Occurrence rate of retinal detachment after small gauge vitrectomy for idiopathic epiretinal membrane

VITREORETINAL OUTCOMES FOLLOWING SECONDARY INTRAOCULAR LENS IMPLANTATION WITH PARS PLANA VITRECTOMY

BACKGROUND

Retrospective cohort study of 561 adult patients undergoing secondary intraocular lens (IOL) implantation by vitreoretinal surgeons at a single institution from April 2015 to December 2020.

METHODS

Patient historical factors, intraoperative/postoperative complications, and outcomes of IOL type (anterior chamber IOL versus scleral sutured IOL versus scleral fixated IOL versus. sulcus) were assessed. Primary outcomes were rates of postoperative retinal tears and rhegmatogenous retinal detachment. Secondary outcomes were rates of intraoperative endolaser, intraoperative retinal tear, and further IOL surgery.

RESULTS

The incidence of intraoperative retinal tears was 7.3% and not significantly different between techniques. Rates of intraoperative endolaser use were 17.5% among all techniques and not significantly different between techniques. Rates of postoperative retinal tear were low (0%-2.7%). Rates of postoperative rhegmatogenous retinal detachment were not significantly different between techniques (anterior chamber IOL 9/198 [4.5%], SFIOL 1/54 [1.9%], scleral sutured IOL 14/274 [5.1%], sulcus 2/35 [5.7%], total 26/561 [4.6%], P = 0.79). Rates of repeat IOL surgery trended higher in sulcus lenses (anterior chamber IOL 5/198 [2.5%], SFIOL 4/54 [7.4%], scleral sutured IOL 16/274 [5.8%], sulcus 5/35 [14.3%], total 30/561 [5.3%], P = 0.12).

CONCLUSION

Intraoperative endolaser use and intraoperative retinal tear are not uncommon in secondary IOL surgery and underscore the importance of careful vitreoretinal management among these patients.

Accuracy of biomicroscopy, ultrasonography and spectral-domain OCT in detection of complete posterior vitreous detachment

BACKGROUND

To evaluate the accuracy of preoperative biomicroscopy (BM), ultrasonography (US), and spectral domain optical coherence tomography (SD-OCT) to determine complete posterior vitreous detachment (PVD) confirmed by intraoperative findings of triamcinolone acetonide-assisted pars plana vitrectomy (PPV).

METHODS

This prospective study included all consecutive patients admitted for surgical treatment of the epiretinal membrane (ERM) and macular hole (MH). The presence of complete PVD was determined one day before PPV using BM, US, SD-OCT. The preoperative findings were compared to the PVD status determined during PPV.

RESULTS

A total of 123 eyes from 123 patients were included in the study. Indications for PPV included ERM in 57 (46.3%), full thickness macular hole in 57 (46.3%) and lamellar macular hole in 9 (7.3%) patients. Complete PVD during PPV was observed in 18 (31.6%; 95%CI:18.7-49.9) patients with ERM and 13 (19.7%; 95%CI:10.4-33.7) patients with MH. The sensitivity of preoperative BM, US, SD-OCT was 48.4% (95%CI:30.2-66.9), 61.3% (95%CI:42.2-78.2) and 54.8% (95%CI:36.0-72.7) respectively. The specificity of preoperative BM, US, SD-OCT was 81.5% (95%CI:72.1-88.9), 90.2% (95%CI:82.2-95.4) and 85.9% (95%CI:77.0-92.3) respectively. With a prevalence of 25.2% of PVD in our sample the positive predictive value of preoperative BM, US, SD-OCT was 46.9% (95%CI:29.1-65.3), 67.9% (95%CI:47.6-84.1) and 56.7% (95%CI:37.4-74.5) respectively.

CONCLUSION

Preoperative BM, US, and SD-OCT showed relatively low sensitivity but also good specificity in assessing complete PVD. A combination of all three diagnostic methods can provide a good assessment of the vitreoretinal interface state.

Trends in Secondary Intraocular Lens Surgery among Vitreoretinal Surgeons

OBJECTIVE

To identify changes in secondary lens techniques over time and to determine common complications of each technique.

DESIGN

Retrospective cohort study.

