Evaluation of the efficacy and safety of pars plana vitrectomy with irido-zonulo-hyaloidotomy for malignant glaucoma

PURPOSE

To assess the efficacy and safety of pars plana vitrectomy with irido-zonulo-hyaloidotomy (IZH) for fluid misdirection syndrome (FMS) in pseudophakic eyes.

METHODS

This was a retrospective case series study of patients treated with pars plana vitrectomy with IZH for FMS between February 2017 and March 2020. Complete success was defined as central anterior chamber (AC) deepening with an intraocular pressure (IOP) of 21mmHg or less (on 2 consecutive visits at least 1 week apart) without topical or systemic glaucoma medications. Qualified success was defined as central AC deepening with an IOP of 21mmHg or less (on 2 consecutive visits at least 1 week apart) with topical or systemic glaucoma medications.

RESULTS

Twelve eyes of 12 patients with a diagnosis of FMS were included. The mean age of the population was 73.6±15.4 years [39-90] with a majority of women (58.3%). Prior surgeries at the time of FMS diagnosis were trabeculectomy (4 eyes) and non-perforating deep sclerectomy (2 eyes). At presentation, mean IOP was 38.2±9.8mmHg, which decreased to 17.9±7.7mmHg (P<0.0001) at final follow-up (mean follow-up of 4.9±4.3 months). Complete success was achieved in 6 eyes (50%) and qualified success in 10 eyes (83%), with two eyes failing treatment. There was no statistical significant relationship between demographic data and clinical success (P > 0.05).

CONCLUSION

Pars plana vitrectomy combined with IZH appears to be a safe and effective technique for the treatment of FMS in pseudophakic patients.

[Medico-surgical management of intravitreal hemorrhage in diabetic patients]

Vitreous hemorrhage (VH) is the main complication of proliferative diabetic retinopathy and remains the primary indication for vitrectomy in diabetic patients. The objective of our study is to compare our medical and surgical management of VH with data from the literature and to report the functional results of our series. We studied a series of 284 cases collected over 2 years in two tertiary care centers. In our series, 90.1% of patients had type 2 diabetes, and 70% had glycosylated hemoglobin greater than 7.5%. On fundus examination, 35.2% presented with stage 1 VH, 42.6% with stage 2, 3.6% with stage 3 and 5.2% with stage 4. Ocular ultrasound performed when fundus exam was difficult diagnosed an associated tractional retinal detachment in 8.8% of patients. Medical treatment was sufficient in 77.8% of patients, while 22.2% of our patients underwent vitrectomy, argon laser endophotocoagulation and postoperative anti-VEGF injection. Peeling of tractional fibrovascular membranes and or associated epiretinal membranes was performed in 69.8% of cases. Iatrogenic tears were noted in 11.8% of patients. In this study, 31.5% of patients underwent intraocular gas tamponade, while 23.8% of cases underwent silicone oil tamponade. Postoperative visual acuity improved by at least 2 lines in 60% of our patients, and the VH recurred in 24.2% of cases after surgery.

Human amniotic membrane graft for refractory macular hole: A single-arm meta-analysis and systematic review

PURPOSE

The treatment of refractory macular holes is controversial, with human amniotic membrane grafts emerging recently as an attractive option. We performed a meta-analysis and systematic review in this paper to assess the results of human amniotic membrane (hAM) in the treatment of refractory macular hole (MH).

METHODS

We searched the Cochrane Database of Systematic Reviews, Web of Science, PubMed, Embase, China National Knowledge Infrastructure databases, VIP database, Wanfang Data Knowledge Service Platform, Sinomed, Chinese Clinical Trial Registry, and Clinical Trials.gov. Studies reporting hAM for the treatment of refractory MH were included. The outcomes are MH closure rate, visual acuity (VA) improvement rate, and graft dislocation/contracture rate.

RESULTS

A total of 8 studies on 103 eyes were included, all of which had undergone failed vitrectomy and internal limiting membrane (ILM) peeling. In all studies, the VA improvement rate was 66% (95%CI: 45 to 84%), the MH closure rate was 94% (95%CI: 84 to 100%) and the hAM graft dislocation/contracture rate was 6% (95%CI: 0 to 15%). In the studies using cryopreserved hAM grafts, the MH closure rate was 99% (95%CI: 94 to 100%) and the hAM graft dislocation/contracture rate was 3% (0%, 10%). The VA improvement rates were 94% (95%CI: 79 to 100%) in the retinal detachment subgroup, 37% (95%CI: 20 to 56%) in the pathologic myopia subgroup, and 62% (95%CI: 14 to 100%) in the idiopathic MH subgroup.

CONCLUSION

Human amniotic membrane in the treatment of refractory MH results in visual improvement. It has a high macular hole closure rate and low dislocation/contracture rate. Cryopreserved hAM grafts might have better outcomes than dehydrated grafts.

