Repeat Vitrectomy Research Articles

Macular fold after limited macular translocation treated with scleral shortening release and intravitreal gas

PURPOSE: To describe a case developing a macular fold as a complication of limited macular translocation, which was successfully managed without repeat vitrectomy. METHODS: Interventional case report. A 34-year-old woman who underwent limited macular translocation for subfoveal choroidal neovascularization secondary to myopic degeneration developed a postoperative macular fold. Her visual acuity deteriorated from 20/100 to 20/200 postoperatively. RESULTS: She underwent scleral shortening release and intravitreal gas injection 4 days after the initial surgery and had a resolution of macular fold with adequate foveal displacement. Her visual acuity had improved to 20/40 3 months postoperatively. CONCLUSION: Scleral shortening release and intravitreal gas injection may be considered for the management of severe macular fold caused by limited macular translocation.

Traumatic endophthalmitis in children

Objective Analyze the clinical features of 31 cases of traumatic endophthalmitis in children.Methods The traumatic causes,etiologic agents,age,the duration of trauma,clinical manifestations and the final results of treatment were investigated respectively.Results Nearly 65.6% cases were caused by disposable syrnge needles.The eyes with long duration of trauma and severely impaired visual function when they diagnosed could not be even having been operated immediately.Conclusion The prophylaxis of endophthalmitis should be stressed in children with eye trauma.In time diagnosis and treatment were the key points of rescue functional vision.

Ciliary body melanoma masquerading as chronic uveitis

PURPOSE: To report a case of ciliary body melanoma that masqueraded as chronic uveitis. METHODS: A patient experienced persistent unilateral panuveitis and elevated intraocular pressure. Inflammation and pressure worsened after cataract extraction and lens implantation. Diagnostic vitrectomy was non-revealing. RESULTS: Repeat vitrectomy and lens implant removal revealed a ciliary body mass, suggestive of melanoma. Ultrasonography and clinical evaluation by the retinal oncologists supported this diagnosis. The uveitis persisted despite aggressive medical treatments, including methotrexate. Proton beam irradiation of the melanoma led to resolution of uveitis and restoration of normal intraocular pressure. CONCLUSIONS: Ciliary body melanoma can present as chronic uveitis and refractory glaucoma.

Outpatient Postoperative Fluid—Gas Exchange after Early Failed Vitrectomy Surgery for Macular Hole

Vitrectomy surgery with fluid-gas exchange and prone positioning has been shown to close macular holes and improve vision. In those eyes that have failed surgery, repeat vitrectomy has been advocated. As an alternative, the authors performed an outpatient postoperative fluid-gas exchange on eyes when the macular hole failed to close after vitrectomy surgery. The authors reviewed all cases of failed vitrectomy surgery for macular holes that underwent a postoperative fluid-gas exchange. Eyes were considered to have failed initial surgery if a rim of subretinal fluid surrounded an open full-thickness macular hole. Twenty-three consecutive eyes underwent outpatient fluid-gas exchange 1 week to 8 weeks after vitrectomy surgery. In 17 eyes (74%), fluid-gas exchange resulted in flattening and closure of the macular hole. In all 17 eyes, visual acuity improved 2 or more lines, with 8 (35%) of the 23 eyes achieving 20/50 or better visual acuity. Postoperative fluid-gas exchange may achieve successful closure of macular holes and improve vision in eyes that have failed surgery for full-thickness macular holes and should be considered as a cost-effective alternative to repeat vitrectomy.

Laser Photocoagulation Repair of Macula-sparing Cytomegalovirus-related Retinal Detachment

