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Resumen Proposito Evaluar la percepcion de las barreras en la asistencia sanitaria y del impacto de las inyecciones intravitreas en los pacientes con degeneracion macular asociada a la edad neovascular (DMAEn). Metodos Estudio transversal de 108 pacientes con DMAEn en tratamiento con inyecciones intravitreas mediante un cuestionario de 26 preguntas (puntuacion del 1 al 5) divididas en 3 bloques: 1) enfermedad y su tratamiento con inyecciones; 2) barreras en la asistencia sanitaria, y 3) nuevas tecnologias. Resultados La edad media fue 80,4 ± 7,0 anos y la agudeza visual (AV) de 75,2 ± 12,4 letras. Las principales barreras en la asistencia sanitaria fueron los largos tiempos de espera en consulta (72%), seguida por otras comorbilidades (10%). El 63% de los pacientes dedican entre 3 y 5 h para acudir a la consulta. Se aprecio una ansiedad notable debida a las inyecciones (2,8 ± 1,3), estando presente en el 71% el dia antes. Se observo un gran miedo a la ceguera y a dejar de ser independientes (4,4 ± 0,9 y 4,3 ± 1,1), sin existir diferencias en relacion con la AV, la edad o el sexo (p ≥ 0,135). El 28% de los pacientes refieren que les cuesta bastante o mucho la asistencia a consulta, presentando el 69% del total un gran interes en tener un aparato diagnostico en el domicilio. Conclusiones La DMAEn y su tratamiento suponen una importante carga asistencial para los pacientes, existiendo un gran miedo a la ceguera y a perder su independencia, siendo la principal barrera el largo tiempo de espera en consulta.

To assess the vision-related quality of life and the depression and anxiety rates in patients with neovascular Age-Related Macular Degeneration (nAMD).A cross-sectional study of patients with nAMD treated with intravitreal injections was performed. The patients completed two validated questionnaires: the Visual Functioning Questionnaire (VFQ-25, score from 0 to 100), and the Hospital Anxiety and Depression Scale (HADS) questionnaire. Age, gender and visual acuity (VA) in the Early Treatment Diabetic Retinopathy Study (ETDRS) scale was registered.Fifty-five patients with nAMD participated with a mean age of 80.9 ± 6.6 years-old (range 67-93) and a mean VA in the best eye of 73.5 ± 12.7 letters (range 44-95). The global VFQ-25 mean score was 57.4 ± 21.9 being 38.9 ± 13.2 for the general vision and 42.0 ± 19.5 for the general health. VA in the best eye was associated with the global score of the VFQ-25 scale (R = 0.608; P .001), but no correlation was observed with general health (P = .936). In the HADS scale, 26.9% and 25.5% of patients had symptoms of depression and anxiety respectively. A negative correlation was found between the HADS and VFQ-25 scales for the general vision score (R = -0.438).This study elucidates the impact of vision impairment and the visual functioning in nAMD, describing an important rate of depression and anxiety symptoms.

Resumen Proposito Evaluar la calidad de vida relacionada con la vision, asi como la presencia de sintomas de depresion y ansiedad en los pacientes con degeneracion macular asociada a la edad neovascular (DMAEn). Metodos Se realizo un estudio transversal de pacientes con DMAEn en tratamiento con inyecciones intravitreas de antiangiogenicos. Los pacientes realizaron 2 cuestionarios validados: el cuestionario de funcion visual (VFQ-25, cuya puntuacion varia de 0 a 100) y la Escala hospitalaria de ansiedad y depresion (HADS). Se registraron la edad, el sexo y la agudeza visual (AV) en la escala Early Treatment Diabetic Retinopathy Study. Resultados Se incluyeron 55 pacientes con DMAEn con una edad de 80,9 ± 6,6 anos (rango 67 a 93) y una AV en el mejor ojo de 73,5 ± 12,7 letras (rango 44 a 95). La puntuacion global media en el VFQ-25 fue de 57,4 ± 21,9, siendo 38,9 ± 13,2 para la vision general y 42,0 ± 19,5 para la salud general. La AV se correlaciono con la puntuacion global de la escala VFQ-25 (R = 0,608; p Conclusiones Este estudio muestra el impacto en la calidad de vida y funcion visual en los pacientes con DMAE neovascular, presentando en un porcentaje considerable de los casos sintomas de depresion y ansiedad.

