Sulfur Hexafluoride Gas Tamponade Research Articles

Dexamethasone Intravitreal Implant to Treat Persistent Full-Thickness Macular Hole.

Purpose: To describe a new technique for the secondary repair of persistent full-thickness macular holes (FTMHs). Methods: This series evaluated 3 cases of a persistent FTMH after pars plana vitrectomy, internal limiting membrane peeling, and 20% sulfur hexafluoride gas tamponade. After at least 4 weeks (mean, 36.3; range, 32-40) of unsuccessful topical treatment with nonsteroidal anti-inflammatory drugs, an intravitreal dexamethasone implant was injected. Results: The intravitreal dexamethasone implant led to anatomic closure and visual improvement in all 3 cases over a 3-month follow-up. Conclusions: An intravitreal dexamethasone implant could be considered in the management of selected cases of persistent FTMH. Further studies and a consistent number of cases are needed to fully understand the role of intravitreal dexamethasone implants in persistent FTMHs.

Conjunctival Pigmentation Following Pars Plana Vitrectomy (PPV) for Rhegmatogenous Retinal Detachment: Risk Factors and Outcomes.

To investigate the incidence and the risk factors for conjunctival pigmentation at the sclerotomy sites following valved and non-valved cannula pars plana vitrectomy (PPV) performed by different surgical techniques. This is a prospective observational study which included 70 eyes of 70 patients who underwent PPV for rhegmatogenous retinal detachment with follow-up visits at 1, 3, 6, 12, and 24 months. Twenty-eight eyes were operated using 25G non-valved cannulas (Group A), 22 eyes using 25G non-valved cannulas (Group B), and 20 eyes using 25G valved cannulas (Group C). The evaluated clinical parameters include the surgical technique, the patients' age, the number of retinal tears, the tamponade agent, the presence of residual sub-retinal fluid (SRF), and the duration of postoperative posturing. Group A was associated with significant conjunctival pigmentation at up to 6 months after PPV. Sulfur hexafluoride (SF6) gas tamponade was associated with less conjunctival pigmentation at 3 months follow-up visit [odds ratio, OR 0.09 (95% confidence interval, CI 0.01; 0.67)], whereas the presence of residual SRF was a significant risk factor for postoperative pigmentation at 1-year follow-up visit [OR 5.89 (95% CI 1.84; 23.12)]. The area of measured pigmentation was also positively correlated to the number of retinal tears at all follow-up visits over 2 years. Six patients presented with conjunctival pigmentation at 2 years follow-up visit. New vitrectomy techniques with valved cannulas prevent the postoperative appearance of conjunctival pigmentation. The number of retinal tears, the presence of SRF, and the use of long-standing tamponade agents were the most significant predisposing factors. The post-vitrectomy conjunctival pigmentation gradually reduces over time.

AIR VERSUS SULFUR HEXAFLUORIDE GAS TAMPONADE IN VITRECTOMY FOR UNCOMPLICATED RETINAL DETACHMENT WITH INFERIOR BREAKS

To compare surgical outcomes of filtered air and sulfur hexafluoride (SF6) as an internal tamponade in patients undergoing primary 25-gauge pars plana vitrectomy for uncomplicated rhegmatogenous retinal detachment with inferior breaks. Patients with uncomplicated rhegmatogenous retinal detachment associated with inferior breaks (between 4 and 8 o'clock positions) who were undergoing primary pars plana vitrectomy were enrolled. All eyes underwent pars plana vitrectomy and complete drainage of subretinal fluid, followed by filtered air or 20% SF6 tamponade. The main outcome measures included single-surgery anatomical success rates and final visual recovery. Overall, 116 eyes of 116 patients (81 men and 35 women with a mean age of 55.2 years) were assessed. Air was used in 52 eyes (air group) and gas in 64 eyes (gas group). Single-surgery anatomical success was achieved in 50 (96.2%) and 60 (93.8%) eyes in the air and gas groups, respectively (P = 0.69), and final anatomical success was achieved in all eyes. The mean final Snellen visual acuity was similar in the air (20/23) and gas groups (20/21; P = 0.13). No significant differences were observed in single-surgery anatomical success rates and final visual recovery when comparing air with SF6 gas tamponade in pars plana vitrectomy for primary uncomplicated rhegmatogenous retinal detachment with inferior breaks.

