Postoperative Anatomical Outcomes Research Articles

ANATOMICAL AND VISUAL RESULTS OF VITREORETINAL SURGERY FOR STAGE 5 RETINOPATHY OF PREMATURITY

To provide a historical perspective on outcomes of surgery for infants with stage 5 retinopathy of prematurity (ROP) as performed by a single surgeon over a 24-year period. Retrospective observational cohort study. Clinical practice of the Charles Retina Institute. The 601 infants with stage 5 ROP in at least one eye who were referred for surgery between 1977 and 2001. Charts were reviewed for demographic data and postoperative anatomical and visual acuity outcomes in eyes that underwent surgery. The postoperative anatomical status of the retina and visual function were assessed after surgery. Anatomical outcome was categorized as success (macula attached), partial success (macula detached), failure (total retinal detachment), or lost eye (opaque cornea, secluded pupil, or phthisis). Visual function was classified as>20/200, 20/200-5/200, hand movement, light perception, or no light perception. Multivariable logistic regression was used to explore relationships between outcomes and baseline characteristics. Only a minority of eyes had prior cryotherapy (15%) or laser photocoagulation (7%) therapy. The mean follow-up was 44 months for the 956 eyes treated surgically. The 608 eyes with available follow-up data were classified as follows: 28% success, 5% partial success, 55% failure, and 11% lost eye. Visual function of light perception or better was achieved in 74% of the 183 eyes with data on visual acuity. Controlling for other baseline factors, early postpartum age at the time of surgery was a statistically significant predictor of failure/lost eye (OR=2.08, 95% CI 1.09-3.97) and no light perception (OR=5.13, 95% CI 1.45-18.14). Surgery for stage 5 ROP on the fellow eye was also a predictor of failure/lost eye (OR=2.38, 95% CI 1.39-4.08). Surgery resulted in anatomical success for approximately one third of infant eyes with stage 5 ROP, and only a minority of eyes (8 of 183) achieved visual acuity better than 5/200. However, some initially successfully attached retinas redetached. Although this study is limited by follow-up and may represent a group of patients with a more vascularly active disease state due to the low proportion of patients with prior peripheral ablation, this cohort of infants provides results against which future interventions may be compared.

LASIK Outcomes in Patients with Underlying Systemic Contraindications: A Preliminary Study

To determine the anatomic and functional outcomes of photorefractive surgery in patients with underlying systemic diseases that are traditionally listed as relative or absolute contraindications. Observational retrospective case-control study. The case groups were composed of 275 eyes of 141 consecutive patients who underwent a LASIK procedure with any of the following underlying conditions: autoimmune connective-tissue disorders (n = 62), psoriasis (n = 91), intestinal inflammatory diseases (n = 67), diabetes mellitus (n = 44), and history of keloid formation (n = 18). Twenty-nine patients (56 eyes) were receiving systemic immunosuppressive therapy. The control group comprised 358 eyes of 181 patients without the above-mentioned conditions who underwent LASIK. The study had 2 parts, relating to the anatomic and functional (visual and refractive) outcomes. For anatomic outcome, we compared the entire sample of both groups. For functional outcome, only myopic eyes of each group were compared. Independent comparisons were performed between each disease group and the control group. Anatomic outcomes included perioperative and postoperative epithelial, flap, and interface complications. Functional outcomes were evaluated using visual and refractive indicators, percentage of eyes undergoing enhancement, and number of postoperative visits. Mild anatomic complications were observed in the case and control groups with similar percentages, and there were no statistical differences between groups. Regarding functional outcome, the only significant finding was a worse refractive outcome in the collagen vascular diseases group compared with controls. There were no other statistical differences detected in the other systemic disease groups. In our experience, LASIK can be performed effectively and safely in selected patients with stable and controlled systemic diseases with favorable postoperative anatomic and visual outcomes. The absolute exclusion of certain systemic contraindications should be reconsidered.

