Birth Year-Dependent Increase in Axial Length of Japanese Adult

PURPOSE

To determine whether the correlations between the axial length and the aging-dependent and birth year-dependent age are significant.

DESIGN

Retrospective cross-sectional study.

METHODS

This study included Japanese patients ≥50 years who had undergone cataract surgery at numerous clinics from 2002 to 2020. Only 1 eye/patient was analyzed. The axial length was measured with the IOL Master. The age-dependent changes were determined by the significance of the correlation between the axial length and age by the birth year. The birth year-dependent changes were determined by the significance of the correlation between the axial length and birth year in the different age groups. The age refers to the age at the time of the cataract surgery. Spearman correlations were calculated. The turning points were identified by the LOESS, NLIN, and HPMIXED procedures.

RESULTS

A total of 62,362 eyes (35,508 women, 26,854 men) were studied. The mean age was 72.9 ± 8.4 (standard deviation) years (range, 50-101 years), and the mean axial length was 23.90 ± 1.66 mm (standard deviation) (range, 19.20-37.07 mm). The birth year ranged from 1908 to 1970. Analyses of the birth year-dependent changes showed significant positive correlations in 48 of 81 (59.3%) groups for women and men. The increase in the axial length was birth year-dependent, and the turning point was 1939.4 for women and 1936.7 for men.

CONCLUSIONS

The negative and significant correlation between the axial length and age is due to birth year-dependent changes. A birth year-dependent increase in axial length might have continued for several decades from the birth year of the late 1930s.

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.

Long-term outcomes of intravitreous bevacizumab or tissue plasminogen activator or vitrectomy for macular edema due to branch retinal vein occlusion

Purpose

The purpose of this study was to determine the long-term outcomes of intravitreal bevacizumab (IVB) or intravitreal tissue plasminogen activator (tPA) or vitrectomy for macular edema associated with a branch retinal vein occlusion (BRVO).

Methods

This was a retrospective, interventional case series. Forty-one patients received a single 1.25 mg of IVB injection and followed by pro re nata protocol, 71 patients received a single intravitreal tPA, and 116 patients underwent phacovitrectomy with intraocular lens implantation.

Results

The baseline characteristics and follow-up periods were not significantly different among the three groups. The mean follow-up period was 55.5 months with a range of 12-160 months. Sixteen patients (39.0%) in the IVB group, 24 patients (33.8%) in the tPA group, and two patients (1.7%) in the vitrectomy group underwent additional surgeries during the follow-up period. The best-corrected visual acuity (BCVA) significantly improved in all groups at 1 year after the initial treatment (all, P<0.0001) and at the final visit (all, P<0.0001). The differences in the BCVA between the three groups were not significant at all times after the initial treatment.

Conclusion

The three groups led to similar long-term good visual outcomes. However, additional surgeries were performed in more than 30% of patients in the IVB and tPA groups.

Early centripetal displacements of capillaries in macular region caused by internal limiting membrane peeling

Purpose

The aim of this study was to determine whether the centripetal displacement of the capillaries in the macular region after vitrectomy is caused by internal limiting membrane (ILM) peeling.

Methods

Eighteen patients with different types of retinal diseases but with a normal or approximately normal foveal contour underwent successful vitrectomy with (n=12) or without (n=6) ILM peeling. Optical coherence tomography angiography (OCTA) images of the inner retinal vascular plexus in the macular region were analyzed pre- and postoperatively. Four concentric polygonal areas were marked in the OCTA images with the corners selected to be easily identified by vessel bifurcations. The areas of the postoperative foveal avascular zone (FAZ) and the four polygonal regions at about 1 month postoperatively were compared to the baseline areas.

Results

Vitrectomy was performed for eleven eyes with vitreomacular tractions, three with macular-on retinal detachments, and four with thin epiretinal membranes. A significant decrease in the FAZ area was observed postoperatively in only the ILM-peeled eyes (P=0.0002). The four polygonal areas in the ILM-peeled eyes decreased after surgery, and the decrease was fit by a linear regression line (R²=0.985–0.999; n=7). The time course of the postoperative decrease of the FAZ area was fit by a hyperbolic curve (R²=0.969–0.998; n=6). The average postoperative time required to reach one-half of the final FAZ area was 1.16 days (0.81–1.62 days).

Conclusion

These findings suggest that ILM peeling causes an early centripetal displacement of the capillaries in the macular region.

Efficacy of 0.05% epinastine and 0.1% olopatadine for allergic conjunctivitis as seasonal and preseasonal treatment

Purpose

To evaluate the efficacy and safety of 0.05% epinastine and 0.1% olopatadine eye drop preparations as seasonal and preseasonal treatments in patients with seasonal allergic conjunctivitis (SAC).

Subjects and methods

This was a prospective, randomized, case-control study involving two institutions. The subjects were patients diagnosed with SAC at two institutions between February and March in 2014. To examine the clinical effects of seasonal treatment, 0.05% epinastine and 0.1% olopatadine were administered, and their effects were investigated every 2 weeks (Stage 1). To evaluate the clinical effects of preseasonal therapy, in January 2015, the same eye drop preparations as adopted in Stage 1 were administered to patients who had participated in Stage 1 and provided consent to participate in this study, and their effects were investigated every month (Stage 2).

Results

In Stage 1, the 0.05% epinastine group consisted of 43 patients, and the 0.1% olopatadine group consisted of 42 patients. There were significant improvements in the total symptom and objective finding scores at each time point after administration in comparison with those before its baseline, but there were no significant differences between the two groups. In Stage 2, the 0.05% epinastine group consisted of 15 patients, and the 0.1% olopatadine group consisted of 14 patients. The rate of change in the total symptom score in comparison with that at the baseline of preseasonal treatment was significantly higher in the 0.1% olopatadine group 1 month after the start of treatment, suggesting symptom deterioration (P=0.025). There was no significant difference in the rate of change in the total objective finding score between the two groups.

Conclusion

Seasonal treatment with 0.05% epinastine or 0.1% olopatadine was equally effective for patients with allergic conjunctivitis. However, for preseasonal therapy, 0.05% epinastine was more effective than 0.1% olopatadine.

Increase in average foveal thickness after internal limiting membrane peeling

PURPOSE

To report the findings in three cases in which the average foveal thickness was increased after a thin epiretinal membrane (ERM) was removed by vitrectomy with internal limiting membrane (ILM) peeling.

METHODS

The foveal contour was normal preoperatively in all eyes. All cases underwent successful phacovitrectomy with ILM peeling for a thin ERM. The optical coherence tomography (OCT) images were examined before and after the surgery. The changes in the average foveal (1 mm) thickness and the foveal areas within 500 μm from the foveal center were measured. The postoperative changes in the inner and outer retinal areas determined from the cross-sectional OCT images were analyzed.

RESULTS

The average foveal thickness and the inner and outer foveal areas increased significantly after the surgery in each of the three cases. The percentage increase in the average foveal thickness relative to the baseline thickness was 26% in Case 1, 29% in Case 2, and 31% in Case 3. The percentage increase in the foveal inner retinal area was 71% in Case 1, 113% in Case 2, and 110% in Case 3, and the percentage increase in foveal outer retinal area was 8% in Case 1, 13% in Case 2, and 18% in Case 3.

CONCLUSION

The increase in the average foveal thickness and the inner and outer foveal areas suggests that a centripetal movement of the inner and outer retinal layers toward the foveal center probably occurred due to the ILM peeling.

Decrease of the foveal avascular zone area after internal limiting membrane peeling: single case study

PURPOSE

To report a patient whose foveal avascular zone (FAZ) decreased after vitrectomy with internal limiting membrane (ILM) peeling.

METHODS

A 58-year-old woman underwent successful phacovitrectomy with ILM peeling for a thin epiretinal membrane in an eye with a normal foveal contour. Optical coherence tomography angiographic en face images of the 3 mm×3 mm superficial and deep inner retinal vascular plexuses were examined preoperatively, and on days 1, 2, 9, and 37 postoperatively. The changes in the FAZ areas and the thicknesses of the parafoveal retinal layers at 500 μm from the foveal center were assessed in the vertical and horizontal B-scan images.