Purpose Thrombotic events (TE) represent one of the major complications of SARS-CoV-2 infection. The objective is to evaluate vessel density (VD) and perfusion density (PD) by optical coherence tomography angiography (OCTA) in COVID-19 patients, and compare the findings with healthy controls. The secondary objective is to evaluate if there are differences in OCTA parameters between COVID-19 patients with and without associated TE. Methods Cross-sectional case–control study that included patients with laboratory-confirmed diagnosis of COVID-19 with and without TE related to the infection and age-matched healthy controls. Ophthalmological examination and OCTA were performed 12 weeks after diagnosis. Demographic data and medical history were collected. Macular OCTA parameters in the superficial retinal plexus were analyzed according to ETDRS sectors. Results Ninety patients were included, 19 (20%) COVID-19 patients with associated TE, 47 (49.5%) COVID-19 patients without TE, and 29 (30.5%) healthy controls. Fifty-three (55.7%) were male, mean age 54.4 (SD 10.2) years. COVID-19 patients presented significantly lower VD than healthy controls: central (p = 0.003), inner ring (p = 0.026), outer ring (p = 0.001). PD was also significantly decreased: outer ring (p = 0.003), full area (p = 0.001). No differences in OCTA parameters were found between COVID-19 patients with and without TE. Conclusions OCTA represents a promising tool for the in vivo assessment of microvascular changes in COVID-19. Patients with SARS-CoV-2 infection show lower VD and PD compared to healthy controls. However, no differences were found between COVID-19 when considering TE. Prospective studies are required to further evaluate the retinal microvascular involvement of SARS-CoV-2 and its impact on the vasculature of other organs. Supplementary Information The online version contains supplementary material available at 10.1007/s00417-021-05186-0.

Resumen La coriorretinopatia serosa central (CSC) es una de las principales causas de disminucion de la agudeza visual en pacientes menores de 60 anos. Su fisiopatologia sigue siendo parcialmente desconocida, aunque se ha postulado una hiperpermeabilidad coroidea que produce tipicamente un desprendimiento neurosensorial y/o un desprendimiento del epitelio pigmentario de la retina en el polo posterior. La CSC aguda generalmente no requiere tratamiento, mientras que cuando es cronica debe ser tratada para evitar un deterioro visual. Con el desarrollo de las nuevas tecnicas de imagen ha existido una mejora en el diagnostico y se han propuesto diferentes estrategias terapeuticas. Actualmente diversos tratamientos para el manejo de la CSC cronica han demostrado ser utiles para mejorar o estabilizar la agudeza visual, la resolucion del fluido subretiniano y para prevenir recurrencias. Los tratamientos mas empleados en la actualidad son la terapia fotodinamica con verteporfina, el laser subumbral de micropulso, el tratamiento con antagonistas de los mineralocorticoides o los farmacos intravitreos antiangiogenicos. Pero existen otras propuestas y, ademas, se estan desarrollando nuevos tratamientos con resultados prometedores. Esta revision pretende ofrecer al lector una vision global de la evidencia cientifica actual de las diferentes opciones de tratamientos disponibles para la CSC para ayudar en la toma de decisiones en la practica clinica.

Central serous chorioretinopathy (CSC) is one of the main causes of impaired visual acuity in patients younger than 60 years. Its pathophysiology remains partially unknown, although it has been postulated that choroidal hyper-permeability may be involved. This typically produces a neurosensory retinal detachment and/or a detachment of the retinal pigment epithelium in the posterior pole. Although acute CSC generally does not require treatment, when chronic it must be treated to avoid visual impairment. With the development of new imaging techniques, there has been an improvement in diagnosis, and different therapeutic strategies have been proposed. Various treatments for the management of chronic CSC have currently been shown to be useful to improve or stabilise visual acuity, the resolution of subretinal fluid, and to prevent recurrences. The most commonly used treatments today are photodynamic therapy, micropulse subthreshold laser, mineralocorticoid antagonists, or anti-vascular endothelial growth factor drugs. There are also other proposals and new treatments being developed, with promising results. This review aims to provide the reader with an overview of the current scientific evidence of the different treatment options available for CSC in order to help decision-making in clinical practice.

