Vitreoretinal Surgical Techniques Research Articles

Platelet rich plasma for primary macular hole: A case series.

To evaluate the anatomical and functional macular results and rate of complications following surgical treatment of primary macular hole (MH) with autologous platelet rich plasma (a-PRP) use. retrospective, interventional, non-randomized case series. A cohort of 9 consecutive patients from January 1, 2019 to August 31, 2021 who underwent vitrectomy with a-PRP use for primary MH were included. Anatomical results based on spectral domain- optical coherence tomography (SD-OCT) and visual acuity were analyzed. 10 pseudophakic eye of 9 patients were enrolled. Six patients were female and three patients were male. The mean age was 69.9 years ± 1.48. The baseline MH minimum diameter was 486.1 μm ± 37.1, and mean pre operative best-corrected visual acuity (BCVA) was 0.91 ± 0.03 logMAR (Snellen equivalent 20/160). Mean 1 month post operative BCVA was 0.81 ± 0.57 logMAR (Snellen equivalent 20/130; p = 1.000); mean 3 month post operative BCVA was 0.66 ± 0.04 logMAR (Snellen equivalent 20/90; p = 0.006); mean 6 month post operative BCVA was 0.6 ± 0.04 logMAR (Snellen equivalent 20/80; p < 0.001). In all eyes, 10/10 (100%), there was a complete MH closure at 6 months follow up: 5 eyes (50%) with a U-type closure pattern, 4 eyes (40%) with a V-type pattern and 1 eye (10%) with an irregular foveal contour closure at 6 month follow-up. No ocular and systemic complications were reported. The a-PRP use is a successful and promising vitreoretinal surgical technique option for primary MH.

Flanged Sutureless Intrascleral Fixation of Dislocated Hard 1-Piece Polymethyl Methacrylate Intraocular Lenses.

To describe the vitreoretinal surgical technique and report the outcomes of our method of sutureless flanged intrascleral haptic fixation of dislocated 1-piece polymethyl methacrylate intraocular lenses with rigid haptics. Ciliary sulcus-based scleral tunnels were created by placing valved 27-gauge (g) trocar cannulas limbus parallel with conjunctival displacement. After complete vitrectomy, the rigid haptics were then externalized using 27g forceps. Cautery was then used to form flanges at the haptic tips. The haptics were then pushed back into the mouths of the scleral tunnels. Flanged intrascleral fixation was successfully achieved in eight eyes of seven patients. The average age at the time of surgery was 75 ± 13.7 years, with a mean follow-up of 17.9 ± 16.3 months (range 3-42 months). Intraocular lens dislocation/subluxation was the most common indication for surgery. All patients fully recovered to their potential acuity by their third postoperative visit. The most significant complication was erosion of one haptic in one patient, which was successfully managed without requiring intraocular lens exchange. There were no complications of subsequent dislocation, endophthalmitis, retinal detachment, or uveitis-glaucoma-hyphema syndrome. Flanged sutureless intrascleral fixation of dislocated 1-piece polymethyl methacrylate intraocular lenses with rigid haptics can be safely and successfully performed, avoiding the large wound creation accompanying intraocular lens exchange and the disadvantages of suture-based techniques.

