Iatrogenic retinal breaks in ultrahigh-speed 25-gauge vitrectomy: a prospective study of elective cases

Role of Vitreous Detachment in Epiretinal Membrane Peeling: A Multimodal Imaging and Microperimetry Study

Background: To investigate anatomical and functional changes of the macula caused by epiretinal membrane (ERM) peeling procedures in patients with or without posterior vitreous detachment (PVD). Methods: This is a multicentric prospective observational study on thirty-seven (37) patients affected by symptomatic ERM who underwent 25-gauge pars plana vitrectomy (PPV), induction of a PVD (as needed) and peeling of both the internal limiting membrane (ILM) and ERM. Optical coherence tomography-angiography (OCT-A) (RS 3000, Nidek, Japan) and microperimetry (MP-3, Nidek, Japan) were performed; central retinal thickness (CRT), foveal avascular zone (FAZ) area and perimeter, vessel density and perfusion density, retinal sensitivity and fixation stability (as a total mean retinal sensitivity (MRS), and MRS in the ellipse area and bivariate contour ellipse area (BCEA)) were recorded at baseline and up to postoperative month 3. Results: Eyes were classified as having complete PVD (51.4%) or incomplete PVD (48.6%). At baseline, patients with incomplete PVD had worse best-corrected distance visual acuity (BCDVA), total MRS, MRS in the ellipse area and BCEA, and higher CRT than patients with complete PVD. At month 3, the differences in BCDVA between the two groups remained statistically significant, with patients with incomplete PVD having worse results (difference: 0.199 logMAR, p < 0.001). The difference in the MRS in the ellipse area was statistically significant at month 3 (-3.378 Db, p = 0.035), with greater improvement in patients with complete PVD. Conclusions: Our study shows that patients with incomplete PVD have worse conditions at baseline than patients with complete PVD, and the differences in visual acuity and retinal sensitivity were maintained postoperatively.

Long-term outcomes of autologous platelet treatment for optic disc pit maculopathy

PURPOSE

Optic disc pits (ODPs) are rare congenital cavitary abnormalities of the optic nerve head, which can lead to serous macular detachments. The aim of this study was to evaluate the long-term efficacy of pars plana vitrectomy (PPV) combined with autologous platelet concentrate (APC) for the treatment of optic disc pit maculopathy (ODP-M).

METHODS

A retrospective analysis was performed on eleven eyes of ten patients with ODP-M, who received PPV combined with APC. Nine eyes operated primary, four of which had a repeat surgery also with injection of APC and two eyes underwent a rescue surgery, after they have been operated in another eye center without APC. Morphological and functional results were the main outcome parameters, determined by optical coherence tomography (OCT) and best-corrected visual acuity (BCVA), respectively.

RESULTS

The mean duration of visual loss before surgery was 4.7 ± 3.89 months (range 0-12 months). The mean BCVA increased significantly from 0.82 ± 0.33 logMAR (range 0.4-1.3) preoperatively to 0.51 ± 0.36 logMAR (range 0-1.2) at the last examination (p = 0.0022). A significant morphological improvement was also noticed with decrease of the mean foveal thickness from 935.82 ± 248.48 µm (range 559-1400 µm) preoperatively to 226.45 ± 76.09 µm (range 110-344 µm) at the final examination (p < 0.0001). The patients were followed-up for a mean 65.36 ± 48.81 months (range 1-144 months). Two eyes developed postoperatively a retinal detachment. Cataract surgery was performed in 5 eyes during the follow-up period.

CONCLUSION

Our study demonstrated that PPV with APC can improve functional and morphological outcomes, both as a primary and a rescue therapy, without any recurrence over a long follow-up period. To the best of our knowledge, this was the longest observation period regarding the use of APC in treatment of ODP-M.

Optimized design of surgical steps in pars plana vitrectomy for macular hole retinal detachment in pathological myopia decreases rate of iatrogenic retinal break and shortens length of operation

BACKGROUND

To investigate the effect of surgical steps optimization in pars plana vitrectomy (PPV) with internal limiting membrane (ILM) flap for macular hole retinal detachment (MHRD) in pathological myopia.

METHODS

A retrospective, consecutive, nonrandomized comparative study. High myopic eyes diagnosed with MHRD receiving PPV with ILM flap from March 2019 to June 2020 in Department of Ophthalmology, Xiangya Hospital, Central South University were included in the study. Patients were included into two groups based on different design of surgical steps. In the routine group, extension of posterior vitreous detachment (PVD) towards periphery was performed right after induction of PVD. In the experiment group, the retina was reattached with drainage of subretinal fluid through macular hole before peripheral vitreous was dealt with. Complete ophthalmic examinations were performed before and after surgery. The follow-up time was at least 6 months. The rate of iatrogenic retinal break and length of operation were compared between the two groups.

