Consequences of the EVS Recommendations

Vitrectomy for endophthalmitis was becoming increasingly popular 3 when the publication of the EVS in 1995 dramatically and abruptly changed the treatment philosophy. As advocated by the EVS, vitrectomy is now reserved for the most severe cases, and this vitrectomy is limited to the anterior vitreous. (Systemic antibiotics are still used by many ophthalmologists.) The following quote is a typical example If a vitrectomy is indicated (e.g., a patient with visual acuity of light perception ), a...

Staining of Internal Limiting Membrane with Indocyanine Green

Brooks reported internal limiting membrane (ILM) peeling for macular hole (MH) surgery in 1995 and achieved an improvement in anatomical and functional results 4 . ILM peeling has not been widely performed, however, because ILM peeling is technically difficult due to poor visibility of the ILM. Indocyanine green (ICG)-staining of ILM makes ILM peeling much easier and more complete 5,18 . There are several reports with favorable results following ICG-assisted ILM peeling. Meta-analysis of these...

Detachments in Eyes Undergoing Vitrectomy and Gas Exchange PVR

To identify patients at a high risk of developing PVR, a regression formula, based on previous analysis of PVR risk factors, was used 19 . The formula is as follows Risk of PVR developing 2.88 x (preoperative grade C PVR) + 1.85 x (preoperative grade B PVR) + 2.92 x (aphakia or pseudophakia without intact posterior capsule) + 1.77 x (anterior uveitis) + 1.23 x (quadrants of detachment) + 0.83 x (vitreous hemorrhage) + 1.23 x (previous cryotherapy) If a risk factor is present, 1 is added to the...

Rhegmatogenous Retinal Detachment

We have not seen rhegmatogenous retinal detachment in any of our patients, despite omitting retinopexy and internal tamponade (although one of our patients was treated surgically for retinal detachment by the referring ophthalmologist despite our reassurance that this was exudative and not rhegmatogenous). Our encouraging experience is similar to that of trans-retinal FNAB, which is generally performed without laser treatment or intraocular gas injection. Our impression is that the tumor itself...

Early Pars Plana Vitrectomy

Since the results of the Endophthalmitis Vitrectomy Study 10 have been published it has generally been believed that immediate pars plana vitrectomy (PP V) is not advantageous over simple intravitreal administration of antibiotics. However, some surgeons still prefer early PPV, possibly together with extraction of the intraocular lens implant, in the case of endophthalmitis after cataract surgery. Early PPV supports the ancient surgical principle of relieving an abscess immediately ( Ubi pus,...

Risk of Full Thickness Macular Hole in the Fellow

The majority of full-thickness macular holes are unilateral. Since many affected individuals have normal visual acuity in their fellow eye at the time of presentation, the risk of macular hole development in the fellow eye is an important consideration in clinical management. While a stage 1 macular hole is associated with an estimated 40-50 risk of progression to a full-thickness hole, the presence of a complete posterior vitreous detachment, as indicated by a Weiss ring, is associated with a...

Unselected Primary Retinal Detachments in Eyes Undergoing Vitrectomy and Gas Exchange PVR

The increasing trend toward managing rheg-matogenous retinal detachment by primary vitrectomy and the positive result of the use of adjunctive 5FU and LMWH in high-risk retinal detachments raised the question of whether the treatment regime should be used in all primary vitrectomy operations for retinal detachment. Because of the high primary success rate of retinal detachment repair and the relatively low rate 3.5 Implications for Clinical Use 37 of PVR, a much higher sample size was required...

Alternative Assessment of Visual Function

Snellen visual acuity is the most widely used measure of vision testing. This parameter is often misleading in patients with visually disturbing vitreous floaters. Floaters are not recognized as a disease. The clinician cannot understand the complaints of affected patients who then feel frustrated and misunderstood. Other measures, including contrast sensitivity, stereopsis, reading speed, colour discrimination, visual field, and glare testing, have demonstrated that visual acuity is a...

Role of Ultrasonography

In the case of opaque media, ophthalmic ultrasound may give valuable information about the clinical situation of the posterior segment in acute endophthalmitis. A recent ultrasonographic study of 137 eyes suggested that some echographic parameters might help to assess the functional outcome of infectious endophthalmi-tis 5 . There was a positive correlation between poor visual outcome and the presence of dense vitreous opacities and choroidal detachment. Furthermore, the authors found an...