Management and Outcomes of Posterior Persistent Fetal Vasculature

To describe the clinical features, management and outcomes of posterior persistent fetal vasculature (PFV) and suggest a management algorithm. Retrospective consecutive case series. All children diagnosed with posterior PFV and treated or followed at the Rothschild Foundation Hospital in France between June 2011 and September 2021. Retrospective analysis of the clinical characteristics of posterior PFV. We reported at diagnosis: age, gender, presenting symptoms, intraocular pressure (IOP), visual acuity (VA). Patients were divided in four group depending on severity and involvement or not of the anterior segment. We reported the vitreoretinal surgical techniques used. Anatomical results, ocular hypertension, BCVA, presence of post-operative adverse events and additional surgical interventions were recorded at each follow-up visit. A total of 96 patients were included. Median age at diagnosis was 8 months (mean 18.9±30.9 months) with a mean follow-up of 27±31.2 months. Although PFV is often an isolated disease, it was associated with a systemic disease in 8% of cases. Posterior PFV was associated with anterior involvement in 62 eyes (64%). Forty-one eyes (42.7%) were microphthalmic and were more frequently associated with severe PFV [53% vs. 25%; (p=0.01)]. Surgery was performed in 85 patients (89%). Of them, 69 (81%) were a total success, 5 (6%) were a partial success due to a persistent limited peripheral retinal detachment (RD), and 11 (13%) were a failure due to persistent total RD after surgery. Twenty-four eyes presented post-operative adverse events including ocular hypertension requiring eye drop medication (6.6%), secondary cell proliferation around the IOL (7.7%), intravitreal hemorrhages (6.6%), persistent tractional RD (9.9%). A second surgery was performed in 15 patients (16%). At last follow-up, VA could be measured in logMAR in 43 children (45%), was light perception in 21 eyes (22%), and no light perception or impossible to assess in 32 eyes (33%). In our case-series, most of patients presenting PFV with posterior involvement received complex vitreoretinal surgery. Goals of the surgery varies, and include retinal flattening, reduction of vitreoretinal traction, freeing of the visual axis and aesthetic concerns. We proposed a surgical and medical management algorithm for PFV.

Long-term visual outcomes in familial exudative vitreoretinopathy (FEVR)

Anatomical and visual outcomes in familial exudative vitreoretinopathy (FEVR) have historically been disappointing. The present study seeks to determine the anatomical and functional outcomes of patients diagnosed with FEVR and maximally treated with available vitreoretinal surgical techniques.

Surgical Outcomes of Acute Retinal Necrosis–Related Retinal Detachment in Polymerase Chain Reaction–Positive Patients: A Single-Center Experience

To evaluate the clinical features, operative techniques, and surgical outcomes of patients who underwent surgery for acute retinal necrosis (ARN)-related retinal detachment (RD). Retrospective, longitudinal, consecutive case series. Patients with polymerase chain reaction-positive ARN presenting from 2011 to 2021 who underwent vitreoretinal surgery for ARN-related RD at our institution. Univariate, multivariate, and survival analyses were used to determine predictors of anatomic and functional outcomes. Single-surgery anatomic success rate, recurrent RD, and visual acuity (VA) at 1year. Thirty-four eyes of 34 patients (32.4% women, mean age, 45.1 ± 20.4 years) were included for analysis with a median follow-up of 2.5 years (interquartile range [IQR], 0.8-5.5 years). Presenting VA was 1.1±0.8 logarithm of the minimum angle of resolution (LogMAR) (Snellen ∼20/250). The median time from presentation to RD surgery was 1.7 months (IQR, 0.8-4.1 months), and the mean preoperative VA was 1.6 ± 0.8 LogMAR (Snellen ∼20/800). Small-gauge pars plana vitrectomy (PPV) with or without a scleral buckle (SB) was performed for all eyes with an overall single-surgery success rate of 63.6%, with no statistically significant differencesin visual/anatomic outcomes between PPV and PPV/SB cases. Silicone oil was used for tamponade in 33 (97.1%) cases and was removed in 10 (30.3%) with good anatomic and final functional outcomes (Snellen∼20/80). Independent predictors of recurrent RD included the female sex (hazard ratio, 8.38; 95% confidence interval, 2.03-34.68; P < 0.01) and zone 1 retinitis involvement at presentation (hazard ratio, 10.95; 95% confidence interval, 2.12-56.48; P < 0.01). The mean VA at 1 year (VA1year) and at the final follow-up both had a Snellen equivalent of 20/640 (P > 0.05 for both compared with preoperative VA, respectively). Eyes that achieved single-surgery success had VA1year of 20/200 versus hand movements in those with single-surgery failure (P < 0.01). On multivariate linear regression, younger age (P= 0.04) and better presenting VA (P<0.01) were both associated with better VA1year. Moderate single-surgery anatomic success can be achieved with modern vitreoretinal surgical techniques for ARN-related RD, although visual outcomes remain poor. Further studies investigating interventions for increasing single-surgery success rates, for the inflammatory complications of ARN, and for preventing ARN-related RD are needed.

