Treatment Of Retinal Detachment Research Articles

Recent advances in polymeric vitreous substitutes

The vitreous humor occupies two thirds of the volume of the eye and is the major component behind the lens. The human vitreous is a gelatinous substance predominantly composed of water (98–99%). Its functions include holding the retina in place and circulating metabolites throughout the eye. The vitreous liquifies with age, facilitating posterior vitreous detachment, which can lead to retinal tears, intravitreal hemorrhage or retinal detachment. Vitreous substitutes are needed to tamponade the retina or during vitrectomies for treatment of retinal detachments. Gases, perfluorocarbon liquids and silicone or fluorosilicone oils are currently used as vitreous substitutes; however, none of these substitutes can be used long term due to the short retention time of the gaseous substitutes, cell toxicity or other complications, such as glaucoma or cataracts. Vitreous substitutes, both experimental and clinical, will be reviewed, along with promising experimental artificial vitreous; polymeric hydrogels.

Sclerai buckling combined with laser photocoagulation for treatment of retinal detachment

目的 观察巩膜扣带术联合激光光凝术治疗非复杂性孔源性视网膜脱离的疗效.方法 回顾性分析2003年1月～2005年9月我院行巩膜扣带术联合激光光凝术治疗的非复杂性孔源性视网膜脱离27例(28眼).术后随访3～6月,观察视网膜复位情况,视力及并发症.结果 视网膜复位27眼(96.43%),视力提高25眼,视力无改变2眼,下降1眼.结论 巩膜扣带术联合激光光凝术治疗非复杂性孔源性视网膜脱离效果满意。

Intracranial hyperdense subarachnoid perfluorocarbon droplets after attempted retinal detachment treatment

Unexpected intracranial foreign materials may pose a diagnostic dilemma. We present a case of a gunshot wound resulting in severe orbital trauma and open-globe injury. The patient was treated with vitreoretinal surgery and intravitreous perfluorocarbon liquid (PFCL) injection. Postoperative head computed tomography exam demonstrated migration of PFCL into the intracranial subarachnoid space.

How to keep photoreceptors alive

Over the last 40 years, there has been increasing success in the surgical treatment of retinal detachment in that the retinal reattachment could be achieved in a high proportion of cases but visual recovery was frequently poor. An explanation for this poor visual outcome was derived from work on experimental retinal detachment in which it was shown that photoreceptor cell death occurred because of a wave of apoptosis during the first few days of retinal detachment (1). It is recognized that apoptosis or programmed cell death is a genetically encoded potential of all cells (2). It is characterized by cleavage of most of the nuclear DNA into short but well organized chains of nucleosomes in multiples of 200 bp by an endogenous nonlysosomal nuclease (3, 4) and may be triggered by changes in the metabolic environment of the cell. The photoreceptor cells are closely approximated to the retinal pigment epithelium (Fig. 1) and depend on the retinal pigment epithelium for their metabolic sustenance. Physical separation of the two and loss of metabolic exchange as occurs in retinal detachment (Fig. 2) might have been supposed to cause a sequence of events that would inevitably induce cell loss that was not amenable to treatment. However, apoptosis may be manipulated by altering the metabolic environment, and it has been shown that brain-derived growth factor injected into the eye reduces the rate of photoreceptor cell loss in experimental retinal detachment (5), although the precise means by which apoptosis was induced and the mechanism of the therapeutic effect were uncertain.

Triamcinolone Acetonide as an Adjuvant in the Surgical Treatment of Retinal Detachment With Proliferative Vitreoretinopathy

To report the efficacy of intravitreal triamcinolone acetonide as an adjuvant in the surgical management of cases with advanced proliferative vitreoretinopathy (PVR). Patients with complicated rhegmatogenous retinal detachment and PVR grade C2 or greater were recruited for this interventional, noncomparative, prospective study. All patients underwent three-port pars plana vitrectomy, membrane peeling, laser photocoagulation, and silicone oil injection to reattach the retina followed by 0.1 mL (4 mg) of triamcinolone acetonide injected through the pars plana into the silicone oil. All patients had supplemental laser therapy around retinal breaks and retinectomy edges at 1 to 2 weeks postoperatively. Patients included 15 males and 9 females, with an average age of 53.6 years (range: 15 to 84 years) and PVR grade C2 to PVR C9. The mean follow-up period was 11.0 months (range: 3 to 26 months). Twenty-one (87.5%) patients had attached retinas at the final followup visit. Visual acuity improved in all patients following surgery (P < .05). Triamcinolone acetonide may have potential as an adjuvant in the treatment of retinal detachment with PVR. Further research is required to evaluate the efficacy of this adjuvant treatment.

