A Case Of Descemet Membrane Detachment Postcataract Surgery

Descemet Membrane Detachment is a vision-threatening complication of Cataract Surgery. If not treated promptly it can lead to serious vision impairment with the possible need for corneal transplantation. We present a case report of a 60 years old female who presented with blurry vision post phacoemulsification and lens placement after a cataract in the left eye. She was diagnosed with Descemet membrane detachment on slit-lamp examination that was confirmed on Anterior-segment Optical Coherence Tomography and treated with intracameral 20% SF6 injection. There was a marked improvement in her vision with complete resolution of corneal oedema. Conclusion: Anterior Segment OCT can be used as a diagnostic tool to accurately ascertain the site and extent of detachment and monitor disease progress. 20% Sulfur-hexafluoride intracameral injection can be used as a surgical option for large, central detachments.

The impact of microbubble-enhanced therapeutic ultrasound combined with prothrombin on microwave ablation in the rabbit liver

AIM

This study aimed to investigate the effect of microbubble-enhanced ultrasound (MEUS) combined with prothrombin on regional hepatic circulation and microwave ablation (MWA) in rabbit livers.

MATERIALS AND METHODS

High-pressureamplitude therapeutic ultrasound (TUS) was used to treat 52 surgically exposed livers of healthy New Zealand rabbits: 13 livers were treated with MEUS alone, 13 with MEUS and prothrombin (PMEUS), 13 with ultrasound plus normal saline and 13 with ultrasound plus prothrombin as controls. Contrast-enhanced ultrasound (CEUS) imaging was performed on the exposed livers before and after treatment, and acoustic quantification was done to assess liver perfusion. Then, the liver was divided into two parts, one was used for pathologic examination and the other was ablated with microwave (MWA) and then processedfor pathologic examination.

RESULTS

The CEUS images and Peak value after treatment in the PMEUS group were significantly reduced as compared to the remaining 3 groups (p<0.05). Occasional piecemeal hemorrhage was evidenced in the pathological examination in the MEUS group. Obvious cellular degeneration and necrosis with thrombosis were observed in the PMEUS group. Electron microscopy showed endothelial damage in both the MEUS group and PMEUS group. After MWA, coagulated volumes (V) in the PMEUS group were larger than in the remaining 3 groups (p<0.05). The cell ultrastructure disorder wasmore severe in the PMEUS group than in remaining 3 groups.

CONCLUSION

PMEUS promotes endothelial injury and produces more obvious thrombotic occlusion, improving the therapeutic effect of MWA on the rabbit liver.

Contrast-enhanced ultrasound for evaluation of high-intensity focused ultrasound treatment of benign uterine diseases: retrospective analysis of contrast safety

As a noninvasive treatment technique, ultrasound-guided high-intensity focused ultrasound (HIFU) has been considered as a routine treatment for uterine fibroids and adenomyosis in China. Contrast-enhanced ultrasound (CEUS) has been proposed as another option to assess the treatment efficacy during HIFU treatment. The aim of this investigation is to evaluate the adverse effects of HIFU ablation for benign uterine diseases in a group of patients studied with ultrasound contrast agent (UCA), in comparison with a group of patients not exposed to UCA. From November 2010 to December 2013, 2604 patients with benign uterine diseases were treated with HIFU. Among them, 1300 patients were exposed to an UCA, whereas 1304 patients were not.During HIFU procedure, the incidences of leg pain, sacral/buttock pain, groin pain, treatment area pain, and the discomfort "hot" sensation on skin were higher in the patients who were exposed to SonoVue (Bracco, Milan, Italy) than those who were not (20.5% vs 11.7%, 52.5% vs 42.3%, 6.5% vs 4.5%, 68.9% vs 55.4%, and 48.1% vs 42.9%, respectively). Among the postoperative adverse effects, the incidence of lower abdominal pain was significantly higher in patients who were exposed to an UCA than those who were not (51.2% vs 39.9%, P < 0.05). Two patients who were exposed to an UCA had acute renal function failure.In conclusion, UCA may increase the incidences of some common HIFU-related adverse effects during HIFU treatment for benign uterine diseases, but most of which were acceptable and self-limited. After HIFU treatment, renal function should be monitored in patients with a history of hypertension or taking nonsteroidal anti-inflammatory drugs.

Investigation into the impact of diagnostic ultrasound with microbubbles on the capillary permeability of rat hepatomas

Ultrasound-targeted microbubble destruction (UTMD) takes advantage of transiently increased capillary permeability to enhance the release of tumor-specific drugs from blood vessels into sonicated tumor tissues. However, the application of focused ultrasound is limited because of the lack of an appropriate image-monitoring system. In this study, hepatoma-bearing Sprague-Dawley rats were insonicated with low-frequency diagnostic ultrasound and injected with Evans Blue (EB) dye and microbubbles through their tail veins to test changes in capillary permeability. We studied how the mechanical index, sonication duration and the injected microbubble (MB) concentration affect the hepatoma vascular permeability by quantitatively evaluating the EB delivery efficiency. Confocal laser scanning microscopy was used to observe the deposition of red fluorescence-dyed EB in tumor tissues. In addition, P-selectin, a type of biochemical marker that reflects vascular endothelial cell activation, was identified using an immunoblotting analysis. The experimental results reveal that EB delivery efficiency in tumor tissues was greater in groups with the diagnostic ultrasound-mediated UTMD (8.40 ± 0.71 %ID/g) than in groups without UTMD (1.73 ± 0.19 %ID/g) and EB delivery efficiency could be affected by MI, sonication duration and MB dose. The immunoblotting analysis indicates that diagnostic ultrasound-induced UTMD results in the vascular endothelial cell activation to increase capillary permeability, justifying the high quantity of EB deposited in tumor tissues.

Intravitreal recombinant tissue plasminogen activator without and with additional gas injection in patients with submacular haemorrhage associated with age-related macular degeneration

PURPOSE

To compare intravitreal recombinant tissue plasminogen activator (rt-PA) treatment with and without gas injection in patients with submacular haemorrhage associated with age-related macular degeneration.

METHODS

We conducted a retrospective, non-randomized comparative case study of 110 eyes from 76 women and 34 men (mean age 78.1 ± 6.9 years). Evaluations of the data were performed for baseline visit (t1), and visits 1-3 weeks (t2), 3 months (t3) and 6 months after (t4). The patients were classified according to gas treatment into group A (without gas, n = 46) and group B (with gas, n = 64) and according to rt-PA-dosage into group A1 and B1 (50 μg), group A2 and B2 (100 μg), and group A3 and B3 (200 μg).

RESULTS

 At t4, the patients in group A had a median increase of 0.4 logMAR, and those in group B had a decrease of 0.1 logMAR (p = 0.183). The best corrected visual acuity (BCVA) remained stable or increased in 55% and 62% of patients in groups A and B, respectively (p = 0.151), in 50% and 68% of patients in groups A1 and B1, respectively (p = 0.620), in 40% and 100% of patients in groups A2 and B2, respectively (p = 0.250), and in 75% and 63% of patients in groups A3 and B3, respectively (p = 0.463). Complications were observed in 13.6% of patients.

CONCLUSIONS

Best results were obtained in patients treated with 50 and 100 μg of rt-PA and in those cases BCVA development was more beneficial if additional gas was injected.