Vitreoretinal Surgery in the Treatment of Dislocations of Intraocular Lens and Nucleus-Lens Particules into the Vitreous Cavity

Drops of lens nucleus/cortex particles into the vitreous cavity or dislocations of intraocular lenses (IOLs) are one of the serious complications of cataract surgery with an increasing relative frequency with the increase in the number of cataract surgeries. In addition, spontaneous and traumatic dislocations are other common case groups that should be treated. In this article, the vitreous dislocations of nucleus/cortex residues or IOL dislocations are discussed with different vitreoretinal surgical techniques.

Retinal arterial macroaneurysm in a patient with arterial hypertension

Purpose: To present a case of retinal arterial macroaneurysm in a 48–year–old male patient with systemic arterial hypertension.&#x0D; Case report: A 48–year–old male was admitted to our department because of progressive deterioration of visual acuity in his right eye. He reported diplopia and blurred central field vision. The patient was treated for systemic arterial hypertension and had no other known medical problems. Medical treatment, examination results, and therapy were presented in this case report.&#x0D; Conclusions: In the treatment of patients with retinal arterial macroaneurysm a holistic approach is important. In an attempt to optimize the final outcome of the patient's treatment, both the ocular symptoms and systemic risk factors should be treated. Therapeutic interventions for eyes with retinal arterial macroaneurysm include laser photocoagulation, pneumatic displacement of haemorrhage, vitreoretinal surgical techniques, the use of neodymium–doped yttrium aluminium garnet or argon laser, and intravitreal injections of anti–vascular endothelial growth factor drugs. Their precise roles should be evaluated in further studies.

Endoscopic Vitreoretinal Surgery; Basic Principles, Indications and New Directions

In this review, we aimed to give information about the historical development, basic features, and major indications of microendoscopy in vitreoretinal surgery. Microendoscopy permits vitreoretinal surgery for tissues that are not visible using operating microscopy ophthalmoscopy. Evolving technology may overcome the technical limitations of current endoscopic technology. Endoscopic vitreoretinal surgery is particularly useful when tissue details blurred by ocular media opacities or anterior chamber aberrations in contemporary surgical microscopic ophthalmoscopy. Microendoscopy is a robust platform for vitreoretinal surgery. Ophthalmic microendoscopy as a complementary method to modern vitreoretinal surgical techniques is very useful for safe surgery when an operating a microscope becomes insufficient.

EARLY DESCRIPTIONS OF VITREOUS SURGERY.

Vitreoretinal surgical techniques have evolved during the last decades because of the development and evolution of pars plana vitrectomy. The introduction of modern vitrectomy is credited to Robert Machemer (1933-2009). The aim of this review is to characterize the early developments of vitreous removal. We used the PubMed web platform to search the terms: complications of cataract surgery, vitrectomy, vitreous body, vitreous humor, vitreous humour, vitreous tap, and vitreous transplantation. Other publications were also considered as a potential source of information when referenced in relevant articles. The first description of vitreous removal for treatment of eye disorders dates the 17th century; it was conducted by a Dutch surgeon Anton Nuck (1650-1692) in a case of hydrophthalmia. In English literature, the first description of vitrectomy is attributed to the American surgeon John Collins Warren (1778-1856). This method was implemented in the spontaneous dislocation of the crystalline lens. As the fibrillar structure of the vitreous once destroyed could not be regenerated, the researchers aimed to restore the chemical composition of the vitreous. For several decades, vitreous transplantation was performed for the treatment of vitreous hemorrhages and retinal detachment. Although the achievements of vitreoretinal surgery preceding Machemer's inventions are uncommonly reported, they have contributed to the concept and understanding of the treatment modalities.

Perfluorocarbon liquid-assisted intraocular foreign body removal

Traumatic ocular injury is an uncommon yet leading cause of monocular blindness among the working-age group. Retained intraocular foreign body (IOFB) are associated with 41% of open globe injuries. Pars plana vitrectomy is often required for posterior segment IOFB removal. Advances in vitreoretinal surgical techniques and instrumentation have resulted in better treatment outcomes with reduced ocular morbidity. We report a case of modified ILM forceps with perfluorocarbon liquid-assisted non-magnetic IOFB removal in a young man after a motor vehicle accident with zone one open globe injury and a large glass IOFB in the right eye. We describe the use of perfluoro-N-octane to slide the IOFB extramacularly and reorient the IOFB plane for stable and safe retrieval by ILM end-gripping forceps. The modified design of the ILM end-gripping forceps with adjunctive use of perfluorocarbon liquid in pars plana vitrectomy reduces slippage during IOFB extraction and prevents collateral iatrogenic retinal injury.