Biomechanical Effect of Segmental Scleral Buckling Surgery

Purpose: The current paper studies the mechanical effect of segmental buckling surgery for treatment of retinal detachment using the finite element (FE) method. The effects of different eye sizes, intraocular pressures, and silicon sponge size and locations are examined. Indicative study on the visual optics from the emmetropia to the myopia by the surgery is also carried out. Ophthalmologists may have an advanced understanding of the possible surgical outcomes from the current study in order to plan better patient-specific surgical procedure. Methods: The solid tissues in the 3D FE model are modeled by eight-node hexagonal solid elements using a Lagrangian mesh. The inner vitreous and aqueous liquids are modeled by a Eulerian mesh. The eye tissues are treated as hyperelastic solids, and the liquids are represented with linear polynomial equations of state. Results: The segmental scleral buckling procedure induces stress concentrations in the suture region, which may lead to bleeding. A smaller eye sustains relatively higher stress, thus has a greater chance to bleed. Smaller silicon implant leads to much higher stress, and the effect of the relative posterior and anterior positions of the silicon sponge is inconsistent. The surgery causes or aggravates myopia due to the average corneal curvature increase, although the optical length of the eye is reduced at high indentations. Exceptions are eyes with very large or small intraocular pressure at moderate indentation. Eyes with small intraocular pressure may sustain more severe refractive error by the surgery. Astigmatism may be caused or aggravated by the irregular deformation of the cornea and the deflection of the crystalline lens.

Field-induced motion of ferrofluids through immiscible viscous media: Testbed for restorative treatment of retinal detachment

Biocompatible, hydrophobic ferrofluids comprised of magnetite nanoparticles dispersed in polydimethylsiloxane show promise as materials for the treatment of retinal detachment. This paper focuses on the motion of hydrophobic ferrofluid droplets traveling through viscous aqueous media, whereby the movement is induced by gradients in external fields generated by small permanent magnets. A numerical method was utilized to predict the force on a spherical droplet, and then the calculated force was used to estimate the time required for the droplet to reach the permanent magnet. The calculated forces and travel times were verified experimentally.

Surgical Management of Pseudophakic Retinal Detachments: A Meta-analysis

To compare the success of pars plana vitrectomy (PPV) versus scleral buckle (SB) in the management of uncomplicated pseudophakic retinal detachments (RDs). Meta-analysis of published studies from 1966 to 2004 regarding surgical treatment of pseudophakic RDs. Two thousand two hundred thirty eyes: 1579 operated by SB, 457 by PPV, and 194 by the combined method of PPV and SB. We compared reattachment and functional success rates after 3 commonly practiced surgical interventions for pseudophakic RDs: PPV, SB, and the combined method. Twelve hundred thirty-two articles were retrieved from Medline and by cross-reference searches. Articles with sufficient data on preoperative evaluation, applied surgical technique, and anatomical and functional success rates were included in this analysis. Articles regarding complex pseudophakic RDs, treatment by laser or pneumatic retinopexy, studies with indistinguishable treatment outcomes from phakic and pseudophakic RDs, or reviews without original data were excluded. Anatomical success rates after initial surgical intervention and after reoperation(s) for primary failures, and best or final visual outcome at the end of follow-up. Of 1232 papers, 29 matched inclusion criteria. After controlling for variation between study characteristics, PPV and the combined method resulted in higher initial reattachment rates (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.07-2.68, and OR, 3.54; 95% CI, 1.57-7.97, respectively) as compared with SB. The differences between the procedures persisted for final reattachment outcome despite reoperation for primary failures. Final visual outcome also was found to depend on the choice of primary surgical intervention. After controlling for differences in the study characteristics, the probability of visual improvement was higher after PPV (OR, 2.34; 95% CI, 1.58-3.46) or the combined method (OR, 11.52; 95% CI, 4.42-30.04) as compared with SB. A meta-analysis of published literature implies that PPV with or without SB is more likely to achieve a favorable anatomical and visual outcome than conventional SB alone in uncomplicated pseudophakic RDs. However, the inherent limitations of differing study protocols, quality of included studies, and publication bias in a pooled analysis should be recognized.

