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Open sky vitrectomy was performed on 23 eyes in 18 children between 4 and 35 months of age with stage V retinopathy of prematurity (ROP). Postoperatively, the retina was reattached in the posterior pole in eight eyes (34.7%). Follow-up ranged between 7 and 55 months (average, 16 months). Prognostic factors based on preoperative findings and surgical observations are analyzed.
During the past two decades, the number of diabetic patients requiring vitrectomy for nonresolving vitreous hemorrhage has decreased four-fold, whereas there has been a substantial increase in diabetic patients with traction and combined traction/rhegmatogenous retinal detachment (RD) requiring surgery. Additional contemporary surgical indications are progressive fulminant neovascular proliferation, massive preretinal hemorrhage, massive fibrin response, and progressive retrolental fibrovascular proliferation. Surgical techniques for management of tractional detachments have evolved from circumscription of tractional epicenters to en bloc removal of all proliferative tissue.
The authors operated on 95 eyes with retinal detachment (RD) complicated by proliferative vitreoretinopathy (PVR) using vitrectomy combined with scleral buckling. The retina was successfully reattached in 10 (91%) of 11 eyes with mild PVR (B, C1), 14 (93%) of 15 eyes with moderate PVR (C2-C3), and 52 (75%) of 69 eyes with severe PVR (D1-D3). Thirteen (88%) of 15 eyes in which silicone oil was injected were successfully reattached. Eighty-eight percent of the 76 successfully reattached cases had a postoperative visual acuity of 5/200 or better; the median postoperative visual acuity was 20/200. Severe PVR was the cause of failure in 17 (89%) of 19 eyes in which the retina was not reattached.
The Landers-Foulks temporary keratoprosthesis was used to combine penetrating keratoplasty, pars plana vitrectomy, and scleral buckling in the management of 13 eyes with opaque cornea and posterior segment abnormalities. In seven cases, trauma precipitated the ocular disease. Complications of cataract surgery resulted in anterior and posterior segment pathology in six cases. The corneal graft was initially clear in all cases. However, corneal edema complicated phthisis bulbi in four cases and followed homograft reaction in two cases. Eight eyes with retinal detachment (RD) preoperatively were successfully reattached. In five eyes, the retina redetached as these eyes became phthisical. Visual function improved in six cases. In general, eyes with a history of trauma had a much poorer outcome than did eyes with anterior and posterior segment problems related to previous cataract surgery.
A procoagulant effect was reported previously after injection of 0.50 to 0.75 ml of sodium hyaluronate (Healon) into the vitreous cavity at the end of phakic diabetic vitrectomies. A multicenter, randomized, prospective trial was done to study this effect. In the treatment group the media was clear in 50% of eyes in the immediate postoperative period compared with only 8% in the control group. At 2 to 6 weeks, there was no statistically significant difference between the two groups. The authors conclude that such sodium hyaluronate injection provides clear media in a significant number of eyes in the immediate postoperative period, potentially allowing thorough postoperative evaluation and early retinal photocoagulation if needed.
The authors reviewed the medical records of 191 patients (232 eyes) who underwent closed vitrectomy for complications of diabetic retinopathy to evaluate the clinical picture of postvitrectomy hemorrhage (PVH). One hundred thirty-nine eyes (59.9%) had at least one episode of PVH (average, 1.5 per eye) that was variable in onset, not associated with a known cause in four fifths, with no noted source in two thirds, and severe in three fourths of the cases. Using logistic regression statistical analyses, the factors significantly associated with decreased incidence of PVH include older age of patient (P = 0.0004), long duration of surgery (P = 0.0002), and poor preoperative vision (P = 0.05). Of the 139 eyes with PVH, 65 (47%) had spontaneous clearing in an average of 11.3 weeks, 53 (38%) required repeat surgery, and 21 (15%) were inoperable, lost to follow-up, or refused reoperation. Postvitrectomy hemorrhage did not significantly influence the final visual outcome.