RESULTS

The areas of the superficial and deep FAZ decreased after the surgery. The course of the postoperative decrease of the FAZ area in the superficial plexus can be fit by a hyperbolic curve (R²=0.993). An increase in the thicknesses of the retinal nerve fiber layer, ganglion cell-inner plexiform layer, and inner nuclear layer was observed at all times postoperatively.

CONCLUSIONS

We observed one case that the FAZ area decreased and the parafoveal inner retinal thickness increased after the vitrectomy with ILM peeling. The decrease in the FAZ area suggests that a centripetal movement of the inner retinal layer is probably due to the ILM peeling.

Effect of vitreomacular separation on macular thickness determined by spectral-domain optical coherence tomography

PURPOSE

To determine the effects of vitreomacular separation on macular thickness.

METHODS

This was a retrospective, observational, cross-sectional study. Average foveal and central minimum thicknesses were measured by spectral-domain optical coherence tomography (SD-OCT) in 308 eyes of 308 healthy subjects (healthy group) and 298 normal fellow eyes of 298 patients with a unilateral macular hole (MH group). Multiple regression analyses were performed to determine the effects of various factors on the macular thickness.

RESULTS

The mean age of the healthy group was 67.3 ± 9.6 years (range 40-88 years) and that of the MH group was 67.8 ± 7.0 years (range 43-91). SD-OCT images showed that 149 eyes (48.4 %) in the healthy group and 174 eyes (58.4 %) in the MH group had a vitreomacular separation. In the healthy group, the central minimum thickness of eyes with a vitreomacular separation (196 µm) was significantly thinner than those without a vitreomacular separation (205 µm; P < 0.001). In the MH group, the average foveal thickness (234 µm) and the central minimum thickness (177 µm) in eyes with a vitreomacular separation were thinner than those without it (247 and 199 µm, respectively; both P < 0.001). Multiple regression analyses showed that a vitreomacular separation was significantly correlated with thinner central minimum thicknesses in both groups (P < 0.001) and also with the average foveal thickness in the MH group (P < 0.001).

CONCLUSIONS

A vitreomacular separation caused thinning of the central fovea in both the healthy eyes and the normal fellow eyes of unilateral MH patients; the extent of foveal thinning is greater in the MH group.

Effect of vitreomacular adhesion and vitreous gel on age-related reduction of macular thickness: a retrospective observational study

OBJECTIVE

To investigate the effects of vitreomacular adhesion (VMA), vitreomacular separation (VMS) and absence of vitreous gel due to vitrectomy on macular thickness measured in the spectral domain optical coherence tomographic (SD-OCT) images.

DESIGN

A longitudinal, retrospective, observational study.

SETTING

Secondary multicentre study.

PARTICIPANTS

218 eyes of 218 healthy patients and 119 vitrectomised eyes of 119 patients were studied. The healthy individuals were classified into a VMA group (54 eyes) and a VMS group (164 eyes), while the vitrectomised patients were classified into an internal limiting membrane (ILM)-on group (26 eyes) and an ILM-off group (93 eyes). In all participants, 2 Cirrus HD-OCT recordings were made with an average interval of 36 months (range 24-60 months).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was the rate of change in macular thickness in the central sector. The secondary outcomes were the rates of change in macular thickness in the inner 4 sectors.

RESULTS

The annual rate of change in the macular thickness of the central sector was 0.76±1.8 µm/year in the VMA group, -0.58±2.3 µm/year in the VMS group, -1.57±1.9 µm/year in the ILM-on group and -0.86±3.1 µm/year in the ILM-off group. There was a significant difference between the rate of the central sector thickness change in the VMA and VMS groups (p=0.0001). The presence of VMA was a significant factor associated with an increase in the central sector thickness (p=0.0055). When the healthy and ILM-on groups were compared, the rate of decrease in the central sector thickness was faster in the ILM-on group (p=0.0043). Multiple regression analyses showed that not peeling the ILM during the vitrectomy was a significant factor associated with a decrease in the central sector thickness (p=0.044).

CONCLUSIONS

The presence of a VMA and a vitreous gel may help restrain the macular thickness reduction.

Clinical results of Trabectome surgery for open-angle glaucoma

Background

The purpose of this study was to determine outcomes when using Trabectome surgery and to evaluate factors associated with its effects in primary open-angle glaucoma (POAG) and exfoliation glaucoma (EXG).

Methods

This was a prospective, non-randomized, observational, comparative cohort study in which Trabectome surgery was used alone in patients with POAG or EXG. Trabectome surgery was considered to have failed when at least one of the following three criteria was fulfilled: intraocular pressure (IOP) ≥21 mmHg and a <20% reduction below the baseline IOP on two consecutive follow-up visits 3 months or more after surgery; need for additional glaucoma surgery; and an increase in number of medications compared with baseline.

Results

The subjects were 32 males (34 eyes) and 46 females (48 eyes). POAG was observed in 43 eyes and EXG in 39 eyes. IOP after Trabectome surgery decreased significantly from 22.3±6.8 mmHg at baseline to 14.0±3.9 mmHg (23.0% reduction) at month 24 in all cases (P<0.0000). The success rate at 2 years was 51.2% for all cases (POAG, 50.9%; EXG, 49.2%). There was no significant difference in success rate between POAG and EXG (P=0.91). Preoperative IOP (P=0.033) and number of medications (P=0.041) were significant factors for surgical success/failure in multivariate logistic regression. No serious complications were observed.

Conclusion

Trabectome surgery achieved favorable IOP control and was equally effective in patients with POAG and those with EXG. Its effects were influenced by preoperative IOP and number of preoperative medications.

Plateau iris in Japanese patients with primary angle closure and primary angle closure glaucoma

Purpose

To determine the prevalence of plateau iris in Japanese patients with primary angle closure (PAC) and primary angle closure glaucoma (PACG) and analyze the biometric parameters in patients with plateau iris using ultrasound biomicroscopy (UBM).

Methods

In this cross-sectional observational study, subjects aged >50 years with PAC and PACG who had previously undergone a patent laser peripheral iridotomy underwent UBM in one eye. UBM images were qualitatively analyzed using standardized criteria. Plateau iris in a quadrant was defined by anteriorly directed ciliary body, absent ciliary sulcus, steep iris root from its point of insertion followed by a downward angulation, flat iris plane, and irido-angle contact. At least two quadrants had to fulfill these UBM criteria for an eye to be classified as having plateau iris. A-scan biometry was used to measure anterior segment parameters.

Results

Ninety-one subjects with PAC (58 subjects) or PACG (33 subjects) and 68 normal controls were recruited. The mean (standard deviation) ages of PAC and PACG patients and normal controls were 73.5 (6.2) and 72.6 (7.3), respectively. Based on UBM criteria, plateau iris was found in 16 eyes (17.6%) of 91 eyes. In these 16 eyes, quadrant-wise analysis showed ten eyes (62.5%) had plateau iris in two quadrants; four eyes (25%) had plateau iris in three quadrants; and two eyes (12.5%) had plateau iris in four quadrants. Anterior chamber depth, lens thickness, axial length, lens position, and relative lens position were not statistically significant between the group having plateau iris and that not having plateau iris, respectively.

Conclusion

Approximately 20% of Japanese subjects with PAC and PACG with a patent laser peripheral iridotomy were found to have plateau iris on UBM. No morphological difference was noted in the anterior segment of the eye between those with or without plateau iris.

Peripheral iris thickness and association with iridotrabecular contact after laser peripheral iridotomy in patients with primary angle-closure and primary angle-closure glaucoma

Purpose

To investigate the relation between the quantitative iris parameters and iridotrabecular contact (ITC) in patients with primary angle-closure (PAC) and PAC glaucoma (PACG).

