ARVO 2014 Annual Meeting Abstracts 276 Vitreoretinal Surgery

Transcription

ARVO 2014 Annual Meeting Abstracts
276 Vitreoretinal Surgery
Monday, May 05, 2014 3:45 PM–5:30 PM
Exhibit/Poster Hall SA Poster Session
Program #/Board # Range: 2294–2350/A0342–A0398
Organizing Section: Retina
Contributing Section(s): Lens
Program Number: 2294 Poster Board Number: A0342
Presentation Time: 3:45 PM–5:30 PM
Retinotomies and Retinectomies: When and How? Technique,
Results and Complications. An Update
Marcelo Zas, Arturo Alezzandrini, Lucas Adamo, Matias Iglicki,
Carmen N. Demetrio, Gaston Gomez Caride, Juan Pablo Francos,
Liliana Coletti, Paola Rinaudo, Pablo Chiaradia. Ophthalmology,
Hospital de Clinicas, School of Medicine, University of Buenos
Aires, Ciudad Autonoma, Argentina.
Purpose: To assess the techniques, indications, and complications
of relaxing retinotomies and retinectomies for complicated retinal
detachment (RD) with severe proliferative vitreoretinopathy (PVR).
Methods: We studied 36 patients of complicated retinal detachment
with severe PVR in a noncomparative retrospective study. Follow
up was at least 12 months. Techniques included scleral buckling,
vitrectomy 23 and 25 g (MIVS), membrane peeling, relaxing
retinotomy and/or retinectomy and intraocular tamponade with
silicon oil (SO).
Results: Retina was reattached in 30 (83 %) of our cases. Retinal
detachment was recurrent in 6 eyes in follow-up. Visual acuity (VA)
was light perception in 28 (77%) eyes and hand motion in 8 (22%)
eyes in the preop. and was better than 4/60 in 20 eyes (66 %) in the
postop. Intraoperative complications included bleeding, iatrogenic
retinal breaks, recurrent fibrous proliferation and subretinal SO.
Conclusions: Retinotomy and retinectomy can improve the
therapeutic effect of complicated retinal detachment in PVR cases.
Complications of these maneuvers are high and should be manage
properly.
Commercial Relationships: Marcelo Zas, None; Arturo
Alezzandrini, None; Lucas Adamo, None; Matias Iglicki, None;
Carmen N. Demetrio, None; Gaston Gomez Caride, None; Juan
Pablo Francos, None; Liliana Coletti, None; Paola Rinaudo, None;
Pablo Chiaradia, None
Outcomes After Inferior Retinectomy in Complex Retinal
Detachment
Fernando Nobrega1, Mario J. Nobrega2, 3. 1Medical Student,
University of Alfenas (UNIFENAS), Alfenas, Brazil; 2Departament of
Retina and Vitreous, Sadalla Amin Ghanem Eye Hospital, Joinville,
Brazil; 3University of Joinville (UNIVILLE), Joinville, Brazil.
Purpose: To evaluate anatomical and visual outcomes after
retinectomy in patients operated on retinal detachment and
proliferative vitreoretinopathy in a referential eye-care centre in
Joinville, southern Brazil.
Methods: Retrospective, non-comparative, consecutive case series.
Cases included all patients with retinal detachment and grade C
posterior proliferative vitreoretinopathy examined and operated from
May 2002 to May 2013. The initial surgery, performed in all the
eyes, included pars plana vitrectomy, 360-degree scleral buckling,
laser endophotocoagulation around the retinal tears and silicone oil
infusion or gas tamponade in the vitreous cavity.
Results: Twenty four patients underwent inferior retinectomy.
Fourteen (58,3%) were men and the mean age was 46,9 years-old
(range 12-72 yo). Follow-up varied between 119 days and 3664 days
(medium 1298,7 days). Fifteen (62,5%) had the retina attached at the
last examination and nine (37,5%) had a recurrent retinal detachment
after retinectomy. Visual acuity improved in 13 patients (54,1%),
stabilized in 5 patients (20,8%) and decreased in 6 patients (25%).
Conclusions: Silicone oil removal provided good anatomical and
visual results in most of the patients. Nevertheless, 3 cases had
unfavorable outcomes, particularly one with a severe and unexplained
vision loss. Surgeons must be aware of this possibility and analyse
the costs and benefits of silicone oil extraction. Prospective and
comparative studies are required to assess properly not only the
advantage of removing silicone oil but also the safety and efficacy of
a previous prophylactic peripheral laser photocoagulation in patients
with complex retinal detachments.
Commercial Relationships: Fernando Nobrega, None; Mario J.
Nobrega, None
COMPARISON OF CLINICAL OUTCOMES
BETWEEN 27-GAUGE TRANSCONJUNCTIVAL
NONVITRECTOMIZING VITREOUS SURGERY AND
25-GAUGE VITRECTOMY IN PATIENTS WITH
EPIRETINAL MEMBRANE
Cesare Mariotti1, Francesca Viti1, Andrea Saitta1, Michele Nicolai1,
Salvatore Faro2, Emanuele Orsini1, Livio Giulio Marco Franco2,
Caterina Gagliano2, Santo Stella2, Michele Reibaldi2. 1Clinica
Oculistica, Universita Politecnica delle Marche, Ancona, Italy;
2
Ophthalmology, University of Catania, Catania, Italy.
Purpose: To compare the clinical outcomes and the rate of
complications between 27-gauge transconjunctival nonvitrectomizing
vitreous surgery (NVS) and 25-gauge transconjunctival sutureless
vitrectomy surgery for idiopathic epiretinal membrane (ERM)
removal.
Methods: In this retrospective, comparative study, all consecutive
phakic patients with an idiopathic ERM, that underwent 25-gauge
standard vitrectomy (Standard-group), or 27-gauge NVS (NVS
group), between May 2010 and January 2012, with a minimal followup of 12 months, were evaluated. Main outcome measures were
best-corrected visual acuity (BCVA), optical coherence tomography
(OCT) changes, and nuclear sclerotic cataract progression, at 6
months and 12 months after surgery.
Results: Mean logarithm of the minimal angle of resolution BCVA
improved significantly at all time points (P < .01,Tukey–Kramer test),
in the standard group from 0.43 to 0.24 at 12 months and in the NVS
group from 0.46 to 0.16, without significant difference between the 2
groups. Compared with baseline, at 6 and 12 months after treatment,
central foveal thickness decreased significantly in both groups (P <
.01,Tukey–Kramer test), with no significant difference between the
2 groups at any time point. At 12 months eyes undergoing standard
vitrectomy surgery developed significantly more nuclear light scatter
than in the lens of the NVS-group ones (79 % vs 12 %; P < .001,
chi-square). At 12 months, the ERM recurred in 4% of eyes in the
Standard-group and in 14% of eyes in the NVS-group, without
significant difference between the 2 groups.
Conclusions: The 27-gauge NVS is an effective method as
vitrectomy in the treatment of ERM, with less progression of cataract.
Commercial Relationships: Cesare Mariotti, None; Francesca
Viti, None; Andrea Saitta, None; Michele Nicolai, None; Salvatore
Faro, None; Emanuele Orsini, None; Livio Giulio Marco Franco,
None; Caterina Gagliano, None; Santo Stella, None; Michele
Reibaldi, None
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at [email protected].
Outcomes and Complications of Vitreoretinal Surgery in Patients
with Proliferative Sickle Retinopathy
Royce W. Chen, Harry W. Flynn, Wen-Hsiang Lee, David W. Parke,
Ryan F. Isom, Janet L. Davis, William Smiddy. Bascom Palmer Eye
Institute, Miami, FL.
Purpose: To report the outcomes and complications of proliferative
sickle retinopathy.
Methods: Retrospective, interventional case series. Patients were
managed with vitreoretinal surgery over a 12-year period at a single
institution.
Results: The study included 15 eyes of 14 patients. Nine patients had
an SC hemoglobin profile, 1 was S beta-thal, and 4 were AS. All 15
eyes underwent pars plana vitrectomy (PPV). Indications for surgery
included: vitreous hemorrhage (VH), 6 eyes, epiretinal membrane
(ERM), 1 eye, and tractional retinal detachment (TRD) and/or
rhegmatogenous retinal detachment (RRD), 8 eyes. 20-gauge PPV
was used in 7 cases, 23-gauge in 3, and 25-gauge in 5. All 7 eyes
with VH or ERM had improved vision postoperatively. Of the eyes
with TRD and/or RRD, 4 (50%) developed recurrent detachments
associated with proliferative vitreoretinopathy and required a second
operation. Additionally, among the patients with retinal detachments,
2 patients had an encircling scleral buckle. All retinas were attached
at last follow-up, and visual acuity was 20/400 or better in all eyes.
Anterior segment ischemia did not occur.
Conclusions: Using current vitreoretinal surgery techniques, the
anatomic and visual outcomes were favorable, and anterior segment
ischemia was avoided. Eyes with TRD/RRD often required a second
surgical procedure.
Commercial Relationships: Royce W. Chen, None; Harry W.
Flynn, Santen (C); Wen-Hsiang Lee, None; David W. Parke, None;
Ryan F. Isom, None; Janet L. Davis, Clearside (C), Santen (C),
Xoma (C); William Smiddy, None
Support: NIH Center Core Grant P30EY014801, Research to
Prevent Blindness Unrestricted Grant, Department of Defense (DODGrant#W81XWH-09-1-0675). RC was supported by a merit award
from the Heed Ophthalmic Foundation and Society of Heed Fellows.
Anterior Vitrectomy vs Triamcinolone Assisted Vitrectomy
Jose A. Nava. Instituto de Oftalmologia - Catarata, Centro Medico
Zambrano Hellion - Tec de Monterrey, San Pedro Garza Garcia,
Mexico.
Purpose: To compare the postoperative results in patients who had
Anterior Vitrectomy (VAS) vs Triamcinolone Assisted Vitrectomy
(VAT) in an ophthalmology training center.
Methods: Cataract surgery cases with vitreous loss from an
ophthalmology training center were randomly injected with air
and triamcinolone suspension (40 mg/ml). A maximum dose of
4mg/0.1ml was injected into the anterior chamber to visualize the
vitreous. The anterior chamber was refilled with BBS and anterior
vitrectomy was performed. Postoperative results were compared
Results: 24 cases with vitreous loss were evaluated. VAT vs VAS
results were: residual vitreous strands to the wound VAT(0) / VAS(8);
intraocular pressure > 25 mmHg VAT(3) / VAS(3); corneal edema
VAT(0) / VAS(6); Retinal detachment VAT(0) / VAS(1).
Conclusions: The use of triamcinolone during anterior vitrectomy
improved visualization of vitreous and reduced postoperative
inflammation
Commercial Relationships: Jose A. Nava, None
Recombinant Tissue Plasminogen Activator for Submacular
Hemorrhage Displacement in Age-Related Macular Degeneration
Emilia Maggio1, Antonio Polito1, Massimo Guerriero2, Grazia
Pertile1. 1Ophthalmology, Sacrocuore Hospital, negrar, Italy;
2
Computer Science, University of Verona, Verona, Italy.
Purpose: The visual prognosis of submacular hemorrhages (SMH)
secondary to age-related macular degeneration (AMD) is potentially
devastating when left untreated. The displacement of SMH with
intravitreal recombinant tissue plasminogen activator (rtPA) and
gas injection may allow extrafoveal resorption of the hemorrahage,
postoperative diagnostic testing and, potentially, subsequent
treatments.
Methods: We retrospectively analyzed medical records of all
patients with acute SMH secondary to AMD treated with a single
0.05-mL intravitreal injection of 50 μg alteplase, 0.3 mL of 100%
sulphur hexafluoride gas (SF6) and face down positioning for 1 week
from 2004 to 2012. The majority of eyes also received additional
treatments for AMD following two months after the procedure. The
main outcome measures were the displacement of the hemorrhage,
complication rate and visual acuity (VA) at 1 month after the
procedure, at 1 year and at the last follow-up visit.
Results: Seventy-eight eyes were eligible for the study. One week
after the procedure, the hemorrhage was successfully displaced
in all eyes. No significant complications from the procedure were
identified. Mean follow-up was 26 months (min 6 months; max 8
years). Additional treatments during the follow-up were: anti-VEGF
intravitreal injections (32,1%), macular translocation (26.9%),
autologous RPE-choroid patch graft (3,8%) and membranectomy
(5,1%). Twenty-five patients (32,1%) did not undergo additional
treatments. Mean VA at baseline was 1,7(0,94) logMar. It
significantly improved to 1,26(0,79) logMAR at 1 month and
1,29(0,78) logMAR at 1 year (p=0,00001). At the last follow-up
visit mean VA was 1.35(0,87) logMAR. Worst VA was found after
longer follow-up period and in eyes who did not receive additional
treatments.
Conclusions: The use of intravitreal rtPA and gas injection is
safe and effective to displace recently developed SMH in patients
with AMD and to prevent macular damage from retinotoxic blood
components such as hemosiderin, fibrin and iron. Although the
final visual outcomes may be limited by the progression of AMD,
significant visual restoration is possible in selected cases after the
application of additional treatments.
Commercial Relationships: Emilia Maggio, None; Antonio Polito,
None; Massimo Guerriero, None; Grazia Pertile, None
Persistent submacular fluid after vitrectomy with immediate
postoperative face down positioning for macula off
rhegmatogenous retinal detachment
Trishna U. Mohite1, Rajeev Buddi2. 1Phillips Exeter Academy, Exeter,
NH; 2Northeast Wisconsin Retina Associates, Neenah, WI.
Purpose: To determine the incidence of and clinical factors
associated with persistent submacular fluid (SMF) after pars
plana vitrectomy (PPV) with immediate postoperative face down
positioning for macula off rhegmatogenous retinal detachment
(RRD).
Methods: A retrospective chart review was done for all patients
with macula off RRD who underwent uncomplicated primary
PPV with internal drainage of SRF without intraoperative use of
perfluorocarbon liquid and with immediate postoperative face down
positioning. Eyes with pre-existing pathology including proliferative
vitreo-retinopathy, macular degeneration, retinal vein occlusion,
epiretinal membrane, macular hole, and diabetic macular edema
were excluded as were patients requiring immediate reoperation. All
procedures were performed by the same surgeon over a 5 year period.
Clinical factors evaluated included duration of RRD, high myopia
(> 6 diopters), and duration of tamponade (C3F8 gas or air). Clinical
evaluation and optical coherence tomography (OCT) for SMF was
done at 3 weeks or later following surgery.
Results: Eighty five eyes met the criteria for inclusion in this study.
Of these, nine eyes (10.5%) showed SMF at some point (> 3 wks)
after surgery. None of the eyes in the high myopia group (n=9) had
SMF. Neither the duration of RRD prior to surgery (p>0.05), nor the
duration of tamponade (p>0.05) influenced the presence of SMF.
Conclusions: Compared to published literature (PPV for RRD),
immediate postoperative face down positioning did not influence
the incidence of SMF for macula off RRD. Duration of retinal
detachment, high myopia and duration of postoperative tamponade
did not show any statistical association with presence of SMF.
Commercial Relationships: Trishna U. Mohite, None; Rajeev
Buddi, None
Posterior vitreous detachment in highly myopic eyes undergoing
vitrectomy
Elise Philippakis1, Aude Couturier1, Vincent Gualino1, David
Gaucher2, Alain Gaudric1, Pascale G. Massin1, Ramin
Tadayoni1. 1Ophthalmology, Lariboisiere Hospital, Paris, France;
2
Ophthalmology, Strasbourg University Hospital, Paris, France.
Purpose: To report the rate of complete posterior vitreous
detachment (PVD) in highly myopic eyes requiring vitreoretinal
surgery, using intraoperative observation.
Methods: A retrospective observational analysis was performed
on highly myopic eyes (refractive error (RE)<-6,00D, Axial length
(AL)>26mm or biomicroscopy signs of high myopia) who had
undergone 25G 3-port pars plana vitrectomy in the department of
Ophthalmology of Lariboisiere Hospital between 2009 and 2012. The
main outcome was the intra operative evaluation of complete PVD :
absence of residual posterior vitreous cortex after staining or peeling.
The complete PVD was considered absent when either there was no
PVD, partial PVD or remnants of posterior vitreous cortex.
Results: Ninety six eyes of 95 patients were included. Mean age was
62,15 years (range 29-95), mean refractive error(RE) was -13,9D
and mean axial length(AL) was 29,2mm. Surgical indications were
epiretinal membrane (ERM), Macular Hole (MH), foveoschisis
(FVS), rhegmatogenous retinal detachment (RD) or macular hole
retinal detachment (MHRD).
Complete PVD was identified in 52.1% of eyes. This PVD rate
varied widely among diseases. It was higher in RD and ERM (85%
and 74.2% respectively) and lower in FVS and MH (14.3% and 10%
respectively). It was 42.9% in MHRD. In the whole population of
eyes, no statistical influence of gender, age, AL or lens status on PVD
rate was found.
Conclusions: This is the first study reporting the PVD rate in
highly myopic eyes using intraoperative examination. We reported a
complete PVD rate of 52.1%. This rate appears to be lower than the
complete PVD prevalence previously estimated by biomicroscopic
examination and macular SD-OCT . However, this PVD rate varied
widely among diseases. In RD and ERM, the reported rate was
high and similar to PVD rate of emmetropic eyes. In FVS and MH,
posterior vitreous cortex was attached in the vast majority of eyes.
Commercial Relationships: Elise Philippakis, None; Aude
Couturier, None; Vincent Gualino, None; David Gaucher, None;
Alain Gaudric, None; Pascale G. Massin, None; Ramin Tadayoni,
None
A pilot randomized controlled trial of ranibizumab pre-treatment
for diabetic vitrectomy (The RaDiVit study)
Oliver Comyn, James W. Bainbridge. NIHR Biomedical Research
Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL
Institute of Ophthalmology, London, United Kingdom.