Effect of healthy tissue ablation surrounding VX2 rabbit liver tumors by high-intensity focused ultrasound combined with an ultrasound contrast agent

OBJECTIVES

The purpose of this study was to determine the minimum amount of healthy peripheral tissue that should be ablated when treating VX2 liver tumors with high-intensity focused ultrasound combined with an ultrasound contrast agent.

METHODS

Fifty-one rabbits with hepatic tumors were established and randomly divided into the following groups: group A, which only had their tumors ablated; group B, which had their tumors and 2 mm of healthy adjacent tissue ablated; and group C, which had their tumors and 4 mm of healthy adjacent tissue ablated. The pathologic characteristics of the target tissue, serum alanine aminotransferase (ALT) level, presence of intrahepatic and distant metastases, and survival time between different groups were compared after high-intensity focused ultrasound treatment.

RESULTS

After ablation, coagulative necrosis was observed in all targeted tissue. The serum ALT level in group C was the highest and the level in group A was the lowest on the third and fifth days after ablation (P < .05), respectively. Fourteen days later, the serum ALT level in groups B and C decreased to normal, whereas the level in group A was abnormal and significantly higher (P < .05). Compared with group A, the prevalence of metastases in groups B and C was significantly lower (P < .05), and the survival time was significantly longer (P < .05); there appeared to be no statistically significant difference between groups B and C (P > .05).

CONCLUSIONS

Ablation of a tumor along with 2 mm of healthy surrounding tissue is a more effective strategy for treating hepatic cancer with high-intensity focused ultrasound coupled with an ultrasound contrast agent.

Face-down positioning or posturing after macular hole surgery

BACKGROUND

Macular holes cause significant loss of central vision. With the aim of improving the outcome of surgery, a variable period of face-down positioning may be advised.

OBJECTIVES

To evaluate the evidence of the impact of postoperative face-down positioning on the outcome of surgery for macular hole.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 8), MEDLINE (January 1950 to August 2011), EMBASE (January 1980 to August 2011), the International Standard Randomised Controlled Trial Number Register (ISRCTN Register) (http://www.controlled-trials.com), the WHO International Clinical Trials Registry Platform (ICTRP) (http://www.who.int/ictrp/search/en) and ClinicalTrials.gov (http://clinicaltrials.gov). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 29 August 2011.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which postoperative face-down positioning was compared to no face-down positioning following surgery for macular holes.

DATA COLLECTION AND ANALYSIS

Data were collected and analysed independently by two authors.

MAIN RESULTS

Three RCTs were identified, A, B and C; one of which was unpublished data. We were unable to conduct a meta-analysis due to study heterogeneity regarding duration of face-down positioning and surgical methods (use of inner limiting peel). All three studies suggested an overall beneficial effect of posturing in terms of closure of holes: (A: risk ratio (RR) 1.10; 95% confidence interval (CI) 1.00 to 1.20, P = 0.05); B: RR 1.58, CI 1.0 to 2.5, P = 0.01; C: RR 1.03, CI 0.9 to 1.17, P = 0.67). For holes which were smaller than 400 microns in size, all three studies reported that there was no significant effect of face-down positioning on successful hole closure (A: RR 1.03, CI 0.95 to 1.12; B: RR 1.0, CI 0.68 to 1.46; C: RR 1.03, CI 0.9 to 1.17). However, for holes which were larger than 400 microns in size, both of the studies which examined macular holes of this size agreed on the effectiveness of face-down positioning on hole closure following surgery (A: RR 1.2, CI 1.01 to 1.42, P = 0.04; B: RR 2.27, CI 1.04 to 4.97, P = 0.04).

AUTHORS' CONCLUSIONS

There is currently insufficient evidence from which to draw firm conclusions about the impact of postoperative face-down positioning on the outcome of surgery for macular hole. Of three RCTs, two suggested a benefit in larger holes but none demonstrated evidence of a benefit in smaller holes.CONSORT adherent RCTs and large scale, well designed non-randomised observational studies are needed to determine with confidence the value of this intervention.

[Management of subretinal hemorrhage with r-TPA, SF-6 and ranibizumab]

CASE REPORT

We present a case of a patient with subretinal hemorrhage treated with intravitreal r-TPA, SF-6 and ranibizumab.

DISCUSSION

Subretinal hemorrhages secondary to age-related macular degeneration are associated with poor visual outcome. A wide variety of management approaches has been developed, but the prognosis of these patients has not been modified by any of them. The association of an intravitreal anti VEGF drug to r-TPA and gas, may improve its results as we add the treatment of the subjacent etiology to the pneumatic displacement.

Fibrinolytic effects of transparietal ultrasound associated with intravenous infusion of an ultrasound contrast agent: study of a rat model of acute cerebral stroke

The aim of this study was to evaluate the thrombolytic effect of focused transparietal ultrasound in combination with a specific contrast agent (microbubbles) in acute cerebral ischemia. Acute cerebral ischemia was induced in 10 rats by intra-arterial clots injection. Five rats (group 1) were treated with a combination of transparietal ultrasound (probe 2 MHz, acoustic power 500 mW/cm(2)) and intravenous injection of 0.6 mL of the ultrasound contrast agent (UCA) sulfur hexafluoride. Five rats (group 2) were treated by fibrinolytic intravenous infusion (recombinant tissue plasminogen activator). Cerebral cellular energy production was determined by measuring the cellular phosphorylation using phosphorus magnetic spectroscopy before and during ischemia induction and after treatment. Measures were performed on a dedicated 2.35T magnet. The ratio phosphocreatine (P(Cr)) on inorganic phosphate (P(i)), P(Cr)/P(i), estimation of the oxidative phosphorylation metabolism and the intracellular pH (pHi) were measured in the two groups. Compared with the ischemia induction period, both treatments were associated with an increase of P(Cr)/P(i) and pHi values, respectively, +80% and +100% in group 1 (p=0.07) and +100% and +80% in group 2 (p=0.04). There was no significant difference between the two groups for the response treatment. To conclude, treatment with intravenous fibrinolytic infusion and treatment with focused ultrasound in combination with UCA seems to be equally effective in treating acute cerebral ischemia in rats. (E-mail: j.p.tasu@chu-poitiers.fr).

Transmission electron microscopy of VX2 liver tumors after high-intensity focused ultrasound ablation enhanced with SonoVue

INTRODUCTION

The purpose of this study was to observe sequential changes in rabbit VX2 liver tumors using transmission electron microscopy after high-intensity focused ultrasound (HIFU) ablation enhanced with the contrast agent SonoVuer (Bracco, Milan, Italy).

METHODS

Thirty New Zealand rabbits with VX2 liver tumors were randomly divided into two groups. The liver tumors of rabbits in Group A underwent single HIFU ablation; those in Group B were given the ultrasound contrast agent SonoVue 0.2 mL/kg before HIFU exposure. Five rabbits from each of the two groups were killed at 0 hours, 6 days, and 14 days after HIFU ablation. Tissue samples that included targeted and untargeted tissue were observed using transmission electron microscopy.