PARTICIPANTS

All patients in the database from January 2015 to December 2021 who underwent secondary lens placement (anterior chamber intraocular lens [IOL, ACIOL], scleral-fixated IOL [SFIOL], or scleral-sutured IOL [SSIOL]).

METHODS

Rates of secondary IOL surgery techniques were analyzed in 3597 participants in a nationwide aggregated electronic health care database using 2-sample independent t tests. Rates of postoperative rhegmatogenous retinal detachment (RRD) after secondary IOL surgery were assessed using chi-square test of proportion. Postoperative visual acuity (VA) was assessed using 2-sample independent t tests.

MAIN OUTCOME MEASURES

The primary outcome was change in IOL technique over time. Secondary data points examined were the development of postoperative RRD after secondary IOL surgery, VA changes, the development of endophthalmitis, suture erosion, haptic erosion, or corneal edema after IOL surgery.

RESULTS

Anterior chamber IOL use decreased over the 7-year period from 93% of cases to 36% of cases (P < 0.0001), while SFIOL use increased from 3% to 34% (P < 0.0001) and SSIOL use increased from 4% to 30% (P < 0.0001). Visual acuity increased for each surgical technique (ACIOL: 44.1 vs. 49.2 ETDRS letters, P < 0.001; SFIOL: 48.7 vs. 57.6 letters, P < 0.001; SSIOL: 51.5 vs. 61.2 letters, P < 0.001), with larger VA gains seen in SFIOL and SSIOL use (ACIOL vs. SFIOL, P = 0.004; ACIOL vs. SSIOL, P = 0.002; SFIOL vs. SSIOL, P = 0.64). Average RRD rates did not significantly differ between techniques. Rates of endophthalmitis, haptic erosion, and suture erosion were low and did not significantly differ between techniques. Rates of corneal edema were significantly higher in ACIOL cases (vs. SFIOL, P < 0.0001; vs. SSIOL, P < 0.0001).

CONCLUSIONS

Rates of ACIOL implantation performed by vitreoretinal surgeons have decreased over time with more vitreoretinal surgeons electing to place either an SFIOL or SSIOL toward the end of the study period; complication profiles among the 3 techniques may be similar.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Inverse drainage Nd:YAG membranotomy for pre-macular hemorrhage

AIM

To report the outcomes of the "inverse drainage Nd:YAG laser membranotomy" technique for the management of pre-macular hemorrhage (PMH), which has its inferior margin near the fovea.

METHODS

This retrospective study included eyes with PMH, with its inferior margin located within 0.5 disc-diameter (DD) of the fovea. Laser membranotomy was performed near the superior margin of PMH followed by intravitreal injection of 0.3 mL undiluted sulphur hexafluoride (SF6) gas. The patients were advised to maintain a prone position for three days.

RESULTS

Twenty patients (20 eyes) with a mean age of 46.1 ± 18.6 years were included in the study. The mean duration of symptoms was 6.9 ± 7.0 days. The mean size of PMH was 4.1 ± 1.2DD. The causes of PMH were Valsalva retinopathy (n = 11) and retinal artery macroaneurysm (RAM, n = 9). The mean maximum height of the blood collection, measured by optical coherence tomography (OCT), within 1 disc-diameter from the inferior and superior borders of the PMH was 738.9 ± 232.9μm and 1240.6 ± 338.1μm respectively (p = 0.001). The mean best-corrected visual acuity (BCVA) improved from logMAR 1.32 ± 0.44 (Snellen equivalent, 20/418) to logMAR 0.11 ± 0.20 (Snellen equivalent, 20/26) (p = 0.001). Vitrectomy was not required in any case. Persistent pre-macular cavity, macular hole, epiretinal membrane (ERM), intra-ocular pressure spike, or rhegmatogenous retinal detachment (RRD) was not noted in any patient.

CONCLUSION

This technique can be safely used to treat eyes with PMH having its inferior margin near the fovea.

Incidence of rhegmatogenous retinal detachment following macular surgery in France between 2006 and 2016

PURPOSE

To report the incidence of postoperative rhegmatogenous retinal detachment after macular surgery in France between 2006 and 2016 and identify associated factors.

DESIGN

Nationwide population-based cohort study.

