[Visual outcome of macular hole surgery with internal limiting membrane peeling]

PURPOSE

To evaluate the efficacy of the internal limiting membrane(ILM) peeling on macular hole surgery.

METHODS

A series of 102 patients(105 eyes) who underwent primary macular hole surgery between October 1994 and April 1999 was used for this retrospective study. The mean age was 65.6 +/- 7.1 years (mean +/- standard deviation). Of the study eyes, 34 eyes(32%) had a Stage II hole, 49 eyes(47%) had a Stage III hole, and 22 eyes(21%) had a Stage IV hole based on the Gass classification. Here we compared the surgical and visual outcome of the ILM peeling-treated group(treated group: 51 eyes) with those of ILM peeling-untreated group(untreated group: 54 eyes).

RESULTS

The hole closure rate after initial surgery was 98.0% in the treated group and 90.7% in the untreated group, and mean postoperative visual acuity, excluding cases where the hole was not closed by initial surgery, was 0.44 and 0.47, respectively. Visual improvement of 2 or more lines on Snellen chart was achieved in 84.3% and 57.4%(p < 0.01), and that of 4 or more lines in 54.9% and 25.9% (p < 0.01), respectively. Of the eyes with Stage II and III holes, visual outcome of the treated group was significantly better than that of the untreated group(p = 0.034, p = 0.037). In Stage IV, the initial closure rate of the treated group was significantly better than that of the untreated group(p = 0.02), but the visual outcome was not significantly different.

CONCLUSION

Vitreous surgery combined with ILM peeling for the management of idiopathic macular hole is effective not only on hole closure but also on visual recovery.

Optical cross-sectional evaluation of successfully repaired idiopathic macular holes by retinal thickness analyzer

PURPOSE

To describe optical cross-sectional images of successfully repaired idiopathic macular holes and to determine the influences of epiretinal membranes and retinal pigment epithelial (RPE) changes on foveal reconstruction and the correlation between retinal thickness and postoperative visual acuity.

METHODS

In a prospective study, optical cross-sectional imaging and retinal thickness measurement of the macula using a retinal thickness analyzer were performed on 63 eyes of 63 patients who underwent successful macular hole surgery.

RESULTS

Cross-sectional images of foveal reconstruction were morphologically categorized into four patterns: normal fovea (23 eyes [37%]), cavernous fovea (19 eyes [30%]), flat fovea (11 eyes [17%]), and irregular fovea (10 eyes [16%]). Epiretinal membranes were observed in the last two groups (55% and 40%) and RPE changes were observed only in the irregular fovea group (16%). The mean retinal thickness of the fovea in all eyes was 213 +/- 92 microm (mean +/- SD; range, 93-570 microm), which varied significantly (P < 0.001) among the four groups. Linear regression analysis showed a significant correlation between retinal thickness at the fovea and logarithmic converted visual acuity (R2 = 0.42, P < 0.001).

CONCLUSIONS

Structural features of foveal reconstruction following successful macular hole surgery involved four patters: normal fovea, cavernous fovea, flat fovea, and irregular fovea. Retinal thickness of the fovea, which varied among the groups, correlated with postoperative visual acuity. Postoperative epiretinal membrane formation and RPE damage may disturb normal foveal reconstruction and visual recovery.

Two-year follow-up study comparing primary vitrectomy with scleral buckling for macula-off rhegmatogenous retinal detachment

PURPOSE

To compare the anatomic and visual outcomes achieved by scleral buckling and primary vitrectomy for the repair of macula-off rhegmatogenous retinal detachment.

METHODS

The records were reviewed for a consecutive series of 167 patients (167 eyes) who were initially treated with scleral buckling or pars plana vitrectomy for primary macula-off retinal detachment. Patients were treated between January 1993 and December 1996. After adjustments for preoperative characteristics, data from 102 cases (55 scleral buckle cases and 47 primary vitrectomy cases) were used for the final comparison. There had been a minimum follow-up period of 24 months.

