Iatrogenic retinal breaks in 25-gauge vitrectomy under air compared with the standard 25-gauge system for macular diseases

T-shaped pars plana scleral incision to remove large intraocular foreign body

Aim

To investigate the efficacy and safety profile of T-shaped pars plana scleral incision technique in removing large intraocular foreign bodies, during 23-gauge pars plana vitrectomy.

Methods

Retrospective interventional case series that included patients diagnosed with a large intraocular foreign body (IOFB). Possible postoperative complications were recorded 24 h, 1 month, 3 and 6 months postoperatively.

Results

Thirty eyes of 30 patients (48 ± 5 years old) were enrolled. All IOFBs were successfully removed: mean diameters of 7.8 ± 2.0 mm and 2.6 ± 0.3 mm. Silicone oil and sulfur hexafluoride were used in 27 and 3 eyes, respectively. Lensectomy was performed in 27 eyes. Intraocular lens was implanted at first attempt in 12 eyes; during a second operation in 12 eyes and 6 eyes remained aphakic. At any follow-up, no signs of postoperative complications were observed. Secondary retinal detachment occurred in 12 eyes. Mean preoperative corrected distance visual acuity was 0.04, on the Snellen scale; it increased to 0.07, at last follow-up. Mean intraocular pressure was 17.97 mmHg. All eyes were preserved.

Conclusion

T-shaped scleral incision could be an effective, safe and easy-to-perform standard procedure to remove large IOFBs during pars plana vitrectomy, without increasing the risk of surgical complications and additional damage to the ocular tissues.

Intra- and post-operative risk of retinal breaks during vitrectomy for macular hole and vitreomacular traction

BACKGROUND/OBJECTIVE

To evaluate the development of intra- and post-operative retinal breaks after pars plana vitrectomy (PPV) for macular hole (MH) and/or vitreomacular traction (VMT).

SUBJECTS/METHODS

Medical records of patients who underwent PPV at Kellogg Eye Center between 1/1/2005-6/30/2018, were evaluated in three groups: group 1, MH/VMT (n = 136); group 2, epiretinal membrane (ERM) without VMT (n = 270); and group 3, diagnostic vitrectomy (DV) or vitreous opacities (n = 35). Statistical analyses were conducted using SAS.

RESULTS

20.6% of patients with MH/VMT, 8.5% of patients with ERM, and 5.7% of patients with DV or vitreous opacities had either intra-operative or post-operative breaks. Indication of MH/VMT versus ERM was a significant predictor for this outcome (p = .0112). The incidence of retinal breaks was higher in operations using 23-gauge versus 25-gauge PPV (25.0% vs. 7.4%, p < .0001).

CONCLUSIONS

The presence of MH and/or VMT is a significant risk factor for retinal breaks from PPV, as is use of 23-gauge vitrectomy.

Outcomes of a novel bubble ultra-wide field viewing system for vitreoretinal surgery

PURPOSE

To report the clinical outcomes and evaluate the efficacy of a novel bubble ultra-wide field viewing system for vitreoretinal surgery.

DESIGN

Prospective, noncomparative, interventional case series.

PARTICIPANTS

One hundred and fifty-one eyes of 146 consecutive patients with proliferative diabetic retinopathy (PDR), vitreous haemorrhage originating from retinal vein occlusion (VH-RVO), epiretinal membrane (EM), macular hole (MH) or retinal detachment (RD) who underwent vitreoretinal surgery using the bubble ultra-wide field viewing system were included.

METHODS

A standard phacoemulsification was performed on each patient. Core humour and mid-peripheral vitreous humour were removed using a planoconcave lens. A suitably sized bubble was infused to attach to the posterior capsule or the anterior chamber depending on the integrity of the posterior capsule. The planoconcave lens and the air bubble formed the wide-angle viewing system, through which peripheral vitrectomy was performed.

MAIN OUTCOME MEASURES

Range of applications, field of view, model validation and complications were recorded.