RESULTS

Thirty-one eyes from 31 patients were included in the study with 15 in the experiment group and 16 in the routine group. Demographics showed no statistically significant difference between the two groups. Post-op BCVA, rate of macular hole closure and rate of retinal reattachment were similar in the two groups. The rate of iatrogenic retinal break in the experiment group was significantly lower than that in the routine group (6.7% vs. 37.5%, P < 0.05). The average length of operation was 78.6 ± 18.8 min in the routine group and 64.0 ± 12.1 min in the experiment group (P < 0.05).

CONCLUSIONS

Optimized design of surgical steps in PPV for MHRD could effectively decrease the rate of iatrogenic retinal tear and shorten the length of operation.

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.

Limited Vitrectomy versus Complete Vitrectomy for Epiretinal Membranes: A Comparative Multicenter Trial

Purpose

To evaluate whether limited vitrectomy is as effective as complete vitrectomy in eyes with epiretinal membrane (ERM) and to compare the surgical times and rates of complications.

Methods

In this multicentre European study, data of eyes with ERM that underwent vitrectomy from January 2017 to July 2018 were analyzed retrospectively. In the limited vitrectomy group, a posterior vitreous detachment (PVD) was induced up till the equator as opposed to complete PVD induction till the vitreous base in the comparison group. Incidence of iatrogenic retinal breaks, retinal detachment, surgical time, and visual outcomes were compared between groups.

Results

We included 139 eyes in the analysis with a mean age being 72.2 ± 6.9 years. In this, sixty-five eyes (47%) underwent limited vitrectomy and 74 eyes (53%) underwent complete vitrectomy. Iatrogenic retinal tears were seen in both groups (5% in limited vitrectomy versus 7% in complete vitrectomy, p=0.49). Retinal detachment occurred in 2 eyes in the limited vitrectomy group (3%) compared to none in the complete vitrectomy group (p=0.22). Best-corrected visual acuity (BCVA) and central macular thickness improved significantly with no intergroup differences (p=0.18). Surgical time was significantly shorter in the limited vitrectomy group with 91% surgeries taking less than 1 hour compared to 71% in the complete vitrectomy group (p < 0.001).

Conclusion

A limited vitrectomy is a time-efficient and effective surgical procedure for removal of epiretinal membrane with no additional complications.

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.

Management of vitreous floaters: an international survey the European VitreoRetinal Society Floaters study report

BACKGROUND/OBJECTIVES

To evaluate the efficacy and safety of pars plana vitrectomy for symptomatic floaters.

SUBJECTS/METHODS

Forty-eight vitreoretinal surgeons from 16 countries provided information on 581 eyes who underwent vitrectomy for floaters in this retrospective survey study conducted by European VitreoRetinal Society. Percentage symptomatic improvement, incidence of retinal tears/detachment and post-vitrectomy cataract surgery, and the factors associated with satisfaction and complications were investigated.

RESULTS

Ninety-two percent were satisfied with the results, with 86.3% reporting complete resolution of daily-life symptoms. Overall satisfaction was lower in patients with smaller vitreous opacities at presentation (OR:0.4). Iatrogenic retinal breaks occurred in 29 eyes (5%). Core vitrectomy and cut rates of 1500-4000 or >4000 cuts/min were associated with lower risk of retinal breaks than complete vitrectomy (OR:0.05) and cut rates < 1500 cuts/min (OR: 0.03, 0.12, respectively). Fourteen eyes (2.4%) developed retinal detachment at a median of 3 months; and 84 (48.6%) developed cataract at a median of 16 months post-vitrectomy.

CONCLUSIONS

Pars plana vitrectomy resulted in high patient satisfaction with relatively low rate of severe complications in a large group of patients. The procedure may be safer when core vitrectomy and cut rates > 1500 cuts/min are favoured. Proper patient selection and informed consent are the most important aspects of surgery.