Air versus Sulfur Hexafluoride Gas Tamponade for Small and Medium-Sized Macular Holes: A Randomized Noninferiority Trial

To investigate whether air tamponade is noninferior to sulfur hexafluoride (SF6) gas tamponade for small (≤ 250 μm) and medium-sized (> 250 μm and ≤ 400 μm) macular holes (MHs). Multicenter, randomized controlled, noninferiority trial. Patients aged ≥ 18 years undergoing surgery for primary MHs of ≤ 400 μm in diameter. The patients in both groups underwent conventional pars plana vitrectomy with peeling of the internal limiting membrane. At the end of the surgery, the patients were randomized to receive either air or SF6 gas tamponades, stratified by MH size. Postoperatively, the patients followed a nonsupine positioning regimen for 3 days. The primary end point was the MH closure rate after a single surgery, confirmed by OCT after 2 to 8 weeks. The noninferiority margin was set at a 10-percentage-point difference in the closure rate. In total, 150 patients were included (75 in each group). In the intention-to-treat (ITT) analysis, 65 of 75 patients in the air group achieved primary closure. All 75 MHs in the SF6 group closed after a single surgery. Six patients were excluded from the per-protocol (PP) analysis. In the PP analysis, 63 of 70 patients in the air group and all 74 patients in the SF6 group achieved MH closure after a single surgery, resulting in closure rates of 90% (95% confidence interval [CI], 79.9%-95.5%) and 100% (95% CI, 93.9%-100%), respectively. For the difference in closure rates, the lower bound of a 2-sided 95% CI exceeded the noninferiority margin of 10% in both ITT and PP analyses. In the subgroups of small MHs, all 20 patients in the air group and all 28 patients in the SF6 group achieved primary closure. This prospective randomized controlled trial proved that air tamponade is inferior to SF6 tamponade for MHs of ≤ 400 μm in diameter.

Selection Criteria for Air Tamponade During Vitrectomy for Rhegmatogenous Retinal Detachment.

PurposeTo compare air tamponade and sulfur hexafluoride (SF6) gas tamponade during vitrectomy for the treatment of rhegmatogenous retinal detachment (RRD).MethodsWe reviewed 294 eyes with RRD treated with 25-gauge vitrectomy by a single surgeon between June 2011 and April 2018 retrospectively. The exclusion criteria for the proposed air tamponade selection were more than 2 weeks since onset, giant retinal tears, history of complications following cataract surgery, high myopia, and proliferative vitreoretinopathy classified as grade C or higher. We examined the differences in the therapeutic effect between the air group and SF6 group at 6-month follow-up.ResultsA total of 294 eyes were included in the study, 156 eyes in the air group and 138 eyes in the SF6 group. No difference was observed in the primary anatomical success rates between the air group (99.4%; 155/156 eyes) and the SF6 group (96.5%; 135/138 eyes; P = 0.102). Postoperative intraocular gas half-life was shorter in the air group (3.97 ± 0.87 days) compared with the that in the SF6 group (8.67 ± 1.47 days; P = 0.0001). The incidence of postoperative ocular hypertension was lower in the air group (19.9%; 31/156 eyes) than in the SF6 group (62.3% 86 /138 eyes; P = 0.0001).ConclusionWe compared the criteria for proper selection between air and SF6 gas tamponade during vitrectomy for the treatment of RRD. Air tamponade was able to reduce the period of prone position and the risk of ocular hypertension without reducing the therapeutic effect.

Intraoperative Observation of a Macular Holes Using Optical Coherence Tomography.