Materials and methods

PAC and PACG with laser peripheral iridotomy were recruited prospectively. Anterior-segment optical coherence tomography (ASOCT) was performed under light and dark conditions, and scans were taken along the vertical and horizontal axes. Iris thickness at 500 μm (IT500) and 750 μm (IT750) from the scleral spur, maximal iris thickness (MIT), and cross sections of the iris area (I-Area) were measured by using software. ITC was defined by the ASOCT as the contact between the peripheral iris and angle wall anterior to the scleral spur. The ITC⁺ and ITC⁻ groups were defined as eyes that had ITC in two or more quadrants and in no or one quadrant, respectively.

Results

A total of 79 eyes of 60 patients (consisting of 48 PAC and 31 PACG) were recruited. The prevalence of superior, inferior, temporal, and nasal ITC was 44 eyes (55.7%), 48 eyes (60.8%), 18 eyes (22.8%), and 16 eyes (20.2%), respectively. These iris parameters of the inferior quadrant, which had the highest prevalence of all the quadrants, were used for the analysis. After adjusting for age, sex, pupil size, and central anterior chamber depth, mean values of IT500 and IT750 were significantly greater in the ITC⁺ group than the ITC⁻ group (P<0.05). Multivariate-adjusted odds ratios of parameters for the ITC⁺ group compared with the ITC⁻ group were: IT500, 1.9 (P=0.029); IT750, 2.0 (P=0.011), MIT, 1.4 (P=0.244), and I-Area, 0.97 (P=0.406), respectively, per 0.1-unit increase.

Conclusion

Peripheral iris thickness is associated with ITC in patients with angle closure.

Foveal thickness in healthy fellow eyes of patients with unilateral macular holes

PURPOSE

To compare the morphologic parameters of ophthalmoscopically and tomographically normal foveae of the fellow eyes of patients with a unilateral macular hole (MH), other unilateral retinal diseases, and healthy eyes.

DESIGN

Observational, cross-sectional study.

METHODS

Of the 849 subjects studied, 183 eyes were excluded because they had an abnormal vitreofoveal interface that might have affected the foveal thickness. The average regional retinal thicknesses of the Early Treatment Diabetic Retinopathy Study sectors determined by spectral-domain optical coherence tomography were compared among 160 patients with MH, 175 patients with epiretinal membrane, 145 patients with retinal vein occlusion, and 186 healthy subjects. The foveal depression was quantified as the foveal pit depth divided by the foveal pit diameter.

RESULTS

The fovea (1 mm) and central fovea were significantly thinner in the MH group (243 and 192 μm) than in the other groups (P < .0001). There were no significant differences in the thickness of the fovea and central fovea among the eyes with epiretinal membrane (254 and 203 μm) or retinal vein occlusion (251 and 202 μm) or in the healthy group (254 and 201 μm). The foveal depression was significantly greater in the MH group (0.063) than in the retinal vein occlusion group (0.059) or in the healthy group (0.058; P = .014 and P = .0014, respectively). Multiple regression analyses showed that a thinner fovea and a deeper foveal depression were associated significantly with the presence of MH (P = .0054 to P < .0001).

CONCLUSIONS

These results suggest that patients with MH have unique foveal morphologic features that predispose them to MH development.

Three-dimensional foveal shape changes after asymptomatic macular posterior vitreous detachment

Purpose

To show a case in which the shape of the fovea changed after an asymptomatic macular posterior vitreous detachment (PVD).

Methods

The foveal shape was determined from the spectral-domain optical coherence tomography (OCT) images before and after a spontaneous macular PVD.

Results

A 66-year-old man with a unilateral macular hole in the right eye presented with a perifoveal PVD in the asymptomatic left eye. One year later, the left eye developed a macular PVD, and OCT measurements showed a 16.7% decrease in the central foveal thickness, and increases in the pit depth by 20.5%, foveola diameter by 14.7%, and pit volume by 19.4%. The thicknesses of the macular subfields of the Early Treatment Diabetic Retinopathy Study were decreased by 13.0% in the central subfield and by 1.4%–6.6% in the other subfields.

Conclusion

The deepening and widening of the fovea after a macular PVD indicate that a PVD can alter the shape of the fovea.

Retinal thickness after vitrectomy and internal limiting membrane peeling for macular hole and epiretinal membrane

Purpose

To determine the retinal thickness (RT), after vitrectomy with internal limiting membrane (ILM) peeling, for an idiopathic macular hole (MH) or an epiretinal membrane (ERM). Also, to investigate the effect of a dissociated optic nerve fiber layer (DONFL) appearance on RT.

Methods

A non-randomized, retrospective chart review was performed for 159 patients who had successful closure of a MH, with (n = 148), or without (n = 11), ILM peeling. Also studied were 117 patients who had successful removal of an ERM, with (n = 104), or without (n = 13), ILM peeling. The RT of the nine Early Treatment Diabetic Retinopathy Study areas was measured by spectral domain optical coherence tomography (SD-OCT). In the MH-with-ILM peeling and ERM-with-ILM peeling groups, the RT of the operated eyes was compared to the corresponding areas of normal fellow eyes. The inner temporal/inner nasal ratio (TNR) was used to assess the effect of ILM peeling on RT. The effects of DONFL appearance on RT were evaluated in only the MH-with-ILM peeling group.

Results

In the MH-with-ILM peeling group, the central, inner nasal, and outer nasal areas of the retina of operated eyes were significantly thicker than the corresponding areas of normal fellow eyes. In addition, the inner temporal, outer temporal, and inner superior retina was significantly thinner than in the corresponding areas of normal fellow eyes. Similar findings were observed regardless of the presence of a DONFL appearance. In the ERM-with-ILM peeling group, the retina of operated eyes was significantly thicker in all areas, except the inner and outer temporal areas. In the MH-with-ILM peeling group, the TNR was 0.86 in operated eyes, and 0.96 in fellow eyes (P < 0.001). In the ERM-with-ILM peeling group, the TNR was 0.84 in operated eyes, and 0.95 in fellow eyes (P < 0.001). TNR in operated eyes of the MH-without-ILM peeling group was 0.98, which was significantly greater than that of the MH-with-ILM peeling group (P < 0.001). TNR in the operated eyes of the ERM-without-ILM peeling group was 0.98, which was significantly greater than that of ERM-with-ILM peeling group (P < 0.001).

Conclusion

The thinning of the temporal retina and thickening of the nasal retina after ILM peeling does not appear to be disease-specific. In addition, changes in RT after ILM peeling are not related to the presence of a DONFL appearance.

Additive intraocular pressure-lowering effect of dorzolamide 1%/timolol 0.5% fixed combination on prostaglandin monotherapy in patients with normal tension glaucoma

Purpose

To evaluate the intraocular pressure (IOP)-lowering effect of adding dorzolamide 1.0%/timolol 0.5% fixed combination (DTFC) to prostaglandin analogs (PGAs) as monotherapy in patients with normal tension glaucoma.

Methods

A prospective, clinical, case-controlled study of patients with normal tension glaucoma. Patients had been on a once-daily night dose of prostaglandins (PGs) as monotherapy and then received DTFC added to PGs for 8 weeks. The IOP was measured at 9 am, week 0 (baseline), week 4, and week 8.

Results

The baseline IOP of 40 patients who had previously been treated by prostaglandin monotherapy was 15.6 ± 2.0 mmHg at baseline. The IOPs at 4 and 8 weeks after adding DTFC to PGs were 13.5 ± 2.1 mmHg and 13.7 ± 2.2 mmHg, respectively. Significant decrease of the IOP was observed at each time point of measurement as compared with the baseline IOP before adding DTFC (P = 0.01). The percent IOP reduction from the baseline IOP at week 4 and week 8 was 13.5% ± 12.3% and 11.7% ± 13.1%, respectively. The percentage of patients who achieved 10% or more IOP reduction from the baseline IOP at week 8 was 62.5%. The baseline IOP was significantly correlated with the percent IOP reduction at week 8 (P = 0.03, r = 0.34).

Conclusion

DTFC therapy added to PGAs as glaucoma monotherapy is effective in patients with normal tension glaucoma.