PurposeTo ascertain the anatomic factors that help achieve non-surgical sealing in full thickness macular hole (FTMH).MethodsRetrospective collaborative study of FTMH that closed without surgical intervention.ResultsA total of 78 patients (mean age 57.9 years) included 18 patients with blunt ocular trauma, 18 patients that received topical or intravitreal therapies and 42 patients with idiopathic FTMH. Mean±SD of the initial corrected visual acuity (VA) in logMAR improved from 0.65±0.54 to 0.34±0.45 (pConclusionOur data suggest an observation period in new onset FTMH for non-surgical closure, in the setting of trauma, treatment of CME and size

To describe macular vessel density and perfusion in COVID-19 patients using coherence tomography angiography (OCTA) and to investigate whether there is a correlation between retinal vascular abnormalities and clinical and laboratory parameters.Cross-sectional analysis conducted at the Hospital Clinico San Carlos in Madrid, Spain. Patients with laboratory-confirmed COVID-19 that were attended in the Emergency Department (ED) from March 23 to March 29, 2020 were included. Fundus examination and OCTA were performed 4 weeks after being attended in ED. Macular OCTA parameters were analyzed and correlated with clinical (severity and hypoxemia- oxygen saturation 92%) and laboratory parameters during hospital stay (D-Dimer-DD, lactate dehydrogenase-LDH and C-reactive protein-CRP).80 patients were included, mean age 55(SD9) years old; 46.3% male. We reported macular vessel density and perfusion measurements in COVID-19 patients. Those patients with D-Dimer ≥ 500 ng/ml during SARS-CoV-2 infection had a decrease of central vessel density (mean difference 2.2; 95%CI 0.4-3.9) and perfusion density (mean difference 4.9; 95%CI 0.9-8.9) after the acute phase of COVID-19. These variations of vessel density and perfusion density were not documented in patients with LDH ≥ 500 U/L, CRP ≥ 10 mg/L and hypoxemia.COVID-19 patients showed short-term retinal vasculature abnormalities which may be related to a prothrombotic state associated with SARS-CoV-2 infection. Since the retinal microvasculature shares many morphological and physiological properties with the vasculature of other vital organs, further research is needed to establish whether patients with increased D-Dimer levels require more careful assessment and follow-up after COVID-19.Evaluar la densidad vascular (DV) y la perfusión vascular (PV) retiniana en pacientes con COVID-19 mediante una angiografía por tomografía de coherencia óptica (OCTA), e investigar si existe una correlación entre las anomalías vasculares de la retina y los parámetros clínicos y de laboratorio.Análisis transversal realizado en el Hospital Clínico San Carlos, Madrid. Se incluyeron pacientes con diagnóstico confirmado de COVID-19 atendidos en el Servicio de Urgencias (SU) del 23 al 29 de marzo del 2020. Se realizó una exploración oftalmológica y OCTA cuatro semanas después de acudir al SU. Se analizaron los parámetros maculares de OCTA y se correlacionaron con parámetros clínicos (gravedad e hipoxemia-saturación de oxígeno92%) y de laboratorio durante la estancia hospitalaria (dímero D [DD], lactato deshidrogenasa [LDH] y proteína C reactiva [CRP].Se incluyeron 80 pacientes, edad media 55 (DE nueve) años; 46,3% hombres. Las personas con DD500 ng/mL durante la infección por SARS-CoV-2 tuvieron una disminución de la DV central (diferencia de medias 2,2; IC 95% 0,4 a 3,9) y PV central (diferencia de medias 4,9; IC 95% 0,9 a 8,9) después de la fase aguda de COVID-19. Estas variaciones no se documentaron en los pacientes con LDH= 500 U/L, CRP= 10 mg/L y con hipoxemia.Los pacientes con COVID-19 mostraron anomalías de la vasculatura retiniana a corto plazo que pueden estar relacionadas con un estado protrombótico asociado con la infección por SARS-CoV-2. Dado que la microvasculatura de la retina comparte muchas propiedades morfológicas y fisiológicas con la vasculatura de otros órganos vitales, es necesario seguir investigando para determinar si los pacientes con niveles elevados de DD requieren una evaluación y un seguimiento más cuidadoso.