RESULTS

Using transmission electron microscopy, it was evident that most of the cellular organs in the targeted areas of tumors in Groups A and B had disappeared early after HIFU, but the basic cell structure was seen in Group A. On the sixth day after HIFU ablation, all cells in the targeted areas were disrupted, and fibrous bands were detected in the rims of targeted areas in both groups. In the surrounding areas, cell swelling in Group B was more severe than in Group A, and a greater number of apoptotic bodies were found in Group B.

CONCLUSION

The use of an ultrasound contrast agent can enhance the effects of HIFU ablation on the destruction of cell ultrastructure and can enlarge the region of HIFU ablation; this provides experimental evidence for the use of contrast agents in controlling the effects of HIFU.

Combined treatment of acute subretinal haemorrhages with intravitreal recombined tissue plasminogen activator, expansile gas and bevacizumab: a retrospective pilot study

PURPOSE

To assess the effectiveness of consecutive intravitreal injections of recombined tissue plasminogen activator (rtPA), expansile gas and bevacizumab in eyes with acute subretinal haemorrhage (SRH).

METHODS

A retrospective, non-randomized consecutive case series included 19 eyes in 19 patients with SRH related to exudative age-related macular degeneration (AMD). The initial size of the subfoveal SRH was 1-3 disc diameters. Each patient received a triple procedure using 0.05 ml rtPA (50 microg), 0.3 ml of sulphur hexafluoride (SF6) gas and 0.05 ml bevacizumab (1.25 mg). Lesion size, location of the SRH and early treatment in diabetic retinopathy study (ETDRS) visual acuity were evaluated pretreatment as well as 1 and 3 months after the procedure.

RESULTS

At the initial presentation, the patients' mean age was 77 years (range 63-88 years) and the mean duration of symptoms was 9.3 days (range 4-12 days). The mean visual acuity pretreatment (20/133) improved significantly to 20/86 at 1 month and to 20/74 at 3 months. The mean ETDRS visual acuity improved from baseline by 2.1 lines at 1 month (Wilcoxon ranks test; P < 0.005) and 3.7 lines at 3 months after treatment (Wilcoxon ranks test; P < 0.005). None of our patients had reading visual acuity prior to treatment, with visual acuity below 0.3. One month after the triple procedure, 25% of our patients had reading visual acuity (> or = 0.4); at 3 months, the figure was 35%. A successful inferior displacement of the SRH was achieved in 17/19 eyes. Eyes with elevated intraocular pressure were treated immediately by a corneal paracentesis.

CONCLUSION

The intravitreal application of rtPA, gas and bevacizumab appears to be beneficial and well tolerated in the treatment of SRH in the short term. The triple approach seems a logical alternative to the current combined dual approach in limiting the progression of the underlying disease and achieving better visual outcome. Further randomized evaluations are warranted.

High-speed optical observations and simulation results of SonoVue microbubbles at low-pressure insonation

Abstract-Modified Rayleigh-Plesset models are commonly used to characterize the acoustic response of microbubbles under ultrasound exposure. In most instances these models have been parameterized through acoustic measurements taken from bulk suspensions of microbubbles. The aim of this study was to parameterize the Hoff model for the commercial contrast agent SonoVue using optically observed oscillations from individual microbubbles recorded with a high-speed camera. The shell elasticity model term was tuned to fit simulation data to the measured oscillations while the shell viscosity parameter was held constant at 1 Pa??s. The results demonstrate a limited ability of the model to predict the microbubble behavior. The shell elasticity parameter was found to vary proportionally between 10 and 80 MPa with the initial microbubble diameter, implying the viscoelastic shell terms are not a constant property of the shell material. Further analysis using a moving window optimization to probe the microbubble responses suggests that the elasticity of the shell can increase by up to 50% over the course of insonation, particularly for microbubbles oscillating nearer to their resonant frequency. Microbubble oscillations were modeled more successfully by incorporating a varying elasticity term into the model.

[Traumatic submacular hemorrhage treated with rt-PA and SF6]

CASE REPORT

This patient was afflicted by a traumatic submacular hemorrhage. A posterior vitrectomy was performed and intravitreal rt-PA and SF6 were administered. Four weeks later, the visual acuity had increased from 0.1 to 0.8. No complications due to the treatment with rt-PA were reported.

DISCUSSION

It is known that waiting for the spontaneous blood removal in such cases results in a poor visual acuity recovery due to a toxic effect of the blood products. Both rt-PA and the SF6 are useful for the treatment of submacular hemorrhages secondary to age-related macular degeneration, and this case report has shown they are also useful to lyse traumatic blood clots, thus contributing to a better recovery of visual acuity.

Microbubble potentiated transcranial duplex ultrasound enhances IV thrombolysis in acute stroke

BACKGROUND

We studied whether 2 MHz transcranial color-coded duplex ultrasound (TCCD), combined with a second generation ECA, accelerate IV rtPA-thrombolysis in the acute phase of MCA stroke more than TCCD monitoring alone.

METHODS

Non-randomized acute MCA stroke patients undergoing IV rtPA-thrombolysis and 2 MHZ-TCCD monitoring over 60 min, with (N = 11) or without (N = 15) additional continuous ECA (5 ml, SonoVue perfusion, were compared. Recanalization of the MCA was measured pre- and post-thrombolysis with the thrombolysis in brain ischemia (TIBI) grading system, clinical outcome was assessed at admission and 24 h after treatment using the NIH stroke scale (NIHSS).

RESULTS

Patients who received ECA improved their NIHSS significantly more than those who were only TCCD monitored (Mann-Whitney U = 48.0; P = 0.050), and their flow signal improved more (Mann-Whitney U = 40.0; P < 0.03).

CONCLUSIONS

The results of this pilot study show that in IV-thrombolysis the use of ECA in addition to TCCD monitoring lead to a greater immediate clinical improvement and to a better flow signal.

Pars plana vitrectomy with and without peeling of the inner limiting membrane for diabetic macular edema

PURPOSE

A prospective, comparative, nonrandomized study to evaluate the efficacy of pars plana vitrectomy (PPV) with and without inner limiting membrane (ILM) peeling for persistent diffuse clinically significant macular edema.

METHODS

Eighteen patients with persistent diffuse clinically significant macular edema despite laser photocoagulation were recruited for the study. Clinical assessment included determination of best-corrected visual acuity, fundus fluorescein angiography, optical coherence tomography, and perifoveal cone function testing. Eight patients underwent PPV with elevation and removal of the posterior hyaloid alone, and 10 patients underwent vitrectomy and ILM peeling. The follow-up was 12 months.

RESULTS

Patients with ILM peeling had improvement in foveal thickness (P = 0.07) and significant improvement in the macular volume (P = 0.039) 12 months after surgery but did not have significant improvement in Early Treatment Diabetic Retinopathy Study vision or perifoveal cone function. There was no significant difference in outcome parameters between the no peeling group and the ILM peeling group.

CONCLUSIONS

In this prospective, comparative study of PPV with and without ILM peeling for diffuse clinically significant macular edema, structural improvement was seen but with limited visual improvement after ILM peeling.

TREATMENT OF RETINAL DETACHMENT RESULTING FROM POSTERIOR STAPHYLOMA–ASSOCIATED MACULAR HOLE IN HIGHLY MYOPIC EYES

PURPOSE

To evaluate the surgical outcome of retinal detachment resulting from a posterior staphyloma-associated macular hole in highly myopic eyes.

