Successful Surgical Reattachment Research Articles

Cellular remodelling of the inner retina and the retinal ganglion cells in experimental retinal detachment

AbstractPurpose: Anatomical surgical outcomes for the treatment of retinal detachment (RD) are outstanding; however, only 50% of the patients with a detached macula regain 5/10 or better vision. Thus, to preserve or restore visual function in RD, several gaps in our understanding of the pathophysiology of the disease need to be bridged. Therefore, the purpose of the current study, was to investigate the anatomical/morphological changes of retinal interneurons and retinal ganglion cells (RGCs) in an experimental model of RD.Methods: Experimental RD was induced in C57BL6/J mice by a subretinal injection of 1% sodium hyaluronate. Following RD, mice were euthanized at 1‐, 3‐, 7‐, 30‐ and 90‐days post‐surgery and eyes or retinas were isolated and proceed for sectioning or retinal whole mounts respectively. Immunofluorescence and electron microscopy studies were performed against protein kinase C alpha (PKC‐α) to target rod bipolar cells, calretinin and calbindin D to target horizontal cells and brain‐specific homeobox/POU domain protein 3A (Brn3a) and neuron‐specific class III beta‐tubulin (β‐tubulin III) to target RGCs.Results: Three days post‐RD, PKC‐α+ neurons (rod bipolar cells) began to migrate towards the outer nuclear layer (ONL), while 30 days post‐RD they had significantly migrated towards the ONL and displayed irregular distribution of their cell bodies in the inner nuclear layer. Similarly, processes of horizontal cells also migrated towards the ONL, 7 days post‐RD and became more invasive and disoriented after longer‐term detachment (30 days post‐surgery). Moreover, there was a significant increase in the intensity of calbindin D, 30‐days post‐RD. Brn3a/β‐tubulin ΙΙΙ+ RGCs were significantly fewer 30‐ and 90‐days post RD. All retinal neurons that were examined, did not show any noteworthy differences 1 day post RD.Conclusions: RD resulted in significant anatomical changes in both rod bipolar and horizontal neurons of the retina along with a notable reduction of RGCs. The cellular response of the inner retina and the RGCs of the detached retina might play an important role in the imperfect visual score of an anatomical successful surgical reattachment.

Loss of retinal tension and permanent decrease in retinal function: a new porcine model of rhegmatogenous retinal detachment.

PurposePermanent loss of visual function after rhegmatogenous retinal detachment can occur despite successful surgical reattachment in humans. New treatment modalities could be explored in a detachment model with loss of retinal function. In previous porcine models, retinal function has returned after reattachment, regardless of height and duration of detachment. Difference in retinal tension between the models and the disease might explain these different outcomes. This study investigates, for the first time in an in vivo porcine model, another characteristic of rhegmatogenous retinal detachment – the loss of retinal tension.MethodsLeft eyes (n = 12) of 3‐month‐old domestic pigs were included. Baseline multifocal electroretinogram (mfERG) and a fundus photograph were obtained following anaesthesia (isoflurane). The pigs were vitrectomized, saline was injected subretinally, and the RPE was removed. The eyes were evaluated at 2, 4 and 6 weeks after surgery. Four eyes were enucleated at each evaluation for histologic examinations.ResultsA retinal detachment structurally resembling rhegmatogenous retinal detachment was induced in 11 out of 12 pigs. MfERG amplitudes were significantly decreased despite partial reattachment four and 6 weeks after detachment. The retinal thickness decreased with 27%, the inner nuclear layer degenerated, Müller cells hypertrophied, and outer segments were lost. In the ganglion cell layer, cellularity increased and there was cytoplasmic staining with Cyclin D1. Vimentin and GFAP staining for glial cells increased. After 2 weeks of detachment, the ganglion cells had lost their nucleus and nucleolus.ConclusionsLoss of retinal tension in the detached retina seems to induce permanent damage with loss of retinal function. Death of ganglion cells, observed as soon as 2 weeks after detachment, explains the permanent loss of retinal function. The new model enables investigations of time‐relationship between retinal detachment and lasting damage in addition to exploration of novel treatment modalities.