Purpose: Vitreous surgery in diabetes can be complicated by
iatrogenic retinal breaks and vitreous cavity haemorrhage. Trials
of bevacizumab as a pre-operative adjunct to surgery have yielded
variable results. Concerns remain over the safety of anti-vascular
endothelial growth factor (VEGF) agents in this condition with
reports of exacerbation of pre-existing tractional retinal detachment.
The aim of this pilot study was to assess the impact of ranibizumab
pre-treatment on the outcome of surgery for advanced proliferative
diabetic retinopathy.
Methods: This was a randomized, double-masked clinical trial.
Thirty eyes of 30 subjects with proliferative diabetic retinopathy
having vitrectomy and delamination of fibrovascular complexes
were randomized to ranibizumab intravitreal injection or control
(saline subconjunctival injection) 7±1 days prior to surgery. The
primary outcome measure was best corrected ETDRS visual acuity
at 12 weeks post-op. Secondary outcome measures comprised
technical difficulty of surgery; intra-operative and post-operative
haemorrhage; extent of tractional retinal detachment; extent of retinal
neovascularization; vitreous and plasma levels of VEGF and related
cytokines.
Results: Mean (SD) visual acuity 12 weeks following surgery for
ranibizumab treated subjects was 53 (21) letters and for control
subjects was 47 (25). We detected no difference in duration
or technical difficulty of surgery; the degree of intraoperative
haemorrhage was similar between the two groups. Persisting vitreous
cavity haemorrhage was evident in 2 subjects in the control group
at 12 weeks, and in none of the ranibizumab group. Four subjects
in the ranibizumab group had no visible retinal neovascularization
at trial exit; one in the control group. Vitreous levels of VEGF and
interleukin (IL)-1α were lower following ranibizumab treatment. We
identified no progression of tractional retinal detachment following
ranibizumab and no new safety issues.
Conclusions: Ranibizumab treatment as an adjunct to diabetic
vitrectomy appears safe and may lead to improved visual acuity and
reduced vitreous cavity haemorrhage at 12 weeks post-op. Reduced
levels of VEGF and IL-1α were found following ranibizumab
administration. These findings will help inform the design of an
appropriately powered clinical trial.
Commercial Relationships: Oliver Comyn, Novartis (F), Novartis
(R); James W. Bainbridge, Novartis (F)
Support: Novartis (unrestricted research grant); NIHR Moorfields
Biomedical Research Centre; The Wellcome Trust (multiuser
equipment grant 099173/Z/12/Z)
Clinical Trial: NCT01306981
Visual and surgical midterm outcome of minimally invasive pars
plana vitrectomy for diabetic retinopathy
Shulamit Schwartz1, 2, Ramanath Bhandari1, 3, Adiel Barak2,
Naresh Mandava3, Anat Loewenstein2, Hugo Quiroz-Mercado1,
3 1
. Ophthalmology, Denver Health Medical Center, Denver,
CO; 2opthalmology, Tel Aviv Medical Center, Tel Aviv, Israel;
3
ophthalmology, Rocky Mountain Lion Eye institute, University of
colorado, aurora, CO.
Purpose: To evaluate the visual outcome and complications rate of
minimally invasive pars plana vitrectomy (PPV) in diabetic patients
with complications of proliferative diabetic retinopathy (PDR).
Methods: Retrospective, interventional, consecutive case series.
117 patients who underwent 144 small gauge (23 or 25) PPV for
PDR were included. Main indications were none clearing vitreous
hemorrhage (NCVH) in 78 eyes, tractional retinal detachment (TRD)
in 33 eyes and macular pathologies in 18 eyes. 36% had a combined
vitrectomy and cataract extraction. Primary outcome was change in
visual acuity (VA) 3 and 6 six months after operation. Secondary
outcomes were complications rate and risk factors.
Results: Mean age was 54.5±10.2 years. Mean diabetes duration
was 12.3±8 years. 21.4% had Type I diabetes, 63.4% of all patients
were treated with Insulin and 32.5% required dialysis perioperatively.
Mean HbA1c was 8.4% ±1.9. 29.1% of patients had more than one
vitrectomy overall.
Mean pre-operative VA was 1.62 logMAR. 81.9% of eyes were
legally blind at the time of operation with 6 showing light perception
(LP), 25 detecting hand movements (HM), and 54 counting fingers
(CF). At 3 and 6 months post-operative visits, mean VA improved
to 1.2 and 1.13 logMAR respectively (p<0.0001). At 6 months only
55 eyes (38.2%) had poor VA of 1.0 logMAR or less, with 2 with
no LP, 3 showing LP, 12 detecting HM, and 13 CF. In all, 63.6% of
eyes with TRD and 68.4% with NCVH achieved a better VA than 1.0
logMAR at 6 months. VA was preserved in 43 patients between visits.
Hispanic race (p=0.018), Insulin treatment(p=0.042), prior cataract
extraction(p=0.003), internal limiting membrane peeling (p=0.001)
and operation length (p=0.0005) were found to be significant risk
factors for less favorable VA at 3 and/or 6 months.
Complications included NCVH (12.5%), TRD (4.9%), macular
edema (4.9%), rubeosis (4.2%), neovascular glaucoma (2.8%),optic
atrophy (4.2%), hypotony and phthisis (0.007%). Transient VH,
ocular hypertension and hyphema occurred in 15.3%, 12.5% and
3.5% of eyes respectively. 23.1% of phakic eyes developed visually
significant cataract. 11.8% required another vitrectomy for either
NCVH or TRD.
Conclusions: Diabetic patients can observe improvement in VA with
a low complications rate after minimally invasive PPV for PDR,
which is maintained during mid-term follow-up.
Commercial Relationships: Shulamit Schwartz, None; Ramanath
Bhandari, None; Adiel Barak, None; Naresh Mandava, None;
Anat Loewenstein, None; Hugo Quiroz-Mercado, None
Retinal blood flow levels measured by Laser Speckle Flowgraphy
significantly increased after vitrectomy for diabetic macular
edema
Makiko Matsumoto, Kiyoshi Suzuma, Eiko Tsuiki, Azusa Fujikawa,
Takashi Kitaoka. Ophthalmology, Nagasaki Univ School of
Medicine, Nagasaki, Japan.
Purpose: The present study was designed to report retinal blood flow
levels measured by Laser Speckle Flowgraphy (LSFG) in refractory
diabetic macular edema (DME) patients and idiopathic epiretinal
membrane (ERM) patients before and after undergoing vitrectomy.
Methods: From March in 2011 to July in 2013, vitrectomy was
performed on 30 eyes of 25 consecutive patients with clinically
refractory DME, and 35 eyes of 35 ERM patients as controls. The
mean blur rate (MBR) that represents retinal blood flow velocity of
the major vessels at the optic disc and the relative flow volume (RFV)
which represent retinal blood volume of a specific blood vessel were
measured by LSFG. The 1000-μm central retinal thickness (CRT)
was measured by optical coherence tomography using Macular
Cube 512 x 128 scanning protocol. Visual acuity was measured
preoperatively and postoperatively, and the results were converted to
the logarithm of the minimum angle of resolution (logMAR).
Results: CRT decreased and visual acuity improved 3 months after
vitrectomy in ERM and DME patients. MBR and RFV in ERM
patients did not change after surgery. In contrast, MBR in DME
patients significantly increased after surgery (118%, P<0.001). The
RFV artery and the RFV vein were also significantly increased (160 ±
127%, P=0.02 and 165 ± 142%, P=0.02 respectively).
Conclusions: Vitreous surgery may improve retinal blood flow levels
in patients with diabetic macular edema. In DME, LSFG can become
one of the index of curative effects. LSFG can evaluate blood flow
levels noninvasively and quantitatively in the diseases which bases
are circulatory disorder, such as diabetic retinopathy.
Commercial Relationships: Makiko Matsumoto, None; Kiyoshi
Suzuma, None; Eiko Tsuiki, None; Azusa Fujikawa, None;
Takashi Kitaoka, None
Dynamic OCT vs Ultrasound in retinal detachment and hypotony
maculopathy
Jessica Taibl1, 2, Samir I. Sayegh1. 1The EYE Center, Champaign, IL;
2
University of Illinois, Urbana, IL.
Purpose: Previous work has shown that cSLO/SD-OCT can be
an excellent alternative to B-mode ultrasound in cases of inferior
recurrent retinal detachment with silicone oil tamponade. Using
ultra-widefield non-contact cSLO imaging in combination with
Dynamic cSLO/SD-OCT allows for unique and complicated retinal
conditions to be examined and progression to be monitored closely.
This provides more detail and information than ultrasonography
alone. Inferior retinal detachment, with or without silicone oil
tamponade, peripheral retinal lesions, and hypotony maculopathy
are all conditions in which this imaging methodology has proved
extremely useful.
Methods: Patients with rhegmatogenous inferior retinal detachments
and hypotony maculopathy were imaged using both B-mode
ultrasound and Spectralis HRA/OCT (Heidelberg Engineering).
Spectralis is capable of both ultra-widefield cSLO imaging and
cSLO/SD-OCT imaging. Dynamic imaging, where a technician
moves the OCT line scan to anywhere on the en face image, allows
the precise real time delineation of the areas of reattachment, redetachment or suspect detachment, with the ability to follow them
and evaluate the retinal architecture. This “live viewing” approach
can sometimes be more beneficial than capturing a raster scan.
Results: The combined use of Dynamic OCT and ultra-widefield
imaging can delineate the origin of detachment and characterize the
extent and amount of fluid behind it. It is beneficial in elucidating
hypotony maculopathy, when ultrasound may suggest a possible
detachment. Images can be viewed live, captured in standard mode
through use of the manufacturer provided software, or live video can
be recorded of the session of patients who are difficult to image, or
where a dynamic record is desired.
Conclusions: The combined use of Dynamic OCT and ultrawidefield imaging to monitor retinal integrity in eyes with potential
retinal detachments with or without silicone oil tamponade, or
hypotony maculopathy, is highly beneficial as a complement or
alternative to ultrasound. Dynamic OCT and ultra-widefield imaging
provide more diagnostic information than ultrasonography alone,
allow better resolution, and work in difficult to image patients
providing increased comfort and exposure to a single instrument.
Commercial Relationships: Jessica Taibl, None; Samir I. Sayegh,
None
Visualization of retinal vessel printings using the confocal
scanning laser ophthalmoscope and the fundus camera in
vitreoretinal pathologies
Mariaelena Filippelli, Roberto dell’Omo, Francesco Cifariello,
Dario Giorgio, Rocco Calo, Roberto Di Iorio, Michele Cardone,
Angela Di Salvatore, Ciro Costagliola. Medicine and Health
Sciences, University of Molise, Campobasso, Italy.
Purpose: To compare the sensitivity of the confocal scanning laser
ophthalmoscope (cSLO) and the modified fundus camera (FC) in
detecting retinal vessels printings (RVPs), associated to different
vitreoretinal pathologies, in fundus autofluorescence (FAF) images.
Methods: prospective observational case series. Eyes with macular
pucker (n= 24), with lamellar macular hole associated to epiretinal
membrane (n=9), and operated on for rhegmatogenous retinal
detachment with vitrectomy and gas (n=27) were included into
the study. Fifty degrees FAF images were taken with the cSLO
Heidelberg retina angiograph (Heidelberg Engineering, Heidelberg,
Germany) that uses a 488 nm laser for excitation and a >500 nm
barrier filter and the Topcon NW8F FC (Topcon, Tokyo, Japan) that
uses a 535-580 nm filter for excitation and a 615-715 nm barrier filter.
Only pseudophakic eyes or eyes with mild to moderate (AREDS
classification grade 1-3) were admitted. The following scores were
attributed, by three different graders, to the images on the basis of
the visualization of the RVPs: 0 = RVPs not visible, 1= RVPs barely
visible, 2 = RVPs easily visible.
Results: Retinal vessel printings were detected in 27 eyes.
Indipendently from the lens status, the RVPs were more readily
visible using the FC than the cSLO. Mean ± (SD) scores were 1.65
± 0.48 and 1.19 ± 0.4 in the FC and in the cSLO group respectively
(P>0.001). However only in one case the RVPs were detected
exclusively by the FC, while in the remaining 26 eyes they were
visualized by both instruments. Interobserver variability for the
evaluation of the RVPs visualization was not significant.
Conclusions: Retinal vessel printings associated to macular pucker,
lamellar hole with epiretinal membranes and repaired retinal
detachment can be visualized using both, the modified FC and the
cSLO. In the images obtained with the FC, the RVPs are, in general,
more easily visible in comparison to images recorded with the
cSLO. The differences in the excitation and barrier wavelengths may
probably explain the differences between the resulting FAF images.
Commercial Relationships: Mariaelena Filippelli, None; Roberto
dell’Omo, None; Francesco Cifariello, None; Dario Giorgio, None;
Rocco Calo, None; Roberto Di Iorio, None; Michele Cardone,
None; Angela Di Salvatore, None; Ciro Costagliola, None
Structural abnormalities of the macula as causes of incomplete
recovery of vision post successful primary rhegmatogenous
retinal detachment repair
Alice Y. Zhang, Sulaiman Alhumaid, Aaron Rosen, Christina ryu,
Michael Kapusta, John Galic, John Chen. Ophthalmology, McGill
University, Montreal, QC, Canada.
Purpose: To assess the visual outcome in patients with successful
primary macula-off rhegmatogenous retinal detachment and to
investigate the prevalence of macular structural abnormalities in
those with poor visual outcome.
Methods: A retrospective chart review from McGill University’s
surgical retina service was conducted, with prospective follow-up.
Operative records from surgical repairs with the diagnosis of “retinal
detachment” were reviewed, including pneumatic retinopexy, pars
plana vitrectomy, scleral buckle or a combination of these. All
patients with prior diagnosis of a maculopathy, serous or tractional
retinal detachment, fovea-on or recurrent rhegmatogenous retinal
detachment were excluded. Patients with at least a 6-month follow-up
period were included.
Results: 152 patient charts were retrieved, of which 41 fulfilled the
above criteria. Of these patients, at 6 months post-operatively, 24%
had a visual acuity of 20/40 or better, 66% had a visual acuity worse
than 20/40 but better than or equal to 20/200, and 10% had a visual
acuity worse than 20/200. Of patients with decreased visual acuity
(less than 20/40), excluding those with media opacity, structural
macular pathologies were found on optical coherence tomography
(OCT) in 56%. These macular abnormalities include: epiretinal
membrane and/or cystoid macular edema (33%), persistent subretinal
fluid (33%), macular hole (7%), and retinal atrophy and/or IS/OS
disturbance (27%).
Conclusions: Many patients post-macula-off retinal detachment
repair can have good visual acuity. Preliminary data suggest that
patients with decreased visual acuity (less than 20/40) may have
media opacities which are treatable as well as other potentially
treatable macular abnormalities including: epiretinal membrane,
cystoid macular edema, persistent subretinal fluid, or macular
hole. Incomplete visual recovery due to retinal atrophy or IS/OS
disturbance form a minority of patients.
Commercial Relationships: Alice Y. Zhang, None; Sulaiman
Alhumaid, None; Aaron Rosen, None; Christina ryu, None;
Michael Kapusta, None; John Galic, None; John Chen, None
Inner and outer central retinal findings after surgery for
rhegmatogenous retinal detachment using different spectraldomain optical coherence tomography devices
Juliane Matlach1, Baerbel Pflueger1, Johannes Hain2, Winfried
Goebel1. 1Department of Ophthalmology, University of Wuerzburg,
Wuerzburg, Germany; 2Department of Biometrics, University of
Wuerzburg, Wuerzburg, Germany.
Purpose: To image macular changes after rhegmatogenous retinal
detachment (RRD) repair using spectral-domain optical coherence
tomography (SD-OCT).
Methods: Forty eyes with macula-on and 27 eyes with macula-off
RRD underwent scleral buckling or vitrectomy and were imaged
using 2 different SD-OCT devices (Cirrus® HD-OCT 4000,
RTVue-100®).
Results: Mean follow-up was 27.4 months with a range of 12-46
months. Visual acuity (VA) improved in both groups and was ≥20/63
in the macula-off and ≥20/40 in the macula-on group postoperatively.
Outer retinal findings of macula-off patients included disruption of
the external limiting membrane, photoreceptor inner/outer segments
and cone outer segment tips layer in 4 eyes (14.8%). Inner retinal
segments composing of retinal nerve fiber (RNFL), ganglion cell
(GCL) and inner plexiform layer (IPL) were thicker in both surgery
groups compared to normal controls for both instruments.
Conclusions: Visual acuity significantly improved even in eyes with
macula-involving detachment independent of preoperative VA or
duration of symptoms. Agreement between both OCT-systems was
excellent for overall and inner retinal thickness, although RTVue
basically measured a thicker RNFL-GCL-IPL complex. Thinning
of inner retinal layers as a potential cause of poor postoperative
VA was rarely detected, possibly due to secondary changes at the
vitreomacular interface after detachment repair.
Commercial Relationships: Juliane Matlach, None; Baerbel
Pflueger, None; Johannes Hain, None; Winfried Goebel, None
Incidence of rhegmatogenous retinal detachments following
intravitreal injections
Harry Dang1, 5, Rajeev H. Muni1, 4, Robert G. Devenyi1, 3, Wai-Ching
Lam1, 3, Kenneth Eng1, 2, Carol E. Schwartz1, 2, Radha P. Kohly1,
2
, Peter J. Kertes1, 2. 1Department of Ophthalmology and Vision
Sciences, University of Toronto, Toronto, ON, Canada; 2Sunnybrook
Health Sciences Centre, Toronto, ON, Canada; 3Toronto Western
Hospital, University Health Network, Toronto, ON, Canada; 4St.
Michael’s Hospital, Toronto, ON, Canada; 5Faculty of Medicine,
University of Ottawa, Ottawa, ON, Canada.
Purpose: To report the incidence of rhegmatogenous retinal
detachments (RRD) after intravitreal injections.
Methods: A multicentre, retrospective case series measured the
incidence of RRD in patients receiving intravitreal injections.
