The rationale of opportunistic bilateral salpingectomies (OBS) during benign gynaecological and obstetric surgery: a consensus text of the Flemish Society of Obstetrics and Gynaecology (VVOG)

Ovarian cancer (OC), is a disease difficult to diagnose in an early stage implicating a poor prognosis. The 5-year overall survival in Belgium has not changed in the last 18 years and remains 44 %. There is no effective screening method (secondary prevention) to detect ovarian cancer at an early stage. Primary prevention of ovarian cancer came in the picture through the paradigm shift that the fallopian tube is often the origin of ovarian cancer and not the ovary itself. Opportunistic bilateral salpingectomy (OBS) during benign gynaecological and obstetric surgery might have the potential to reduce the risk of ovarian cancer by as much as 65 %. Bilateral risk-reducing salpingectomy during a benign procedure is feasible, safe, appears to have no impact on the ovarian function and seems to be cost effective. The key question is whether we should wait for a RCT or implement OBS directly in our daily practice. Guidelines regarding OBS within our societies are therefore urgently needed. Our recommendation is to inform all women without a child wish, undergoing a benign gynaecological or obstetrical surgical procedure about the pro's and the con's of OBS and advise a bilateral salpingectomy. Furthermore, there is an urgent need for a prospective registry of OBS. The present article is the consensus text of the Flemish Society of Obstetrics and Gynaecology (VVOG) regarding OBS.

The role of leptin in choroidal neovascularization

PURPOSE

The purpose of this study was to investigate the role of leptin in choroidal neovascularization.

METHODS

We examined the localization of leptin by immunohistochemistry in nine choroidal neovascular membranes surgically excised from patients with age-related macular degeneration, idiopathic choroidal neovascularization, and ocular histoplasmosis. Controls included omission of primary antibody, use of an irrelevant primary antibody and leptin staining of posterior segment of four normal donor eyes.

RESULTS

Leptin was present in eight membranes and appeared vesicular, within the cytoplasm. The more vascular membranes and those consisting of a larger number of retinal pigment epithelium cells were associated with greater leptin staining. Leptin was not seen in the posterior segment of the four normal eyes.

CONCLUSION

We suggest that leptin plays an active role in choroidal neovascularization, although further experiments are necessary to establish a causal relationship.

Identification of diabetic retinopathy by stereoscopic digital imaging via teleophthalmology: a comparison to slide film

BACKGROUND

Diabetic retinopathy is a leading cause of vision loss in North America. We compared mydriatic seven-field stereoscopic digital imaging to 100 ASA slide film photography for the identification of diabetic retinopathy via teleophthalmology.

METHODS

Patients from a northern Alberta community with diabetes mellitus diagnosed by a physician were asked to participate in a teleophthalmology pilot project. Patients were enrolled at four different times between October 1999 and June 2000. Seven 30 degree fields of the retina were photographed with both slide film and digital imaging (resolution 2008 x 3040 pixels) through a dilated pupil. Slide film was developed and reviewed in a masked fashion by a retinal specialist. Digital images for each patient were transmitted by satellite to Edmonton and analysed a minimum of 2 months after the original slide film. Retinal abnormalities were graded with the use of the Early Treatment Diabetic Retinopathy Study extension of the modified Airlie House classification. We calculated the sensitivity and specificity of digital imaging for the identification of features of diabetic retinopathy as seen on slide film. Pearson's correlation coefficient was also calculated.

RESULTS

A total of 121 patients (241 eyes), of whom 114 (94.2%) had non-insulin-dependent diabetes, participated in the study. The average duration of diabetes was 8.5 years. Of the 121 patients 57 (47.1%) had diabetic retinopathy, 12 (9.9%) had clinically significant macular edema and 2 (1.6%) had neovascularization. Pearson's correlation coefficient for the presence of retinopathy between slide film and stereoscopic digital imaging was 0.92 for microaneurysms, 0.80 for hemorrhages, 0.45 for intraretinal microvascular abnormalities, 0.32 for venous beading, 1.00 for neovascularization of the disc, 1.00 for neovascularization elsewhere in the retina and 0.97 for clinically significant macular edema (p < 0.001). The correlation between the two techniques for severe nonproliferative diabetic retinopathy (NPDR) was 0.86 and for high-risk proliferative diabetic retinopathy 1.00 (p < 0.001).

INTERPRETATION

Stereoscopic digital imaging has a high level of correlation with slide film for the identification of most features of diabetic retinopathy, including microaneurysms, hemorrhage, severe NPDR, high-risk proliferative diabetic retinopathy and clinically significant macular edema.