Background The purpose of this paper is to study the utility of adhesives (artificial-cyanoacrylate and biological-fibrin glue) for improving transconjunctival sutureless vitrectomy (TSV) sclerotomy closure competency. Methods Experimental and observer-masked study in which after performing TSV in cadaveric pig eyes, different adhesives were tested on sclerotomy entrances in order to determine if they improved closure competency in face of progressive intraocular pressure increase. In 76 eyes cyanoacrylate-treated sclerotomies were compared with sclerotomies in which no additional manoeuvre to aid closing was performed; in 76 eyes fibrin glue with no manoeuvre; and in the last 76 eyes, cyanoacrylate-treated sclerotomies were compared with fibrin glue-treated sclerotomies. Results A total of 228 eyes had a 23-gauge TSV performed. Both cyanoacrylate and fibrin glue treated sclerotomies achieved higher mean opening pressures when compared with nontreated sclerotomies in the same eye (p p = 0.216). Discussions This experimental study provides support for the possible role of adhesives in improving TSV sclerotomy closure competency in clinical practice.

Purpose To report an unusual case of multifocal and bilateral perifoveal exudative vascular anomalous complex (PEVAC) lesions in an otherwise healthy patient. Observations A 62-year-old male with complaints of long-term progressive blurred vision in both eyes. There was no history of diabetes, arterial hypertension or inflammatory disease. Best-corrected visual acuity was 75 and 80 letters in his right eye (OD) and left eye (OS) respectively. Fundus examination showed three perifoveal isolated large aneurysmal lesions in his OD and an additional one in his OS, associated with smaller microaneurysms, haemorrhages and intraretinal exudation. On optical coherence tomography PEVAC appeared as a round lesions with a hyperreflective wall and lumen containing variably reflective material, typically surrounded by intraretinal fluid. Dye-based angiography demonstrated three and one well-defined large hyperfluorescent aneurysmal lesions in his OD and OS respectively, with no leakage. The optical coherence tomography angiography images showed flow signal within the intraretinal aneurysmal lesions. No anomalous flow signal in the outer retina and choriocapillaris was present. After one bilateral anti-vascular endothelial growth factor intravitreal injection no anatomical or functional improvement was observed, and no changes in the lesions or visual acuity were observed at 6 months follow-up. Conclusions and importance We describe an atypical case of PEVAC, an uncommon and poorly known macular disorder, with bilateral presentation and multifocal lesions in one eye. To our knowledge, this is the first reported case of bilateral PEVAC lesions. Hence, PEVAC should be included in the differential diagnosis of bilateral perifoveal aneurysmal lesions with macular edema.

Suturing is the most widely used technique to close leaking sclerotomies after transconjunctival sutureless vitrectomy (TSV). However, with the aim of avoiding the disadvantages caused by conjunctival stitches, there have been described other closure techniques, such as the cauterization of the conjunctiva placed over the incisions. To continue advancing knowledge of the incisional occlusion effect achieved by conjunctival diathermy, it would be also interesting to study the wound closure resistance obtained under intraocular pressure (IOP) changes, given that in the early postoperative period eyes are subjected to pressure stress. In our study, we compare the mechanical resistance observed in sclerotomies treated with bipolar diathermy after TSV compared to that found in incisions in which cauterization was not performed. This was an experimental, randomized, and observer-masked study in which 23-gauge TSV was performed in 80 cadaveric pig eyes. Once each vitrectomy was finished, cauterization was performed with bipolar diathermy forceps on the conjunctiva placed over one of the superior sclerotomy sites; no maneuver was performed over the other superior incision. IOP was gradually increased by means of the vitrectomy system (Accurus; Alcon Laboratories, TX) until one of the superior sclerotomies opened, allowing internal ocular solution to escape. In 35 % of cases (28 of 80 eyes), sclerotomies subjected to diathermy allowed intraocular fluid escape first (p = 0.01). When comparing opening pressure values, cauterized incisions leaked at significantly higher pressure levels than those in which diathermy was not applied (p

