Pars plana vitrectomy for chronic pseudophakic cystoid macular edema

Intravitreal Dexamethasone Implant at the Time of Silicon Oil Removal to Treat Persistent Macular Edema after Rhegmatogenous Retinal Detachment Repair

BACKGROUND

An intravitreal dexamethasone implant (DEX-I) was found to be effective and safe for the treatment of cystoid macular edema (CME) after vitrectomy for rhegmatogenous retinal detachment (RRD) and in silicone oil (SO)-filled eyes. We aimed to investigate the efficacy and safety of DEX-I at the time of SO removal for the treatment of recalcitrant CME after successful RRD repair.

METHODS

A retrospective review of the medical records was performed on 24 consecutive patients (24 eyes) with recalcitrant CME after RRD repair who were treated with a single 0.7-mg DEX-I at the time of SO removal. The main outcome measures were changes in best-corrected visual acuity (BCVA) and central macular thickness (CMT). A regression model was performed to assess the relationship between BCVA and CMT at 6 months and independent variables.

RESULTS

In all 24 patients, CME occurred after RRD repair and remained despite topical therapy. The mean time of CME onset was 27.4 ± 7.7 days after vitrectomy. The mean time between vitrectomy and DEX-I was 106.8 ± 10.1 days. The mean CMT was significantly decreased from 429.6 ± 59.1 µm at baseline to 294 ± 46.4 µm at month 6 (p < 0.0001). The mean BCVA significantly improved from 0.99 ± 0.3 at baseline to 0.60 ± 0.3 at month 6 (p < 0.0001). An elevation of intraocular pressure was observed in one (4.1%) eye, which was medically managed. A univariate regression model revealed a relationship between month-6 BCVA after DEX-I and gender (β = -0.27; p = 0.03) and macular status (β = -0.45; p = 0.001) when RRD occurred. No relationship between month-6 CMT and independent variables was found.

CONCLUSIONS

DEX-I at the time of SO removal had an acceptable safety profile and achieved favorable outcomes in eyes affected by recalcitrant CME that occurred after RRD repair. RRD-related macular status is significantly associated with visual acuity after DEX-I.

Mid-term safety and effectiveness of intravitreal dexamethasone implant to treat persistent cystoid macular edema in vitrectomized eyes for bacterial endophthalmitis

PURPOSE

To evaluate the mid-term safety and effectiveness of intravitreal dexamethasone implant (DEX-i) for treating unresponsive to medical therapy cystoid macular edema (CME) in vitrectomized eyes for endophthalmitis.

METHODS

Retrospective and interventional case series study conducted on vitrectomized eyes for endophthalmitis that developed a CME that did not adequately respond to medical therapy, who underwent 0.7-mg DEX-i. Main outcome measures were changes in central retinal thickness (CRT) and best corrected visual acuity (BCVA).

RESULTS

Eleven eyes were included in the study. Microbiological findings of vitreous biopsies were 7 (63.6%) staphylococcus epidermidis; 3 (27.3%) Pseudomonas aeruginosa; and 1 (9.1%) Propionibacterium acnes. Median (interquartile range, IqR) duration of CME was 4.0 (3.0-4.0) months. Median (IqR) time between vitrectomy and DEX-i was 9.0 (9.0-11.0) months. Median CRT was significantly decreased from 548.0 (412.8-572.5) µm at baseline to 308.0 (281.3-365.5) µm at month 6 (p = 0.0009, Friedman test). Median BCVA significantly improved from 38.0 (30.5-44.8) letters at baseline to 50.0 (46.8-53.0) letters at month 6 (p < 0.0001, Friedman), with 9 (81.8%) eyes gaining ≥ 10 letters. Elevation of intraocular pressure was observed in one (9.1%) eye, which was successfully controlled with medical therapy. No recurrence of endophthalmitis or other complications was observed. Eight (72.7%) eyes required an additional DEX-i, while 3 (27.3%) were successfully controlled with only one DEX-i. CME recurrence occurred in 5 (62.5%) Gram-positive and 3 (100.0%) Gram-negative bacteria (p = 0.2357).

CONCLUSION

In vitrectomized eyes for endophthalmitis affected by CME unresponsive to medical therapy, DEX-i had an acceptable safety profile and achieved favorable outcomes. The possibility of suppressing mechanisms for infection control should be taken into account, although correct management of endophthalmitis and long time without reactivation before DEX-i reduce the risk.

Simultaneous existence of three intraocular lens inside one eye

The purpose of the study was to report an unusual case of recurrent pseudophakic cystoid macular edema (PCME) in an eye with three simultaneous intraocular lenses (IOLs) inside. A 57-year-old female with diabetes mellitus (DM) and a history of complicated cataract surgery was diagnosed with cystoid macular edema (CME). Upon examination, an anterior chamber intraocular lens (ACIOL) with vitreous strand in her right eye was noted. The fluorescence angiography revealed CME of the right eye and microaneurysms in both eyes. Pars plana vitrectomy was performed to release the vitreous prolapse and traction around the ACIOL. During the surgery, two sunken posterior chamber IOLs in the vitreous were incidentally found and removed. The vitreous traction strand around the inappropriately placed anterior chamber ACIOL was also released. It was rarely reported that two dislocated IOL and ACIOL simultaneously existed in the same eye. Chronic recurrent PCME in this patient was possibly associated with posteriorly dislocated IOL, DM, and vitreous traction.

The effects of intravitreal adalimumab injection on pseudophakic macular edema

Objective

Pseudophakic macular edema is a frequent complication following cataract surgery. Inflammation is a major etiologic factor in the development of pseudophakic cystoid macular edema. Tumor necrosis factor-alpha has an important role in ocular inflammation. Adalimumab (Humira) is an inhibitor of tumor necrosis factor-alpha that has been approved in the United States. An open-label, uncontrolled, prospective, interventional study of five consecutive patients (5 eyes) with cystoid macular edema who were treated with off-label intravitreal adalimumab at Khalili Hospital was conducted. Slit-lamp examination and optical coherence tomography were done for all patients.