To Macular Hole Surgery

The application of biological adjuncts to the macula during vitrectomy has been advocated with the aim of improving anatomical and functional outcomes by promoting glial repair of the hole after surgery. Biological adjuncts used in macular hole surgery have included transforming growth factor-beta 2 (TGF-P2), autologous platelet concentrate (APC), autologous serum, and thrombin and fibrin mixtures. In a randomized controlled trial including 90 patients, anatomical closure of full-thickness...

Complications of Macular Hole Surgery

Peeling of the posterior vitreous cortex from the retinal surface can result in iatrogenic retinal tears. In the MMHS, retinal tears occurred in 3.2 of eyes and were effectively treated intraop-erativelyby retinopexy 13 . Retinal detachments occurred in 5.6 of eyes in the MMHS and in 11 of eyes in the VMHS 73 . Retinal detachments generally occur within the first 6-8 weeks postoperatively and have a high success rate of anatomic re-attachment following further surgery 13 . Although retinal...

Summary for the Clinician

The use of a preoperative combined adjunctive regime of 5FU and LMWH to prevent PVR or recurrent PVR following retinal detachment has now been investigated in three large, prospective, randomized, controlled trials. These have demonstrated improved results in high-risk retinal detachments, but no benefit in unselected primary detachments or established PVR. Reduced visual acuity was observed in unselected macula-sparing retinal detachments receiving the adjuncts and may be due to a toxic...

Wide Angle Viewing System

A wide-angle viewing system using a binocular indirect ophthalmomicroscope (BIOM) or contact lens has become popular because the surgeon can see a wider area of the fundus simultaneously (Fig. 7.11) 37 . By viewing a wider area of the fundus, the surgeon can recognize the fundus pathology better and can treat lesions more safely and efficiently. The focus of the new BIOM system can be adjusted by the surgeon using a foot-pedal, while the focus needs to be adjusted by a handle in the old BIOM...

Complications and Their Management

It must be emphasized that the decision whether to undergo surgery is the patient's the ophthalmologist should inform the patient about the condition and the risks benefits of each treatment option in a way that allows the patient to make a choice that he is comfortable with 9 . The authors strongly believe that the primary line of treatment for the vast majority of eyes with endophthalmitis should be vitrectomy i.e., purely medical treatment is the exception, not the rule (Fig. 5.6). The...

Postoperative Management

All patients are re-examined on the first postoperative day and then within 7 days of surgery at our center or by the referring ophthalmologist. Topical antibiotic, steroid, and cycloplegic drops are administered in the standard fashion as for other vitrectomy procedures. In patients in whom a ruthenium plaque is applied, the radiation doses required for both melanoma and metastasis are calculated. Once the histopathological diagnosis is known, 1 or 2 days after the plaque insertion,...

Perfluorocarbon Liquid and Heavy Silicone

Perfluorocarbon liquid (PFCL) is a liquid that is 2. heavier than water and has been used to reattach the retina during surgery. It is crucial to treat retinal detachment due to a giant tear or complicated vitreoretinopathy and macular translocation 6, 3. 25 . PFCL cannot be used as a tamponade agent in the long term and has tobe removed at the end of surgery because tamponading for long periods causes severe damage to the retina. Perfluorohexyloctane is a semifluorinated 4. alkane and its...

Angiography

Fluorescein angiography is not particularly helpful in distinguishing between the various choroidal tumors, being most useful for recording secondary changes, particularly after radiotherapy and other conservative therapy. Indocyanine green angiography is better at demonstrating the extent of a choroidal tumor and can provide some diagnostic clues, such as dye wash-out in choroidal hemangiomas. veal extraocular tumor extension. B-scan ultra-sonography can demonstrate a mushroom shape, which is...

Prognosis

Choroidal and ciliary melanomas tend to develop partial or complete loss of chromosome 3 (i.e., monosomy 3) 21, 22 . In addition, they tend to show gains of the long arm of chromosome 8 21, 22 . They also develop gains in the short arm of chromosome 6 23 . Monosomy 3 is associated with a reduction in the actuarial 5-year survival probability from over 90 to less than 50 24, 25 . Chromosome 8 gains are also associated with an adverse prognosis. Conversely, gains in chromosome 6p indicate a very...