Comparison of two techniques in posterior lens dislocations: Scleral suture fixation vs. modified Yamane intrascleral lens fixation

PURPOSE

To compare the use of Yamane flanged intrascleral haptic fixation and scleral suture fixation (SSF) techniques in combination with pars plana vitrectomy (PPV) for treatment of posterior lens dislocations.

METHODS

Patients who underwent PPV and scleral fixated IOL implantation due to subluxation/luxation of the crystalline lens/intraocular lens (IOL) were included in this retrospective study. The Yamane group included patients who underwent Yamane flanged intrascleral haptic fixation technique, while the SSF group consisted of patients who underwent conventional SSF. All patients underwent comprehensive ophthalmologic examinations preoperatively and postoperatively. Intraoperative and postoperative complications were recorded.

RESULTS

The Yamane group comprised of 39 eyes of 39 patients, and the SSF group included 35 eyes of 35 patients. Postoperative complications included hyphema (Yamane group: 2/39 (5.1%); SSF group: 0/35 (0%)) IOL decentration (Yamane group: 5/39 (12.8%); SSF group: 0/35 (0%)), corneal edema (Yamane group: 4/39 (10.2%); SSF group: 0/35 (0%)) cystoid macular edema (CME) (Yamane group: 1/39 (2.5%); SSF group: 3/35 (8.5%)) and retinal detachment (Yamane group: 1/39 (2.5%); SSF group: 1/35 (28.5%). The mean surgery time was significantly lower in the Yamane group compared with the SSF group (P<0.001). No cases of hypotony, conjunctival erosion, haptic exposure or endophthalmitis were encountered throughout follow-up.

CONCLUSION

SSF remains a safe and effective technique for management of posterior lens dislocations. The Yamane intrascleral IOL fixation technique is an effective alternative to conventional SSF, which has a relatively steep learning curve. Postoperative complications, including IOL tilt and decentration, may be experienced in the initial cases.

[Retained lens fragments after cataract surgery: Comparison of same-day versus delayed vitrectomy]

PURPOSE

To evaluate and to compare functional outcomes and complication rates of the same-day versus delayed pars plana vitrectomy (PPV) for intravitreal retained lens fragments after cataract surgery.

METHODS

Retrospective comparative series of 135 eyes with retained lens fragments that underwent PPV between August 2014 and July 2016. Sixty-two eyes received same-day PPV (group 1) and seventy-three eyes underwent delayed PPV (group 2). Outcome measures included best-corrected visual acuity (BCVA) at 6 months and postoperative complications.

RESULTS

The mean time to PPV in group 2 was 4.3±5.3 days. Mean axial length, lens fragment size and surgical technique were comparable in both groups. At 6 months, BCVA was 0.27±0.40 logMAR in group 1, and 0.35±0.30 logMAR in group 2, with no significant difference (P=0.205). Fifty-one (82.2%) eyes in group 1 and 53 (72.6%) eyes in group 2 achieved BCVA of+0.30 logMAR (20/40) or better (P=0.183). The most common complications were macular edema, elevated intraocular pressure>25mmHg, and retinal detachment occurring respectively in 10 (16.1%) eyes, 4 (6.4%) eyes and one eye (1.6%) in group 1 and 11 (15.0%) eyes, 5 (6.8%) eyes and 2 (2.7%) eyes in group 2. Overall, the complication rate was similar in both groups (P=1).

CONCLUSION

Our study shows that visual acuity outcomes and complication rates were similar regardless of timing of the PPV. The optimal timing of surgery remains a multifactorial decision involving patient preferences, transportation, surgeon availability and severity of the initial presentation.

[Long-term functional and anatomical effects after macular hole surgery with internal limiting membrane peeling]

INTRODUCTION

To study the functional and anatomical effects of internal limiting membrane (ILM) peeling in macular hole surgery with a minimum follow-up of 10 years.

METHODS

Retrospective study of patients who underwent successful macular hole surgery prior to 2010. All patients underwent vitrectomy and ILM peeling after staining. Functional assessment included measurement of visual acuity and retinal sensitivity using microperimetry (NIDEK MP-3) as well as a subjective visual function questionnaire. Anatomical assessment was based on evaluation of the macular region and optic nerve using spectral domain optical coherence tomography (SD-OCT) with comparison to the fellow eye.

RESULTS

Fourteen women and five men were included. Visual acuity of operated eyes (0.07±0.08logMar) was not significantly different from that of fellow eyes (0.04±0.08logMar) (P=0.10). The mean retinal sensitivity of the operated eyes was 25.1±1.9dB with no difference from the fellow eyes 25.2±1.6dB (P=0.82). However, 2 patients exhibited 2 relative scotomas >10dB. On questioning, 3/19 patients (16%) described a disturbing scotoma in monocular vision, while 11/19 (58%) described metamorphopsia, and 3 subjectively assessed their visual loss at more than 60%. The external limiting membrane was present and intact in all patients, and the ellipsoid zone was restored in 16/19 patients (84%). The cone interdigitation zone was intact in 9 patients, altered in one patient and not interpretable in 9 patients. Retinal optic nerve fiber layer thickness showed a moderate loss of fibers in the operated group 95.9±9.5 versus 101.5±10.9 (P=0.001) in the fellow eyes. The ganglionic complex thickness in the operated eyes (90.1±8.3) was not significantly different from that of fellow eyes (91.9±8.8) (P=0.37).

