Long-term visual outcomes of vitrectomy for cystoid macular edema due to nonischemic central retinal vein occlusion

Vitrectomy for macular edema due to retinal vein occlusion

Purpose: To determine the long-term outcomes of vitrectomy for the macular edema associated with a retinal vein occlusion (RVO).

Methods: This was a retrospective, consecutive, interventional case series. The intraoperative procedures included internal limiting membrane peeling, arteriovenous sheathotomy, radial optic neurotomy, and intravitreal triamcinolone acetonide injection at the end of the surgery. The main outcome was the best-corrected visual acuity (BCVA).

Results: Eight hundred and fifty-four eyes of 854 patients were studied. The eyes consisted of 602 with branch RVO (BRVO), 74 with hemi-central RVO (hemi-CRVO), 87 with nonischemic central retinal vein occlusion (CRVO), and 91 with ischemic CRVO. The mean follow-up period was 68.6 months with a range of 12 to 262 months. The mean BCVA was significantly improved at the final visit (P<0.0001 to 0.0016). The final BCVA improved in 74.4% of the BRVO eyes, in 58.1% of the hemi-CRVO eyes, in 57.4% of the nonischemic CRVO eyes, and in 51.6% of the ischemic CRVO eyes. Multiple regression analysis showed there was no significant relationship between the intraoperative combined procedures and the final BCVA.

Conclusions: The results indicate that the type of RVO is significantly associated with the final BCVA, and vitrectomy is a treatment option to improve and maintain BCVA for a long term.

Pars Plana Vitrectomy Combined with Internal Limiting Membrane Peeling to Treat Persistent Macular Edema after Anti-Vascular Endothelial Growth Factor Treatment in Cases of Ischemic Central Retinal Vein Occlusion

OBJECTIVE

To evaluate the efficacy of pars plana vitrectomy (PPV) combined with internal limiting membrane (ILM) peeling in cases of ischemic central retinal vein occlusion (CRVO) where macular edema (ME) persisted after anti-vascular endothelial growth factor (anti-VEGF) treatment.

METHODS

Fifteen eyes with ischemic CRVO-related ME were included in the study. Nine were treated with panretinal photocoagulation after initial examination. Anti-VEGF agents were injected intravitreally. Persistent ME was treated with PPV combined with ILM peeling. During surgery, laser photocoagulation was further applied to the non-perfused area.

RESULTS

Mean retinal thickness gradually decreased after surgery (p = 0.024 at 6 months), although visual acuity did not improve significantly during the follow-up period (14.7 ± 11.6 months). Neovascular glaucoma subsequently developed in three cases and a trabeculectomy was performed in one case.

CONCLUSION

In eyes with ischemic CRVO, PPV combined with ILM peeling contributed to a reduction in persistent ME. However, there was no significant improvement in visual acuity.

Combination therapy in diabetic macular oedema and retinal vein occlusion--past and present

This paper summarizes the recent evidence for combined therapies in the intravitreal medical treatment of diabetic macular oedema or macular oedema, secondary to retinal vein occlusion. Since the introduction of anti-inflammatory or anti-VEGF drugs combined with or used alternatively to laser, visual acuity can be stabilized or improved in a significant number of patients. However, there is an ongoing debate regarding the safety, efficiency and economic concerns related to these intravitreal monotherapies because they warrant frequent repetition to maintain the clinical effect. In the literature, the combination of photolasercoagulation, intravitreal steroids or VEGF-inhibitors, or both, shows early compelling evidence that some patients may benefit from less retreatment compared to monotherapy. To provide a conceptual and perspective approach for a first-line combined therapy, this paper also summarizes own results of pilot interventional case series of a 1.5 cc core pars plana vitrectomy and intravitreal substitution with balanced salt solution (BSS), 1.25 mg bevacizumab and 8 mg triamcinolone.

Bevacizumab for macular edema in central retinal vein occlusion: a prospective, randomized, double-masked clinical study

PURPOSE

To evaluate the efficacy of intraocular injections with bevacizumab in patients with macular edema (ME) secondary to central retinal vein occlusion (CRVO).

DESIGN

Prospective, randomized, sham injection-controlled, double-masked clinical trial.

PARTICIPANTS

Sixty patients with ME secondary to CRVO.

METHODS

At baseline, patients were randomized 1:1 to receive intraocular injections of bevacizumab or sham injections every 6 weeks for 6 months.

MAIN OUTCOME MEASURES

The primary outcome measure was the proportion of patients gaining at least 15 letters at 6 months. Secondary outcome measures included mean change from baseline best-corrected visual acuity (BCVA), foveal thickness, and neovascular glaucoma.

RESULTS

At the end of follow-up, 18 of 30 patients (60.0%) in the study group had gained ≥15 letters compared with 6 of 30 patients (20.0%) in the control group (P=0.003). The BCVA improved by 14.1 letters at 24 weeks compared with a decrease of 2.0 letters in the control group (P < 0.003). The mean decrease in central retinal thickness (CRT) was significantly greater in the study group (426 μm) than in the control group (102 μm) at all time points up to week 24 (P < 0.001). No residual edema, defined as CRT <300 μm at 24 weeks, was found in 26 of 30 patients (86.7%) in the treatment group compared with 6 of 30 patients (20%) in the control group (P < 0.001). In the sham group, 5 of 30 patients (16.7%) had developed iris rubeosis at week 24. No patients in the study group had rubeosis at week 24 (P=0.052). There were no events of endophthalmitis, retinal tear, or retinal detachment during the 24-week treatment period. No serious non-ocular adverse events were reported.