Acute Retinal Necrosis Secondary to Varicella Zoster Virus in an Immunosuppressed Post-Kidney Transplant Patient

A woman, aged 42 years, presented to the ophthalmologist complaining of right eye redness, tearing, photosensitivity, and blurred vision of a 1-month duration. Her past medical history was significant for a kidney transplant for which she was immunosuppressed with mycophenolate mofetil 750 mg twice a day and prednisone 10 mg daily. Ophthalmologic examination of the right eye revealed visual acuity of 20/60, intraocular pressure of 16 mmHg, scleral injection, and a significant inflammatory reaction in the anterior chamber. Funduscopy revealed vitreous haze, optic nerve edema, arteriolar sheathing and attenuation, and peripheral 360° of retinal whitening – a clinical picture consistent with retinitis (figure 1). The left eye examination was entirely normal. Figure 1 (A) Examination of the fundus on day of presentation shows peripheral whitening and vasculitis as evidenced by optic nerve edema, vitreous haze, and retinal arteriolar narrowing. The decrease in clarity of the photograph is secondary to the vitreous haze, ... The differential diagnosis for retinitis in an immunocompromised host includes acute retinal necrosis (ARN), progressive outer retinal necrosis, cytomegalovirus (CMV) retinitis, and toxoplasmosis. Less common causes of acute retinitis include syphilis,1 Bechet's disease, and lymphoma. Aqueous fluid obtained from the anterior chamber was sent for polymerase chain reaction (PCR) viral DNA analysis, and the patient was treated with 2 mg of ganciclovir injected intravitreally on the day of presentation. A 2-week course of renal-dose adjusted intravenous (IV) acyclovir was started with subsequent regression of the retinal whitening (figure 2). Varicella zoster virus (VZV) infection with a viral load of 6.5 × 107 IU was later confirmed with PCR of the aqueous fluid. The vision initially improved to 20/40 in the right eye. She was transitioned from IV acyclovir to oral valacyclovir. Figure 2 (A) After treatment with anti-viral medication, there is regression of retinal whitening and atrophic retinal tissue. (B) Areas of regression are indicated by white asterisks. The arterioles that previously were narrowed, indicated by the white arrows, ... Seven weeks later, the patient developed a rhegmatogenous retinal detachment that was diagnosed after she complained of an abrupt decrease in vision. Despite successful surgical reattachment of the retina with pars plana vitrectomy, scleral buckle, and silicon oil, the patient's vision remained at light perception level only. Necrotizing herpetic retinopathies are caused by VZV, herpes simplex virus 1 and 2, CMV, and rarely, Epstein Barr virus. A spectrum of clinical presentations may occur depending on the virus and the host's immunity.2 Immunosuppressed patients are at risk for development of necrotizing retinopathies typically associated with immunocompromised states, such as CMV retinitis and progressive outer retinal necrosis. They may also develop syndromes that are typically seen in immunocompetent hosts, such as ARN. Acute unilateral decrease in vision, photophobia, and eye pain are the usual presentations of ARN.3 The key feature seen on examination is white-yellow, multifocal, peripheral patches that later coalesce into diffuse areas of full-thickness, peripheral retinal necrosis.4 Other signs of ocular inflammation including vitritis, vasculitis, optic disc edema, keratic precipitates, and posterior synechiae may also be seen. Untreated ARN results in blindness from retinal scarring, retinal detachment, or optic atrophy; therefore, ARN is an ophthalmic emergency. One-third of patients develop the disease in the fellow eye within one month of presentation, if left untreated.5 The diagnosis of ARN is made on the basis of clinical appearance, and antiviral treatment should be initiated promptly. Timely referral to a uveitis or retina specialist experienced in the care of such patients and collaboration with an infectious disease specialist are essential.

Proximal hamstring avulsion in a professional soccer player

Acute hamstring strains are a common athletic injury, which may be treated non-operatively with a satisfactory outcome. A complete proximal hamstring avulsion is a rare and potentially career ending injury to an elite athlete. For these high demand patients, surgical reattachment should be immediately undertaken to shorten return to sport and to improve functional outcome. This report describes the occurrence of a complete avulsion of the proximal hamstrings in a professional footballer during an international match. We highlight the clinical presentation, the appropriate diagnostic investigations, the surgical technique and the rehabilitation protocol for this injury. The successful surgical reattachment of the common hamstring tendon was confirmed by magnetic resonance imaging done 5 months after repair and allowed the player a full return to competition at 6 months after surgery. Hamstrings isokinetic peak torque was 80% at 6 months and 106% at 11 months after repair comparing with the uninjured side.