CONCLUSION

ILM peeling in macular hole surgery induces anatomical changes in the inner layers of the retina, still visible on SD-OCT 10 years after the procedure. However, this remodeling of the inner layers does not appear to have significant deleterious effects on patients' retinal sensitivity or vision.

Posterior segment Intra-Ocular Implant (IOL) dislocation: Predisposing factors, surgical management, outcome analysis

PURPOSE

To evaluate the predisposing factors, management and visual prognosis of intraocular Lens (IOL) dislocation into the posterior segment.

METHODS

The cases of posterior IOL dislocation from January 2012 to May 2017 at 2 centers were reviewed. Only eyes with dislocations requiring IOL explantation or repositioning were included. Predisposing factors, interval between cataract surgery and IOL dislocation, circumstances of onset, management, and postoperative complications are reported.

RESULTS

72 eyes of 72 patients were included. The mean age was 67.6 years. 47 patients (68%) were men. The mean time interval from cataract surgery to IOL dislocation was significantly shorter in the out-of-the bag group than the in-the-bag IOL dislocation group (3.8 months vs 132 months, P=0.002). Predisposing factors for out-of-the-bag IOL dislocation were mainly capsular rupture and/or zonular dehiscence (83%) after complicated cataract surgery. The predisposing factors for in-the-bag IOL dislocation were high myopia (40%), pseudoexfoliation syndrome (40%), previous vitrectomy (38%), or Marfan syndrome (3%) with uneventful cataract surgery. The type of luxated implant was mainly a 3-piece foldable IOL (50%), followed by foldable one-piece IOL (28%) and a rigid one-piece IOL (17%). Most cases of posterior chamber IOL dislocation occurred spontaneously (80%) without a trigger event. Management consisted of a posterior approach in 24 cases (33%) or an anterior approach in 48 cases (67%), associated with IOL repositioning in 20 eyes (28%), and IOL replacement in 34 eyes (47%). Finally, 18 eyes (25%) were left aphakic. Postoperative complications occurred in 7 cases (9.7%).

CONCLUSIONS

Predisposing factors and time from cataract surgery to IOL dislocation were different for out-of-the bag versus in-the-bag IOL dislocation. Management of IOL dislocation varied considerably, depending on surgeon preference and experience. Surgery for IOL dislocation significantly improved best corrected visual acuity and was associated with a low complication rate.

[Treatment of submacular hematoma by vitrectomy, subretinal injection of rtPA and gaseous tamponade: A single-center retrospective observational study]

OBJECTIVES

To evaluate the functional and anatomic recovery of submacular hemorrhage (SMH), treated with vitrectomy, subretinal injection of rtPA and gas tamponade, to highlight the risk factors for their occurrence as well as the factors influencing prognosis.

MATERIALS AND METHODS

This is a single-center retrospective study. Thirty-two eyes of 30 patients from the Clermont-Ferrand University Hospital were included, with a submacular hemorrhage (SMH) requiring surgical evacuation. The primary endpoint was final postoperative visual recovery. Visual acuities (AV) were converted to the logarithmic minimum angle of resolution scale (logMAR) for statistical analysis.

RESULTS

The average time from onset of symptoms to surgery was 4.8±3.3 days. The initial VA was 2.1±0.3 logMAR, with an average improvement of 0.7±0.7 logMAR (P=0.0004) at the final visit. The mean thickness of the SMH decreased by 729±352μm (P<0.0001) at the final visit.

CONCLUSION

Treatment of SMH with vitrectomy, subretinal injection of rtPA and gas tamponade results in a statistically significant improvement in final VA, as well as a significant decrease in SMH thickness on OCT.

[Combined vitrectomy-lensectomy surgery with bag-in-the-lens or lens in the bag implantation: comparison of final visual acuity]

INTRODUCTION

Combined vitrectomy-lensectomy surgery is a safe and effective procedure. Nevertheless, it is frequently complicated by posterior capsule opacification and the formation of posterior synechiae. These complications can be avoided by placing a "bag in the lens" (BIL) implant. The objective of this study is to compare the visual acuity gain (VA) after combined vitrectomy-lensectomy surgery between a group implanted with the BIL technique and a group with implantation in the bag (LIB).

MATERIAL AND METHODS

We included in the study all vitrectomy-lensectomy procedures for epiretinal membrane and vitreomacular traction performed between May 2013 and July 2016 at the Hospital and University Center of Caen. We compared the VA gain between the BIL group and the LIB group six months after surgery.

RESULTS

A total of 33 patients were included in the study, consisting of 28 eyes in the BIL group and 8 eyes in the LIB group. The mean VA gain in the BIL group was -0.52 LogMAR (P<0.0001) and -0.56 LogMAR (P=0.0047) for the LIB group. The difference between the two groups was not significant (P=0.74).