Black diaphragm aniridia intraocular lens for aniridia and albinism

Our aim was to assess the safety and efficacy of primary and secondary implantation of a black diaphragm aniridia intraocular lens (IOL) in patients that lacked a complete iris diaphragm. This was a retrospective non-comparative study of six eyes in five patients with iris defects. The causes of such defects included congenital aniridia, traumatic aniridia, and oculocutaneous albinism. Three eyes underwent primary implantations of a black diaphragm IOL, and three eyes were given secondary implantations. The visual acuity, subjective severity of glare, postoperative anatomical outcome and any intraoperative or postoperative complications were reviewed. The mean follow-up period was 20.6 months (range 3-29 months). All patients showed stable or improvement in best-corrected visual acuity postoperatively. Glare and photophobia had improved subjectively in all patients after implantation of the black diaphragm IOL. Intraoperative complication included one case of hyphaema and iris damage during insertion of the IOL. Postoperative complications included intraocular inflammation with choroidal detachment, secondary glaucoma, and persistent epithelial defect after surgery. None of the patients developed decentration of IOL after surgery. The black diaphragm aniridia IOL is useful in the management of the condition in patients with iris deficiency including oculocutaneous albinism. Intraoperative and postoperative complications are not uncommon, and patients should be monitored carefully in the perioperative period.

Long-term follow-up of indocyanine green–assisted peeling of the retinal internal limiting membrane during vitrectomy surgery for idiopathic macular hole repair

To determine the long-term efficacy of indocyanine green (ICG)-assisted retinal internal limiting membrane (ILM) peeling during macular hole repair. Retrospective, interventional, noncomparative case series. One hundred twenty-one eyes of 114 patients with stage 2, 3, or 4 idiopathic macular holes that underwent ICG-assisted macular hole repair during the period of August 1999 to January 2003. All eyes underwent a pars plana vitrectomy, including peeling of the posterior cortical hyaloid when necessary. Indocyanine green dye (0.5%) was instilled over the macula, and after removal of the ICG, the retinal ILM was peeled. Medium- to long-acting gas tamponade was used in all cases, and all patients were asked to position themselves facedown for 1 to 2 weeks. Long-term postoperative anatomic results, visual acuity (VA), and complications. Patients were observed postoperatively for an average of 26 months (range, 12-53). Anatomic closure of the macular hole was achieved in 118 eyes (98%) with a single surgery. Reoperation was successful at closing 2 of the 3 macular holes that did not close initially. One macular hole reopened 16 months after the original surgery, and the patient has not yet undergone further surgery. Visual acuity improved by > or =2 lines in 116 eyes (96%). Mean visual improvement after surgery was 6 lines (range, 0-14), and 96 eyes (79%) achieved a final VA of 20/50 or better. There were no intraoperative or postoperative complications attributed to the use of ICG. Long-term follow-up of patients who underwent ICG-assisted ILM peeling for idiopathic macular hole repair demonstrates excellent anatomic and visual results.

A systematic review of anatomical and visual function outcomes in preterm infants after scleral buckle and vitrectomy for retinal detachment.

This article is a systematic review of the literature examining the anatomical and visual function outcomes after scleral buckle and/or vitrectomy for Stage 4 or 5 retinopathy of prematurity. The literature published between 1994 through May 2003 was reviewed via a computer search accessing MEDLINE via OVID. Eight applicable studies were retrieved and analyzed. The study designs were descriptive, retrospective, non-comparative, consecutive case series. The postoperative anatomical outcomes varied dramatically between studies with retinal reattachment rates of 0.8% to 90%. Surgeries that achieved a 50% or higher rate of reattachment occurred primarily between 2 and 9 months of age. Surgeries that occurred between 7 and 11 months of age achieved a lower percentage of retinal reattachment. Further, the longer the duration of follow-up, the lower the percentage of retinas that remained attached. Most importantly, at least in these reports, the degree of retinal reattachment did not correlate well with the level of visual function. One report demonstrated no statistical correlation between visual and anatomical success. Poor visual outcomes were noted in both timely and delayed cases of surgical reattachment of the retina. Many of the reports described challenges in accurately measuring low levels of vision.