Results

No statistically significant difference was detected between best corrected visual acuity and central macular thickness before and after injection in pseudophakic macular edema. One patient developed uveitis approximately 2 weeks after injection. Based on the results, adalimumab does not appear to be an effective treatment for pseudophakic macular edema, and it may cause uveitis. Caution should be exercised when using this drug.

Trial registration Iranian Registry of Clinical Trials IRCT2016100430130N1, 2016.12.03, Retrospectively registered

The Role of Subthreshold Micropulse Yellow Laser as an Alternative Option for the Treatment of Refractory Postoperative Cystoid Macular Edema

BACKGROUND

To evaluate the efficacy and the safety of subthreshold micropulse yellow laser (SMYL) in the treatment of chronic postoperative cystoid macular edema (PCME), which is refractory to standard therapies.

METHODS

A retrospective chart review of ten eyes of ten patients affected by refractory PCME who underwent SMYL was performed. Five PCME cases were subsequent to uncomplicated cataract surgery (CS), two cases to complicated CS (CCS) with posterior capsule rupture and three cases occurred after retinal detachment surgery (RD). All conditions were refractory to conventional treatments prior to SMYL interventions for at least 4 months, including nonsteroidal anti-inflammatory eyedrops, topical steroids, oral indomethacin, sub-Tenon's triamcinolone injections and Dexamethasone intravitreal implants. All patients underwent one or more treatments with 577 nm SMYL photo-stimulation, with 7 × 7 grids with confluent spots and a 5% duty cycle covering the whole edematous retina, including the foveal center. Best corrected visual acuity (BCVA) and central macular thickness (CMT) were obtained using OCT, and evaluated before and after the treatment at 1, 2, 3 and 6-month follow-ups.

RESULTS

A complete subfoveal macular edema resolution was observed in all of the eyes, with statistically significant improvements in terms of BCVA and CMT in all of the follow-up timelines (at 6 months, p = 0.002 and p = 0.005, respectively). The mean number of laser treatments was 1.3. At the final follow-up, a complete subfoveal edema reabsorption was observed in all patients with visual acuity improvement. No complications were observed in any case.

CONCLUSIONS

SMYL seems to be a safe and effective treatment for the long-term resolution of refractory PCME and may be a useful alternative to expensive and invasive therapeutic options.

Ocriplasmin treatment for vitreomacular traction in real life: can the indication spectrum be expanded?

PURPOSE

To evaluate the efficacy of intravitreal ocriplasmin for the resolution of vitreomacular traction (VMT) with or without a full thickness macular hole (FTMH) in the clinical setting and to assess whether the indication spectrum of this treatment modality can be expanded beyond that of the MIVI-TRUST trials.

METHODS

The records of patients with VMT with or without FTMH, who were treated with intravitreal ocriplasmin were reviewed. Patients were divided in two groups. In the first group, VMT with or without FTMH was present without any other macular pathology. In the second group, VMT with or without FTMH occurred alongside of other macular disease including age-related macular degeneration, diabetic maculopathy and post-operative pseudophakic cystoid macular edema.

RESULTS

Release of the VMT was achieved in 12/20 patients (12/20 eyes) of the first group. 16 eyes in this group met 3 or more criteria known to be associated with favorable prognosis after intravitreal ocriplasmin treatment. No cases of release of the VMT were observed in the second group, which included 15 patients (15 eyes). Significant improvement of visual acuity and reduction of the central macular thickness was observed only in the subgroup of eyes which responded to treatment.

CONCLUSIONS

Concomitant macular pathology was a significant factor for treatment failure and we suggest that ocriplasmin should be regarded with caution in these cases. Careful patient selection for treatment with ocriplasmin using specific criteria in the clinical setting can provide superior results to those reported in the MIVI-TRUST trials.

Intravitreal dexamethasone implant for recurrent cystoid macular edema due to Irvine-Gass syndrome: a prospective case series

PurposeTo determine the preliminary efficacy and safety of off-label dexamethasone implant for treatment of recurrent cystoid macular edema (CME) secondary to Irvine-Gass syndrome (IGS).Patients and methodsThis study was set in Raghudeep Eye Clinic, Ahmedabad and LV Prasad Eye Institute, Hyderabad (India). It is a Prospective Case Series. Prospective case series comprising of patients with uncomplicated pseudophakia and CME due to IGS who recurred after one course of topical steroids with NSAIDS and a sub-Tenon corticosteroid injection. A complete ocular and systemic exam, fluorescein angiography, and central subfield thickness (CST) on optical coherence tomography scans were performed. Follow-up visits were on days 1, 15, and 30 and then monthly for a year. Appropriate statistical analysis was done. The primary outcome measure was the change in CDVA at months 1, 6, and 12. Secondary outcome measures were recurrence of CME and complications if any as noted at months 1, 2, 6, and 12.ResultsAbout 27 patients (27 eyes) with 16 males were included. Median age: 63.24±5.62 years. At 1 month, the CDVA improved to 0.04±0.02 (20/25) logMAR from 0.52±0.12 logMAR (20/70) (P=0.001) with a reduction in CST from 454.2±45.3 to 218.32±38.15 microns(P=0.013). The CDVA was 0.04±0.03 logMAR(P<0.001) at month 6 and 0.05±0.02 logMAR(P<0.001) at month 12. The CST was 221±35.2 microns (P=0.013) at month 6 and 214±43.34 microns (P=0.0124) at month 12. All improvements were maintained for a year. Only one patient required a second injection. No complications were noted.ConclusionThe implant is safe and effective for the treatment of recurrent CME due to IGS.