RESULTS

The new ultra-wide field viewing system was successfully applied in all eyes, including 34 with PDR, 28 VH-RVO, 28 EM, 25 MH and 36 RD. Peripheral vitrectomy, local or panretinal laser photocoagulation, and removal of the peripheral proliferative membrane were successfully performed while viewing through this system. Maximum peripheral retinal area observable during the procedure was positively correlated with pupil diameter. Model analysis results showed that when the pupil diameter was 6 mm, the maximum field of view was approximately 128.1- 148.0 degrees with this system. Of 142 eyes, the main intraoperative complication was iatrogenic retinal breaks (IRBs) in 8 eyes (5.3%) and posterior capsule injury by vitreous cutter during bubble removal in 6 eyes (4.2%). The postsurgery mean best-corrected visual acuity (BCVA) (0.48 ± 0.39 logMAR) was significantly improved compared with the preoperative mean BCVA (1.60 ± 1.08 logMAR, p < 0.001). No incidents of postoperative choroidal detachment, secondary glaucoma or endophthalmitis were recorded.

CONCLUSIONS

For patients with lens excision or absence, vitreoretinal surgery can be successfully performed using the novel viewing system described here. The system is a safe, convenient and economical ultra-wide field viewing system with a wide range of applications.

Association of Microvasculature and Macular Sensitivity in Idiopathic Macular Epiretinal Membrane: Using OCT Angiography and Microperimetry

Purpose: To investigate the correlation between retinal capillary structure and macular function in patients with idiopathic epiretinal membrane (iERM) by using optical coherence tomography angiography (OCTA) and microperimetry.

Methods: This retrospective and observational study included 30 idiopathic ERM eyes of 30 consecutive patients. OCTA was performed to evaluate macular microvasculature including the superficial capillary plexus, deep capillary plexus, and foveal avascular zone. Best corrected visual acuity (BCVA) and microperimetry were measured at baseline and 3 months after surgery. Associations between macular microvasculature and visual function were assessed.

Results: Visual function including BCVA and macular sensitivity improved significantly at 3 months post-operatively (p < 0.001). At baseline, BCVA was positively correlated with foveal or parafoveal sensitivities and negatively correlated with central foveal thickness (p < 0.05). Pre-operative foveal sensitivity was significantly correlated with the vessel density of foveal or parafoveal superficial capillary plexus (p < 0.05). A multiple regression model revealed that pre-operative vessel density of foveal deep capillary plexus was an independent positive prognostic factor for post-operative BCVA (B = −0.020 ± 0.006, p = 0.006) and macular sensitivity (B = 0.200 ± 0.081, p = 0.027).

Conclusion: Integrated evaluation of iERM by using OCTA and microperimetry shows an association between microvasculature and macular sensitivity. Pre-operative vessel density of foveal deep capillary plexus assessed by OCTA may be a potentially valuable prognostic factor for iERM surgery.

Morphological Changes in Lamellar Macular Holes According to SD-OCT Examination over a Long Observation Period

BACKGROUND

The aim of this study was to evaluate the quantitative morphological changes in lamellar macular holes (LMHs) based on SD-OCT examinations and to assess the correlations among minimal retinal thickness (MRT), reading vision (RV), and best corrected visual acuity (BCVA) over a 36-month follow-up period.

METHODS

A group of 40 patients (44 eyes) with LMH was evaluated, with an average age of 69.87 (SD = 10.14). The quantitative parameters monitored in the follow-up period (at 0, 3, 6, 12, 18, 24, 30, and 36 months) were tested for normality of distribution by Shapiro-Wilk and Kolmogorov-Smirnov tests.

RESULTS

The RV and BCVA values were stable, and no significant changes were found at any of the check-ups during the 36-month follow-up period (BCVA p = 0.435 and RV p = 0.0999). The analysis of individual quantitative LMH parameters during the 36-month follow-up period did not demonstrate statistically significant differences: MRT (p = 0.461), Max RT temporal (p = 0.051), Max RT nasal (p = 0.364), inner diameter (ID) (p = 0.089), and outer diameter (OD) (p = 0.985).