To Study Presentation of Ocular Cysticercosis and Evaluate Its Demographic Data, Diagnosis, Treatment and Outcome in a Hill Population of Northern India

<i>Aim:</i> To study presentation of ocular cysticercosis and to evaluate its demographic data, diagnosis, treatment and outcome in hill population of Northern India. <i>Materials and methods:</i> This is a retrospective study carried out in Dehradun, Uttarakhand in a tertiary eye care hospital over 4 years from 2016-2020. The study involved 38 patients who presented with unilateral eye disease and were diagnosed to have ocular or adenexal cysticercosis. We analysed retrospectively their geographical data, clinical presentation, serology, imaging, response to treatment and clinical outcome. <i>Results:</i> Age of patients ranged from 16-54 years. Male to female ratio was 1:3.75. Total no. of eyes affected were 38. All were unilateral presentation. 30 eyes (78.94%) presented with extraocular cysticercosis and 8 eyes (21.05%) with intraocular cysticercosis. 27 of the patients (71.05%) were from lower socioeconomic status with poor hygiene and sanitation conditions. 32 (89.21%) patients gave history of association with non-vegetarian diet. Extraocular cysticercosis group had restriction of ocular motility as most prevalent presentation seen in 16 eyes (53.33%) and proptosis as the most prevalent sign seen in 17 eyes (56.66%). Cyst prevalence was most frequently detected in superior rectus muscle seen in 14 eyes (53.84%). Intraocular cysticercosis group had blurring of vision as the most prevalent presenting symptom in 8 eyes (100.0%). Panuveitis in 6 eyes (75%) and presence of subretinal cyst in 4 eyes (50%) was the most prevalent sign seen in intraocular cysticercosis group. Enzyme linked immunosorbent assay test confirmed serology in 35 cases (92.10%). The USG B-scan detected presence of scolex in 36 eyes (94.73%). Magnetic resonance imaging (MRI) confirmed deep seated extraocular cysticercosis lesions and neurocysticercosis (NCC) undetected by computerized tomography (CT). CT was diagnostic for NCC in 5 cases (13.15%). Oral Albendazole and prednisolone were successful in management of extraocular cysticercosis. Intraocular cysticercosis was treated well with pars plana vitrectomy surgery with good visual recovery. <i>Conclusion:</i> Extraocular cysticercosis was more prevalent than intraocular cysticercosis. Early diagnosis and treatment made a difference in final outcome of the two groups. Imaging studies of orbital B-scan ultrasonography (USG B scan), CT and MRI with immune serological test of enzyme linked immunosorbet assay (ELISA) and Western blot for anticysticercus antibodies helped in confirming the diagnosis. Extraocular cysticercosis can be managed well medically with good clinical outcome. Intraocular cysticercosisis is best treated surgically. Safer and modern vitreoretinal surgical techniques promise good surgical outcome and visual recovery. Timely intervention and frequent postoperative follow up would help in keeping a watch on development of complications and maintenance of good vision.

Implantation and Extraction of Penetrating Electrode Arrays in Minipig Retinas.