METHODS

All surgical procedures for an epiretinal membrane or a macular hole performed in France from January 1, 2006 to October 31, 2016 were identified in the French national administrative database (Programme de Médicalisation des Systèmes d'Information). We investigated the incidence of rhegmatogenous retinal detachment occurring within 90 days of a macular surgical procedure.

RESULTS

From January 1, 2006 to October 31, 2016, 152,034 macular surgical procedures for epiretinal membranes or macular holes were recorded in France. We identified 3,605 cases of rhegmatogenous retinal detachment occurring within 90 days of the procedure. The incidence of rhegmatogenous retinal detachment was 2.37% overall, 1.95% for epiretinal membrane surgery and 3.43% for macular hole surgery. In multivariable Poisson regression analysis, rhegmatogenous retinal detachment was associated with macular hole surgery (incidence rate ratio [IRR], 1.76; 95% CI, 1.63-1.90; P < .001), history of cataract extraction in the previous year (IRR, 1.20; 95% CI, 1.08-1.34; P = .001), age < 60 years (P < .001), and male gender (IRR, 1.63; 95% CI, 1.51-1.76; P < .001).

CONCLUSIONS

The incidence of rhegmatogenous retinal detachment within 90 days of macular surgery was 2.37% overall in France between 2006 and 2016 and it was higher for macular hole surgery than for epiretinal membrane surgery.

Prevalence and predictive factors for posterior vitreous attachment in eyes undergoing epiretinal membrane surgery

BACKGROUND

To report the prevalence of posterior vitreous attachment (PVA) in patients with idiopathic epiretinal membrane (iERM) and to determine associated preoperative predictive factors.

METHODS

Retrospective observational case series of 408 eyes who underwent surgery for iERM without vitreomacular traction. The status of the posterior hyaloid was assessed intraoperatively. Predictive factors were analysed using univariate and multivariate logistic regression. We also evaluated the effect of PVA on the anatomical and functional outcomes of surgery.

RESULTS

Eighty-two (20.1%) eyes were found to have an undetached posterior hyaloid during vitrectomy. In multivariate analysis, axial length (AL) and lens status were strongly associated with the posterior vitreous status (p = 0.031 and p = 0.048). The odds of having a PVA decreased by a factor 0.81 per mm of AL (95% CI, 0.66-1.00). Phakic eyes had a 2.88-fold increased risk of exhibiting PVA compared to those with previous cataract extraction (95% CI, 1.10-7.52). The presence of PVA did not have any effect on postoperative anatomical and functional outcomes. In contrast, we found that eyes with shorter axial length, low preoperative visual acuity and disruption of the ellipsoid zone exhibited worse visual recovery (p = 0.006, p < 0.001 and p = 0.037).

CONCLUSION

PVA was observed in 20.1% of eyes undergoing vitrectomy for iERM. Shorter AL and phakic status were strong predictive factors of PVA in those eyes. However, the morphological features and the surgical prognosis of iERMs with PVA did not differ from those with posterior vitreous detachment.

Better visual outcome associated with early vitrectomy in the management of endophthalmitis

AIMS

To examine the role of early vitrectomy in the management of endophthalmitis from all causes.

METHODS

Retrospective study of 290 consecutive subjects diagnosed with endophthalmitis at Auckland District Health Board between 1 January 2006 and 31 July 2019. Main outcome measure was visual acuity at 9-month follow-up and proportion of subjects with severe vision loss (≤20/200).

RESULTS

Median age at presentation was 70.4 years and 151 subjects (52.1%) were women. Cataract surgery was the most common cause of endophthalmitis in 92 subjects (31.7%) followed by intravitreal injection in 57 (19.7%), endogenous endophthalmitis in 48 subjects (16.6%), non-surgical trauma in 42 subjects (14.5%), glaucoma surgery in 24 subjects (8.3%), vitrectomy in 22 subjects (7.6%) and corneal in 5 subjects (1.7%). Culture was positive in 136 (46.9%) with gram-positive organisms most common (76.5%). Early vitrectomy was performed in 82 subjects (28.3%). Median visual acuity at 9 months was 20/100 (IQR 20/30 to light perception), and severe vision loss occurred in 100 (43.5%). Retinal detachment occurred in 35 eyes (12.1%) and 26 eyes were enucleated. On multivariate analysis, younger age, poor presenting visual acuity and culture-positive endophthalmitis were associated with worse outcomes, and early vitrectomy was associated with better outcomes.

