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A 2-year-old girl presented with a 2-month history of anterior and posterior uveitis associated with the presence of an intravitreal larva. A Hypoderma species larva was successfully removed using a pars plana vitrectomy technique. A combined traction/rhegmatogenous retinal detachment and epiretinal membrane formation occurred later, requiring a second operation, but a good visual result was obtained.
Transvitreal diathermy was combined with vitrectomy, scleral buckling, and silicone oil injection to treat 28 eyes with severe proliferative vitreoretinopathy and fore-shortened peripheral retina. A special gold tip on the diathermy probe prevented adhesions to the retina. The probe can be used for coaxial bipolar diathermy or for internal-external bipolar diathermy when combined with an electrode on the external scleral surface. Nineteen (68%) of 28 eyes treated with these methods achieved anatomic success and 10 eyes obtained final visual acuity ranging from 5/200 to 20/70.
Complete surgical removal of the posterior vitreous requires the presence of a posterior vitreous separation from the retina. Although a partial or complete posterior vitreous detachment is usually present before surgery, occasionally this separation must be induced during the course of a pars plana vitrectomy. A simple method for creation of a posterior vitreous detachment during surgery is described. This alternative technique seems to be an efficient and safe method for achieving this important surgical objective.
The clinicopathologic findings of light and electron microscopic examination of a 78-year-old woman who underwent successful bilateral pars plana vitrectomy for bilateral stage III macular holes are reported. Examination disclosed anatomical repair of the full-thickness macular holes by glial cell proliferation in the left eye. The hole apparently collapsed with no glial cell proliferation in the right eye. The photoreceptors adjacent to the healed macular holes appeared normal. Defects in the internal limiting membrane in the foveal area were noted in both eyes.
The purpose for this study was to evaluate the results of silicone oil use in patients who have undergone vitrectomy for proliferative vitreoretinopathy (PVR). The authors reviewed the 5-year results of 50 consecutive patients (52 eyes) with grade C1/D3 PVR operated on in 1987. Silicone oil has been removed in 42 eyes. The retina remained attached in 38 eyes. Visual acuities were finger counting in 12 eyes and 0.1 or greater in 19 eyes. Glaucoma was thought to be the major cause of loss of visual acuity after an initial improvement (9 eyes), as well as the most frequent complication of surgery (13 eyes). Silicone oil was deemed nonremovable in 10 operated eyes. A questionnaire was developed to determine the patients' perceptions of the use of silicone oil, and 46 patients responded to the questionnaire. Four patients indicated that they would not have elected to have surgery again. Six patients thought that surgery was not worthwhile, but would permit treatment again. Most patients thought that a modest amount of improvement had taken place and that vision was stable. Subjectively, most patients believed that surgery was worthwhile.
PURPOSE: The cellular composition of primary and recurrent periretinal proliferations has been widely described. The use of daunomycin, an antiproliferative antibiotic, has been recommended to reduce these proliferations. Two recurrent membranes after intraoperative application of daunomycin were examined. METHODS: Two epiretinal membranes, which were removed 5 months and 20 months after vitrectomy with daunomycin, were examined by light and electron microscopy to determine the structure and cellular composition of these membranes. RESULTS: The matrix of the membranes consisted of new collagen with fiber diameters between 20 and 22 nm. Fibrocytes and macrophages were present in both specimens. Retinal pigment epithelial cells and fibrous astrocytes were present in only one specimen. CONCLUSION: Retinal pigment epithelial cells, which are consistently present in primary periretinal membranes, were found in only one of the two specimens examined. Myofibroblasts, also normally present, were not found. The other cells found are typically seen in primary periretinal proliferations.
PURPOSE: To describe the clinical characteristics of the vitreomacular traction syndrome with macular detachment and to report our surgical experience with this condition. METHODS: A retrospective chart and photographic review was performed on nine patients (nine eyes) who had a symptomatic decrease in visual acuity from a macular traction retinal detachment caused by vitreomacular traction syndrome. Vitrectomy was performed in each eye to reattach the retina. RESULTS: Intraoperative observation confirmed partial posterior vitreous separation with adherence of the posterior hyaloid to the detached retina and separation of the posterior hyaloid from the attached retina. After surgery the macula was reattached in seven eyes (78%). Visual acuity was improved in four eyes, stable in four eyes, and worse in one eye. CONCLUSION: Macular detachment may occur secondary to vitreomacular traction syndrome. Although the retina may be reattached surgically in these cases, visual improvement may be limited by chronic detachment, premacular fibrosis, cystoid macular edema, or macular schisis.