Pseudophakic cystoid macular edema: update 2016

Pseudophakic cystoid macular edema (PCME) is the most common complication of cataract surgery, leading in some cases to a decrease in vision. Although the pathogenesis of PCME is not completely understood, the contribution of postsurgical inflammation is generally accepted. Consequently, anti-inflammatory medicines, including steroids and nonsteroidal anti-inflammatory drugs, have been postulated as having a role in both the prophylaxis and treatment of PCME. However, the lack of a uniformly accepted PCME definition, conflicting data on some risk factors, and the scarcity of studies comparing the role of nonsteroidal anti-inflammatory drugs to steroids in PCME prevention make the problem of PCME one of the puzzles of ophthalmology. This paper presents an updated review on the pathogenesis, risk factors, and use of anti-inflammatory drugs in PCME that reflect current research and practice.

Surgical complications of primary rhegmatogenous retinal detachment: a meta-analysis

BACKGROUND

To investigate the surgical complications of scleral buckling (SB) and pars plana vitrectomy (PPV) performed on primary rhegmatogenous retinal detachment (RRD) and to discover which surgical procedures bring fewer complications.

METHODS

An electronic literature search using the PubMed database, ISI Web of Knowledge and the Cochrane Central Register of Controlled Trials to identify randomized controlled trials and observational studies comparing SB with PPV on primary RRD. Outcome measures included intra-operative complications and early and late post-operative complications.

RESULTS

During the operation, significantly less subretinal hemorrhage occurred in the PPV group than in the SB group (OR = 4.71; 95%CI, 1.33-16.64; p = 0.02) and the hypotony incidence was significantly higher in the SB group (OR = 18.24; 95%CI, 2.37-140.44; p = 0.005); however, the occurrence of iatrogenic breaks was significantly lower in the SB group (OR = 0.05; 95%CI, 0.01-0.21; p<0.0001). In the early stage of post-operation, significantly higher incidence of choroidal detachment was identified in the SB group than in the PPV group (OR = 10.19; 95%CI, 2.36-44.09; p = 0.002); patients undergoing SB had significantly higher odds of residual subretinal fluid (OR = 14.71; 95%CI, 1.84-117.32; p = 0.01); the occurrence of high intraocular pressure was significantly lower in the SB group (OR = 0.46; 95%CI, 0.23-0.89; p = 0.02); and no significant difference was shown in the incidence of epithelia defect (p = 0.37) between the two groups. In the late stage of post-operation, the incidence of diplopia/extraocular muscle dysfunction was significantly higher in the SB group (OR = 4.04; 95%CI, 1.30-12.52; p = 0.02); and significantly less cataract was observed in the SB group (OR = 0.20; 95%CI, 0.14-0.30; p<0.00001); no significant difference was found in the incidences of cystoid macular edema (p = 0.65), macular pucker (p = 0.52), post-operative proliferative vitreoretinopathy (p = 0.73) and epiretinal membrane (p = 0.47) in other late post-operative complications.

CONCLUSIONS

This meta-analysis suggests that PPV could be considered as potential surgical management on primary RRD.

Management of pseudophakic cystoid macular edema

Pseudophakic cystoid macular edema (PCME) is a common complication following cataract surgery. Acute PCME may resolve spontaneously, but some patients will develop chronic macular edema that affects vision and is difficult to treat. This disease was described more than 50 years ago, and there are multiple options for clinical management. We discuss mechanisms, clinical efficacy, and adverse effects of these treatment modalities. Topical non-steroidal anti-inflammatory agents and corticosteroids are widely used and, when combined, may have a synergistic effect. Intravitreal corticosteroids and anti-vascular endothelial growth factor (anti-VEGF) agents have shown promise when topical medications either fail or have had limited effects. Randomized clinical studies evaluating anti-VEGF agents are needed to fully evaluate benefits and risks. When PCME is either refractory to medical therapy or is associated with significant vitreous involvement, pars plana vitrectomy has been shown to improve outcomes, though it is associated with additional risks.

A Study Investigating a Possible Link Between Lens Protein in the Vitreous Fluid of Eyes After Uncomplicated Cataract Surgery and Chronic Cystoid Macular Edema

PURPOSE

This study aimed to determine if the lens protein aquaporin 0 (AQP0) is present in the vitreous of pseudophakic eyes of patients presenting with chronic cystoid macular edema (CME).

DESIGN

A case-control study was conducted.

METHODS

Ten patients undergoing therapeutic vitrectomy for chronic CME after uncomplicated cataract surgery were enrolled in this study. Fourteen patients with pseudophakia undergoing vitrectomy surgery for indications other than CME acted as the comparison group.The vitreous fluid from the 2 groups was analyzed for the presence of the lens protein AQP0 and type II collagen (used as a positive control).

RESULTS

Type II collagen was detected in all the vitreous samples, whereas AQP0 was documented in 50% of eyes with chronic CME but was not found in the vitreous of any eyes without a documented history of CME.

CONCLUSIONS

Aquaporin 0 is found in some eyes with chronic CME after uncomplicated cataract surgery, suggesting contamination of the vitreous by lens protein may have a role in the pathogenesis of this disorder.

Macular edema following cataract surgery in eyes with previous 23-gauge vitrectomy and peeling of the internal limiting membrane

PURPOSE

To investigate intraretinal changes after successful cataract surgery in patients with previous pars plana vitrectomy (PPV) and indocyanine green-assisted peeling of epiretinal membrane and internal limiting membrane (ILM).

DESIGN

Prospective nonrandomized controlled clinical study.