Anatomic outcome of scleral buckling surgery in primary rhegmatogenous retinal detachment

To evaluate the factors affecting the anatomic success of treatment of retinal detachments (RD) by scleral buckling surgery. One-hundred and two eyes of 102 patients with rhegmatogenous RD operated on by scleral buckling surgery were included in the study. Results were analyzed according to the anatomic status of the retina at the most recent follow-up examination. The chi-squared test was used to determine the relationship between preoperative and intraoperative variables and anatomic results, and the relative risk of failure was determined for each variable. Retinal reattachment was achieved in 85 of 102 eyes (82.5%) after initial surgery. The success rate for anatomic reattachment was 95% after two operations. After three operations reattachment was achieved for 98 eyes (96%). Predictive factors for anatomic failure (P<0.05) were the presence of grade C(1) PVR and multiple breaks. Grade C(1) PVR and multiple breaks were found to be significant risk factors for anatomic failure in rhegmatogenous RD treated by conventional buckling surgery.

Pars Plana Vitrectomy and Perfluoropropane (C 3F 8) Tamponade for Retinal Detachment Due to Myopic Macular Hole: A Prognostic Factor Analysis

To determine the prognostic factors associated with anatomical success in the treatment of retinal detachment (RD) due to myopic macular hole by pars plana vitrectomy (PPV) and perfluoropropane (C3F8) gas tamponade. Retrospective, interventional, comparative case series. In an institutional setting, 57 eyes with myopic macular hole RDs treated by PPV and C3F8 tamponade, with or without concomitant internal limiting membrane (ILM) peeling, endolaser photocoagulation, and/or phacoemulsification, were analyzed. Outcome measures were anatomical success, defined as closure of macular hole with reattachment of the surrounding retina, and postoperative best-corrected visual acuity (BCVA). The mean postoperative follow-up was 26.9 +/- 16.5 months. The anatomical success rate after primary PPV and C3F8 tamponade was 63.2%. Regression analysis showed that shorter axial lengths (odds ratio [OR] = 6.73, 95% confidence interval [95% CI] 1.86 to 12.22, P = .010), concomitant ILM peeling (OR 1.59, 95% CI 1.14 to 2.38, P = .013), and shorter duration of macular hole RD (OR 0.81, 95% CI 0.67 to 0.98, P = .033) were associated with a higher anatomical success. The mean pre- and postoperative BCVAs were 1.430 +/- 0.273 (range, 0.523 to 1.700) and 1.403 +/- 0.271 (range, 0.699 to 1.800) logarithm of minimal angle of resolution units, respectively. The postoperative BCVA was significantly better in eyes with macular hole closure than in eyes without (P = .021). Axial length, concomitant ILM peeling, and duration were important prognostic factors for PPV and C3F8 tamponade in the treatment of myopic macular hole RDs.

Vitrectomie assistée par triamcinolone dans le traitement des récidives de décollement de rétine par trou maculaire du myope fort

To report the use of triamcinolone-assisted vitrectomy to assess the cause of vitrectomy failure in the treatment of retinal detachment due to myopic macular hole. We report the cases of three myopic patients presenting with recurrent retinal detachment due to macular hole after initial vitrectomy treatment with posterior vitreous detachment, a systematic attempt at membrane peeling, and gas injection (SF6). No retinal traction or tear other than the macular hole was observed. The recurrence of retinal detachment was treated with vitrectomy and intraoperative use of triamcinolone, which demonstrated persistent posterior hyaloid and thin and strongly adherent membrane remnants in each case. Anatomic success was obtained after peeling these structures. Intraoperative use of triamcinolone reduces the risk of overlooking hyaloid or membrane remnants during vitrectomy for the treatment of myopic retinal detachment. Transparent remnants of posterior hyaloid and membranes were visualized by triamcinolone-assisted vitrectomy. They could lead to traction on the retina and explain the failure of the initial vitrectomy. Anatomic success was obtained after peeling these structures.