CONCLUSION

The use of the BIL technique during vitrectomy-lensectomy allows visual recovery as good as implantation within the capsular bag. In addition, this implant has the advantage of significantly reducing the occurrence of posterior synechiae and preventing anterior and posterior capsular proliferation.

[Treatment of hematomas in age related macular degeneration by vitrectomy and subretinal injection of r-tPA: Preliminary results (French translation of the article)]

PURPOSE

To evaluate anatomical and functional outcomes of surgical displacement of macular hemorrhages complicating exsudative age-related macular degeneration (AMD) after vitrectomy, subretinal rtPA (recombinant tissue plasminogen activator) injection, intravitreal bevacizumab injection and gaz tamponade.

METHODS

Retrospective case series, including 26 patients with submacular hemorrhage, who underwent a surgical displacement within 15 days after the onset of symptoms. Optical coherence tomography (OCT) was carried out to measure the diameter of the hemorrhage and to specify the relation with retinal pigment epithelium. Anatomical success was defined as a total displacement of the hemorrhage away from the fovea at first postoperative visit. Visual acuity improvement was measured at 1 and 6 months and at final postoperative visit.

RESULTS

The procedure resulted in hemorrhage displacement away from the fovea in 20 eyes (81%). Visual acuity significantly improved by 5,8 (±7,2) lines (P=0.0003) at 1 month postoperatively, 7,4 (±6,7) lines (P=0.0004) at 6 months and 7,4 (±7,4) lines (P=0.0002) at final postoperative visit (16,5±19,8 months). There was an inverse correlation between hemorrhage diameter and final acuity improvement (Pearson correlation coefficient P=-0.60 (IC 95% [-0.81; -0.26]; P=0.002)).

CONCLUSION

Vitrectomy with subretinal rtPA injection was found to be effective for the displacement of AMD hemorrhage in 81 % of the patients. Mean final visual acuity improved by more than 7 lines.

Anatomical and functional outcomes of ILM interposition in surgery for large macular holes: A retrospective study

INTRODUCTION

While surgery for small macular holes (<400μm) is well-described, the results are not as clear-cut for larger holes (>400μm). Our purpose is to demonstrate the difference in terms of closure and final visual acuity between 3 techniques: the classical technique, the FLAP technique and internal limiting membrane (ILM) transfer.

METHODS

This retrospective non-randomized study included consecutive patients with a macular hole greater than 400μm. Myopic eyes (>26.5mm or >6.50D) and eyes with other retinal comorbidities were excluded. All patients underwent pars plana vitrectomy in combination with one of the 3 techniques.

RESULTS

We included 84 eyes of 77 patients between 2005 and 2018; 57 in the classic group (A), 13 in the FLAP group (B) and 14 in the ILM transfer group (C). The closure rate at 3 months was 70.18 % in group A, 100 % in group B and 92.86 % in group C. The closure rate was significantly higher in group B and C compared to group A. There was no significant improvement between pre- and post-operative best corrected visual acuity in any group. The gain in BCVA was 2.90 lines (±2.98) in group A, 3.40 lines (±2.40) in group B, and 1.07 lines (±1.04) in group C. The gain was significantly lower in group C compared to group A and B.

CONCLUSION

ILM interposition appears to offer a true anatomical advantage for closing large holes, but the functional recovery does not appear to be better or worse.

[Cyclodialysis, a therapeutic challenge: Review of the literature on current practices]

INTRODUCTION

Cyclodialysis is a rare condition that is difficult to manage. We present the case of a woman with a cyclodialysis complicated by chronic hypotony requiring two surgeries to achieve reattachment of the ciliary body. We also report the results of a review of the literature regarding the treatment of this condition.

DESCRIPTION

This is a 46-year-old woman with history of trauma to the right eye. Examination revealed an intra-ocular pressure (IOP) of 7mmHg, a shallow anterior chamber and signs of chronic hypotony on fundus examination (vascular tortuosity, hypotony maculopathy) due to an extensive 360° cyclodialysis, confirmed by ultrasound biomicroscopy. Transcleral cryotherapy as a first-line approach did not achieve reattachment of the ciliary body. Secondary pars plana vitrectomy with gas tamponade (C2F6) reattached the ciliary body and restored the intraocular pressure (12mmHg) and normal fundus appearance. The patient recovered corrected visual acuity of 20/20.

DISCUSSION

To our knowledge, there is no standardized management for cyclodialysis. The study of the literature available on the Medline database showed that direct cyclopexy remains the most common treatment, followed by vitrectomy with internal tamponade. Neither the extent nor the duration of the cyclodialysis can predict the visual recovery, which can be major even after weeks of hypotony.

CONCLUSION

The management of cyclodialysis is not well-defined; it remains a true therapeutic challenge.

The outcomes of bimanual posterior segment intraocular foreign body removal with vitrectomy and description of two different handshake techniques: A single surgeon case series

PURPOSE

To evaluate the outcomes of bimanual intraocular foreign body (IOFB) removal with vitrectomy and describe the techniques of "active aspiration to forceps" and "forceps to forceps handshake" for IOFB removal.

