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A new form of carbon dioxide laser has been developed that allows placement of infrared energy within a fluid medium. Transvitreal photocautery, vitrectomy, and laser scalpel incisions have been accomplished utilizing this delivery modality of infrared energy. Clinical trials are presently underway.
The general characteristics, preoperative findings, and operative procedures of 56 consecutive eyes having pars plana vitrectomies for complications of diabetic retinopathy are presented in this paper. Of the 34 eyes available for follow-up examinations five years after surgery, 50% had ambulating vision and 15% had 20/40 or better visual acuities. The vitreous cavities were clear in 59% and the maculae attached in 50% of the 34 eyes.
Nineteen eyes on which pars plana vitrectomy was performed were studied with fluorescein angiography. The degree of background diabetic retinopathy before and after surgical treatment appeared unchanged. The degree of proliferative retinopathy not only was less after surgical treatment, but continued to show regression with time.
This report describes a series of 13 patients who underwent anterior vitrectomies for chronic aphakic cystoid macular edema (CME). All eyes had formed vitreous adherent to the intracapsular wound, vision of 20/50 or worse, and fluorescein angiographically documented CME for six months or more. Following the presentation of the results (success rate of 69%) and a discussion of this form of treatment, the beginning of a national, randomized, prospective study designed to evaluate the effectiveness of this treatment is described.
This paper describes experience gained with 663 eyes of patients with diabetic vitreous hemorrhage treated by closed vitrectomy with a follow-up period of six months. Hemorrhages were nearly always associated with proliferative retinopathy (97%) and were thought to be caused always by ruptured proliferative vessels. Membrane removal was performed in 42% of all cases but in 60% when the retina was detached. The most common surgical complication was creation of retinal holes; more common when the posterior retina was detached (32%) than when it was attached (18%). The lens was removed in 73% of the cases. Eighty-two percent of the retained clear lenses remained clear at the six months follow-up period. Therefore, clear lenses should not be removed. Visual improvement could be achieved in 59% of the cases where the posterior retina was attached but only in 25% where it was detached resulting in an overall major visual improvement in 46% of the cases. If one adds to this group the cases that retained reasonable vision of 20/200 or better, the overall success rate was 51%. Posterior retinal detachment and rubeosis of the iris were the main factors for a bad prognosis. Forty-two percent of all eyes had at least some degree of rubeosis iridis. Most of the preoperative rubeotic eyes had rubeosis postoperatively (71%). Twenty-three percent of all eyes ended up with neovascular glaucoma.
We describe our technique for the surgical removal of hyphema using the Ocutome vitrectomy system and report the results in 12 patients. Blood was removed successfully with just one operation in all 12 eyes. Eleven of the 12 eyes maintained intraocular tension of less than 20 mm Hg. Vision improved in 11 of 12 eyes and six had a vision of 6/18 or better. Permanent vision loss could not be attributed to the operative technique.
Intraocular pressure was artificially elevated above systolic blood pressure in 40 owl monkey eyes. Diffuse retinal whitening of the posterior pole and subsequent retinal pigment epithelial disruption were produced in nine of ten eyes with high pressure for 90 minutes or longer, but also in a few eyes with high pressure for a shorter duration. Fluorescein angiography and histologic examination demonstrated damage of the photoreceptors and retinal pigment epithelium with sparing of the inner retinal layers. This animal model duplicates the acute visual loss due to outer retinal infarction that sometimes occurs after closed vitrectomy or after continuous external ocular compression in preparation for surgery.
This report describes a peculiar syndrome occurring as a complication of cataract extraction. The syndrome is characterized initially by (1) acute loss of central and paracentral vision discovered usually on the first postoperative day; (2) diffuse and patchy whitening of the outer retinal layers in the posterior fundus; (3) normal angiographic retinal and choroidal appearance and circulation time; (4) a peculiar polygonal pattern of fluorescein staining of the pigment epithelium and outer retina in the area of retinal whitening, and followed later by (5) clearing of the retinal whitening and mottled changes in the pigment epithelium; (6) partial recovery of the central visual field; and (7) preservation of normal optic disc and retinal vessel caliber. Prolonged elevation of the intraocular pressure sufficient to obstruct choroidal blood flow occurring during the use of intraocular volume-reducing devices before surgery, during phakoemulsification or closed vitrectomy is postulated as the major cause of this complication.
