinal break during surgery was associated with a lower rate of retinal reattachment, worse final visual acuity, and a higher rate of re-operation (p = 0.002, p = 0.02, and p = 0.002, respectively). The location of the identified retinal break was more common in the superotemporal quadrant than in the other quadrants.

CONCLUSIONS

The inability to identify a retinal break during surgery was associated with a poor final outcome. Other factors were less important for the functional and anatomic success in patients with pseudophakic RDs.

Risk factors for development of choroidal detachment after scleral buckling procedure

PURPOSE

To determine risk factors of choroidal detachment after scleral buckling procedure for treatment of retinal detachment.

DESIGN

Retrospective chart review.

METHODS

The authors performed a retrospective study of 69 consecutive cases of retinal detachment from January 2007 to January 2008 treated by scleral buckling surgery. Two groups of patients were defined according to the absence or apparition of choroidal detachment, and a comparison of several parameters between these 2 groups was performed.

RESULTS

Fifteen patients developed a choroidal detachment. The study found an average higher level of systolic blood pressure during surgery in the group with choroidal detachment than in the absence group (127.3 vs 119.1 mm Hg; P = .008). The authors also observed a statistically significant difference between the 2 groups when comparing the intraoperative peak value of systolic blood pressure (149.3 vs 138.5 mm Hg; P = .019). Finally, in the group that developed choroidal detachment, there were statistically more patients with high myopia (P = .02).

CONCLUSION

This study highlights that the 2 main risk factors for development of choroidal detachment during scleral buckling surgery are high blood pressure during the intervention and the existence of high myopia.

Pseudophakic rhegmatogenous retinal detachment in a large Asian tertiary eye centre: a cohort study

BACKGROUND

To determine the incidence and identify risk factors for the development of rhegmatogenous retinal detachment in patients who had cataract surgery at the Singapore National Eye Centre between 2001 and 2003.

DESIGN

Retrospective case-control study.

PARTICIPANTS

All patients who had cataract surgery between 2001 and 2003 and subsequently retinal detachment surgery in the same eye, between 2001 and June 2008, at Singapore National Eye Centre.

METHODS

Review of case records.

MAIN OUTCOME MEASURES

Incidence of posterior capsular rupture and retinal detachment.

RESULTS

Thirty-nine eyes, out of 24 846 cataract operations performed between 2001 and 2003, developed rhegmatogenous retinal detachment in the follow-up period from 2001 to 2008 (cumulative incidence 0.16%, 95% confidence interval 0.11-0.21%). Of the 508 eyes with posterior capsular rupture during cataract surgery, nine developed retinal detachment (cumulative incidence 1.77%, 95% confidence interval 0.87-3.23%). Men were more likely to develop retinal detachment (P < 0.001). On Kaplan-Meier survival analysis, younger patients had a higher probability of retinal detachment in comparison with older subjects (P < 0.001). Similarly, eyes with posterior capsular rupture during surgery had shorter interval duration to retinal detachment, compared with eyes that did not (P = 0.002). When compared with patients more than 70 years of age, younger patients had significantly higher hazard ratios of retinal detachment (hazard ratio 19.7, 95% confidence interval 3.6-107.3, P < 0.05).

CONCLUSION

The incidence of pseudophakic retinal detachment in our institution is low. Posterior capsular rupture during surgery, men and younger age at time of surgery increases the risk of developing retinal detachment, and careful observation for the occurrence of retinal detachment may be warranted in these groups of patients.

Comparison of pars plana vitrectomy with and without scleral buckle for the repair of primary rhegmatogenous retinal detachment

PURPOSE

To compare pars plana vitrectomy (PPV) with combined PPV and scleral buckle (SB) for the repair of noncomplex primary rhegmatogenous retinal detachment (RRD).

DESIGN

Retrospective, nonrandomized, interventional case series.

METHODS

We reviewed 181 consecutive cases of vitrectomy for primary RRD at 2 major medical centers in Israel. The follow-up was at least 3 months. There were 96 eyes in the PPV group and 85 eyes in the PPV plus SB group. Main outcome measures were single-surgery anatomic success (SSAS) and final visual acuity (VA).

