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Purpose To report 24-month vision and fluorescein angiographic outcomes from trials evaluating photodynamic therapy with verteporfin in patients with subfoveal choroidal neovascularization (CNV) caused by pathologic myopia. Design and setting Multicenter, double-masked, placebo-controlled, randomized clinical trial at 28 ophthalmology practices in Europe and North America. Participants Patients with subfoveal choroidal neovascular lesions caused by pathologic myopia measuring no more than 5400 micro m and best-corrected visual acuity (approximate Snellen equivalent) of 20/100 or better. Methods Similar to methods described for 1-year results with follow-up examinations beyond 1 year, continuing every 3 months (except Photograph Reading Center evaluations only at the month 24 examination). During the second year, the same regimen (with verteporfin or placebo as applied at baseline) was used if angiography showed fluorescein leakage from CNV. Main outcome measures The primary outcome was the proportion of eyes with fewer than 8 letters (approximately 1.5 lines) of visual acuity loss at the month 24 examination, adhering to an intent-to-treat analysis and using the last observation carried forward method to impute for any missing data. Results Seventy-seven of 81 patients (95%) in the verteporfin group, compared with 36 of 39 patients (92%) in the placebo group, completed the month 24 examination. At this time point, 29 of 81 verteporfin-treated patients (36%) compared with 20 of 39 placebo-treated patients (51%) lost at least 8 letters (P = 0.11). The distribution of change in visual acuity at the month 24 examination was in favor of a benefit for the cases assigned to verteporfin (P = 0.05). This included improvement by at least 5 letters (equivalent to at least 1 line) in 32 verteporfin-treated cases [40%] vs. five placebo-treated cases (13%) and improvement by at least 15 letters (equivalent to at least 3 lines) in 10 verteporfin-treated cases (12%) vs. zero placebo-treated cases. No additional photosensitivity adverse reactions or injection site adverse events were associated with verteporfin therapy in the second year of follow-up. Conclusions Verteporfin therapy for subfoveal CNV caused by pathologic myopia safely maintained a visual benefit compared with a placebo therapy through 2 years of follow-up. Although the primary outcome was not statistically significantly in favor of verteporfin therapy at 2 years as it had been at 1 year of follow-up, the distribution of change in visual acuity at the month 24 examination was in favor of the verteporfin-treated group and showed that this group was more likely to have improved visual acuity through the month 24 examination. The VIP Study Group recommends verteporfin therapy for subfoveal CNV resulting from pathologic myopia based on both the 1- and 2-year results of this randomized clinical trial.

Purpose To review our experience with vitrectomy surgery techniques for the treatment of traumatic macular holes and the biomicroscopic and surgical findings. Design Retrospective noncomparative, multicenter, case series. Participants and intervention Twenty-five patients with traumatic macular hole underwent surgical repair. Intervention Vitrectomy with membrane peeling and gas injection followed by prone positioning for 7 to 14 days. Main outcome measures Postoperative evaluation included visual acuity testing, closure of the macular hole, and ocular complications. Results The macular hole was successfully closed in 24 of 25 cases (96%). The visual acuity improved two or more lines in 21 (84%) cases, and 16 (64%) achieved 20/50 or better vision. Conclusions Vitrectomy surgery can successfully close macular holes associated with trauma and improve vision.

Keywords: Photomedicine group Reference LPAS-ARTICLE-2001-009 Record created on 2007-07-20, modified on 2016-08-08