METHODS

Twenty eyes of 20 patients with cataract with previous 23-gauge PPV and ILM peeling (PPV group) and 15 consecutive eyes with senile cataract with a healthy macula (control group) were included. Best-corrected visual acuity (BCVA), spectral-domain optical coherence tomography (OCT), infrared fundus imaging, and biomicroscopy were performed at baseline and at week 1, month 1, and month 3 after cataract surgery. OCT raster scans were further analyzed regarding the central millimeter thickness (CMMT), area of retinal thickening size on the topographic map, and changes in retinal structural morphology.

RESULTS

The baseline mean visual acuity in the PPV group was 0.3 ± 0.18 Snellen lines, which improved significantly to 0.85 ± 0.18 (P < .05) 3 months after cataract surgery. CMMT was 393 (± 44) μm at baseline and increased to 408 (± 47) μm at month 3 (P < .05). One patient was not seen at the final visit, so data of 19 patients was used. In the PPV group, 8 of 19 patients (42%) developed an increase in CMMT more than 35 μm 1 month after cataract surgery; 5 of these 8 patients (26%) developed macular edema with cyst formation. Three months after surgery, the area of retinal thickening was significantly larger in most patients compared with baseline values. No cystoid macular edema was observed in the control group.

CONCLUSIONS

This study provides evidence that patients with previous PPV and membrane and ILM peeling often develop macular edema after successful cataract surgery.

Recent developments in the treatment of posterior uveitis

Uveitis is an intraocular inflammation that can be caused by infection, autoimmune disease, trauma or malignancy. It is a serious cause of visual handicap and therapy is targeted at: removal of possible infectious agents, the immunological processes that lead to or sustain the inflammation and finally to prevent or treat the destructive effects of the inflammation on the delicate ocular structures. In this review the latest developments concerning the treatment of posterior uveitis are illuminated, e. g., new approaches concerning the treatment of infectious uveitis including the therapy of herpes virus (VZV, HSV and CMV), bacterial and toxoplasma infections of the eye. Several new ways to influence the immune response and inflammation are described including the use of interferons, modulation of cytokines, soft steroids, other new immunosuppressive drugs and treatment of autoimmune uveitis by oral tolerization. An overview is given to illustrate new ways to administer drugs into eyes, such as intravitreal devices. Finally new developments in the field of the treatment of the various complications of uveitis (cystoid macular edema) are described.

Pseudophakic cystoid macular edema associated with extrafoveal vitreoretinal traction

Purpose:

To describe an association between extrafoveal vitreoretinal traction and intractable chronic pseudophakic cystoid macular edema (CME) by the use of optical coherence tomography (OCT).

Methods:

In a retrospective case series study, charts and OCT findings of patients who had postoperative recalcitrant pseudophakic CME for at least 6 months and vitreoretinal traction membranes were analyzed. Excluded were eyes that either had another vitreoretinopathy that could affect the analysis or had undergone an intravitreal intervention.

Results:

Three eyes (three patients) with macular edema following uneventful cataract surgery were detected to be associated with multifocal extrafoveal vitreoretinal traction sites in each. Retinal edema that was underlying each of the traction sites in all eyes was in continuum in at least one site per eye with the central macular edema, thus manifesting as diffuse macular edema.

Conclusion:

Chronic pseudophakic macular edema may be related to extrafoveal vitreoretinal traction.

Etiology and treatment of the inflammatory causes of cystoid macular edema

Cystoid macular edema in its various forms can be considered one of the leading causes of central vision loss in the developed world. It occurs in a wide variety of pathologic conditions and represents the final common pathway of several basic processes. Therapeutic approaches to cystoid macular edema depend on a clear understanding of its contributing pathophysiologic mechanisms. This review will discuss the mechanism of ocular inflammation in cystoid macular edema with a particular focus on the inflammatory causes: post-operative, uveitic, and after laser procedures. A variety of pharmacologic agents targeting inflammatory molecules have been shown to reduce macular edema and improve visual function. However, the long-term efficacy and safety of most new therapies have yet to be established in controlled clinical trials.

Analysis of the effect of intravitreal bevacizumab injection on diabetic macular edema after cataract surgery

PURPOSE

To determine the feasibility and clinical effectiveness of intravitreal bevacizumab combined with cataract surgery for management of the postoperative increase of retinal thickness in patients with diabetic maculopathy.

DESIGN

Prospective, randomized, masked cohort study.

PARTICIPANTS

Forty-two eyes with diabetic macular edema (DME) of 42 patients with type 2 diabetes mellitus.

METHODS

Patients were randomly assigned to receive either cataract surgery only (control; 21 eyes) or combined with intravitreal injection of 1.25 mg bevacizumab (21 eyes). Efficacy measures included best-corrected visual acuity (BCVA) testing, optical coherence tomography (OCT), and ophthalmoscopic examination.

MAIN OUTCOME MEASURES

Retinal thickness (RT) on OCT and BCVA were measured at baseline and 1 and 3 months after surgery.

RESULTS

There were no significant differences in RT, BCVA, severity of cataract, or systemic condition between the control and bevacizumab groups at the baseline. One and 3 months after surgery, the control group showed a significant increase in RT, whereas the bevacizumab group showed a significant decrease. Although postoperatively the eyes in both groups showed a significant improvement of BCVA, bevacizumab-treated eyes showed significantly better results (mean logarithm of the minimum angle of resolution, 0.38) than the control group (0.51) at month 3. There was a significant relationship between RT and visual acuity (VA) postoperatively in the control (P = 0.0001) and bevacizumab (P = 0.0141) groups. No systemic or ocular adverse events were observed.

CONCLUSIONS

Short-term results suggest that intravitreal bevacizumab has the potential not only to prevent the increase in RT, but also reduce the RT of eyes with DME after cataract surgery. Further improvement of VA in bevacizumab-treated eyes may be dependent on a reduction in central RT.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Etiology and treatment of macular edema

PURPOSE

To summarize current concepts and recent literature regarding the pathogenesis, clinical substrates, and treatment of macular edema, in light of evolving pharmacologic and surgical approaches to this prevalent cause of vision loss.