CONCLUSIONS

Early vitrectomy (within 24 hours) is associated with better visual outcomes at 9 months, while younger age, poor presenting visual acuity and culture-positive endophthalmitis are associated with poorer visual acuity outcomes.

Effect of prophylactic laser during small-gauge vitrectomy for epiretinal membranes

PURPOSE

To determine the rate of post-operative retinal detachment after elective pars plana vitrectomy for epiretinal membrane, and to test for the mitigating effect of prophylactic endolaser.

METHODS

We identified 459 eyes of 411 patients undergoing vitrectomy for epiretinal membrane at Vanderbilt University Medical Center between January 2010 and May 2017. Patients who underwent concurrent endolaser without any identified retinal break were included in the exposure cohort. Patients who underwent no prophylactic retinopexy or ablation were included in the unexposed cohort. Exposure data, demographic data, and outcome data were tabulated for comparison.

RESULTS

The final analysis included 343 eyes of 343 patients. Approximately 7% of eyes undergoing ERM surgery were found to have a full-thickness retinal break which was not seen preoperatively. The overall rate of postoperative RD was 2.04%. Postoperative retinal detachment occurred in 0 of the 34 eyes exposed to prophylactic laser, and in 7 of the 309 control eyes. Odds ratio was found to be 0.60 (p = 0.598 (95%CI 0.0327-10.7), p = 0.72), indicated the results were not statistically significant.

DISCUSSION

Looking at patients undergoing routine vitrectomy surgery for epiretinal membrane, no retinal detachments occurred in the group receiving prophylactic treatment, though this association did not reach statistical significance. With modern surgical techniques, post-operative retinal detachment remains relatively rare after vitrectomy for ERM though a thorough intraoperative exam is critical to identify occult retinal breaks.

Characteristics of secondary epiretinal membrane due to peripheral break

This study aimed to investigate morphological differences between idiopathic epiretinal membrane (ERM) and secondary ERM due to peripheral break (SEPB) and to identify clinical characteristics in eyes with SEPB to facilitate peripheral retinal examination. The retrospective cross-sectional study involved 93 consecutive eyes in 91 patients who underwent ERM removal surgery. Eyes were divided into two groups: the macular pucker group and the idiopathic ERM group. En-face Optical Coherence Tomography (OCT) images, fundus photographs, severity of metamorphopsia (M-score) and clinical characteristics of each group were compared. ERM extent and eccentricity (ratio of the shortest and longest distances from the foveal center to the boundary) were obtained through en-face OCT imaging. Fundus photographs were used to judge whether the membrane was turbid or not. Patients with SEPB were younger than patients with idiopathic ERM (61.3 ± 7.5 vs. 66.6 ± 8.3 years; p < 0.05). Preoperative M-score and myopic refractive error, axial length were also significantly higher in the macular pucker group than in the idiopathic ERM group (all p < 0.05). There was no difference in ERM extent between the two groups. The incidence of ERM eccentricity was 23 of the 34 eyes (67.6%) in the SEPB group and 26 of the 59 eyes (44.1%) in the idiopathic ERM group (p < 0.05). The incidence of turbid ERM was 18 of the 34 eyes (52.9%) in the SEPB group and 10 of the 59 eyes (16.9%) in the idiopathic ERM group (p < 0.01). The SEPB group, compared with the idiopathic ERM group, tended to have eccentric, turbid ERM at a younger age and with more severe metamorphopsia and myopic refractive error.

Subtotal vitrectomy in idiopathic macular hole surgery

Purpose

To assess the outcomes of subtotal vitrectomy in idiopathic macular hole (IMH).

Methods

The patients with idiopathic IMH who had undergone vitreoretinal surgery and followed up for at least 12 months post-operatively were included. First the posterior hyaloid was detached, then cortical vitreous was removed incompletely by leaving anterior vitreous intact. Internal limiting membrane was peeled with the aid of brilliant blue. A non-expanding volume of perfluoropropane was used as a tamponade and face-down positioning for 5 days was suggested to the patients. The main outcome measure was the closure rate of IMH.