The number of injections was determined from billing code and
electronic medical records from seven ophthalmology practices. The
indications for injection included age-related macular degeneration,
central and branch retinal vein occlusion, diabetic macular edema,
and miscellaneous causes. The primary outcome measure was the
incidence of RRD after intravitreal injection.
Results: A total of forty thousand three hundred twenty-two
intravitreal injections were identified for 9525 patients between
January 2000 and September 2013. The mean age of the cohort was
68.6 years (range 25-100) and the mean follow-up duration was 32.27
months (range 0-120.4). Of the 1708 patients reviewed (to date), 6
eyes of 6 patients with RRD after injection were reported. Time from
first injection to RRD was a mean of 1.5 years (range 0.9 – 2.0). The
overall incidence of RRD was 6 in 20294 (0.029% per injection).
Conclusions: The overall rate of intravitreal injection-related RRD is
low (1 per 3382 injections).
Commercial Relationships: Harry Dang, None; Rajeev H. Muni,
None; Robert G. Devenyi, None; Wai-Ching Lam, None; Kenneth
Eng, None; Carol E. Schwartz, None; Radha P. Kohly, None;
Peter J. Kertes, None
Short-time prone posturing reduces the rate of retinal
displacement after vitrectomy for retinal detachment
Roberto dell’Omo, Mariluccia Cassetta, Mariaelena Filippelli,
Dario Giorgio, Rocco Calo, Roberto Di Iorio, Antonio De Lena, Ciro
Costagliola. Medicine and Health Sciences, University of Molise,
Campobasso, Italy.
Purpose: To demonstrate the efficacy of short-time prone positioning
in preventing the rate of unintentional retinal displacement in patients
operated on with vitrectomy for rhegmatogenos retinal detachment
(RRD)
Methods: Prospective interventional case series. Fifty-six eyes of 56
patients with RRD underwent 23 or 25 vitrectomy and tamponade
with 20% sulfur hexafluoride (SF6) or silicone oil (SO) 1000 csk by
a single surgeon. Indipendently from the location of the breaks the
patients maintained a strict face-down posturing for 2 hours after
operation.
Fundus autofluorescence (FAF) images were recorded at 1 month
postoperatively to detect displacement of the retina, as revealed
by the presence of retinal vessel printings (RVPs), i.e. lines of
increased autofluorescence parallel to retinal vessels. Both a confocal
scanning laser ophthalmoscope ( Spectralis HRA+OCT, Heidelberg
Engineering, Heidelberg, Germany) and a fundus camera (Topcon
NW8F, Topcon, Tokyo, Japan) were used in all cases to record the
images.
Results: The mean age of these 56 patients was 56.7 ± 10.7 years
( range 24-79 years). Of the 56 eyes, retinal detachment involved 4
quadrants in 15 eyes, 3 quadrants in 10 eyes, 2 quadrants in 25 eyes,
and 1 quadrant in 6 eyes (mean± SD, 2.6 ± 1.0). Macula-involvement
was observed in 45 eyes. After complete reattachment of the retina,
FAF photography demonstrated RVPs in 16 eyes ( 28.5 %).
Of these 15 had received SF6 and 1 had received SO as tamponade.
RVPs were found above (downward shifting) in 10 cases, below
(upward shifting) in 1 case and laterally (lateral shifting) in 5 cases,
to the retinal vessels. No difference in detecting the RVPs between
the two instruments was found. None of the eyes with macula-on
detachment showed RVPs.
The extent of retinal detachment (P < 0.028) and the macular
status (on or off) were significantly associated (P < 0.021) with
postoperative displacement of the retina.
Conclusions: Short-time prone posturing is effective in reducing the
rate of unintentional retinal displacement after vitrectomy for RRD.
Both the confocal laser ophthalmoscope and the fundus camera are
equally sensible in detecting the RVPs.
Commercial Relationships: Roberto dell’Omo, None; Mariluccia
Cassetta, None; Mariaelena Filippelli, None; Dario Giorgio, None;
Rocco Calo, None; Roberto Di Iorio, None; Antonio De Lena,
None; Ciro Costagliola, None
Randomized Clinically Controlled Trial on Early Versus
Defered Surgery for Epiretinal Membranes. Visual Acuity and
Microperimetri Outcomes
Mads Kofod. Eye Department, Glostrup Hospital, University of
Copenhagen, Glotrup, Denmark.
Purpose: To investigate if early surgery for epiretinal membranes
gave superior long term visual acuity outcomes compared to standard
treatment, where visual acuity deterioration is observed until visual
acuity drops below a set limit allowing for surgery.
Methods: Randomized clinical trial on surgery in eyes with epiretinal
membranes, visual acuity above 0.5 decimal and metamorphopsia
causing binocular daily complaints. Patients were randomized 1:2,
one intervention to two controls. Patients in the control group could
cross over to the intervention if visual acuity declined significantly
or if daily binocular complaints worsened severely. Primary outcome
was visual acuity change 12 months after inclusion to the study for
the control group, or 12 months after vitrectomy. Phacoemulsification
was performed 8 weeks prior to vitrectomy in phakic patients. The
study population was divided in three groups.
Group 1: intervention with early surgery
Group 2: Control group who required surgery due to worsening
Group 3: Control group who did not require surgery
Results: 54 patients participated in the trial. 20 patients were
randomized for early intervention, The control group containing
35 patients was significantly more stable than anticipated and only
7 patients experienced worsening of either visual acuity or daily
binocular complaints to allow cross over within the study parameters.
The patients did not differ significantly in their baseline data. Visual
acuity:
Group 1 gained an average of 4.6 ETDRS (CI95:1.8 to 7.4) letters
following surgery
Group 2 gained an average of 8.3 ETDRS (CI95: -.5 to 17.1) letters
following surgery
Group 3 gained an average of 1.6 ETRDS (CI95: -1.0 to 3.2) letters
during the 12 months observation.
There was no statistically significant difference in visual acuity gains.
There was no statistical significant difference between visual acuity at
the 12 months evaluation between the groups.
Conclusions: This results presented in this poster were unable to
identify if early surgery is preferential to deferred surgery where
patients have more significant daily complaints before surgery is
performed. This study is limited by a ceiling effect of visual acuity
as patientes are just below 1.0 decimal visual acuity. This study finds
that surgery for epiretinal membranes can be performed at high visual
acuity and still gains visual acuity.
Commercial Relationships: Mads Kofod, None
Multimodal Imaging of Emulsified Silicone Oil in Optic Nerve,
Retina and Vitreous
Suqin Yu1, 2, Yale Fisher2, Sarah Mrejen2, Fenghua Wang1.
1
Ophthalmology, Jiaotong University affiliated Shanghai First
People’s Hospital, Shanghai, China; 2Ophthalmology, Vrmny, New
York, NY.
Purpose: To identify the presence of emulsified silicone oil droplets
in optic nerve, retina and vitreous with multimodal imaging.
Methods: This was a retrospective review of 15 eyes of 15 patients
(9 males and 6 females), with a mean age of 63 (range from 29-86),
who underwent vitrectomy and silicone oil tamponade. After silicone
removal surgery, clinical examination, ultrasound and OCT was
performed to identify if there were any remaining silicone droplets in
vitreous cavity, retina or optic nerve. Adaptive optics was performed
in three patients.
Results: Silicone oil emulsification was confirmed by multimodal
imaging in 12 eyes of 12 patients. With color photography, red-free
and near inferred image, emulsified silicone oil can be detected if
the droplet is big enough. In ultrasound, emulsified silicone oil can
be easily detected as obvious highly reflective dots in the vitreous
cavity. In OCT, droplets have several manifestations in retina or optic
nerve: 1) Clear bubbles with/without hyper-reflective tails; 2) Hyperreflective dots with/without hyper-reflective tails; 3) Hyper-reflective
tails without observable dots or bubbles. Adaptive optics confirmed
these oil droplets even they are very tinny in three patients.
Conclusions: Hyper-reflective tails behind hyper-reflective dots is a
peculiar optical effect. We believe that “lensing effect” or “multiple
scattering” could be one of the possible explanations for this artifact.
Emulsified silicone oil may be imaged in many ocular tissues.
Representation varies with techniques. Interpretation of these images
is very important for the retinal specialist to fully understand the
possible impact of emulsified silicone oil on retina and its function.
At present, we believe ultrasound is the best way to demonstrate
emulsified silicone oil droplets in vitreous. OCT is useful for
detecting them in retina and optic nerve and adaptive optics is an
additional and confirming imaging method if available.
Commercial Relationships: Suqin Yu, None; Yale Fisher, None;
Sarah Mrejen, None; Fenghua Wang, None
Incidence of lens touch during pars plana vitrectomy and
outcomes from subsequent cataract surgery
zine Elhousseini, Edward Lee, Tom H Williamson. Ophthalmology, St
Thomas, London, United Kingdom.
Purpose: To establish the incedince of lens touch during pars plana
vitrectomy, and whether leads to increased complications rate in
subsequent cataract surgery
Methods: Data from all patients attending three centers for
vitreoretinal surgery,prospectively entered into electronic patient
record (VITREOR).Patients with pseudophakia or aphakia, or
patients who were scheduled for combined cataract surgery at
the time of pars plana vitrectomy were excluded. The records of
all phakic patients undergoing PPV (without combined cataract
surgery) from January 2001 to March 2013 were analyzed. Patients
undergoing subsequent cataract surgery were identified and case
notes were reviewed where necessary.
Cataract surgeries in patients who had had prior lens touch during
their first vitrectomy were compared with a control group who had
also undergone vitrectomy and then subsequent cataract surgery, but
with no recorded lens touch.
Lens bite with the cutter is considered as a separate entity and was
excluded as a lens touch in this study. Analysis of the study was
performed on Microsoft office Excel 2007 software and Analyse-it
software (Cambridge UK).
Results: A total of 1400 Pars Plana Vitrectomy operations of phakic
eyes, eligible for the inclusion criteria of the study for the period
between January 2001 and April 2013, were analyzed. 54 patients had
a lens touch (3.8%). Most of the operations in which a Lens Touch
occurred where retinal detachments repair (52.5%),and no statistical
significant was found, but using silicon oil and PVR peel where
significant for causing lens touch.
Cataract developed in 49 patients (90.7%) and only 45 patients had
a cataract surgery, while the rest lost to follow up or no surgery.
Cataract surgery in 43 patients (86%) had no complications,
posterior capsule (PC) rupture happened in 5 patients (11%) and in 4
patient (4%) instability of the zonules was noted before the cataract
operation, the PC rupture rate was significantly higher compared to
the control group of cataract surgery in vitroctumized eyes with no
lens touch.
most of the patients achieved >0.3 LogMar visual acuity.
Conclusions: Lens touch during pars plana vitrectomy has a higher
incident than reported. Lens Touch in Vitrectomy has significant risk
factor for PC rupture during the subsequent cataract surgery, and
such cases should be documented and performed with great care and
preferably by the Vitreo-Retinal Team.
Commercial Relationships: zine Elhousseini, None; Edward Lee,
None; Tom H Williamson, None
Refractive Change after Lens-Sparing Pars Plana Vitrectomy
Yoshifumi Okamoto, Fumiki Okamoto, Takahiro Hiraoka, Tetsuro
Oshika. Ophthalmology, Tsukuba Univ., Tsukuba-city, Japan.
Purpose: To evaluate the refractive changes after lens-sparing
vitrectomy for rhegmatogenous retinal detachment (RRD).
Methods: A retrospective chart review was conducted in 66 eyes
of 66 patients (50.0±9.9 years old) who had undergone lens-sparing
vitrectomy for RRD. Spherical equivalent refractive power was
evaluated before, 1, 2, 3, 6, 9, 12, and 15 months after vitrectomy,
and the time course of changes was evaluated. Other data collected
included age, sex, ocular side, axial length, preoperative hemorrhage,
preoperative spherical equivalent, operative time, size of retinal
tear, logMAR best corrected visual acuity, the number of laser
photocoagulation, the use of wide-angle viewing system, the use of
intraoperative adjuvant and gas-tamponade, surgeon or the gauge
of microincision viterectomy system, and postoperative vitreous
hemorrhage and inflammatory reaction.
Results: Significant and continuous myopic shift in refraction was
observed in the operated eyes throughout the study period, and
spherical equivalent was significantly different from the fellow
control eyes after 3 months after lens-sparing vitrectomy (p < 0.05).
Cataract surgery was performed in 27 eyes of 58 patients (47%)
during the study period. When compared between the patients who
received and did not receive cataract surgery during the follow up
period, the former patients were significantly older (p < 0.05), but
there was no significant difference in other all parameters such
as operative time and the use of intraoperative adjuvant and gastamponade (p > 0.05).
Conclusions: There was a significant myopic progression in eyes
after lens-sparing vitrectomy for RRD, causing considerable amount
of anisometropia even in the early postoperative period. Patient age
was only strong risk factor with the potential to progress the nuclear
sclerotic cataract after lens-sparing vitrectomy.
Commercial Relationships: Yoshifumi Okamoto, None; Fumiki
Okamoto, None; Takahiro Hiraoka, None; Tetsuro Oshika, None
Magnet-Assisted Pars Plana Vitrectomy for Metallic Foreign
Body Removal
Rafaella de Cenço Lopes1, Rodrigo Jorge1, Rubens C. Siqueira1,
Andre Messias1, Ingrid U. Scott2. 1Ophthalmology, Ribeirão Preto
Medical School, University of São Paulo, Ribeirão Preto, Brazil;
2
Departments of Ophthalmology and Public Health Sciences, Penn
State College of Medicine, Hershey, PA.
Purpose: To describe the outcomes of patients who underwent
removal of magnetic intraocular foreign bodies (MIFB) with magnetassisted pars plana vitrectomy.
Methods: Medical records were reviewed of all patients who
underwent magnet-assisted pars plana vitrectomy for MIFB removal
at the University of Sao Paulo, Ribeirao Preto between January 2007
and April 2013. Data collected include best-corrected visual acuity
(BCVA), retina status and complications such as endophthalmitis
and phthisis bulbi. The surgery consisted of standard three-port pars
plana vitrectomy and MIFB removal with an external electromagnet
positioned in one of the superior sclerotomies (nasal or temporal).
Comprehensive ophthalmologic evaluation was performed
preoperatively and at weeks 4, 12±1, 24±2 and 48±2.
Results: The study included 26 eyes of 26 patients, all of whom had
48-week follow-up data available. All 26 patients were men, and
the median patient age was 31.5 years (range, 18 to 59 years). The
MIFB was removed successfully in all patients. Median BCVA was
20/252 (range, no light perception to 20/20) at baseline, and 20/200
(range, no light perception to 20/20) at week 48. The median greatest
linear dimension of the MIFB was 3.0mm (range, 2.0mm to 5.0mm).
Retinal detachment was the most common complication (five eyes),
endophthalmitis occurred in one eye (this eye developed phthisis
bulbi).
Conclusions: Magnet-assisted pars plana vitrectomy is a reasonable
alternative surgical technique for removal of MIFB.
Commercial Relationships: Rafaella de Cenço Lopes, None;
Rodrigo Jorge, None; Rubens C. Siqueira, None; Andre Messias,
None; Ingrid U. Scott, None
25-gauge 2 port minimal vitrectomy in selected rhegmatogenous
retinal detachment patients
Stefano Zenoni1, Mario R. Romano3, Simone Donati2, Simona Maria
Caprani2, Riccardo Vinciguerra2, 3, Claudio Azzolini2. 1LifeClinic,
Milano, Italy; 2Dept. of Surgical and Morphological Sciences Section of Ophthalmology, University of Insubria, Varese, Italy;
3
Ophthalmology, Humanitas Clinical Institute, Milano, Italy.
Purpose: To evaluate the efficacy of 25-gauge 2 port minimal
vitrectomy in selected cases of rhegmatogenous retinal detachment.
Methods: This prospective interventional case series study included
42 eyes of 42 patients affected by retinal detachment with superior
retinal tears (not extended to more than one clock hour). All patients
underwent a partial 25-gauge 2 port vitrectomy with the removal
of the central and peripheral vitreous in the retinal tear area. An
endodrainage throughout the retinal tear with a cryo-retinopexy
around the tear and a 15% C3F8 gas tamponade were performed.
All patients underwent complete ophthalmic evaluation including
best corrected visual acuity at baseline and at follow up visits at
month 6 and 12. Statistical analysis was performed on collected data.
Results: 37 out of 42 eyes (80.9%) achieved anatomical success,
defined as complete retinal reattachment. In 5 eyes (11.9%) a
reintervention was carried out: in 2 eyes (4.9%) a persistent retinal
detachment was successfully treated with a pneumatic retinopexy,
in 3 eyes a recurrent retinal detachment required reintervention with
complete vitrectomy and gas tamponade. Postoperative mean BVCA
was 0.42 LogMAR (range 1.0 - 0.0 logMAR) at 12 months. 20 out
of 26 (76.9%) macula off eyes at baseline obtained a postoperative
visual acuity improvement equal to or higher than 3 LogMAR lines.
Postoperative complications included choroidal detachment in one
eye (2.3%) and hypotony in two eyes (4.9%) due to gas leakage
through sclerotomies.
Conclusions: 25-gauge 2 port minimal vitrectomy may be
considered as an alternative technique in managing selected cases
of uncomplicated rhegmatogenous retinal detachment with superior
retina tears and a vitreoretinal traction judged as not amenable for
scleral buckling.
Commercial Relationships: Stefano Zenoni, None; Mario R.
Romano, None; Simone Donati, None; Simona Maria Caprani,
None; Riccardo Vinciguerra, None; Claudio Azzolini, None
Preliminary Evaluation of a Robotic Retinal Surgical
Manipulator
Haoran Yu1, Rohan J. Shah2, Jin H. Shen2, Karen M. Joos2, Nabil
Simaan1. 1Mechanical Engineering, Vanderbilt University, Nashville,
TN; 2Vanderbilt Eye Institute, Vanderbilt University, Nashville, TN.
