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PubMedDate not supplied

Macular hole surgery-associated peripheral visual field loss.

To examine in more detail the peripheral visual field loss after macular hole surgery, we reviewed a series of 38 consecutive patients (44 eyes) with idiopathic macular hole who underwent vitrectomy and fluid-gas exchange. Ten (22.7%) eyes of 9 patients developed peripheral visual field loss shortly after successful surgery. This complication was characterized by mild to moderate wedge-shaped visual field loss that predominantly affected the inferotemporal periphery. Of these 9 patients, 2 complained of peripheral visual field loss, and the 7 others remained asymptomatic. The peripheral visual field loss remained unchanged for a mean follow-up of 18.5 months, except in one case of complete recovery. The thickness of the retinal nerve fiber layer was measured postoperatively to determine whether any damage to the optic nerve head had occurred during surgery. The information obtained in this study did not provide conclusive evidence for the understanding of the pathomechanism of the macular hole surgery-associated visual field loss. Peripheral visual field defect after otherwise uneventful surgery for idiopathic macular hole is probably not uncommon. This complication is variable in its severity and is usually permanent. Whether it is caused by any surgical trauma to the optic nerve head remains to be elucidated.

Aged↗
PubMedDate not supplied

Analysis of changes in corneal shape and refraction following scleral buckling surgery.

PURPOSE: A prospective study was performed to investigate changes in corneal shape and axial length following scleral buckling surgery. METHODS: We investigated the changes in corneal shape, refraction, and axial length following scleral buckling surgery in 24 patients who underwent local buckling and 14 patients who underwent encircling with additional segmental buckling. The corneal shape was determined by corneal topography and autokeratometry, refraction was measured by autorefractometry, and axial length was measured by A-mode ultrasonography before surgery, and 1, 2, and 7 days, and 1, 3, and 6 months after surgery. RESULTS: After local buckling, the axial length shortened and a hyperopic change was observed. After encircling with additional segmental buckling, the axial length elongated and a myopic shift was detected. The direction of the surgically induced corneal astigmatic vectors was almost identical to the direction of the buckle. There was a tendency for shorter distances between the limbus and the buckle to be associated with greater absolute values. Astigmatism gradually decreased following surgery and stabilized in about 3 months. CONCLUSIONS: Surgeons should select a surgical procedure to ensure favorable postoperative visual acuity while minimizing changes in the shape of the cornea.

Astigmatism↗
PubMedDate not supplied

Expression and possible roles of activin A in proliferative vitreoretinal diseases.

PURPOSE: To examine the expression of activin A in eyes and to determine the possible functions of activin A in proliferative vitreoretinal diseases. METHODS: The activin A concentration in vitreous specimens obtained from eyes with or without retinal ischemia was measured by a bioassay using erythroid differentiation factor effects of activin A. The expression of activin A and activin receptors in the preretinal membranes was observed by immunohistochemical analysis. RESULTS: The mean concentration of activin A in the eyes with proliferative diabetic retinopathy was 1. 50 +/- 1.27 ng/mL (mean +/- SD; n = 10), and that in the nondiabetic eyes without retinal ischemia (macular hole and epiretinal membrane) was 0.90 +/- 0.55 ng/mL (n = 5). Neither difference was significant. Activin A and its receptors were detected in the vascular endothelial cells, fibroblast-like cells and round-shaped macrophage-like cells in preretinal proliferative membranes by immunohistochemical analysis. CONCLUSIONS: Activin A is involved in the proliferative membrane formation in both ischemic and nonischemic vitreoretinal proliferative diseases. Activin A, a member of TGF-beta superfamily, regulates angiogenesis and tissue fibrosis in the wound healing process.

Activin Receptors↗
PubMedDate not supplied

The relationship between gap-junctional intercellular communication and the proliferative activity of retinal pigment epithelial cells.