Seven eyes (7 patients) developed massive suprachoroidal hemorrhage (MSCH) during pars plana vitrectomy (PPV) for complicated retinal detachments. The MSCH developed late in the procedure following PPV, air fluid exchange, endolaser, cryopexy, and scleral buckling in five of seven eyes. In two eyes, mild hemorrhagic choroidal detachments noted intraoperatively progressed to MSCH within 72 hours postoperatively. Diagnosis of MSCH was confirmed by echography and CT scan. Multiple scleral buckling surgeries, high myopia, aphakia, and intraocular inflammation were the main risk factors. Placement of a broad posterior scleral buckle with intraoperative hypotony and cryopexy were important precipitating factors. Visual results were poor, with six of seven eyes showing no light perception. The mean follow-up time was 12.8 months. Once acute MSCH is recognized intraoperatively, surgical decompression at that time should be avoided as MSCH itself may tamponade the choroidal bleed. Details of prevention and management are discussed.
Extracapsular cataract extraction (ECCE), placement of a posterior chamber intraocular lens (PC IOL), and pars plana vitrectomy were combined in a single operation in 24 patients. Sixteen of these, 11 of whom are diabetic, have had 6 months or more of follow-up. In all cases, excellent visualization of the posterior segment was obtained, and the surgical objectives were achieved. No diabetic patient without preoperative neovascularization of the iris had this complication later. The advantages and disadvantages of alternative techniques are discussed.
Pars plana vitrectomy and gas-fluid exchange were used to successfully reattach eyes of 12 patients who had symptomatic retinoschisis retinal detachments (RDs) associated with large or posterior outer-layer holes. Visual acuity improved postoperatively in seven (58%) eyes, was unchanged in two (17%) eyes, and decreased in three (25%) eyes. Loss of vision was secondary to a mild posterior subcapsular cataract in one eye and to epiretinal membranes in the other two. In two other eyes, cataracts developed that subsequently required an extracapsular cataract extraction (ECCE) and posterior chamber intraocular lens (PC IOL) implantation with 20/20 visual acuity in both eyes after cataract surgery. All eyes with a macula-involved RD stabilized or improved in visual acuity. Surgical indications, techniques, and results in the management of these retinoschisis RDs are discussed.
Four eyes underwent vitrectomy and epiretinal membrane dissection for tractional retinal detachment (RD) or macular pucker associated with Candida chorioretinitis. The epiretinal membranes were vascularized and, in three of four eyes, were associated with full-thickness retinal scars, presumably at the site of previous active Candida chorioretinitis. The epiretinal membranes were successfully removed in all four cases. Visual results depended on the degree of macular pathology and the presence and location of a full-thickness retinal scar.
Ten patients underwent combined Molteno implantation and pars plana vitrectomy as the primary nonlaser surgical treatment of neovascular glaucoma associated with diabetic retinopathy (9 patients) or central retinal vein occlusion (1 patient). Combined surgery was performed most frequently because media opacities precluded adequate preoperative retinal ablation. Follow-up ranged from 3 to 43 (mean +/- standard deviation, 18.0 +/- 13.2) months. Six patients achieved final intraocular pressures less than 22 mmHg. Visual acuities remained the same or improved in four patients. Four patients had uncomplicated courses. Among the other patients, complications included: recurrent vitreous hemorrhage and retinal detachment (3 patients each); hyphema (2 patients); and tube block, extensive fibrin formation, epiretinal membrane, and total retinal necrosis (1 patient each).
Pars plana vitrectomy with separation of the posterior hyaloid was performed in 10 eyes with diabetic macular edema and traction associated with a thickened and taut premacular posterior hyaloid. Nine of the 10 eyes had previous macular photocoagulation. Preoperative fluorescein angiography showed a deep and diffuse pattern of leakage in the macula. Intraoperatively, the attached and thickened posterior hyaloid was lifted and separated from the retina. Postoperatively, vision improved in nine eyes. The macular traction and edema resolved in eight eyes and decreased in two. Complications included a vitreous hemorrhage, a rhegmatogenous retinal detachment, cataract formation, and a mild epimacular membrane, each occurring in one eye. Vitreous surgery can improve the visual prognosis of some eyes with diabetic macular traction and edema associated with a thickened and taut posterior hyaloid.