METHODS

Fifty-seven consecutive highly myopic eyes with retinal detachment resulting from a posterior staphyloma-associated macular hole diagnosed between January 1993 and June 2003 were retrospectively studied. Anatomical reattachment of the retina and best-corrected visual acuity were measured.

RESULTS

Six different operative methods were used to treat this condition with diverse retinal reattachment rates: long-acting gas tamponade only (12.5%); pars plana vitrectomy (PPV) with long-acting gas tamponade (42.8%); PPV with epiretinal membrane (ERM) peeling and long-acting gas tamponade (50.0%); encircling scleral buckling combined with PPV and long-acting gas tamponade (57.1%); encircling scleral buckling combined with PPV, ERM peeling, and long-acting gas tamponade (40.0%); and encircling scleral buckling combined with PPV and silicone oil tamponade (75.0%). Overall, successful retinal reattachment was achieved in 25 (43.9%) of 57 eyes after the first surgery. However, the ultimate success rate of retinal reattachment was 77.2% (44 of 57 eyes) after subsequent surgery. The mean preoperative visual acuity +/- SEM (in logarithm of the minimal angle of resolution units) was 2.08 +/- 0.55, and the mean postoperative visual acuity +/- SEM was significantly increased to 1.87 +/- 0.54 at the last follow-up (P = 0.038). The major cause of recurrent retinal detachment in the long-acting gas tamponade group was nonclosure of the macular hole. For vitrectomized eyes, the major cause was reopening of the macular hole, even with ERM formation and proliferative vitreoretinopathy. There was no obvious correlation between the extent of the detachment or lens status and the reattachment rate.

CONCLUSIONS

The major causes of recurrent retinal detachment in the long-acting gas tamponade and vitrectomized groups were nonclosure of the macular hole and reopening of the macular hole, respectively. Furthermore, a lesser extent of retinal detachment was not associated with a higher anatomical success rate. More aggressive treatment such as silicone oil tamponade may need to be performed to overcome reduced natural adhesion due to posterior staphyloma with marked chorioretinal atrophy. Failure to initiate aggressive treatment can result in an unsatisfactory outcome and repeated surgery.

Perforated corneal hydrops treated with sulfur hexafluoride (SF6) gas and tissue adhesive

PURPOSE

To report a case of a perforated acute hydrops in a mentally retarded patient that was successfully managed with intracameral sulfur hexafluoride gas and cyanoacrylate tissue adhesive.

METHODS

Interventional case report.

RESULTS

A 14-year-old mentally retarded male patient with keratoconus presented with a perforated acute hydrops. A bandage contact lens was applied. However, following a large emesis 2 days later, the aqueous leak worsened with shallowing of the anterior chamber. Under general anesthesia, sulfur hexafluoride was injected to reform the anterior chamber and cyanoacrylate tissue adhesive was applied to the perforated site and covered by a bandage contact lens and temporary tarsorrhaphy. A follow-up examination at 1 month showed a formed anterior chamber with tissue adhesive in situ and no aqueous leak.

CONCLUSIONS

The successful use of intracameral sulfur hexafluoride and tissue adhesive in the management of perforated acute hydrops may avoid emergency tectonic penetrating keratoplasty and reduce potential complications in the poorly cooperative patient.

Primary vitrectomy for combined rhegmatogenous retinal detachment and choroidal detachment with or without oral corticosteroids: a pilot study

PURPOSE

The occurrence of choroidal detachment (CD) in eyes with primary rhegmatogenous retinal detachment (RRD) is relatively uncommon (2%-4.5%). Recent reports suggest that primary vitrectomy yields better anatomic success than scleral buckling. However, for these inflamed eyes with low intraocular pressure, the influence of preoperative oral steroids on reattachment rates has not been elucidated yet.

METHODS

Twenty eyes with combined RRD and CD that underwent primary vitrectomy were randomized to receive oral steroids (for 1 week) or no oral steroids before surgery.

RESULTS

Preoperative clinical data such as mean age, lens status, Snellen visual acuity, duration of macular detachment, CD (size and extent), and retinal detachment characteristics (e.g., extent, number of retinal breaks, atrophic or tractional retinal break, size of retinal break, and location of retinal break) were similarly distributed in both groups. Single-operation anatomic success was 81.8% (9/11) among those patients who received preoperative oral steroids and was 66.7% (6/9) among those who did not receive preoperative oral steroids. After reoperation, anatomic success was 100% in both groups. The mean follow-up was 20.1 months.

CONCLUSION

The results suggest that administration of oral steroids before primary vitrectomy in eyes with combined RRD and CD improves reattachment rates.

Management of rhegmatogenous retinal detachment in a full-term pregnancy

Although exudative retinal detachments have been well documented to occur during pregnancy, reports of rhegmatogenous retinal detachments occurring during pregnancy are rare. A case is presented herein of rhegmatogenous retinal detachment occurring during pregnancy. Some of the challenges arising from this uncommon clinical scenario are discussed.

Results of intravitreal tissue plasminogen activator and expansile gas injection for submacular haemorrhage in Thais

PURPOSE

To study the results of intravitreal tissue plasminogen activator (tPA) and expansile gas injection for submacular haemorrhage in Thai patients.

METHODS

The medical records of Thai patients who presented with submacular haemorrhage between January 1998 and December 2002 were reviewed. The inclusion criteria were acute onset of bleeding (<1 month), treatment with intravitreal injection of tPA solution (50-100 mug in 0.1 ml) and expansile gas (0.3-0.4 ml of 100% perfluoropropane or sulphur hexafluoride), and at least 6 months of follow-up. Our main outcome measures were best final postoperative visual acuity and surgical complications.

RESULTS

A total of 19 eyes of 19 patients completed the inclusion criteria with a mean duration of 13.1 days. The causes of haemorrhage were age-related macular degeneration in 15 eyes (78.9%), idiopathic choroidal neovascularization in two eyes (10.5%), and traumatic, and valsalva retinopathy in one eye each (5.2%). After a mean follow-up of 13 months (range 6-39 months), postoperative visual acuity improved two lines or greater in 12 eyes (63.2%), stabilized in six eyes (31.6%) and worsened in one (5.2%). The final visual acuity measured 20/63 or better in 10 eyes (52.6%). The surgical complications were breakthrough vitreous haemorrhage (three eyes) and cataracts (three eyes), and two had retinal detachments.

CONCLUSION

The treatment of submacular haemorrhage with intravitreal injection of tPA and expansile gas improved visual acuity in more than half of the patients. In all, 10 in 19 eyes demonstrated final visual acuity at a functional level.

Prediction of postoperative visual outcome based on hole configuration by optical coherence tomography in eyes with idiopathic macular holes

PURPOSE

To evaluate whether an index based on hole configuration can be used to predict visual outcome in eyes with idiopathic macular holes.

DESIGN

Prospective interventional case series.