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.

Incidence and factors related to macular hole reopening

PURPOSE

To determine the incidence and the factors that can cause a reopening of a macular hole (MH) after a surgical closure.

DESIGN

Retrospective, comparative, consecutive case series.

METHODS

The medical charts of all patients who underwent vitrectomy with or without internal limiting membrane (ILM) peeling for an idiopathic full-thickness MH were reviewed. In all cases, the MH was closed successfully. Simultaneous phacoemulsification with intraocular lens implantation was performed on all phakic patients who were older than 40 years.

RESULTS

Eight hundred and seventy-seven eyes of 831 patients with a mean age of 64.9 +/- 8.0 years were studied. Combined cataract extraction with vitrectomy was performed on 763 eyes of 775 phakic eyes. The mean follow-up time after MH surgery was 57.7 +/- 38.4 months (range, 1 to 175 months). Two groups were studied: an ILM-off group (n = 514) and an ILM-on group (n = 363). The MH reopened in 2 eyes (0.39%) in the ILM-off group and in 26 eyes (7.2%) in ILM-on group (P < .0001). Kaplan-Meier analysis showed higher rates of reopening in the ILM-on group than in the ILM-off group (P< .0001, log-rank test). Factors related to the reopening in the ILM-on group were refractive error (r = -0.12; P = .049) and intraoperative peripheral tear formation (r = 0.13; P = .018).

CONCLUSIONS

ILM peeling significantly decreases the incidence of the reopening of an MH. Although the pathogenesis of the reopening of MHs is still undetermined, myopia and intraoperative retinal tears may be related to the reopening.

Results of macular hole surgery combined with PEA and IOL

We evaluated the factors affecting closure and postoperative visual acuity, as well as complications among idiopathic macular hole surgery cases comprising 631 eyes in 576 patients. Almost all the surgeries were combined with simultaneous intraocular lens surgery (triple surgery). In some cases, the standard method was accompanied by internal limiting membrane peeling around the macular hole or abrasion of retinal pigment epithelium at the base of the macular holes. We found that male gender and short eye axial length were associated with closure and postoperative visual acuity. Although the frequency of peripheral retinal tears during surgery was high, the frequency of postoperative retinal detachment was less than 2%. The reopening frequency was about 5% among all cases, and was highest among eyes that underwent the abrasion method. There were no other significant complications. Internal limiting membrane peeling is effective for treatment of cases with unfavorable preoperative conditions. However, the standard method is sufficiently effective for cases with favorable preoperative conditions. Further analysis is required to evaluate postoperative visual function by methods other than visual acuity. Further study of internal limiting membrane peeling, as a treatment alternative, is also required.

Results of epiretinal membrane removal combined with PEA and IOL

We examined 558 eyes from 538 surgical cases of idiopathic epiretinal membrane with respect to the effectiveness of the triple surgery that involves concomitant intraocular lens surgery, the most appropriate timing for the evaluation of postoperative visual acuity, and the relationship between the pre- and postoperative visual acuity. From the viewpoint of the timing of the intraocular lens surgery, we classified our patients into 4 groups: (1) a phakic eye group; (2) a two-step surgery group; (3) a triple surgery group; and (4) an intraocular lens group. The visual acuity evaluation was performed in 22 eyes from the phakic eye group based on the patient's age being 45 years or younger, in all 326 eyes from the triple surgery group, and in all 86 eyes from the two-step surgery group. We excluded the intraocular lens group from the visual acuity evaluation. The timing of the visual acuity evaluation was one year after the surgery for the phakic eye and triple surgery groups, and one year after the intraocular lens surgery for the two-step surgery group. The postoperative visual acuity was correlated with the patient's age. When a patient was less than 55 years of age, the postoperative visual acuity correlated positively with age. In contrast, when a patient was 55 years of age or older, it correlated inversely with age. The postoperative visual acuity was significantly correlated with the preoperative visual acuity, and it was possible to predict the postoperative visual acuity based on a regression equation. The preoperative visual acuity necessary for a postoperative visual acuity of 20/20 or more was 20/20 for patients under 40 years old, 20/40 for 40-59 years, 20/32 for 60-79 years, and 20/20 for 80 years and older.

Advantage of combined procedure in vitreous surgery

Lens preservation facilitates the progression of nuclear cataracts after vitreous surgery among patients over 45 years old, and postoperative nuclear cataracts frequently necessitate intraocular lens surgery. Once the lens is removed, the fundus from the posterior pole to the ciliary process becomes recognizable and surgically reachable, thus making total vitreous removal possible. The complete removal of the incarcerated vitreous to the scleral wound prevents postoperative vitreous base tears, and anterior hyaloidal fibrovascular proliferation. Simultaneous vitreous surgery plus intraocular lens surgery (triple surgery) will prevent these complications before they arise. Triple surgery for patients over 45 years of age is reasonable even if they have amplitude of accommodation, and is an effective surgical strategy in that it improves both the result of the vitreous surgery and the patient's quality of life.

Surgical outcomes for patients who develop macular holes after pars plana vitrectomy

PURPOSE

To characterize outcomes for patients who develop full-thickness macular holes after pars plana vitrectomy.

METHODS

We retrospectively analyzed data for 47 consecutive patients (47 eyes) who developed full-thickness macular holes after initial pars plana vitrectomy for a variety of indications. All patients underwent a second vitrectomy and gas tamponade with or without internal limiting membrane peeling.

RESULTS

Indications for initial vitrectomy included idiopathic epiretinal membranes (11 eyes), epiretinal membranes with a pseudohole (nine eyes), macular edema resulting from various conditions (nine eyes), proliferative diabetic retinopathy (nine eyes), rhegmatogenous retinal detachment (five eyes), and miscellaneous causes (four eyes). Mean interval from initial vitrectomy to macular hole formation was 20.4 months. Mean visual acuity (VA) in the affected eye was 0.13 (20/155, Snellen equivalent). The hole was closed in 32 eyes (68%) after a single procedure. With a mean follow-up of 53 months, mean final VA improved to 0.26 (20/77); 26 (55%) eyes improved, 18 (38%) were stable, and three (6%) worsened. No severe complications occurred except one macular hole that reopened after successful closure.

CONCLUSIONS

Macular holes may develop after pars plana vitrectomy. Although additional vitrectomy can successfully close the hole and improve vision in most patients, postsurgical outcome seems to depend on the underlying condition.

LONG-TERM VISUAL OUTCOMES AFTER VITRECTOMY FOR MACULAR EDEMA WITH FOVEAL HEMORRHAGE IN BRANCH RETINAL VEIN OCCLUSION

PURPOSE

To determine the long-term visual outcomes after vitreous surgery for macular edema with foveal hemorrhage associated with branch retinal vein occlusion (BRVO).

METHODS

One hundred twenty eyes of 120 patients underwent pars plana vitrectomy with or without internal limiting membrane (ILM) peeling for macular edema with foveal hemorrhage due to BRVO with a minimum 12 months of follow-up. Simultaneous cataract extraction with intraocular lens implantation was performed on 117 phakic eyes.

RESULTS

Follow-up after surgery ranged from 12 months to 129 months (average, 48 months). Visual acuity improved in 71% of cases at the 1-year visit. Mean visual acuity significantly increased from 0.24 (median, 0.3) before surgery to 0.57 (median, 0.7) 1 year after surgery (P < 0.0001) and 0.66 (median, 0.9) at the final visit (P < 0.0001). There was a significant difference between visual acuity at 1 year after surgery and visual acuity at the final visit (P < 0.0001). Of 120 patients, 95 (79%) had final visual acuity of > or =0.5, and 55 (46%) had final visual acuity of > or =1.0. ILM removal did not seem to have significant beneficial effects on visual outcomes in this series. No serious complications occurred during the follow-up period.

CONCLUSION

After vitreous surgery for macular edema with foveal hemorrhage associated with BRVO, visual acuity continued to improve beyond 1 year after surgery. A randomized, multicenter clinical trial is warranted to determine the efficacy of this procedure.