CONCLUSIONS

The observations at 0, 6, 12, 18, 24, 30, and 36 months revealed moderate and significant correlations between RV and MRT. No significant correlation between BCVA and MRT was observed.

Antioxidant Status in the Vitreous of Eyes with Rhegmatogenous Retinal Detachment with and without Proliferative Vitreoretinopathy, Macular Hole and Epiretinal Membrane

(1) Background: The aim of the study was to test the hypothesis that the antioxidant status in the vitreous body of eyes, which had been vitrectomized due to rhegmatogenous retinal detachment (RRD) with or without proliferative vitreoretinopathy (PVR), is higher than in eyes vitrectomized due to other retinal diseases. (2) Methods: four patient groups were analyzed: 22 eyes of patients with RRD without PVR, 27 eyes with RRD and PVR, 22 eyes with macular hole (MH) and 10 eyes with epiretinal membrane (ERM). Spectrophotometric methods were used to determine the total antioxidant status (TAS) values as well as superoxide dismutase (SOD) and glutathione reductase (GR) activities in the vitreous fluid samples. (3) Results: no significant differences in TAS values and antioxidant enzyme activities were observed among patient with RRD with and without PVR and with MH and ERM. The longer the duration of RRD leading to PVR and better postoperative visual acuity, the higher the TAS level. No significant differences were found between "macula on" and "macula off" subgroups within the RRD group and the RRD combined with PVR group. (4) Conclusions: The preliminary results do not support the thesis that the antioxidant status of vitrectomized eyes is different in patients with RRD with or without PVR in comparison to patients with MH and ERM. In patients with RRD, PVR presence and detached macula do not affect the values of TAS, SOD and GR in the vitreous fluid. The duration of the disease influences TAS in the vitreous in eyes with RRD complicated with PVR.

Outcomes of Vitrectomy Under Air for Idiopathic Macular Hole

Objectives

To evaluate the outcomes of 23-gauge pars plana vitrectomy (PPV) under air compared with standard PPV for idiopathic macular hole (MH).

Materials and Methods

In this prospective, comparative, interventional case series, 42 eyes of 42 patients with idiopathic MH were enrolled. Twenty-one eyes had vitrectomy with an air-infused technique and 21 eyes underwent vitrectomy with a traditional balanced salt solution-infused technique as a control group. Effective vitrectomy time, total surgery time, microperimetry (MP1), and anatomical and functional results were evaluated.

Results

The mean effective vitrectomy time was significantly lower in the air group than in the control group (7.5±0.3 min and 13.3±0.5 min, respectively, P<0.001). The mean total surgery time was significantly lower in the air group than the control group (21.8±2.0 min and 25.9±1.1 min, respectively, P<0.001). There were no statistically significant changes between preoperative and 3-month postoperative retinal sensitivity values evaluated by MP1 in either group. Anatomical success at 3 months was 100% in both groups. Intraoperative complications noted during the air-infused vitrectomy were retinal touch (10%) and sudden hypotony (10%); in the two pseudophakic eyes, migration of air into the anterior chamber occurred in one (50%) and fogging of the intraocular lens in one eye (50%).

Conclusion

Vitrectomy under air infusion for idiopathic MH showed some advantages over a traditional vitrectomy technique in terms of vitreous visualization, effective vitrectomy time, and total surgery duration, without significantly increasing intraoperative and postoperative complication rates. Postoperative microperimetry results indicated no specific damage to the retina or optic nerve related to the continuous air infusion.

Secondary Vitrectomy with Internal Limiting Membrane Plug due to Persistent Full-Thickness Macular Hole OCT-Angiography and Microperimetry Features: Case Series

Purpose

To study the features in OCT-angiography and microperimetry in eyes with persistent full-thickness macular hole (FTMH) closed with the secondary plana vitrectomy (PPV) with autologous internal limiting membrane (ILM) plug.