To Treat or Not to Treat: Management Options for Symptomatic Vitreous Floaters

Vitreous floaters are a common cause for presentation to ophthalmologists, and may significantly affect visual function. In the absence of some more serious underlying pathology such as uveitis, many patients may not experience significant persistent visual impairment from floaters. For some patients, the symptomatic effects of floaters may persist. For these patients, treatment options are available, of which the most commonly reported is vitrectomy. Other treatment modalities have also become more common, notably YAG vitreolysis. Selection of appropriate patients for surgery is often difficult, in part due to the relative lack of objective outcomes with which to measure both visual impairment and improvement post-procedure. Although well-tolerated, vitrectomy does carry with it risks, including iatrogenic retinal breaks, retinal detachment, and in phakic patients, subsequent cataract formation. Techniques such as small gauge vitrectomy, intraoperative examination and treatment of breaks or other worrying lesions, and careful consideration of the need for posterior vitreous detachment induction may help limit the incidence of these adverse events. For other treatment options such as YAG vitreolysis, research and clinical experience remain more limited, and as such the long-term efficacy and risks of these therapies are still unclear. Here, we review the evidence surrounding the role of vitrectomy and YAG vitreolysis in the treatment of vitreous floaters and potential means to minimize therapeutic complications.

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.

Iatrogenic retinal breaks and postoperative retinal detachments in microincision vitrectomy surgery compared with conventional 20-gauge vitrectomy: a meta-analysis

PURPOSE

To assess the incidence of iatrogenic retinal breaks (IRBs) and postoperative retinal detachments (RDs) in microincision vitrectomy surgery (MIVS) compared with 20-gauge (20 G) vitrectomy.

METHODS

A comprehensive literature search was performed to find relevant studies and a meta-analysis of the IRBs and postoperative RDs rates after 20 G vitrectomy versus MIVS was conducted.

RESULTS

Thirty-two studies were selected, including 14,373 eyes (6932 eyes in the 20 G group, 7441 eyes in the MIVS group). The meta-analysis demonstrated that the incidence of IRBs was significantly higher in 20 G vitrectomy vs. MIVS (OR = 2.22, 95% CI, 1.93-2.57, P < 0.00001) and in a subanalysis vs. 23 G MIVS (OR = 2.19, 95% CI, 1.87-2.56, P < 0.00001) and vs. 25 G MIVS (OR = 2.27, 95% CI, 1.62-3.18, P < 0.00001). Similar result was obtained in a subanalysis for macular surgery (OR = 2.44, 95% CI, 1.99-2.99, P < 0.00001), and also for sclerotomy-related IRBs (OR = 3.73, 95% CI, 2.55-5.44, P < 0.00001), but not for surgically induced posterior vitreous detachment-related IRBs (OR = 1.59, 95% CI, 0.89-2.84, P = 0.12). The incidence of postoperative RDs in 20 G vitrectomy was significantly higher compared to MIVS (OR = 1.72, 95% CI, 1.21-2.46, P = 0.003) and in a subanalysis vs. 23 G MIVS (OR = 2.45, 95% CI, 1.50-4.00, P = 0.0003), but not for 25 G MIVS (OR = 1.01, 95% CI, 0.63-1.64, P = 0.96). Similar result was obtained in a subanalysis for macular surgery (OR = 1.89, 95% CI, 1.26-2.85, P = 0.002).

CONCLUSION

This meta-analysis demonstrated that MIVS is associated with a lower risk of IRBs and postoperative RDs compared to 20 G vitrectomy.

Nitinol basket-assisted pars plana vitrectomy for retained lens material removal

PURPOSE

To evaluate the usefulness of different types of nitinol baskets to capture, lift and hold the lens material, dropped during a complicated phacoemulsification, as an adjunctive surgical tool in vitreoretinal surgery and to evaluate the outcomes and complication of this new surgical technique in a small series of patients.

METHODS

Patients who underwent pars plana vitrectomy (PPV) for retained lens fragments operated during December 2014 and March 2015 at the Academic Medical Center (AMC), Amsterdam, were included in this study. The PPV was performed using different settings and types of nitinol stone extractors (NSE). Three different stone extractors were used for the above-mentioned purpose. Preoperative (pre-op) and postoperative (post-op) data including best corrected visual acuity at 6 months follow-up visit, intra- and postoperative complications were recorded.

RESULTS

Seven eyes of seven patients with a follow-up of 6 months were included in this study. All the vitrectomies were performed the same day of the complicated cataract extraction. Mean pre-op Snellen visual acuity was 20/160; mean post-op visual acuity was 20/32. No complications were encountered due to the use of the NSE intraocularly. No retinal breaks were observed due to traction of the catheter at the site of insertion or due to his movement in and out the vitreous cavity.

CONCLUSION

The use of the nitinol lens cage seemed feasible and showed no complications in our small group of patients. It made easier the management of dropped nucleus without the need for a larger scleral opening also in case of very hard lens.

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.