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

PURPOSE

To report the long-term surgical outcome of vitrectomy for cystoid macular edema due to nonischemic central retinal vein occlusion (CRVO).

METHODS

A retrospective chart review of 25 consecutive eyes (25 patients) with cystoid macular edema due to nonischemic CRVO treated with vitrectomy was performed. All patients underwent a pars plana vitrectomy with the creation of a posterior vitreous detachment if still attached. Simultaneous phacoemulsification with intraocular lens implantation was also performed in phakic eyes. The main outcome measures were best-corrected visual acuity (BCVA) and changes in macular edema shown by contact-lens biomicroscopy. The mean follow-up time was 49 months (range, 16-108).

RESULTS

The median BCVA before surgery was 0.31 and the median BCVA at last follow-up was 0.67. The BCVA at the last follow-up improved at least two Snellen lines in 17 (68%), remained unchanged in 4 (16%), and worsened in 4 (16%). The BCVA was 20/40 or better in 3 eyes (12%) preoperatively and in 18 eyes (72%) at the last follow-up. During the follow-up, four patients progressed to ischemic CRVO; one of them had neovascular glaucoma requiring surgical intervention.

CONCLUSION

The data indicate that vitrectomy appears to be a possibly effective treatment in some eyes with cystoid macular edema associated with nonischemic CRVO.

Reduced incidence of intraoperative complications in a multicenter controlled clinical trial of triamcinolone in vitrectomy

PURPOSE

To evaluate the benefits and potential complications of using triamcinolone acetonide (TA) in pars plana vitrectomy (PPV).

DESIGN

Multicenter, prospective, controlled clinical trial.

PARTICIPANTS

In total, 774 patients from 8 Japanese hospitals were enrolled, with 391 patients undergoing TA-assisted PPV and 383 control patients undergoing conventional PPV.

INTERVENTION

Intraoperative use of TA to aid visualization of the vitreous.

MAIN OUTCOME MEASURES

The incidence of intraoperative complications, including retinal breaks, was evaluated. Early postoperative complications, intraocular pressure (IOP), and adverse events occurring within 3 months of the operation were also monitored.

RESULTS

The incidence of both retinal breaks and intraoperative retinal detachment was significantly lower in TA-assisted PPV than in conventional PPV. Retinal breaks were seen in 34 eyes (8.7%) undergoing TA-assisted PPV compared with 54 eyes (14.1%) undergoing conventional PPV (odds ratio [OR], 0.603; 95% confidence interval [CI], 0.381-0.955; P = 0.031). Retinal detachment was seen in only 3 eyes (0.8%) in which TA was used compared with 14 eyes (3.7%) in which TA was not used (OR, 0.204; 95% CI, 0.057-0.727; P = 0.014). In total, 388 eyes in the TA-assisted PPV group (99.2%) and 374 eyes in the conventional PPV group (97.6%) were followed up for 3 months after the operation. Although the mean postoperative IOPs were comparable in both groups, antiglaucoma eye drops were used more frequently by patients in the TA-assisted group than by those in the conventional PPV group (OR, 1.673; 95% CI, 1.126-2.484; P = 0.011). No serious adverse events, such as endophthalmitis or retinal degeneration, were observed in either group.

CONCLUSIONS

Intraoperative use of TA reduced the incidence of retinal breaks and retinal detachments in eyes undergoing PPV. There were no serious adverse events related to the intraoperative use of TA. Although antiglaucoma eye drops were required more frequently after TA-assisted PPV than after conventional PPV, IOP was well-controlled in both groups.

Long-term outcomes of vitrectomy with or without arteriovenous sheathotomy in branch retinal vein occlusion

PURPOSE

To evaluate the long-term effect of vitrectomy with or without arteriovenous sheathotomy for macular edema secondary to branch retinal vein occlusion (BRVO).

METHODS

The study was a prospective, randomized, comparative, interventional case series of 36 patients (36 eyes) who underwent pars plana vitrectomy with or without arteriovenous sheathotomy for macular edema due to BRVO of <or=8 weeks' duration of symptoms. Eighteen eyes with arteriovenous sheathotomy (sheathotomy group) were compared with 18 eyes without sheathotomy (vitrectomy group). Main outcomes measures were best-corrected visual acuity and central foveal thickness as evaluated by optical coherence tomography.

RESULTS

Baseline demographic characteristics of the groups were similar. Postoperative follow-up period ranged from 12 months to 45 months (31 months). Median best-corrected visual acuity significantly improved from 0.4 at baseline to 1.0 at the final visit in both groups, and there was no significant difference in best-corrected visual acuity at any postoperative period between the groups. Of 16 patients with duration of symptoms of <4 weeks, those with arteriovenous sheathotomy had a tendency toward better visual outcomes than those without arteriovenous sheathotomy (P = 0.064). The central foveal thickness also significantly decreased after surgery in both groups, but the differences were not significant for the two groups at each time point. No patients had severe intraoperative and/or postoperative complications.

CONCLUSIONS

Our findings suggest that vitrectomy with or without arteriovenous sheathotomy may improve the long-term functional and tomographic outcomes for patients with macular edema secondary to BRVO. Although additional arteriovenous sheathotomy did not lead to a distinct functional benefit in this series, early surgical intervention may result in better visual outcomes.

TRIAMCINOLONE ACETONIDE–ASSISTED PARS PLANA VITRECTOMY IMPROVES RESIDUAL POSTERIOR VITREOUS HYALOID REMOVAL

OBJECTIVE

To determine whether triamcinolone acetonide (TA) can facilitate residual posterior vitreous hyaloid removal in pars plana vitrectomy (PPV), we examined the ultrastructure of inner limiting membrane (ILM) removed in TA-assisted PPV for diabetic macular edema (DME).

PATIENTS AND METHODS

In this retrospective series of 38 eyes of 37 patients who underwent PPV and ILM removal for diffuse DME with posterior hyaloid attachment, 24 eyes underwent standard PPV without TA (control group), and 14 eyes underwent TA-assisted PPV (TA group). Excised ILMs during PPV were examined by transmission electron microscopy (control group, n = 20; TA group, n = 10) or scanning electron microscopy (control group, n = 4; TA group, n = 4).

RESULTS

Transmission electron microscopy clearly demonstrated that the ratio of the posterior vitreous hyaloid remaining on ILM was significantly lower (P = 0.0187) in the TA group than in the control group and also that TA-assisted PPV successfully removed posterior hyaloid in five of seven eyes with TA granules remaining on the retinal surface even after surgical separation of the posterior vitreous. Scanning electron microscopy enabled spatial analysis of the residual posterior hyaloid on ILM, which appeared in a patchy fashion in the control group.

CONCLUSIONS

TA-assisted PPV clearly demonstrated the residual posterior hyaloid on ILM and allowed more efficient removal of the posterior hyaloid than standard PPV.

LONG-TERM OUTCOMES OF INTERNAL LIMITING MEMBRANE PEELING WITH AND WITHOUT INDOCYANINE GREEN IN MACULAR HOLE SURGERY

PURPOSE

To compare the long-term anatomic closure rate and visual outcome in patients who underwent internal limiting membrane (ILM) peeling with and without indocyanine green (ICG) dye staining for idiopathic macular hole repair.

DESIGN

Retrospective, nonrandomized, comparative study of consecutive case series.

METHODS

A total of 190 eyes of 182 patients with idiopathic macular holes underwent macular hole repair between March 1998 and June 2003. Surgery consisted of pars plana vitrectomy, lensectomy if phakic, ILM peeling, intravitreal gas tamponade, and 1 week's face-down positioning. In the initial 94 consecutive eyes, ILM peeling was performed without adjuvants (non-ICG group). The subsequent 96 eyes underwent surgery with ICG-stained ILM peeling (ICG group), in which the ILM was stained with intravitreal application of 0.1 to 0.2 mL of 0.1% ICG solution.