PurposeThis study aimed to observe intraoperative changes in macular hole (MH) form using intraoperative optical coherence tomography (iOCT).MethodsA total of 10 eyes from 10 patients with MH who underwent vitrectomy using iOCT from May 2015 to October 2015 at the Yamagata University Hospital were retrospectively evaluated. Accordingly, 25-gauge pars plana vitrectomy using iOCT with internal limiting membrane (ILM) peeling and sulfur hexafluoride gas tamponade was performed on each patient. During surgery, MHs were observed using iOCT over four points, namely, before posterior vitreous detachment (PVD) formation, after PVD formation, after ILM peeling, and after fluid–gas exchange. Thereafter, basal MH diameter and minimum aperture MH diameter were postoperatively analyzed.ResultsBefore PVD formation, after PVD formation, after ILM peeling, and after fluid–gas exchange, the mean basal MH diameters were 690.7 ± 268.4, 683.3 ± 274.2, 683.7 ± 269.5, and 668.3 ± 261.4 μm, while the mean minimum aperture MH diameters were 278.3 ± 165.2, 283.0 ± 170.2, 257.0 ± 127.8, and 188.0 ± 105.0 μm, respectively. The mean minimum aperture MH diameter decreased significantly after fluid–gas exchange (one-way repeated measures ANOVA, p < 0.05). None of the patients exhibited intraoperative closure of the MHs. However, MH closure was confirmed in all patients after the surgery.ConclusionNone of the patients demonstrated intraoperative MHs closure. Accordingly, the minimum aperture MH diameter was the first change formation to close after fluid–gas exchange.

Sulphur hexafluoride (SF6) intravitreal injection combined with argon laser photocoagulation for treatment of optic disc pit maculopathy.

To evaluate clinical efficacy of combined sulphur hexafluoride (SF6) gas tamponade and laser photocoagulation for optic disc pit maculopathy (ODPM). Eleven eyes of nine patients with optic disc pit maculopathy were treated with intravitreal injection of 0.6 ml 100% sulphur hexafluoride (SF6) combined with laser photocoagulation treatment. Patients were followed up for a mean of 28.54 months (range of 14-57 months) after treatment. The anatomical success was shown by optical coherence tomography (OCT) and the functional outcome was judged by best corrected visual acuity. Treatment with SF6 gas tamponade followed by laser photocoagulation in OPDM patients resulted in resolution of subretinal fluid (SRF) in 82% of eyes after single injection. Repeated injection was needed in two eyes to achieve resolution of SRF. Visual acuity improved significantly from a mean of 0.83 ± 0.14 logMAR preoperatively to a mean of 0.26 ± 0.11 logMAR postoperatively. Visual acuity stayed stable throughout the follow-up period. SF6 gas tamponade combined with laser photocoagulation represents simple, effective, minimally invasive treatment option for ODPM without vitreomacular traction. Repeated injection was required in some patients.

Internal limiting membrane peeling effect on visual outcomes after diabetic vitrectomy

Aim and Objectives To determine whether Internal Limiting Membrane (ILM) peeling has an effect on visual outcomes after vitrectomy for diabetic tractional retinal detachment. Settings and Design A prospective randomized interventional case series. Patients and Methods Pars Plana Vitrectomy (23-Gauge) was performed on 34 cases with diabetic epi-macular traction affecting the vision due to advanced proliferative diabetic retinopathy. The usual steps of vitrectomy were performed. The ILM was randomly chosen to be peeled in 16 cases (group I), or left not peeled in 18 cases (group II). Eventually, either air, Sulphur hexafluoride (SF6) gas or silicone oil tamponade was used. Final visual acuity results were tabulated six months after surgery, and compared between the two groups. Results The mean pre-operative visual acuity (VA) was 0.06 (decimals) and 0.03 in groups I and II respectively. The mean post-operative VA was significantly better: 0.26 and 0.27 in groups 1 and 2 respectively (P=0.001). There were no statistically significant differences between VA gains in both groups (P=0.721). Air tamponade was used in 18.8% and 33.3%, SF6 in 37.5% and 33.3%, and silicone oil in 43.8% and 33.3% in groups I and II respectively. Conclusions ILM peeling had no effect on the final visual outcome after vitrectomy for diabetic tractional retinal detachments.