The purpose of the study is to investigate the role of laser photocoagulation in the treatment of macula-sparing cytomegalovirus (CMV)-related retinal detachment (CMVRD) in patients with acquired immune deficiency syndrome (AIDS). Seven macula-sparing CMVRD identified between July 1995 and February 1997 were managed with laser photocoagulation and observed prospectively (group I). Seven CMVRD reattached with pars plana vitrectomy (PPV) and silicone oil injection (group II) between January 1992 and June 1996 were analyzed retrospectively. Patients with AIDS with macula-sparing rhegmatogenous CMVRD with no proliferative vitreoretinopathy and visual acuity better than 20/30 were studied. Demarcation laser photocoagulation (group I) or PPV with silicone oil injection (group II) was performed. Postoperative best-corrected visual acuity (BCVA), temporary or permanent visual loss, CMVRD progression or recurrence, and cataract were measured. Follow-up ranged from 2 to 19 months (mean, 9 months) in group I. Post-treatment BCVA was unchanged in all eyes after laser. One retina redetached 9 months after laser treatment. Final visual acuity was less than 20/40 in one eye because of progressive CMV retinitis. Follow-up ranged from 2 to 24 months (mean, 10.4 months) in group II. All group II RDs were reattached successfully with PPV and silicone oil injection. Best-corrected visual acuity was an average of 1.6 lines worse after vitrectomy. Silicone-induced hyperopic shift caused temporary visual loss in all eyes (mean duration, 5.6 weeks). Delayed visual loss due to cataract formation occurred in five eyes. Three eyes had cataract extraction within 6 months. Two partial redetachments developed. One was repaired with repeat vitrectomy. Final visual acuity was less than 20/40 in five of seven eyes because of progressive CMV retinitis (1), dense cataract (2), uncorrected refractive error (2), and uncertain cause (1). Demarcation laser photocoagulation appears to be an effective treatment for many macula-sparing CMVRD. Loss of BCVA, temporary postoperative visual loss due to silicone-induced refractive error, and delayed visual loss due to cataract after vitrectomy with silicone oil injection may be avoided. Demarcation laser photocoagulation may be an effective alternative to vitrectomy in macula-sparing CMVRD.

Reoperation after failed macular hole surgery.

The authors determined the anatomic and visual success rates of vitrectomy in patients who have failed previous macular hole surgery. Standardized Early Treatment Diabetic Retinopathy Study (ETDRS)-style best-corrected visual acuity was measured in each patient pre- and postoperatively. Surgery was performed at two centers using a standardized protocol, as previously reported, using 1330 ng bovine-derived transforming growth factor-beta 2 (TGF-beta 2) and 16% perfluoropropane internal gas tamponade. Endpoint analyses were conducted for anatomic closure of the hole, visual improvement of three or more ETDRS lines, and final visual acuity of > or = 20/63 and > or = 20/40. Forty-eight failing macular hole surgery were reoperated. The anatomic results showed closure of the hole in 40 (83%) cases at the end of the mean follow-up interval of 7.4 months. The visual acuity improved in greater than or equal to three lines in 52%, was > or = 20/63 in 54%, and was > or = 20/40 in 25% of reoperated eyes. The only factor associated with a better final visual acuity was preoperative visual acuity better than 20/80. Nuclear sclerosis leading to cataract extraction was observed in 13 (30%) of 43 initially phakic eyes. Macular hole closure was induced in this subset of reoperated patients. Visual improvement occurred often, although in a lower percentage than has been reported for primary surgical eyes. Repeat vitrectomy should be considered in patients with persistent macular hole after failure of primary surgery.

Vitrectomy, Fluid—Gas Exchange and Transforming Growth Factor—Beta-2 for the Treatment of Traumatic Macular Holes

Purpose: To evaluate whether vitreous surgery is successful in closing full-thickness traumatic macular holes and whether there is subsequent improvement in visual acuity.Methods: Twelve eyes from 12 consecutive patients with traumatic macular holes underwent vitrectomy, fluid-gas exchange and instillation of bovine or recombinant transforming growth factor (TGF)-beta-2. Three of four eyes underwent repeat vitrectomy with TGF-beta-2 after the initial procedure failed to close the macular hole.Results: Eleven (92%) of 12 eyes had closure of the macular hole. Follow-up ranged from 3 to 33 months. Visual acuity improved by 2 or more lines in 8 (67%) of 12 eyes. Six (50%) of 12 eyes improved to 20/40 or better. All 3 eyes that underwent reoperation had successful closure of the macular hole and achieved 2 or more lines of visual improvement.Conclusion: Treatment of full-thickness traumatic macular holes with vitrectomy, fluid-gas exchange, and TGF-beta-2 may result in successful anatomic closure and visual improvement.

Silicone oil in vitreoretinal surgery.

Silicone oil has been in use as a vitreoretinal surgical adjunct for more than 30 years. The literature from late 1993 through 1994 is dominated by reports from the Silicone Study, which addresses outcome differences after primary versus repeat vitrectomy, combined retinotomy and retinectomy, and silicone oil removal, as well as the problem of postoperative intraocular pressure abnormalities. Contemporary retrospective series reporting on the use of silicone oil for pediatric, cytomegalovirus retinitis-related, and diabetic retinal detachments are also reviewed.