METHODS

Retrospective, interventional, single surgeon case series. The patients who had an IOFB and underwent vitrectomy with bimanual IOFB removal techniques and had a minimum follow-up period of 12 months were included. The main outcome measure was the functional and anatomical results of the bimanual surgical techniques.

RESULTS

Twenty eyes were included. The mean follow-up time after surgery was 16.5±3.6 months (range 12-24 months). The baseline best corrected visual acuity (BCVA) was light perception in 8 eyes (40%), hand motions in one eye (5%), and≥1.0LogMAR in 11 eyes (55%). BCVA improved in 14 eyes (70%); was stable in 3 eyes (15%), and decreased in 3 eyes (15%).

CONCLUSIONS

Both bimanual handshake techniques were safe and effective methods in the surgical treatment of IOFBs<5mm in size. The "active aspiration to forceps handshake" technique might be a gentle technique for the removal of IOFBs that are located on the surface of or trapped within the retina.

[Prognostic factors for idiopathic macular hole surgery: Report of 107 eyes (Approach by univariate statistical analysis)]

PURPOSE

To identify prognostic factors influencing the success of idiopathic macular hole surgery, including initial visual acuity, hole size and stage, and type of gas used for tamponade.

PATIENTS AND METHODS

Retrospective single-center descriptive analysis of all patients with an idiopathic macular hole operated by the same surgeon, treated in the ophthalmology department of Mulhouse hospital, between January 2004 and July 2014. Patients whose functional and anatomical results could be confounded by the coexistence of other ocular pathologies and patients with secondary macular holes were excluded.

RESULTS

We included and followed 107 eyes of 104 patients for at least 6 months. Initial closure after the first surgery was obtained in 92 eyes (85.98 %), allowing 2 groups to be defined, the cases of success and failure. Initial visual acuity, hole size, stage according to Gass, Gaudric and IVTS classifications, and presence or absence of a PVD, were statistically significant prognostic factors (P<0.05) CONCLUSION: Our univariate statistical analysis identified multiple prognostic factors. These factors may predict success and the choice of surgical technique, including whether to peel the internal limiting membrane, the choice of gas for tamponade, and postoperative positioning.

[Anatomical and functional results of macular hole surgery using a temporal inverted internal limiting membrane flap. Experience with 24 cases]

PURPOSE

To evaluate the anatomical and functional outcomes of macular hole (MH) surgery with a temporal inverted internal limiting membrane (ILM) flap technique.

METHODS

Monocentric retrospective study of 24 patients who were operated on for macular hole between March 2014 and April 2017 at Nancy University Hospital. All patients underwent pars plana vitrectomy with the inverted ILM flap technique. ILM peeling was restricted to the temporal side of the fovea, and the macular hole was then covered with the ILM flap, followed by SF6 tamponnade and first day face-down positioning. The main outcome measures included macular hole closure rate and visual acuity at 1 month postoperatively.

RESULTS

Eight men and 16 women of mean age 67.0±5.4 years were included. The mean axial length was 23.5±1.2mm. The mean diameter of the MH was 362±123μm. Closure of the MH was achieved in 23 of 24 eyes (95.8%) after one surgery. The mean BVCA improved significantly from 0.71±0.20 logMar to 0.29±0.22 logMar (P<0.001) at 1 month postoperatively, for a gain of 0.42±0.24 logMar.

CONCLUSION

Macular hole surgery with the inverted ILM flap technique results in good anatomical and functional outcomes, comparable to those obtained with the classic technique with complete ILM peeling.

Medical management of a subretinal Klebsiella pneumoniae abscess with excellent visual outcome without performing vitrectomy

OBJECTIVE

To report the case of a Klebsiella pneumoniae endogenous endophthalmitis (KPEE) of hepatic and urinary origin that was successfully treated with systemic antibiotherapy and 13 intravitreal antibiotics injections without performing a vitrectomy.

PATIENT AND METHOD

Case report of a 60-year-old man with a subretinal abscess in the left eye that developed 3 days after initial presentation for K. pneumoniae bacteremia, liver abscess and urinary tract infection.

RESULTS

Ophthalmic examination of the left eye showed anterior uveitis and a single subretinal abscess located in mid-peripheral temporal retina. BCVA dropped to 20/50. Follow-up was made with clinical examination and multimodal imaging (SD-OCT, FA, ICGA) with high field photographs. A total of 13 intravitreal injections (IVI) of ceftazidime were performed, and no vitrectomy was required. Ocular signs regressed and prognosis was excellent with 20/20 of final BCVA.

CONCLUSION

KPEE is a rare but severe condition with a typically poor ocular prognosis. When diagnosis is made early, subretinal abscess with partially conserved BCVA could be treated successfully with medical management that includes systemic antibiotics and repeated intravitreal injections without requiring vitrectomy.