Functional and morphological results of treatment of macula-on and macula-off rhegmatogenous retinal detachment with pars plana vitrectomy and sulfur hexafluoride gas tamponade

BackgroundTo examine morphological and functional results after pars plana vitrectomy (PPV) with sulfur hexafluoride (SF6) gas tamponade due to macula-on and macula-off rhegmatogenous retinal detachment (RRD) during 6 months of the follow-up.MethodsThe study included 62 eyes that underwent successful PPV with SF6 tamponade with macula-on (34 eyes) and macula-off (28 eyes) RRD preoperatively. The best-corrected visual acuity (BCVA), Amsler test, M-charts, optical coherence tomography (OCT) and microperimetry were performed at 1, 3 and 6 months postoperatively.ResultsResults of the Amsler test were abnormal postoperatively in 54% of the patients in the group with macula-off and in 32% of the patients with macula-on RRD. Horizontal M-charts improved significantly from 0.33 to 0.2, vertical M-charts– from 0.29 to 0.17 during 6 months of the follow-up. There was a significant increase in the central retinal thickness (CRT) and average thickness (AT) between follow-up examinations only in the macula-off group. 29 of 62 eyes (47%) after surgery (equally with macula-on and macula-off RRD) showed morphological changes in OCT in the macular region, as epiretinal membrane, macular edema, subretinal fluid or alterations of the outer layers of the retina. The average threshold in microperimetry increased significantly within both groups during the follow-up.ConclusionBoth horizontal and vertical M-charts scores, as were as microperimetry sensitivity improved significantly during the 6 months of the follow-up both in macula-on and macula-off group. Although PPV with SF6 gas tamponade was successful, almost half of eyes revealed anatomical changes in the macular region in OCT both with macula-on and macula-off group.Trial RegistrationCurrent Controlled Trials NCT03902795 registered on 03/04/2019. Retrospectively registered.

Nonsupine Positioning after Macular Hole Surgery: A Prospective Multicenter Study

To evaluate the postoperative closure rate of full-thickness macular holes (MHs) after nonsupine positioning, which means that the patients avoid upward gaze and a supine sleeping position, and to investigate the correlation between postoperative positioning compliance and closure rate. Prospective, multicenter study (ClinicalTrials.gov identifier, NCT02295943). Patients undergoing primary surgery for primary MH. Patients underwent pars plana vitrectomy with internal limiting membrane peeling and sulfur hexafluoride gas tamponade followed by 3 to 5 days of nonsupine positioning. A positioning measuring device that recorded the time spent in the supine position was attached to patients' forehead after surgery for 24 hours. Anatomic closure rate of MH at 2 weeks or more after surgery and the time spent in supine position during the first 24 hours after surgery. A total of 205 participants were included, of whom 2 were lost to follow-up. Two hundred two of 203 MHs closed after a single operation, giving a closure rate of 99.5% (95% confidence interval, 97.3%-99.9%). The median time of supine positioning during the first 24 hours was 28 seconds (range, 0:00:00-01:52:28). Because of the very high closure rate, a correlation between positioning compliance and closure rate could not be established. Pars plana vitrectomy with internal limiting membrane peeling followed by a short-term nonsupine positioning accomplished a very high MH closure rate. Thus, face-down positioning was not necessary to achieve excellent closure rates in this study.