PURPOSE: To evaluate the incidence of cystoid macular edema (CME) in patients undergoing either combined or consecutive pars plana vitrectomy (PPV) and phacoemulsification (PE) for the treatment of macular hole and cataract. METHODS: Retrospective review of a consecutive surgical series of 22 patients with idiopathic macular holes. Seven patients underwent combined PPV with air-fluid-C3F8 gas exchange and PE with intraocular lens insertion; 15 patients underwent PE subsequent to PPV. RESULTS: Visual acuity improved by 2 or more lines in 3/7 patients in the combined group and in 15/15 in the consecutive group. Of seven patients in the combined group, two required a second PPV for treatment of the macular hole and one declined further treatment. Of importance, 3/7 in the combined group and 1/15 in the consecutive group developed clinical and angiographic CME, all treated successfully with sub-Tenon's triamcinolone injections. CONCLUSIONS: Both combined PPV/PE and consecutive PPV/PE offer excellent potential therapeutic benefits for the treatment of idiopathic macular holes. The incidence and pathogenesis of CME must be further investigated.
PURPOSE: To develop an improved surgical technique making full-thickness retinal transplant possible, thereby achieving a normal laminated transplant with minimal rosette formation. METHODS: A total of 23 rabbits underwent vitrectomy, retinotomy, and subsequent subretinal transplant of a complete embryonic neuroretina using a specially crafted glass cannula. Of the 23 animals, 15 received a prenatal day 16 or 19 (E16 or E19) retina; the remaining eight received an E15 retina. The animals were followed from 10 to 35 days, and after this period, the transplants were sectioned and stained for light microscopy. RESULTS: In 11 of the 15 transplants with E16 or E19 donors, histology showed regions up to 1.8 mm of straight, correctly positioned transplants with layering corresponding to their age. The eight animals kept alive longest postoperatively, 31 or 35 days, all showed normal retinal layers, including photoreceptor outer segments appositioned against the host retinal pigment epithelium. Tissue from the youngest donors (E15) yielded less well-organized transplants, indicating a critical stage in retinal embryogenesis before which transplant in this respect is less favorable. CONCLUSIONS: Our procedure makes it possible to transplant embryonic retina to the appropriate position adjacent to the host retinal pigment epithelium, keeping the transplant architecture intact. The transplants show good layering and well-developed photoreceptors abutting the retinal pigment epithelium.
PURPOSE: To assess the effectiveness of a combined procedure (pars plana vitrectomy with temporary keratoprosthesis, penetrating keratoplasty, and pars plana seton implant) in preserving vision and controlling intraocular pressure (IOP). METHODS: We reviewed the course of visual acuity, IOP, graft clarity, retinal status, and complications in 18 patients who underwent the above procedure during one operating sitting. RESULTS: Preoperative diagnoses were varied. The majority of patients had pseudophakic bullous keratopathy and failed corneal transplants with glaucoma. Preoperative mean visual acuity was hand motions. Preoperative mean IOP was 27+/-13 mm Hg. Initially, all patients had attached retina. With a mean follow-up of 17+/-9 months, six patients had improved vision greater than 2 lines and 10 had unchanged vision. Only two patients lost vision greater than 2 lines. The final average IOP was 16+/-6 mm Hg and only one eye had a pressure above 22 mm Hg. Three eyes were classified as complete failures; two of the three became phthisical. Two patients developed rhegmatogenous detachments requiring further surgery. CONCLUSION: The combined procedure offers reasonable improvement in vision, good pressure control, and a tolerable number of complications. It is a useful procedure in eyes that probably would not have been treatable otherwise.
PURPOSE: To evaluate visual and surgical outcomes as well as complication rates after cataract extraction and primary intraocular lens (IOL) implantation during pars plana vitrectomy for removal of foreign bodies embedded or impacting in the retina. METHODS: Six consecutive cases of simultaneous cataract extraction and IOL implantation combined with vitreous surgery and intraocular foreign body extraction were retrospectively analyzed. In five cases, the foreign body was intraretinal; in one case, it was preretinal with retinal impact site. The follow-up period ranged from 5 to 45 months (mean 21.3 months). RESULTS: Visual acuity improved by two or more lines in five of six eyes. In five eyes, best-corrected postoperative visual acuity was better than 20/40. One eye was successfully reoperated for retinal detachment that developed 2 months postoperatively. In four eyes, the IOL was implanted into the capsular bag; in two cases, the IOL was placed in the ciliary sulcus. No postoperative complication was attributed to IOL implantation. CONCLUSION: Primary IOL implantation after combined cataract and vitreoretinal surgery is a safe and attractive option, reducing the need for two separate operations in selected patients with penetrating ocular injury and retained intraocular foreign bodies. The main advantage is more rapid visual rehabilitation with a single operation, reducing costs and patient discomfort.