Objective To report the authors' clinical experience with submacular surgery for subfoveal membranes in children and to evaluate the histopathologic findings of membranes in children with various etiologies of choroidal neovascularization. Design Retrospective, noncomparative, interventional case series. Participants Twelve eyes of 12 consecutive children with subfoveal choroidal neovascularization treated by vitrectomy and excision of the choroidal neovascular complex. Intervention Vitrectomy, excision of the choroidal neovascular complex, and air-fluid exchange. Main outcome measures Visual acuity and recurrence of choroidal neovascular membrane. Results Preoperative visual acuities ranged from 20/60 to 20/800 (median, 20/300). Postoperative visual acuities ranged from 20/25 to 20/400 (median, 20/80) after an average follow-up of 20 months (range, 7–62 months). Ten of 12 eyes improved from immediate preoperative visual acuity, and four eyes developed recurrence of neovascular membranes over a mean follow-up of 18 months. Histopathologic examination of six excised membranes showed that the most common components of the membranes were retinal pigment epithelium, fibrocytes, vascular endothelium, and collagen. Conclusion Selected eyes of children with subfoveal neovascular membranes and no evidence of membrane regression may benefit from submacular surgery. The histopathologic findings were similar to adult choroidal neovascularization not associated with age-related macular degeneration.

Objective: To determine whether lysing subretinal fibrin with tissue plasminogen activator (t-PA) before excising subfoveal choroidal neovascularization improves visual acuity in patients with age-related macular degeneration. Design: Randomized, double-masked trial. Participants: Eighty eyes fo 80 patients with subfoveal choroidal neovascularization secondary to age-related macular degeneration were studied. Intervention: Each eye underwent pars plana vitrectomy and received a subretinal injection of t-PA or balanced salt solution (BSS) before the neovascular membrane was excised. Preoperative and postoperative protocol refraction, ophthalmic examination, color photography, and fluorescein angiography were performed in all 80 eyes. Main Outcome Measures: Visual acuity and fluorescein angiographic evidence of leakage after 1 year. Results: Visual acuity did not differ between the t-PA group (n = 40) and the BSS group (n = 40), and median best-corrected visual acuity was 20/320 for both groups ( P = 0.38). Changes in visual acuity from baseline were also equal, with a median loss of 1 line in each group ( P = 0.78). Patients whose initial visual acuity was 20/250 or less were more likely to improve by 2 or more lines ( P = 0.01) and less likely to lose 2 or more lines ( P P = 0.02) and less likely to lose 2 or more lines ( P P = 0.78). Conclusions: With current surgical techniques, the use of t-PA before surgical excision of subfoveal choroidal neovascularization is of no visual or anatomic benefit to patients with age-related macular degeneration.

Background: As part of the design of the Silicone Study, a new classification of proliferative vitreoretinopathy (PVR) was developed that distinguishes the different types of contraction found in PVR. In contrast to the original Retina Society system that emphasized the post-equatorial retinal pathology (posterior PVR), the Silicone Study classification system included the characteristic types of contraction found in both the equatorial region and the pre-equatorial retina and vitreous base (anterior PVR). Methods: The authors contrast (1) preoperative and intraoperative findings and (2) vision and anatomic outcomes in the cohort of anterior PVR eyes with the cohort of posterior-only PVR eyes. For the cohort of eyes randomized to perfluoropropane gas (C 3 F 8 ) or silicone oil, the authors carry out univariate and multivariate analyses to assess the predictive value of baseline and intraoperative parameters on vision and anatomic outcome. Results: Anterior PVR was present in 321 eyes (79%)and was more prevalent in eyes that had undergone an unsuccessful vitrectomy before study entry than in eyes that underwent a primary vitrectomy for PVR (88% versus 73%; P P P = 0.003), (3) have more hypotony (24% versus 11 %; P = 0.03), more edema (8% versus 2%; P = 0.04), more aqueous flare ( P = 0.02), more macular pucker (69% versus 52%; P = 0.005), and more intravitreal contraction (21 % versus 6%; P = 0.002). When compared with eyes that had anterior PVR, eyes with posterior PVR had a better outcome at the 6-month postoperative examination: complete attachment of the retina (76% versus 62%; P = 0.04), visual acuity of 5/200 or better (64% versus 45%; P = 0.006), and normal intraocular pressure (86% versus 71 %; P = 0.04). For eyes with anterior PVR, significant predictors of poor ( 3 F 8 gas as the intraocular tamponade. Conclusion: The Silicone Study classification of anterior PVR permits greater specificity in characterizing PVR and is prognostic of anatomic and vision outcome. Eyes with anterior PVR and clinically significant posterior PVR changes had a better visual prognosis if silicone oil was used. With the current understanding of the pathoanx ~ atomy of anterior PVR and the recent development of new surgical techniques, the incidence of anterior PVR in eyes that previously underwent vitrectomy may decline, and the prognosis in eyes with anterior PVR may improve.