PRIMARY PARS PLANA VITRECTOMY VERSUS SCLERAL BUCKLE SURGERY FOR THE TREATMENT OF PSEUDOPHAKIC RETINAL DETACHMENT

To compare the anatomical and functional outcome of scleral buckle (SB) surgery with that of pars plana vitrectomy (PPV) alone in the treatment of primary rhegmatogenous pseudophakic retinal detachment (RD). In this prospective, randomized clinical trial, 150 eyes of 150 patients with pseudophakic RD and proliferative vitreoretinopathy (PVR) stage B or less were randomized to SB surgery (75 eyes) or primary PPV (75 eyes). SB surgery involved break localization, cryotherapy, placement of a circumferential 240 style 2.5-mm solid silicone band, combined with a local buckle when indicated, and transscleral drainage of subretinal fluid. PPV included extensive vitreous removal, perfluoro-n-octane injection or endodrainage of subretinal fluid to flatten the retina, cryopexy treatment of breaks, and fluid/air exchange with injection of 20% SF6. Postoperative follow-up was 1 year. Break diagnosis, operating time, intraoperative and postoperative complications, retinal reattachment rate for single as well as multiple surgeries, axial length changes, and best-corrected visual acuity at 1 year after surgery were the main outcome measures. The number of eyes that were diagnosed with additional breaks inter-operatively was higher in the PPV group (P=0.004, chi test). Mean operating time was significantly less (P=0.0001, t-test) in the PPV group. With a single surgery, the retina was reattached in 62 eyes (83%) in the SB surgery group and in 71 eyes (94%) in the PPV group (P=0.037, Fisher exact test). With subsequent surgeries, final anatomical reattachment was achieved in 71 cases in the SB surgery group and in 74 cases in the PPV group (P=0.37, Fisher exact test). Mean axial length change at 1 year was 0.95 mm in the SB surgery group and 0.1 mm in the PPV group (P=0.0001, t-test). Mean final best-corrected visual acuity (logMAR) was 0.40 in the SB surgery group and 0.33 in the PPV group (P=0.26, t-test). Primary PPV offers potential advantages over SB surgery in the treatment of pseudophakic RD, including less operating time, accurate diagnosis of breaks, higher reattachment rate with a single surgery, and no postoperative axial length changes. Retinal reattachment rate with multiple surgeries and final visual acuity at 1 year were similar for SB surgery and PPV.

How to interpret a healthcare economic analysis

The purpose of the review is to present guidelines to help the clinician to interpret healthcare economic analyses and review pertinent recent analysis in the ophthalmic literature. There are four variants of healthcare economic analyses: (1) cost-minimization analysis; (2) cost-benefit analysis; (3) cost-effectiveness analysis and (4) cost-utility analysis. Cost-utility utility analysis has assumed an increasingly important role in healthcare, with increasing number of analyses occurring in the peer-reviewed ophthalmic literature. These include cost-utility analyses of cataract surgery in the first and second eyes, amblyopia treatment, and cost-utility analyses encompassing the vitreoretinal interventions of the following: (1) laser photocoagulation for exudative macular degeneration; (2) laser treatment for diabetic retinopathy; (3) laser photocoagulation for branch retinal vein obstruction; (4) diabetic vitrectomy; (5) treatment of proliferative retinopathy of prematurity and (6) treatment of retinal detachment associated with proliferative vitreoretinopathy. As an increasing number of cost-utility analyses become available they will provide the information system for the practice of value-based medicine, or medicine based upon the patient-perceived value conferred by interventions. Increasing numbers of cost-utility analysis in the ophthalmic literature suggest that ophthalmic interventions, including vitreoretinal interventions, are cost effective. Cost-utility analysis is a major tool in value-based medicine, the practice of medicine based upon the patient-perceived value conferred by healthcare interventions.