Methods

Secondary PPV was performed with closing the persistent FTMH with ILM plug, C₃F₈ tamponade, and face-down positioning. Four patients were followed for 6 months with best corrected visual acuity (BCVA) measurement, SD-OCT and OCT-A, and microperimetry. The results were compared with the fellow eye; in two patients, it was the healthy eye, and in two remaining eyes, successfully closed FTMH after primary PPV.

Results

ILM flap was integrated in all cases with V-shape of closure, and atrophy was found in one case, with the largest diameter of FTMH. BCVA improved in two cases and remained the same in two cases. In OCT-A, the area of foveal avascular zone (FAZ) was larger, and foveal vessel density (FVDS) was smaller in eyes after secondary PPV in comparison to fellow eyes. In microperimetry, retinal sensitivity was lower in eyes after secondary PPV, and eccentric fixation was found in 2 of 4 patients.

Conclusion

Although the anatomical results of repeated surgeries of FTMH with ILM plug are favorable, visual function results may be limited. Secondary closure of FTMH with ILM plug may lead to atrophy, changes in the macular vasculature, and eccentric fixation. The trial is registered with NCT03701542.

A possible strategic role of air during pars plana vitrectomy for macula-involving rhegmatogenous retinal detachment

AIM

To evaluate the advantages and safety of vitrectomy under air for treating macula-involving rhegmatogenous retinal detachment (RRD).

METHODS

Consecutive patients with macula-involving RRD who underwent vitrectomy under air were recruited. Demographic and clinical data were: age, gender, eye, lens status, best corrected visual acuity (BCVA) in logarithm of the minimum angle of resolution (logMAR), axial length, intraocular pressure (IOP). RRD parameters were: RRD extent, retinal breaks number. Surgical data were: cataract surgery, tamponade used. Postoperative parameters were: BCVA, IOP at first, third, sixth month, recurrent RD, incidence of retinal folds, subretinal fluid (SRF) persistence, macular displacement.

RESULTS

Seventy-one eyes (71 patients) were recruited. Cataract surgery was performed in 32 of 45 phakic patients. The tamponade used was: sulfur hexafluoride 18% (41), silicon oil (SO) (26), high-density SO (4). BCVA improved significantly from baseline (1.2 ± 0.4 logMAR) to the last control (0.8 ± 0.7 logMAR) (P = 0.03285). Recurrent RD incidence was 14.1%. Postoperative complications were: retinal folds (2), SRF persistence (3), macular displacement (2).

CONCLUSION

Vitrectomy under air is a safe alternative technique for treating macula-involving RRD. Vitrectomy under air allows surgeon to remove accurately the vitreous from the peripheral retina and facilitates the removal of SRF reducing the complications related to its postoperative persistence.

Minimal internal limiting membrane peeling with ILM flap technique for idiopathic macular holes: a preliminary study

Background

Internal limiting membrane (ILM) peeling increases the idiopathic macular hole (IMH) closure rate but causes the inner retina dimplings. This study is to introduce a method to minimally peel the ILM, and with the ILM flap to ensure the IMH closure.

Methods

Twelve consecutive IMH eyes were treated with the minimal ILM peeling with ILM flap technique. The ILM around the MH is peeled off in an annular shape with a width of approximately 200 to 300 μm. A tongue-shape ILM flap is created in the superior retina and the inferior margin of ILM is not peeled off. The ILM flap is then inverted to cover the MH, followed by fluid-air exchange and air or silicon tamponade. Spectral domain-optical coherence tomography (SD-OCT) and en face OCT for morphological assessment, best corrected visual acuity (BCVA) and multifocal electroretinogram (ERG) for functional evaluation were performed at baseline and at each postoperative follow-up.

Results

All the 12 eyes achieved macular hole closure on SD-OCT after surgery (100%). At baseline, the mean preoperative BCVA was 0.83 ± 0.33 and it improved to 0.39 ± 0.28 postoperatively (p <  0.001). En face OCT showed the inner retinal dimplings were localized only in superior ILM-free retinas (7 eyes). The mERG response density in the central (R1), para-central (R2), R1/R2 ring ratios were remarkably improved at the last follow-up (p = 0.001, p = 0.033, p = 0.018, respectively).