RESULTS

SSAS was achieved in 81.3% and 87.1% in the PPV and PPV plus SB groups, respectively (P=.29). Final anatomic success rate was 98.9% and 98.8%, respectively (P=.61). Final VA was 0.41 (20/51) in the PPV group and 0.53 (20/68) in the PPV plus SB group (P=.13). The final VA was significantly better than the preoperative VA in both groups (P<.0001). In detachments caused by inferior tears, SSAS rates were 80.9% and 81.5% in the PPV and PPV plus SB groups, respectively (P=.74). In phakic eyes, SSAS rates were 92% and 87.5%, respectively, and in pseudophakic eyes, SSAS rates were 77.5% and 86.7%, respectively, in the PPV and PPV plus SB groups (P=.29).

CONCLUSIONS

The reattachment rate and the final VA were similar in both groups. The addition of SB did not improve the results and was associated with slightly lower VA than with PPV alone. Tear location or lens status had no significant effect on success rates. It is likely that in eyes undergoing PPV for primary RRD, addition of a SB is not warranted.

Pars plana vitrectomy for primary rhegmatogenous retinal detachment

Pars plana vitrectomy (PPV) is growing in popularity for the treatment of primary rhegmatogenous retinal detachment (RD). PPV achieves favorable anatomic and visual outcomes in a wide variety of patients, especially in pseudophakic RD. A growing number of clinical series, both retrospective and prospective, have demonstrated generally comparable outcomes comparing PPV and scleral buckling (SB) under a variety of circumstances. The Scleral Buckling Versus Primary Vitrectomy in Rhegmatogenous Retinal Detachment (SPR) study is a multicenter, randomized, prospective, controlled clinical trial comparing SB versus PPV. This study should provide useful guidelines in the future. At this time, the choice of SB versus PPV should be based on the characteristics of the RD, the patient as a whole, and the experience and preference of the individual retinal surgeon.

Pars plana vitrectomy versus combined pars plana vitrectomy and scleral buckle for primary repair of rhegmatogenous retinal detachment

OBJECTIVE

To compare pars plana vitrectomy (PPV) with PPV and scleral buckle (PPV/SB) for repair of rhegmatogenous retinal detachment (RRD).

DESIGN

A retrospective chart review.

PARTICIPANTS

Patients who underwent PPV or PPV/SB for RRD repair at a single institution.

METHODS

A retrospective chart review of patients in two different treatment groups and analysis of the anatomic and functional results.

RESULTS

Single-surgery anatomic success was achieved in 31 of 37 (83.8%) phakic eyes that underwent PPV and in 66 of 68 (97.1%) phakic eyes that underwent PPV/SB (p = 0.0216). Among pseudophakic eyes, 42 of 48 (87.5%) in the PPV group and 62 of 66 (93.9%) in the PPV/SB group achieved single-surgery reattachment (p = 0.3175). Visual acuity improvement was marginally greater in the PPV group among phakic (p = 0.4898) and pseudophakic (p = 0.2465) eyes.

CONCLUSIONS

PPV/SB may be associated with a decreased risk for retinal redetachment when compared to PPV for repair of phakic RRD. In pseudophakic eyes, the anatomic success rate between the two techniques appears to be similar.

LASIK for -6.00 to -12.00 D of myopia with up to 3.00 D of cylinder using the ALLEGRETTO WAVE: 3- and 6-month results with the 200- and 400-Hz platforms

PURPOSE

To report the refractive results after LASIK for high myopia and cylinder at one center with one surgeon comparing two laser platforms.

METHODS

A total of 206 eyes of 121 patients were treated for -6.00 to -12.00 diopters (D) of spherical equivalent refractive error with up to 3.00 D of cylinder. All eyes underwent LASIK with the ALLEGRETTO WAVE 200-Hz (n=141) or 400-Hz (n=65) laser (Alcon Laboratories Inc) between 2003 and 2009. Corneal flaps were created with the IntraLase femtosecond laser (Abbott Medical Optics) at an intended thickness of 100 or 110 μm in all cases.

RESULTS

At 3- and 6-month follow-up in the 200-Hz group, 77% (109/141) and 86% (121/141) of eyes, respectively, were within ±0.50 D of intended correction. In the 400-Hz group, 98.5% (64/65) and 100% (65/65) of eyes were within ±0.50 D of intended correction at 3 and 6 months postoperatively. At 3- and 6-month follow-up, 84% (119/141) and 77% (109/141) of eyes, respectively, in the 200-Hz group and 80% (52/65) and 92% (60/65) of eyes, respectively, in the 400-Hz group had 20/20 or better uncorrected distance visual acuity. At 6-month follow-up, refractive predictability and visual acuity were statistically superior in eyes in the 400-Hz group (chi square, P<.01). No eyes underwent retreatment as a secondary procedure during the time of analysis.