PURPOSE: To determine the incidence, duration, risk factors, and clinical outcomes for ciliary detachment after pars plana vitrectomy (PPV). METHODS: A total of 109 eyes of 103 patients who underwent PPV for various disease entities were included. Ultrasound biomicroscopy was applied to determine the tomographic features of the ciliary body before and 1, 3, and 7 days after the surgery. All eyes were then examined once weekly for 2 months. Demographic, preoperative, intraoperative, and postoperative parameters were evaluated to assess their predictive value in the formation of postvitrectomy ciliary detachment. RESULTS: Ciliary detachment was observed in 46 eyes (42%) after surgery and persisted for less than 3 weeks in 40 of 46 eyes. It most frequently occurred in eyes of patients with proliferative diabetic retinopathy (PDR) (64%) or retinal vascular obstructive diseases (RVO) (47%). Extensive retinal photocoagulation and retinal cryopexy positively predisposed to its formation whereas fluid-gas exchange had a protective effect. No clinical complications were observed in eyes with postoperative ciliary detachment. CONCLUSION: Ciliary detachment occurred frequently after PPV. A diagnosis of PDR or RVO and surgical procedures with extensive retinal photocoagulation and retinal cryopexy may have a higher incidence of its occurrence.
PURPOSE: The therapeutic armamentarium for functional improvement after branch retinal vein occlusion (BRVO) is limited with uncertain efficacy. Some surgeons have proposed surgical decompression of the vein at the arteriovenous (AV) crossing. METHODS: Forty-three patients with BRVO were treated in the authors' department from August 1999 to April 2001 with AV decompression. Twenty-five patients with comparable BRVO who refused this surgical intervention served as a control group. All 68 patients received an isovolemic hemodilution therapy for 10 days. The surgical procedure consisted of a standard pars plana vitrectomy and separation of the overlying artery from the vein using microscissors. In 16 cases dissection of the internal limiting membrane (ILM) in the macular area and around the AV crossing was also performed. Assessment of visual acuity, fluorescein angiography, and multifocal electroretinography were performed preoperatively and 6 weeks after surgery in seven patients. RESULTS: Surgical procedure and postoperative course were uneventful. In most of the treated eyes visual acuity improved and fluorescein angiography revealed capillary reperfusion. Functional results in patients with AV decompression were highly significantly better than in the control group. Furthermore, removal of the ILM seems to have an additional beneficial effect on the functional outcome. CONCLUSION: These results demonstrate the therapeutic effect of surgical AV decompression in BRVO. Additional removal of the ILM seems to improve the functional results. Further experience may answer some open questions.
PURPOSE: To determine indications and document anatomic and functional outcomes for lens-sparing vitreous surgery in eyes with predominantly posterior persistent fetal vasculature syndrome and nonaxial lens opacification. STUDY DESIGN: Retrospective interventional clinical series. METHODS: The authors performed lens-sparing vitreous surgery on nine eyes of infants with predominantly posterior persistent fetal vasculature syndrome and nonaxial lens opacification without removing the crystalline lens. Indications for surgery included primarily posterior complications of persistent fetal vasculature syndrome (localized tractional retinal detachment), a centrally clear lenticular axis, and frequently strabismus. RESULTS: Postoperatively, seven of nine eyes showed no evidence of increasing lens opacification with a median follow-up period of 16.8 months (range, 5-29 months). The first eye operated on developed a rapidly progressive cataract and prompted modification of the surgical technique. One additional eye also required cataract extraction for progressive lenticular opacification 23 months after surgery. No eyes developed postoperative retinal detachment, and all eyes maintained vision at the final follow-up. Of the seven eyes with strabismus, five improved after vitreous surgery alone, and two required additional strabismus surgery. CONCLUSIONS: This series shows that, in selected cases of persistent fetal vasculature syndrome that are predominantly posterior in nature with nonaxial lens opacification, lens-sparing vitrectomy can be of benefit.
PURPOSE: Postoperative visual field defects are sometimes found after macular hole surgery. We have previously shown that damage to the retina by air infusion from an infusion cannula is a causative factor. To minimize such damage, we modified the infusion cannula and examined its effects experimentally. METHODS: An infusion cannula with a closed tip and openings on four sides was created. Experimentally, a vitrectomy was performed in rabbit eyes using this new infusion cannula or a conventional cannula. After fluid-air exchange at an air pressure of 40 mmHg, eyes were removed and processed for histologic examination. The areas of the retinal damage caused by air infusion were evaluated. RESULTS: The area of retinal damage created by the new cannula was reduced significantly when compared with damage from conventional cannula use. CONCLUSION: This new cannula, designed for the purpose of scattering the air infusion, can reduce retinal damage, which leads to less frequent postoperative visual field defects.