Conclusions

The minimal ILM peeling with ILM flap technique can achieve favorable MH closure with less inner retinal dimplings and has promising visual recovery for IMH eyes.

Intraoperative iatrogenic retinal breaks in 23-gauge vitrectomy for stage 3 and stage 4 idiopathic macular holes

AIMS

To investigate characteristics of intraoperative iatrogenic retinal breaks in 23-gauge vitrectomy for idiopathic macular hole and classify the breaks based on their causes to analyse the risk factors.

METHODS

This retrospective study enrolled patients with stage 3 or 4 idiopathic macular hole who underwent 23-gauge vitrectomy in Beijing Tongren Hospital from July 2015 to August 2018. The intraoperative iatrogenic retinal breaks were classified into three types: by induction of posterior vitreous detachment (type 1), by peripheral vitreous cutting (type 2) and by others (type 3). The types, incidence and distribution of the breaks were analysed, and all clinical features were compared between eyes with and without the breaks.

RESULTS

A total of 364 eyes from 341 patients were recruited. Twenty-five breaks from 24 eyes (6.6%) were encountered, 52% (13/25) of which distributed in the superior region. Type 1 and type 2 breaks contributed 52% (13/25) and 44% (11/25) to all, respectively. Eyes with stage 3 and stage 4 holes showed no significant differences in incidence or distribution in type 2 breaks. No breaks occurred on the surface of lattice degenerations. All clinical features showed no significant differences between eyes with and without the breaks.

CONCLUSION

Distribution of intraoperative iatrogenic retinal breaks shows no preference for the superior or inferior region. Induction of posterior vitreous detachment and traction from peripheral vitreous cutting are major causes of the breaks, which classify them into two main types. The presence of lattice may not be one of the risk factors if treated properly.

SCLERAL SELF-INDENTATION DURING CHANDELIER-ASSISTED PERIPHERAL VITRECTOMY UNDER AIR FOR RHEGMATOGENOUS RETINAL DETACHMENT: A Retrospective Cohort Study

PURPOSE

To evaluate incidence of iatrogenic retinal breaks in eyes for whom self-indentation during chandelier-assisted peripheral vitrectomy under air, for primary retinal detachment, had been performed compared with eyes for whom a nonindentation chandelier-assisted peripheral vitrectomy under air had been performed.

METHODS

Retrospective cohort study. One hundred and thirty eyes with primary rhegmatogenous retinal detachment were identified. All the patients had undergone a chandelier-assisted peripheral vitrectomy under air. Scleral self-indentation had been used in 68 eyes (study group; indentation), whereas nonindentation had been used in 62 eyes (comparison; nonindentation). Outcome variables included the following: trimming-induced retinal breaks, retinal redetachment rate, final logMAR best-corrected visual acuity, and intraoperative complications.

RESULTS

The number of eyes with trimming-induced retinal break was statistically less in indentation group than in nonindentation group (0/68 and 3/62 eyes, 0% and 4.8%, respectively) (P = 0.04). Redetachment was observed in one eye (indentation) (1/68) and in three eyes (nonindentation) (3/62) (P = 0.267). There was no statistically significant difference in logMAR best-corrected visual acuity between both groups (P = 0.229). Chandelier repositioning was needed in 22 eyes (indentation) compared with 46 eyes (nonindentation) (P < 0.001).

CONCLUSION

Self-indentation, during chandelier-assisted peripheral vitrectomy under air, enables complete trimming of the vitreous base without causing iatrogenic retinal breaks, with a higher retinal reattachment rate, and with less need for chandelier repositioning than with nonindentation approach. By contrast with previous reports, we consider scleral self-indentation as an advantage for chandelier air vitrectomy.

Results of Peripheral Vitrectomy Under Air in Rhegmatogenous Retinal Detachment

BACKGROUND AND OBJECTIVE

To evaluate the safety and efficacy of peripheral vitrectomy under air in rhegmatogenous retinal detachment (RRD).