Phakic Intraocular Lens to Correct High Myopic Amblyopia in Children

In a clinical investigation, we evaluated anatomical and functional outcomes of posterior phakic chamber lens (ICL) implantation for correction of high myopia with amblyopia in children. Twelve eyes of 11 children, age 3 to 16 years, with high myopic amblyopia were operated with implantation of a Staar Surgical ICL. In these patients, conventional therapy with spectacles or contact lenses was unsuccessful. Mean preoperative spherical equivalent refraction was -12.70 D (range -8.00 to -18.00 D) and best spectacle-corrected visual acuity ranged from count fingers to 20/63. Mean follow-up was 20.5 months (range 3 to 48 mo) Preoperative and postoperative anatomical and functional outcomes were compared. We noted good tolerance of ICLs without inflammatory reactions or secondary capsular opacity, stable intraocular pressure, and good ICL position in all eyes. Predictability was +0.71 D (range -0.75 to +2.00 D). Mean postoperative best spectacle-corrected visual acuity was 20/63. Recovery of binocular vision was achieved in six patients and orthotropic position in seven patients. Quality of life was improved in all patients. The Staar Surgical phakic ICL appeared to be an effective method to treat high myopia in children with amblyopia. Good results with high satisfaction were noted.

Evaluation of primary surgical procedures for retinal detachment with macular hole in highly myopic eyes: A randomized comparison of vitrectomy versus posterior episcleral buckling surgery

Purpose To evaluate postoperative outcomes between pars plana vitrectomy (PPV) and posterior episcleral buckle procedure (PEBP) in myopic eyes with retinal detachment (RD) and macular hole (MH). Design Retrospective nonrandomized comparative interventional trial. Participants and intervention The study included 30 phakic, highly myopic eyes (from 19–30 negative diopters) of 30 patients with an RD and MH. The patients were divided into two groups: They were assigned to PPV (15 eyes, group A) or to PEBP (15 eyes, group B). No significant ( P > 0.01) differences in preoperative visual acuity (VA) between group A and group B eyes were found. Follow-up was 12 months. Main outcome measures Anatomic attachment of the retina was determined, and VA was measured. Results Retinal reattachment was obtained on 11 of 15 (73.3%) eyes of group A and on 14 of 15 (93.3%) eyes of group B. In group A eyes the VA was substantially unmodified after surgical treatment, whereas in group B eyes the VA observed after surgical treatment increased significantly ( P < 0.001) with respect to the preoperative values. Conclusions PEBP resulted in better postoperative anatomic and functional results compared with PPV in eyes with extreme degrees of myopia, pronounced posterior staphyloma, and posterior vitreous schisis affected with RD caused by MH.

Prosthetic iris implantation for congenital, traumatic, or functional iris deficiencies

Purpose: To determine the efficacy and safety of surgical implantation of prosthetic iris devices in patients with anatomic or functional iris deficiencies. Setting: Cincinnati Eye Institute, Cincinnati, Ohio, USA. Methods: Twenty-five patients were enrolled in an interventional prospective noncomparative case series. Twenty-eight eyes had prosthetic iris diaphragm implantation for traumatic iris defects, congenital aniridia or iris coloboma, herpetic iris atrophy, surgical iris loss, or ocular albinism. Prosthetic iris implantation was performed with phacoemulsification and intraocular lens (IOL) implantation in 20 eyes, secondary IOL implantation in 6 eyes, and IOL exchange in 1 eye. A single pseudophakic eye with disabling glare secondary to traumatic aniridia had secondary prosthetic iris implantation alone. The surgical ease of insertion, intraoperative and postoperative complications, postoperative anatomic results, visual acuity, and subjective glare reduction were evaluated. Results: Patients were followed postoperatively for a mean of 10.2 months (range 1.4 to 25.7 months). All eyes achieved the desired anatomic result. Visual acuity was improved in 22 of 28 eyes (79%), unchanged in 5 eyes, and worsened by a single line in 1 eye. Patients were surveyed postoperatively to determine the change in glare disability. The severity of glare disability was subjectively improved in 23 of 24 patients (96%) who responded to the survey. Intraoperative complications included 3 fractured implants as well as an incomplete or torn capsulorhexis in 3 eyes. Postoperative complications included transient hypotony in 2 eyes, mild persistent inflammation in 1 eye, and macular edema followed by a retinal detachment in 1 eye with recent severe trauma. Conclusions: Implantation of prosthetic iris devices improved postoperative outcomes by reducing glare disability and, in selected cases, by correcting aphakia. Although operating on traumatized, congenitally aniridic, or uveitic eyes presents special challenges, implantation of prosthetic iris devices appears to be a safe and effective method for reducing the ubiquitous glare in patients with iris deficiency.