RESULTS

No significant differences in single-procedure reattachment incidence (91%), final success incidence (100%) and incidence of postoperative proliferative vitreoretinopathy development (4%) were observed between the two treatment groups. Preoperative visual acuity, preoperative intraocular pressure, and duration of macular detachment were the three best predictors of postoperative visual recovery in both groups. Favorable overall visual recovery was obtained postoperatively, with no significant differences between the two groups throughout the follow-up period. However, in the eyes with poor preoperative visual acuity (<0.1), ocular hypotony (intraocular pressure <7 mm Hg), or prolonged macular detachment (more than 7 days), visual recovery in the primary vitrectomy group was significantly better (P <.05) than in the scleral buckle group from the first postoperative month.

CONCLUSION

Both procedures achieved favorable anatomic and visual outcomes in the majority of patients with primary macula-off retinal detachment. Primary vitrectomy may be more effective than scleral buckling for achieving early visual rehabilitation in cases complicated by poor preoperative vision, ocular hypotony, and prolonged macular detachment.

White thread-like retinal arterioles associated with antiphospholipid antibody syndrome

BACKGROUND

Report of 2 patients with antiphospholipid antibody syndrome (APS) who had elevated anti-beta2-glycoprotein I antibodies and showed white thread-like retinal arterioles.

CASES

A complete ophthalmological examination was conducted on 2 patients who presented with blurred or distorted vision. Fluorescein angiography was used to examine the integrity of the retinal circulatory system. Laboratory blood studies were conducted.

OBSERVATIONS

In both patients, some of the major retinal arterioles appeared white and had a thread-like appearance. Fluorescein angiography demonstrated progressive occlusion or stenosis of these major arterioles with extensive insufficiency of the regional capillary bed. Patient 2 had systemic lupus erythematosus and was treated with oral corticosteroid and aspirin. Recanalization occurred during a 3-year follow-up in one of the patients.

CONCLUSIONS

APS should be considered in cases of white thread-like retinal arterioles. Occlusion of the retinal arterioles in APS may be progressive and responsible for the chronic hypoxia of the retina.

[Macular morphologic reconstruction and visual recovery in patients following macular hole surgery]

PURPOSE

To examine the characteristics of retinal reconstruction at the macula following macular hole surgery and to assess the impact of postoperative macular morphological changes on the visual outcome.

METHODS

A prototype of the scanning retinal thickness analyzer (RTA) was used to obtain optical section images at the macula in 53 eyes of 52 patients who underwent macular hole surgery between April 1994 and July 1997. The mean age of participants was 64.7 years. At the time of RTA examination, macular hole was biomicroscopically closed in 49 eyes (91%) and unclosed in 5 eyes (9%).

RESULTS

There were 5 types of cross-sectional images of postoperative maculae: normal foveal depression [19 eyes (36%)], crater-like fovea formation [12 eyes (22%)], flattened fovea [8 eyes (15%)], fovea with abraded retinal pigment epithelium [9 eyes (17%)], and persistant macular hole [5 eyes (9%)]. Central macular thickness measured by RTA was 165 +/- 39 (mean +/- standard dereation) microns in the normal foveal depression group, 210 +/- 67 microns in the crater-like fovea formation group, and 300 +/- 50 microns in the flatened fovea group. There were statistically significant differences (p < 0.01) between groups. Postoperative visual acuity was significantly different (p < 0.01) between these three groups, and central macular thickness was highly correlated with postoperative visual acuity (R = 0.70).

CONCLUSION

Visual recovery following macular hole surgery is closely associated with the retinal reconstruction at the macula.

Survey of surgical indications and results of primary pars plana vitrectomy for rhegmatogenous retinal detachments

BACKGROUND

Several surgical techniques to repair rhegmatogenous retinal detachment have been developed. Recently, both the method of reattaching the retina and of obtaining an early visual recovery are considered important factors when determining which surgical techniques to perform to treat retinal detachment.