Purpose To evaluate the relationship between the photoreceptor layer status (inner segment ellipsoid band and external limiting membrane) and the foveal avascular zone size, as a result of macular perfusion, in patients with diabetic macular edema. Methods This observational case series study included 151 eyes of 118 patients with naive diabetic macular edema. The length of the disrupted photoreceptor layer was assessed by optical coherence tomography. The foveal avascular zone diameter was measured on fluorescein angiogram. Results No significant association was found between the foveal avascular zone size and the mean lengths of the disrupted inner segment ellipsoid band nor the external limiting membrane in patients with naive diabetic macular edema. Conclusion Macular ischemia, which lengthens the distance from the perifoveal vessels to the center of the fovea and may disrupt the normal flow of nutrients by simple diffusion to the photoreceptor line, does not seem to influence on inner segment ellipsoid band nor external limiting membrane integrity. Future studies may evaluate the effect of choroidal vascularization on the photoreceptor layer status to enhance the knowledge about the photoreceptor layer nutrients source.

To assess the influence that hydration applied on the sclerotomy edges may have on incisional closure resistance after transconjunctival sutureless vitrectomy (TSV).Experimental, randomized and observer-masked study in which 23-gauge TSV was performed in 80 cadaveric pig eyes. Once each vitrectomy was finished, hydration with balanced salt solution (BSS) was applied on the sclerotomy edges of one of the superior incision sites; no maneuver was performed on the other superior sclerotomy. Intraocular pressure (IOP) was gradually increased by means of the vitrectomy system (Accurus; Alcon Laboratories, TX) until one of the superior sclerotomies opened, allowing internal ocular solution to escape.In 45% of cases (36 of 80 eyes), sclerotomies subjected to hydration allowed intraocular fluid escape (p = 0.43). There were no differences when comparing opening pressure values of hydrated and non-hydrated sclerotomies (p = 0.19).Scleral hydration did not demonstrate increase in the sclerotomy closure resistance in our experimental model. Given the widespread use of sutureless TSV around the world, the results obtained in our research, in spite of being negative, may contribute to the knowledge of the behavior of sutureless sclerotomies.

Case report We report a familial case of 2 siblings that suffered choroidal neovascularization (CNV) secondary to angioid streaks. They were both treated with a monthly intravitreal injection of ranibizumab (Lucentis®) for 3 months. Visual acuity was stabilized and fluorescein angiography revealed complete resolution of CNV. Neither recurrent CNV lesion nor new hemorrhages were reported during the follow-up period. Discussion The use of intravitreal ranibizumab for the treatment of CNV in patients with angioid streaks has shown favorable results. However, further studies with a longer follow-up and larger number of patients are necessary to more precisely determine the results of this therapy.

To evaluate the influence that the origin of incisional vitreous incarceration may have on the presence of postoperative conjunctival blebs over sclerotomies after transconjunctival sutureless vitrectomy (TSV). Blebs are formed by incisional leakage due to incompetent closure.Twenty-three-gauge TSV was performed in 83 cadaveric pig eyes. Once each vitrectomy was finished, ultrasound biomicroscopy (UBM) was used to assess the presence of postoperative conjunctival blebs over the sclerotomy sites, as well as the existence of vitreous incarcerated in incisions. Vitreous strands may come from the perisclerotomy area, running parallel to the sclera toward the inner hole of the sclerotomies, or may radiate from the core of the vitreous cavity.Vitreous entrapment was found in 73.9% of the sclerotomies; 43.4% of the incisions showed vitreous strands coming parallel to the sclera (12.9% of them showed conjunctival bleb), 19.7% of the wounds presented vitreous aiming toward the core of the vitreous cavity (2% of them had conjunctival bleb) and 10.8% of the entrances presented both vitreous incarceration sources (none of them showed bleb). Incisions with vitreous entrapment parallel to the sclera were associated with a significantly greater sclerotomy leakage rate.Sclerotomies with vitreous incarceration coming from the core of the vitreous cavity showed a greater incisional closure competency than that observed in incisions with vitreous entrapment coming from the pericannular area; if these results were confirmed in humans, different postoperative suture rates may be expected on sclerotomies according to the vitrectomy degree performed in different areas of the vitreous cavity.