Indocyanine green-assisted peeling of the retinal internal limiting membrane during vitrectomy surgery for macular hole repair.

To determine the efficacy and safety of indocyanine green (ICG)-assisted retinal internal limiting membrane (ILM) peeling during macular hole repair. Interventional, noncomparative, prospective case series. Twenty-four consecutive patients (24 eyes) with stage 3 or 4 macular holes. All eyes underwent a pars plana vitrectomy, including peeling of the posterior cortical hyaloid when necessary. Indocyanine green dye (0.5%) was instilled into the posterior vitreous cavity over the macula and left in place for 3 to 5 minutes. After removal of the ICG, the retinal ILM was peeled. Medium- to long-acting gas tamponade was used in all cases, and all patients were asked to position face down for 1 to 2 weeks. Intraoperative staining properties of ICG, technical ease of peeling of the retinal ILM, postoperative anatomic results, visual acuity, and complications were recorded. Indocyanine green stained the retinal ILM, but did not stain the underlying retina. Indocyanine green staining greatly facilitated the surgeons' ability to visualize and peel the ILM in each case. Peeled tissue was sent for both light and electron microscopic studies, which confirmed that the ICG-stained tissue was truly retinal ILM. Patients were observed after surgery for an average of 123 days (range, 23-195 days). Anatomic closure of the macular hole was achieved in 21 eyes (88%) with a single surgery. Visual acuity improved in 23 of 24 patients (96%) after surgery. There were no intra- or postoperative complications related to ICG use, and there was no clinical or fluorescein angiographic evidence of ICG toxicity. Indocyanine green stains the retinal ILM. This property facilitates ILM peeling by providing a stark contrast between the stained ILM and the unstained retina. Indocyanine green staining of the ILM appears to be a safe and useful adjunct in vitreous surgery for macular hole repair.

Vitrectomy for traction macular detachment in diabetic retinopathy.

A small number of eyes with proliferative diabetic retinopathy develop massive central fibrovascular membranes characterized by vitreoretinal tractions along the arcades and optic disk and retinal traction lines extending through the macula. The aim of our study was first to present the results of vitrectomy for removal of these central membranes and second to determine the correlation between preoperative parameters and postoperative visual outcome. We treated 28 eyes with severe central fibrovascular diabetic membranes by a modified bi-manual en bloc excision technique during vitrectomy. Preoperative examination included general status, visual acuity, slit-lamp investigation, binocular funduscopy, ultrasound investigation and visual evoked potentials (VEP). Further, we analyzed intraoperative complications and postoperative anatomic and functional outcomes. The retinas of 27 eyes with central traction retinal detachments were reattached by surgery. With a minimum of 6 months' follow-up, the macula remained attached in 24 eyes, while the retinas were completely attached in 22 eyes. Preoperative visual acuity was defective light perception to 0.1; an increase in visual acuity to maximal 0.1 was seen in 50% of the patients postoperatively. Preoperative visual acuity of light perception was associated with no functional improvement. Preoperative ultrasound investigation gave information about the real anatomic situation of the retina, especially if funduscopy was not possible. The other preoperative parameters could not predict correctly the functional outcome of vitrectomy in diabetics with severe central fibrovascular membranes because of the damage of the optic nerve and the retina. The high rate of anatomical reattachment after vitrectomy in diabetic eyes with severe central fibrovascular membranes is associated with a slight improvement of function; only preoperative visual acuity of hand motions or better was associated with an improvement of function.