CONCLUSIONS

Intraocular injections of bevacizumab given every 6 weeks for 6 months improve visual acuity (VA) and reduce ME significantly compared with sham.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Mathematical function describing visual gain curves following vitrectomy for different macular diseases

PURPOSE

To determine whether the time course of average visual recovery (visual gain curve) after vitrectomy for different macular diseases can be described by a mathematical function.

METHODS

The medical records of 1951 eyes that underwent vitrectomy for different macular diseases such as macular hole, epiretinal membrane, and macular edema were reviewed. All surgeries were performed by one surgeon (NO), and simultaneous phacoemulsification with intraocular lens implantation was performed on all phakic patients who were >40 years of age. All patients were followed at least 30 months postoperatively. The best-corrected visual acuity (BCVA) in decimal units was converted to the logarithm of the minimum angle of resolution (logMAR) for the analyses. The visual gain (G) was defined as the preoperative BCVA minus postoperative BCVA in logMAR units. The average visual gain was plotted as a function of the postoperative time, T, in months. T(m) was defined as the postoperative time required to reach one-half the maximum visual gain (G(max)). We examined whether the visual gain curve for different macular diseases could be fit by a hyperbolic function, G = G(max) × T/(T(m) + T).

RESULTS

The visual gain curve for an idiopathic macular hole (n = 485) can be fit by the hyperbolic function G = 0.63T/(0.86 + T) with r(2) = 0.98. In the other macular diseases, significant correlations were also obtained (0.88 ≤ r(2) ≤ 0.99).

CONCLUSIONS

Although the mechanism was not determined, the visual gain curve after vitrectomy for different macular diseases can be well fit by a hyperbolic function.

Long-term effects of vitrectomy and internal limiting membrane peeling for macular edema secondary to central retinal vein occlusion and hemiretinal vein occlusion

PURPOSE

The purpose of this study was to evaluate the long-term effects of vitrectomy and internal limiting membrane peeling for macular edema secondary to central retinal vein occlusion (CRVO) and hemiretinal vein occlusion (HRVO).

METHODS

Best-corrected visual acuity, central foveal thickness by optical coherence tomography, and fluorescein angiography were evaluated retrospectively in 20 patients (20 eyes). The mean follow-up time was 61.2 months. Pars plana vitrectomy and internal limiting membrane peeling using indocyanine green staining were performed in all patients.

RESULTS

Preoperative mean central foveal thickness of all 20 eyes decreased significantly by 6 months, and this reduction was maintained until 60 months. The mean central foveal thickness of the group with perfused type CRVO, ischemic type CRVO, and HRVO at 6 months significantly decreased from the preoperative value, and the significant reduction was maintained until 60 months. Best-corrected visual acuity of the perfused CRVO and HRVO groups tended to improve in contrast to the ischemic CRVO group postoperatively. Best-corrected visual acuity of the perfused CRVO group at 24 months or later was significantly improved from preoperative best-corrected visual acuity.

CONCLUSION

Pars plana vitrectomy with internal limiting membrane peeling in eyes with macular edema secondary to CRVO and HRVO produces an anatomical improvement, which persists up to 5 years, and a best-corrected visual acuity improvement, at least in perfused CRVO and HRVO.

A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with observation to treat vision loss associated with macular edema secondary to central retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 5

OBJECTIVE

To compare the efficacy and safety of 1-mg and 4-mg doses of preservative-free intravitreal triamcinolone with observation for eyes with vision loss associated with macular edema secondary to perfused central retinal vein occlusion (CRVO).

METHODS

Multicenter, randomized, clinical trial of 271 participants.

MAIN OUTCOME MEASURE

Gain in visual acuity letter score of 15 or more from baseline to month 12.

RESULTS

Seven percent, 27%, and 26% of participants achieved the primary outcome in the observation, 1-mg, and 4-mg groups, respectively. The odds of achieving the primary outcome were 5.0 times greater in the 1-mg group than the observation group (odds ratio [OR], 5.0; 95% confidence interval [CI], 1.8-14.1; P = .001) and 5.0 times greater in 4-mg group than the observation group (OR, 5.0; 95% CI, 1.8-14.4; P = .001); there was no difference identified between the 1-mg and 4-mg groups (OR, 1.0; 95% CI, 0.5-2.1; P = .97). The rates of elevated intraocular pressure and cataract were similar for the observation and 1-mg groups, but higher in the 4-mg group.

CONCLUSIONS

Intravitreal triamcinolone is superior to observation for treating vision loss associated with macular edema secondary to CRVO in patients who have characteristics similar to those in the SCORE-CRVO trial. The 1-mg dose has a safety profile superior to that of the 4-mg dose. Application to Clinical Practice Intravitreal triamcinolone in a 1-mg dose, following the retreatment criteria applied in the SCORE Study, should be considered for up to 1 year, and possibly 2 years, for patients with characteristics similar to those in the SCORE-CRVO trial. Trial Registration clinicaltrials.gov Identifier: NCT00105027.

Use of intravitreal triamcinolone in the treatment of macular edema related to retinal vein occlusion

Objective:

To analyze the increasing trend of intravitreal triamcinolone (IVTA) use in the treatment of retinal vein occlusion-related macular edema.

Methods:

We performed MEDLINE/PUBMED searches (September 1984 - December 2007) to identify articles containing the keywords macular edema and triamcinolone. Case reports, reviews and abstracts were identified from references in the reviewed literature. This review focuses on literature published during the past 7 years with more than two-thirds of the articles that we reviewed being printed during the past 5 years. These reports analyzed the success of IVTA in the treatment of macular edema over a 12 month course of time.

Results:

The majority of studies suggested promising results for short time periods (4-6 months) after IVTA treatments. However, long term results were not encouraging.

Conclusions:

The success of IVTA therapy for short durations has been the impetus for development of sustained release devices to be used in the treatment of macular edema associated with various retinal diseases including edema related to retinal vein occlusion.