Tele-ophthalmology via stereoscopic digital imaging: a pilot project

Diabetic eye disease is present in remote communities across Canada. A pilot study was designed to assess the feasibility of stereoscopic digital imaging to identify levels of diabetic retinopathy via teleophthalmology. Diabetic patients were assessed for diabetic retinopathy by seven field stereoscopic digital imaging through a dilated pupil. Images were transferred by satellite to a tertiary eye center for review by a retinal specialist. Images were viewed stereoscopically on a video monitor, with grading of all images using a modified Early Treatment Diabetic Retinopathy Study (ETDRS) classification. Patients found to have treatable diabetic retinopathy were transferred to a tertiary eye center for assessment and treatment by a retinal specialist. One hundred patients (199 eyes) had stereoscopic digital imaging of the retina. Microaneurysms were identified in 70 eyes, hard exudates in 31 eyes. Two eyes were identified with neovascularization of the disc (NVD) and 15 eyes with clinically significant macular edema (CSME). All eyes identified by stereoscopic digital imaging with treatable disease were confirmed by clinical examination with contact lens biomicroscopy. Stereoscopic digital imaging of the retina enables the identification of diabetic retinopathy. Further research is needed to delineate the sensitivity and specificity of stereoscopic digital imaging when compared to slide film and clinical examination.

Use of a macular buckle in the treatment of exudative age-related macular degeneration

BACKGROUND AND OBJECTIVE

To evaluate a macular buckle for exudative choroidal neovascularization secondary to age-related macular degeneration (ARMD).

PATIENTS AND METHODS

Forty-two eyes with choroidal neovascular membranes (CNVM) secondary to ARMD underwent surgical placement of a macular buckle. A Gore-Tex strip (2.0-2.5 mm wide) was button-holed through a 5 mm diameter silicone sponge (9 mm long) and placed behind the macula underneath the CNVM by the same surgeon (Dr Peyman) in all cases. Follow-up ranged from 7-76 months (mean, 20.9 months).

RESULTS

Of 12 eyes with classic subfoveal CNVM: 4 (33%) gained 2 or more lines of Snellen visual acuity; 3 (25%) gained 1 line, remained the same, or lost 1 line; and 5 (42%) lost 2 or more lines (range + 6 to - 6 lines). Of 22 eyes with ill-defined subfoveal CNVM: 12 (54%) gained 1 line, remained the same, or lost 1 line; and 10 (46%) lost 2 or more lines (range + 1 to - 8 lines). Eight eyes with ill-defined juxtafoveal CNVM had the following visual acuity outcomes: 5 eyes (62%) maintained the same level of Snellen visual acuity (gained 1, 0, or lost 1 line); and 3 (38%) got worse (lost 2 or more lines of Snellen visual acuity, range + 1 to - 6 lines). Ten eyes (24%) bled subretinally during the follow-up period (average 11.5 months, range 14 days to 27 months), all outside the area of indentation of the macular buckle.

CONCLUSIONS

The macular buckle treatment for exudative subretinal choroidal neovascular membranes in ARMD stabilized visual decline and displaced significant subfoveal hemorrhage.

Surgical closure of macular hole using an absorbable macular plug

BACKGROUND

The surgical management of macular holes has been a subject of controversy in recent years. Various techniques such as vitrectomy, membrane peeling, and gas tamponade with or without transforming growth factor-beta 2, and recently the use of autologous platelets have produced closure rates from 58% to 96%, depending on the stage of the hole.

METHODS

The authors present preliminary results in a study of 19 consecutive patients with stage 3 or stage 4 macular hole who underwent vitrectomy followed by placement of an absorbable partially cross-linked gelatin plug in the macular hole. The vitreous cavity was filled with a nonexpanding gas or air alone; the patient was instructed to maintain prone positioning for 2-3 days.

RESULTS

Anatomic attachment of the edges of the macular hole was achieved in 19 out of 19 patients with a minimum follow-up period of 6 months (average 11.5 months).

CONCLUSIONS

A cross-linked gelatin plug can effectively reattach the edges of macular holes of stages 3 and 4. Its use is recommended only in macular holes in high myopes with posterior staphyloma or recurrent macular hole.

Relaxing retinotomy under perfluorocarbon liquid

A technique of performing a relaxing retinotomy under the perfluorocarbon liquid perfluoroperhydropenanthrene (Vitreon, Vitrophage, Inc., Lyons, IL) is described. This procedure allows perfluorocarbon liquid to be used to maintain the retina in the desired position and to dissect proliferative membranes prior to the retinotomy without having to remove the Vitreon to perform the retinotomy.

Direction and location of retinotomy for removal of subretinal neovascular membranes

We describe two cases in which a new retinotomy technique is used to remove subretinal neovascular membranes. The direction and location of the retinotomy are of ultimate importance in prevention of damage to retinal nerve fibers and the corresponding visual field loss. The retinotomy is made with an angled 20-gauge needle in nondiathermized retina. The direction of the retinotomy is parallel to the nerve fiber layer and located over the subretinal neovascular membrane. No laser retinopexy was necessary after removal of the subretinal neovascular membrane.