To compare ultrasound biomicroscopy (UBM), anterior-segment optical coherence tomography (AS-OCT), and direct visualization for detecting conjunctival blebs in sutureless sclerotomies after vitrectomy. Conjunctival blebs are formed by sclerotomy leakage due to incompetent closure.Experimental, randomized, and observer-masked study in which 23-gauge vitrectomies were performed in cadaveric pig eyes. Postoperative conjunctival blebs were assessed by UBM, AS-OCT, and direct visualization. No conjunctival blebs were classified as Grade 0 (G0), thin blebs (less than or equal to one-half of scleral thickness) as Grade 1 (G1) and thick blebs (greater than one-half of scleral thickness) as Grade 2 (G2).Fifty pig eyes were included. Conjunctival blebs were found in 13.3% (8% G1, 5.3% G2) of the incisions analyzed by UBM, in 20% (14.7% G1, 5.3% G2) of the sclerotomies studied by AS-OCT, and in 7.3% (2% G1, 5.3% G2) of the wounds evaluated by direct visualization. AS-OCT was the most sensitive method for identifying conjunctival blebs when compared with UBM and direct visualization (p0.001). In turn, UBM was better than direct visualization for observing sclerotomy blebs (p=0.004).AS-OCT is the most sensitive technique for detecting subclinical blebs (G1) and thus, it may be useful in research for studying the influence that surgical factors and maneuvers may exert on sclerotomy closure capacity after vitrectomy. Direct visualization, that is used in routine clinical practice to determine which sclerotomies should be sutured, is useful only to identify thick blebs (G2) after vitrectomy.

To evaluate the influence of the cannula removal maneuver on the postoperative incisional vitreous incarceration using an experimental model of vitrectomized eye.Prospective, experimental, randomized and observer-masked experimental study in which 23-gauge transconjunctival sutureless vitrectomy was performed through oblique sclerotomies in cadaveric pig eyes. Once the vitrectomy was finished, one of the superior cannulas was removed with the light probe introduced through it, and the other cannula was extracted with the cannula plug inserted. Postoperative incisional vitreous incarceration was evaluated by ultrasound biomicroscopy (UBM).60 eyes included. Considering the 60 superior sclerotomies whose cannulas were extracted with the light pipe inserted, vitreous incarceration was observed in 35% of them. On the other hand, 71.6% of the incisions whose cannulas were removed with the cannula plug inserted showed vitreous incarceration (p = 0.00013).Interposing the light probe through the cannula when it is removed seems to reduce the postoperative wound vitreous incarceration rate in our experimental model.

To evaluate the influence of superior sclerotomy use (vitreous cutter or illumination probe entrance) on the postoperative sclerotomy closure competency using an experimental model of vitrectomized eye.Prospective, experimental, randomized and observer-masked experimental study in which 23 and 25-gauge transconjunctival sutureless vitrectomy was performed through oblique sclerotomies in the same cadaveric pig eye. Closure competency was determined by the resistance to intraocular fluid leak through the superior incisions in face of a progressive intraocular pressure (IOP) rise.120 eyes included. In 52.5% of cases, the vitreous cutter probe sclerotomy showed intraocular fluid leakage first (p = 0.65). When comparing opening pressure values, there were no significant differences (p = 0.77) between the leakage pressure level of both sclerotomies depending on their use.Different uses of superior sutureless oblique sclerotomies do not seem to influence on TSV incision mechanical resistance to IOP rise in our experimental model.

A scleral fixation technique for posterior dislocated intraocular lens performed through 23-gauge vitrectomy cannulas is presented. It is based on the creation of polypropylene loops at opposite meridians through which haptics are engaged and placed in the sulcus. Repositioning of the intraocular lens (as opposed to substitution that requires new or reopening of corneal incisions) associated with microincisional vitrectomy techniques (23 gauge) allows for faster patient recovery. Free rotation of haptics through the loops aids in providing spontaneous good intraocular lens centering. The technique provides a minimally invasive solution for dislocated intraocular lenses after the unavoidable vitrectomy procedure to liberate the lens from the vitreous chamber.