METHODS

Thirty-five eyes of 32 patients with idiopathic stage 2 or 3 macular hole were enrolled in this study. The best-corrected visual acuity (BCVA), cross-sectional image of the macular hole by optical coherence tomography (OCT), and retinal thickness in the central (<1000 microm), inner (1000 to 2220 microm), and outer ring areas (2220 to 3450 microm) as defined by the OCT retinal mapping program were evaluated preoperatively and at 1, 3, 6, and 12 months postoperatively. The change in retinal thickness of the inner ring area at the 6-month postoperative period was used to evaluate the degree of preoperative retinal deformation. The macular hole index (MHI) (ratio of hole height to base diameter of hole) was calculated and correlated with minimum diameter of hole, base diameter of hole, the postoperative decrease in macular thickness, and the postoperative BCVA. The postoperative BCVA was further evaluated in two patient-matched groups.

RESULTS

Retinal thickness values in the inner ring area were decreased at the 1-month postoperative period. MHI significantly correlated with the postoperative decrease in macular thickness in the inner ring area at 6 months (correlation coefficient = -0.632, P = .030, Spearman analysis) and with the postoperative BCVA (P = .013, multiple regression analysis). Postoperative BCVA in the MHI >/=0.5 group was better than that in the MHI <0.5 group (P = .032, Mann-Whitney test).

CONCLUSIONS

The MHI is a ratio easily calculated from OCT transverse images of the macular area. The MHI represents the preoperative configuration of a macular hole and is a prognostic factor for visual outcome.

Vitrectomy with internal limiting membrane removal for clinically significant macular oedema

BACKGROUND

Little has been published on internal limiting membrane (ILM) removal for clinically significant macular oedema (CSME) in eyes not improving following maximal laser treatment.

METHODS

Retrospective review of the charts and intraoperative video films of 30 consecutive eyes of 27 patients undergoing vitrectomy, ILM peeling, and gas tamponade by a single surgeon.

RESULTS

The average patient was 52 years old; 56% were males. The oedema was caused by diabetes in 87% of the eyes, 42% of which had proliferative disease. The oedema was diffuse in 16 eyes (53%) and cystoid (CME) in 14 (47%). In 21% of eyes, spontaneous vitreous detachment was present or the eye had already undergone vitrectomy. All but one eye had at least 6 months of follow-up (mean 12 months). The oedema resolved completely in 26 eyes (90%) and partially in 3 eyes (10%). The visual acuity improved at least two Snellen lines in 19 eyes (66%) and one line in 4 eyes (14%); the average improvement was 4 lines. The acuity was unchanged in three eyes (10%) and worsened in three eyes (10%), all due to cataract. Among the 14 eyes with CME, 11 (79%) became completely dry and the visual acuity improved in 11 eyes (79%). No ILM-related complication was encountered in any eye.

CONCLUSIONS

Vitrectomy with ILM peeling is a promising approach to eyes with CSME. It appears to offer visual improvement at a much higher rate than laser therapy and with a longer-lasting effect than that of intravitreal triamcinolone. A larger study is necessary to confirm these preliminary findings.

LONG-TERM RESULTS OF VITRECTOMY FOR REMOVAL OF SUBMACULAR HARD EXUDATES IN PATIENTS WITH DIABETIC MACULOPATHY

PURPOSE

To investigate long-term results of vitrectomy for the removal of submacular hard exudates in patients with diabetic maculopathy.

METHODS

Thirteen eyes of 10 patients with diabetic maculopathy underwent vitrectomy to remove submacular hard exudates from December 1993 to March 1999. The mean preoperative logMAR visual acuity +/- SD was 1.54 +/- 0.43. Preoperatively, the exudates ranged from 0.5 to 3 disk diameters (average, 1.25 disk diameters). Exudates were removed using subretinal forceps through a minimal paramacular retinotomy after vitrectomy. In all cases, 20% SF6 gas tamponade was added. The mean postoperative observation period was 43.2 months.

RESULTS

Visual acuity was improved in 7 eyes (54%) 1 year after surgery; however, visual acuity over longer periods was improved in only 5 eyes (38%) as compared with the preoperative findings. The mean final visual acuity +/- SD was 1.62 +/- 0.59, which did not show statistically significant improvement over that in the control group. Although submacular hard exudates and macular edema disappeared during the postoperative period, atrophic or degenerative changes occurred in many cases.

CONCLUSION

Visual improvement could not be obtained for a long period after removing submacular hard exudates in most of the patients, suggesting that diabetic maculopathy should be treated before massive exudate deposits appear in the macula.

[Heterochromia of the Iris after t-PA and Gas Injection of Sulfur Fluoride]

BACKGROUND

Are changes in iris colour and retinal pigment epithelium after t-PA and gas injection and subsequent vitreous haemorrhage caused by blood cells, or is this a toxic effect?

CASE

A 81-year old female presented for vitrectomy with a persistent vitreous haemorrhage two months after t-PA and gas injection because of subretinal macular haemorrhage. Sonographic control revealed attached retina. The examination disclosed a new heterochromia of the iris with a change from blue to green-brown. A discrete anterior chamber flare and blood cells were found. Subsequent vitrectomy revealed a thick, rubber-like haemorrhage in the vitreous with suspect pigmentation. A change in retinal pigmentation was also evident.

CONCLUSION

The cause for the heterochromia and the change in pigmentation of the retinal pigment epithelium remained unclear. It may have been a consequence of the persistent bleeding with iron apposition on the iris. A toxic effect of t-PA has to be discussed which led to the alteration in pigmentation.

Stabilization of post-trabeculectomy flat anterior chamber with Healon and sulfur hexafluoride

We present the management of 2 cases of post-trabeculectomy flat anterior chamber with hypotony due to an overflowing fistula. When separate attempts to reform the anterior chamber by intracameral injection of sulfur hexafluoride (SF(6)) and sodium hyaluronate 1.0% (Healon) failed, we injected SF(6) 100% with Healon into the anterior chamber. This stabilized the anterior chamber without compromising the integrity of the filtering bleb. No complications were observed. This simple, safe, and effective procedure offers another option for the management of a flat anterior chamber due to overfiltration.

Suture fixation of an intraocular lens combined with pars plana vitrectomy and gas tamponade

We describe suturing an intraocular lens (IOL) after pars plana lensectomy and vitrectomy combined with gas tamponade in 4 patients with vitreoretinal disease and subluxated lenses that could not be managed with capsular tension rings. The IOL haptics were sutured before the fluid-gas exchange in a horizontal (case 1), oblique (cases 2 and 4), and vertical (case 3) manner. In a case of unavoidable horizontal fixation due to limited scleral space, the upper part of the IOL tilted anteriorly postoperatively because of the enhanced effect of the gas bubble. A peripheral anterior iris synechia also occurred. The IOL remained well positioned in cases with oblique and vertical fixations, and no other complications occurred. Careful preoperative planning of the surgical design can help avoid unnecessary horizontal fixation.

Inverted pneumatic retinopexy: a method of treating retinal detachments associated with inferior retinal breaks

PURPOSE

To introduce the new approach of inverted pneumatic retinopexy for the management of rhegmatogenous retinal detachments with inferior retinal breaks.

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

Eleven patients presenting with rhegmatogenous retinal detachments with causative inferior retinal breaks.

INTERVENTION

Sterile gas/air injection, cryopexy/laser retinopexy, with inverted positioning.

MAIN OUTCOME MEASURES

Postoperative primary and final anatomical outcome, visual acuity, and complications.