RESULTS

Two groups of patients had comparable clinical backgrounds preoperatively. Mean follow-up time was 30.7 months in non-ICG group and 26.2 months in ICG group. Anatomic closure of the macular hole was achieved in 99% of the cases in both groups, with both groups showing statistically significant visual improvement. There was no statistically significant difference in visual acuity between the two groups at each follow-up visit. There were also no intraoperative or postoperative complications attributed to the use of ICG.

CONCLUSIONS

Long-term follow-up of patients undergoing ILM peeling for idiopathic macular hole repair shows equivalent anatomic and visual outcomes with and without the use of ICG.

Vitreous surgery with and without internal limiting membrane peeling for macular hole repair

PURPOSE

To compare surgical results for idiopathic macular holes with and without internal limiting membrane (ILM) peeling in a series of consecutive patients during an 8-year period.

METHODS

A retrospective, nonrandomized, comparative trial. Four hundred seventeen eyes with macular holes without ILM peeling were compared with 175 eyes with ILM peeling. All eyes underwent pars plana vitrectomy with intravitreous gas, followed by head-down positioning. No adjunctive therapies were used. Comparison of closure and reopening rates and visual acuity with and without ILM peeling was analyzed.

RESULTS

Initial success rate significantly improved from 81% to 92% with ILM peeling. ILM peeling significantly improved the initial success rates in all categories of preoperative features. Reopening rates significantly decreased from 7% to 0.6% with ILM peeling. Among successful cases, line improvement was 6.0 in ILM-reserved eyes and 5.8 in ILM-peeled eyes. Among all cases, line improvement was 5.4 in ILM-reserved eyes and 5.7 in ILM-peeled eyes. Initial success rate of holes measuring more than 400 microm was significantly less than that of holes measuring less than 400 microm with or without ILM peeling. Initial success rate of holes older than 6 months old was significantly less than that for holes less than 6 months old without ILM peeling.

CONCLUSIONS

Internal limiting membrane peeling shows high closure and low reopening rates in macular hole surgery. ILM peeling is beneficial in older holes but is limited in larger holes. ILM peeling does not significantly improve visual acuity.

[The efficacy of arteriovenous adventitial sheathotomy for macular edema in branch retinal vein occlusion]

PURPOSE

To examine the efficacy of arteriovenous adventitial sheathotomy (or arteriovenous decompression) for macular edema (ME) in branch retinal vein occlusion (BRVO).

PATIENTS AND METHODS

Eighty-three patients (83 eyes) who had ME in BRVO for 26 weeks or less underwent pars plana vitrectomy and internal limiting membrane dissection and were followed post-operatively for more than one year. The eighty-three eyes were divided into 38 eyes with sheathotomy(sheathotomy group) and 45 eyes without sheathotomy(non-shesthotomy group). The absorption period for ME and the difference between pre- and postoperative visual acuity(VA) at one year in the two groups were compared, and statistically significant factors were extracted.

RESULTS

The mean absorption period for ME was 3.4 months in the sheathotomy group and 4.2 months in the non-sheathotomy group, and the mean difference between pre- and postoperative VA at one year was 0.37 and 0.28, respectively. There was no significant difference between the two groups. There was no significant factor related to the absorption period for ME, but the difference between preoperative VA and postoperative VA at one year was significant.

CONCLUSION

Sheathotomy may have no additional effect on the absorption of ME or the improvement of VA after vitrectomy for BRVO.

[The influence of hard exudates on the results of vitrectomy for macular edema due to diabetic retinopathy]

PURPOSE

To demonstrate surgical results of diabetic macular edema from the distribution of hard exudates.

METHODS

We reviewed 485 eyes of 325 patients followed up more than 1 year who underwent vitreous surgery for diabetic macular edema. Four groups were identified from the distribution of hard exudates in the macular region: no hard exudate type, 179 eyes; hard exudate type, 211 eyes; macular deposit type, 73 eyes; and waxy type, 22 eyes. We evaluated the preoperative characteristics, the period required for absorption of macular edema, visual outcome, and postoperative complications among the four types.

RESULTS

In the waxy type, the macular edema was absorbed more slowly than no hard exudate type and hard exudate type(p < 0.05) more patients had proteinurea and were treated by grid photocoagulation before surgery than the other types, and the rate of occurrence of rubeotic glaucoma and attrition by death was higher than in the other types. Visual acuity was significantly improved in all types postoperatively(p < 0.05). Preoperative and postoperative visual acuity were as follows: no hard exudate type, 0.28, 0.48; hard exudate type, 0.21, 0.33; macular deposit type, 0.10, 0.17; and waxy type, 0.04, 0.11.

CONCLUSION

The distribution of hard exudates was directly related to surgical results for diabetic macular edema. The waxy type had poor prognosis.

[Subretinal washout for subtle subfoveal hard exudates in diabetic macular edema]

PURPOSE

To evaluate the efficacy of subretinal washout for subtle subfoveal hard exudates in diabetic macular edema.

METHODS

This study was done retrospectively on a series of patients with diffuse diabetic macular edema accompanied with subtle subfoveal hard exudates and operated on by one surgeon(NO). Patients ranged in age from 30 to 76 years(mean, 59 years). The postoperative follow-up interval ranged from 12 to 76 months, with a mean of 35 months. Two groups were identified. The first group contained all 26 eyes that had vitreous surgery with subretinal washout. This was compared with a second group of 51 eyes without subretinal washout. We compared the rate of occurrence of postoperative massive foveal hard exudates, visual acuity results, and complications with and without subretinal washout.

RESULT

There was no significant difference in base line demographics between the two groups. Massive foveal hard exudates did not occur in eyes with subretinal washout, but occurred in 29 (57%) of the eyes without subretinal washout(p < 0.0001) and in 15 eyes which had undergone reoperation with subretinal washout. Visual acuity improved in 54% of the subretinal washout eyes and 45% of the eyes without it. Visual acuity improved to 20/30 or better in 23% of the eyes with subretinal washout and in 8% of the eyes without subretinal washout. There was no serious complication related to subretinal washout.

CONCLUSION

Subretinal washout for subtle subfoveal hard exudates in diabetic macular edema may prevent massive subfoveal exudates and improve visual results. Further study is needed to investigate the pathogenesis.

Strabological findings after macular translocation surgery with 360 degrees retinotomy

PURPOSE

To examine the strabological findings after macular translocation surgery with a 360 degrees retinotomy.

METHODS

Thirty-two patients who underwent macular translocation surgery were divided into three groups based on their responses to the Bagolini striated lenses test: fusion, ignoring the image, and diplopia. The relevant factors affecting binocularity were compared among the three groups.

RESULTS

Five patients had peripheral fusion and three of these had gross stereopsis. Fifteen patients ignored the second image, and 12 patients had diplopia. The objective angle of macular rotation was smaller in the patients with peripheral fusion (15.0 +/- 6.1 degrees) than in those with diplopia (32.7 +/- 11.7 degrees). The subjective angle of cyclotorsion in those with peripheral fusion (6.0 +/- 4.2 degrees) was smaller than in those who ignored the image ("ignoring" group; 20.5 +/- 9.19 degrees) and the diplopia group (30.7 +/- 12.8 degrees). The amount of torsional sensory compensation in patients with diplopia (2.08 +/- 3.83 degrees) was significantly smaller than in those with peripheral fusion (9.00 +/- 7.42 degrees) and in the ignoring group (6.73 +/- 3.86 degrees). Patients with peripheral fusion were significantly younger (54.2 +/- 14.3 years) than those in the ignoring group (67.7 +/- 10.0 years) and those with diplopia (68.0 +/- 5.4 years).

CONCLUSIONS

Adaptive mechanisms are activated to reduce the surgically induced objective angle of cyclotorsion, and a cyclodeviation of 15 degrees was the critical angle separating those who had peripheral fusion from those who did not. This value corresponds to the cyclofusional amplitude in normal adults.

