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Concept: Vitrectomy

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: To compare the intermediate-term intraocular pressure (IOP) control and complication profile of the Ahmed Glaucoma Valve (AGV) implanted posteriorly through the pars plana in eyes undergoing concurrent pars plana vitrectomy (PPV) with device implantation in the anterior chamber (AC) in nonvitrectomized eyes.

Concepts: Intraocular pressure, Glaucoma, Ophthalmology, Vitrectomy, Glaucoma valve

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Purpose: To evaluate the outcome, intraoperative and postoperative complications of refractive lens exchange (RLE) by phacoemulsification with posterior chamber intraocular lens (IOL) implantation combined with simultaneous pars plana vitrectomy (PPV) in the management of high myopia. Methods: This prospective study consisted of 45 eyes of 26 patients with preoperative myopia greater than -12.5 dpt. Clear lens phacoemulsification with IOL implantation surgery was combined with PPV. Main outcome measures were best-corrected visual acuity (BCVA), stability of the spherical equivalent (SE) and complications at follow-up. Results: The combined procedure of clear lens phacoemulsification combined with PPV has a favorable outcome with acceptable SE predictability and improvement in BCVA. The postoperative BCVA was 0.67 ± 0.21 compared to 0.15 ± 0.10 preoperatively (p < 0.001). The mean postoperative SE was -1.6 ± 0.9 dpt, showing a significant difference when compared with a mean value of -20.0 ± 5.2 dpt before the operation (p < 0.001). During the follow-up, all IOLs were placed stably in the bag with no capsular tear occurring and only 1 case (2.2%) developed retinal detachment. Conclusion: RLE and implantation of an IOL combined with simultaneous PPV is a reasonable refractive surgery option for middle-aged patients with high myopia.

Concepts: Retina, Ophthalmology, Vitrectomy, Myopia, Lens, Presbyopia, Contact lens, Intraocular lens

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BACKGROUND: Primary vitreous floaters can be highly bothersome in some patients. In the case of persistently bothersome floaters, pars plana vitrectomy may be the most effective treatment. The aim of this study is to evaluate the incidence of complications, and patient satisfaction, after pars plana vitrectomy for disabling primary vitreous opacities. METHODS: We included a total of 110 eyes that underwent pars plana vitrectomy between February 1998 and August 2010. Fifty-seven eyes (51.8 %) underwent 20-gauge vitrectomy, whereas 53 eyes (48.2 %) underwent 23-gauge vitrectomy. In a retrospective manner, we assessed intraoperative and postoperative complications. There was a considerable range of time between surgery and questionnaire (range: 4-136 months). Patient satisfaction was assessed by a questionnaire based on a modified NEI VFQ-25 questionnaire. RESULTS: A retinal detachment occurred in 10.9 % of cases, and the incidence did not differ significantly between the 20-gauge and 23-gauge vitrectomy groups. In 4.5 % of the eyes, a retinal detachment developed within the first 3 months, and 6.4 % occurred later in the postoperative period. Cystoid macular edema occurred in 5.5 %, and an epiretinal membrane was seen postoperatively in 3.6 % of cases. Development of glaucoma requiring glaucoma surgery, a macular hole, and postoperative scotoma, each occurred in 0.9 % of cases. No cases of endophthalmitis occurred. Eighty-five percent of patients were satisfied or very satisfied with the results of the vitrectomy. Eighty-four percent of all patients were completely cured from their troublesome vitreous floaters, and an additional 9.3 % of patients were less troubled by vitreous floaters. Ten patients (9.3 %) were dissatisfied, and six of these patients (5.6 %) had a serious complication that resulted in permanent visual loss. CONCLUSIONS: Pars plana vitrectomy is an effective approach to treat primary vitreous floaters, resulting in a high rate of patient satisfaction. Postoperative complications may be more frequent than previously reported, so patients should be well-informed about the complication rate before reaching informed consent about this surgical intervention. Additional preventive measures should be considered to reduce this complication rate.

Concepts: Surgery, Medical signs, Retina, Ophthalmology, Vitrectomy, Diabetic retinopathy, Vision loss, Floater