[Evaluation of surgical simulation sessions of the French society of ophthalmology. A new surgical instruction method]

INTRODUCTION

Since 2013, at the French society of ophthalmology (FSO) meetings, two simulators for intraocular surgeries have been available. The goal of this study was to assess the satisfaction of the participants in these organized training sessions.

MATERIALS AND METHODS

A questionnaire was mailed to participants in the FSO sessions as well as those carried out during the annual congress. This questionnaire collected data on the participants and the practical modalities of the sessions, and assessed participants' feelings and satisfaction with these sessions.

RESULTS

The participants in the SFO sessions were young members of the SFO (31.8±12.3 years). 53.8 % were in training, looking to improve a problematic surgical step (capsulorhexis in 51.5 %). They spent nearly 5hours on simulators (4.8hours) and were alone on a simulator 50 % of the time. The sessions held during the annual congress were used by older physicians (41.9±26.4 years) already in practice (66.6 %). The goal of such training was curiosity in a third of the cases (to try the simulators). The majority spent less than an hour on the devices and were at least two participants per machine. Despite these differences, participants cited a role for their surgical learning curve and recommended such training to their colleagues.

CONCLUSIONS

The participants' enthusiasm for this new training technique is highlighted by the results of this study.

Prognostic factors of epiretinal membranes: A systematic review

INTRODUCTION

Epiretinal membranes (ERM) have been increasingly characterized with the advent of new optical coherence tomographies (OCTs). We intended to perform a systematic review regarding prognostic factors (PF) of ERM after surgery.

MATERIALS AND METHODS

Systematic review of electronic databases was performed (last date of search was 10 August 2015): Medline, Scopus, Google Scholar, clinicaltrials.gov and current controlled trials. Search queries included: "membrane", "pucker", "prognosis", "prognostic", "epiretinal", "épirétinienne". Inclusion criteria were: (1) primary purpose was to identify a PF of ERM; (2) prospective or retrospective study, case series (more than 10 patients), or clinical trials; (3) follow-up of at least 3 months; (4) complete ophthalmological evaluation in each patient with visual acuity and OCT, preoperative and≥3months after surgery; (5) vitrectomy with ERM peeling performed in each patient. Eligibility criteria verification, data extraction and evaluation of risk of bias were performed according to Cochrane's recommendations.

RESULTS

From 817 studies found, 21 were included (9 prospective, 12 retrospective, 0 trials). In all studies, there was significant visual acuity improvement after surgery. The majority of the studies included pars plana vitrectomy (PPV) combined with phacoemulsification.

DISCUSSION AND CONCLUSION

PF for visual acuity (VA) improvement after ERM surgery included: shorter duration of symptoms before surgery, lesser central foveal thickness at baseline identified by the OCT, good integrity of the inter segment/outer segment photoreceptor junction at baseline, and thinner ganglion cell inner plexiform layer at baseline. To avoid bias, studies should analyze VA separately if phacoemulsification is also performed. The knowledge of these PF may assist in planning surgery.

Follow-up after surgery for hemorrhagic AMD

INTRODUCTION

The long-term functional results of macular hematoma (MH) surgery in exudative AMD are often limited. The goal of this study was to compare visual outcomes of monthly versus bimestrial follow-up in these patients.

METHODS

Retrospective, interventional case series. Population : 21 eyes of 21 patients with SMH associated with exudative AMD.

INCLUSION CRITERIA

first SMH associated with exudative AMD, with 1-year postoperative follow-up.

EXCLUSION CRITERIA

blood located exclusively underneath the retinal pigment epithelium on OCT imaging, SMH due to different etiology, lost to follow-up, ≤5 postoperative visits and a different surgical protocol as described. Patients were divided into two groups according to the number of postoperative visits (number of intravitreal injections [IVT] combined with the number of consultations, only one visit was recorded when IVT and consultation occurred on the same day) during the 1-year postoperative follow-up: group 1 had ≥11 visits (n=8); group 2 had 6 to 10 visits (n=13). All eyes underwent vitrectomy with subretinal injection of recombinant tissue plasminogen activator, fluid-gas exchange and anti-VEGF intravitreal injection. The main outcome was change in best-corrected visual acuity (BCVA).

RESULTS

Considering visual acuity (VA) change between 1-month and 1-year postoperative follow-up examinations, group 1 had statistically significant greater VA changes (logMAR -0.29±0.44 vs logMAR 0.42±0.73; P=0.016; P=0.016). In patients that had exudative recurrences (ER), group 1 received more anti-VEGF IVT than group 2 (P=0.045).

CONCLUSION

Our results showed that monthly follow-up, between the IVT series, is highly recommended to preserve postoperative VA in patients undergoing surgery for SMH associated with AMD.