Prognostic Factors in Breast Cancer and their Limitations

Evaluation of the prognosis of patients with breast cancer is criticai in determining post-surgical adjuvant therapy because of great heterogeneity in response to the therapy, At present, the decision-making for adjuvant therapy largely depends on histologic nodal status, but a significant number of patients without nodal involvement undergo relapse. Although great efforts have been made for more accurate and potent factors, significant indicators have not yet been found. One of the promising candidates, however, is histologic angiogenesis in tumors, which we and others have indicated as an independent prognostic factor in node-negative subset by the multivariate analysis. Here we will evaluate several prognostic factors in clinical use.

[Vitreous surgery for macular edema in branch retinal vein occlusion]

PURPOSE

To examine the efficacy of vitreous surgery for macular edema in branch retinal vein occlusion (BRVO).

PATIENTS AND METHODS

This study included 183 patients (183 eyes) that underwent vitreous surgery for macular edema in BRVO. They were 77 males and 106 females. The average age of the patients was 65 years (range, 35-87 years). The average duration of macular edema was 18 weeks (range, 1-161 weeks). Mean preoperative visual acuity was 0.32 (0.01-1.2). Preoperative visual acuity was less than 0.1 in 27% and more than 0.5 in 26% of the cases. The average follow-up period was 24 months (range, 12-83 months).

RESULTS

Macular edema was absorbed in 21% at 1 month, 54% at 3 months, 81% at 6 months, and 95% at 12 months postoperatively. The mean absorption period of macular edema was 4.5 months. Postoperative visual acuity improved to 0.68, which was statistically significant. Postoperative visual acuity was less than 0.1 in 9% of the cases, more than 0.5 in 68%, and more than 0.8 in 47%.

CONCLUSION

After vitreous surgery for macular edema in BRVO, macular edema was absorbed rapidly and visual acuity improved. Vitreous surgery may be an effective treatment.

[Surgical removal of subfoveal hard exudates in diabetic maculopathy]

PURPOSE

To examine the efficacy of surgical removal of subfoveal hard exudates during surgery in diabetic maculopathy.

PATIENTS AND METHODS

This study was done on 60 patients (66 eyes) that all underwent surgical removal of subfoveal hard exudates under the same surgeon. Thirty-two men (37 eyes) and 28 women (29 eyes) were included in this study. The average age of the patients was 60 years (range, 30-77 years). The average follow-up period was 21 months (range, 12-48 months). All eyes were classified into 3 groups: 13 postoperative massive type eyes, 31 massive type eyes, and 22 scatter type eyes. We evaluated the visual results of these types.

RESULTS

Preoperative and postoperative mean visual acuity was as follows: postoperative massive type 0.11, 0.22, massive type 0.12, 0.29, and scatter type 0.19, 0.33. Postoperatively visual acuity improved significantly in all types. There were no subfoveal hard exudates postoperatively in any eyes.

CONCLUSION

Surgical removal of massive subfoveal hard exudates is effective, but its effects on vision are limited. Surgical removal of deposited subfoveal hard exudates may prevent massive subfoveal hard exudates postoperatively and improve visual prognosis.

[Internal limiting membrane peeling in vitreous surgery for diabetic macular edema]

PURPOSE

To evaluate the effect of internal limiting membrane (ILM) peeling in vitreous surgery for diabetic macular edema.

METHODS

This study was done on 135 eyes of 103 patients who all underwent diabetic macular edema surgery under the same surgeon. The subjects were 74 eyes of 55 males and 61 eyes of 48 females, aged 35-81 years, with an average of 62 years. The postoperative follow-up period ranged from 12 to 39 months, with an average of 20 months. The ILM peeling was performed in 74 eyes. The subjects were divided in two types of macular edema from the presence (type II, 81 eyes) or absence (type I, 54 eyes) of hard exudates in the macular region. We evaluated the effects of the ILM peeling on the absorption rate of macular edema, the period required for absorption of macular edema, and the postoperative visual acuity.

RESULTS

The absorption rate of macular edema was more than 90% with or without the ILM peeling. The period required for absorption of macular edema in eyes with ILM peeling was shorter in type II. There was no difference in the postoperative visual acuity with or without ILM peeling. ILM peeling was not an important factor for the postoperative visual acuity.

RESULTS

ILM peeling accelerates the absorption of edema in more severe diabetic macular edema, but we could not find any improvement of visual acuity.

[Vitrectomy for pseudophakic cystoid macular edema]

PURPOSE

To evaluate the effect of vitrectomy for pseudophakic cystoid macular edema(CME).

PATIENTS AND METHODS

This study included 34 eyes of 31 patients that underwent vitrectomy for CME after intraocular lens(IOL) surgery without complications. CME was diagnosed by slit-lamp biomicroscopy with contact lens. Visual acuity and CME status were evaluated preoperatively and postoperatively. The interval between IOL surgery and vitrectomy was from 1 to 52 months, with an average of 11 months. Vitreous gel was beneath the iris in all cases, and there was no adhesion to the anterior segment. Preoperative visual acuity ranged from 0.1 to 0.9, with an average of 0.44.

RESULTS

CME was resolved postoperatively in all cases. Resolution period ranged from 1 to 12 months, with an average of 2.6 months. Visual acuity improved postoperatively and ranged from 0.1 to 1.2, with an average of 0.84. The factors related to postoperative visual acuity were IOL-CME interval, preoperative visual acuity, and the period of CME resolution. The factor related to the period of CME resolution was preoperative visual acuity.

CONCLUSION

After vitrectomy for CME after IOL surgery without complications, CME resolves quickly and visual acuity improves. Early vitrectomy has good visual results.

[Clinical features of idiopathic macular holes-differences between sexes and stages]

PURPOSE

The purpose of this study was to evaluate the differences in the clinical features of idiopathic macular holes between sexes and stages.

METHODS

Five hundred and twenty-six eyes of 480 patients with stage 3 or 4 idiopathic macular hole that had undergone vitrectomy were observed consecutively in this study. The each stage ratio, bilaterality, and affected eye were examined and the differences in age, hole duration, hole size, visual acuity, refractive power, axial length, and corneal refractive power were evaluated.

RESULTS

Twenty-six % of the cases were stage 4 in males and 31% in females. There were no significant differences in bilaterality or affected eye between the sexes. Younger age and larger size were found in females of stage 3. Larger size was found in stage 4. More myopic eye and longer axial length were found in males of stage 4. There were no significant differences in hole duration and visual acuity between sexes or stages.

CONCLUSIONS

In females the onset of macular hole occurred at a younger age than in males, size of the hole was larger from an earlier stage, and refractive power was less myopic. More myopic eye and longer axial length were found in stage 4, especially in males. This fact might be related to the existence of posterior vitreous detachment. We concluded that there were some differences in the mechanism of the onset and the progression of idiopathic macular hole between males and females.

[Operculum in idiopathic macular holes]

PURPOSE

To detect the factors related to the operculum in idiopathic macular holes and present a pathogenesis of idiopathic macular holes.

METHODS

This study included 583 eyes of idiopathic macular hole that underwent macular hole surgery. To detect the factor related to the operculum, the variables of age, duration of symptoms, hole size, preoperative visual acuity, refraction, axial length, refraction axial length ratio were used for the comparison between two groups and multiple regression. The success rate of surgery and postoperative visual acuity were examined whether the operculum was present or not.

RESULTS

The variables that were significantly related to the operculum were as follows: refraction axial length ratio (r = 0.18, p = 0.0092) in women of stage 3, duration of symptoms (r = -0.44, p < 0.001), preoperative visual acuity (r = -0.33, p = 0.0025), and refraction axial length ratio (r = -0.22, p = 0.020) in women of stage 4, and age (r = 0.19, p = 0.047) in men of stage 3. There were no significant differences in the success rate of surgery and postoperative visual acuity whether the operculum was present or not.

CONCLUSIONS

Generally, operculum tends to occur in aged and round eyes and possibly does not occur in younger and back projected eyes because of retinal fissure. In women of stage 4, the operculum is possibly a torn retina and does not occur in atrophic holes.

[Factors related to intraoperative retinal breaks in macular hole surgery]

PURPOSE

To evaluate the factors of intraoperative retinal breaks in macular hole surgery.