PurposeThis work was motivated by the goals of demonstrating methods to fabricate and implant large numbers of penetrating arrays into the retina and the feasibility of extraction.MethodsArrays of inactive, three-dimensional (3D) SU-8 structures were microfabricated onto 13-µm polyimide substrates. Standard vitreoretinal surgical techniques were used with an ab externo approach for subretinal implantation of arrays in 12 mini-pigs. In the first three surgeries, different post-geometries were explored, while a preferred design (128-µm tall, 30-µm diameter, 200-µm spacing) was used for the remaining nine implantations. Two arrays were extracted. Funduscopy, optical coherence tomography (OCT) and immunohistochemistry of the retinae were performed. The unoperated eyes and tissue far from implantation served as controls. A thirteenth pig was implanted with a planar array.ResultsTen implant surgeries had no significant complication, and two arrays were successfully extracted. One retinal tear occurred after implantation due to too long posts in an early surgery. In “successful” cases, OCT showed close apposition of the arrays to the retina and integration of the posts, the tops of which were positioned at the junction of the inner plexiform and ganglion cells, without significant gliosis.ConclusionsThese results provide a proof-of-concept that relatively large numbers of 3D posts can be implanted into, and extracted from, the retina of mini-pigs. Our surgical numbers were relatively small, especially for the extractions, and our conclusions must be viewed with that limitation. Our methods are applicable for human surgeries.Translational RelevanceThis study provides results of implantation and extraction of relatively large numbers of 3D posts from the retina of minipig eyes. If similar technology were used in humans, a 3D array of this type should lower perceptual thresholds, provide safer long-term stimulation, and perhaps provide better perceptual outcomes.

&lt;p&gt;The Evolving Treatment of Diabetic Retinopathy&lt;/p&gt;

PurposeTo review the current therapeutic options for the management of diabetic retinopathy (DR) and diabetic macular edema (DME) and examine the evidence for integration of laser and pharmacotherapy.MethodsA review of the PubMed database was performed using the search terms diabetic retinopathy, diabetic macular edema, neovascularization, laser photocoagulation, intravitreal injection, vascular endothelial growth factor (VEGF), vitrectomy, pars plana vitreous surgery, antiangiogenic therapy. With additional cross-referencing, this yielded 835 publications of which 301 were selected based on content and relevance.ResultsMany recent studies have evaluated the pharmacological, laser and surgical therapeutic strategies for the treatment and prevention of DR and DME. Several newer diagnostic systems such as optical coherence tomography (OCT), microperimetry, and multifocal electroretinography (mfERG) are also assisting in further refinements in the staging and classification of DR and DME. Pharmacological therapies for both DR and DME include both systemic and ocular agents. Systemic agents that promote intensive glycemic control, control of dyslipidemia and antagonists of the renin-angiotensin system demonstrate beneficial effects for both DR and DME. Ocular therapies include anti-VEGF agents, corticosteroids and nonsteroidal anti-inflammatory drugs. Laser therapy, both as panretinal and focal or grid applications continue to be employed in management of DR and DME. Refinements in laser devices have yielded more tissue-sparing (subthreshold) modes in which many of the benefits of conventional continuous wave (CW) lasers can be obtained without the adverse side effects. Recent attempts to lessen the burden of anti-VEGF injections by integrating laser therapy have met with mixed results. Increasingly, vitreoretinal surgical techniques are employed for less advanced stages of DR and DME. The development and use of smaller gauge instrumentation and advanced anesthesia agents have been associated with a trend toward earlier surgical intervention for diabetic retinopathy. Several novel drug delivery strategies are currently being examined with the goal of decreasing the therapeutic burden of monthly intravitreal injections. These fall into one of the five categories: non-biodegradable polymeric drug delivery systems, biodegradable polymeric drug delivery systems, nanoparticle-based drug delivery systems, ocular injection devices and with sustained release refillable devices. At present, there remains no one single strategy for the management of the particular stages of DR and DME as there are many options that have not been rigorously tested through large, randomized, controlled clinical trials.ConclusionPharmacotherapy, both ocular and systemic, will be the primary mode of intervention in the management of DR and DME in many cases when cost and treatment burden are less constrained. Conventional laser therapy has become a secondary intervention in these instances, but remains a first-line option when cost and treatment burden are more constrained. Results with subthreshold laser appear promising but will require more rigorous study to establish its role as adjunctive therapy. Evidence to support an optimal integration of the various treatment options is lacking. Central to the widespread adoption of any therapeutic regimen for DR and DME is substantiation of safety, efficacy, and cost-effectiveness by a body of sound clinical trials.

Endoresection utilizing pars plana vitrectomy for benign and malignant intraocular tumors.