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

PurposeTo assess the occurrence rate of retinal detachment (RD) after small gauge vitrectomy for idiopathic epiretinal membrane (ERM).Patients and methodsRetrospective observational case series. The records of consecutive patients operated on for idiopathic ERM using small gauge pars plana vitrectomy between August 2012 and December 2014 with at least a 1-year follow-up were reviewed. All patients were contacted by phone to assess the occurrence of RD during the post-operative follow-up. The main outcome was the occurrence of RD. Patients who underwent surgery for senile cataract over the same period with at least a 1-year follow-up were also contacted by phone for comparison.ResultsTwo hundred and sixteen eyes of 212 patients who had undergone ERM surgery were included, with a mean follow-up of 892±211 days (216-1238). RD occurred in two eyes (0.92%). Over the same period, two RD occurred in the 203 eyes (0.98%) of 157 patients operated on for senile cataract in our department.ConclusionsThe occurrence of RD after 25-gauge vitrectomy for idiopathic ERM was <1%. Using small gauge sutureless vitrectomy systems has improved the safety of ERM surgery, with a RD rate similar to that observed after cataract surgery.

PARS PLANA VITRECTOMY AND LENSECTOMY FOR ECTOPIA LENTIS WITH AND WITHOUT THE INDUCTION OF A POSTERIOR VITREOUS DETACHMENT

PURPOSE

Posterior hyaloid removal during pars plana vitrectomy and lensectomy for ectopia lentis is commonly performed, but may increase the risk of intraoperative retinal breaks and postoperative retinal detachment. This study evaluated outcomes after pars plana vitrectomy and lensectomy with or without posterior hyaloid removal.

METHODS

This retrospective observational cohort study included ectopia lentis cases that underwent pars plana vitrectomy and lensectomy (2005-2014), with or without intraoperative induction of a posterior vitreous detachment (PVD). The primary outcome was postoperative retinal detachment. The secondary outcomes were the incidence of iatrogenic retinal breaks, and change in visual acuity.

RESULTS

Twenty-six cases were included. The posterior hyaloid was preserved intraoperatively in 11 cases (non-PVD group). In the remainder (15 cases), the vitreous was removed completely (PVD group). Postoperative retinal detachment occurred in 2 cases in each group (18.2% non-PVD vs.13.3% PVD, P = 0.7). Intraoperative breaks occurred more frequently in the PVD group (2 vs. 9 cases; P = 0.03). There was no difference in mean improvement in visual acuity (7 [PVD] vs. 3 [non-PVD] ETDRS lines; P = 0.2).

CONCLUSION

The preservation of posterior hyaloid attachment during vitreolensectomy for ectopia lentis was associated with fewer iatrogenic retinal breaks. Postoperative retinal detachment did not seem to be influenced by the choice of surgical technique.

Valved versus nonvalved cannula small-gauge pars plana vitrectomy for repair of retinal detachments with Grade C proliferative vitreoretinopathy

Purpose

Valved cannulas are a recent addition to small-gauge pars plana vitrectomy (PPV) and provide stable intraocular fluidics. The goal of this study was to compare outcomes and postoperative complication rates of valved vs nonvalved cannula small-gauge PPV for repair of retinal detachments (RDs) complicated by Grade C proliferative vitreoretinopathy (PVR).

Methods

A retrospective chart review of 364 consecutive eyes with either valved or nonvalved cannula PPV for RD repair was performed. The primary outcomes were single surgery and final anatomic success and change in best-corrected visual acuity for repair of RDs complicated by Grade C PVR.

Results

We identified 36 eyes in the valved group and 31 eyes in the nonvalved group with Grade C PVR RD. The single surgery success was 83% vs 77% (P=0.555) and the final anatomic success was 94% vs 87% (P=0.404) in the valved vs nonvalved eyes, respectively. The mean final visual acuity gain was −0.36 logarithm of the minimum angle of resolution (logMAR; approximate Early Treatment Diabetes Retinopathy Study [ETDRS] score =17 letters) in valved eyes vs −0.33 logMAR (approximate ETDRS score =16 letters) in nonvalved eyes (P=0.81). Postoperative complication rates including postoperative day 1 hypotony, hypertony, and anterior chamber fibrin formation; postoperative retention of intraocular or subretinal perfluorocarbon liquid; and subsequent epiretinal membrane peel were not statistically different between groups.

Conclusion

Valved cannula PPV yields equivalent visual acuity and anatomic outcomes without increased postoperative complication rates compared to traditional nonvalved cannula PPV for Grade C PVR-associated RD repair.