Non-Lasered Drainage Retinotomies for Repair of Primary Rhegmatogenous Retinal Detachments

Drainage retinotomies are a technique used for treating rhegmatogenous retinal detachments (RRDs). These retinotomies are commonly surrounded by barricade laser. This paper aims to evaluate operative success of non-lasered drainage retinotomies during 25-gauge pars plana vitrectomy (PPV) for repair of primary RRD. Retrospective review of a consecutive interventional case series. Study includes 45 eyes of 45 patients who underwent 25-gauge PPV with a non-lasered drainage retinotomy for primary RRD. Eyes with previous retinal detachments or less than 3 months of follow-up were excluded. All PPV with non-lasered drainage retinotomies were carried out by one surgeon (RFI); 25-gauge PPV instrumentation, a wide-angle viewing system, endolaser photocoagulation, and air or sulfur hexafluoride gas tamponade were utilized for each eye. Single surgery anatomical success was achieved in 42 out of 45 eyes (93%). Retinal detachment repair utilizing non-lasered drainage retinotomies had a high anatomic success rate comparable to that of standard retinal detachment repair.1,2 [Ophthalmic Surg Lasers Imaging Retina. 2018;49:955-960.].

Vitrectomy without prone positioning for rhegmatogenous retinal detachments in eyes with inferior retinal breaks.

PurposeTo compare the anatomic and functional outcomes of pars plana vitrectomy (PPV) for treating rhegmatogenous retinal detachments (RRDs) between two groups with and without postoperative prone positioning.MethodsThis retrospective cohort study included 142 eyes of 142 patients with a primary RRD. All patients underwent PPV with 20% sulfur hexafluoride gas tamponade and were divided into two groups: the groups that did and did not maintain a prone position postoperatively. All patients were followed for more than 3 months. The main outcome measures were the best-corrected visual acuity (BCVA), retinal reattachment rate, and postoperative complications.ResultsSixty-five eyes were included in the prone position group and 77 eyes in the group without prone positioning; the respective initial reattachment rates were 83.1% and 96.1%, a difference that reach significance (p = 0.011). In the eyes with inferior breaks, the initial reattachment rate was 94.7% (18 eyes) without prone positioning, which was significantly (p = 0.036) better than the 60% (6 eyes) initial reattachment rate in the group with prone positioning. In the eyes without inferior breaks, there was no significant difference in the initial reattachment rates between the two groups. The BCVAs at the 3-month postoperative visit did not differ significantly between the two groups. An epiretinal membrane (ERM) was observed postoperatively in 10 (13.0%) eyes in the group without prone positioning; no ERMs were seen postoperatively in eyes in which the internal limiting membrane (ILM) was peeled during PPV.ConclusionsPPV without postoperative prone positioning is associated with a higher reattachment rate in eyes with a RRD, especially those with inferior retinal breaks. PPV with postoperative supine and lateral positioning might be beneficial to manage RRDs associated with inferior retinal breaks if ILM peeling is performed intraoperatively.

Comparison of Sulfur Hexafluoride (SF6) and Air Tamponade in Noniridectomized Descemet Membrane Endothelial Keratoplasty.

To compare the efficacy and safety of 20% sulfur hexafluoride gas (SF6) and air tamponade in patients who underwent noniridectomized Descemet membrane endothelial keratoplasty (DMEK). A retrospective chart review of patients who underwent DMEK with either air or SF6 tamponade: 41 eyes received air tamponade (group 1) and 41 received SF6 tamponade (group 2). Best spectacle-corrected visual acuity, endothelial cell density, and complications including graft detachment and elevated intraocular pressure were compared. The mean follow-up time was 8 ± 4 months in group 1 and 3 ± 2 months in group 2. Mean best spectacle-corrected visual acuity improved from 1.12 ± 0.88 to 0.64 ± 0.78 logarithm of the minimum angle of resolution (logMAR) in group 1 (P = 0.009) and from 1.00 ± 0.78 to 0.62 ± 0.53 logMAR in group 2 (P = 0.006). The graft detachment rate was 39% (16 eyes) in group 1 and 42% (17 eyes) in group 2 (P = 0.822). The rate of graft detachment larger than one third of the graft area was 17% in group 1 and 20% in group 2 (P = 0.775). Rebubbling was performed in 26.8% and 20% of eyes in group 1 and 2, respectively (P = 0.43). Average endothelial cell loss was 32% in group 1 and 33% in group 2 (P = 0.83). In the immediate postoperative period, elevated intraocular pressure was observed in 2 eyes (5%) in group 1 and in 4 eyes (10%) in group 2 (P = 0.4). There was 1 primary graft failure in each group. Use of air with it being readily available and short acting is a good method of Descemet membrane tamponade in noniridectomized DMEK.