Pars plana vitrectomy with separation of the posterior hyaloid was performed in 10 eyes with diabetic macular edema and traction associated with a thickened and taut premacular posterior hyaloid. Nine of the 10 eyes had previous macular photocoagulation. Preoperative fluorescein angiography showed a deep and diffuse pattern of leakage in the macula. Intraoperatively, the attached and thickened posterior hyaloid was lifted and separated from the retina. Postoperatively, vision improved in nine eyes. The macular traction and edema resolved in eight eyes and decreased in two. Complications included a vitreous hemorrhage, a rhegmatogenous retinal detachment, cataract formation, and a mild epimacular membrane, each occurring in one eye. Vitreous surgery can improve the visual prognosis of some eyes with diabetic macular traction and edema associated with a thickened and taut posterior hyaloid.

The introduction of intraoperative perfluorocarbon liquids in the management of giant retinal tears has allowed exact anatomic reapposition of the retina and the giant retinal tear. Therefore, the authors managed 11 eyes with giant retinal tears and no proliferative vitreoretinopathy without scleral buckling. Maximum removal of the basal vitreous gel was performed in all cases, and perfluoro-octane was used intraoperatively to unfold the inverted posterior flap and reattach the retina completely. Endophotocoagulation was applied to the edges of the tear and perfluoropropane or silicone oil was used as an intraocular tamponade. Although 1 eye required reoperation for a redetachment from posterior proliferative vitreoretinopathy, all retinas were reattached with final visual acuity of 5/200 or better in 9 eyes. Eight additional major procedures were necessary in seven eyes: removal of silicone oil in four (with removal of perisilicone proliferation in three), repeat vitrectomy and membrane removal with photocoagulation twice in one eye, cataract extraction in one eye, and removal of a macular pucker in one eye. Four eyes required postoperative fluid-gas exchange and three eyes had tissue plasminogen activator injections into the anterior chamber for postoperative fibrin reactions.

Choroidal neovascular membranes (CNVMs) developed in eight patients after photocoagulation for clinically significant diabetic macular edema (DME). The CNVMs developed in areas where Bruch's membrane was ruptured and were diagnosed 2 weeks to 5 months after treatment. Only six patients had symptoms. The CNVMs were treated in four patients; final visual acuity was poor in all eight patients. This serious complication that follows laser treatment for DME may be related to the use of repeated small-size, short-duration laser or intense laser burns, or both.