The Correlation between Height of Macular Detachment and Visual Outcome in Macula-Off Retinal Detachments of ≤7 Days’ Duration

To determine the relationship between the height of macular detachment and visual recovery after treatment of macula-off retinal detachments (RDs) of < or = 7 days' duration. Prospective comparative case series. Fifty-two eyes of 52 consecutive patients who presented to one institution with macula-off RDs of < or = 7 days' duration were prospectively enrolled in the study. Gender, age, lens status, duration of macular detachment, and presenting visual acuity (VA) were recorded for all patients. Each patient underwent a 3-dimensional B-scan ultrasound examination at the time of presentation. The height of macular detachment was calculated using the mean measured distance between the retinal pigment epithelium and the outer neurosensory retina 3, 4, and 5 mm temporal to the center of the optic nerve head. All patients underwent primarily successful reattachment surgery within 7 days of macular detachment. Final vision was recorded with a minimum of 6 months' follow-up. Postoperative VA evaluated as a continuous variable. For the 52 subjects, a direct correlation between lower height of macular detachment and better final postoperative vision (dependent variable) was observed with linear regression (slope, 0.114; 95% confidence interval, 0.022-0.206; P = 0.016). Multivariate linear regression analysis with a backward stepwise approach did not demonstrate any significant association between postoperative vision and predictor variables (gender, age, lens status, duration of macular detachment, macular height, and preoperative vision), except for macular height. Lower height of macular detachment correlates with better visual recovery after treatment of macula-off RDs of < or = 7 days' duration.

Clinical management of silicone intraocular lens condensation

To report a novel technique in the management of silicone intraocular lens condensation after gas-fluid exchange. Interventional case report. Clinical management of an obstacle to treatment. setting: Private retina practice. patient population: One patient with silicone posterior chamber intraocular lens implant and posterior capsulotomy who subsequently experienced complicated retinal detachment. intervention: Application of a heating pad to clear intraocular lens condensation. main outcome measure: Visibility of the fundus for laser treatment. Application of a heating pad to the closed eyelid significantly reduced the intraocular lens condensation and provided a clear view for the surgeon to apply laser retinopexy. Treatment of retinal detachment is complicated by lens condensation after gas-fluid exchange in patients who have undergone silicone posterior chamber intraocular lens implantation and posterior capsulotomy. We report a simple, inexpensive, and effective method to reduce lens condensation and enable in-office examination and laser treatment.

Traitement des décollements de la rétine par déchirure géante : résultats de l’échange perfluorocarbones liquides-silicone avec indentation circulaire

Anatomical and functional results of the treatment of retinal detachment associated with giant retinal tear have been markedly improved with the development of the vitrectomy procedure and especially the use of perfluorocarbon liquids. In this study, we report treatment results of retinal detachment associated with giant tear in 17 patients. Our study included 17 patients (17 eyes), aged between 18 and 61 years, with retinal detachment associated with giant retinal tear. The size of the tear was between 90 degrees and 220 degrees . Proliferative vitreoretinopathy grade C was present in two eyes. Preoperative visual acuity ranged between 40/50 and light perception. All patients underwent scleral buckling, vitrectomy, perfluorocarbon liquid injection to flatten the retina, endophotocoagulation, cryoapplication and temporary silicone oil tamponade. Mean follow-up was 20 months +/- 16. Recurrent retinal detachment occurred in five eyes under silicone oil and in two eyes after its removal. Anatomical success at final follow-up was obtained in 14 eyes (82.3%). Visual acuity improved in all cases with anatomical success in all but one. The most frequent postoperative complications were cataract in 10 cases among 12 phakic eyes and ocular hypertension in four cases. Vitrectomy with internal silicone oil tamponade improves the anatomical and functional prognosis of retinal detachment associated with giant retinal tear. Recurrent retinal detachment is usually due to relapsing proliferative vitreoretinopathy. The most frequent postoperative complications remain lens opacification and ocular hypertension.