RESULTS

Patients were followed for a minimum of 3 months (mean, 5.1 months). Primary retinal reattachment was obtained in 10 of 11(91%) patients. One patient sustained a redetachment secondary to proliferative vitreoretinopathy, resulting in a single operation reattachment rate of 82%. Final reattachment was obtained in 11 of 11 (100%) patients. Mean visual acuity improved about 3 lines from 20/60 to 20/30, with 11 of 11 patients experiencing improvement in their visual acuity. Two patients required an additional surgical procedure to achieve final anatomic success. No new breaks were identified in the postoperative period, and no complications resulted from the pneumatical procedure.

CONCLUSIONS

Inverted pneumatic retinopexy can successfully repair retinal detachments with inferior retinal breaks under appropriate conditions.

Submacular deposition of triamcinolone acetonide after triamcinolone-assisted vitrectomy

PURPOSE

We describe a case demonstrating a submacular deposition of triamcinolone acetonide (TA) after a TA-assisted vitrectomy for retinal detachment.

DESIGN

Interventional case report.

METHODS

A 48-year-old Japanese man with rhegmatogenous retinal detachment in his left eye underwent a TA-assisted vitrectomy, endolaser photocoagulation, and sulfur hexafluoride (SF(6)) gas tamponade.

RESULTS

At the end of the surgery and the day after undergoing vitrectomy, the deposition of TA was observed between the retinal pigment epithelium and neurosensory retina in the submacular area. These TA granules disappeared after 2 weeks. Two months after the operation, the retina was observed to be successfully attached and no abnormality was observed in the macula. The patient's visual acuity improved to 20/16, and no ophthalmoscopic or functional damage was observed.

CONCLUSION

No apparent adverse effect was found in this case demonstrating a submacular deposition of TA.

Retinal detachment in the mentally retarded

PURPOSE

To report the clinical features and surgical outcomes of retinal detachment in mentally retarded patients.

METHODS

Retrospective review of records of mentally retarded patients who had retinal reattachment surgery at the authors' institutions between February 1994 and February 2000. There were 8 patients with 13 surgically treated eyes. Demographic and clinical data were abstracted from the patients' medical records.

RESULTS

The retina of 12/13 (92%) eyes remained reattached after a follow-up ranging from 9 to 78 months. In 6 eyes of the 4 patients whose visual acuity (VA) could be determined, VA improved in 5 eyes of 3 patients. In the remaining 4 patients whose VA could not be determined, improved behavioral patterns suggesting a successful surgical outcome were observed in 3 patients with bilateral retinal detachment, although in one of these patients only unilateral retinal reattachment was achieved. The findings in the eyes in this study agree with the findings in reports on patients with traumatic retinal detachment.

CONCLUSIONS

The retinal reattachment rate is fair in the mentally retarded compared with the rate in other segments of the population. Ophthalmological examinations should be provided regularly for mentally retarded persons to keep open the possibility for early sight-improving surgery.

Cone photoreceptor recovery after experimental detachment and reattachment: an immunocytochemical, morphological, and electrophysiological study

PURPOSE

To compare the morphologic and functional recovery of the retina after detachment and reattachment in an animal with a cone-dominant retina, the ground squirrel.

METHODS

Ground squirrel (Spermophilus beecheyi) retinas were detached for 1 day and reattached for 7, 35, or 96 days (n = 2, each time point). Flicker ERGs were recorded 1 day after the detachment and at various times after reattachment. Contrast-response functions were measured for isochromatic modulation and for selective modulation of short-wavelength-sensitive (S) and middle-wavelength-sensitive (M) cones. At the end of the experiment, retinas were prepared for light microscopy or immunocytochemical staining with antibodies to rod opsin, S and M cone opsins, cytochrome oxidase, synaptophysin, glial fibrillary acidic protein (GFAP), cellular retinaldehyde-binding protein (CRALBP), interphotoreceptor-binding protein (IRBP), and peanut agglutinin lectin (PNA). Photoreceptor density maps were created from wholemount preparations labeled with biotinylated PNA and anti-S cone opsin. Cell counts of photoreceptor nuclei and cone outer segments (OS) were compared with flicker ERG data. Cell death was examined by the TUNEL method.

RESULTS

Reattachment stopped photoreceptor cell death and reversed the disruption of interphotoreceptor matrix as well as the redistribution of Müller cell proteins. It also activated some astrocytes based on anti-GFAP staining. S- and M-cone OS showed a gradual recovery in length after reattachment, and this recovery continued to the longest time points examined. ERG contrast gains also recovered after reattachment, but these reached asymptotic levels by approximately a week after reattachment. There were significant correlations between outer nuclear layer (ONL) cell counts and ERG contrast gains. No differences were noted in the indices of recovery of M and S cones.

CONCLUSIONS

The ERG can be used to follow specifically the changes in the retina that occur after retinal detachment and reattachment.

Descemet's membrane detachment after cataract surgery: management and outcome

OBJECTIVE

To analyze the possible causes of Descemet's membrane detachment (DMD) and the treatment and outcome of patients after cataract surgery.

DESIGN

Retrospective noncomparative interventional case series.

PARTICIPANTS

Fifteen eyes of 12 patients.

METHODS

We reviewed clinical data on 15 eyes of 12 patients with nonscrolled DMD after cataract surgery who presented to the Cornea Service at Wills Eye Hospital from 1986 to 2001. Institutional review board/ethics committee approval was obtained.

MAIN OUTCOME MEASURES

Visual acuity and reattachment of Descemet's membrane.

RESULTS

Cataract procedures involved nine clear-corneal eyes, four limbal incisions, one trabeculectomy/combined phacoemulsification, and one extracapsular cataract extraction. From 1986 to 1990, we had 1 patient; from 1991 to 1995, no patients; and from 1996 to 2001, 11 patients (including all clear-corneal eyes). Of the 15 eyes, 8 resolved with medical treatment alone, with a mean time to resolution of 9.8 weeks. One patient was lost to follow-up while improving on medical treatment, and another required a penetrating keratoplasty (PK) after medical treatment failed. Five eyes received anterior-chamber SF(6) gas injection. Of these eyes, three DMDs resolved, one underwent repeated injection (not improving after 10 weeks), and another required a PK.

CONCLUSIONS

Referrals for DMD seem to be increasing. This may be explained by the increase in clear-corneal cataract procedures. Medical treatment seems to be adequate in many cases and may be appropriate initial therapy. When needed, SF(6) gas injection may also be successful, but not in all cases.

Management of submacular hemorrhage

Submacular hemorrhage is a vision-threatening complication of choroidal and retinal disease. Visual outcome after submacular hemorrhage is dependent on the underlying disease process, amount of subretinal hemorrhage, and duration before treatment. Treatment options include observation, surgical evacuation with or without tissue plasminogen activator (tPA), or pneumatic displacement with or without tPA. The preoperative amount of subretinal hemorrhage may help dictate what treatment modality is chosen.

Postoperative laser coagulation as retinopexy in patients with rhegmatogenous retinal detachment treated with scleral buckling surgery: a prospective clinical study

PURPOSE

To evaluate postoperative laser photocoagulation as retinopexy mode in patients with rhegmatogenous retinal detachment treated with scleral buckling surgery.