To report 24-month vision and fluorescein angiographic outcomes from trials evaluating photodynamic therapy with verteporfin in patients with subfoveal choroidal neovascularization (CNV) caused by pathologic myopia.Multicenter, double-masked, placebo-controlled, randomized clinical trial at 28 ophthalmology practices in Europe and North America.Patients with subfoveal choroidal neovascular lesions caused by pathologic myopia measuring no more than 5400 micro m and best-corrected visual acuity (approximate Snellen equivalent) of 20/100 or better.Similar to methods described for 1-year results with follow-up examinations beyond 1 year, continuing every 3 months (except Photograph Reading Center evaluations only at the month 24 examination). During the second year, the same regimen (with verteporfin or placebo as applied at baseline) was used if angiography showed fluorescein leakage from CNV.The primary outcome was the proportion of eyes with fewer than 8 letters (approximately 1.5 lines) of visual acuity loss at the month 24 examination, adhering to an intent-to-treat analysis and using the last observation carried forward method to impute for any missing data.Seventy-seven of 81 patients (95%) in the verteporfin group, compared with 36 of 39 patients (92%) in the placebo group, completed the month 24 examination. At this time point, 29 of 81 verteporfin-treated patients (36%) compared with 20 of 39 placebo-treated patients (51%) lost at least 8 letters (P = 0.11). The distribution of change in visual acuity at the month 24 examination was in favor of a benefit for the cases assigned to verteporfin (P = 0.05). This included improvement by at least 5 letters (equivalent to at least 1 line) in 32 verteporfin-treated cases [40%] vs. five placebo-treated cases (13%) and improvement by at least 15 letters (equivalent to at least 3 lines) in 10 verteporfin-treated cases (12%) vs. zero placebo-treated cases. No additional photosensitivity adverse reactions or injection site adverse events were associated with verteporfin therapy in the second year of follow-up.Verteporfin therapy for subfoveal CNV caused by pathologic myopia safely maintained a visual benefit compared with a placebo therapy through 2 years of follow-up. Although the primary outcome was not statistically significantly in favor of verteporfin therapy at 2 years as it had been at 1 year of follow-up, the distribution of change in visual acuity at the month 24 examination was in favor of the verteporfin-treated group and showed that this group was more likely to have improved visual acuity through the month 24 examination. The VIP Study Group recommends verteporfin therapy for subfoveal CNV resulting from pathologic myopia based on both the 1- and 2-year results of this randomized clinical trial.

Purpose: Peripheral angiomas have been associated with epiretinal membranes and traction retinal detachment. The authors investigated the timing, results, and complications of vitreous surgery to remove the retinal traction and treat the peripheral vascular tumor. Methods: The authors reviewed the results of ten eyes that had undergone vitrectomy for macular pucker and/or traction retinal detachment. These eyes had either preoperative or intraoperative treatment of the peripheral tumor. Results: Patients were followed 4 to 95 months. Six eyes had nonfamilial peripheral acquired retinal hemangioma, three had von Hippel angiomas, and one had multiple large peripheral retinal angiomas associated with extensive retinal telangiectasis. Four eyes received cryotherapy and/or laser photocoagulation 2 to 3 months before surgery. In the remaining six eyes, initial treatment to the peripheral angioma was performed at the time of vitreous surgery. At final follow-up, all eyes were attached without retinal traction. Vision improved in all eyes; six (60%) achieved 20/50 or better visual acuity. Complications included recurrent epiretinal membrane (n = 3); nonregressed angiomas (n = 3); increased nuclear sclerosis (n = 2); and retinal detachment (n = 1). Conclusion: Vitreous surgery, when applied to epiretinal membranes or traction retinal detachments associated with peripheral vascular tumors, has a good chance of improving vision. Treatment of the hemangioma, before or during vitrectomy, usually results in tumor regression.

Purpose: Removal of intraocular lenses (IOLs) dislocated into the vitreous cavity can be hazardous and result in severe complications and visual loss. Recognizing limitations in current management, the authors developed a new, safer surgical technique to reduce intraoperative and postoperative complications. Methods: The authors report eight eyes of eight patients with posteriorly dislocated IOLs in which perfluorocarbon liquids were injected into the eye after vitrectomy to float the IOL off the retina. The IOL haptics were repositioned in the residual capsular bag or ciliary sulcus, and the positioning holes of the optic were sutured to the sclerotomies under a scleral flap. Results: With a minimum follow-up of 8 months (average, 12 months), all eight eyes improved in Snellen visual acuity, and six of them achieved a final Snellen visual acuity of 20/40 or better. Complications did not occur in any of the eight eyes. Preoperative cystoid macular edema resolved in three of four eyes, and the retina has remained attached in the one eye with a preoperative retinal detachment. Conclusion: Application of vitreoretinal microsurgical techniques and the use of liquid perfluorocarbons allow for the safer management of eyes with posteriorly dislocated IOLs.