DESIGN

Interpretive essay.

METHODS

Review and synthesis of selected recent literature, with interpretation and perspective.

RESULTS

Macular edema occurs in a wide variety of pathologic conditions and represents the final common phenotype of several basic pathophysiologic processes. A variety of pharmacologic agents targeting inflammatory and vasopermeability molecules have been shown to reduce macular edema and improve visual function over the short-term. Vitreous surgery effectively addresses the tractional components of macular edema, where present. Despite recent advances, laser photocoagulation remains the treatment of choice for macular edema associated with nondiffuse patterns of vascular leakage.

CONCLUSIONS

Effective management of macular edema is based on recognizing and addressing the pathogenic factors that are operative in a given disease setting. Although treatment options are expanding with the development of new drugs and surgical procedures, the long-term efficacy and safety of most new approaches have yet to be established in controlled clinical trials.

Intravitreal pegaptanib sodium for refractory pseudophakic macular oedema

PURPOSE

Evaluate the efficacy of intravitreal pegaptanib sodium (Macugen) in refractory pseudophakic cystoid macular oedema (CME).

DESIGN AND METHODS

Prospective, nonrandomized, interventional case series. Four eyes of four patients with refractory pseudophakic CME to pars plana vitrectomy and intravitreal bevacizumab and triamcinolone, were treated with pegaptanib sodium, with a mean follow up of 4 months. Pre- and postinfection examinations included assessment of best-corrected visual acuity (BCVA) using the Early Treatment Diabetic Retinopathy Study chart (ETDRS), fluorescein angiography (FA), and optical coherence tomography (OCT).

RESULTS

Visual acuity increased in all patients after intravitreal pegaptanib sodium. OCT showed improvement of the retinal thickness in the macular area.

CONCLUSION

Intravitreal pegaptanib sodium (Macugen) is a promising treatment for pseudophakic cystoid macular oedema resistant to other medical treatment strategies. However, further study is needed to assess the treatment's long term efficacy and the need for retreatment.

INTRAOCULAR TRIAMCINOLONE ACETONIDE FOR PSEUDOPHAKIC CYSTOID MACULAR EDEMA

PURPOSE

To evaluate pseudophakic cystoid macular edema (CME) by optical coherence tomography (OCT) and multifocal electroretinography (mf-ERG) and determine the efficacy of intravitreal triamcinolone acetonide injections.

METHODS

In this nonrandomized retrospective study, 14 eyes of 14 patients with persistent pseudophakic CME were treated with triamcinolone acetonide injection and were followed up for 1 year. All patients underwent complete ophthalmologic examination including determination of best-corrected visual acuity, slit-lamp examination, tonometry, and funduscopy. Results of OCT and mf-ERG were also recorded before and after the injection.

RESULTS

Visual acuity and mf-ERG values increased in all patients after intravitreal triamcinolone acetonide injections. OCT showed improvement of the retinal thickness in the macular area. Temporary increase of intraocular pressure was controlled with topical use of antiglaucoma drops.

CONCLUSION

Intravitreal triamcinolone acetonide injection is a promising therapeutic tool for chronic pseudophakic edema resistant to other medical treatment. However, further study is needed to assess the treatment's long-term efficacy, its safety, and the need for retreatment.

Anatomic and visual outcomes of scleral buckling versus primary vitrectomy in pseudophakic and aphakic retinal detachment: six-month follow-up results of a single operation--report no. 1

PURPOSE

To compare the anatomic and visual results and complications of conventional scleral buckling versus primary vitrectomy for management of pseudophakic and aphakic retinal detachment.

DESIGN

Prospective, randomized, multicenter clinical trial.

PARTICIPANTS

Two hundred twenty-five eyes of 225 patients with pseudophakic or aphakic retinal detachment.

INTERVENTION

Eligible eyes were assigned randomly either to conventional scleral buckling or primary vitrectomy without any buckle.

MAIN OUTCOME MEASURES

Visual results, retinal reattachment rate, proliferative vitreoretinopathy, macular pucker, cystoid macular edema, choroidal detachment, intraocular pressure, extraocular muscle dysfunction, and anisometropia.

RESULTS

There were no statistically significant differences between the 2 treatment groups regarding the single-operation retinal reattachment rate at the 1-, 2-, 4-, and 6-month follow-up examinations. Patients in the buckle group had 28% greater likelihood of anatomic success compared with those in the vitrectomy group (odds ratio, 1.28; 95% confidence interval, 0.73-2.24), indicating no statistically significant difference. Proliferative vitreoretinopathy was the main cause of anatomic failure in both groups and occurred independent of the surgical technique used. Best-corrected visual acuity at the 1-, 2-, 4-, and 6-month postoperative follow-up examinations showed no statistically significant difference between the 2 groups. Six months after surgery, 12.8% of eyes in the buckle group and 11.3% of eyes in the vitrectomy group achieved visual acuity of 20/40 or better. The difference between the 2 groups was not statistically significant. Corresponding figures were 66.3% and 64.5% for visual acuity of 20/200 or better in the buckle and vitrectomy groups, respectively, again with no statistically significant difference. There were no statistically significant differences in rates of complications.

CONCLUSIONS

Scleral buckling and primary vitrectomy without an encircling band have comparable results in pseudophakic and aphakic retinal detachment. The choice of surgical technique depends on various factors, including patient compliance, cost of surgery, experience and capability of surgeons, and availability of appropriate instrumentation.

Treatment of acute pseudophakic cystoid macular edema: Diclofenac versus ketorolac

PURPOSE

To investigate whether topical diclofenac sodium 0.1% solution (Voltaren Ophthalmic) is as efficacious as topical ketorolac tromethamine 0.5% solution (Acular) in the treatment of established, chronic cystoid macular edema (CME) after uneventful phacoemulsification cataract extraction with posterior chamber intraocular lens (IOL) implantation.