CONCLUSIONS

LASIK with the ALLEGRETTO WAVE 200- and 400-Hz laser is effective and predictable for the treatment of high myopia with astigmatism in appropriately selected patients. The acuity and predictability of refractive results may be slightly better when using the 400-Hz platform.

Dealing with retinal detachment in a patient with aphakia, an Artisan lens, and an ExPress valve in situ

PURPOSE

To report our experience from a case with a retinal detachment in an eye with aphakia, an Artisan phakic anterior chamber lens, and an ExPress valve and describe its course after vitrectomy and gas tamponade.

METHODS

Interventional case report.

RESULTS

A 65-year-old man who had previously undergone cataract extraction, Artisan/Verisyse lens implantation, and ExPress valve insertion for the treatment of aphakia and refractory glaucoma presented with a superior retinal detachment. The patient underwent a 20-g pars plana 20g vitrectomy, cryotherapy, and sulfur hexafluoride (SF(6)) tamponade. Twenty days after vitrectomy, the Artisan lens remained in place and the retina attached. Twelve months postoperatively, the situation remained unchanged.

CONCLUSION

Iris-claw lenses have been introduced in 2004 as an alternative option for the correction of aphakia. Vitreoretinal surgeons face a new therapeutic challenge since data with regard to retinal detachment repair in patients with Artisan lenses are very limited. In our case, all intraoperative vitrectomy manipulations were performed without difficulty through the Artisan lens, which remained stable during fluid-air exchange as well as postoperatively, despite the movements of the gas bubble and the presence of the ExPress valve. Moreover, there was no displacement of the ExPress valve during the intraoperative manipulations of vitrectomy or dysfunction of the valve due to the existence of the gas in the postoperative period.

[Cataract surgery. Effect on the posterior segment of the eye]

Cataract surgery is a safe procedure with a high patient satisfaction rate. However, pseudophakia changes the physiology of the eye and immediate changes include release of inflammatory cytokines. Deformation of the globe and intraoperative fluctuations of intraocular pressure may induce microlesions and alterations of ocular perfusion. The barrier function between the anterior and the posterior segment is compromised after surgery and the geometry of the intraocular chambers changes. Especially the vitreous body is subject to increased destruction during the years after surgery. The occurrence of pseudophakic cystoid macular edema after cataract surgery is a well known complication. Several studies have described a progression of diabetic retinopathy, especially of diabetic macular edema after cataract surgery. In contrast cataract surgery does not seem to have a significant impact on the progression of age-related macular degeneration. However the risk for retinal detachment is significantly increased in pseudophakia for at least 10 years after surgery. Awareness of special risk factors can make cataract surgery, one of the most effective procedures in medicine, even safer.

Risk factors for pseudophakic retinal detachment after intraocular lens scleral fixation with or without pars plana vitrectomy

PURPOSE

To identify the risk factors of pseudophakic retinal detachment after intraocular lens scleral fixation.

METHODS

We retrospectively reviewed the medical records of all patients who underwent intraocular lens implantation with scleral fixation and had at least 6 months of follow-up between January 2002 and December 2007. The risk factors for pseudophakic retinal detachment were investigated using various surgical variables. To find the significant predictors among the variables, we carried out binary logistic regression analysis with a backward selection method based on likelihood ratios.

RESULTS

Data from 395 eyes were analyzed. The pseudophakic retinal detachment rates were 8.46% (11 of the 130 eyes) in patients treated with pars plana vitrectomy (PPV) and 3.02% (8 of the 265 eyes) in patients treated without the PPV. Performing PPV (P = 0.023) was the only significant risk factor for pseudophakic retinal detachment after intraocular lens scleral fixation by logistic regression analysis. The odds ratio for PPV was 2.970 (95% confidence interval: 1.164-7.574).

CONCLUSION

Performing PPV could be a risk factor of the pseudophakic retinal detachment after intraocular lens scleral fixation. If there is a choice, it should be decided carefully whether a PPV is performed at the time of intraocular lens scleral fixation.

Intravitreal injection of therapeutic agents

BACKGROUND

Intravitreal injection (IVI) with administration of various pharmacological agents is a mainstay of treatment in ophthalmology for endopthalmitis, viral retinitis, age-related macular degeneration, cystoid macular edema, diabetic retinopathy, uveitis, vascular occlusions, and retinal detachment. The indications and therapeutic agents are reviewed in this study.