Late Re-opening of Macular Holes after Initially Successful Treatment with Vitreous Surgery

In more than 50% of eyes with idiopathic, full-thickness macular holes, vitrectomy results in clinical closure of the hole and improvement in visual acuity. Other than cataract formation, late complications of the procedure have not been reported. Over a 4-year period, 167 eyes underwent successful vitreous surgery for idiopathic macular holes documented by clinical closure of the hole and an improvement in visual acuity of at least two Snellen lines. The authors retrospectively studied eight of these eyes. All initially had successful surgery; however, they subsequently had spontaneous late re-opening of the macular hole with acute diminution in vision. Late re-opening developed in these eyes between 2 and 22 months after initial surgery. The mean time for re-opening was 12.5 months. Three of eight eyes underwent a second vitrectomy, which was successful in improving visual acuity in two eyes. Another patient manifested the growth of an epiretinal membrane that apparently sealed the re-opened macular hole and improved vision. Late re-opening can complicate initially successful macular hole surgery and may occur in at least 4.8% (8 of 167) of initially successful operations. Re-opening has been documented as late as 22 months after initial surgery. Repeat vitrectomy with gas injection may result in reclosure of the hole and improvement in vision.

A Modified En Bloc Excision Technique during Vitrectomy for Diabetic Traction Retinal Detachment: Results and Complications

The visual results and complications were determined for a modified en bloc excision technique for management of diabetic traction macular detachment. A consecutive series of 30 eyes with this condition underwent pars plana vitrectomy, during which all posterior hyaloid except for portions essential for membrane dissection were excised. Bimanual dissection techniques then allowed excision of fibrovascular membranes "en bloc" with the retained hyaloid. After 6 to 44 months of follow-up, visual acuity of 5/200 or better was obtained in 23 (77%) of 30 eyes, with complete reattachment in 29 (97%) of 30 eyes. Iatrogenic retinal breaks occurred in 6 (20%) of 30 eyes. Two eyes required repeat vitrectomy. The modified en bloc excision technique allowed similar visual outcome, a higher reattachment rate, and less postoperative morbidity than previously reported surgical approaches to diabetic traction macular detachment.

Intraocular Lymphoma: Clinical and Histopathologic Diagnosis

Intraocular lymphoma is associated with significant morbidity and mortality, but early diagnosis and treatment may improve prognosis. The diagnostic features of 12 cases of intraocular lymphoma diagnosed at the National Eye Institute between 1984 and 1992 were retrospectively reviewed. A pathologic diagnosis of large B-cell lymphoma was made on vitrectomy specimens in ten patients, cerebral spinal fluid in one, and on an enucleation specimen in one. The mean time from onset of symptoms to diagnosis was 21.4 months (range, 1-66 months). All 12 patients were given a final diagnosis of non-Hodgkin's lymphoma of the central nervous system (NHL-CNS), based on the epidemiology, pathology, and clinical course of their tumors. Although an initial vitrectomy was negative for malignant cells in three of ten patients, a repeat vitrectomy specimen subsequently showed intraocular lymphoma. Results of examination of the cerebrospinal fluid (CSF) showed malignant cells in 5 of 11 patients, although malignant cells were only identified after repeat examination of additional samples of CSF in three of these patients. Malignant cells often are difficult to identify, and an experienced cytopathologist was critical in making the correct diagnosis. In addition, corticosteroids are lympholytic to the lymphoma cells, and they appeared to decrease the viability of tumor cells obtained in samples of vitreous and CSF. The prompt, appropriate handling of specimens and review by an experienced cytopathologist are critical to the diagnosis of intraocular lymphoma. Malignant cells often are present in the cerebral spinal fluid at the time that ocular lymphoma is diagnosed. Nevertheless, multiple vitrectomies and lumbar punctures may be necessary before the correct diagnosis is made.