CASES

The surgical outcome in a series of 63 consecutive patients, who were treated at Osaka Rosai Hospital between 1993 and 1996, was reviewed retrospectively to evaluate the efficacy of primary vitrectomy to treat uncomplicated rhegmatogenous retinal detachment associated with posterior hyaloid separation. The criteria for vitrectomy included the presence of not only posterior retinal breaks, but also of multiple peripheral retinal breaks.

OBSERVATIONS

The reattachment rate after the first surgery was 92.1% (58 eyes), and by the final examination it increased to 100%. Of the 46 eyes with macular detachment, good visual rehabilitation and a visual acuity improvement of 5 or more lines was obtained in 33 eyes (71.7%) by 1 month postoperatively. No statistically significant difference in the reattachment rate was found when eyes that underwent an encircling procedure were compared with those that did not. In eyes with lens opacity, cataract surgery was also performed and intraocular lenses were implanted uneventfully in all but one case with myopia. There was a high incidence (53.8%) of cataract progression in phakic eyes. However, no other serious complications, such as proliferative vitreoretinopathy, were found throughout the follow-up period.

CONCLUSIONS

The results indicate that vitrectomy performed to alleviate peripheral vitreoretinal traction is an effective surgical technique to treat primary rhegmatogenous retinal detachment. Vitrectomy combined with cataract surgery may also be a valuable surgical option in selected cases to maintain long-standing visual rehabilitation.

[A comparative study of visual outcomes following primary vitrectomy and scleral buckling procedures to manage macular off rhegmatogenous retinal detachments]

PURPOSE

To determine the difference between two types of retinal detachment surgery in postoperative visual recovery in the management of macular-off rhegmatogenous retinal detachment.

METHODS

We evaluated retrospectively the postoperative visual acuity (VA) in 37 patients who underwent primary vitrectomy (group V) and 39 patients treated with conventional scleral buckling (group S).

RESULTS

Although the mean preoperative VA in group V (0.03) was significantly worse (p = 0.04) than that in group S (0.06), there was no statistically significant difference between the groups in postoperative VA throughout the follow-up period. However, in the cases with poor preoperative VA (VA < 0.1), ocular hypotony (IOP < 7 mmHg), or prolonged macular detachment (duration > 7 days), the visual recovery was significantly better (p < 0.05) in group V than in group S from 1 month postoperatively. There were more eyes with a final VA of more than 0.5 in group V than in group S. When considering only the eyes with lenses spared intraoperatively, postoperative cataract progression resulting in secondary visual reduction was statistically significantly greater (p < 0.01) in group V (62%) than in group S (8%).

CONCLUSIONS

Primary vitrectomy is effective to attain early visual rehabilitation, especially to manage macula-off retinal detachments with poor preoperative VA, ocular hypotony, and prolonged macular detachment. To prevent a secondary visual reduction, cataract surgery combined with vitrectomy is recommended in selected cases.

Quantitative assessment of macular thickness in normal subjects and patients with diabetic retinopathy by scanning retinal thickness analyser

AIMS

To evaluate the scanning retinal thickness analyser (RTA), a novel non-invasive imaging instrument, in diagnosing and quantitatively characterising diabetic macular oedema, and to investigate the relation between central macula thickness measured by RTA and other clinical examinations.

METHODS

Central macular thickness was measured using the RTA in 40 normal subjects and 60 patients with diabetic retinopathy. The reproducibility of the retinal thickness measurements was evaluated by calculating the mean of the inter- and intrasession variations. Central macular thickness was correlated with the results of visual acuity measurements, biomicroscopy, and fluorescein angiography.