METHODS

This study included 558 eyes of 506 patients who underwent idiopathic macular hole surgery by one surgeon. Multiple regression was performed using the variables of gender, age, affected eye, lens status, stage, duration of symptoms, hole size, axial length, and lattice degeneration.

RESULTS

The rate of retinal breaks was higher in stage 3 (16.0%) than in stage 4 (8.2%) (p = 0.014). In eyes with lattice degeneration intraoperative retinal breaks occurred in about 40% of the cases. Major factors were as follows: lattice degeneration (r = 0.24, p < 0.0001) in all eyes, stage (r = 0.090, p = 0.048) in eyes without lattice degeneration, and gender (r = -0.18, p = 0.035) in eyes of stage 4 without lattice degeneration.

CONCLUSIONS

The factors of intraoperative retinal breaks in macular hole surgery were lattice degeneration in all eyes and stage 3 in eyes without lattice degeneration. The high incidence of intraoperative retinal breaks in stage 3 was mainly due to the occurrence of posterior vitreous detachment. Male gender was a significant factor associated with intraoperative retinal breaks.

Refraction and Anterior Chamber Depth Change After Vitrectomy for Pseudophakia

Purpose: To evaluate the association between the vitreous and the refractive error in pseudophakia.Methods: Vitrectomy was performed in 67 eyes of 61 patients who underwent cataract surgery. Vitrectomy was needed for epiretinal membrane in 30 eyes, macular edema in 22 eyes, macular hole in 3 eyes, lamelar macular hole in 2 eyes, macular hole in 3 eyes, lamelar macular hole in 2 eyes, vitreous opacity in 6 eyes, and vitreous hemorrhage in 4 eyes. Refraction was measured before the operation, and 1 month, 3 months, 6 months, and 12 months after operation. Anterior chamber depth was measured in 10 eyes before the operation, and 1 month, 3 months, and 6 months after operation. We evaluated the refractive error after vitrectomy in 49 eyes that had predicted refraction.Results: The mean value of refractive change was -0.3 D 1 month postoperatively, and then gradually became positive. The variation of refraction (6-month postoperative refraction minus preoperative refraction) was negatively correlated with preoperative refraction (P =.0052, R(2) = 0.146). If preoperative refraction was more myopic than -1.5 D, then refraction became positive. If preoperative refraction was not more myopic than -1.5 D, then refraction became negative.Conclusion: About 15% of postoperative refractive error may be associated with the vitreous, but further investigation is required.

Incidence of Reopening and Variables That Influence Reopening After Macular Hole Surgery

Purpose: To evaluate the incidence and variables of reopening of macular holes after macular hole surgery.Methods: Our study included 467 eyes in which macular holes were successfully closed after surgery. Surgical techniques consisted of conventional methods (358 eyes) and scalping methods (109 eyes) with retinal pigment scalping of the macular hole basis added in such cases: reoperation, hole size (more than 0.4 disc diameter), duration of symptoms (more than 2 years). Long term incidence of reopening was predicted by life table method. After we compared reopened cases with non-reopened cases, the variables of gender, stage, biocular occurrence, age, duration of symptoms, hole size, preoperative visual acuity, refraction axial length ratio, and intraoperative retinal tears were used for the multiple regression.Results: Reopening was found in 20 eyes (5.6%) treated by conventional methods and in 10 eyes (9.2%) treated by scalping methods. Survival ratio was 87% for the conventional methods in 6 years and 79% for the scalping methods in 5 years. The variables influencing reopening were as follows: conventional methods: gender (r = 0.065, P =.19), biocular occurrence (r = 0.12, P =.026), and refraction axial length ratio (r = -0.11, P =.045); scalping methods: hole size (r = 0.14, P =.25).Conclusions: Incidence of reopening in scalping methods was high. The variables that influenced reopening after macular hole surgery were biocular occurrence and refraction axial length ratio in conventional methods. The shape of the eye may be related to reopening.

Variables That Influence Visual Acuity After Macular Hole Surgery

Purpose: To evaluate the variables that influence visual acuity and visual improvement after macular hole surgery.Methods: Our study included 421 eyes in which macular holes were successfully closed after surgery and followed up at least 1 year after the last surgery. Surgical techniques were conventional methods (Group 1: 350 eyes) with retinal pigment scalping of the macular hole basis added in the refractory cases (Group 2: 71 eyes). The variables used for the multiple regression were gender, age, preoperative visual acuity, hole stage, duration of symptoms, hole size, and axial length.Results: The variables that most influenced postoperative visual acuity were as follows: Group 1: gender (r = -0.011, P =.016), age (r = -0.17, P =.005), preoperative visual acuity (r = 0.51, P <.0001), duration of symptoms (r = -0.015, P <.0001), and axial length (r = -0.090, P =.045). Group 2: age (r = -0.18, P =.047), and preoperative visual acuity (r = 0.47, P <.0001).Conclusions: The variables that influenced visual acuity and visual improvement after macular hole surgery were common. In Group 1: gender, age, preoperative visual acuity, duration of symptoms, and axial length; in Group 2: age and preoperative visual acuity.

DNA sequence and comparison of virulence plasmids from Rhodococcus equi ATCC 33701 and 103

The virulence plasmids of the equine virulent strains Rhodococcus equi ATCC 33701 and 103 were sequenced, and their genetic structure was analyzed. p33701 was 80,610 bp in length, and p103 was 1 bp shorter; their sequences were virtually identical. The plasmids contained 64 open reading frames (ORFs), 22 of which were homologous with genes of known function and 3 of which were homologous with putative genes of unknown function in other species. Putative functions were assigned to five ORFs based on protein family characteristics. The most striking feature of the virulence plasmids was the presence of a 27,536-bp pathogenicity island containing seven virulence-associated protein (vap) genes, including vapA. These vap genes have extensive homology to vapA, which encodes a thermoregulated and surface-expressed protein. The pathogenicity island contained a LysR family transcriptional regulator and a two-component response regulator upstream of six of the vap genes. The vap genes were present as a cluster of three (vapA, vapC, and vapD), as a pair (vapE and vapF), or individually (vapG; vapH). A region of extensive direct repeats of unknown function, possibly associated with thermoregulation, was present immediately upstream of the clustered and the paired genes but not the individual vap genes. There was extensive homology among the C-terminal halves of all vap genes but not generally among the N-terminal halves. The remainder of the plasmid consisted of a large region which appears to be associated with conjugation functions and a large region which appears to be associated with replication and partitioning functions.

[Factors related to initial success in macular hole surgery]

PURPOSE

To evaluate the factors of initial success in macular hole surgery.

METHODS

This study included 526 eyes of 480 patients who underwent idiopathic macular hole surgery by one and the same surgeon. Surgical methods included conventional method (392 eyes), retinal pigment epithelium (RPE) scalping (61 eyes), internal limiting membrane (ILM) removal (62 eyes), and RPE scalping combined with ILM removal (11 eyes). To evaluate the factors of initial success multiple regression was performed using the variables of (gender, age, stage, duration of symptoms, hole size, axial length, and preoperative visual acuity).

RESULTS

The rate of initial success was 81.4% in all eyes, 80.9% in the conventional method, 78.7% in RPE scalping, 83.9% in ILM removal, and 100% in RPE scalping combined with ILM removal. Significant factors of initial success were as follows: gender (r = -0.091, p = 0.053), age (r = -0.14, p = 0.0062), duration of symptoms (r = -0.23, p < 0.0001), hole size (r = -0.23, p < 0.0001), and axial length (r = -0.21, p < 0.0001) in the conventional method, hole size (r = -0.56, p = 0.0006) in ILM removal and stage (r = -0.43, p = 0.0011) and preoperative visual acuity (r = 0.30, p = 0.018) in RPE scalping.

CONCLUSIONS

Significant factors of initial success were being male being young, shorter duration of symptoms, smaller hole size, and shorter axial length in the conventional method, smaller hole size in ILM removal and stage 4 and better preoperative visual acuity in RPE scalping method.