Results

Forty-three eyes were included. The mean follow-up time was 15.0 ± 3.8 months after surgery. Single surgery anatomical success was 86.0%. The mean BCVA at baseline, month 1, 3, 6, 12 and at the last follow-up was 0.99 ± 0.33 LogMAR (0,5–1.80), 1.04 ± 0.33 LogMAR (0.5–1.8), 0.94 ± 0.46 LogMAR (0.3–3.0), 0.84 ± 0.33 LogMAR (0.3–1.5), 0.82 ± 0.35 (0.2–1.5), and 0.70 ± 0.34 (0.1–1.5) (p > 0.05, for all). The mean visual acuity increased by 2.9 lines at the last follow-up visit and 51.2% of the patients gained ≥ 3 lines of vision.

Conclusion

The results of this study indicated limited core vitrectomy as a safe and effective surgical technique in the treatment of IMH, resulting in acceptable functional and anatomical outcomes without significant intra- and post-operative complications.

Epiretinal Membrane Surgery in Daily Clinical Practice: Results of a Proposed Management Scheme

Purpose

To report the results of the epiretinal membrane (ERM) management guidelines followed in our center.

Methods

Patients with ERM seen between 2014 and 2015, with ≥2 years follow-up or who had undergone ERM surgery, were included. Corrected visual acuity (VA), lens status, and ERM configuration were recorded at each visit. Our guidelines for ERM are if VA is ≥20/30, observation is recommended unless there is moderate/intense metamorphopsia. Vitrectomy is recommended during follow-up if there is a drop >one line in VA with changes in ERM configuration. If VA at diagnosis is <20/30, vitrectomy is recommended. If visual loss is thought to be due to cataract, phacoemulsification is performed first and visual status reevaluated.

Results

Ninety-nine eyes of 94 patients were included; 52 eyes underwent vitrectomy, and 47 eyes were monitored. From eyes with VA at diagnosis <20/30 (41 eyes), 8 eyes underwent isolated phacoemulsification: VA improved to ≥20/30. Vitrectomy was recommended but refused by 4 patients. The other 29 eyes underwent vitrectomy. Of the 58 eyes with VA at diagnosis ≥20/30, 5 underwent surgery due to metamorphopsia. Eighteen eyes underwent vitrectomy during follow-up. VA improved a mean of 0.13 logMAR (SD 0.30) after vitrectomy. There were no differences in mean VA improvement between eyes that underwent vitrectomy within six months of diagnosis (0.24, SD 0.32) and those that underwent surgery more than six months after diagnosis (mean 0.17, SD 0.17), p=0.106. Three eyes developed postsurgical complications with visual loss: persistent macular edema in one eye, two consecutive retinal detachments in one eye, and a central visual defect in another eye. At the end of follow-up, VA was similar in the observation group (0.14, SD 0.14) and in the vitrectomy group (0.16, SD 0.28), p=0.528.

Conclusions

Our proposed guidelines lead to visual preservation in most patients while limiting surgery and its possible complications.

The outcomes of subtotal vitrectomy in macular surgeries: a single surgeon case series

PURPOSE

To investigate the outcomes of subtotal vitrectomy in epiretinal membrane (ERM) and idiopathic macular hole (IMH) surgeries.

METHODS

The patients who underwent vitrectomy for primary ERM and IMH were included. After the truncation of posterior hyaloid, cortical vitreous was incompletely removed and anterior vitreous was left in place. The main outcome measure was the complications of the surgical technique during the postoperative 12 months of follow-up.

RESULTS

Fifty-two eyes were included. Thirty-seven eyes had ERM, and 15 had IMH. During the 12 months of follow-up period, 33% of the phakic patients showed progression in the lens opacities and required cataract surgery. Other postoperative complications were listed as follows: transient intraocular pressure increase in 3 (5.9%), endophthalmitis in 1 (2.0%), and retinal detachment in 1 patient (2.0%).

CONCLUSION

Subtotal vitrectomy seems as an effective and safe surgical technique in the treatment of macular diseases.