[Eales' disease]

The syndrome of recurrent vitreous hemorrhages in young men was described for the first time by Henry Eales in 1880. The association with a clinical manifestation of ocular inflammation was reported 5years later. Eales disease affects young adults who present with ischemic retinal vasculitis, with the peripheral retina most commonly affected. Most cases have been reported in South Asia. Although the etiology of this abnormality is unknown, it may be related to an immune sensitivity to Mycobacterium tuberculosis antigens. Its pathogenesis is related to extensive ischemia that affects the retina, secondary to an obliterative retinal vasculopathy with release of angiogenic factors of the VEGF type. Involvement of the retina is the hallmark of the disease, which manifests as follows: periphlebitis, retinal capillary ischemia most often affecting the periphery with secondary proliferative retinopathy and retinal and/or papillary neovascularization, recurrent vitreous hemorrhages and tractional retinal detachment. These complications are potentially blinding. The natural history of Eales disease varies, with temporary or permanent remission in some cases and continuous progression in others. Progression is often bilateral, which necessitates regular follow-up. The treatment of Eales disease depends on the stage of the disease and is not well defined. Observation only, pars plana vitrectomy surgery and/or intravitreal injections of anti-VEGF are recommended in cases of vitreous hemorrhage, associated with corticosteroids when retinal vasculitis is present. Laser pan-retinal photocoagulation is necessary when neovascularization is present.

[Neurotrophic keratitis after vitrectomy and circumferential endophotocoagulation for retinal detachment]

INTRODUCTION

Circumferential (360°) endophotocoagulation is frequently implemented during vitrectomies for retinal detachment. This photocoagulation may result in neurotrophic keratitis by damaging the ciliary nerves in the suprachoroidal space on their way to the pupil. We report a series of 4 cases of neurotrophic keratitis following a circumferential endophotocoagulation.

PATIENTS AND METHODS

A retrospective observational case series of 4 non-diabetic patients having presented with a neurotrophic keratitis following a retinal detachment treated with vitrectomy and circumferential endophotocoagulation (532 nm) at Caen University Hospital. We report the various forms of corneal lesions and the diagnostic criteria allowing for the diagnosis of neurotrophic keratitis.

DISCUSSION

Neurotrophic keratitis is caused by lesions occurring at various levels of corneal innervation. Endophotocoagulation may cause a neurotrophic keratitis by damaging the short and long ciliary nerves on their way to the pupil in the suprachoroidal space. The sequelae of this condition can limit visual recovery. Hence, it is probably advisable to screen for corneal anesthesia or severe hypesthesia following a retinal detachment treated with vitrectomy and circumferential endophotocoagulation and to implement prophylactic treatment (intensive lubricant therapy; preservative-free eye drops) if needed.

CONCLUSION

The risk of neurotrophic keratitis should be weighed against the dose of laser retinopexy necessary and sufficient to obtain a sustained retinal reattachment. If circumferential endophotocoagulation is implemented, it is probably sensible to monitor corneal sensitivity and to adapt postoperative treatment if necessary.

[The periphery of the vitrectomised eye]

The periphery of the vitrectomised eye is the site of retinal breaks in 1 to 15% of cases. These breaks must be looked for and treated to avoid retinal detachment. They are more frequent in the presence of fragile lesions in high myopia, or vitreoretinal traction. They can be related to vitreous incarceration in a sclerotomy site or with the movements of the vitrectomy probe. Traction is proportional to aspiration rate, and inversely proportional to the distance between the cutter and the vitreous base. Twenty-three- or 25-gauge transconjunctival vitrectomy seems to decrease the risk of vitreous incarceration and peripheral retinal tear.

[Pathogenesis of cataract after vitrectomy]

Cataract is the most common complication after vitrectomy. At first posterior subcapsular, it evolves into a nuclear type. A better understanding of the pathophysiologic mechanisms could help to develop strategies to prevent this complication. The main causative factors are oxidative stress, as evidenced by the persistence of an elevated partial pressure of oxygen in the lens after vitrectomy and the ionic changes in the lens. Mechanical factors may also be implicated: direct contact by gas tamponade or by silicone oil leads to desiccation cataract. The key of prevention of the formation of these cataracts is based on the reduction of oxidative stress.

[Successful phacoemulsification in vitrectomized eyes: technical considerations]

Cataract surgery after pars plana vitrectomy significantly improves visual acuity in 85% of cases, limited by retinal comorbidity and surgical complications. However, despite recent advances, this surgery remains a special challenge. Indeed, the surgeon must be aware of its many pitfalls and often adapt his surgical technique to avoid the 10% rate of intraoperative complications reported in the literature - ten times higher than for the non-vitrectomized eye. During the postoperative period, the most common complication is posterior capsule opacification, which may require early laser capsulotomy.

[Pseudophakic retinal detachment: how to manage?]

INTRODUCTION

Retinal detachment, a common complication of cataract surgery, requires urgent surgical treatment. The external approach combining retinopexy with scleral buckling remains the gold standard in the surgical management of pseudophakic retinal detachment (RD) without marked proliferative vitreoretinopathy (PVR), although intraocular surgery is currently preferred by most of the authors. The purpose of this study is to compare the anatomical and functional results obtained with both techniques.