RESULTS

Intra- and intersession reproducibility of the RTA in normal subjects was plus or minus 5.2% (16 microns) and plus or minus 6.1% (19 microns), respectively. The mean central macular thickness was 182 (SD 16) microns in normal subjects, 283 (116) microns in diabetic eyes without clinically significant macular oedema (CSMO), and 564 (168) microns in diabetic eyes with CSMO. Central macular thickness was significantly greater (p < 0.001) in eyes with diabetic retinopathy than in normal subjects, even when macular thickening did not meet the standard for CSMO (p = 0.019) measured by biomicroscopy. Although greater fluorescein leakage at the macula results in greater central macular thickness, only eyes with diffuse leakage had statistically significant macular thickening compared with normal subjects (p = 0.022). Central macular thickness measured with the RTA was significantly correlated with the logarithmic converted visual acuity (r2 = 0.76) in diabetic eyes.

CONCLUSION

Scanning RTA, which has good reproducibility, might be useful to quantitatively detect and monitor macular thickening in diabetic retinopathy. Central macular thickness was highly correlated with logarithmic converted visual acuity in diabetic macular oedema.

Methicillin-resistant Staphylococcus aureus infections after scleral buckling procedures for retinal detachments associated with atopic dermatitis

OBJECTIVE

To determine the incidence and the clinical course of methicillin-resistant Staphylococcus aureus as a cause of acute-onset infections in patients with atopic dermatitis after a scleral buckling procedures.

DESIGN

A retrospective chart review.

PARTICIPANTS

Two hundred eighty-seven patients (293 eyes) who underwent scleral buckling procedures to treat rhegmatogenous retinal detachments at either Osaka Rosai Hospital or Osaka University Medical School between July 1, 1995, and June 30, 1997, participated. Of these, 32 eyes (10.9%) were associated with atopic dermatitis.

INTERVENTION

Demographic and clinical data were abstracted from patients' medical records.

MAIN OUTCOME MEASURES

The incidence, clinical features, and management of postoperative infections associated with methicillin-resistant S. aureus were studied.

RESULTS

Methicillin-resistant S. aureus infection after scleral buckling procedures was identified in 6 (18.8%) of 32 eyes of patients with atopic dermatitis but in only 1 (0.4%) of the other 261 cases without atopic dermatitis (P < 0.001). The average interval from the scleral buckling procedures to the initial onset of infection was 8.3 +/- 9.1 days (range, 2-28 days). Bacterial infection and inflammation were controlled in four eyes by prompt removal of the infected buckle in combination with vancomycin administration. In the other three eyes, however, repeat intravitreous injections of vancomycin or emergent vitrectomies were required because of the development of endophthalmitis.

CONCLUSIONS

Methicillin-resistant S. aureus is an important causative pathogen of scleral buckling infections, particularly in patients with retinal detachment associated with atopic dermatitis. Preoperative evaluation and intraoperative attention to contamination are recommended to prevent methicillin-resistant S. aureus infections in these patients.

Complete epiretinal membrane separation in highly myopic eyes with retinal detachment resulting from a macular hole

PURPOSE

Epiretinal membranes (ERMs) in highly myopic eyes may result in macular holes and subsequent retinal detachment. However, removing friable, thin ERMs from detached retinas is often difficult. We report the efficacy of a diamond-dusted silicone cannula in the removal of ERMs from detached retinas.

METHODS

Seventeen consecutive highly myopic eyes (16 patients) with retinal detachment underwent pars plana vitrectomy with gas tamponade. Peeling of the ERM adjacent to the macular hole was performed using either conventional tools (n = 11) or a diamond-dusted silicone cannula (n = 6). The rate of complete membrane peeling and the effect of membrane removal on the anatomic success rate were compared between groups.

RESULTS

Retinal reattachment occurred in 13 (92.9%) of the 14 eyes in which the ERM was removed completely; redetachment occurred in the other three eyes, with further surgical interventions in two eyes. The reattachment rate was significantly higher (P = .005) when ERM removal was complete than when there was residual ERM. In the initial surgery, the ERM was successfully removed in all 6 eyes (100%) in the diamond-dusted silicone cannula group and in 5 of 11 eyes (45.5%) in the conventional group (P = .041); the reattachment rate was 100% in the diamond-dusted silicone cannula group and 45.5% in the conventional group (P = .005). When a second surgery was performed, the use of the diamond-dusted silicone cannula was also better than conventional tools for removing the residual ERMs, resulting in retinal reattachment.