An Analysis of Metamorphopsia Using Preferential Hyperacuity Perimeter Following Macular-off RRD Surgical Repair

Purpose: To determine the efficacy of using the preferential hyperacuity perimeter (PHP) for the analysis of metamorphopsia following macular-off rhegmatogenous retinal detachment (RRD) surgical repair. Methods: PHP examination was performed in those who complained of metamorphopsia after successful surgical reattachment of RRD. The subjective symptoms were evaluated based on a scale, ranging from 0 to 10, and were compared with the results of PHP examination. Patients age, duration of retinal detachment, pre and post-operative visual acuity, postoperative presence of subretinal fluid (SRF), surgical methods, presence of epiretinal membrane, and time from operation to PHP test were analyzed to find the correlation with the PHP results. Results: Of the 19 eyes included in this study, nine eyes were found to have a hyperacuity defect upon PHP examination. In this group, the subjective level of metamorphopsia was significantly worse (p

Endothelial Keratoplasty: Case Selection in the Learning Curve

Many corneal surgeons are making the transition from penetrating keratoplasty to endothelial keratoplasty techniques such as Descemet's stripping endothelial keratoplasty and Descemet's stripping automated endothelial keratoplasty in the routine treatment of corneal endothelial failure. Donor dislocation is the commonest complication of these newer techniques. We set out to determine whether preoperative lens/iris diaphragm integrity might influence the rate of donor dislocation and whether donor endothelial failure was more common after surgical intervention for donor dislocation. A retrospective multisurgeon comparative case series from a large teaching and referral center. Ninety-three eyes of 85 patients: consecutive cases of Descemet's stripping endothelial keratoplasty (n = 77) or Descemet's stripping automated endothelial keratoplasty (n = 16) performed between March 2004 and January 2007. A retrospective review of case notes. The number of eyes with an open communication between the anterior and posterior chambers (an iridectomy or lens capsular defect not covered by a posterior chamber intraocular lens), the number of eyes requiring surgical intervention to correct donor dislocation, and the number of eyes with donor endothelial failure within the follow-up period. Complete data sets were available for analysis in 89 eyes. The median follow-up interval at the time of the audit was 7 months (range 1-34 months). Donor dislocation was significantly more common (P = 0.017) in eyes with an open communication between the anterior and posterior chambers, occurring in 11 of 25 cases (44%) versus 12 of 64 cases (19%) with an intact iris/lens diaphragm. Early endothelial failure was significantly more common (P = 0.011) in cases requiring additional surgical intervention for donor dislocation, occurring in 6 of 21 cases (29%) after successful surgical reattachment of a dislocated donor disc versus 4 of 67 cases (6%) in which no additional intervention was required. Donor dislocation after endothelial keratoplasty is more common in cases with an open communication between the anterior and posterior chambers. The risk of donor endothelial failure is increased in cases of donor dislocation. Trainee surgeons and surgeons in making the transition from penetrating keratoplasty should initially select cases with an intact lens/iris diaphragm.

Horizontal and vertical micropsia following macula-off rhegmatogenous retinal-detachment surgical repair

Dysmetropsia or distorted image size perception (smaller: micropsia; larger: macropsia) is known to occur after successful surgical re-attachment for macula-off rhegmatogenous retinal detachment. However, the vertical and horizontal components of size distortion have not been previously quantified separately. The purpose of this article is to describe horizontal and vertical dysmetropsia occurring in patients following pars plana vitrectomy and gas treatment (octafluoropropane, C(3)F(8) or sulfur hexafluoride, SF(6)) for macula-off rhegmatogenous retinal detachment. Four patients (mean+/-SD, 59+/-8 years; three women and one man) who had had pars plana vitrectomy and gas treatment for macula-off rhegmatogenous retinal detachment 6-7 months earlier underwent ocular examination, best corrected visual acuity test, threshold horizontal and vertical dysmetropsia measurement using a computerised version of the New Aniseikonia Test, slit-lamp examination and optical coherence tomography of the macula. All patients had binocular visual complaints including difficulty judging distances or reading, rivalry or asthenopia. The logMAR visual acuity (mean+/-SD) in the operated eye was 0.52+/-0.199 and 0.02+/-0.171 in the unaffected eye. All patients perceived the image as smaller (micropsia) with the affected eye, with differences ranging from -9 to 0%. Four patients showed 3% or more size difference between horizontal and vertical meridians. Dysmetropsia does occur in symptomatic patients following successful surgical repair of macula-off rhegmatogenous retinal detachment by pars plana vitrectomy and gas treatment. The effect on image size is heterogenous across the retinal area affected.

Implications of the natural course of retinopathy of prematurity.