Purpose: Although robotic surgery remains in the experimental
phase for ophthalmic surgery, it has had a tremendous impact on
other surgical fields. We developed a telemanipulation system for
retinal surgery and present experimental results evaluating the
potential benefits of using robot-assistance for membrane peeling and
micro-manipulation close to and on the retina surface.
Methods: A seven degrees-of-freedom (DoF) manipulator with a
6 DoF robot and a 1 DoF motor-driven surgical gripper were used
to comprise a robotic telemanipulation slave. A manual gripper
(Grieshaber Revolution® DSPs forceps (Alcon)) and a modified
motor-driven gripper were used. An experimental hardware and
control setup was designed to obey the pars plana incisional
constraints of the eye. This setup was built accordingly with agar gel
as the phantom mimicking retinal surface, liquid bandage coating as
the phantom membrane, and a plastic ring with phantom mimicking
1 mm (20-gauge) ocular pars plana surgical ports. Surgical phantom
interventions of intraocular manipulation and membrane peeling were
performed. The robot’s performance was evaluated by comparing one
surgeon’s (RS) telemanipulative ability versus the surgeon’s manual
manipulation during surgical tasks. Several experimental trials were
used to evaluate the manual approach and robot-assisted approach to
the retina. Similarly, robot-assisted membrane peeling experiments
were performed on the phantom retinal model. The depth of
excursion into the retinal substrate, average completion time, stability
of the tool and success rates during membrane peeling were used as
evaluation metrics.
Results: The surgeon was able to manipulate the robot without
instruction after one practice session. The data showed that the
average penetration depth for both methods were very similar (P=
0.6479). However robotic assistance improved the success rates in the
membrane peeling task by more than 2 times (P= 0.0041). Robotic
assistance also improved the task average completion time and the
tool tip stability.
Conclusions: A retinal telemanipulation system was developed and
evaluated. The results indicated potential advantages of using robotassistance for retinal surgery. These advantages manifest in increased
efficiency of micro-manipulation and membrane peeling.
Commercial Relationships: Haoran Yu, None; Rohan J. Shah,
None; Jin H. Shen, None; Karen M. Joos, None; Nabil Simaan,
Auris Surgical Robotics, Inc (P)
Support: Vanderbilt University Interdisciplinary Discovery Grant,
NIH Grant 1R21EY019752-02, and Unrestricted Grant to the
Vanderbilt Eye Institute by Research to Prevent Blindness, Inc., N.Y.
Free-Radical Formation during Vitrectomy Vitreous Substitutes
Nathan Ravi1, 3, Paul D. Hamilton2, 1. 1Ophthalmolgy, Washington
University School of Medicine, St Louis, MO; 2Research, VA Health
Care System, St. Louis, MO; 3Chemical Engineering, Washington
University, St. Louis, MO.
Purpose: Complications such as nuclear sclerotic cataract and
glaucoma are associated with vitrectomy in elderly patients.
Increased oxygen tension in the vitreous cavity is associated with
these complications, but causality is unclear. We have reported
that significant hydroxyl free-radicals (OHFR) were formed during
cutting of biomimetic vitreous hydrogels (ARVO #2144, 2013), and
may provides an alternative mechanism of tissue damage during the
vitrectomy. We have supplement previous data and have studied the
quenching of free-radicals by naturally occurring anti-oxidants.
Methods: Synthetic acrylamide/acrylic acid cross-linked hydrogels
were used as vitreous substitutes during vitrector cutting in the
presence and absence of anti-oxidants. A cut rate 3000 cuts per
minute was used, with variable suction pressures. Free-radical
formation was followed by electron spin resonance (ESR), using
5,5-Dimethyl-1-Pyrroline-N-Oxide (DMPO) as a spin-trap and a
magnetic field strength of 330-338 milli tesla (mT), focusing on the
free-radical peaks between 333-334 mT. Separately, OHFR were
calibrated using 40 uM FeSO4 plus H2O2, giving 80 uM of radicals.
The anti-oxidants glutathione, lipoic acid and ascorbic acid were
added at 80 uM concentration in the presence of the FeSO4 and H2O2.
Results: Measurable quantities of OHFR were produced during
the hydrogel cutting over a period of 20 minutes (Fig 1). Figure 2
suggests that glutathione is more effective than lipoic acid while
ascorbate eliminated the OHFR peaks but produced its own ascorbyl
FR peaks. The effect of glutathione and lipoic acid was additive, and
the combination of all three also eliminated the OHFR and ascorbic
acid FR peaks. The ESR signal produced by cutting in the presence
of anti-oxidant was also quenched
Conclusions: Cutting of macromolecules by vitrector produces
free radicals. Free radical production is mitigated in the presence of
anti-oxidants. Ascorbic acid radicals were observed. Results indicate
that it may be important to maintain a high antioxidant environment
during vitrectomy, to prevent damage to the ocular tissues, especially
in ageing patients where redox values are diminished. These results
need to be validated in vivo.
Figure 1. OHFR signal with respect to time of cutting.
emulsifications after silicone fill and consecutive laser treatments
were to be expected. Also it was to be expected that diseases like
HIV cause serious emulsifications because of a battered immune
system. However, the surgeon and his technique during entering and
removal of the silicone oil is a factor which is difficult to measure.
A difficult removal of the silicone oil can cause small bubbles which
are not caused by the human body but nevertheless counted by the
software. Based on the results of this study the counting method and
the evaluation-process are going to be optimized for more consistent
results.
Commercial Relationships: Svenja Deuchler, None; Pankaj
Singh, None; Michael Mueller, None; Thomas Kohnen, None;
Frank H. Koch, None
Figure 2. Quenching of OHFR free radical signal by ESR at 333334 mT with anti-oxidants; lipoic acid (LA), glutathione (Glu) and
ascorbic acid (Asc) singly and in combination.
Commercial Relationships: Nathan Ravi, None; Paul D.
Hamilton, None
Support: This research was supported by the Grace Nelson Lacy
Glaucoma Foundation Award to Dr. Nathan Ravi, Washington
University, Research to Prevent Blindness, Inc., NIH Core Grant
(P30 EY 02687) NIH grant EYE021620 and VA Rehab R&D grant
RX000657-01 and the Veterans Administration Health Care System.
Peri- and intraoperative factors affecting the emulsification of
silicone oil used for retinal re-attachment in complicated retinal
detachments
Svenja Deuchler, Pankaj Singh, Michael Mueller, Thomas Kohnen,
Frank H. Koch. retina and vitreous unit, university eye clinic,
Frankfurt/M., Germany.
Purpose: The aim of this study was to compare the grade of
emulsification in patients carrying silicone oil tamponade in regard to
viscosity of the oil and peri- and intraoperative factors.
Methods: After silicone oil removal, severity of emulsification
was measured and the results were compared to various patientspecific factors to point out the critical ones. The study contained 19
patients and silicone oils with a viscosity of 5,000, 4,300 and 2,000
mPas were considered. For determination, oil samples were placed
immediately after SO removal on a silanized stage. A second thinner
stage was placed in a distance of 0.25 mm to create a chamber with
a defined height/volume. The bubbles caused by emulsification
were counted and an image was taken. A software determined size
and number of the bubbles per square centimeter. The results were
categorized and evaluated.
Results: The evaluation showed no significant gain of emulsification
through the different viscosities or gender. There was no coherence
between emulsification and forgone cataract-surgery or silicone oil
usage. However, a higher emulsification rate was detected if silicone
oil was implanted after using PFC ( 1,8 times higher) and when laser
was applied not before but after silicone oil installation (2,0 time
higher). Diseases such as diabetes or HIV boosted the emulsification
of silicone oil.
Conclusions: This study offers an easy and convenient method
to evaluate emulsification in silicone oil tamponade and shows
how peri- and intraoperative factors of a patient influence the
emulsification.The silicone oils themselves seem to have very
little if at all influence on the severity of emulsification. High-level
The influence of retinal oxygenation on the clinical outcomes in
eyes with epiretinal membrane after successful vitrectomy
Guenther Weigert1, Robert A. Blum1, Stefan Sacu1, Michael
Georgopoulos1, Stefan Palkovits2, Sandra Rezar1, Katharina
Eibenberger1, Leopold Schmetterer2, 3, Ursula Schmidt-Erfurth1.
1
Department of Ophthalmology, Medical University of Vienna,
Vienna, Austria; 2Department of Clinical Phamacology, Medical
University of Vienna, Vienna, Austria; 3Center for Medical Physics
and Biomedical Engineering, Medical University of Vienna, Vienna,
Austria.
Purpose: In the present study patients with epiretinal membrane
underwent 23G vitrectomy and ICG membrane peeling. Little
information is available about the effects of this treatment on
retinal oxygenation. Hence, we set out to investigate the effects
of vitrectomy on retinal oxygenation in patients with epiretinal
membrane.
Methods: In this unmasked, prospective study, patients with
macular edema as a result of epiretinal membrane scheduled to
undergo vitrectomy without endotamponade, were included. The
main outcome measure was oxygenation of the retinal vessels. The
measurement of oxygenation in retinal vessels and retinal vessel
diameters was performed with the Retinal Vessel Analyzer at
baseline, then at day 1, day 7, week 4, week 12, and month 6 after
surgery. At each follow-up visit, a high-definition OCT examination
and ETDRS visual acuity were also performed.
Results: Retinal venous diameter increased significantly at the first
follow-up examination. There was no significant change in oxygen
saturation in retinal arteries. After an increase at day 1, retinal oxygen
saturation in retinal veins decreased significantly at the 6 months
follow-up visit versus baseline. Visual acuity tended to increase after
6 months and central retinal thickness was decreased after 6 months
as expected.
Conclusions: Vitrectomy for epiretinal membrane may show
beneficial short-term effects on retinal oxygenation. In eyes with
macular edema due to other pathologies, vitrectomy may be
performed as an additional treatment modality. Further studies
evaluating whether these effects are associated with changes in longterm visual acuity are warranted.
Commercial Relationships: Guenther Weigert, None; Robert
A. Blum, None; Stefan Sacu, Allergan (C), Bayer (C), Novartis
(C); Michael Georgopoulos, None; Stefan Palkovits, None;
Sandra Rezar, None; Katharina Eibenberger, None; Leopold
Schmetterer, None; Ursula Schmidt-Erfurth, Alcon (C), Bayer (C),
B√∂hringer (C), Novartis (C)
Surgical Outcome of Minimal Incision Vitrectomy System for
Ocular Complications in Patients with Granulomatous Uveitis
Atsushi Tanaka1, Kei Takayama2, Tadashi Muraoka1, Sho Ishikawa1,
Kohzou Harimoto1, Masaru Takeuchi1. 1National Defense Medical
College, Tokorozawa, Japan; 2Nagoya University, Nagoya, Japan.
Purpose: The primal treatment of granulomatous uveitis is to
reduce ocular inflammation by medical techniques. However,
in the case that chronic and recurrent inflammation gives rise to
irreversible complications that are refractory to medical treatment,
surgical treatment is performed to maintain or improve the patient’s
visual function. In this study, we indicate outcome of 23g or 25g
minimal incision vitrectomy system (MIVS) performed for ocular
complications in patients with granulomatous uveitis.
Methods: Vitreous surgery was performed for 19 patients 24
eyes (Male 6 patients 9 eyes, Female 13 patients 15 eyes) with
complications in the posterior segment of the eye resistant for
medical treatment of granulomatous uveitis including sarcoidosis
attending the uveitis clinic at National Defense Medical college
between April 2010 and November 2013.The average age was
66.3 +/- 9.3 years (ranging from 44 to 79 years). Sarcoidosis
was 10 patients 14 eyes, and granulomatous uveitis who fulfilled
the diagnostic criteria of ocular sarcoidosis but not fulfilled the
diagnostic criteria of systemic sarcoidosis was 9 patients 10 eyes.
The complications treated by vitreous surgery were vitreous opacity,
21 eyes; vitreous hemorrhage, 1 eye; epiretinal membrane, 9 eyes;
retinal detachment, 3 eyes; macula hole, 1 eye; cystoid macular
edema, 9 eyes (including overlaps). All patients were operated in
clinically inactive inflammation phase in all eyes, and operated for
cataract in 17 eyes at the same time. The average follow period was
15 months (ranging from 0 to 40months).
Results: Visual acuity was improved in 16 out of 24 eyes after
operation, in which sarcoidosis-associated uveitis was 11 of 14
eyes (78.5%) and the other granulomatous uveitis was 5 of 10
eyes (50.0%). However visual acuity was aggravated in 1 eye of
sarcoidosis-associated uveitis and 3 eyes of the other granulomatous
uveitis. The complications after vitreous surgery were vitreous
hemorrhage in 2 eye and glaucoma in 4 eyes of only eyes with
sarcoidosis.
Conclusions: Vitrectomy was generally effective for medically
refractory ocular complications of granulomatous uveitis including
sarcoidosis, with favorable outcomes of improved visual acuity.
However, the efficacy would be sometimes not expected in
subclinically inflamed eyes with sarcoidosis.
Commercial Relationships: Atsushi Tanaka, None; Kei
Takayama, None; Tadashi Muraoka, None; Sho Ishikawa, None;
Kohzou Harimoto, None; Masaru Takeuchi, None
SOP for removal of PVD induced vitreous opacities
Frank H. Koch, Svenja Deuchler, Pankaj Singh, Thomas Kohnen,
Henrik Schaefer. House 7c, University Eye Clinic, Frankfurt / M.,
Germany.
Purpose: To present the concept of a new standard operating
procedure (SOP) enhancing the diagnostic examinations and
surgical procedures to the exacting needs of patients suffering from
symptomatic vitreous opacities.
Methods: A retrospective study of 102 patients (117 eyes)
was performed to evaluate patient satisfaction associated with
symptomatic vitreous opacaties. We perform an interactive evaluation
to detect the clinical significance of patient’s opacities using (1)
quality-of-life questionaires (the NEI-VFQ-25 and a customized
FFQ-22 test), (2) pictures drawn by hand on paper and (3) into a
scanner and (4) a contrast vision test (CVA). Before surgery, we use
biomicroscopy, OCT and eventually ultrasonography to select the
preferred device for performing a core pars plana vitrectomy (cPPV)
in the individual eye: (a) single-incision-site Intrector®, (b) a two–
incision-site Retrector® or (c) a three-port cannula setup.1
Results: 117 eyes were followed over 24 months. No eye showed
clinically significant lens changes post cPPV. 95% were satisfied after
the initial intervention and 100% after the second one. In one eye
we found a retinal hole with a limited retinal detachment. In 86% of
cases, the response to a single or two-site 23 g cPPV was immediate.
14% noticed visual perception changes over a time period of 90-120
days. In a subgroup analysis (n = 20), the NEI-VFQ-25 and the
FFQ-22 correlated well preoperatively (rho = 0.510, p < 0.05) and
postoperatively (rho = 0.476, p < 0.05). The FF-22 described the
changes in quality of life (p = 0.001289), wellbeing (p = 0.072834)
and the type of vision disorder (p = 0.000082) with significant
changes in 85% of eyes (Wilcoxon-matched-pair-test: p = 0.000082).
When quality of vision was recorded with the CVA, remarkable
details about the vision under mesopic and glare conditions were
obvious.
Conclusions: PVD induced vitreous opacities have a significant
impact on the patients quality of life.2
As part of this SOP, performing all tests contributed substantially to
the patient’s satisfaction and subsequent decision regarding removal
of symptomatic vitreous opacifications in their second eye.
1
Frank H. Koch, MD, PhD; Michael J. Koss, MD, FEBO.
Microincision Vitrectomy Procedure Using Intrector Technology.
Arch Ophthalmol. 2011;129:1599-1604
2
Jerry Sebag. Am. J. Ophthalmology, 2011; 152 Editorial, 3e.1-4 e.1
Commercial Relationships: Frank H. Koch, Insight Instruments,
Inc. (C); Svenja Deuchler, None; Pankaj Singh, None; Thomas
Kohnen, None; Henrik Schaefer, None
Micrometer-precision penetration motion in robot-assisted
vitreoretinal surgery
Thijs H. Meenink1, 2, Marc D. de Smet3, 4, Gerrit Naus2, Maarten
Beelen2, Maarten Steinbuch1. 1Mechanical Engineering, Technische
Universiteit Eindhoven, Eindhoven, Netherlands; 2PRECEYES
Medical Robotics, Eindhoven, Netherlands; 3Retina and
Inflammation, MIOS, Lausanne, Switzerland; 4Ophthalmology,
University of Amsterdam, Amsterdam, Netherlands.
Purpose: Precision is a major requirement in vitreoretinal surgery.
Instrument positioning inside the eye involves 4 degrees of freedom;
axial instrument rotation, instrument penetration motion and two
rotations around the entry point of the eye. Both for safety and for
procedure efficacy, the most important motion in vitreoretinal surgery
is the instrument penetration motion. For different tasks, different
motion profiles are desirable, ranging from slowly approaching the
retina, e.g., for membrane peeling, to fast puncturing motions over
a short distance, e.g., for subretinal or intravenous injections. The
human hand precision of experienced vitreoretinal surgeons typically
is in the order of 100mm [Riviere, 1997]. Both to enable treatment
of manually untreatable indications and to improve existing surgical
tasks, a higher precision would be beneficial. The purpose of this
study is to evaluate positional precision of a vitreoretinal instrument
using the PRECEYES Surgical System [Meenink, 2012] versus
freehand motion.
Methods: A phantom eye model with a simulated retinal surface
was used to determine the positioning and the penetration precision.
The surgeon was asked to touch the surface of a paper grid at
several locations and to penetrate repeatedly to the same depth at
pre-specified locations. Freehand and robot-assisted performance
were compared. Robotic assistance was adjusted to filter tremor
and automatically execute small, predefined motion profiles. After
positioning the instrument above the target area, an incremental
penetration motion was automated upon user request using a foot
pedal.