A prospective study of 222 consecutive patients undergoing pars plana vitrectomy was done to determine the incidence and mechanisms of postoperative intraocular pressure (IOP) elevation. Within 48 hours of surgery, postoperative IOP increased by at least 5 to 22 mmHg in 136 eyes (61.3%) and to 30 mmHg or more in 79 eyes (35.6%). Presumed mechanisms of open-angle glaucoma included intraocular gas expansion (28.4%), inflammatory trabecular meshwork obstruction (4.5%), silicone oil-related glaucoma (3.6%), and erythroclastic glaucoma (2.2%). Closed-angle mechanisms included pupillary block glaucoma (6.8%) and ciliary body edema (3.6%). Factors which were associated with postvitrectomy pressure elevation included placement of a scleral buckle, either intraoperatively (P = 0.003) or before vitrectomy (P = 0.001), intraoperative scatter endophotocoagulation (P = 0.041), intra-operative lensectomy (P = 0.024), and development of postoperative fibrin membranes (P = 0.038). Surgery was required to lower IOP or relieve pupillary block in 25 eyes (11.3%).

A clinicopathologic study of multiple extramacular drusen (MED) was performed on 784 eyes of 412 consecutive autopsies and on 100 eyes of 50 consecutive patients with MED. The clinical and histopathologic characteristics of MED and its correlation with reticular degeneration of the pigment epithelium (RDPE) and with macular degenerative abnormalities are presented. Multiple extramacular drusen was associated with macular degenerative abnormalities in 88% of autopsy cases, in contrast to 2% of cases in a control population without MED or RDPE. Multiple extramacular drusen and macular degenerative abnormalities are associated findings and apparently have similar pathogenetic mechanisms.

The natural history of peripheral uveitis may eventually lead to indications for vitreous surgery. Over a 7-year period, a consecutive series of 12 eyes in nine patients with peripheral uveitis underwent vitreous surgery. Indications for surgery included persistent dense vitreous inflammation, vitreous hemorrhage, traction retinal detachment (RD), and epiretinal membrane formation. Patients were followed for an average of 22 months. Six eyes (50%) required further surgery after the development of RD, recurrent vitreous hemorrhage, or cataract formation. The preoperative finding most frequently associated with postoperative complications was the presence of active neovascularization of the vitreous base. Final visual acuity ranged from 20/30 to 20/100 showing an average improvement of 5 Snellen lines. Persistent cystoid macular edema significantly limited visual improvement in five patients. Patients undergoing vitreous surgery for management of peripheral uveitis may show a significant degree of visual improvement though multiple operations may be required. Control of active neovascularization is an important factor in limiting postoperative complications and the need for further surgery.

The authors report nine cases of endodrainage retinotomy site complications that occurred after vitreous surgery for complicated retinal detachments (RDs). Postoperative subretinal neovascularization developed in four eyes at the retinotomy drainage site. In two eyes, postoperative proliferation at a posteriorly placed endodrainage site created traction macular detachments. Redetachment due to retinotomy opening caused by postoperative drainage site proliferation developed in three eyes. The retinas of all nine eyes were eventually reattached, and vision improved from the preoperative level. These complications are related to retinal pigment epithelium and/or Bruch's membrane damage during internal subretinal fluid drainage and retinotomy endolaser photocoagulation. Careful evaluation of extrusion instruments, drainage techniques, retinotomy placement, and subsequent endolaser treatment is necessary to minimize these complications.

Subretinal membranes (SRMs) are an important but rarely identified component of proliferative vitreoretinopathy (PRV). In 153 consecutive cases that had vitreoretinal surgery for this condition and were followed for at least 6 months, SRMs were encountered in 72 eyes (47%). In 20 (28%) of the 72 eyes, the SRMs prevented complete retinal reattachment and needed to be removed or excised through one or multiple retinotomies. Intraoperative complications related to the SRMs or their removal included choroidal or retinal hemorrhage in three eyes (15%), subretinal air in three eyes (15%), and unplanned extension of the retinotomies in two eyes (10%). The 20 eyes requiring SRMs removal were followed for a median of 11 months. Retinas were reattached in 13 eyes (65%), although only 4 eyes (20%) had a visual acuity of 5/200 or better. Recognizing SRMs as a component of PVR is important in helping to maximize the anatomic success rate although the effects on visual function are not fully known.