PATIENTS AND METHODS

Consecutive patients who underwent 23-gauge pars plana vitrectomy for RRD were included. After removal of core vitreous and drainage of subretinal fluid, peripheral vitreous was removed under air infusion without scleral indentation. Silicone oil or C3F8 gas was used as tamponade.

RESULTS

Forty-five eyes of 45 patients were evaluated retrospectively. Mean LogMAR, which was 1.65 LogMAR ± 1.44 LogMAR preoperatively, decreased to 0.26 LogMAR ± 0.28 LogMAR (P < .001; paired t-test). Initial and final reattachment rates were 91% and 98%, respectively. Scleral indentation was not necessary in any case. Iatrogenic retinal breaks occurred in three initial cases. Macular hole developed in one case after reoperation.

CONCLUSIONS

Peripheral vitrectomy under air is safe and effective in cases with RRD. Air eliminates the need for scleral indentation, stabilizes the retina, and allows sufficient clarity for vitrectomy. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:51-54.].

TRANSCONJUNCTIVAL NONVITRECTOMIZING VITREOUS SURGERY VERSUS 25-GAUGE VITRECTOMY IN PATIENTS WITH EPIRETINAL MEMBRANE: A Prospective Randomized Study

PURPOSE

To compare the clinical outcomes and the rate of complications of 27-gauge transconjunctival nonvitrectomizing vitreous surgery (NVS) and of 25-gauge transconjunctival sutureless vitrectomy surgery for idiopathic epiretinal membrane removal.

METHODS

In this prospective randomized study, 83 phakic eyes of 83 consecutive patients with an idiopathic epiretinal membrane were randomized to receive 27-gauge NVS (NVS-group) or 25-gauge vitrectomy (Standard-group). Main outcome measures were best-corrected visual acuity, central retinal thickness, nuclear density units' changes, and rate of complications.

RESULTS

Thirty-nine eyes of the Standard-group and 40 of the NVS-group were considered in final analysis. Mean best-corrected visual acuity improved significantly in both groups, with a significant better result at 12 months in NVS-group (P = 0.039; t-test). Central retinal thickness decreased significantly in both groups (P < 0.001, Tukey test), without significant difference between the two groups at any time point. At 12 months, nuclear density increased significantly in the Standard-group (analysis of variance, P < 0.001), and it did not change in the NVS-group (analysis of variance, P = 0.537). Epiretinal membrane recurred in 5.1% of eyes in the Standard-group and in 7.5% of eyes in the NVS-group (Fisher's exact test, P = 1.000).

CONCLUSION

The 27-gauge NVS is an effective surgical procedure in eyes with epiretinal membrane and it induces less progression of nuclear sclerosis than 25-gauge vitrectomy.

25-gauge vitrectomy combined with half-fluence photodynamic therapy for the treatment of juxtapapillary retinal capillary hemangioma: a case report

A rare case of juxtapapillary retinal capillary hemangioma (JRCH) with tractional macular detachment that was managed successfully with minimally invasive 25-gauge vitreoretinal surgery, followed by two sessions of half-fluence photodynamic treatment (PDT) with good visual outcome, is presented. A 13-year-old female patient had progressive deterioration of the vision of her right eye due to the presence of tractional macular detachment associated with JRCH in von Hippel-Lindau (VHL) disease. A 25-gauge sutureless vitreoretinal surgery was successfully performed. Two months following surgery, the JRCH was treated with two sessions of half-fluence PDT at an interval of 4 months. Visual acuity improved from a preoperative level of 20/50 to 20/25 24 months postoperatively. Resolution of the tractional macular detachment, reduction of papillomacular area fluid, and reduction in size of the JRCH were observed during the follow-up period. No serious adverse events were observed. Small-gauge vitreoretinal surgery followed by PDT can be effective and safe in relieving tractional macular detachment and recovering useful visual acuity in JRCH in VHL disease.