Sampling Error

Fig. 8.4 The 25-gauge biopsy of suspected choroidal metastasis in the right eye of a 69-year-old man. a Preoperative photograph showing an amelanotic tumor, which measured 11.2 x 9.8 x 2.7 mm on ultrasonography. b Hematoxylin and eosin, showing malignant cells. c Hematoxylin and eosin, showing necrotic tissue. d Keratin stain (positive). e Melan-A stain for melanocytes (negative). f HMB-45 stain for melanoma (negative). g Prostate-specific antigen (negative). h Prostatic alkaline phosphatase...

Prognosis Following Macular Hole Surgery

Visual recovery following surgical closure of macular holes may be gradual. Although substantial improvement in visual acuity occurs soon after cataract extraction, further improvement may be observed for up to 2 years 79 . Visual recovery is inversely correlated with vision in the fellow eye, tending to be greater where vision in the fellow eye is subnormal 80 . Bilateral visual function improves in a significant proportion of patients after macular hole surgery, particularly where vision in...

Cons of Treating

Risk of diplopia, refractive shift, bleeding, choroidal effusion, and extrusion of the explant in scleral buckling surgery. 11.5 Subclinical Retinal Detachment Diagnosed with Optical Coherence Tomography 139 Detachment Diagnosed with Optical Coherence Tomography After Successful Surgery for Rhegmatogenous Retinal Detachment Risk of cataract formation, glaucoma, endophthalmitis, iatrogenic retinal tears, cystoid macular edema, macular pucker, and prolifer-ative vitreoretinopathy in cases of...

Of a Chorioretinal Scar

Pars plana vitrectomy (PPV) is increasingly used for primary repair of pseudophakic retinal detachment 1-22 . The development of wide-angle viewing systems and improvements in vitrectomy instrumentation have contributed to expanding the role of PPV in the management of RRD. At the end of the surgical procedure the vitreous cavity is filled with a tamponade agent (air, gas or silicone oil) to allow sufficient time for chorioretinal adhesion to develop and avoid seepage of fluid through the...

Free Graft Translocation Surgery and Complication Profile

Translocation of a free graft of the RPE and choroid was successfully performed in all patients. Four patients presented with tight retina-RPE adhesion resulting in macular hole formation during hydrodissection in one instance. In one patient a small peripheral retinal tear or dialysis occurred intraoperatively and was treated by cryotherapy or by photocoagulation. Postoperative complications presented as PVR with retinal detachment in 5 eyes, subretinal hemorrhage in 1 eye, fibrinous reaction...

Air Versus Silicone Oil Exchange for PFCL

It has been noted that slippage does not occur so readily when a direct silicone oil PFCL exchange is used instead of first exchanging the PFCL for air and then injecting silicone oil 23 . When silicone oil is exchanged for PFCL, there are two endotamponades inside the vitreous cavity and four phases in contact with one another. The situation is very complicated, as with four phases there are multiple interfaces, namely silicone Fig. 4.5 Procedure of silicone oil PFCL exchange. a The edge of...

Info

Pars plana vitrectomy with a ntimycotics within 1 day possibly IOL explanation Pars plana vitrectomy with a ntimycotics within 1 day possibly IOL explanation all over the world have been divided into two camps those who avoided early vitrectomy and those who claimed the obligation of immediate complete pars plana vitrectomy. Even though recent peer-reviewed literature includes numerous publications on the treatment of postoperative endophthalmitis, none of the papers offers a prospective,...

Therapeutic Options

So far, the treatment of failed MH persistent or re-opening MH is still a challenge for the retinal surgeon. Many therapies have been suggested over time, but in the literature only non-randomized and noncontrolled studies have been reported, carried out in small anecdotal series. Therefore, at present there is no first-line management and many surgeons give up treatment after one or two attempts at surgery. Suggested management options have been 2 observation, laser photocoagulation on the...

And Postoperative Posturing

Intraocular tamponade following vitrectomy for macular holes is believed to facilitate re-apposition of the rim of a detached neurosensory retina and to provide an interface with the vitreous fluid component that serves as a template for glial migration across the macular hole. Consistently favorable anatomic and visual outcomes can be achieved by long-acting gas tamponade with strict face-down posturing as originally advocated 25 . In a comparative study of 52 eyes, use of 16 perfluoropropane...