METHODS

The authors conducted a prospective feasibility study of consecutive patients with rhegmatogenous retinal detachment treated with scleral buckling surgery and postoperative laser during an 18-month period with a minimal follow-up of 6 months. Outcome measures were total retinal reattachment and the occurrence of proliferative vitreoretinopathy (PVR).

RESULTS

A total of 123 patients (124 eyes) were included in this study. Seventy-six percent were phakic and 24% were pseudophakic. Fifty percent presented with one horseshoe tear, 15% with multiple tears, 30% with round breaks, and 5% with no identifiable break. Ten percent presented with a vitreous hemorrhage and 25% with three or four quadrants of detached retina. Six patients had PVR C1. Twelve patients required a postoperative gas injection, five patients received an additional buckle, and five patients underwent a vitrectomy, in four because of PVR. In all patients the retina was fully reattached at the end of follow-up. Planned postoperative laser coagulation took place 1 day to 10 weeks (median 3(1/2) weeks) after buckling surgery. Buckling material was removed in three patients without redetachment.

CONCLUSION

Postoperative laser coagulation is a feasible alternative retinopexy mode in scleral buckling surgery, with encouraging anatomical results and a low incidence of PVR.

Evaluation of successful macular hole surgery by optical coherence tomography and multifocal electroretinography

PURPOSE

To evaluate successful macular hole surgery using optical coherence tomography (OCT) and multifocal electroretinography (MFERG).

DESIGN

Interventional case series.

METHODS

In a prospective study, 20 eyes of 20 patients with successful surgery for stage II, III, or IV idiopathic macular hole were evaluated by best-corrected visual acuity (BCVA), ocular examination, OCT, and MFERG preoperatively and 1, 3, 6, and 12 months postoperatively. For statistical analysis, the paired t test and nonparametric methods were used, as well as the Spearman analysis.

RESULTS

Postoperatively, all 20 eyes of 20 patients had anatomic closure of the macular hole confirmed by OCT. The center of the fovea, measured by OCT from the retinal pigment epithelium to the inner retinal surface, had a mean +/- SD thickness of 116.5 +/- 30.9 microm (range, 68-175 microm) 1 year postoperatively. Best-corrected visual acuity significantly improved (preoperative mean +/- standard deviation [SD] value, 0.131 +/- 0.081 and 1 year postoperative mean +/- SD value, 0.407 +/- 0.193). Multifocal electroretinography values area 1 (0-2.8 degrees) and area 2 (2.8-9 degrees from the center of the fovea) significantly improved (preoperative mean +/- SD values 3.10 +/- 1.334 nV/deg(2) and 3.573 +/- 1.545 nV/deg(2), respectively, and 1 year postoperative +/- SD mean values, 5.53 +/- 1.208 nV/deg(2) and 4.748 +/- 1.404 nV/deg(2), respectively). The thickness of the fovea, measured by OCT, significantly correlated with the BCVA 1 year postoperatively. One year postoperative MFERG values areas 1 and 2 were not correlated with 12-month BCVA and OCT findings.

CONCLUSIONS

Twelve months postoperatively BCVA and MFERG values significantly improved in this series of eyes with successful macular hole surgery. Optical coherence tomography findings were correlated to BCVA, but MFERG values were not correlated to BCVA and OCT findings, 1 year postoperatively.

Vitreous surgery in highly myopic retinal detachment resulting from a macular hole

PURPOSE

This study aimed to assess the therapeutic effect of vitreous surgery in conjunction with photocoagulation for highly myopic retinal detachment resulting from a macular hole.

METHODS

Sixty-two consecutive highly myopic patients (65 eyes) with retinal detachment from macular holes underwent vitreous surgery. Gas tamponade in conjunction with laser photocoagulation was performed in 46 eyes (44 cases, group 1); gas tamponade only was performed in 12 eyes (11 cases, group 2); and silicone oil tamponade only was performed in seven eyes (seven cases, group 3). Additional laser photocoagulation was given in group 1 if necessary. The anatomical and functional success rates were compared between the groups.

RESULTS

Primary retinal reattachment was achieved in 43 eyes (93.5%) in group 1, seven eyes (58.3%) in group 2 and four eyes (57.1%) in group 3. Final visual acuity was 6/60 or more in 24 eyes (52.2%) in group 1, in six eyes (50.0%) in group 2 and in three eyes (42.9%) in group 3. The initial retinal reattachment rate was significantly higher in group 1 than in group 2 (P = 0.0075) and group 3 (P = 0.0248). The macular hole was completely closed in 18 eyes in group 1 and one eye in group 2 after 2 months or longer. A thin fibrous membrane and scar could be easily noticed beneath the macula in 15 eyes.

CONCLUSION

Vitreous surgery in conjunction with laser photo-coagulation can improve the surgical success rate for highly myopic retinal detachment resulting from a macular hole.

Tissue plasminogen activator plus gas injection in patients with subretinal hemorrhage caused by age-related macular degeneration: predictive variables for visual outcome

PURPOSE

To assess factors predicting final visual outcome after displacement of subretinal hemorrhage (SRH) by intravitreally injected tissue plasminogen activator (TPA) and gas in patients suffering from age-related macular degeneration (ARMD).

METHODS

We evaluated retrospectively the records of 67 patients (32 men, 35 women, mean age 77.2 years) suffering from SRH caused by ARMD who underwent TPA and gas injection between April 1996 and October 2000. Visual acuity (VA; preoperative, 1 week and 3 months postoperative) was analyzed with respect to duration and dimension of bleeding (diameter and thickness) and patient's age.

RESULTS

Mean preoperative VA was 0.063, compared with 0.1 at 3 months after injection. Twenty-nine of 47 patients (76%) had an increase in VA 1 week after treatment but 14 of these eyes worsened slightly during follow-up. Visual outcome 3 months after therapy was negatively correlated to thickness ( P<0.05) and diameter ( P<0.001) of the SRH. In a statistical model of a multiple regression analysis, postoperative VA and the shift of VA could be predicted by preoperative VA and diameter of SRH. Patient's age, duration and thickness of SRH had no prognostic value for postoperative visual outcome.

CONCLUSION

After SRH caused by ARMD, the best visual outcome after TPA + gas injection can be expected in patients with preoperative VA of less than 0.1 caused by a small SRH. In the presence of large SRH (diameter >5 mm) an increase in VA after therapy is unlikely.

Multiple retinal holes in the macular region: a case report

PURPOSE

To describe the first case of multiple retinal holes in the macular region successfully treated with vitrectomy.

METHOD

A single case report. A 44-year-old man was treated for impaired vision caused by multiple macular holes in the right eye.

RESULTS

Fundus examinations detected six retinal holes in the right macula and a giant macular hole in the left eye. Optical coherence tomography disclosed multiple vitreoretinal adhesions in the right macula. We vitrectomized the right eye to produce posterior vitreous detachment and then tamponaded the vitreous cavity with 20% SF(6) gas, resulting in closure of holes and improvement of the vision.

CONCLUSION

Multiple macular holes may be treated by surgical posterior detachment combined with gas tamponade. Vitreoretinal adhesions are a possible cause of these holes. Similar multiple holes may have coalesced into one giant hole in this patient's left eye.