CONCLUSION

In highly myopic eyes with a macular hole and subsequent retinal detachment, complete ERM removal is closely related to successful retinal reattachment. The diamond-dusted silicone cannula appears to be more effective than conventional tools for removing ERM and may increase the anatomic success rate. Because of the limitations of a small series, a prospective, randomized trial is required to confirm the current beneficial results of using a diamond-dusted silicone cannula.

Chorioretinal damage caused by the excision of choroidal neovascularization

PURPOSE

To determine whether choroidal neovascularization excision causes mechanical damage to the neurosensory retina, retinal pigment epithelium, or choriocapillaris.

METHODS

Prospectively, 18 eyes of 18 consecutive patients who underwent choroidal neovascularization excision were observed. Preoperatively and postoperatively, the integrity of the choriocapillaris circulation in the pathway of choroidal neovascularization extraction was studied by fluorescein and indocyanine green angiography. Using static scanning laser ophthalmoscope microperimetry, the presence of iatrogenic scotomas that developed postoperatively in the pathway of choroidal neovascularization extraction was also investigated.

RESULTS

Postoperatively, a choriocapillaris defect was detected in 17 (94.4%) of 18 cases. In 15 cases (83.3%), the choriocapillaris defect had a clear relationship to the pathway of choroidal neovascularization extraction. Postoperatively, a scotoma was present in 16 (88.9%) of 18 cases. In 14 cases (77.8%), the location of the scotoma had a clear relationship to the pathway of choroidal neovascularization extraction.

CONCLUSION

Surgical excision of choroidal neovascularization leads to severe damage of the choroid and retina in the pathway of the extracted choroidal neovascularization. The injury involves the neurosensory retina, retinal pigment epithelium, and choriocapillaris.

[Long-term results after simple vitrectomy for age-related macular degeneration with vitreous hemorrhage]

We reviewed the cases of 10 eyes with vitreous hemorrhage secondary to submacular hemorrhage associated with age-related macular degeneration, in which vitrectomy was performed without subretinal management. Vitreous hemorrhage occurred within 3 weeks of submacular hemorrhage. After vitrectomy, residual subretinal hemorrhage was rapidly absorbed and choroidal neovascularization was undetectable. After the surgery visual acuity improved over that of submacular hemorrhage in 5 eyes. Mean follow-up was 25 months and final visual acuity was 0.2 or better in 6 eyes (60%). Final visual outcome was highly corelated with the period from subretinal hemorrhage to vitrectomy, the thickness of subfoveal hemorrhage at vitrectomy, position of choroidal neovascularization, and duration of subretinal hemorrhage. Simple virectomy might be effective to stabilize submacular changes and improve visual acuity.

[The time course of white retinal arterioles in two cases of antiphospholipid antibody syndrome]

We report two cases of antiphospholipid antibody syndrome with elevated anti-beta 2-glycoprotein I antibodies. Patient 1 had systemic lupus erythematosus (SLE) and was treated with an oral corticosteroid and aspirin. There were foci of sheathed retinal arterioles appearing as white lines in the fundus of both eyes. The sheathed arterioles of the peripheral fundus of the right eye were completely or incompletely occluded. Recanalization occurred during a 10 month follow-up. Patient 2 had hypertension and multiple brain infarction but no association with collagen diseases. Major retinal arterioles showed sheathing. Fluorescein angiography demonstrated progressive occlusion or stenosis of these major arterioles with extensive insufficiency of regional capillary bed circulation. Retinal photocoagulation was applied to both eyes which developed neovascularization. Vitrectomy was performed in the left eye with recurrent vitreous hemorrhage. Antiphospholipid antibody syndrome should be considered in cases of sheathed or white retinal arterioles.