From 1983 to 1986, silicone oil injections were used to treat 31 patients with retinal detachment (RD) and advanced proliferative vitreoretinopathy (PVR). In 19 eyes (61%), perisilicone proliferation (PSP) developed causing recurrent RDs in 15 eyes (49%). At an average of 5 weeks after surgery, PSP occurred and was characterized by extensive transparent preretinal membranes with denser focal areas. Microscopic examination of five preretinal membranes showed droplets of silicone oil and necrotic cells on the silicone side and glial or retinal pigment epithelial cells, or both, on the retinal side, often in layers separated by extracellular matrix. Silicone oil was present in periretinal membranes removed several months after the intraocular silicone had been evacuated indicating that silicone within cells may persist despite the removal of silicone. The use of silicone oil to provide tamponade in eyes with recurrent PVR is associated with a high incidence of periretinal proliferation that frequently leads to recurrent RD and visual failure.

Retinal detachment (RD) occurs in more than 50% of eyes with acute retinal necrosis (ARN) and is the leading cause of visual loss in this syndrome. In order to decrease the incidence of RD in ARN, the authors treated 12 eyes of 10 patients with prophylactic laser photocoagulation. Retinal detachment occurred in two eyes (17%). Over the same time period, seven eyes with ARN did not receive prophylactic laser treatment, most often because of dense vitreous debris, with a 67% rate of RD. Prophylactic photocoagulation treatment should be considered in the management of patients with ARN.

Of 105 eyes with ocular injuries involving retained intraocular foreign bodies, 63 (60%) had a final visual acuity of 20/40 or better; 20 (19%) were 20/50 to 5/200; and 15 (14%) were worse than 5/200. Six eyes (6%) were enucleated. The extent of visual recovery was limited in selected cases by the characteristics of the initial injury. Multivariate analysis was used to identify prognostic factors. Predictive of a good visual outcome (greater than or equal to 20/40) were: (1) initial visual acuity better than 20/40 and (2) the need for only one or two operations in the treatment of the injury. Predictive of a poor visual outcome (less than 5/200) were: (1) initial visual acuity worse than 5/200 and (2) a wound 4 mm or longer in length, independent of wound location. The visual outcome in this series of patients was compared with other large series of intraocular foreign bodies reported before the development of vitreous microsurgical techniques. The percentage of patients with a visual outcome of 20/40 or better has remained the same, whereas the incidence of enucleation has diminished.

A clinicopathologic study of reticular degeneration of the pigment epithelium (RDPE) was done on 750 eyes of 396 consecutive autopsy cases and on 100 eyes of 50 consecutive patients with RDPE. The clinical, angiographic, macroscopic, and histopathologic characteristics of RDPE and its correlation with macular degenerative abnormalities in the autopsy and clinical eyes are presented. Reticular degeneration of the pigment epithelium and macular degeneration were found to be concomitant manifestations of the aging process, and RDPE may be a significant risk factor associated with age-related macular degeneration. Evaluation of the peripheral fundus is of value in assessing patients with macular degenerative abnormalities.

To establish the clinical and angiographic incidence of cystoid macular edema (CME) after neodymium:YAG (Nd:YAG) laser capsulotomy, the authors have prospectively studied 136 patients who underwent Nd:YAG laser discission for secondary opacification of the posterior capsule after extracapsular cataract extraction. In all patients, fluorescein angiography was obtained before the laser discission. Of the 136 patients, 78 (57%) were followed for at least 6 months, and fluorescein angiography was repeated 4 to 8 weeks after the procedure. CME did not develop in any of the patients in this series.