Fluorescein-Assisted Subretinal Tissue Plasminogen Activator (tPA) Delivery For Submacular Hemorrhage.

To describe a surgical technique for fluorescein-assisted subretinal tissue plasminogen activator delivery during pars plana vitrectomy for submacular hemorrhage. Retrospective, interventional, consecutive case series. Six eyes of 6 patients were reviewed. Etiology of submacular hemorrhage was age-related macular degeneration in 2 eyes and polypoidal choroidal vasculopathy in 4 eyes. Twenty-three-gauge pars plana vitrectomy was performed and fluorescein-stained tissue plasminogen activator was injected in the subretinal space through a 41-gauge cannula in all eyes. Sulfur hexafluoride (SF6) gas (n = 5 eyes) or air (n = 1 eye) tamponade was instilled at the conclusion of surgery. Successful displacement of submacular hemorrhage was achieved in all eyes. Mean visual acuity improved from 20/693 preoperatively to 20/224 postoperatively (P = 0.14) at mean follow-up of 560 ± 464 days. No intraoperative or postoperative complications were encountered. Fluorescein-assisted subretinal delivery of tissue plasminogen activator was well tolerated and allowed for improved visualization of subretinal bleb formation during pars plana vitrectomy for submacular hemorrhage.

The results of 25-gauge vitreoretinal surgery for optic disc pit-associated maculopathy: a report of three cases and mini-review of the literature

We report the outcomes of three consecutive patients with optic disc pit-associated maculopathy who were treated with 25-gauge pars plana vitrectomy, internal limiting membrane (ILM) peeling, fluid-air exchange, barrage endolaser, and sulfur hexafluoride (SF6) gas tamponade. Patients with optic disc pit-associated maculopathy were treated with 25-gauge pars plana vitrectomy followed by ILM peeling, fluid-air exchange, barrage endolaser, and gas tamponade with 20% SF6. All patients were asked to maintain a facedown position for 3days postoperatively. This technique resulted in complete retinal reattachment after 25-gauge vitrectomy, ILM peeling, fluid-air exchange, barrage endolaser, and 20% SF6 gas injection. The best-corrected visual acuity (BCVA) improved in all three patients and successful anatomical results were achieved. There wasn't any macular detachment in all cases at 20th week follow-up. Our outcomes suggest that 25-gauge vitrectomy with ILM peeling, fluid-air exchange, barrage endolaser, and SF6 gas tamponade appears to be an effective treatment option for optic disc pit-associated maculopathy.

Wide-field laser ophthalmoscopy for imaging of gas-filled eyes after macular hole surgery.

Background and objectiveExisting ophthalmoscopy methods are unable to obtain clear fundus autofluorescence (FAF) images in gas-filled eyes. The purpose of this study was to evaluate the capability of wide-field laser ophthalmoscopy (Optos) in obtaining FAF images in gas-filled eyes for the assessment of macular hole (MH) closure after surgery.MethodsThis was an interventional case series. Eighteen consecutive patients with unilateral MH underwent vitrectomy with internal limiting membrane peeling and 20% sulfur hexafluoride gas tamponade. FAF images using Optos were recorded preoperatively and postoperatively (days 1, 2, and 7).ResultsOn postoperative days 1, 2, and 7, FAF images were obtained from 11/18 (61.1%), 9/18 (50.0%), and 17/18 eyes (94.4%), respectively, using Optos. The quality of FAF images using Optos was sufficient to determine MH closure in 9/18 (50.0%) of gas-filled eyes postoperatively. Quantitative analysis of FAF images was helpful in determining complete or partial closure of the MH.ConclusionFAF imaging using Optos might be a useful adjunct to optical coherence tomography as a supportive method to guide the release from facedown posturing in some cases of MH.