PURPOSE: To investigate the relationship between gap-junction mediated intercellular communication and the proliferative activity of retinal pigment epithelial cells in the retinal tear base. METHODS Retinal tears were created experimentally in white rabbits, and the changes of intercellular communication via gap junctions between retinal pigment epithelial cells in the retinal tear base were investigated using the dye-coupling method, which involves observing the spread of a fluorescent dye, Lucifer Yellow CH. In addition, the proliferative activity of these cells was investigated using an antibody for proliferating cell nuclear antigen and was compared with the changes in intercellular communication. RESULTS: Immediately after the creation of retinal tears, extensive spreading of Lucifer Yellow CH into adjacent cells was observed, which was markedly reduced 1 week later. After 1 month, the spreading of dye to adjacent cells was observed again. On the other hand, proliferative activity was enhanced at 1 week after retinal tear creation and was reduced again after 1 month. CONCLUSIONS: It is known that tumor cells with enhanced proliferative activity show decreased intercellular communication via gap junctions. The present study suggests a possible relationship between intercellular communication and the proliferative activity of retinal pigment epithelial cells in the base of retinal tears.

Animals↗
PubMed2003

Anatomy, development, and physiology of the visual system.

This article serves to familiarize the reader with the normal anatomy, embryology, and physiology of the visual system. Other articles in this issue introduce examination techniques and the pathology of the eyes of pediatric patients.

Cornea↗
PubMedDate not supplied

Macular hole.

A macular hole is a full-thickness defect of retinal tissue involving the anatomic fovea, thereby affecting central visual acuity. Macular holes have been associated with myriad ocular conditions and originally were described in the setting of trauma. The pathogenesis of idiopathic, age-related macular holes remains unclear despite a litany of theories. Recently, Gass has described an updated biomicroscopic classification of macular holes and postulated that tangential vitreous traction may play a role. Cellular components surrounding the rim of macular holes may also contribute tangential traction forces and elevate the rim. Pseudomacular holes may be mistaken for macular hole lesions, despite careful clinical examination. Careful biomicroscopic examination with a contact lens and use of the Watzke and laser aiming beam tests help to ensure accurate diagnosis. Newer imaging technology, such as optical coherence tomography, helps distinguish true macular holes from pseudoholes and may provide additional insight into the pathogenesis of this condition. Surgical management with or without pharmacosurgical adjuncts can improve vision in select cases. The most common surgical complication is progressive lens opacification in phakic patients.

Aged↗
PubMedDate not supplied

Controversies in the management of open-globe injuries involving the posterior segment.

There are numerous unresolved issues and controversies regarding the management of open-globe injuries involving the posterior segment. These areas include, but are not limited to, the following issues. Although vitrectomy has been shown to improve visual outcomes and allow retention of the eye in many cases, the extent of visual improvement is often limited because of the nature of the injury. Timing of vitrectomy surgery has been and will continue to be debated by proponents of early versus delayed intervention. The multiple features of acute ocular injury make it very difficult to interpret retrospective data regarding the most appropriate timing for surgical intervention. The use of prophylactic cryotherapy, in the setting of a scleral laceration with possible retinal damage, is not as controversial at present, as there is now sufficient data indicating that cryotherapy may actually exacerbate intraocular proliferation and worsen the situation. The role and benefit of a prophylactic scleral buckle is very widely contested, and it is not known if it truly decreases the risk of subsequent retinal detachment. Another area of debate centers on the use of antibiotics. When there is a known clinical infection, intravitreal antibiotics are the mainstays of therapy. However, in the absence of clinical infection, the use of prophylactic antibiotics and their routes of administration are quite controversial. Although there are significant data regarding the use of antibiotics in the postoperative setting, this information cannot be extrapolated into the setting of open-globe injuries, as organisms and virulence factors differ. Similarly, the use of vitrectomy versus vitreous tap in the setting of traumatic endophthalmitis is not fully resolved, although vitrectomy is used in most cases to repair concurrent damage from the injury itself. Finally, the placement of intraocular lenses in the acute trauma setting is controversial, as the risk of complications is quite high. Prospective, controlled clinical studies have not been done. This article reviews pertinent data regarding these management issues and controversies, and provides recommendations for treatment based on the available published data and the authors' personal experience.