PURPOSE: To study the advantages and complications of triamcinolone acetonide (TA)-assisted pars plana vitrectomy (PPV) for various retinal diseases. METHODS: This report is an interventional case series and nonrandomized study. One hundred seventy-seven eyes from 158 patients underwent PPV with or without TA. Group TA(+) consisted of 94 eyes and group TA(-) consisted of 83 eyes. The improvement in vision and postoperative complications were prospectively studied. RESULTS: Sixty-two percent of the eyes in group TA(+) and 49% of the eyes in group TA(-) had improved vision after surgery (P = 0.34). Twelve eyes in group TA(+) and 12 eyes in group TA(-) had an intraocular pressure higher than 21 mmHg after the operation, with no statistically significant difference (P = 0.63). Four eyes with proliferative diabetic retinopathy in group TA(+) and five eyes with proliferative diabetic retinopathy in group TA(-) needed an additional filtering surgery. Group TA(+) (five eyes) had a lower incidence (P = 0.041) of reoperation caused by preretinal fibrous membrane formation than group TA(-) (13 eyes). No apparent corneal disorder or infectious signs were found in any eyes. CONCLUSIONS: Triamcinolone acetonide-assisted PPV appears to be potentially useful to reduce the incidence of reoperation owing to preretinal fibrosis with no serious complications.
PURPOSE: To determine whether triamcinolone acetonide (TAAC) staining facilitates posterior hyaloid and epiretinal membrane (ERM) removal in patients undergoing pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD) with proliferative vitreoretinopathy (PVR). METHODS: Ten consecutive pseudophakic patients (10 eyes) underwent PPV for RRD with PVR. After a core PPV, a few drops of a commercially available TAAC aqueous suspension (40 mg/mL) with vehicle were injected into the mid vitreous cavity to visualize the posterior hyaloid, thus allowing a complete posterior hyaloidectomy. Next, 0.1 to 0.2 mL of TAAC was applied on the retinal surface to visualize and peel the ERMs. The tamponading agent was silicone oil (1,300 cs) in eight eyes and perfluropropane (C3F8 14%) in two eyes. The minimal follow-up period in all patients was 4 months. RESULTS: In all patients, intraoperative staining with TAAC consistently improved direct visualization and delineation of the posterior hyaloid and ERMs and facilitated their removal. No adverse reaction related to the use of TAAC was observed immediately postoperatively or 4 months after surgery. CONCLUSIONS: Intravitreal TAAC may be an important adjuvant tool in the delineation of posterior hyaloid and ERMs, allowing for a more complete and safer ERM removal in the surgical management of PVR complicating RRD. It is well tolerated with all its vehicle if used at low concentration and rapidly removed during surgery.
PURPOSE: To address the efficacy of surgical intervention for chronic macular holes. METHODS: The cases of 22 patients (23 eyes) who underwent pars plana vitrectomy with or without internal limiting membrane (ILM) peeling and use of 10% to 16% C3F8 gas for macular holes of duration of >1 year (mean, 4.2 years; range, 1.2-15 years) were retrospectively reviewed. Preoperative visual acuity ranged from 20/60 to 5/200 (mean, 20/278). Thirteen eyes (56.5%) had stage 3 macular holes, and 10 eyes (43.5%) had stage 4 macular holes. The mean age of the patients was 70.2 years (range, 47-78 years), and 20 (87%) were female. RESULTS: Nineteen (83%) of 23 macular holes were closed at final follow-ups at >/=9 months (mean, 4.67 years; range, 0.9-10.8 years). With one operation that included ILM peeling, 13 (81%) of 16 eyes had holes that closed. Seven eyes on which initial surgery without ILM peeling failed underwent reoperation with ILM peeling, and all but one had closed holes. ILM peeling was significant for surgical success of one operation (Fisher exact test, P = 0.0005). Postoperative visual acuity ranged from 20/30 to 20/800 (mean, 20/166). Improved vision with halving of the visual angle occurred in 16 eyes (70%). Nine eyes (39%) achieved visual acuity of 20/70 or better, and two eyes (8.7%) achieved visual acuity of 20/40 or better. One eye (4%) had worse visual acuity, and three eyes (13%) remained unchanged. Cataract was a possible cause of decreased vision in six eyes (26%) at the end of follow-up. CONCLUSION: Chronic macular holes can be surgically closed with visual improvement in most patients. ILM peeling is an important surgical factor for closure of the macular hole with one operation.