Results: Manual penetration precision of 203mm was achieved
compared to an automated penetration precision of 19mm. Automated
penetration results in a 10 times more reproducible result compared
to manual penetration. The precision improvement in X and Y
direction is less substantial: a manual X and Y precision of 64μm was
achieved compared to an automated X and Y precision of 24μm.
Conclusions: For vitreoretinal instrument manipulation, the
penetration precision is an important component required for surgical
success. However, this motion is typically difficult to manually
execute with high precision. A 10 times higher precision can be
achieved by semi-automatic execution of a penetrating motion using
robot assistance. This can significantly benefit specific vitreoretinal
tasks such as subretinal and intravenous injections.
Commercial Relationships: Thijs H. Meenink, PRECEYES
Medical Robotics (E); Marc D. de Smet, PRECEYES Medical
Robotics (C); Gerrit Naus, PRECEYES Medical Robotics (E);
Maarten Beelen, PRECEYES Medical Robotics (E); Maarten
Steinbuch, None
Support: STW valorisation grant
Robot-assisted choroidotomy and sub-retinal bleb creation
Marc D. de Smet1, 2, Sicco H. Popma3, Gerrit Naus2, Thijs H.
Meenink2, Maarten J. Beelen2, Maarten Steinbuch4. 1Retina and
Inflammation, MIOS, Lausanne, Switzerland; 2Preceyes Medical
Robotics, Technical University Eindhoven, Eindhoven, Netherlands;
3
Janssens R & D, Radnor, PA; 4Mechanical Engineering, Technical
University Eindhoven, Eindhoven, Netherlands.
Purpose: Delivery of drugs or cells to the sub-retinal space can
be achieved via ab-externo catheterization [1]. The required
choroidotomy and the sub-retinal bleb creation by visco-dissection
of the retina and choroid can lead to retina perforation and tearing.
The purpose of this study is to demonstrate the feasibility of using
robot-assistance to make the procedure available to a wider range of
surgeons.
Methods: Equatorial sclerotomies down to the choroidal vessels
were performed in porcine eyes. The choroidotomy was assisted by
the PRECEYES Surgical System [2], executing a scratching motion
with a wiretip instrument (iScience Interventional). By filtering hand
tremors and by scaling hand movements, micrometer manipulation
precision is achieved. The penetration depth was increased
incrementally, preventing accidental penetration of the retina. While
executing the scratching motion, a visco-elastic fluid is injected to
dissect the retina from the choroid and to create the sub-retinal bleb.
The bleb size and the retinal integrity are visually inspected using an
endoscope.
Results: The results of this study are compared to a previous study
[1] in which 106 manual procedures were performed on similar
porcine eye models by an experienced surgeon. The incidence of
peripheral retinal perforations was 17% and the average required time
of the total procedure was 24 minutes. In this study, 17 robot-assisted
procedures were performed by a surgically unexperienced user. The
incidence of peripheral retinal perforations was 12%, with retinal
perforations in 2 cases. The average preparation time was 15 ±2
minutes, while the robot-assisted choroidotomy and the sub-retinal
bleb creation took 6 ±3 minutes.
Conclusions: Using robot assistance, the precision, the steadiness
and the reproducibility of instrument manipulation are improved.
This is crucial for a successful choroidotomy and the sub-retinal
bleb creation, making the procedure available to a wider range of
surgeons.
References
[1] M. D. de Smet, et al. (2012), Repeated ab-externo catheterization
of the sub-retinal space using a microcatheter for targeted delivery of
a cell therapy product in a pig model, ARVO 2012 Annual meeting
[2] H.C.M. Meenink, R. Hendrix, M.J. Beelen, G.J.L. Naus, E.J.G.M.
van Oosterhout, M.D. de Smet, H. Nijmeijer, M. Steinbuch (2012)
Robot-assisted vitreoretinal surgery, in Surgical Robotics, Part II –
Applications, edited by Paula Gomes, Cambridge Consultants
Commercial Relationships: Marc D. de Smet, Johnson & Johnson
(C), Johnson & Johnson (F), Thrombogenics (F); Sicco H. Popma,
Janssens Pharmaceuticals (E); Gerrit Naus, Johnson & Johnson (F),
Thrombogenics (F); Thijs H. Meenink, Johnson & Johnson (F),
Thrombogenics (F); Maarten J. Beelen, johnson & Johnson (F),
thrombogenics (F); Maarten Steinbuch, None
Outcome of surgical excision and histopathologcial features of
cyclitc membranes in children
Mostafa A. Elgohary1, 2, Pear Pongsachareonnont1, 2, Rajeev H. Muni1,
2
, Peter J. Kertes1, 2, Wai-Ching Lam1, 2, Asim Ali1, 2. 1Ophthalmology,
Hospital for Sick Children, Toronto, ON, Canada; 2Ophthalmology &
Vision Sciences, University of Toronto, Toronto, ON, Canada.
Purpose: To examine the outcome of surgical excision of cyclitc
membranes and describe their histopathological features in a series of
children.
Methods: This is a retrospective case review of 6 consecutive
children that underwent surgical excision of cyclitic membranes and
had a minimum follow up of 6 months. The indications for surgery
included recurrent corneal graft rejection (n=2), chronic anterior
uveitis after intraocular lens implantation (n=2) and recurrent retinal
detachment (n=2). All patients were either pseudophakic (n=4) or
aphakic (n=2) and had had penetrating keratoplasty procedure (n=5),
pars plana vitrectomy for retinal reattachment (n=3) or removal
of vitreous haemorrhage (n=1), silicone oil injection (n=2) and
trabeculotomy or trabeculectomy (n=4). Excision of the cyclitic
membrane was carried out through anterior and pars plana dissection
of the membrane in association with or following anterior or posterior
vitrectomy or removal of silicone oil. The outcome of interest was
the change in intraocular pressure (IOP), visual acuity (VA) and the
results of histopathological examination of the excised membranes.
Results: The mean age was 8.7 years (5 to 14 years). Preoperative
median IOP was 7.4 mmHg (0 to 12 mmHg) and mode VA was
PL (PL to 20/300). After a median follow-up of 12 months (6 to
24 months) the median IOP was 16.4 mmHg (10 to 25.7 mmHg)
and mode VA was HM (PL to 20/300). VA was stable in 4 patients,
improved (from PL to 20/400) in 1 patient and worsened (from CF
to PL) in 1 patient. Causes of poor visual acuity included chronic
retinal detachment under silicone oil with extensive proliferative
vitreoretinopathy (n=1), corneal graft failure or re-rejection with or
without advanced glaucomatous optic neuropathy (n=2).
Histopathological examination showed an abundance of fibrous tissue
with variable lymphocytic and macrophage cellular infiltration and
pigmentation.
Conclusions: In children, cyclitic membranes seem to represent a
fibrotic response resulting from chronic inflammation and multiple
intraocular surgery. Despite the small number, this study suggests
that surgical excision should be considered in children with cyclitic
membranes as it appears to help the restoration of IOP and therefore
preservation of the eye. It may also assist visual recovery at least in
some cases.
Commercial Relationships: Mostafa A. Elgohary, None; Pear
Pongsachareonnont, None; Rajeev H. Muni, None; Peter J.
Kertes, None; Wai-Ching Lam, None; Asim Ali, None
Title: Microbiologic Analysis in 23-ga office-based sutureless pars
plana vitrectomy
Cynthia Qian1, Flavio Rezende2, Przemyslaw Sapieha2.
1
Ophthalmology, Retina Service, Massachusetts Eye and Ear
Infirmary, Boston, MA; 2Ophthalmology, University of Montreal,
Montreal, QC, Canada.
Purpose: To perform a microbiological contamination analysis of
the vitreous during office-based micro-incisional vitrectomy surgery
assessing whether the bacteria detected correlated with patient’s
ocular conjunctival flora.
Methods: Participants were patients undergoing office-based MIVS,
anti-VEGF, and dexamethasone intravitreal injections (triple therapy)
for the treatment of wet age-related macular degeneration (AMD) and
diabetic macular edema (DME).
All patients were operated at a small procedure room in an
ambulatory clinic of the Department of Ophthalmology, University of
Montreal, Quebec, Canada.
Conjunctival samples were done before placing the sclerotomies. The
MIVS was done with a 23-gauge retractable vitrector, a 27-gauge
infusion line, and a 29-gauge chandelier. Undiluted and diluted
vitreous were collected for aerobic, anaerobic and fungal cultures.
Results: Thirty-seven patients (37 eyes) were recruited and
completed over 17 months of follow-up. Twenty-eight had wet AMD
and 9 had DME. There were 13 men and 24 women, with a mean age
of 78 years. 18 patients (46%) had culture positive conjunctival flora.
26 bacterial colonies were tabulated in total from the conjunctival
swabs. All bacteria detected were gram-positive bacteria (100%),
most commonly: Staphylococcus epidermitis in 11 (42%) and
Corynebacterium colonies in 6 (23%). Only 1/18 patients had more
than 3 species isolated, 6/18 patients had 2 species and 11/18 patients
had 1 species identified on the conjunctival swab. Only 1 of the 37
undiluted midvitreous samples was culture positive, equating to a
contamination rate of 2.7%. None of the diluted vitreous samples
were culture positive. All cultures were negative for fungus. No
serious postoperative complications occurred, including bacterial
endophthalmitis, choroidal detachment, and retinal detachment.
Conclusions: This preliminary study of office-based MIVS gives
us insights on the ocular surface microbial profile and vitreous
contamination rate of performing such procedures outside the ORcontrolled environment. Our initial results seem to indicate that there
is little risk of bacterial translocation and contamination from the
conjunctiva into the vitreous. Therefore, if endophthalmitis occurs
post-operatively, the source may likely arise after the procedure.
Larger studies are needed to confirm our data.
Commercial Relationships: Cynthia Qian, None; Flavio Rezende,
None; Przemyslaw Sapieha, None
Choroidal Melanoma Biopsy During Brachytherapy Using
25-Gauge Vitrectomy Technique: Clinical Experience
Deepthi M. Reddy1, 2, Mohammed Naseemuddin1, 2, John O. Mason2,
1
, Jacob J. Yunker3, Duncan A. Friedman2, 1. 1Ophthalmology,
University of Alabama-Birmingham, Birmingham, AL; 2Retina
Consultants of Alabama, Birmingham, AL; 3Ophthalmology
Associates, P.S.C., Louisville, KY.
Purpose: To report the safety and efficacy of a novel surgical
technique for the biopsy of choroidal melanomas utilizing 25-gauge
vitrectomy during brachytherapy.
Methods: A retrospective consecutive interventional case series of
17 consecutive eyes that underwent biopsy of choroidal melanoma
during brachytherapy from September 2012 to May 2013, was
performed to identify postoperative occurrence of vitreous
hemorrhage, tumor seeding or other complications, as well as the
adequacy of biopsy aspirate for genetic analysis.
Results: During the 8-month study interval, 0/17 (0%) eyes had
the complication of postoperative vitreous hemorrhage, or tumor
seeding of vitreous cavity or external extraocular tissue. Adequate
tissue biopsy aspirate was obtained in 17/17 (100%) of cases for
RNA-based gene expression assay. 4/17 (23.5%) were identified as
Class 2 and 13/17 (76.5%) were identified as Class 1. Postoperative
visual acuity was stable in 14/17 eyes (82.3%) and improved in 3/17
(17.7%) eyes.
Conclusions: This study suggests that 25-gauge vitrectomy biopsy
technique, which results in controlled hemostasis and adequate
biopsy samples, is an effective alternative to transvitreal or
transscleral fine-needle aspiration biopsy techniques for choroidal
melanoma biopsy. No short or long-term complications were noted.
Commercial Relationships: Deepthi M. Reddy, None; Mohammed
Naseemuddin, None; John O. Mason, None; Jacob J. Yunker,
None; Duncan A. Friedman, None
Fluidics comparison between dual pneumatic and spring return
high-speed vitrectomy systems
Rodrigo A. Brant Fernandes. 1Ophthalmology, Federal University of
Sao Paulo, Sao Paulo, Brazil; 2Ophthalmology, Doheny Eye Institute,
Los Angeles, CA.
Purpose: To compare the flow rate and duty cycle between two ultrahigh-speed vitrectomy systems: pneumatic with spring return (SR)
and dual pneumatic (DP) cutters.
Methods: Flow rate was calculated using a high-sampling precision
balance (2 samples/second) that measured the mass of water and
vitreous removed from a vial by a vitreous cutter. The difference
between the initial and final weight of water or vitreous was
converted to volume removed as a function of time. Three cutters
for each size (20-, 23- and 25-gauge) were tested with a SR system
and a DP system using the standard duty cycle (DC) setting (biased
open) at 0 (water only), 1,000, 2,000, 3,000, 4,000, and 5,000 cuts per
minute with aspiration levels of 100, 200, 300, 400, 500, and 600 mm
Hg. Frame-by-frame analysis of a high-speed video of the cutter was
used to determine the DC.
Results: The DC was slightly higher for the spring controlled system
although without statistical significance. At lower cut rates, vitreous
flow rates with the SR system tended to be higher than those obtained
with the DP system. However, at higher cut rates, the DP system
generated higher vitreous flow rates; in both cases the difference was
not statistically significant.
Conclusions: Spring return and dual pneumatic systems produced
similar results in terms of water and porcine vitreous flow rates.
Additional studies in human eyes are necessary to confirm these
findings.
Commercial Relationships: Rodrigo A. Brant Fernandes, None
An Automatically Tracking Robotic Endo-Illuminator for
Vitreoretinal Surgery
Ira H. Schachar1, Michael D. Ober3, Flavio Rezende2, Ke
Cao4, Ramiro Pinon4, Shorya Awtar4, Thiran Jayasundera1.
1
Ophthalmology, University of Michigan, Ann Arbor, MI;
2
Ophthalmology, University of Montreal, Montreal, QC, Canada;
3
Ophthalmology, Retinal Consultants of Michigan, Southfield, MI;
4
Engineering, University of Michigan, Ann Arbor, MI.
Purpose: Traditional vitreoretinal surgery is a three-port system
with one port dedicated to the infusion, one for illumination, and one
for a surgical tool and is largely a uni-manual surgical technique.
Currently available illumination devices, which allow for bimanual
vitreoretinal provide inadequate illumination. We sought to create an
endo-illuminator that provides direct illumination by automatically
tracking and directing and internal light source to the surgical field
thereby allowing for improved illumination during bimanual surgery.
Methods: An auto-tracking flexible endo-illuminator was created
which was composed of: an image recognition and processing
module that tracks the tip of a surgical instrument, an intra-ocular
actuation system that bends the flexible end of our proposed endoilluminator towards the instrument tip, and a holder that secures the
rigid end of the endo-illuminator in a fixed orientation during surgery.
Actuation of the endo-illuminator was achieved by constructing
and endo-illuminator with a flexible distal tip that is embedded with
three symmetrically arranged shape memory alloy wire (SMA)
loops, which constrict when heated. Instrument tip localization was
achieved by using image processing filters to localize the tip based on
the video feed from the operating microscope and transmit a signal to
redirect the flexible endo-illuminator.
Results: A 10 time scale-up model of the endo-illuminator was
successfully fabricated and tested in saline solution to simulate
intraocular conditions. When current was applied to the SMA wires
the maximum tip deflection reached 80 degrees with a response
time of less than one second. An image recognition and processing
algorithm was developed to successfully demonstrate the tracking of
an instrument tip. A to-scale holder was fabricated and demonstrated
sufficient stability when attached to a dummy head for typical
vitreoretinal procedures. The total set-up time for holder assembly
was less than one minute.
Conclusions: We have constructed a novel method of endoillumination which facilitates bimanual surgery. Because of the high
force-to-weight ratio, fast reaction time, large deformation range,
ease of manufacture, and low cost, SMA wires provide and ideal
actuation solution which can be housed entirely within the eye.
Miniaturization to 25-gauge system followed by ex vivo and in vivo
testing are necessary to validate this novel robotic endo-illuminator.
Commercial Relationships: Ira H. Schachar, University of
Michigan (P); Michael D. Ober, University of Michigan (P); Flavio
Rezende, University of Michigan (P); Ke Cao, None; Ramiro
Pinon, None; Shorya Awtar, University of Michigan (P); Thiran
Jayasundera, University of Michigan (P)
An Office-Based Procedure for Hyphema Treatment
Divya Sadhwani1, Mikelson MomPremier2, Saad Shaikh3. 1University
of Central Florida, Orlando, FL; 2Department of Ophthalmology,
Howard University, Washington, DC; 3Orlando VA Medical Center,
Orlando, FL.
Purpose: To describe a novel surgical technique for in-office
treatment of hyphema.
Methods: Retrospective non comparative case series. 3 cases of
hyphema in three different eyes treated in office using an anterior
chamber gas fluid exchange technique were analyzed.
Results: Hyphemas were associated with complications of
underlying systemic and retinal disease and occurred in the
postoperative period of other vitreoretinal surgical procedures. All
patients’ hyphemas were succesfully treated using the described
procedure. No patients required operating room surgery. One
patient required repeat in office air fluid exchange. Another received
concomitant anterior chamber bevacizumab injection as adjuvant
therapy for iris neovascularization.
Conclusions: The method described appears to be a safe and
effective procedure to treat hyphemas in certain patient populations.
Figure 1a: Entry into the anterior chamber superiorly with gas
filled syringe. Figure 1b: After partial gas injection, entry in to
the deepened anterior chamber inferiorly with evacuation syringe,
plunger removed.
Insulin dependence was more common in group A (0.68) than group
B (0.35)(P<0.05). Post-op VA measured at 1 day, 1 wk, 1 mo, 2-6 mo,
1 year, 2 years, and 3 years were all significantly better for group B,
with the largest statistical difference found of VA at 1st post-op day
(P<0.0005).
Conclusions: High CS, macular involvement, duration of DM,
insulin dependence, poor 1st post-op day VA were all associated with
poor prognosis in patients with diabetic TRD repaired with PPV and
SO tamponade.