Endoresection of intraocular tumors is a complicated procedure utilizing pars plana vitrectomy techniques. Though it has potential downsides and complications, there is potential for this technique in the treatment of malignant and benign intraocular tumors. Endoresection has been utilized in some form for the last three decades, but recent advances in vitreoretinal surgery have improved the technique. Endoresection is used most commonly to treat posterior uveal melanoma, but success in treating benign tumors, such as astrocytoma or retinal capillary hemangioblastoma has emboldened surgeons to expand its indications. It appears that removal of a malignant tumor, such as uveal melanoma may spare the eye some damaging effects of radiation retinopathy and radiation optic neuropathy. These benefits may occur even when the tumor is treated concurrently with plaque brachytherapy, proton beam irradiation, or stereotactic radiotherapy. The benefits of the technique are tempered, however, by the inherent difficulties associated with performing the surgery. These include potentially severe intraoperative bleeding, recurrent rhegmatogenous retinal detachment with proliferative vitreoretinopathy, air embolism, and recurrence of the tumor at the edge of the resection. Nonetheless, endoresection has recently been used for retinoblastoma in refractory cases in order to spare the globe. Endoresection is an advanced vitreoretinal surgical technique that has potential advantages in the treatment of malignant and benign intraocular tumors.

Factors Affecting the Outcome of Scleral Buckling Surgery for Primary Rhegmatogenous Retinal Detachment.

Introduction Scleral buckle surgery retains a special place in treatment of retinal detachment despite development of new and advanced vitreoretinal surgical techniques. The outcome of any retinal detachment surgery depends on correct selection of patient, type and nature of detachment, and the expertise. This study aims to evaluate various other parameters that determine the outcome of scleral buckle surgery. Method Records of 55 patients with primary rhegmatogenous retinal detachment treated with scleral buckling over a duration of 18 months that had a minimum of 3-month follow-up were retrospectively reviewed. Preoperative and postoperative characteristics were recorded. Parameters that were evaluated to determine the outcome were best-corrected visual acuity (BCVA), anatomical success, and complications. Results A total of 51 eyes of 50 patients that met the inclusion criteria were included. Mean age was 41 ± 19.9 years (range: 9 to 83). Primary anatomical success was achieved in 80.4%. Parameters significantly associated with the anatomical outcome of surgery were status of lens, preoperative visual acuity, and extent of retinal detachment. There was a significant improvement of visual acuity postoperatively. Conclusion Scleral buckle surgery is a highly effective surgery in uncomplicated retinal detachment cases, and single surgery success rates are better in cases with good preoperative visual acuity, partial detachment, and clear crystalline lens.

Differential association of elevated inflammatory cytokines with postoperative fibrous proliferation and neovascularization after unsuccessful vitrectomy in eyes with proliferative diabetic retinopathy.

BackgroundPars plana vitrectomy is the only treatment for advanced proliferative diabetic retinopathy (PDR). However, vitrectomy is not always successful despite current progress in vitreoretinal surgical techniques. The aim of our study was to investigate whether the vitreal concentrations of MCP-1, IL-6, IL-8, and VEGF are elevated after unsuccessful vitrectomy in patients with PDR and to investigate whether the altered levels of these cytokines are associated with the cause for the reoperation.Patients and methodsVitreous samples were collected from 263 eyes of 233 patients: PDR (n=129 eyes), proliferative vitreoretinopathy (PVR; n=24 eyes) and nondiabetic controls (n=110 eyes) prior to vitrectomy. Vitreous samples were also collected from 14 eyes of 14 patients with PDR before vitrectomy and from the same 14 eyes before a second vitrectomy for reoperation. The levels of MCP-1, IL-6, IL-8, and VEGF were measured by flow cytometry using a cytometric bead array (CBA) assay.ResultsThe mean concentrations of vitreal MCP-1, IL-6, IL-8, and VEGF were significantly higher in patients with PDR and PVR (P<0.01). There were significantly high correlations among the concentrations of MCP-1, IL-6, and IL-8, whereas the correlation of VEGF with the other 3 cytokines was lower. Among the 14 patients who required reoperation, the mean vitreal concentrations of MCP-1, IL-6, and IL-8 were higher than that at the time of the initial vitrectomy (P<0.01). At the time of the reoperation vitrectomy, the mean vitreous level of MCP-1, IL-6, and IL-8 in eyes with fibrous proliferation was higher than in those without fibrous proliferation (P<0.05). In contrast, VEGF in eyes with neovascular glaucoma (NVG) or anterior hyaloidal fibrovascular proliferation (AHFVP) was higher than in the eyes without NVG and AHFVP (P<0.05).ConclusionThe elevated levels of MCP-1, IL-6, and IL-8 may be the cause of the postoperative fibrous proliferation. In contrast, VEGF may be the cause of the neovascularization after unsuccessful vitrectomy in the eyes of PDR patients.