The ability of rapid retinal reattachment to stop or reverse the cellular and molecular events initiated by detachment

PURPOSE

To determine the effects of reattachment on the molecular and cellular events initiated by a retinal detachment lasting 1 hour or 1 day.

METHODS

Experimental retinal detachments were created in the right eyes of nine cats. Reattachments were performed 1 hour (n = 3) or 1 day (n = 3) after the detachment, and the animals were killed 3 days after detachment. Three-day detached (n = 3) and normal (n = 3) retinas were used for comparisons. Agarose-embedded sections were double labeled with a panel of antibodies. Some sections were also probed with the TUNEL technique to detect apoptotic cells. Wax-embedded sections were labeled with the MIB-1 antibody to the Ki67 protein to detect proliferating cells.

RESULTS

The 1-hour and 1-day detachments followed by reattachment showed a very similar and consistent reduction in photoreceptor deconstruction and the Müller cell gliotic response when compared with 3-day retinal detachments without reattachment. Light microscopy and immunolabeling with opsin antibodies showed a significant reduction in both rod and cone outer segment (OS) degeneration, even though OS length was shorter than normal. The reattachments also showed a reduction in opsin redistribution, retraction of rod terminals, TUNEL-labeled photoreceptors, loss of cytochrome oxidase staining in photoreceptors, neurite outgrowth from second-order neurons, the number of proliferating cells, and the increase in intermediate filaments and loss of soluble proteins from Müller cells. The apparent re-ensheathing of the OS by the apical processes of the retinal pigment epithelium had begun but was not completely normal.

CONCLUSIONS

These data indicate that, even though the length of the OS is less than normal, retinal reattachment within 1 day of detachment can either greatly retard or reverse many of the molecular and cellular changes initiated by detachment.

Types of macular holes encountered during diabetic vitrectomy

PURPOSE

To determine the types of macular holes encountered during vitrectomy for complicated cases of diabetic retinopathy.

METHODS

This is a retrospective study of consecutive cases of macular holes diagnosed either before or during pars plana vitrectomy for complications of proliferative diabetic retinopathy over a 6-year period. The morphology of these holes is described. Possible mechanisms of their development, surgical considerations, and results after a follow-up of at least 3 months are discussed.

RESULTS

Nineteen consecutive cases of macular holes associated with proliferative diabetic retinopathy were reviewed over a 6-year period. Five cases were lamellar and 14 were full thickness. The 14 cases of full thickness macular holes occurred in patients with the following conditions: tractional rhegmatogenous retinal detachment (5); tractional retinal detachment (3); premacular hemorrhage (3); and cystic macular edema (3). Closure of the full thickness holes was achieved in 8 of 11 patients who were followed up for at least 3 months. All the patients had visual improvement, but no patient had a visual acuity of better than 20/100.

CONCLUSION

Macular holes may occur in proliferative diabetic retinopathy in different configurations. Full thickness macular holes can be closed in most cases. Functional improvement can be achieved.

Intravitreous tissue plasminogen activator injection and pneumatic displacement in the management of submacular hemorrhage complicating scleral buckling procedures

PURPOSE

To evaluate the efficacy of recombinant tissue plasminogen activator (rTPA) and sulfur hexafluoride (SF6) in displacing submacular hemorrhage in patients who had scleral buckling procedures complicated by the development of submacular hemorrhage. Final visual acuity and complications of the procedures were evaluated.

METHODS

Sequential intravitreal injections of 50 microg rTPA in 0.1 mL and 0.4 cc SF6 were performed in eight patients who showed submacular hemorrhage 1 day after a scleral buckling procedure. The fundus was checked daily for 3 days after the injection of TPA and gas, and then was followed every week for 1 month and then every 2 months. Patients were observed for at least 6 months. Visual acuity and the status of complications were evaluated.

RESULTS

Submacular hemorrhage was totally or partially displaced extramacularly in all patients on the day after rTPA and SF6 injection. Vitreous hemorrhage was present in all patients. The retina was attached in all patients and no recurrent retinal detachment was noted. Visual acuity was improved at 6 months after treatment in all seven of the patients with macula-off retinal detachments compared to the preoperative visual acuity. The last patient who had a macula-sparing retinal detachment had decreased vision (20/25) at 6 months compared to preoperatively.

CONCLUSIONS

Recombinant tissue plasminogen activator and SF6 injection is an easy procedure that is less complicated than and as effective as internal drainage in patients with submacular hemorrhage developing as a complication of scleral buckling procedures.

Management of eyes with both idiopathic macular hole and choroidal neovascularization

PURPOSE

To describe the characteristics, treatment, and outcome of five eyes with both choroidal neovascularization (CNV) and macular hole.

METHODS

Medical records of five patients with both macular hole and CNV were reviewed.

RESULTS

All eyes had full-thickness macular holes. Most eyes had atypical-appearing macular holes (subretinal hemorrhage, prominent subretinal fluid, or discoloration at the hole margin) at presentation or subsequently when CNV developed. Fluorescein angiography (FA) confirmed the presence of CNV in each eye. Three eyes underwent combined macular hole repair and CNV removal, and sustained closure of these macular holes was achieved. A fourth eye underwent successful argon laser photocoagulation of extrafoveal CNV, and macular hole surgery was declined. The final eye underwent two macular hole repairs before sustained closure was achieved. Final visual acuity, ranging from 20/100 to hand motions, was limited by macular pathology and/or cataract.

CONCLUSIONS

Choroidal neovascularization can occur in association with a macular hole. In eyes with an atypical-appearing macular hole, FA should be obtained to detect CNV. Excision of the CNV can be done safely in conjunction with macular hole surgery. Final visual acuity may be limited by cumulative retinal and retinal pigment epithelium damage, especially in eyes with underlying macular disease.

Management options for early stages of acutely symptomatic macular holes

PURPOSE

To evaluate management options for acutely symptomatic stage I macular holes, and vitrectomy with intraocular gas tamponade for advanced stage I macular holes.

METHODS

Retrospective noncomparative study.

SETTING

Clinical practice.

STUDY POPULATION

Acutely symptomatic stage I macular holes. MANAGEMENT OPTIONS: (I) spontaneous resolution with observation -7 eyes; (II) stage I holes developing poor visual acuity of 20/50 or worse during observation -9 eyes undergoing pars plana vitrectomy, posterior vitreous separation, fluid -20% sulfur hexafluoride gas exchange; (III) stage I holes acutely progressing to stage II or III during observation -9 eyes with vitrectomy, posterior vitreous separation, membrane peel, fluid -18% perfluoropropane gas exchange.

MAIN OUTCOME MEASURES

visual acuity of 20/40 of better, prevention, or closure of macular hole.

RESULTS

Spontaneous resolution developed in 7 eyes with 20/40 or better vision (group I). 8/9 eyes undergoing vitrectomy for advanced stage I holes (group II) did not progress and recovered 20/40 or better vision. 1/9 recovered 20/40 vision after further surgery. 9/9 eyes following acute progression to full-thickness holes (group III) had closed macular holes with recovery of 20/40 vision after vitrectomy.

CONCLUSIONS

Stage I macular holes can initially be observed. However, excellent visual and surgical results can be obtained in stage I holes with poor vision, or with acute progression to full-thickness holes.