PATIENTS AND METHODS

This study compares the results of two techniques for treating pseudophakic retinal detachment: external surgery (group I), and vitrectomy with internal tamponade (group II). Ab-externo surgery was performed in 24 patients (24 eyes), while 22 patients (22 eyes) underwent primary vitrectomy. In order to make both groups comparable, we excluded recurrences of RD, vitreous hemorrhage and other media opacities, giant tears and initial grade C PVR. Minimum follow-up was 12 months. Postoperative variables analyzed and compared were the rate of initial and final anatomical success, final visual acuity, and causes of failure of the initial surgery.

RESULTS

The retina was reattached with a single operation in 21 eyes in group I (87.5%) and 19 eyes in group II (86.4%) (P=0.91). The causes of anatomical failure in both groups were proliferative vitreoretinopathy (4 cases) and secondary tears or tears not seen on initial examination (2 cases). For patients in group I, secondary surgery consisted of total vitrectomy with encircling buckle. Patients in group II underwent an additional vitrectomy (peeling of vitreoretinal proliferation, and silicone oil tamponade as necessary). After a mean follow-up of 12 months, the final examination noted a reattached retina in 23 eyes in group I (95.84%) and 21 eyes in group II (95.45%) (P=0.95). The final visual results were identical at comparable follow-up periods. Indeed, the final visual acuity was similar in the two groups with nearly 40% of patients having recovered visual acuity between 1/10 and 5/10 (P=0.98).

CONCLUSION

With regard to surgical treatment of pseudophakic retinal detachment, vitrectomy with internal tamponade provides anatomical and functional results comparable to those obtained with external surgery.

[Anatomical and functional prognosis of secondary retinal detachments after sutureless macular surgery]

PURPOSE

To evaluate the incidence, characteristics and risk factors for rhegmatogenous complications of transconjunctival sutureless 23-gauge vitrectomy (TSV) in macular surgery. The results were correlated with those reported in the literature.

METHODS

Multicentric retrospective study of a cohort of patients undergoing macular surgery by 23-gauge TSV between January 2009 and June 2010.

RESULTS

Four hundred and seventy-four patients divided into: epiretinal membrane (MEM) (n=279), vitreomacular traction (n=65) and idiopathic macular hole n=130. Forty-three percent of patients were pseudophakic. Posterior vitreous detachment (PVD) was absent in 60% of cases and was therefore systematically performed intraoperatively. It was seen that 1.7% of patients developed retinal tears and 2.7% retinal detachment with a higher incidence in the vitreomacular traction (VMT) group and the group in which the PVD was performed intraoperatively. Rhegmatogenous lesions were localized mainly in the inferior retina in the macular hole group.

DISCUSSION

Results are consistent with the TSV literature. Their location does not appear to be related to the sclerotomies or handedness as in 20-gauge surgery, probably due to sclerotomy trocars. Localization of rhegmatogenous lesions in the inferior retina in macular hole surgery suggests a role of gas in this subgroup. In addition to instrument-retinal touch, the performance of a surgical PVD represents a major independent risk factor for retinal detachment (RD).

CONCLUSION

Even with limited macular surgery, it is essential to check the retinal periphery for 360 degrees, especially for VMT and intraoperative PVD, and especially inferiorly in the case of gas tamponnade.

[Use of bevacizumab in the treatment of complicated proliferative diabetic retinopathy]

INTRODUCTION

Diabetes is the leading cause of neovascular vitreoretinal proliferation. Several recent publications have appeared showing the efficacy and safety of intravitreal bevacizumab (IVT) in proliferative or complicated diabetic retinopathy (PDR), but with no consensus on the injected dose. We report the results of its use as adjuvant intravitreal injection (IVT) prior to posterior vitrectomy in the setting of complicated PDR. The goal of our work is to evaluate the benefits of and try to establish a protocol for proper use of intravitreal bevacizumab prior to vitrectomy for complicated PDR, so as to incorporate it in the management of this disease.

PATIENTS AND METHODS

A prospective comparative study of series of patients hospitalized for severe complicated PDR requiring vitrectomy was spread over one year, from January 2011 to December 2011. Included patients were divided into two groups: group A: receiving an injection preoperatively at a dose of 1.25mg, and group B, which received an injection of bevacizumab at a dose of 0.75mg (with a time to surgery of either less than 3 days, more than 6, or 3 to 6). We analyzed the epidemiological characteristics, data from the initial eye examination and intraoperative complications and follow-up after vitrectomy.

RESULTS

Thirty-five patients were included. We noted no significant difference in epidemiological characteristics between group A and B. Sixty percent of patients underwent surgery after a period of three to six days post-IVT. The reduction of neovascularization, decreased risk of bleeding and the facilitation of membrane peeling during surgery were significantly similar between group A and B. No complication related to the molecule and no recurrence, including bleeding, were noted throughout follow-up in both groups.

CONCLUSION

We opt for a systematic use of anti-VEGF, particularly bevacizumab prior to all vitrectomies for complicated PDR. A 0.75mg dose at an interval of 3 to 6 days seems to be a good compromise between the desired effect and possible complications that may arise.