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PurposeTo evaluate the effects of intravitreal autologous plasmin enzyme (APE) in patients with focal vitreomacular traction (VMT).MethodsAPE was obtained by incubation of patient-derived purified plasminogen with streptokinase, and intravitreally injected 5-12 days later. Twenty-four hours after injection, in case of incomplete VMT release, a pars plana vitrectomy was performed. The hyaloid internal limiting membrane adherence and removal of the posterior hyaloid were intraoperatively evaluated.ResultsThirteen patients were recruited. During preparation of APE, five patients had spontaneous release of VMT. Eight patients received APE injection (2 IU). In five patients, spontaneous resolution of VMT occurred before APE administration. Twenty-four hours after injection, persistence of VMT was detected in all the eight treated patients. Best-corrected visual acuity was 0.51±0.37 LogMAR at baseline, improving to 0.23±0.14 LogMAR at 6 months (P=0.002). Foveal thickness was 464±180 μm at baseline, reducing to 246±59 μm at 6 months (P<0.001). Hyaloid was intraoperatively judged 'partially detached' in seven cases and 'totally detached' in one case. Hyaloid peeling was evaluated 'easy' in six eyes and 'very easy' in two eyes.ConclusionsIn the current study, there was a large percentage of spontaneous resolution of VMT before an APE administration. A single intravitreal APE injection seems insufficient to induce a complete posterior vitreous detachment in these patients.Eye advance online publication, 14 December 2012; doi:10.1038/eye.2012.248.

Concepts: Eye, Visual acuity, Ophthalmology, Vitrectomy, Retinal detachment, Vitreous humour, Epiretinal membrane, Posterior vitreous detachment

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PURPOSE: To study macular hole (MH) surgery in terms of baseline demographics, intraoperative complications, post-vitrectomy cataract, reoperation, and visual outcome. DESIGN: National Ophthalmology Database study. PARTICIPANTS: A total of 1078 eyes from 1045 patients undergoing primary MH surgery. METHODS: Participating centers prospectively collected clinical data using a single electronic medical record (EMR) system, with automatic extraction of anonymized data to a national database, over 8 years. The following data were extracted for eyes undergoing MH surgery: demographics, procedure elements, intraoperative complications, visual acuity (VA), and further surgery. MAIN OUTCOME MEASURES: Description of the primary procedures performed, intraoperative complication rate, change in VA, proportion of eyes undergoing subsequent surgery for persisting MH, cataract, or retinal detachment. RESULTS: The median age was 70.3 years, with a 2.2:1 female preponderance. All operations included a pars plana vitrectomy (PPV)-41.1% with hexafluoroethane (C(2)F(6)), 25.6% with perfluoropropane (C(3)F(8)), 24.5% with sulfahexafluoride (SF(6)), 2.2% with air, and 0.4% with silicone oil. A PPV was combined with internal limiting membrane (ILM) peel in 94.1% and cataract surgery in 40.5%. One or more intraoperative complications occurred in 12.4%. The median presenting logarithm of the minimum angle of resolution (logMAR) VA improved from 0.80 to 0.50 after a median follow-up of 0.6 years; 57.8% of eyes improved ≥0.30 logMAR units (∼2 Snellen lines). The choice of gas tamponade did not significantly influence the visual outcome, but eyes undergoing ILM peel were significantly more likely to gain ≥0.30 logMAR units, as were eyes with poor presenting VA. Subsequently, 4.2% of eyes underwent repeat surgery for MH and 2.4% for retinal detachment, and, excluding pseudophakic eyes, 64.6% underwent cataract surgery within 1 year. CONCLUSIONS: This study provides pooled, anonymized data on the demographics, complications, and visual outcome of MH surgery. This may enable vitreoretinal surgeons to benchmark their case-mix and outcomes, and facilitate risk-benefit and cost-benefit analyses. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Concepts: Surgery, Retina, Visual acuity, Ophthalmology, Vitrectomy, Cost-benefit analysis, Eye surgery, Cataract

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PURPOSE: To report the optical coherence tomography (OCT) and fundus fluorescein angiography (FFA) results of the Macular Epiretinal Brachytherapy in Treated Age-Related Macular Degeneration study. DESIGN: Prospective, multicenter, interventional, noncontrolled clinical trial. PARTICIPANTS: Fifty-three eyes of 53 participants with chronic, active neovascular age-related macular degeneration (AMD) requiring frequent anti-vascular endothelial growth factor retreatment. METHODS: Participants underwent pars plana vitrectomy with a single 24-gray dose of epimacular brachytherapy (EMB), delivered with an intraocular, handheld, cannula containing a strontium 90/yttrium 90 source positioned over the active lesion. Participants were retreated with ranibizumab administered monthly as needed, using predefined retreatment criteria. Patients underwent FFA at baseline, month 1, and month 12. Patients underwent optical coherence tomography (OCT) at baseline and then monthly for 12 months. The FFA and OCT images were evaluated by independent, central reading facilities. MAIN OUTCOME MEASURES: Change in OCT centerpoint thickness and angiographic lesion size 12 months after EMB. RESULTS: Mean centerpoint thickness increased by 50 μm, from 186 to 236 μm (P = 0.292), but 70% of participants had an increase of less than the mean, with a median increase of only 1.8 μm. The FFA total lesion size increased slightly by 0.79 mm(2), from 14.69 to 15.48 mm(2) (P = 0.710). Total choroidal neovascularization (CNV) area increased by 1.17 mm(2), from 12.94 to 14.12 mm(2) (P = 0.556). The classic CNV area decreased substantially by 3.70 mm(2), from 3.90 to 0.20 mm(2) (P<0.01). Predominantly classic lesions showed the greatest response, with mean Early Treatment Diabetic Retinopathy Study visual acuity improving by 1.5 letters (versus -4.0 for all participants combined); mean centerpoint thickness decreased by 43 μm (P = 0.875). The angiographic and OCT response did not correlate with lesion size at baseline. CONCLUSIONS: In chronic, active, neovascular AMD, EMB is associated with nonsignificant changes in centerpoint thickness and FFA total lesion size over 12 months. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Concepts: Retina, Ophthalmology, Vitrectomy, Diabetic retinopathy, Optical coherence tomography, Macular degeneration, Epiretinal membrane, Fluorescein angiography