Outcome of 2cc pure sulfur hexafluoride gas tamponade for macular hole surgery.

BackgroundIsoexpansile concentrations of intraocular gases are typically used as tamponading agent in macular hole surgery. Using a small volume of the pure form of these gases may achieve the same result without increasing the incidence of postoperative complications. The purpose of this study was to evaluate the anatomical and visual outcomes following macular hole surgery with 2 cc pure (100 %) sulfur hexafluoride (SF6) gas tamponade.MethodsA retrospective study of eyes with idiopathic macular holes that underwent 23-gauge pars plana vitrectomy with 2 cc pure SF6 gas tamponade. Macular hole surgery was performed alone or in combination with phacoemulsification in eyes with cataract. Preoperative and postoperative data including best corrected visual acuity recorded in LogMAR units, slit-lamp biomicroscopy, and optical coherence tomography were analysed. Surgical complications were also recorded.ResultsSeventy six eyes of seventy five patients were analysed. A closure rate of 100 % was achieved with reoperation in 4 eyes. There was a significant improvement in best-corrected visual acuity from a mean of 0.65 LogMAR preoperatively to 0.36 at 6 months (p value 0.004). Forty five (59 %) eyes gained at least 2 lines on the Snellen visual acuity chart. Postoperative elevation in intraocular pressure (≥30 mmHg) was documented in 3 eyes (4 %).ConclusionMacular hole surgery with 2 cc pure SF6 gas tamponade achieved a high success rate with a low incidence of complications. The smaller volume of gas required makes it a cheaper technique.Electronic supplementary materialThe online version of this article (doi:10.1186/s12886-016-0254-9) contains supplementary material, which is available to authorized users.

The Effect of Postoperative Face-Down Positioning and of Long- versus Short-Acting Gas in Macular Hole Surgery: Results of a Registry-Based Study

To determine whether sulfur hexafluoride (SF6) gas is noninferior to longer-acting gases in macular hole surgery and whether withholding postoperative face-down positioning (FDP) is noninferior to FDP. Registry-style, prospective, nonrandomized, observational cohort study. Patients with idiopathic macular holes undergoing primary surgery. Surgeons were invited to submit clinical details of all macular hole cases receiving surgery. Baseline demographic and clinical information were collected, as well as details of surgical intervention and postoperative posturing advice. Primary follow-up data were collected 3 months postoperatively. Macular hole closure at 3 months. A noninferiority approach was used, with a noninferiority margin set at 5% decreased frequency of success. A total of 2456 eyes of 2367 patients were included in the study. Outcomes were available in 94.9% of cases (2330/2456). The rate of macular hole closure was 95.0% (2214/2330). Sulfur hexafluoride gas was found to be noninferior to longer-acting gases (95% confidence interval [CI] for adjusted effect on success,-1.76 to+2.25), and noninferiority was demonstrated regardless of macular hole size. Although withholding FDP was found to be noninferior to FDP for the study population as a whole (95% CI for adjusted effect on success,-4.21 to+0.64), the result was inconclusive in holes >400 μm in diameter (95% CI,-9.31 to+1.04). Lack of internal limiting membrane (ILM) peel, increasing hole size, hole duration ≥9 months, increasing age, and 20-gauge surgery all were associated with lower odds of success. Vitreous attachment to the hole margin was not associated with outcome when corrected for hole size, and combined phacovitrectomy surgery was not observed to affect the odds of success in phakic eyes. Sulfur hexafluoride gas tamponade was noninferior to longer-acting gases in the surgical management of macular hole. Withholding FDP was noninferior to FDP in holes ≤400 μm in diameter. In holes >400 μm in diameter, noninferiority of withholding FDP could not be concluded. We would advise caution ifposturing is withheld in this group on the basis of the results of this study and of others.