Efficacy of Fluid-Air Exchange for Postvitrectomy Diabetic Vitreous Hemorrhage

We reviewed the records of 33 fluid-air exchanges to assess the efficacy of fluid-air exchange in the management of recurrent vitreous cavity hemorrhage after vitrectomy for proliferative diabetic retinopathy. Fluid-air exchange alone was successful in clearing the vitreous cavity in ten of 20 eyes after a mean of 1.5 exchanges per eye. Repeat vitrectomy was required in the remaining ten eyes and anterior hyaloidal fibrovascular proliferation was frequently found. Hemorrhages that occurred in the late postoperative period (more than nine months) appeared more likely to be successfully treated with fluid-air exchange alone. Failure of the initial fluid-air exchange to induce clearing immediately after the procedure appeared to be associated with subsequent exchange failures and need for surgical intervention. Complications from the exchange procedure were infrequent with the development of peripheral retinal detachment in one eye. Our current recommendation for nonclearing recurrent postvitrectomy diabetic vitreous hemorrhage is to perform a fluid-air exchange, provided no other high-risk characteristics are present. If clearing occurs in the immediate postexchange period but rebleeding occurs at a later period, we recommend a second fluid-air exchange. If clearing does not occur in the immediate postexchange period, we recommend proceeding directly to revision of vitrectomy.

Management of Giant Retinal Tears without Scleral Buckling: Use of Radical Dissection of the Vitreous Base and Perfluoro-octane and Intraocular Tamponade

The introduction of intraoperative perfluorocarbon liquids in the management of giant retinal tears has allowed exact anatomic reapposition of the retina and the giant retinal tear. Therefore, the authors managed 11 eyes with giant retinal tears and no proliferative vitreoretinopathy without scleral buckling. Maximum removal of the basal vitreous gel was performed in all cases, and perfluoro-octane was used intraoperatively to unfold the inverted posterior flap and reattach the retina completely. Endophotocoagulation was applied to the edges of the tear and perfluoropropane or silicone oil was used as an intraocular tamponade. Although 1 eye required reoperation for a redetachment from posterior proliferative vitreoretinopathy, all retinas were reattached with final visual acuity of 5/200 or better in 9 eyes. Eight additional major procedures were necessary in seven eyes: removal of silicone oil in four (with removal of perisilicone proliferation in three), repeat vitrectomy and membrane removal with photocoagulation twice in one eye, cataract extraction in one eye, and removal of a macular pucker in one eye. Four eyes required postoperative fluid-gas exchange and three eyes had tissue plasminogen activator injections into the anterior chamber for postoperative fibrin reactions.

Variation of perfluoropropane disappearance after vitrectomy.

In complex cases of retinal detachment, perfluoropropane (C3F8) is frequently used after vitrectomy for tamponade of retinal breaks. Results of previous studies of C3F8 disappearance using 10% C3F8 after vitrectomy in human eyes have differed significantly. A wide variation in the decay rate and half life of C3F8 after vitrectomy was observed in eyes that had similar clinical settings and received the same C3F8 concentration (15%, 20%, or 25%). This occurred even in those eyes where there was no change in the geometric contour of the eye after a repeat vitrectomy.

OUTPATIENT FLUID-AIR EXCHANGE FOR SEVERE POSTVITRECTOMY DIABETIC VITREOUS HEMORRHAGE

An alternative treatment to repeat vitrectomy in postvitrectomy diabetic vitreous hemorrhage (PDVH) is outpatient fluid-air exchange, but the long-term visual results of this procedure are not known. Between January 1986 and April 1989, a pars plana air-pump technique was used to perform outpatient fluid-air exchange in 20 eyes of 17 patients (17 phakic eyes) within 8 weeks of onset of PDVH. A mean follow-up interval of 78 weeks was obtained. Preoperative vitreous hemorrhage was severe enough to obscure all fundus detail (17 eyes) or produce erythroclastic glaucoma (three eyes). Initial visual acuity was hand motions or light perception in 19 eyes and improved to a median visual acuity of 20/300 soon after resolution of the intraocular air bubble. Early complications included postoperative fibrin formation (one eye) and early postoperative intraocular pressure elevation (two eyes). Recurrent vitreous hemorrhage required repeated fluid-air exchanges in seven eyes. Long-term complications included worsening of posterior subcapsular cataract (10 of 17 phakic eyes, 59%), for which cataract extraction was required in five eyes (29%). Fluid-air exchange appeared to exacerbate cataract formation, justifying a period of observation for PDVH. However, it appeared to be a low-risk alternative to repeat vitrectomy, allowing rapid visual recovery from severe PDVH.