Vitreous Substitutes: Old and New Materials in Vitreoretinal Surgery.

Recent developments in vitreoretinal surgery have increased the need for suitable vitreous substitutes. A successful substitute should maintain all the physical and biochemical properties of the original vitreous, be easy to manipulate, and be long lasting. Substitutes can be gaseous or liquid, both of which have associated advantages and disadvantages related to their physical properties and use. Furthermore, new surgical techniques with smaller vitreoretinal instruments have driven the use of more viscous substitutes. In this review, we analyze and discuss the most frequently used vitreous substitutes and look ahead to future alternatives. We classify these compounds based on their composition and structure, discuss their clinical use with respect to their associated advantages and disadvantages, and analyze how new vitreoretinal surgical techniques have modified their use.

Characteristics and Outcomes of Simultaneous Bilateral Rhegmatogenous Retinal Detachments.

To better understand the clinical course and outcomes of simultaneous bilateral retinal detachments managed by modern vitreoretinal surgical techniques. A retrospective review of 21 patients (42 eyes) presenting between April 2000 and June 2015 with simultaneous bilateral rhegmatogenous retinal detachments. Mean visual acuity (VA) improved from 20/100 at presentation to 20/40 at last follow-up (P = .01). The mean final VA for patients undergoing scleral buckle (SB) alone was 20/30 (log MAR 0.17), pars plana vitrectomy (PPV) alone was 20/40 (logMAR 0.33), and combined PPV/SB was 20/80 (logMAR 0.59) (P = .019). Primary reattachment rate in this series was 98%. In contrast to prior studies, which investigated the management of simultaneous bilateral retinal detachments primarily by SB alone, multiple treatment modalities were utilized in this study, including vitrectomy alone, and overall success of retinal detachment repair was high regardless of treatment modality chosen. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:840-845.].