Effect of Internal Limiting Membrane Removal in Treatment of Retinal Detachment Caused by Myopic Macular Hole

The purpose of this study was to evaluate the anatomical outcomes of vitrectomy with internal limiting membrane removal in highly myopic eyes with retinal detachment caused by a macular hole. Nineteen, consecutive, highly myopic eyes with full thickness macular hole with retinal detachment were treated by vitrectomy with internal limiting membrane removal, endolaser photocoagulation on the center of the hole and fluid gas exchange. In five eyes with other peripheral breaks, scleral buckling (3 cases), encircling (1 case) and barrier laser (1 case) were combined. In 15 eyes (79.0%) the macular hole was closed after the initial surgery. In 4 eyes (21%) the macular hole was reopened, but these were successfully treated with fluid gas exchange (1 case) or macular buckling (3 cases). The visual acuity was improved in 15 eyes (79.0%). In conclusion, these results suggest that the removal of the perifoveal internal limiting membrane may be an important adjuvant in the treatment of the myopic macular hole with retinal detachment.

Surgical Treatment of Retinal Detachment due to Macular Hole in High Myopia

The use of vitrectomy combined with the adjunct of 18% C3F8 or silicone oil is a safe and effective method in treating retinal detachment due to macular hole in high myopia. Preoperative careful examination of ocular fundus, appropria te surgical design, and better surgical expertise are basic factors in treating this disease.

Perfluorocarbon liquid utilization in primary vitrectomy repair of retinal detachment with multiple breaks.

To evaluate the efficacy of pars plana vitrectomy in conjunction with intraoperative perfluoro-n-octane (PFO) use as initial treatment of retinal detachment (RD) with multiple breaks located at various distances from the ora serrata. Twenty-two consecutive eyes (15 phakic, 2 aphakic, and 5 pseudophakic) presenting with RD with multiple breaks and tears underwent primary pars plana vitrectomy, PFO retinal reattachment, transcleral cryopexy or endolaser treatment of breaks, PFO/air exchange, and final injection of 18% perfluoropropane (C3F8). Scleral buckles were not used. The mean follow-up period was 29 months. Temporary PFO utilization attached the posterior retina and facilitated the safe removal of vitreous at its base and around the retinal tears. Intraoperative complications included new breaks (3 eyes), enlargement of breaks (2 eyes), and a small bubble of subretinal PFO (1 eye). Postoperatively, the retina remained attached during follow-up in 19 eyes. Cataract developed or progressed in 13 phakic eyes. Pars plana vitrectomy in conjunction with intraoperative PFO utilization is effective as initial treatment of RDs with multiple breaks. The main limitation of this technique is the postoperative progressive cataract formation in phakic eyes.

Elevated proto-oncogene and collagen mRNA expression in PVR retinas

Retinal detachment is often accompanied by proliferation and migration of retinal cells and by increased synthesis of structural proteins, known as proliferative vitreoretinopathy (PVR). Herein we investigate the messenger RNA (mRNA) expression of proto-oncogenes responsible for cell proliferation and of structural proteins that have a role in membrane formation. Retinal samples were obtained from patients undergoing vitreoretinal surgery for the treatment of retinal detachment complicated by PVR. Normal human control retinas were obtained from cornea donors. The mRNA expression of the proto-oncogenes c- myc, c- fos and the proliferation marker Ki67, as well as of collagen type III and type IV, were investigated using the ribonuclease protection assay. Ki67 mRNA expression was not detectable in either sample type, but c- fos and c- myc mRNA expression was found in normal and PVR retinas. Whereas the expression of c- myc showed a marginal increase, the up-regulation in c- fos expression was strongly significant (5.07-fold). The mRNA of collagen type III was detectable at widely varying levels in all the PVR retinas but was found in only 2 of the 16 analysed normal samples. Collagen type IV mRNA was expressed in both PVR and control samples but was higher (2.21-fold) in the PVR retinas. These results indicate that an up-regulation of the proto-oncogene c- fos occurs in human PVR retinas. An increase in mRNA expression of collagen types III and IV takes place simultaneously. These changes in mRNA expression appear to be mainly connected to the initiation of cell proliferation, dedifferentiation and formation of tractional membranes.