Cryotherapy↗
PubMed1999

Psychophysical observations concerned with a foveal lesion (macular hole).

A not uncommon occurrence in elderly people is the development of a 'macular hole' but very few psychophysical observations have been made in such cases. I describe here some distortions of image experienced when I view objects with my right eye which has a macular hole. Objects are distorted by being shrunk towards the fovea. Thus, a disc retains its shape but becomes smaller whereas lines are broken or bent. By analogy with animal experiments it is suggested that the perceptual changes are due to physiological changes in the visual cortex.

Humans↗
PubMed2003

Role of mucins in the function of the corneal and conjunctival epithelia.

The surface of the eye is covered by a tear film, which is held in place by a wet-surfaced, stratified, corneal and conjunctival epithelia. Both are vital for light refraction and protection of vision. Maintenance of tear film on the ocular surface, lubrication, and provision of a pathogen barrier on this wet surface is facilitated by a class of large, highly glycosylated, hydrophilic glycoproteins--the mucins. In the past 15 years, a number of mucin genes have been cloned, and based on protein sequence, categorized as either secreted or membrane associated. Both types of mucins are expressed by ocular surface epithelia. Goblet cells intercalated within the stratified epithelium of the conjunctiva secrete the large gel-forming mucin MUC5AC, and lacrimal gland epithelia secrete the small soluble mucin MUC7. Apical cells of the stratified epithelium of both corneal and conjunctival epithelium express at least three membrane-associated mucins (MUCs 1, 4, and 16), which extend from their apical surface to form the thick glycocalyx at the epithelium-tear film interface. The current hypothesis regarding mucin function and tear film structure is that the secreted mucins form a hydrophilic blanket that moves over the glycocalyx of the ocular surface to clear debris and pathogens. Mucins of the glycocalyx prevent cell-cell and cell-pathogen adherence. The expression and glycosylation of mucins are altered in drying, keratinizing ocular surface diseases.

Animals↗
PubMed2000

Prevalence, correlates, and natural history of epiretinal membranes surrounding idiopathic macular holes. Virectomy for Macular Hole Study Group.

OBJECTIVE: To report on the prevalence, correlates, and natural history of epiretinal membranes (ERM) in eyes with stage II or III/IV macular holes. DESIGN: A subgroup analysis arising from a multicentered, controlled, randomized clinical trial. SETTING: Community and university-based ophthalmology clinics. PATIENTS: Two hundred twenty four eyes with stage II or III/IV macular holes. INTERVENTIONS: No intervention for 100 eyes randomly assigned to observation. OUTCOME MEASURES: Grade of ERM determined by stereoscopic examination of fundus photographs at baseline and at 3, 6, 12, and 24 months of follow-up. RESULTS: The prevalence of ERM was 65% (145 of 224 eyes), was greater in pseudophakic than in phakic eyes (80% vs. 63%, P = 0.10), and increased with increasing severity of the hole (P < 0.0001). Stage III/IV eyes with ERM had a significantly larger hole size than did eyes without ERM (P < 0.01); however, no association between presence of ERM and visual acuity was found (P > 0.5). In the 100 phakic eyes that were randomly assigned to observation, there was a significant increase in the severity of ERM over follow-up (P < 0.0001). CONCLUSIONS: ERM are common in eyes with full-thickness idiopathic macular holes. Although ERM prevalence increases with severity and size of the macular hole, the presence of ERM are not closely correlated with visual acuity. These factors may be important in considering the removal of ERM during vitrectomy for macular hole.

California↗
PubMed2000

Surgical treatment of macular holes with multiple recurrences.