Experience during the learning curve of laser in situ keratomileusis

Purpose: To identify pitfalls and offer hints on achieving a successful outcome during the early laser in situ keratomileusis (LASIK) learning process.Setting: Gimbel Eye Centre, Calgary, Alberta, Canada.Methods: This was a retrospective review of the preoperative planning, surgical procedure, intraoperative and postoperative problems, and early postoperative anatomic and refractive results in the first 73 eyes that had LASIK.Results: Intraoperative complications included failure of the keratome to make a cut, excessively thin cap, repositioning difficulty, and inadequate intraocular pressure elevation. Early postoperative complications included excessive central and peripheral wrinkling of the cap, peripheral lipid deposits, and central edema of the cap. One month postoperatively, mean spherical equivalent refraction was -0.90 diopters (D) (range +1.75 to -6.00 D), and 45 eyes had a best corrected visual acuity between 20/15 and 20/40.Conclusion: Our retrospective review of the problems experienced during the early LASIK learning process should help novice lamellar refractive surgeons avoid such problems and shorten the learning curve.

Use of perfluorocarbon liquids in proliferative vitreoretinopathy: results and complications.

The present study was set up to evaluate the influence of perfluorocarbon liquids on the postoperative anatomical and functional results as well as on the complication rates in eyes with proliferative vitreoretinopathy (PVR). Sixty five consecutive eyes (64 patients) with PVR in different stages requiring surgical intervention where liquid perfluorocarbons were used were compared with 64 consecutive eyes (62 patients) operated without the help of perfluorocarbon immediately before this time. Both groups were similar with regard to severity of PVR, number of operations, and initial visual acuity. The observation period was shorter in the perfluorocarbon group because they were operated more recently (17.4 months as against 24.4 months). The anatomical as well as the functional success rates were not significantly higher in the perfluorocarbon group (69% v 61% and 65% v 53% respectively). However, in cases operated on without perfluorocarbons where reproliferation would occur it was of much greater severity than in cases where perfluorocarbons were used. The number of uncured cases with contraction of the retina at least in the inferior half was more than twice as high in the group operated on without perfluorocarbon. Combined with massive reproliferation secondary glaucoma and bullous or band keratopathy were more frequent in eyes treated before the use of perfluorocarbon. The intraoperative use of perfluorocarbon liquids in vitreoretinal surgery does not prevent postoperative reproliferation but does reduce its severity.

Experience with HEMA Lenses in Paediatric Cataract

In a prospective study, an IOGEL PC 12 intraocular lens was implanted in ten children suffering from monocular congenital (5), developmental (2) or traumatic (3) cataract. The age at implantation ranged from 1.5 to 60 months for the congenital and developmental cataracts, and from 5 to 17 years for the traumatic cataracts. The mean follow-up time is 15 ± 5 months. Postoperative anatomical results were good, and no complications due to the lens have so far been observed. Functional results are satisfactory: final visual acuity ranges from 3/60 to 6/6, and is better for the traumatic and developmental group than for the patients with congenital cataract. The correction of aphakia in children with monocular congenital, developmental or traumatic cataract by means of an IOGEL intraocular lens might be an alternative to other corrective means.

Spermatic vein ligation in varicocele: prognosis and associated male and female infertility factors

The fertility outcome of 129 spermatic vein ligations with good postoperative anatomic results is analyzed. For each couple, specific attention was also directed to other infertility factors. The study analyzes four groups: group I, 55 patients with varicocele only; group II, 16 patients with varicocele and prostatovesiculitis; group III, 16 patients with varicocele and a severe degree of testicular failure; and group IV, 42 patients with a varicocele only and associated female infertility factors. In each group, the pregnancy rate within 6 to 24 months after the operation was recorded. The control subjects were 36 patients with varicocele only who had declined or postponed intervention for 6 months. The best results were obtained in group I. Sperm motility improved following ligation and was associated with a greater percentage of pregnancies within a shorter period: 51% and 62% within 6 and 12 months, respectively, as compared with the control group (14% within 6 months). The prostatic disease required additional treatment for a longer period, but results similar to those of group I were eventually obtained (50% pregnancy rate). With testicular failure or female infertility factors, the prognosis worsened (31% overall pregnancy rate).