Retinopathy of prematurity (ROP) is a derangement of vascular development in the premature infant retina. A tangled network of neovascular channels supplants the orderly arborization that would otherwise continue until the entire retina was supplied with a normal vascular tree. Unchecked neovascularization can lead to local scarring, contracture, and detachment of the retina, with or without intraocular hemorrhage. Extensive retinal detachment in premature infants typically causes severe visual impairment, even with successful surgical reattachment of the retina. Surgical intervention (typically at ∼32–42 postmenstrual weeks) by ablation of the more peripheral unvascularized part of the retina with laser therapy has become the preferred treatment modality in the United States and many other … Reprint requests to (E.A.P.) Casey Eye Institute, Oregon Health & Science University, 3375 SW Terwilliger Blvd, Portland, OR 97239-4197. E-mail: palmere{at}ohsu.edu

Ocular manifestations of genetic and developmental diseases.

Significant advances were reported this year in our understanding of the association of lens opacities with neurofibromatosis type 2 and the genetics of the aniridia-Wilms' tumor association. The first successful surgical reattachment of detached retinas in patients with incontinentia pigmenti are reported. An important retrospective review of young adults with congenital rubella syndrome implies that the timing of infection during gestation is not related to the incidence of individual ocular conditions. The ophthalmic features of the MELAS syndrome, a mitochondrially inherited encephalomyopathy, are described. Cytogenetic techniques are utilized for the first time to investigate the association between conjunctival and uveal melanomas with the dysplastic nevus syndrome. Familial Duane's syndrome and urogenital abnormalities were associated with a bisatellited marker derived from chromosome 22. Finally, another case of the newly described association of microphthalmia, dermal aplasia, and sclerocornea (MIDAS syndrome) is reported.

Management of retinal detachment associated with CMV retinitis in AIDS patients.

In patients with AIDS, the most important ocular opportunistic infection, CMV retinitis, can now be treated effectively with virostatic agents. Associated retinal detachment is encountered frequently, and its management has become increasingly significant to quality of life as improvements in medical care have helped to preserve vision and extend life expectancy. Although retinal detachment in these eyes is typically rhegmatogenous, the pathophysiology is distinctive due to the association with CMV retinitis which, even in remission, is characterised by atrophic changes at all levels of affected retina and alterations of the vitreous. Despite initially successful surgical reattachment, multiple, small, often posterior holes may develop because of progressive CMV infection. For these reasons, vitrectomy and silicone oil injection with scleral buckling may currently provide the best overall means of maintaining retinal reattachment and restoring visual function. Nevertheless, management must be individualised in each case, with the realisation that progressive visual loss frequently ensues from retinitis progression.

REGRESSION OF DIABETIC RUBEOSIS IRIDIS FOLLOWING SUCCESSFUL SURGICAL REATTACHMENT OF THE RETINA BY VITRECTOMY

The relationship between successful surgical reattachment of the retina following diabetic vitrectomy and regression of preoperative rubeosis iridis was investigated. Seventy-nine (9.2%) of 850 diabetic cases undergoing vitrectomy had both preoperative iris rubeosis and retinal detachment. The iris could be adequately evaluated and the retina could be visualized after surgery in 36 cases. Regression of the rubeosis iridis occurred after surgery in 16 (76%) of 21 eyes in which the retina was reattached successfully. Only four (27%) of 15 eyes had regression of rubeosis iridis when the retina was not reattached completely. Retention of the lens also correlated with regression of rubeosis iridis. Regression occurred in 10 (55%) of 18 cases in which the lens was not removed, 13 (28.2%) of 46 eyes in which lensectomy was combined with vitrectomy, and none of eight previously aphakic eyes. Although the combination of preoperative retinal detachment and rubeosis iridis is associated with a worsened prognosis, successful reattachment of the retina and retention of the lens favorably influence later regression of preoperative rubeosis iridis.

Ultrasound in retinal detachment. A preliminary report.

This preliminary report indicates that ultrasound can retrodisplace retinal tissue in certain cases of retinal detachment. Best movement of retinal detachment occurred in those cases exhibiting retinal holes (rhegmatogenous detachments). A 1 megahertz transducer was used. The ultrasonic energy was pulsed. Quantitative measurements of ultrasonic energy delivered from the transducer gave results of 1.95 watts/ sq cm employing a calorimeter. After histopathologic evaluation of 100 rabbit eyes showed no adverse effects on ocular tissue, the transducer was used to treat human retinal detachments. Results indicate that ultrasound may prove to be a prognostic test for successful surgical reattachment of detached retinae. Ultrasound may also prove useful in treating giant retinal breaks, external dissolution of vitreoretinal adhesions, and positioning air bubbles placed within the vitreous cavity.