Safety and Complications of Ocriplasmin

Our ability to examine the vitreoretinal interface has been greatly improved by the invention of spectral-domain optical coherence tomography (OCT). It has allowedearlier andmore accurate diagnosis of abnormalities of vitreomacular adhesion (VMA) that may contribute to vision loss and may benefit fromintervention.While subtle abnormalitiesofVMAmay be observed, symptomatic VMA or that associated with fullthicknessmacularhole (FTMH) requires surgical intervention.1 With improvements in vitreoretinal surgical techniques and better understanding of these conditions, outcomes of surgicalmanagementofVMA-relateddisorders areexcellent.1However, even in thehandsof themost experiencedsurgeon, there are associated surgical risks. There is also expected discomfort to the patient, delay in visual recovery, high cost, and, in cases of surgery for FTMH, postoperative positioning. Furthermore, advanced surgical skills are required for epiretinal membrane or internal limiting membrane peeling. Ocriplasmin (Jetrea) is a recombinant truncated form of human plasminwith amolecularweight of 27.2 kDa. It is a recombinantproteasewithactivity against fibronectinand laminin, which are components of the vitreoretinal interface.2 In 2 phase 3 clinical trials comparing a single intravitreal injection of ocriplasmin (0.125 mg/0.1mL)with aplacebo injection (drug vehicle diluted with saline) inpatientswith symptomaticVMA,where theprimaryendpointwas resolutionofVMAatday28, 26.5%ofocriplasmin-injected eyes had resolution comparedwith 10.1%of placebo-injectedeyes (P < .001).3Nonsurgical closureofmacular holeswas achieved in 40.6%of ocriplasmin-injected eyes, as compared with 10.6% of placebo-injected eyes (P < .001). Consequently, ocriplasminwas approved by the US Food and DrugAdministration (FDA) foruse in symptomaticVMA inOctober 2012. It is notable that ocriplasmin is a first-in-class pharmacologic agent that has been FDA approved to manage symptomatic VMA. Furthermore, the primary end point in the pivotal studieswasbasedonOCTchanges rather thanonvisual acuity improvement, the first time, to my knowledge, that OCT has beenusedas theprimaryoutcomeforaclinical trial inophthalmology. Finally, even when patients do not achieve release of abnormal VMA or closure of FTMH following intravitreal ocriplasmin injection, they can still undergo surgical management.Therefore,ocriplasminofferscliniciansanadditional tool tomanage the anatomical abnormalities of symptomatic VMA in a less invasivemanner thanwith surgery in select cases. However, since the real-worlduseof thedrugbegan, there have been unfavorable anecdotal reports of visual disturbancesafterocriplasmin injection, including transientbutprofound visual decline, raising concerns regarding its safety. While it is not possible to know the frequency of these events in postmarketing surveillance, it is worthwhile to pay attention to safety-related reports. In the report of phase 3 trials of ocriplasmin, ocular adverse events such as vitreous floaters, photopsia, conjunctival hemorrhage, blurred vision, and visual impairment were found to be significantly higher in the treatment group comparedwith theplacebogroup.3However, theauthors state that “most of the adverse events were transient and mild in severity.”3 TheWarnings and Precautions section of the package insert for ocriplasmin4 includesdecreaseof 3ormore lines of best-correctedvisual acuity in 5.6%ofpatients treatedwith ocriplasmin (comparedwith 3.2% in the control group), intravitreal injectionprocedure–associated effects (intraocular inflammation, intraocular hemorrhage, increased intraocular pressure), potential for lens subluxation, retinal breaks, and dyschromatopsia. It states that “dyschromatopsia (generally described as yellowish vision) was reported in 2% of all patients injectedwith Jetrea. In approximatelyhalf of thesedyschromatopsia cases therewerealsoelectroretinographic (ERG) changes reported (aand b-wave amplitude decrease).”4 According to the FDA Advisory Committee briefing document, 9 patients receiving ocriplasmin in various clinical trialswere reportedtohaveexperiencedanacutedecrease invisionwithin 24hours of injection, some to the handmotions level.5 In 8 of 9 patients, vision returned to baseline with a median recovery time of 2 weeks. Dyschromatopsia reportedly resolved within a median time of 3 months. Of the 141 ocriplasmintreatedpatientswhounderwentERGtesting, 11 (7.8%)hadERG changes and 9 of these patients also had dyschromatopsia. Among the 11 patientswithERGchanges, theERGchanges resolved in 6 patients (median time, 6 months), 3 did not have follow-up ERGs, 1 was still undergoing follow-up, and 1 case did not resolve and was thought to be due to concurrent vitelliform dystrophy. Recently, there was a report of a patient with symptomatic VMA, epiretinal membrane, and an impending FTMH who experienced transient vision loss after ocriplasmin injection.6 The patient was found to have disruption of the outer retina, in particular the ellipsoid zone (previously known as the inner segment/outer segment junction), on spectral-domain OCT that partially recovered by 3 weeks along with improvement in visual acuity.6 Two brief reports Related articles pages 484 and 487 Opinion

Drug Delivery to the Back of the Eye Following Topical Administration: An Update on Research and Patenting Activity

Drug delivery to the back of the eye following topical administration remains an unmet need for the scientific community. Treatment of posterior segment diseases requires localized and long-term drug delivery to the retina, choroid, and Bruch's membrane. Until the last decade, there was limited evidence from large clinical trials that demonstrated the usefulness of pharmacotherapy compared to laser therapy or other vitreoretinal surgical techniques for the treatment of retinal diseases. This paradigm has shifted in recent years, with strong evidence demonstrating superior efficacy of ophthalmic drugs compared to previous gold standards. However, ophthalmologists are left with no options other than administering the therapeutics via implants and intravitreal injections, which are highly invasive and associated with patient non-compliance. A non-invasive topical therapy would enhance patient compliance and minimize the side-effects associated with intraocular implants and intravitreal injections. In an attempt to enhance patient compliance, the focus of research has shifted to the development of novel small molecule-based eye drop formulations. This review article discusses the relevant patents and summarizes the resurgence in the treatment of posterior segment eye diseases through topical drug administration.