METHODS

A search of the English, German, and Spanish language MEDLINE database was conducted. A total of 654 references spanning the period through early 2008 were individually evaluated.

RESULTS

The advantage of the IVI technique is the ability to maximize intraocular levels of medications and to avoid the toxicities associated with systemic treatment. Intravitreal injection has been used to deliver several types of pharmacological agents into the vitreous cavity: antiinfective and antiinflammatory medications, immunomodulators, anticancer agents, gas, antivascular endothelial growth factor, and several others. The goal of this review is to provide a detailed description of the properties of numerous therapeutic agents that can be delivered through IVI, potential complications of the technique, and recommendations to avoid side effects.

CONCLUSION

The IVI technique is a valuable tool that can be tailored to the disease process of interest based on the pharmacological agent selected. This review provides the reader with a comprehensive summary of the IVI technique and its multitude of uses.

[Reasons for readmission to hospital after vitreoretinal surgery: 5-year retrospective follow-up]

INTRODUCTION

To study the etiologies and occurrence rate of readmissions after vitreoretinal surgery.

PATIENTS AND METHODS

One hundred fifty-three eyes requiring vitreoretinal surgery in 2000 at the Besançon (France) University Hospital were retrospectively studied. The occurrence rate and etiologies of these readmissions and the time between surgery and readmission were analyzed from the patient files.

RESULTS

The main indications for vitreoretinal surgery were retinal detachment, epiretinal membrane surgery, idiopathic macular holes, neovascular retrovascular membranes, and intravitreal hemorrhage. A total of 40.5% of the patients were readmitted. The major causes were redetachment and cataract for retinal detachment surgery and cataract for epiretinal membrane and macular hole surgeries.

CONCLUSION

The results highlight the possibly iatrogenic association between anterior and posterior eye segment surgeries, in agreement with the literature.

LASIK for myopia of -9.00 to -17.00 D with the VISX STAR S2: 2- to 5-year follow-up

PURPOSE

To evaluate long-term results of LASIK in the correction of high myopia.

METHODS

Preoperative and early postoperative data, including uncorrected and best spectacle-corrected visual acuity and refraction, were collected retrospectively from 77 eyes of 47 patients who underwent LASIK for myopia of at least -9.00 diopters (D) performed with the VISX STAR S2 excimer laser in our hospital from 1999 to 2003. An additional examination with a satisfaction query was performed 2 to 5 years postoperatively.

RESULTS

After 2- to 5-year follow-up, 40% of eyes has a spherical equivalent refraction within 1.00 D of the original intended refraction, 70% within 2.00 D, and 91% within 3.00 D. Only one eye lost two Snellen lines of visual acuity, whereas three eyes gained two lines and the remainder had no significant change. Regression was mild but significant in the long-term, with mean spherical equivalent refraction being -1.21 D at 1 month, -1.82 D at 6 months, and -1.95 D at 2 to 5 years. Stability was similar in a subgroup of eyes followed for at least 4 years. Nine eyes had mild postoperative complications, which resolved without permanent consequences. All patients, except one, were very satisfied with the results and would have chosen the surgery again.

CONCLUSIONS

With careful patient selection and safety precautions, LASIK is a safe alternative with moderate stability but limited predictability in the treatment of myopia of -9.00 to -17.00 D.

Visual and anatomic outcomes of vitreoretinal surgery: results at the Boston VA and a review of the literature

Introduction

The veteran population presents unique challenges in the management of vitreoretinal disorders. We compiled the surgical outcomes for the most common visually significant vitreoretinal diagnoses. Those results were then compared to visual and anatomic outcomes established in the literature.

Materials and Methods

Medical records over a three-year time period, from January 2005 through December 2007, were reviewed for 208 persons who underwent vitreoretinal surgery for vitreous hemorrhage, retained lens fragment, rhegmatogenous and tractional retinal detachment, macular hole, and macular pucker at the Jamaica Plain Campus of the Veterans Affairs Boston Healthcare System in Boston, MA. A comprehensive search of the literature was conducted on Medline. Data from several large case series and meta-analyses were compared to results obtained at the VA Boston.

Results

A total of 208 veterans underwent vitreoretinal surgery from January 2005 to December 2007. After excluding those with rare diagnoses and lack of adequate follow-up data, the outcomes of 181 vitreoretinal procedures were included in this study.

Discussion

Overall, veterans at a regional referral center in Boston demonstrate postoperative visual and anatomic outcomes comparable to outcomes reported in the ophthalmic literature.