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Purpose. To report the efficacy and ocular tolerance of a new tamponade made with ether and silicone oil (HeavySil [HSIL]) for the treatment of retinal detachment (RD) complicated by inferior proliferative vitreous retinopathy (PVR).
Methods. Prospective noncomparative interventional study on 31 consecutive eyes that underwent pars plana vitrectomy and were treated with HSIL as an intraocular tamponade. All patients presented with at least one retinal break and grade B-C PVR located between 4 and 8 o'clock. The main endpoint criteria were retinal reattachment after the removal of HSIL and complications arisen from the use of this tamponade.
Results. Primary anatomic success was achieved in 27 out of 31 cases. Mean visual acuity improved from logMAR 1.4 (SD 0.7) to logMAR 1.1 (SD 0.6) (p=0.02).
The main complications reported were cataract formation (5 out of 7 phakic eyes cases), clinically visible emulsification (6 cases), and difficulty of oil removal in 3 cases. Severe intraocular inflammation with HSIL in situ was found in only one case.
Conclusions. HeavySil, a saturated solution of ether with silicone oil, is a safe and effective tamponade agent for the treatment of complicated RD. The most common complications are cataract formation and oil emulsification.

Concepts: Retina, Visual acuity, Ophthalmology, Vitrectomy, Diabetic retinopathy, Retinal detachment, Intraocular lens, Vision loss

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BACKGROUND: To assess the role of Spectral Domain Optical Coherence Tomography (SD-OCT) measurements as prognostic factors in myopic macular hole (MMH) surgery. METHODS: In a retrospective cohort study, we evaluated 42 eyes of 42 patients (Spherical equivalent > -6.00 D) who underwent pars plana vitrectomy with internal limiting membrane peeling for MMH without foveoschisis. Statistical analysis was performed to correlate postoperative best corrected visual acuity (BCVA) with preoperative BCVA, age, degree of myopia and seven preoperative OCT measurements: macular hole (MH) base, MH minimum diameter, MH height, Hole Form Factor (HFF), Macular Hole Index (MHI), Diameter Hole Index (DHI) and Tractional Hole Index (THI). RESULTS: Primary and final anatomical success rate were 83.3 % (35/42) and 90.5 % (38/42), respectively. Four patients deferred reoperation and three underwent a second surgical approach to achieve MH closure. A posterior staphyloma was observed in 27 of 42 patients, and in three of them the MH was located in the apex of the staphyloma. Two of these three cases showed an open MH after the first surgery. Postoperative visual acuity improved in 22/42 (52.4 %) patients, worsened in 7/42 (16.7 %) and remained unchanged in 13/42 (30.9 %). Only MH minimum diameter (P = 0.03) and HFF (P = 0.02) correlated significantly with postoperative BCVA. CONCLUSIONS: Minimum diameter and HFF are strongly correlated with postoperative visual outcomes in cases of MMH. Since analyzing MH configuration seems to improve the anatomical success rate after vitreous surgery in highly myopic patients, these parameters should be preoperatively evaluated by SD-OCT.

Concepts: Cohort study, Retina, Ophthalmology, Vitrectomy, Optical coherence tomography, Myopia, Eyeglass prescription, Staphyloma

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Whether the position of the ora serrata is normal in patients with choroidal colobomas remains unknown. The aim of this study was to measure the distance between the ora serrata and limbus in these patients and define safe sclerotomy sites for standard three-port pars plana vitrectomy.

Concepts: Retina, Vitrectomy, Ora serrata

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To compare using pars plana vitrectomy (PPV) combined with a scleral buckle versus primary vitrectomy alone in patients with rhegmatogenous retinal detachment at high risk for postoperative proliferative vitreoretinopathy (PVR).

Concepts: Retina, Ophthalmology, Vitrectomy, Retinal detachment, Scleral buckle