TEMPORAL INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE FOR A MACULAR HOLE PATIENT UNABLE TO MAINTAIN POSTOPERATIVE PRONE POSITIONING

To report the surgical technique and efficacy of the temporal inverted internal limiting membrane (ILM) flap technique for a patient with an idiopathic macular hole (MH) who is unable to maintain postoperative prone positioning. Case report. A 73-year-old man with a Stage III MH in his left eye was scheduled to undergo surgery. Owing to his inability to maintain postoperative prone positioning for continuous placement of a transdermal bladder catheter after radical cystoprostatectomy to treat urinary bladder cancer, he underwent pars plana vitrectomy combined with the temporal inverted ILM flap technique and intraocular sulfur hexafluoride gas tamponade. The technique included ILM peeling at a temporal area of the macula to create one 2-disk-diameter semicircular ILM flap and inversion of the ILM flap nasally to cover the MH. Optical coherence tomography showed that MH closure started from the top of the MH just beneath the covered ILM flap; the closure process gradually extended toward the bottom of the MH. The well-aligned fovea recovered in 5 weeks postoperatively. The visual acuity was 20/200 preoperatively and improved to 20/50 postoperatively. The temporal inverted ILM flap technique, a simple surgery to treat MHs, provides scaffolding for retinal gliosis and may facilitate bridge formation between the walls of the MH beneath the flap. The procedure may be a good option to achieve MH closure without postoperative prone positioning.

Can Postoperative Accelerated Lens Opacification be Limited by Lying in "Face-Down Position" after Vitrectomy with Gas as Tamponade?

Developing a post-operative cataract after pars-plana vitrectomy (ppV) or core pars-plana vitrectomy (cppV) with gas as tamponade within 6 to 12 months is a common complication and is mostly accepted as unavoidable. Often a combined cataract-ppV surgery in the first place is recommended. The main goal of this study was to analyse the effects of a "face-down positioning" ("fdp") on the lens transparency and the phaco rate. By using the positive experience of an ergonomic body positioning it should be possible to improve the compliance during the period of "fdp" after surgery. During the study period of up to 24 months, we observed in a prospective, controlled, clinical and randomised pilot study 30 patients who all had undergone a ppV/cppV with sulfur hexafluoride gas tamponade (SF6 25 %). All patients of the supported group (SG) and the control group (CG) were requested to keep their face consequently downwards until the gas bubble was resorbed completely in order to avoid a direct contact with the lens. The real time in "fdp" in hours per day (24 hours) and the grade of lens opacification was documented pre- and postoperatively using a Pentacam HR (Oculus, Wetzlar). The compliance of patients tested measuring the real time of "fdp" in hours per day varied largely (SG: 19.5/24; CG: 5.5/24; p < 0,0001). Cataract development was found to be directly related to the real time of "fdp". A cataract surgery was necessary mainly in the non-supported group (SG: 4/15; CG:12/15; p = 0.012). There was no lens opacification in the supported group after performing the "fdp" for at least 20 hours daily until the resorption of the gas bubble was completed. This result did not correlate with the age of the patient. With the help of sufficient support at the disposal of the patients, it is possible to significantly improve the compliance during the period of "fdp" after surgery. In order to get a safe and painless "fdp" in bed, an ergonomic body positioning is necessary (Schaefer 2012). By practicing the "fdp" until the gas bubble is completely resorbed, the risk of developing a postoperative cataract can be reduced significantly. Provided there is a good compliance to "fdp", the gas bubble can cause the desired tamponade effect even when using shorter acting gases. By performing a consistent "fdp" it is possible to accelerate the healing process and avoid reoperations. Hereby it should even be possible to use an SF6-air mix or optionally simply air as tamponade.