Commercial Relationships: Neil Kalbag, None; Hardik Parikh,
None; Marco Zarbin, None; Neelakshi Bhagat, None
Support: Supported, in part, by an Unrestricted Grant from Research
to Prevent Blindness, Inc., The Lions Eye Bank of New Jersey.
Figure 2a: Evacuation of hyphema with complete or near compete
anterior chamber gas fluid exchange. Figure 2b: Inferior needle
removed while superior gas filled syringe is used to equilibrate
intraocular pressure.
Commercial Relationships: Divya Sadhwani, None; Mikelson
MomPremier, None; Saad Shaikh, None
Factors Associated with Poor Visual Prognosis in Diabetic
Tractional Retinal Detachments Repaired with Silicone Oil
Tamponade
Neil Kalbag, Hardik Parikh, Marco Zarbin, Neelakshi Bhagat.
Institute of Ophthalmology and Visual Science, Rutgers, New Jersey
Medical School, Newark, NJ.
Purpose: To determine prognostic factors for poor visual outcomes
in diabetic tractional retinal detachments (TRDs) who underwent
repair with pars plana vitrectomy (PPV) with 5000 cs silicone oil
(SO) tamponade at University Hospital, Newark, NJ between 2006
and 2012.
Methods: Retrospective series. Patients with prior RD repair were
excluded from the study. Patients were grouped according to most
recent visual acuity (MRVA). MRVAs of NLP, LP, and HM were
considered poor outcomes (group A), and MRVAs of CF and greater
were considered good outcomes (group B). Complexity score (CS)
was calculated for each TRD. Combined rhegmatogenous and TRDs
(rtRDs) were also included.
Results: Forty eyes with TRD treated with PPV and SO were studied.
One eye with dense cataract post-operatively was excluded. Twenty
two (56.4%) eyes resulted in poor visual outcome, and 17 (43.6%)
resulted in good visual outcome. Mean follow-up time was 21.8
months. LogMAR mean MRVAs groups A and B were 2.43 (20/5383)
and 1.20 (20/317), respectively. Pre-op VA in groups A and B were
1.55 and 1.37, respectively. Age, sex, rates of type 1 DM, type 2 DM,
hypertension, hypercholesterolemia, dialysis, vitreous hemorrhage,
rtRD, pre-op VA, or occurrence of IOP>25 post-operatively did
not significantly vary between groups (P>0.05), nor did rates of
history of panretinal photocoagulation (PRP). Complication rates
were statistically indifferent between the groups for hypotony,
cataract, glaucoma, oil migration and emuslification, macular pucker,
subretinal oil, recurrent RD, hyphema, fibrosis, and corneal edema
(P>0.05).
Macular involvement was more prevalent in group A than in group B
(0.95 vs 0.71)(P<0.05). Mean CS was higher in group A (6.32) than
in group B (5.41)(P<0.05). Duration of DM in group A, 19.33±8.11
years, was higher than that of group B, 10.60±6.36 years (P<0.05).
Comparison of reaction response time between hand and foot
controlled devices in simulated microsurgical testing
Marcel Pfister1, 2, Jawchyng L. Lue1, Michael J. Koss1, 2, Francisco
R. Stefanini1, 2, Paulo Falabella1, 2, Mark S. Humayun2. 1Doheny Eye
Institute, Los Angeles, CA; 2Ophthamology, USC, Los Angeles, CA.
Purpose: The cut and vacuum rates of most modern vitreous
cutters are controlled by foot-paddle. We hypothesized that reaction
times (RT) for the switch release are faster for hand- than for
foot-controlled switches for physiological, anatomical (e.g. nerve
conduction speed) and ergonomic reasons. The risk of accidental
trauma to eye (e.g. sucking retina into the vitreous cutter) could be
reduced if the surgeon reacted quicker to reduce vacuum power and
to improve the surgical outcome.
Methods: The study included 47 medical students and ophthalmic
surgeons at USC. Age, dominant/non-dominant hand/foot, gender
and experience level were recorded. Under a microscope, a red light
emitting diode (LED) was shown as a START indicator. After the
start signal, participants expected a green LED signal to trigger their
release of a hand- or footswitch. The duration between start time
and the green LED signal was randomized as was the order of the
four extremities tested. The RT is the time between the green LED
signal and the break in the switch circuitry. Each extremity of each
individual was tested 5 times. A subjective questionnaire was also
administered addressing ergonomic preferences.
Results: The mean RT: hands 318.24ms±51.13; feet
328.69ms±48.70. Comparison: Hand vs. Foot: mean (SD) = -10.45ms
(30.86), p= 0.025. Male subjects’ responses (291ms±9) were
statistically significantly faster than females’ (339ms±10, p = 0.001).
The analysis and comparison of each extremity for the different
experience level groups (years of microscopic surgery (YMS): 0
years to 8 or more years / microscopic surgeries per week (MPW): 0
to 10 or more) showed partially significant differences between the
groups (YMS p=0.01-0.003/ MPW p=0.57-0.002) but no statistically
significant trend toward shorter RTs with more years of practice
(p=0.81-0.4) or more surgeries per week (p=0.8-0.28). According
to the results of the subjective questionnaire, 89% (n=42) of test
subjects prefer to use hand-controls for the vitreous cutter.
Conclusions: Our data show that the RT for hands is faster than feet.
Similarly the subjective questionnaire showed a greater preference
for hand actuation than foot actuation of switch. This data suggest
a hand-controlled ophthalmic instrument might have distinct
advantages than a foot-controlled unit; however, clinical correlation
is required to confirm these findings.
Commercial Relationships: Marcel Pfister, None; Jawchyng
L. Lue, Bausch & Lomb (F); Michael J. Koss, None; Francisco
R. Stefanini, None; Paulo Falabella, None; Mark S. Humayun,
Bausch & Lomb (C), Bausch & Lomb (F), Bausch & Lomb (I),
Bausch & Lomb (P)
Support: Financial support from Bausch & Lomb
Clinical Trial: HS-13-00467
Vitrectomy with or without encircling band for the treatment of
pseudophakic retinal detachment - the prospective randomized
VIPER trial
Peter Walter1, Babac Mazinani1, Sabine Baumgarten1, Amelie
Pielen2, 3. 1Department of Ophthalmology, RWTH Aachen University,
Aachen, Germany; 2Department of Ophthalmology, University
of Freiburg, Freiburg, Germany; 3Department of Ophthalmology,
Medical School of Hanover, Hanover, Germany.
Purpose: To determine the potential benefit of an additional
encircling band in primary vitrectomy with gas for the repair of
rhegmatogenous pseudophakic retinal detachment (PRD).
Methods: Patients with PRD were enrolled in a prospective
randomized multicenter clinical trial and treated either by 20 G
vitrectomy with gas (control group C) or by 20 G vitrectomy with gas
and encircling band (experimental group E1). A smaller proportion
of patients was randomized to a third exploratory arm and treated
with 23 or 25 G vitrectomy with gas alone (experimental group E2).
The primary endpoint was the absence of any indication for a second
retina specific procedure within a follow-up of six months after the
primary surgery. Secondary endpoints were visual acuity, refraction
and adverse events. The study was performed within the German
retina.net framework (www.retina-net.uni-koeln.de).
Results: The VIPER trial is registered in the German Clinical Trials
Register under DRKS00003158. Between August 2011 and August
2013 257 patients were enrolled in the study. 14 vitreoretinal centers
participated in the trial. 100 Patients were randomized to groups C
and E1, 57 patients were randomized to group E2. Last patient last
visit is scheduled for February 2014. Final outcome data will be
presented at the conference.
Conclusions: The VIPER trial investigated the potential effect of
an additional encircling band in primary vitrectomy with gas for
pseudophakic retinal detachment. The VIPER trial results will also
indicate if transconjunctival 23 or 25 G vitrectomy with gas alone is
of similar efficacy in this condition.
Commercial Relationships: Peter Walter, None; Babac Mazinani,
None; Sabine Baumgarten, None; Amelie Pielen, None
Support: retina.net (www.retina-net.uni-koeln.de)
Clinical Trial: DRKS00003158
Subjective satisfaction scale of the patients after surgery for
epiretinal membrane
Joo Eun Lee1, Seung Youn Jea2, Hyun Woong Kim3, Kyung-won
Seok4. 1Department of Ophthalmology, Haeundae Paik Hospital, Inje
University College of Medicine, Busan, Republic of Korea; 2GM
St. Mary’s Eye Clinic, Busan, Republic of Korea; 3Department of
Ophthalmology, Busan Paik Hospital, Inje University College of
Medicine, Busan, Republic of Korea; 4Department of Ophthalmology,
Busan Veterans Hospital, Busan, Republic of Korea.
Purpose: To evaluate subjective satisfaction of the patients after
surgery for epiretinal membrane (ERM).
Methods: Twenty five eyes of 25 patients who received vitrectomy
for ERM removal were included in the study. The patients were
divided into two groups; Group A with their baseline visual acuity
better than 0.22 (LogMAR) and group B equal to or less than 0.22.
Best corrected visual acuity, central macular thickness (CMT)
by optical coherence tomography, metamorphopsia score by
M-chart, and subjective scale regarding postoperative outcomes by
questionnaire (scale range; -5 to +5) at postoperative 6 month were
evaluated.
Results: Mean visual acuity (LogMAR) has changed from 0.06±0.02
to 0.04±0.02 at 6 month postoperatively in group A (p=0.681), and
from 0.50±0.10 to 0.25±0.10 in group B (p=0.005). Mean CMT
changed from 404±15(μm) to 354±11 (p=0.001), and from 443±57 to
344±28 (p=0.016), respectively, in group A and B. Subjective scale
regarding overall satisfaction about surgical outcome at 6 month was
0.8±0.4 in group A and 0.4±0.8 in group B (p=0.188). Horizontal
M-chart score at 6 month was 0.1±0.1 in group A and 0.4±0.2 in
group B (p=0.008). Vertical M-chart score was 0.2±0.1, and 0.5±0.1,
respectively in group A and B (p=0.041).
Conclusions: ERM patients with better visual acuity at baseline seem
to be more satisfied with the surgical outcomes. Earlier intervention
for epiretinal membrane before patients develop significant visual
loss and metamorphopsia would be necessary.
Commercial Relationships: Joo Eun Lee, None; Seung Youn Jea,
None; Hyun Woong Kim, None; Kyung-won Seok, None
Support: None in the Support field below
Un-explained Visual Loss Following Silicone Oil Removal.
Results of the Pan American Collaborative Retina Study
(PACORES) Group
Natalia Alpizar-Alvarez1, Lihteh Wu1, Jose A Roca2, Francisco
Rodriguez3, Arturo Alezzandrini4, Gustavo Alvira5, Raul Velez6, Hugo
Quiroz-Mercado6, J Fernando Arevalo7, Martin Serrano8. 1Retina,
Instituto de Cirugia Ocular, San Jose, Costa Rica; 2Retina, Clinica
Ricardo Palma, Lima, Peru; 3Retina, Fundacion Oftalmológica
Nacional. Universidad del Rosario, Bogota, Colombia; 4Retina,
OFTALMOS. Catedra de Oftalmologia. Universidad de Buenos
Aires, Buenos Aires, Argentina; 5Retina, Hospital Metropolitano,
Quito, Ecuador; 6Retina, University of Colorado, Denver, CO;
7
Retina, The King Khaled Eye Specialist Hospital, Riyadh, Saudi
Arabia; 8Retina, Clinica Oftalmologica Centro Caracas, Caracas,
Venezuela, Bolivarian Republic of.
Purpose: To report the incidence and clinical features of patients
that experienced un-explained visual loss following silicone oil (SO)
removal.
Methods: Multicenter retrospective study of patients that underwent
SO removal during 2000-2012. Visual loss of ≥ 2 lines was
considered significant.
Results: A total of 324 eyes underwent SO removal during the study
period. 34 (10.5%) eyes suffered a significant visual loss following
SO removal. Eleven (3.4%) of these eyes lost vision secondary
to known causes such as retinal redetachment and proliferative
vitreoretinopathy (7 eyes), vitreous hemorrhage secondary to
diabetic retinopathy (3 eyes) and glaucoma (1 eye). In the remaining
23 (7.1%) eyes the loss of vision was not explained by any other
pathology. 15 of these 23 patients (65.2%) were male and 8 (34.8%)
were female. The mean age of this group was 51.8 (16-73) years.
Systemic co-morbidities included 1 patient with cardiovascular
disease, 7 with diabetes mellitus, and 7 with systemic hypertension.
In 11 patients 5000cs SO was used and in 12 eyes 1000cs SO was
used. A multivariate analysis comparing eyes with visual loss and
those without visual loss identified intraocular pressure and length of
time of silicone oil tamponade as factors associated with visual loss.
Eyes that lost vision had a mean IOP while the eye was filled with SO
of 16.8 mmHg (11-20). The length of time that the eye was filled with
SO was 8 months (3-24). In comparison, eyes that did not experience
visual loss had a mean IOP of 15.6 mm Hg (10-24, p<0.005) and a
mean tamponade duration of 4.8 months (2-72, p<0.005).
Conclusions: Severe visual loss after SO removal was observed
in 7% of patients with otherwise good visual potential.Factors
associated with unexplained visual loss included IOP and SO
tamponade duration.
Commercial Relationships: Natalia Alpizar-Alvarez, None;
Lihteh Wu, None; Jose A Roca, None; Francisco Rodriguez, None;
Arturo Alezzandrini, None; Gustavo Alvira, None; Raul Velez,
None; Hugo Quiroz-Mercado, None; J Fernando Arevalo, None;
Martin Serrano, None
Clinical Trial: no
Integrative Surgical Instrument Solutions for Optimizing
Intraoperative OCT for Ophthalmic Surgery
Justis P. Ehlers, Sunil K. Srivastava, Yuji Itoh, Yuankai K. Tao.
Ophthalmic Imaging Center Cole Eye Institute, Cleveland Clinic,
Cleveland, OH.
Purpose: Previous studies have also demonstrated the limitations
of conventional metallic instruments for OCT-based visualization
(e.g., shadowing of underlying tissue, poor instrument identification).
Optimal integration into the surgical environment will require
significant advances in surgical instrumentation to optimize OCTbased visualization of maneuvers utilizing a microscope integrated
OCT (MIOCT) system. The purpose of this study was to assess novel
surgical instrumentation prototypes specifically designed for use with
a MIOCT system to assess OCT-based visualization of instrumenttissue interactions.
Methods: CT-compatible instrumentation, including vitreoretinal
forceps and surgical picks, were prototyped based on optimal material
properties for OCT transparency and contrast. MIOCT imaging was
performed in fresh cadaveric porcine eyes using a second-generation
MIOCT prototype system with enhanced ergonomic/functional
features (FIGURE 1). Volumetric imaging and real-time OCT-based
motion capture using custom imaging acquisition protocols were used
for instrument/tissue visualization at numerous locations, including
mid-vitreous and retinal surface.
Results: High-resolution MIOCT images allowed prototype
instrument visualization at all locations. OCT-compatible surgical
instruments exhibited excellent optical properties, including minimal
shadowing and optimal light scattering. Minimizing shadowing
provided outstanding views of the underlying tissue, increasing the
capacity for instrument-tissue interaction visualization (FIGURE
2). The light scattering properties provided for excellent B-scan
resolution of the instrument tip, compared to specular reflection
artifacts often seen with metallic instruments. Motion capture and
volumetric OCT scans were successfully obtained during surgical
maneuvers.
Conclusions: Enhanced visualization of instrument/tissue
interactions is possible utilizing a second generation MIOCT system
in combination with OCT-friendly instrumentation. This represents
an important achievement for improved integration of intraoperative
OCT and the potential to fully integrate this technology into the
ophthalmic operating room.
Microscope integrated OCT system
Figure 2: OCT-compatible surgical pick with 3D reconstruction and
parallel/perpendicular B-scans at instrument tip revealing excellent
visualization of underlying tissue and instrument tip.
Commercial Relationships: Justis P. Ehlers, Bioptigen (P),
Regeneron (R), Thrombogenics (C), Thrombogenics (R); Sunil
K. Srivastava, Alimera (C), Allergan (F), Bausch and Lomb (C),
Bioptigen (P), Clearside (F), Novartis (F), Regeneron (C); Yuji Itoh,
None; Yuankai K. Tao, None
Support: NIH/NEI K23EY022947 & 1R01EY023039
FocalSeal® for Closure of Sutureless Sclerotomies of Vitrectomy:
An In Vivo and Histological Study
Shoko Ishida1, Fumiki Okamoto1, Sujin Hoshi1, Shinichi Fukuda1,
Yoshimi Sugiura1, Mikki Arai2, 3, Tatsuo Hirose3, Tetsuro Oshika1.
1
Ophthalmology, Institute of Medicine, University of Tsukuba,
Ibaraki, Japan; 2Arai Eye Clinic, Fukuoka, Japan; 3The Schepens Eye
Research Institute, Harvard Medical School, Boston, MA.
Purpose: FocalSeal® is an absorbable polyethylene glycol-based
synthetic hydrogel sealant. This liquid is polymerized under visible
xenon illumination, and forms clear, flexible, and firmly adherent
hydrogel. In this study, we evaluated the ability of FocalSeal® to
close sclerotomies of microincision vitrectomy.
Methods: Dutch pigmented normal rabbits were used in this
in vivo study. We performed 23-gauge 3-port vitrectomy on a
unilateral eye of each study animal. The sclerotomy was made by
inserting a 23-gauge microvitreoretinal knife at an angle of 45°
transconjunctivally. After core vitrectomy, vitreous gel around the
cannula was removed with the vitrectomy cutter and then fluid-air
exchange was performed. After cannulas except for irrigation were
removed, 0.625% Povidone-iodine was dropped over the conjunctiva
on the sclerotomy site to confirm air leakage from the sclerotomy.
Then, FocalSeal® was injected subconjunctivally to cover the
sclerotomies, and was polymerized with 60-second application of
xenon light. Povidone-iodine was again dropped over the conjunctiva
on the sclerotomy site to check whether air leakage from the
sclerotomies exists. The eyes were enucleated 7 days after operation
for histological examinations.