SETTING

Referral-based vitreoretinal private practice.

METHODS

This randomized prospective study comprised 34 consecutive patients with clinical CME after uneventful phacoemulsification cataract extraction with posterior chamber IOL implantation who were referred to a private vitreoretinal practice for evaluation and management. Exclusion criteria included a history of previous intraocular surgery, vitreous loss during cataract surgery, CME, uveitis, and vitreoretinal pathology. The eye with CME was treated with 1 drop 4 times daily of diclofenac sodium 0.1% solution or ketorolac tromethamine 0.5% solution. Outcomes were measured by observing for improvement in CME and visual acuity.

RESULTS

Both treatment methods resulted in a significant reduction in CME and a significant improvement in visual acuity. Within 26 weeks, diclofenac reduced CME in 16 patients (89%) and ketorolac, in 14 patients (88%) (P =.92, confidence interval [CI] 95%). Within 26 weeks, diclofenac eliminated CME in 14 patients (78%) and ketorolac, in 12 patients (75%) (P =.86, CI 95%). The mean time to initial CME reduction was 7.5 weeks with diclofenac and 8.0 weeks with ketorolac (P =.41, CI 95%). The mean time to CME resolution was 13.6 weeks with diclofenac and 12.8 weeks with ketorolac (P =.49, CI 95%).

CONCLUSIONS

Diclofenac sodium 0.1% solution and ketorolac tromethamine 0.5% topical ophthalmic solution eyedrops were equally effective in reducing the severity and duration of CME after uneventful phacoemulsification with posterior chamber IOL implantation. Either solution may be considered for CME after cataract surgery, especially in patients who may not tolerate corticosteroid treatment.

Intravitreal triamcinolone acetonide for refractory chronic pseudophakic cystoid macular edema

PURPOSE

To determine the safety and efficacy of intravitreal triamcinolone acetonide (TAAC) injections in patients with refractory cystoid macular edema (CME) after cataract extraction.

SETTING

LSU Eye Center, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA.

METHODS

In this nonrandomized retrospective case review, 8 eyes of 8 patients with a history of pseudophakic CME recalcitrant to current standard treatment modalities were enrolled. The mean duration of the CME was 20 months. The patients received intravitreal injections of 1 mg of TAAC and were followed for a mean of 8 months. The main outcome measures included visual acuity, the presence of CME on biomicroscopic examination, angiographic evidence of perifoveal leakage, intraocular pressure (IOP), and complications related to treatment.

RESULTS

The visual acuity increased in all patients. The magnitude of improvement was mainly restricted by underlying macular pathology and correlated well with the level of visual acuity at entry into the study. Angiographic improvement occurred in all patients. Temporary increases in IOP were easily controlled with topical medications. No other adverse effects could be attributed to this technique. Repeated injections were required.

CONCLUSIONS

Intravitreal administration of TAAC was safe and effective in recalcitrant cases of pseudophakic CME with a beneficial effect on the macular edema and visual acuity. A prospective randomized study is needed to determine with accuracy the efficacy, safety, and exact timing of this technique and possibly to recognize subtypes with a more favorable response. Repeated injections were required in all eyes. The development of a sustained-release intravitreal drug-delivery system would be beneficial.

Office-based sutureless transconjunctival pars plana vitrectomy

PURPOSE

This is a preliminary report to describe our technique of office-based vitrectomy (OVIT) and to report the incidence of complications over a 6-year period.

METHODS

In a retrospective, noncomparative case series, OVIT was performed on 225 patients in four participating offices. Each patient was operated on with a 23-gauge vitreous cutter that the authors have developed. They have also developed a 23-gauge transconjunctival infusion needle device. Diagnoses included endophthalmitis, uveitis, intravitreal lens fragments, ghost cell glaucoma, and rhegmatogenous retinal detachment.

RESULTS

The surgical goal was accomplished in all cases, but supplemental office procedures were required for two eyes, and a scleral buckle was necessary in one eye. There were 15 complications in 14 eyes: "fish-egg" gas bubbles (one eye), intraocular hemorrhage (nine eyes), choroidal detachment (two eyes), new retinal breaks (one eye), retinal detachment (one eye), and temporary elevation of intraocular pressure (one eye). The hemorrhages, choroidal detachments, and fish-egg bubbles all resolved spontaneously.

CONCLUSION

Office-based sutureless transconjunctival pars plana vitrectomy, with infusion when needed, is an effective operation for selected diseases of the posterior segment. In a multicenter series of 225 eyes, there were 15 complications in 14 (6%) eyes. Two of the complications were successfully managed with additional office procedures; one was managed in the operating room; and 12 resolved spontaneously.

Results and complications of temporary silicone oil tamponade in patients with complicated retinal detachments

BACKGROUND

To assess the results and complications of temporary silicone oil tamponade in the treatment of complicated retinal detachments.

METHODS

Fifty-eight consecutive eyes undergoing silicone oil removal were studied in a retrospective fashion. Forty-two eyes with proliferative vitreoretinopathy, nine eyes with giant tears, and seven traumatized eyes were included. In addition to anatomic and visual results, the following complications and their associated preoperative and intraoperative variables were assessed: glaucoma, hypotony, and keratopathy.

RESULTS

Anatomic success was achieved in 81% of the eyes. Postoperative glaucoma was found in 12%, hypotony in 9%, and keratopathy in 7% of the eyes. Twenty-six (45%) of the 58 eyes had an increase in visual acuity of at least two Snellen lines after silicone oil removal. After multivariate logistic regression analysis for all variables versus the visual and anatomic results and versus the complications of glaucoma, hypotony, and keratopathy successively, a total of three or more operations (P < 0.05; odds ratio, 14.7) and the absence of an encircling band (P < 0.05; odds ratio, 29.9) were associated with redetachment, and a retinectomy size of more than 180 degrees was associated with hypotonia (P < 0.05; odds ratio, 67.5).