PURPOSE: The purpose of this study is to evaluate the accuracy of diagnostic ultrasonography in the preoperative evaluation of eyes with media opacity after penetrating ocular trauma and correlate the preoperative findings with ultimate visual outcome. METHODS: A retrospective comparison was made between the preoperative ultrasound diagnoses and the intraoperative findings in 46 eyes of 45 patients undergoing pars plana vitrectomy after penetrating ocular trauma associated with dense media opacities. The preoperative echographic findings were correlated with long-term visual and anatomic outcome. RESULTS: Preoperative echography was both sensitive and specific in evaluating traumatized eyes for retinal detachment, intraocular foreign bodies, posterior scleral wounds, and hemorrhagic choroidal detachments. The overall anatomic success rate was 87% (40/46) with 48% (22/46) of eyes obtaining visual acuity of 20/200 or better after surgery. The visual prognosis was worse in those eyes in which preoperative echography detected retinal detachment, subretinal blood, massive choroidals, or posterior exit wounds. CONCLUSION: Diagnostic echography is accurate and provides useful prognostic information in eyes with media opacity after penetrating ocular trauma.
PURPOSE: The purpose of this study is to assess the rate of posterior segment complications after vitreous surgery for macular holes and to evaluate the effect of such complications on final visual outcome. METHODS: The authors reviewed retrospectively all cases of vitreous surgery for macular holes performed between June 1990 and October 1993. Among 98 patients with a followup of 3 months or more, all patients with posterior segment complications during the postoperative course were identified. The rate of complications was compared with that seen after vitreous surgery for macular pucker performed by the same surgeons. RESULTS: Posterior segment complications were noted in 23 (23%) of 98 patients. These included peripheral retinal breaks (3%), rhegmatogenous retinal detachment from a peripheral retinal break (14%), enlargement of the hole (2%), late reopening of the hole (2%), retinal pigment epithelium loss under the hole (1%), photic toxicity (1%), and endophthalmitis (1%). In 40% of these eyes, the final visual acuity was two lines or more below preoperative visual acuity. When compared with the macular pucker group, the rate of posterior segment complications, in particular the rate of peripheral retinal tears and detachments, was significantly higher (P < or = 0.05). CONCLUSIONS: The authors conclude that visually significant posterior segment complications may occur after vitrectomy for macular hole, and the rate of these complications appears to be higher than expected.
PURPOSE: To assess the effectiveness of vitrectomy for stage V retinopathy of prematurity (ROP) at the authors' institution, 33 patients with ROP who had initially successful total or partial anatomic retinal attachments (51 eyes) were evaluated for visual function and long-term anatomic stability. In addition, this study was an attempt to differentiate levels of visual function in children with very low vision and attendant developmental delays. METHODS: Visual function was assessed before retinal examination by an experienced pediatric vision specialist. The behavioral visual assessment was divided into seven segments with two to five tasks in each segment designed to establish a level of functional vision, ranging from light perception to form identification (and ambulation). The status of the retina was classified by the patient's retinal surgeon. RESULTS: The median follow-up was 61 months, and median age at the time of examination was 68 months. Of 51 eyes treated, form identification was achieved in 5, and all five patients had ambulatory vision. Of 51 eyes, 15 had no light perception, 11 had light perception, 6 could localize light, 10 could follow lights, and 4 were able to detect form. Only one eye in ten children with comparable ROP in each eye underwent surgery, and vision improved in six of ten of the surgical eyes. Redetachment was high, with 35 retinas totally or partially detached and only 13 retinas fully attached 61 months after surgery. CONCLUSION: The visual results are very low and disappointing. Initially successfully attached retinas can detach. There is some evidence that vitrectomized eyes function better than nonvitrectomized eyes. There is also evidence that visual function lower than form identification is useful to these children and that they are able to use their limited vision better than previously though.
OBJECTIVE: To study complications of vitrectomy surgery for full-thickness macular holes. DESIGN: A multicentered, randomized, controlled clinical trial. PARTICIPANTS: Community and university-based ophthalmology clinics. INTERVENTION: Standardized macular hole surgery versus observation. MAIN OUTCOME MEASURES: Assessment of anatomic and visual outcomes and determination of postoperative complications at 12 months after randomization. RESULTS: Posterior segment complications were noted in 39 eyes (41%). The incidence of retinal pigment epithelium (RPE) alteration and retinal detachment (RD) were 33% and 11%, respectively. One RD due to a giant retinal tear resulted in a visual acuity of light perception. Other complications included a reopening of the macular hole in 2 eyes (2%), cystoid macular edema in 1 eye (1%), a choroidal neovascular membrane in 1 eye (1%) and endophthalmitis in 1 eye (1%). Eyes with complications had significantly worse visual acuity outcomes as determined by the Early Treatment Diabetic Retinopathy Study, Word Reading, and Potential Acuity Meter charts (P < 0.01 for all comparisons). Eyes with macular holes greater than 475 microns were more than twice as likely to have complications than eyes with holes less than 475 microns (odds ratio [OR] = 2.2, P = 0.07). Before surgery, the stage of the hole was related to postoperative RPE changes (P < 0.0001) and the occurrence of postoperative RD (P = 0.0002). Intraoperative trauma was related to the occurrence of these complications (P < 0.0001 for RPE changes, P = 0.02 for RDs). Epiretinal membrane removal was related to RPE changes (P = 0.02) but not RDs. CONCLUSIONS: The RPE alterations and RDs are common after macular hole surgery and result in significantly reduced postoperative visual acuity. The RPE changes may be related to surgical trauma or light toxicity. Further efforts to reduce complications associated with macular hole surgery are indicated.