Results: After subconjunctival injection and application of xenon
light, FocalSeal® polymerized rapidly. No air leakage was observed
when povidone-iodine was dropped over the sclerotomy site. On
histological examination, linear scar formations were observed at the
sclerotomy sites and sclerotomy tunnels were tightly closed.
Conclusions: This experiment suggests that FocalSeal® allows
secure closure of sutureless vitrectomy incisions.
Commercial Relationships: Shoko Ishida, None; Fumiki
Okamoto, genzyme (F); Sujin Hoshi, None; Shinichi Fukuda,
None; Yoshimi Sugiura, None; Mikki Arai, None; Tatsuo Hirose,
None; Tetsuro Oshika, None
A cross-linked hyaluronic acid hydrogel (Healaflow ®) as a
potential vitreous substitute
Henrik Barth1, 2, Sven W. Crafoord3, 4, Cyrille Vinchon5, Sten
Andreasson1, 2, Fredrik K. Ghosh1, 2. 1Ophthalmology, Lund
University, Lund, Sweden; 2Ophthalmology, Skåne University
Hospital, Lund, Sweden; 3Ophthalmology, School of Health
and Medical Sciences, Örebro University, Örebro, Sweden;
4
Ophthalmology, Örebro University Hospital, Örebro, Sweden;
5
Anteis S.A., Plan Les Ouates, Switzerland.
Purpose: Vitrectomy surgery mandates a way to substitute the natural
vitreous and to tamponade any retinal breaks. The clinically available
alternatives are still flawed with side effects such as inflammation,
rise in intraocular pressure, cataract formation, and a need for head
posturing. In this study, a hydrogel of cross-linked sodium hyaluronic
acid (Healaflow®) is evaluated for use as a novel vitreous substitute
utilizing an in vivo model.
Methods: A combined 25-20-gauge pars plana vitrectomy with
posterior vitreous detachment was performed in the right eye of
twelve pigmented rabbits, with subsequent injection of approximately
1 ml of Healaflow®. Clinical evaluation, intraocular pressure
measurement and full-field ERG were performed postoperatively
at intervals up to 105 days. The rabbits were sacrificed at different
time-points between 42 and 105 days. After enucleation, the eyes
were examined macroscopically, photographed, and prepared
for histological examination with routine microscopy and
immunohistochemical analyses.
Results: The cross-linked sodium hyaluronic acid hydrogel was
injected successfully and remained translucent but did not retain its
structural integrity throughout the postoperative period of up to three
months, although some viscous remnants were seen. One rabbit was
lost due to unrelated causes. In two eyes iatrogenic partial retinal
detachments were seen and in two eyes significant cataract were
formed due to intraoperative complications. A slight postoperative
rise in intraocular pressure was observed. ERG-recordings revealed
no toxic effect on rod or cone function on follow up to three months.
Microscopy and immunohistochemistry demonstrated normal
morphology with some Müller cell activation (up-regulation of
glial acidic fibrillary protein) compared to un-operated eyes and no
significant DNA-fragmentation (TUNEL-assay).
Conclusions: A multitude of compounds have been investigated
as candidates for vitreous substitution. To date, none of these
compounds have been able to meet both physical demands and
provide a good biocompatibility. Healaflow® did not affect retinal
morphology or function negatively, making it highly interesting
in this setting. The gel remained, and its viscous structure was
maintained for at least a couple of weeks allowing for an effective
tamponade. Future work will include an increased ratio of crosslinking to prolong gel structural integrity even further.
Commercial Relationships: Henrik Barth, None; Sven W.
Crafoord, None; Cyrille Vinchon, Anteis SA (E); Sten Andreasson,
None; Fredrik K. Ghosh, None
Support: The Faculty of Medicine, University of Lund; The Swedish
Research Council no90247201; The Princess Margaretas Foundation
for Blind Children; The Wallenberg Foundation MMW 2011.0009
Characteristics, Demographics, Anatomic and Functional
Outcomes, and Complications of Diabetic Tractional Retinal
Detachments Treated with Silicone Oil Tamponade
Hardik Parikh1, 2, Neil Kalbag1, 2, Marco Zarbin1, 2, Neelakshi Bhagat1,
2 1
. Institute of Ophthalmology and Visual Science, Rutgers, New
Jersey Medical School, Newark, NJ; 2Rutgers, the State University of
New Jersey, Newark, NJ.
Purpose: To describe the characteristics, demographics, anatomic
and functional outcomes, and complications of diabetic eyes with
tractional (TRD) or combined tractional/rhegmatogenous retinal
detachment (trRD) that underwent pars plana vitrectomy (PPV)
silicone oil (SO) tamponade at University Hospital in Newark, NJ
between 2006 and 2012.
Methods: Retrospective chart review. Exclusion criteria included
previous PPV.
Results: Forty eyes of thirty-seven patients were identified. Twentythree (62%) patients were male. Eleven (30%) patients had type I
DM, 23 (62%) had type II, and 3 (8%) others were undocumented.
The mean age of the patients was 46.9 years (range 23-68 years). The
average follow-up was 22.4 months (range 7 days-6.8 years). Twenty
four (60%) eyes presented with a combined trRD. A detached macula
was present in 33 (82.5%) eyes. Eyes with macula-sparing TRDs had
better pre-op VA (~20/400), final VA (~20/400), and BCVA (~19/200)
than those with a detached macula (~20/400, ~HM, and ~5/200,
respectively). The mean pre-operative complexity score (CS) of the
TRDs was 5.95 (range 4-8). Eyes with lower CSs had a better mean
final VA: ~20/400 for CS 4, ~HM for CS 6, and ~1/200 for CS 8.
The average BCVA for all 40 eyes was ~5/200, and occurred at a
mean of 6.5 months post-op. Eyes of patients on dialysis had poorer
final VA (~1/200) than those patients who were not (~5/200). Eyes
with 3 or more pan-retinal photocoagulations attained better mean
final VA (~5/200) than eyes with 0 pre-operative PRP’s (~1/200).
Complications in patients with 6 or more months of follow-up
included cataracts (46%), pre-retinal fibrosis (33%), oil migration
to anterior chamber (12%), corneal edema (12%), RD (9%), oil
emulsification (9%), glaucoma (6%), oil migration under the
conjunctiva (6%), subretinal oil (6%), rubeosis iridis (6%), hyphema
(3%), and hypotony (3%). In patients with at least 6 months of
follow-up, only 4 of 33 (12%) eyes had no complications. Only 10 of
40 (25%) eyes underwent silicone oil removal.
Conclusions: The average complexity score in diabetic eyes
that underwent TRD repairs with silicone oil was high, at 5.95.
Complication rates with oil tamponade for diabetic TRDs were low in
this series.
Commercial Relationships: Hardik Parikh, None; Neil Kalbag,
None; Marco Zarbin, None; Neelakshi Bhagat, None
Support: Unrestricted Grant from Research to Prevent Blindness,
Inc., The Lions Eye Bank of New Jersey
Outcomes after silicone oil extraction in complex rhegmatogenous
retinal detachment
Renata L. Tavares1, Mario J. Nobrega2, 1, Fernando Nobrega3,
Fernando J. Novelli2, Carlos Augusto C. Oliveira1. 1University of
Joinville, Joinville, Brazil; 2Sadalla Amin Ghanem Eye Hospital,
Joinville, Brazil; 3University of Alfenas, Alfenas, Brazil.
Purpose: To evaluate anatomical and functional outcomes after
silicone oil extraction in patients with retinal detachment and
proliferative vitreoretinopathy in an eye care referral center in
Joinville, SC, southern Brazil.
Methods: Retrospective, noncomparative study of patients
with retinal detachment and grade C posterior proliferative
vitreoretinopathy followed up after silicone oil removal. Prophylactic
360-degree peripheral laser photocoagulation was performed one
to three months before silicone oil extraction. Patients with cataract
underwent a combined clear corneal phacoemulsification with
intraocular lens implantation in the same procedure. Anatomical
outcomes were related to the duration of silicone oil tamponade and
the surgical procedure performed. Functional outcomes were divided
into three categories (stability, worsening, or improvement) according
to visual acuity variation before the surgery and at the last follow-up
visit.
Results: Fifty-three patients were followed up for a mean period
of 1,262 days. Fourteen eyes (26.4%) underwent cataract surgery
combined with silicone oil extraction. Forty-eight eyes (90.5%)
had attached retina at the last follow-up visit. Time of intraocular
tamponade and association of phacoemulsification with silicone
oil extraction were not considered as risk factors for retinal
redetachment. Twenty-three cases (43.4%) showed visual acuity
improvement, whereas 11 cases (20.8%) were stable and 19 cases
(35.8%) showed visual acuity worsening. Five patients with attached
retina had unexplained optic disc atrophy.
Conclusions: Most patients had good anatomical and visual
outcomes with silicone oil extraction. Prophylactic 360-degree laser
retinopexy may have led to favorable outcomes. Benefits of silicone
oil extraction must be compared with its extended duration in the eye
and the risk of complications due to a new surgical procedure.
Commercial Relationships: Renata L. Tavares, None; Mario J.
Nobrega, None; Fernando Nobrega, None; Fernando J. Novelli,
None; Carlos Augusto C. Oliveira, None
What happens to visual acuity following removal of silicone oil?
Rachel Milne1, David Miller1, Kirstin Griffin2, 1, David Yorston1.
1
Ophthalmology, Ophthalmology Department, Gartnavel General
Hospital, Glasgow, United Kingdom; 2Medical School, University of
Glasgow, Glasgow, United Kingdom.
Purpose: Silicone oil is an effective tamponade in complex retinal
detachment, including proliferative vitreoretinopathy (PVR), giant
retinal tear (GRT) and proliferative diabetic retinopathy(PDR).
However prolonged tamponade is associated with cataract, glaucoma,
and reduced visual acuity. Whenever possible silicone oil is removed
within a few months of its insertion. Although removal of silicone oil
(ROSO) reduces the risk of complications, a few patients experience
an unexplained drop in visual acuity, despite an apparently normal
fundus. The purpose of this study was to estimate the incidence of
this complication, and to identify any risk factors associated with it.
Methods: Retrospective case note review of 115 removal of silicone
oil patients treated by 4 tertiary vitreoretinal consultants in the West
of Scotland regional centre at Gartnavel General Hospital
Results: 115 patients were included. Indications for silicone oil were
PVR (68, 59%), PDR (14, 12%), Giant retinal tear (19, 17%).
Following ROSO, 21 (18.3%) eyes redetached. Redetachment was
not associated with the following risk factors: type of oil, duration
of tamponade, 360 degree laser, retinectomy, PVR, PDR, GRT, or
number of operations.
The median LogMar (Fig.1) at presentation was 2.6, improving to
1.0 before ROSO (Mann-Whitney, p = 0.0005), and 0.78 after ROSO
(Mann-Whitney, p = 0.0084). In the 94 eyes that remained attached,
corrected vision improved by ≥0.3 LogMar units in 39 (41.1%,
95% ci 31.2-51.6%), and worsened by ≥0.3 LogMAR in 5 (5.3%,
95% ci 2.0 – 12.6%). 50 patients (52.6%, 95% ci 42.2 – 62.9%)
had little change in VA. In four eyes (4.3%, 95%ci 1.4-11.2%) there
was no apparent cause for the loss of vision. Vision deterioration or
improvement following ROSO was not associated with presenting
visual acuity, indication for silicone oil, type of oil, duration of
tamponade, 360 degree laser, retinectomy, or number of operations.
Conclusions: VA is improved or stabilized in most patients having
ROSO. Although unexplained reduction in vision is a well-known
complication, this is the first report that attempts to estimate the
incidence. Our data suggests that the complication may be more
common than originally thought. All patients undergoing ROSO
should be informed of the risk of unexplained visual loss as well as
the risk of redetachment.
Fig.1 Box plot of LogMAR visual acuities at presentation, prior to
ROSO, and after ROSO.
Commercial Relationships: Rachel Milne, None; David Miller,
None; Kirstin Griffin, None; David Yorston, None
Removal of Silicone Oil with 25 Gauge and 23 Gauge Cannula
Systems
Homayoun Tabandeh1, Francesco Boscia2, David S. Boyer1. 1Retina
Vitreous Assoc Med Group, Los Angeles, CA; 2Dept. Ophthalmology,
University of Bari, Bari, Italy.
Purpose: Small gauge vitrectomy has become the standard of care
for most vitreo-retinal procedures. Removal of silicone oil through
small gauge cannula may be associated with prolonged removal
time, influencing surgeon’s preferred method of removal of silicone
oil. The purpose of the current study was to evaluate the time taken
for removal of silicone oil through 23 gauge and 25 gauge cannula
systems.
Methods: Interventional, non-comparative, clinical case series.
Participants included patients undergoing removal of silicone
oil as part of their vitreoretinal procedure. The silicone oil was
removed using the automated viscous fluid extraction device (Alcon
Constellation) at standard settings (Vacuum 650 mmHg, intraocular
pressure 35 mmHg). Time taken to remove 1 ml of silicone oil using
the “extraction sleeve” or the cannula was measured for each case.
Typically, for each case two measurements were obtained using the
“extraction sleeve” and two measurements were obtained using the
cannula. The two values were averaged for each case.
Results: Twenty nine eyes.
Group 1: 25 gauge, 1000 cs silicone oil. N=14. The mean time
for removal of silicone oil was 25.5 seconds/ml (SD 1.3 ) for the
“extraction sleeve”, and 38.4 seconds/ ml (SD 2.1 ) for the cannula.
Group 2: 23 gauge, 1000 cs silicone oil. N= 12. The mean time
for removal of silicone oil was 12.5 seconds/ml (SD 1.0 ) for the
Group 3: 23 gauge, 5000 cs silicone oil. N= 3. The mean time
for removal of silicone oil was 49.8 seconds/ml (SD 3.4) for the
Assuming an average of 4.5 ml volume of silicone oil in the vitreous
cavity, the estimated average time for removal of 1000 cs silicone
oil would be 115 seconds for 25 G “extraction sleeve”, 173 seconds
for 25 G cannula, 56 seconds for 23 G “extraction sleeve”, and 99
seconds for 23 G cannula. For 5000 cs silicone oil, the estimated
average time for removal of silicone oil would be 224 seconds for 23
G “extraction sleeve”, and 415 seconds for 23 G cannula.
Conclusions: Removal of 1000 cs silicone oil through small gauge
cannula systems is associated with an acceptable time ranging from
an estimated average time of 56 seconds for a 23 G “extraction
sleeve” to 173 seconds for a 25 G cannula. For the 5000 cs silicone
oil the estimated average time was significantly higher.
Commercial Relationships: Homayoun Tabandeh, Alcon (C);
Francesco Boscia, Alcon (C); David S. Boyer, Alcon (C)
A Comparison of Same-Setting versus Delayed Vitrectomy in the
Management of
Retained Lens Fragments Following Cataract Surgery
Steven J. Ryder1, Anton Orlin1, George J. Parlitsis1, Ya-Lin
Chiu2, Donald J. D’Amico1, Robison V. Chan1, Szilard Kiss1.
1
Ophthalmology, Weill Cornell Medical College, New York, NY;
2
Publich Health, Division of Biostatistics and Epidemiology, Weill
Cornell Medical College, New York, NY.
Purpose: Intravitreal retained lens fragments (RLF) are a rare but
potentially serious complication of phacoemulsification. The purpose
of our study is to compare same setting (“no wait”) vitrectomy to
delayed surgery in the management of RLF in as single academic
setting.
Methods: Retrospective, non randomized study of all patients
undergoing pars plana vitrectomy (PPV) for RLF following cataract
surgery from 2007-2012. Outcomes included visual acuity and the
development of various complications such as retinal detachment,
elevated intraocular pressure (IOP) >30 mm Hg and cystoid macular
edema. Multivariate analysis was performed to adjust for potentially
confounding variables such as age and preoperative visual acuity.
Results: 28 consecutive eyes (13 same setting, 15 delayed setting)
were included in the analysis. Patients in the same setting group
were older than in the delayed one (81.00 vs 72.87 yrs, p=0.053). No
other preoperative differences existed between groups (axial length,
preoperative vision, IOP). Mean time to PPV in the delayed group
was 26.6 days (range 1-91 days). Mean follow up time was 363 days
(same setting) and 643 days (delayed). At most recent follow up,
no significant difference existed in mean vision between the same
setting (logMAR 0.42) and delayed group (logMAR 0.57), p=0.132.
Multivariate analysis showed no difference in final vision when
adjusting for age and preoperative vision. Although there was a trend
for eyes in the same setting group to obtain good vision (>/= 20/40)
faster, a higher percentage of eyes in the delayed group obtained good
vision at most recent follow up (66.7% vs 23.1%, p=0.02). More
eyes in the delayed group had an IOP>30 at any point (p=0.055).
There was no significant difference between groups in any other
complications such as retinal detachment, choroidal detachment, and
CME during follow up.
Conclusions: In our cohort, same setting PPV offers no significant
visual acuity advantage over delayed PPV in patients with retained
lens fragments. Fewer eyes in the same setting group “ever” had
an intraocular pressure >/= 30 during follow up, while no other
complication differences were seen between groups.
Commercial Relationships: Steven J. Ryder, None; Anton Orlin,
None; George J. Parlitsis, None; Ya-Lin Chiu, None; Donald J.
D’Amico, None; Robison V. Chan, None; Szilard Kiss, None
Support: Research to Prevent Blindness
Refractive Outcome after Combined Microincision Cataract
Surgery and 23-Gauge Vitrectomy
Christiane I. Falkner-Radler, Susanne Binder. The Ludwig
Boltzmann Institute of Retinology and Biomicroscopic Laser Surgery,
Department of Ophthalmology, Rudolf Foundation Clinic, Rudolf
Foundation Clinic, Vienna, Austria.