CONCLUSIONS

Temporary silicone oil tamponade may be associated with a lower incidence of complications than recent studies have reported. Despite the acceptable risk of recurrent retinal detachment, the early removal of silicone oil may yield a lower rate of anterior segment complications and an increase in visual acuity in approximately half the eyes.

Pars plana vitrectomy for cystoid macular edema secondary to sarcoid uveitis

OBJECTIVE

To examine the results of pars plana vitrectomy for cystoid macular edema secondary to sarcoid uveitis resistant to medical treatment.

DESIGN

Retrospective, interventional, noncomparative case series.

SUBJECTS

Fourteen consecutive subjects (18 eyes) with cystoid macular edema associated with sarcoid uveitis resistant to medical treatment.

INTERVENTION

All eyes underwent pars plana vitrectomy. Nine eyes also underwent peeling of the epiretinal membrane or removal of the posterior vitreous cortex.

MAIN OUTCOME MEASURES

Status of macular edema, visual acuity, and complications.

RESULTS

Ten eyes (56%) improved 2 or more lines of Snellen visual acuity within 12 months. Six eyes (33%) remained unchanged, within a line of preoperative Snellen visual acuity, and two eyes (11%) worsened by 2 or more lines of Snellen visual acuity. Slit-lamp biomicroscopy showed that cystoid macular edema had resolved in 14 eyes (78%) within 9 months postoperatively. One eye (6%) had minimal edema, whereas three eyes (17%) remained unchanged biomicroscopically at the final visit. Postoperative complications included cataract formation, glaucoma, optic nerve atrophy, epiretinal membrane formation, and tractional retinal detachment. No severe postoperative inflammation was noted.

CONCLUSIONS

Pars plana vitrectomy seems to have a beneficial effect on cystoid macular edema caused by sarcoidosis resistant to medical treatment.

Ultrastructure of the vitreoretinal interface following plasmin assisted vitrectomy

AIMS

To investigate the ultrastructure of the vitreoretinal interface following plasmin induced posterior vitreous detachment.

METHODS

Plasmin (1 or 2 U/0.1 ml) was injected into the vitreous cavity of 24 eyes of freshly slaughtered pigs. The 24 fellow eyes received calcium-free and magnesium-free PBS and served as a control. After incubation at 37 degrees C for 30 and 60 minutes, the globes were placed in fixative and hemisected. Specimens for light, scanning, and transmission electron microscopy were obtained from the posterior pole, the equator, and the vitreous base using a corneal trephine.

RESULTS

All plasmin treated eyes showed posterior vitreous detachment. However, the inner limiting membrane (ILM) was covered by remnants of cortical vitreous at the posterior pole and at the equator. There was a direct correlation between the concentration and exposure times of plasmin and the degree of vitreoretinal separation. Eyes exposed to 1 U plasmin for 30 minutes had a dense network of residual collagen fibrils while those exposed to 1 U plasmin for 60 minutes had only sparse collagen fibrils covering the ILM. Eyes treated with 2 U plasmin for 60 minutes had a smooth retinal surface, consistent with a bare ILM. At the vitreous base there was no vitreoretinal separation. In all control eyes the vitreous cortex was completely attached to the retina. There was no evidence of retinal damage in any plasmin treated eye.

CONCLUSION

Plasmin induces a cleavage between the vitreous cortex and the ILM without morphological changes to the retina. In contrast with previous reports, plasmin produces a smooth retinal surface and additional surgery is not required in this experimental setting. The degree of vitreoretinal separation depends on the concentration and length of exposure to plasmin.

The expanding role of primary pars plana vitrectomy in the treatment of rhegmatogenous noncomplicated retinal detachment

The surgical management of rhegmatogenous retinal detachment has evolved dramatically during the past 2 decades. Investigators have introduced and refined alternative techniques to scleral buckling surgery including pneumatic retinopexy and primary pars plana vitrectomy (PPV). Rapid parallel developments in instrumentation, including wide-angle viewing systems, perfluorocarbon liquids, novel vitrectomy machines, intraocular tamponades, and endolaser photocoagulators have led to increasing sophistication in primary PPV surgical techniques for the treatment of rhegmatogenous uncomplicated retinal detachment. However, the precise role of primary PPV in new uncomplicated retinal detachment remains debatable owing to the lack of controlled randomized trials. This article examines primary vitrectomy treatment for rhegmatogenous uncomplicated retinal detachment and presents the specific types of retinal detachments for which primary PPV may be optimal, according to personal and reported results, the surgical instrumentation and technique, as well as the complications and limitations of this surgical method.

Cystoid macular edema following cataract surgery

Cystoid macular edema (CME) remains a troublesome problem after cataract surgery and other types of ocular surgical procedures. It is recognized as the most frequent cause of decreased vision in patients following cataract surgery. Although the disease was first described more than 40 years ago, its cause is unclear, and all available therapeutic interventions, mainly based on theories regarding the pathogenesis of the condition, are of doubtful effectiveness and are still far from being satisfactory. Most published literature on the incidence and treatment of CME consists of small, retrospective case series and cannot provide reliable answers as to whether a given factor or intervention is associated with the occurrence or outcome of the disease.

Vitrectomy for chronic pseudophakic cystoid macular edema

PURPOSE

We report the results of pars plana vitrectomy for chronic pseudophakic cystoid macular edema unresponsive to medical treatment.