OBJECTIVE: This study aimed to describe the intraoperative and postoperative complications and visual acuity outcomes of patients undergoing Kelman phacoemulsification (KPE) and intraocular lens (IOL) implantation after pars plana vitrectomy (PPV). DESIGN: The study design was a retrospective review of a consecutive surgical series. PARTICIPANTS: Forty-four eyes of 43 patients who underwent surgery at the Jules Stein Eye Institute, Los Angeles, California, or Advanced Vision Care, West Hills, California, were studied. INTERVENTION: Office records, referring retina specialists' records, and operative reports were reviewed for demographic information, indications for PPV, preoperative cataract severity, unplanned intraoperative events and complications, early and late postoperative complications, and postoperative visual acuities. MAIN OUTCOME MEASURES: Complications and postoperative visual acuities were measured. RESULTS: The mean interval from PPV to KPE was 20 months. The mean interval from KPE to final examination was 19 months. Primary indications for PPV included development of a macular epiretinal membrane, macular hole, proliferative diabetic retinopathy, retinal detachment, vitreous abscess, and vitreous hemorrhage. The degree of nuclear sclerosis in postvitrectomy eyes was greater than that in typical cataract eyes (P = 0.00002). The most common intraoperative problem was the discovery of a posterior capsule plaque. In a few cases, surgery was made difficult by unusual fluctuations in anterior chamber depth and lens zonule instability. The most common early postoperative complication was corneal edema; the most common late complication was the need for neodymium:YAG (Nd:YAG) laser posterior capsulotomy. An IOL was implanted in every eye. There were no retinal detachments. Median visual acuity improved from 20/125 before cataract surgery to 20/40 6 weeks after surgery to 20/30 on final examination. Visual acuity of 20/40 or better was achieved by 63.6% of eyes at 6 weeks and by 72.7% of eyes by final examination. CONCLUSIONS: Kelman phacoemulsification and IOL implantation can be performed safely after PPV. Intraoperative and postoperative complications are uncommon. Pre-existing posterior segment pathology limits the ultimate improvement in visual acuity, but substantial gains in visual acuity are realized by most patients.
OBJECTIVE: This study aimed to determine the efficacy of photocoagulation to the retinal pigment epithelial (RPE) cells and fluid-gas exchange (FGX) in the treatment of persistent macular holes. DESIGN: A clinical trial. PARTICIPANTS: Thirteen eyes of 12 patients who had undergone photocoagulation to the RPE and FGX for persistent macular holes after initial vitrectomy and gas tamponade were examined. All eyes had persistent full-thickness macular holes (diameter range, 290-820 microns; 610 +/- 190, mean +/- standard deviation) and no vitreous cortex around the holes on biomicroscopic examination. INTERVENTION: Argon laser photocoagulation was applied to the RPE in the hole bed, and FGX with 20% sulfur hexafluoride was then performed, followed by 2 weeks with the patient in a prone position. The follow-up period of the patients ranged from 3 to 18 months (10.2 +/- 4.2; mean +/- standard deviation). MAIN OUTCOME MEASURES: Anatomic success and final visual outcome were measured. RESULTS: Macular holes were closed successfully after treatment in 12 (92%) of 13 eyes, and visual acuity improved 2 or more lines in 6 eyes (46%). Two eyes (15%) attained visual acuities of 20/40 or better, and seven eyes (54%) attained 20/67 or better visual acuity. There were no intraoperative complications. Cataract formation or progression was recognized during follow-up in five (83%) of six phakic eyes. CONCLUSIONS: Although this study includes only a small number of patients, it suggests that photocoagulation and FGX can be effective in the treatment of persistent macular holes.