PURPOSE: To evaluate the results of a third macular hole surgery in eyes with recurrent macular holes and two prior macular hole surgeries. DESIGN: Retrospective consecutive noncomparative case series. PARTICIPANTS: Sixteen eyes of sixteen patients with two prior macular hole surgeries with recurrent macular hole. INTERVENTION: A third vitreous surgery was performed in each eye using a long-acting gas bubble. MAIN OUTCOME MEASURE: Closure of the macular hole and change in visual acuity. RESULTS: The macular hole was closed in 12 of 16 eyes (75%) at 3 months after the third surgery. Visual acuity improved 2 or more Snellen lines in 9 of 16 eyes (56%), and 5 of 16 eyes (31%) achieved 20/40 or better vision. Six eyes (37.5%) had cataract surgery after the third macular hole surgery, and visual acuity results were similar in eyes with or without cataract surgery. Successful closure of the macular hole improved the visual acuity from 20/80 -1 to 20/50 +1 (P < 0.001). Eyes in which one of the previous surgeries had been temporarily successful in closing the macular hole improved from a mean of 20/80 to 20/40 (P = 0.003). Eyes in which both prior macular hole surgeries had been primary failures had minimal benefit with a preoperative visual acuity of 20/100 +1 and a postoperative visual acuity of 20/100 +2 (P = 0.67). CONCLUSIONS: Repeat macular hole surgery should be considered in eyes with recurrent macular holes and two prior surgeries when the macular hole was temporarily closed by at least one of the two previous surgeries. Successful closure of a macular hole in such cases usually results in significant visual acuity improvement.

Adult↗
PubMed2000

A new approach to stage 3 macular holes.

PURPOSE: The purpose of this article is to demonstrate the feasibility of a surgical approach that might be possible in an office setting for idiopathic stage 3 macular holes. The posterior hyaloid of the vitreous and perihole tissue is enzymatically manipulated to create an atraumatic posterior vitreous separation and may stimulate cell proliferation to close macular holes. DESIGN: Prospective noncomparative interventional case series. PARTICIPANTS: Nine eyes of eight patients with idiopathic stage 3 macular holes were treated. METHODS: The patients were treated with an injection of 0.4 IU of autologous plasmin enzyme into the midvitreous cavity and lavage of the vitreous cavity with an infusion light pipe and vitreous cutter followed by filling 70% to 80% of the vitreous cavity with 14% C3F8 and head-down positioning. MAIN OUTCOME MEASURES: Posterior vitreous detachment, macular hole closure, and vision improvement. RESULTS: Eight of nine eyes showed a spontaneous posterior vitreous detachment. One eye required minimal suction of less than 50 mmHg to elevate the posterior hyaloid off the retinal surface. Eyes were followed for a minimum of 6 months. All holes closed, and there was an average visual acuity improvement of four lines. The average surgical time for this procedure was 20 minutes. CONCLUSIONS: Autologous plasmin enzyme-assisted vitreous surgery techniques can reduce operative time, expense, and patient inconvenience while maintaining excellent surgical results, which may allow office-based vitreous surgery for idiopathic stage 3 macular holes.

Aged↗
PubMed2000

Macular hole surgery with and without internal limiting membrane peeling.