METHODS

Retrospective analysis of 23 consecutive eyes of 23 patients with chronic pseudophakic cystoid macular edema was performed. Eyes with vitreous incarceration into the cataract wound or vitreous-cornea contact were excluded from the study. Preoperatively, all eyes had cystoid macular edema confirmed on fluorescein angiography and were unresponsive to medical treatment. Pars plana vitrectomy was performed using standard techniques and vitreous adhesions to the iris, intraocular lens, or both were lysed if present.

RESULTS

The mean interval between cataract surgery and vitrectomy was 32.3+/-30.9 months (median, 20 months; range, 3 to 110 months). The vitreous was adherent to the iris or intraocular lens in 12 eyes (52.2%) and was present in the anterior chamber with no evidence of adhesions in seven eyes (30.4%). In four eyes (17.4%) the vitreous was posterior to the iris plane with no adhesions to anterior segment structures. The median preoperative best-corrected visual acuity was 20/200, and the median final postoperative best-corrected visual acuity was 20/60 (P<.0001) after a mean follow-up of 30.2+/-31.2 months (median, 14 months; range, 2 to 109 months). Final best-corrected visual acuity improved by a mean of 3.3+/-2.6 Snellen lines, with a median percent change of 70% (mean, 57.3%; range, 0% to 99%). In all 23 eyes the cystoid macular edema resolved postoperatively by biomicroscopic examination in a mean period of 3.3 months (median, 2 months; range, 1 to 12 months).

CONCLUSIONS

In pseudophakic eyes with chronic cystoid macular edema unresponsive to medical treatment, vitrectomy resulted in resolution of the cystoid macular edema with improved visual acuity in some cases. Clinical improvement may occur in eyes with no apparent vitreous disturbance.

Pseudophakic cystoid macular edema treated with high-dose intravenous methylprednisolone

PURPOSE

To evaluate the efficacy of high-dose methylprednisolone in the treatment of pseudophakic cystoid macular edema (CME).

SETTING

University-affiliated hospital.

METHODS

Four patients with pseudophakic CME who reported decreased visual acuities were treated with oral prednisolone (20 mg daily for 5 days), oral acetazolamide (500 mg daily for 5 days), and topical dexamethasone 0.1% and diclofenac 0.1% (4 times a day for 14 days). The CME did not resolve. Next, they were treated with high-dose (1000 mg daily) intravenous methylprednisolone for 3 days.

RESULTS

In 3 of 4 eyes, the CME resolved and visual acuity improved.

CONCLUSION

High-dose methylprednisolone may be effective in the treatment of pseudophakic CME.

Treatment of pseudophakic CME

Pseudophakic cystoid macular edema is now an infrequent complication of cataract surgery. However, since cataract surgery continues to be one of the most commonly performed surgical procedures, the prevalence of pseudophakic cystoid macular edema is high. In addition, although pseudophakic cystoid macular edema has been a well-defined entity since the 1950s and 1960s, little progress has been made in understanding its pathogenesis or in deriving an effective treatment of the condition. While acute pseudophakic cystoid macular edema may resolve spontaneously, chronic visually significant pseudophakic cystoid macular edema remains difficult to treat. Nonsteroidal anti-inflammatory agents and corticosteroids in various forms can be used, but each type of treatment lacks satisfactory success. Eyes with abnormal vitreous or refractory to medical therapy can be improved with vitrectomy surgery. It must be concluded, however, that there is a real need for significant advances in both the understanding and treatment of pseudophakic cystoid macular edema.

Intraocular lens complications requiring removal or exchange

Intraocular lens (IOL)-related complications are caused primarily by mechanical trauma, inflammatory or infectious complications, or optical problems. Complications may occur at the time of surgery or be the result of an ongoing postoperative process. Mechanical and inflammatory injury may produce corneal decompensation, cystoid macular edema, hyphema, uveitis, and glaucoma, causing reduced vision and in some cases chronic pain. Optical problems may be due to a wrong power of the IOL or to postoperative decentration or dislocation of the lens. Ophthalmologists should be aware of the indications for IOL removal or exchange in those patients who have ongoing IOL-induced injury or impairment. Removal or exchange of an IOL frequently involves a complex decision-making process and is often associated with immense technical challenge. Various medical and surgical treatments may be tried to correct IOL problems before the decision is made to remove or exchange the lens.

A comparison of retrobulbar versus sub-Tenon's corticosteroid therapy for cystoid macular edema refractory to topical medications

OBJECTIVE

The objective is to compare the effectiveness of retrobulbar and posterior sub-Tenon's injection of corticosteroids for treatment of post-cataract cystoid macular edema that was refractory to topical medications.

DESIGN

A retrospective study was performed.

PARTICIPANTS

A total of 48 patients (49 eyes) with post-cataract cystoid macular edema refractory to topical medications was studied.

INTERVENTION

Patients received either a single retrobulbar injection (18 eyes) or 3 biweekly posterior sub-Tenon's injections (31 eyes) of corticosteroids.

MAIN OUTCOME MEASURES

Patients were observed for clinical resolution of the cystoid macular edema, visual acuity, and intraocular pressure.

RESULTS

Both treatment methods resulted in significant improvement in visual acuity. The posterior sub-Tenon's group had a visual improvement from 20/92 pretreatment to 20/50 post-treatment (P = 0.0001) with a median follow-up of 12 months. The retrobulbar group had a visual improvement from 20/97 pretreatment to 20/58 post-treatment (P = 0.035) with a median follow-up of 10 months. The visual improvement was not significantly different between the two groups. The average intraocular pressure increased from a pretreatment level of 14.1 mmHg to a high of 17.7 mmHg (P < 0.00005) in the sub-Tenon's group. The average intraocular pressure increased from 15.1 mmHg to a high of 17.6 mmHg (P = 0.04) in the retrobulbar group.

CONCLUSIONS

Cystoid macular edema that persists after treatment with topical medications may improve after retrobulbar or posterior sub-Tenon's corticosteroid injections. There was no significant difference in outcome between the two treatment groups.