An analysis of posterior segment complications after vitrectomy using the perfluorocarbon perfluoroperhydrophenanthrene (Vitreon). Vitreon Collaborative Study

We report posterior segment complications encountered with the use of the liquid perfluorocarbon, perfluoroperhydrophenanthrene (Vitreon) as an intraoperative adjunct to vitreoretinal surgery in 640 patients participating in the Vitreon Collaborative Study. We also evaluated postoperative complications in 60 patients in whom Viteron was intentionally left inside the vitreous cavity for periods ranging from 5 days to 4 weeks as a short-term retinal tamponade. The five most common postoperative complications among these patients as a whole were recurrent retinal detachment, with or without proliferative vitreoretinopathy (11.28%); macular pucker (5.85%); fibrinous reaction (4%); residual Vitreon (3.85%); and vitreous hemorrhage (2.57%).

Subretinal hemorrhage removal with multiple retinotomy sites in age-related macular degeneration

We report a case of subretinal hemorrhage associated with age-related macular degeneration, in which tissue plasminogen activating factor was used to help remove the subretinal blood. The surgical technique involved using multiple small retinotomy sites and alternating suction and backflushing to produce fluid flow from the subretinal space to the vitreous cavity.

Postoperative chronic pressure abnormalities in the vitreon study

Perfluoroperhydrophenanthrene (Vitreon) was used as an intraoperative hydrokinetic retinal manipulator, followed by C3F8 or SF6 gases, silicone oil, or Vitreon as postoperative tamponading agents in 234 eyes. Two chronic intraoperative pressure abnormalities were defined: hypotony (5 mm Hg or less) and elevated intraocular pressure (IOP) (25 mm Hg or more at three or more postoperative visits). Postoperatively, 28 eyes (12%) had chronically elevated IOP, and 41 (18%) had chronic hypotony. There was no significant difference in the incidence of abnormal IOP among the groups of eyes in which the various tamponading agents had been used. In particular, the use of Vitreon as an intraoperative tool or as a short-term tamponade did not affect the incidence of chronic abnormal IOP any more than did the use of silicone oil, C3F8, or SF6 as tamponading agents.

Repair of retinal detachment associated with proliferative vitreoretinopathy using perfluoroperhydrophenanthrene (Vitreon). Vitreon Study Group

A total of 140 consecutive patients underwent repair of retinal detachment associated with grade C2 to D3 proliferative vitreoretinopathy with perfluoroperhydrophenanthrene (Vitreon) as an intraoperative hydrokinetic tool. In seven patients the Vitreon was left in the eye for extended tamponade. Intraoperative reattachment was obtained in 98% of patients. At the final follow-up examination (mean 7 months) 84% of retinas remained attached, and 92% of patients had stable or improved visual acuity. Vitreon was found to be safe and effective in the repair of complicated retinal detachments. No complications were directly related to Vitreon when used intraoperatively or when left in the eye for extended tamponade.

The surgical management of retinopathy of prematurity using a perfluorocarbon liquid

Retinopathy of prematurity with retinal detachment continues to present a challenge to the vitreoretinal surgeon despite many advances in technique. We report on two eyes with stage 4 and 5 ROP operated on using vitrectomy techniques and a perfluorocarbon liquid (Vitreon). The surgical technique is described in detail.

Perfluoroperhydrophenanthrene (Vitreon) in the management of giant retinal tears: results of a collaborative study

Fifty cases of retinal detachment with a giant retinal tear were managed using perfluoroperhydrophenanthrene (Vitreon) as an intraoperative and postoperative tool. The giant tear was less than 180 degrees in 76% of the eyes, greater than 180 degrees in 22%, and greater than 270 degrees in 2%. Proliferative vitreoretinopathy was present in 40%. Vitreon was used only intraoperatively in 84% of the eyes, and was left in 16% for up to 4 weeks. Intraoperative retinal reattachment was achieved in 98%. Retinal attachment was maintained in 88%, with a mean follow up of 8.6 months. Postoperative visual acuity was better than 20/400 in 52%. Postoperative complications included cataract in 23%, choroidal effusion in 2%, hypotony in 4%, and recurrent retinal detachment with proliferative vitreoretinopathy in 26%.

Use of perfluoroperhydrophenanthrene in the management of posteriorly dislocated crystalline and intraocular lenses

We describe a series of 28 patients in whom a posteriorly dislocated crystalline or intraocular lens was successfully removed with the intraoperative use of perfluoroperhydrophenanthrene (Vitreon), a heavy liquid perfluorocarbon. The Vitreon was used to float the lens into the midvitreous cavity, thereby avoiding hazardous micromanipulation with intraocular instruments in the macular area. In addition, the Vitreon served to protect the posterior retina by keeping the posteriorly dislocated lens fragments from falling backward onto the posterior pole as the lens was being removed from the eye. Postoperative visual acuity improved in 73% of the patients, remained the same in 15%, and worsened in 12%.