[Surgical indications and results of primary pars plana vitrectomy for rhegmatogenous retinal detachments]

To evaluate the efficasy of primary vitrectomy for uncomplicated rhegmatogenous retinal detachment associated with posterior hyaloid separation, a series of 63 eyes were reviewed retrospectively. The criteria for vitrectomy included not only eyes with posterior retinal breaks but also those with multiple peripheral retinal breaks. The reattachment rate was 92.1% (58 eyes) after the initial surgery, and finally this increased to 100%. Of the 46 eyes with macular detachment, good visual rehabilitation, i.e., visual acuity improved by 5 or more lines, was obtained in 71.8% (33 eyes) one month postoperatively. There was no statistically significant difference in the reattachment rate whether an encircling procedure was also done or not. In eyes with lens opacity, cataract surgery was also done and intraocular lenses were implanted uneventfully in all but one myopic case. No serious complications such as proliferative vitreoretinopathy were found throughout the follow-up period except for the high incidence (53.8%) of cataractous progression. The results indicate that vitrectomy, removing the peripheral vitreo-retinal traction directly, is an effective procedure for primary rhegmatogenous retinal detachment. Vitrectomy combined with cataract surgery is also proposed as a valuable strategy in selected cases to maintain visual rehabilitation.

Differentiating full thickness macular holes from impending macular holes and macular pseudoholes

AIMS

The reliability of scanning laser ophthalmoscope (SLO) microperimetry in differentiating full thickness macular holes from macular pseudoholes and impending macular holes was evaluated.

METHODS

106 eyes with the clinical diagnosis of full thickness macular holes, macular pseudoholes, and impending (stage 1) macular holes were examined for the presence of deep or relative scotoma using SLO microperimetry. The relation between these scotomas and the clinical diagnosis was studied.

RESULTS

Deep and relative scotomas were detected in all 57 eyes with clinically defined full thickness macular holes. In contrast, among 49 eyes diagnosed with macular pseudoholes or impending macular holes, no deep and only one relative scotoma was observed. The sensitivity of the presence of a deep scotoma as an indicator of the clinical diagnosis of a full thickness macular hole was 100% (57 of 57), and the specificity was 100% (49 of 49). The sensitivity of the presence of a relative scotoma was 100% (57 of 57) and the specificity was 98.0% (48 of 49).

CONCLUSION

With SLO microperimetry, full thickness macular holes can be precisely and objectively distinguished from other conditions that mimic macular holes.

Chronic ocular ischemia associated with the Eisenmenger's syndrome

We studied the ocular findings of two adult patients with the Eisenmenger's syndrome who had atrial septal defects that were diagnosed before the age of 10 years but not operated on and pulmonary hypertension. Both eyes of these patients showed microaneurysms, multiple small blot hemorrhages, or capillary dilation in the temporal peripheral fundus. Multiple microaneurysms and retinal collaterals were confirmed by fluorescein angiography. One of the patients developed bilateral rubeosis iridis with slow progression. These retinal lesions and the rubeosis iridis are probably related to chronic ocular ischemia caused by chronic systemic hypoxia.

Presence of epidermal growth factor in human tears

Epidermal growth factor (EGF) is a polypeptide that stimulates the growth of various tissues, including the cornea. The presence of EGF in tears from normal volunteers and in aqueous humor from cataract patients was investigated via human EGF (hEGF)-specific radioimmunoassay. Immunoreactive hEGF was found to be present at similar concentrations in both reflex (ranging from 0.7 to 8.1 ng/ml) and non-reflex tears (ranging from 1.9 to 9.7 ng/ml), but was undetectable in aqueous humor. Immunoreactive EGF in human tears was indistinguishable immunologically, biologically and biochemically from urine EGF and standard hEGF.