Purpose: To evaluate preoperative biometry and outcomes after
combined microincision cataract surgery and 23-gauge vitrectomy in
a prospective clinical trial.
Methods: Inclusion criteria were defined as (a) patients presenting
with vitreoretinal disorders and coexisting significant cataract, (b) the
need for combined unilateral surgery, (c) the use of the IOL Master
for preoperative lens calculation; and (d) the implantation of the
iSERT preloaded 250/251 intraocular lens (IOL). Exclusion criteria
were (a) the need for silicone oil tamponade; (b) diabetic vitreous
hemorrhage and significant diabetic macular edema; (c) full-thickness
macular holes, (d) posterior subcapsular and mature cataract; (e)
myopia and hypermetropia of more than 5 diopters; (f) astigmatism
of more than 2 diopters; (g) previous laser refractive surgery; (h)
previous buckle surgery; and (i) pseudophakia on the non-study eye.
Main outcome measure was the IOL power prediction error (PE).
Cofactor analysis included intraocular pressure (IOP), best corrected
visual acuity functional (BCVA) and anatomical outcomes and
complication rates. For statistical analysis a regression model was
used.
Results: Thirty seven patients with a mean age of 70 years were
evaluated. The vitreoretinal diagnosis was epiretinal membrane in
29 eyes, lamellar macular hole in 7 eyes and asteroid hyalosis in one
patient. In 24 eyes an intraocular air or gas tamponade was used.
The mean final IOL power PE was 0,23 diopters, ranging from +1.78
to -1.40. Baseline BCVA was 0,60 logMAR and improved to 0,15
logMAR at the 3 months follow-up, IOP was 17.0 mmHG before
surgery and 16.5 mmHG at the last follow-up. Complication rates
included a mild postoperative vitreous hemorrhage in one patient, a
postoperative hypotony, which stabilized after air injection, in another
patient. An IOL dislocation in one patient required repositioning after
surgery. In 3 patients the sclerotomies were sutured.
Conclusions: Our first results suggest good and stable refractive
results after this combined surgical approach including promising
anatomic and functional results. The use of an intraocular tamponade
seems to induce a slight hyperopic shift after this combined surgical
approach.
Commercial Relationships: Christiane I. Falkner-Radler, None;
Susanne Binder, None
Clinical Trial: no
Purpose: To describe multimodal imaging findings using spectral
domain optical coherence tomography (SD-OCT), near-infrared and
short-wave fundus autofluorescence (NIR-FAF and SW-FAF) in eyes
with rhegmatogenous retinal detachment treated with vitrectomy and
gas or silicone oil tamponade and evaluate presence or signs of sticky
silicon oil phenomenon.
Methods: Retrospective case series. We studied 158 consecutive
patients affected by rhegmatogenous retinal detachment underwent
3-port pars plana vitrectomy with gas or silicone oil tamponade from
January 2010 to September 2013. Ophthalmological examination,
SD-OCT and FAF were performed before (when the anatomical
situation made it possible) and after surgery (always). SD-OCT
analysis was performed by mean of Spectralis-OCT Blue Peack
(Heidelberg Engineering, Germany) and NIR-FAF / SW-FAF was
analysed with spectralis HRA (Heidelberg Engineering, Germany).
In vitro Autofluorescence analysis was performed also to all the
liquid substances used.
Results: Presence of silicon oil in camera vitrea creates an image
of ‘‘level’’ on the OCT and masks physiologic autofluorescence and
reflectivity with a blurred image. Epiretinal sticky oil gives hyper
reflective spots that are hyper autofluorescent in NIR and SW-FAF.
Cases with complete retinal detachment, underwent to multiple
tamponades, presented hyper autofluorescent spots in NIR-AF that
were associated with chronic retinal edema.
Conclusions: SD-OCT and FAF can be useful to reveal
intravitreal, epiretinal or subretinal presence of tamponades.
Hyperautofluorescence in NIR-AF can be associated with presence
of tamponades under the retina (not or barely detectable with OCT),
that causes chronic inflammation of the retina, with macular edema.
Multimodal retina imaging can be useful to evaluate presence of the
sticky oil phenomenon and consequent inflammation.
Epiretinal sticky oil gives hyper reflective spots that are hyper
autofluorescent in SW and NIR-FAF and were associated with
chronic retinal edema
Multimodal imaging of sticky oil phenomenon in eyes with
rhegmatogenous retinal detachment treated with vitrectomy and
gas or silicone oil tamponade
Alessandro Papayannis1, Daniela Bonsanto1, Pierluigi Iacono3,
2
, Saumil Sheth4, Dimitrios S. Kontadakis5, Maurizio B. Parodi2,
Flavio Foltran1, Giovanni Prosdocimo1, Francesco Bandello2.
1
U.O.OCULISTICA, U.L.S.S. 7 Veneto Orientale, Conegliano, Italy;
2
Department of Ophthalmology, University Vita-Salute Scientific
Institute San Raffaele, Milano, Italy; 3Fondazione Bietti, Roma, Italy;
4
S.Sheth Eye Clinic, Mumbai, India; 5Department of ophthalmology,
General hospital of Chania, Chania, Greece.
Results: Infused air flowed straightly into vitreous cavity from the
infusion port. During air infusion, highest pressure was observed
at a point on the part of retina contralateral to the infusion port
(vulnerable point). With a 20-gauge system, pressures at optic nerve
head and vulnerable point were 11.8 and 13.7 mmHg at infusion
pressures of 20 mmHg, and 25.0 and 29.0 mmHg at infusion pressure
of 40 mmHg, respectively. Pressure differential between the optic
nerve head and vulnerable point were 1.9 mmHg at infusion pressure
of 40 mmHg in 23-gauge system, and smaller in 25-gauge system.
Dynamic pressure (tractional force) induced by infused air were
under 1.0 mmHg at each infusion pressure.
Conclusions: According to the simulation, tangential element of
force (shearing force) induced by infused air particles is insignificant
to cause the retinal surface damage. Considering the retinal perfusion
pressure and retinal capillary pressure, pressure difference more than
4 mmHg can cause the focal collapse of retinal capillaries. Prolonged
focal collapse can induce the ischemic changes of corresponded
retinal structures. The findings of our study can provide a better
understanding of fluid dynamics during fluid-air exchange.
Cases with complete retinal detachment, underwent to multiple
tamponades, presented hyper autofluorescent spots in NIR-AF that
was associated with chronic retinal edema.
Hyperautofluorescence in NIR-AF can be associated with presence of
tamponades under the retina (not or barely detectable with OCT) that
causes chronic retinal inflammation, with macular edema.
Commercial Relationships: Alessandro Papayannis, None;
Daniela Bonsanto, None; Pierluigi Iacono, None; Saumil Sheth,
None; Dimitrios S. Kontadakis, None; Maurizio B. Parodi, None;
Flavio Foltran, None; Giovanni Prosdocimo, None; Francesco
Bandello, ALCON, INC (C), ALIMERA SCIENCES, INC (C),
ALLERGAN, INC (C), BAUSCH AND LOMB (C), BAYER
SCHERING PHARMA (C), FARMILA-THEA (C), GENENTECH,
INC (C), Hoffmann-La Roche, Ltd (C), NOVAGALI PHARMA (C),
NOVARTIS PHARMACEUTICALS CORPORATION (C), PFIZER,
INC (C), SANOFI-AVENTIS (C), THROMBOGENICS, INC (C)
Pressurized Air Infusion Induced Intraocular Jet Flow and Focal
Pressure Increase: Mechanisms of Focal Chorioretinal Damage
During Fluid-air Exchange
Yong Joon Kim, Kyung-Seek Choi. Department of ophthalmology,
Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea.
Purpose: The primary aim of this study was to analyze the flow
of the infused air and pressure distribution on retina based on fluid
dynamics, so that we can understand the mechanisms of retinal
damage by pressurized air infusion.
Methods: A computer simulation was conducted using threedimensional modeling software. We simulated the fluid dynamics
of infused air in an air-filled eye. Air flow in the vitreous cavity was
simulated with a conventional mesh-based techniques. Infusion port
size and infusion pressure were altered for each simulated iteration.
Detailed pressure distribution on retina and vitreous cavity, and flow
velocity of infused air were recorded.
Figure 1. Pressure distribution on the retina and vitreous cavity with
various gauge port and infusion pressures during continuous air
infusion in air-filled eye. Highest pressure is always observed at the
part of retina contralateral to the infusion port.
breaks in 1 eye. After treatment, BCVA improved significantly (P
< 0.000, ANOVA). Mean final visual acuity (SD) was 0.28 (0.34)
logarithm of the minimum angle of resolution (logMAR) compared
with 0.94 (0.84) logMAR before surgery (P < 0.001, Tukey–Kramer
test). The most common postoperative complication was hypotony,
detected in 4 eyes (3%) on postoperative day 1.
Conclusions: Primary 25 gauge airbag vitrectomy provides a high
anatomic success rate in eyes with PsRD and is associated with a low
rate of complications.
Commercial Relationships: Michele Reibaldi, None; Teresio
Avitabile, None; Antonio Longo, None; Michele Nicolai, None;
Andrea Saitta, None; Vincenza Bonfiglio, None; Andrea Russo,
None; Francesca Viti, None; Mario Toro, None; Cesare Mariotti,
None
Figure 2. Schematic drawing of air flow in the vitreous cavity during
continuous air infusion in air-filled eye. Each air particle which
collides with retina, brings the shearing force on the retina in the
tangential direction.
Commercial Relationships: Yong Joon Kim, None; Kyung-Seek
Choi, None
Primary 25-Gauge Airbag-Vitrectomy in Pseudophakic
Rhegmatogenous Retinal Detachment
Michele Reibaldi1, Teresio Avitabile1, Antonio Longo1, Michele
Nicolai2, Andrea Saitta2, Vincenza Bonfiglio1, Andrea Russo1,
Francesca Viti2, Mario Toro1, Cesare Mariotti2. 1Ophthalmology,
University of Catania, Catania, Italy; 2Ophthalmology, University of
Ancona, Ancona, Italy.
Purpose: To evaluate the anatomic and functional outcomes and
the rate of complications of primary 25-gauge airbag-vitrectomy in
the treatment of pseudophakic rhegmatogenous retinal detachment
(PsRD) uncomplicated by severe proliferative vitreoretinopathy.
Methods: In this prospective, nonrandomized, surgical technique
study, 141 eyes of 141 consecutive patients with PsRD with
proliferative vitreoretinopathy grade A or B underwent primary
25-gauge airbag vitrectomy, consisting in pars plana vitrectomy
performed under continuous infusion of air, and air or gas
endotamponade. Eyes with minimum follow-up of 6 months were
evaluated. The preoperative and postoperative characteristics were
analyzed. Main outcome measures were primary anatomical success
rate, defined as retinal reattachment at final follow-up after a single
operation without additional surgery, visual outcome at the last
follow-up visit, and rate of complications.
Results: At six months the retina was reattached successfully after
a single surgery in 98% of eyes (138/141). Recurrence of retinal
detachment occurred in 3 eyes (2%) during the follow-up period,
caused by proliferative vitreoretinopathy in 2 eyes and by new retinal
Indications and Outcomes of Combined Pars Plana Vitrectomy
and Penetrating Keratoplasty
Randee C. Miller, Yannek I. Leiderman. University of Illinois at
Chicago, Chicago, IL.
Purpose: To report the indications for and outcomes of combined
pars plana vitrectomy and penetrating keratoplasty surgery.
Methods: A retrospective review of the medical records of all
patients who underwent combined pars plana vitrectomy and corneal
transplantation (PKP-PPV) at the Illinois Eye and Ear Infirmary from
January 1, 2001 to May 31, 2013 was performed. Demographics,
ocular history, surgical procedures performed, pre- and postoperative
visual acuities, occurrence of surgical complications, and final
anatomic outcomes were recorded for all patients.
Results: Combined PKP-PPV was performed in ninety patients
during the study period. Eleven patients were excluded because of
insufficient data in the medical record. Of the remaining 79 patients
(61% male, 39% female), 65 underwent a single combined PPV-PKP,
11 had two combined surgeries, and 3 required a third combined
procedure. The mean age at first surgery was 48 years. The most
common indications for vitreoretinal surgery were retinal detachment
(43%) and proliferative vitreoretinopathy (30%). The most common
indications for corneal transplantation were corneal decompensation
(43%), traumatic corneal scar (20%), and failed corneal graft (19%).
Forty-two patients (53%) had a history of ocular trauma; thirty-six
(86%) of these eyes had a history of open globe injury. A temporary
keratoprosthesis was utilized in 80% of combined surgeries. The
mean preoperative visual acuity (VA) was LogMAR 2.4 (handmotions). The mean final VA was LogMAR 2.3 (p=0.05) at a mean
follow-up interval of 26 months. At final follow up 54% of retinas
were attached and 56% of corneal grafts were clear. Eighty-two
percent of patients had at least one postoperative complication, the
most frequent being corneal graft failure (62%), recurrent retinal
detachment (34%), and hypotony (31%). Thirty-one patients (40%)
required at least one subsequent surgical procedure.
Conclusions: Patients requiring combined PPV-PKP were likely to
maintain stable VA relative to preoperative VA for the indications
in this study, most commonly retinal detachment and corneal
decompensation associated with ocular trauma. Combined PPV-PKP
may confer improved visual and anatomic outcomes relative to no
intervention. Patients should be educated regarding likely outcomes
and potential for subsequent surgical interventions.
Commercial Relationships: Randee C. Miller, None; Yannek I.
Leiderman, None
Support: Departmental support from Research to Prevent Blindness
Comparison of Peripheral Vitreous Incarceration using Valved
and Non-Valved Cannula
Dina Joy K. Abulon1, Martin Charles2. 1Global Medical Affairs,
Alcon Labs, Lake Forest, CA; 2Medico Oftalmologico, Centro
Oftalmologico, Buenos Aires, Argentina.
Purpose: Sclerotomy for vitrectomy surgery has evolved from large
gauge surgical techniques requiring sutures to sutureless incisions
using microcannula. These microincisional trocar cannula designs
were less invasive and demonstrated improved patient comfort. A
new valved design allowed surgeons to maintain intraoperative IOP
better than non-valved designs. A previous study evaluated vitreous
incarceration with 23-gauge valved and non-valved cannulas. The
purpose of this study is to expand upon previous data and compare
peripheral vitreous incarceration after pars plana incisions using 27-,
25-, and 23-gauge valved and non-valved cannula.
Methods: A total of twelve cadaveric porcine eyes were tested.
Edgeplus® 27-, 25-, and 23-gauge valved entry systems (Alcon Labs,
CA, US) were compared to Edgeplus® non-valved entry systems
of equivalent gauge size. In each eye, two adjacent incisions were
created 2.5mm apart: one incision housed the valved cannula and
the adjacent incision housed the non-valved cannula. Triamcinalone
was injected through the sclera between the valved and nonvalved cannula. A 1.9mm diameter rod lens boroscope (Karl Storz,
Tuttlingen, Germany) was inserted through a 1.9mm incision in the
posterior segment, opposite from the two trocar cannula incisions.
Endoscopic video captured the presence of incarcerated vitreous into
the inner lumen of the trocar cannulas. Using ImageJ software (NIH,
Maryland, US), the amount of vitreous incarcerated into the cannula
was quantified and reported as a percentage of the analyzed area.
Results: On average, the 27-gauge non-valved cannulas showed
30% incarcerated vitreous around the inner lumen of the cannula
while valved 27-ga cannulas showed 0% incarcerated vitreous. The
25-gauge non-valved cannulas showed 46% incarceration compared
to 1% incarceration with valved cannulas. With 23-gauge non-valved
cannulas, incarceration was 30% compared to 0% with valved
cannulas.
Conclusions: The 27-, 25-, and 23-gauge non-valved cannulas all
generated more vitreous incarceration through the trocar cannula than
the corresponding valved cannulas. Election of valved cannulas may
improve surgical outcomes.
Commercial Relationships: Dina Joy K. Abulon, Alcon Labs (E);
Martin Charles, Alcon Labs (F)
Results: The average age of patients undergoing IMT placement was
81.9 years. The average preoperative best spectacle-corrected visual
acuities (BSCVA) in patients selected to undergo placement of the
IMT was 1.443 logMar (20/550) vision. At postoperative month 3
and 6 visits, BSCVA improved to 1.210 (20/320) and 1.210 (20/320)
with an average of 2 Snellen lines of improvement in BSCVA.
Preoperatively, the mean IOP of these patients was 14, with mean
IOPs of 12 and 12 at 3 and 6 months postoperatively. The average
endothelial count of patients preoperatively was 2106 and the average
endothelial count at the 6 month visit was 1758. The average number
of occupational therapy visits that patients went to was 7 (range
2-10). In terms of postoperative complications, one patient had a fall
with expulsion of the IMT.
Conclusions: The use of IMTs in selected patients suffering from
end-stage age related macular degeneration appears to improve visual
acuity.
Commercial Relationships: Shabnam Taylor, None; Mark
Mannis, None; Jennifer Li, None
The Implantable Miniature Telescope for Age-Related Macular
Degeneration: Initial Postoperative Clinical Outcomes
Shabnam Taylor, Mark Mannis, Jennifer Li. UC Davis, Sacramento,
CA.
Purpose: The purpose of this study is to evaluate the postoperative
clinical outcomes of the first 10 patients that underwent placement of
an implantable miniature telescope (IMT) for end-stage age-related
macular degeneration (ARMD) at the UC Davis Eye Center.
Methods: A retrospective analysis of the first 10 patients with endstage ARMD who underwent IMT placement at the UC Davis Eye
Center between 5/2012 and 7/2013 was performed. Visual acuities,
intraocular pressures (IOPs), and specular microscopy were analyzed
at the preoperative visit and postoperative month 3 and 6 visits.
The frequency and number of occupational therapy visits and any
postoperative complications were also evaluated.

ARVO 2014 Annual Meeting Abstracts 276 Vitreoretinal Surgery

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