The postoperative, six-month visual acuities of 1056 diabetic vitrectomy cases were compared to the following preoperative findings: duration of decreased vision associated with detachments, pupillary responses, iris rubeosis, intraocular tensions, extent of neovascularization, macular status, the ability to recognize entoptic phenomena, bright-flash ERG, and ultrasonography. By comparing these findings to the postoperative visual results, several factors were detected that could be helpful in determining the preoperative prognosis for improved vision. However, major operative complications reduced the incidence of successful visual results from 53% to 22%.
Fifteen infants between the ages of 5 months and 2 years suffering from severe retrolental fibroplasia with near total and total retinal detachment and retrolental scar tissue formation were operated upon with closed vitrectomy. The surgical technique and the problems related to the smallness of the eye and the changes caused by RLF are discussed in detail. Seven retinas were reattached completely and one retina partially reattached. Vision was definitely improved, although the visual acuity was probably low.
The use of low-vision aids to improve postoperative vision after successful closed vitrectomy for vitreous hemorrhage was evaluated in 30 diabetic patients. The distance vision improved with telescopic systems in 28 of 30 patients, whereas the near vision improved with microscopic systems in all cases. Patient acceptance of these low-vision aids was 50% for telescopic systems and 83% for microscopic systems.
In 30 cases of panuveitis which did not respond to treatment with drugs (corticosteroids and/or immunosuppressors), pars plana vitrectomy was performed with good functional results. There were no further recurrences and it was possible to discontinue anti-inflammatory or respectively immunosuppressive treatment after surgery.
A lens holder for posterior segment vitrectomy is described. Its advantages are: better centering, optional use during surgery, simple handling and optimal exploitation of the prismatic effect for a better view into the periphery.
A retrospective study on 184 eyes of 167 diabetics which had been submitted to a vitrectomy because of various affections of the vitreous body and retina shows, that aphakic eyes, cases suffering from repeated bleeding into the vitreous cavity, and eyes with advanced stages of diabetic retinopathy are mostly preposed to the development of rubeosis iridis. Coincidence of two of these factors was found in more than two thirds of the eyes with post-operative rubeosis iridis. The stage of the diabetic retinopathy was preoperatively determined by means of ultrasonography.
Report on 82 consecutive cases in which pars plana vitrectomy was performed because of intravitreal hemorrhage. Postoperative follow-up ranged from 3 to 4 1/2 years. Although an incipient improvement of the visual acuity was achieved in 54%, recurrent hemorrhages as well as progression of the proliferative diabetic retinopathy lead to visual deterioration of blindness in 64% of the eyes.
Local and systemic applications of antibiotics in cases of vitreous bacterial infections have proved insufficient because of blood-vitreous barriers. Intravitreal antibiotic injections overcome these barriers and may control the infection. Recommendations are given for intravitreal therapy with Gentamicin, combined with a pars plana vitrectomy in advanced infections.
A safety suture with twisted 6-0 silk material for immediate closure of a sclerotomy wound after pars plana vitrectomy is described. The needle is first carried about 5 mm intrasclerally toward the edge of the sclerotomy and, after an oblique pass across the scleral incision, another intrascleral passage of 5 mm follows on the opposite side (Fig. 1). Bimanual stretching of the safety suture (Fig. 2) by the assistant provides a watertight adaptation of the sclerotomy and facilitates the placing of about four 10-0 interrupted nylon sutures without loss of intraocular pressure. After closing the sclerotomy, the safety suture is cut close to the sclera, and the remaining end of the suture is gently pulled out of the sclera.
Rubeosis iridis following pars plana vitrectomy was studied in 150 patients. In patients with vasoproliferative diseases, retinal detachment and chronic uveitis there is a high risk that rubeosis iridis will develop. Rubeosis is more frequent in aphakic patients. In most cases rubeosis iridis is already present and progresses following surgery. Irisangiography may be necessary to demonstrate the existing iridic neovascularization. Rubeosis iridis influences the visual prognosis. The success rate in patients with postoperative rubeosis iridis is only half that in patients who are not suffering from this condition.