OBJECTIVE: To compare results of surgery for idiopathic macular hole with and without internal limiting membrane (ILM) peeling in a series of consecutive patients over a 5-year period. DESIGN: A retrospective, nonrandomized, comparative trial with concurrent control group. PARTICIPANTS: Forty-four eyes with macular holes of less than or equal to 6 months duration without ILM peeling were compared to 116 eyes with ILM peeling and the same hole duration. A third group of 65 eyes with ILM peeling and duration greater than 6 months was also evaluated. INTERVENTION: All eyes underwent pars plana vitrectomy with or without ILM peeling, intravitreous gas, and positioning face down. No adjunctive therapies were used in any group. MAIN OUTCOME MEASURES: Comparing the closure and/or reopening rate, prognosis, visual acuity, and complications for macular holes with and without ILM peeling. RESULTS: All patients had postsurgical follow-up of 18 months or greater. Primary closure was significantly improved with ILM peeling with 116 of 116 eyes (100%) showing no reopenings versus 36 of 44 holes (82%) primarily closed, 9 of which (25%) reopened without ILM peeling (P: < 0.00001) in holes less than or equal to 6 months. The 27 eyes without ILM peeling that had successful surgery displayed a mean postoperative vision of 20/40, which is the same as the successful eyes with ILM peeling (P: = 0.6). The 52 stage II eyes with ILM peeling had a mean postoperative vision of 20/30, and 48 of the 52 eyes (92%) were 20/40 or better. Stage III eyes (greater than 400-microm holes) without ILM peeling had a poor prognosis, with 6 of the 25 eyes (24%) having initial surgery fail and an additional 4 of 25 eyes (16%) reopening. Without ILM peeling, holes less than 300 microm had only one reopen, whereas holes greater than or equal to 300 microm had 16 of the 17 (94%) primary failures and/or reopenings (P: < 0.001). All 12 holes that reopened and/or primarily failed were repaired with ILM peeling with excellent visual recovery. Macular holes with a duration greater than 6 months were treated with ILM peeling, and 63 of 65 holes (97%) were closed primarily and 65% had an increase in vision by two or more Snellen lines. CONCLUSIONS: ILM peeling significantly improves visual and anatomic success in all stages of recent and chronic macular holes and reopened and failed holes, while eliminating reopening for holes greater than 300 microm.

Aged↗
PubMed2000

Surgical repair of full-thickness idiopathic macular holes associated with significant macular drusen.

OBJECTIVE: To evaluate the visual and anatomic results of surgically repaired macular holes in eyes with intermediate or large-sized macular drusen. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Thirty-four eyes of 32 patients undergoing macular hole surgery with preoperative intermediate or large-sized macular drusen as defined by the Age-Related Eye Disease Study (AREDS). INTERVENTION: Pars plana vitrectomy for standard macular hole repair performed by multiple surgeons. MAIN OUTCOME MEASURES: Visual acuity, anatomic hole closure. RESULTS: Initial hole closure failed in 8 eyes (24%) overall, 5 of 28 eyes (18%) with AREDS category 2 drusen and 3 of 6 eyes (50%) with category 3 drusen (P = 0.1263). Final macular hole closure was seen in 93% of category 2 and 67% of category 3 eyes (P = 0.1347). Mean final visual acuity was 20/60 overall, 20/60 for category 2, and 20/50 for category 3 eyes. CONCLUSIONS: A trend of reduced initial macular hole closure was seen in eyes with significant macular drusen. Reoperation improved closure rates. If closure was accomplished, visual outcomes were excellent.

Aged↗
PubMed2001

Clinicopathologic findings in eyes with retained perfluoro-n-octane liquid.

OBJECTIVE: To describe the clinical and histopathologic findings in five eyes with retained perfluoro-n-octane (PFO) liquid after retinal reattachment surgery. DESIGN: Retrospective, noncomparative, clinicopathologic case series. PARTICIPANTS: Surgical specimens from five eyes were studied. METHODS: Surgical specimens from eyes with prior intraoperative PFO use submitted to the W. Richard Green Eye Pathology Laboratory at the Wilmer Ophthalmological Institute were identified and reviewed. MAIN OUTCOME MEASURES: Histopathologic analysis and energy dispersive spectroscopy identified intracellular vacuoles containing PFO. RESULTS: Five cases were identified. Three specimens were obtained at the time of further surgery for recurrent retinal detachment; one at repeat penetrating keratoplasty, and one at removal of retained PFO. Each eye had macroscopic white flake-like material on intraocular structures noted before or during surgery. Histopathologic analysis disclosed an inflammatory response featuring macrophages with intracellular vacuoles containing PFO. Removal of the PFO in all five eyes combined with repeat retinal reattachment surgery in three eyes resulted in resolution of the inflammatory response. CONCLUSIONS: Retention of PFO after surgery elicits an inflammatory response. We suspect that young patients, those with considerable residual vitreous gel, and eyes with larger amounts of retained PFO may be at higher risk for this complication.

Adolescent↗