Inverted retinal detachments secondary to giant retinal tears are sometimes difficult to unfold with the perfluorocarbon (PFC) bubble even after complete epiretinal dissection due to the tendency of the flap to maintain its inverted configuration. The following maneuver has been performed in two cases. After reducing the PFC bubble volume to the level of the border of the flap, the tip of the same perfluorocarbon injection cannula is used to capture the inverted retinal flap with gentle suction. The flap is lifted and brought centripetally to “cover” the PFC bubble and then released by stopping suction. Then bubble volume can be increased to reapply the entire retina, allowing for continuation of surgery. This simple maneuver allows, in one quick surgical step and without the introduction of new instruments, unfolding of persistently inverted giant retinal tears. [Ophthalmic Surg Lasers Imaging 2010;41:394–396.]

Purpose To develop a surgical incisional technique that helps overcome incompetent sclerotomy closure previously reported in sutureless 25-gauge vitrectomy. Design Prospective interventional case series report. Methods We performed this surgical technique in 12 eyes of 12 consecutive patients scheduled for 25-gauge vitrectomy. The sclerotomy was created performing an oblique incision, a structural modification that helps the closure stay watertight once the cannulas are removed. Results This technical variation resulted in no intraoperative leakage after cannula removal in any of the 36 sclerotomies performed. Conclusions Incision construction using this technique may resolve the reported sclerotomy leakage that in some cases had to be solved by suturing.

PURPOSE To evaluate the influence that vitreous incarceration may exert on the presence of postoperative conjunctival blebs over sclerotomies after transconjunctival sutureless vitrectomy (TSV). Blebs are formed by incisional leakage due to incompetent closure. METHODS Experimental study in which 23-gauge TSV was performed in 146 cadaveric pig eyes. Once the vitrectomy was finished, triamcinolone was injected inside the vitreous cavity for staining residual vitreous, one of the superior cannulas was extracted over the light probe, and the other cannula was removed with the plug inserted. Postoperative conjunctival blebs in superior sclerotomies were assessed by anterior-segment optical coherence tomography (AS-OCT) in a masked fashion; nondetectable blebs were classified as grade 0 (B0), thin bleb (≤half scleral thickness) as grade 1 (B1), and thick bleb (>half scleral thickness) as grade 2 (B2). Postoperative incisional vitreous entrapment was evaluated by slit-lamp photographs in a masked way; no incarceration was classified as grade 0 (V0), thin incarceration as grade 1 (V1), and thick incarceration as grade 2 (V2). RESULTS Conjunctival blebs were found in 13.7% of the sclerotomies (11.3% bleb-B1, 2.4% bleb-B2). Vitreous incarceration was found in 96.5% of the sclerotomies without bleb (B0), 81.8% of the incisions with bleb-B1, and 14.3% of the wounds with bleb-B2. Vitreous incarceration was significantly associated with the absence of conjunctival bleb (P < 0.001). CONCLUSIONS Vitreous incarceration in sclerotomies is related to less incisional leakage in our experimental model. Maneuvers that reduce vitreous entrapment, such as the interposition of a nonhollow probe during the cannula extraction, could decrease the sclerotomy closure competency.

BACKGROUND AND OBJECTIVE: To compare anterior-segment optical coherence tomography (AS-OCT), ultrasound biomicroscopy (UBM), and direct visualization for detecting vitreous incarceration in sutureless sclerotomies. MATERIALS AND METHODS: Prospective, randomized, and observer-masked experimental study in which 23-gauge vitrectomy was performed in pig eyes. Postoperative incisional vitreous incarceration was evaluated by AS-OCT, UBM, and direct visualization. RESULTS: One hundred eighteen pig eyes were included. Vitreous entrapment was found in 7.9% (28 of 354), 59.6% (211 of 354), and 95.5% (338 of 354) of the sclerotomies analyzed by AS-OCT, UBM, and direct visualization, respectively. Direct visualization was the most sensible method for identifying incisional vitreous when compared with UBM and AS-OCT ( P < .0001). In turn, UBM was superior to AS-OCT for observing vitreous incarceration ( P < .0001). CONCLUSION: Direct visualization is the most effective method for detecting vitreous entrapment. Regarding the imaging techniques, UBM was superior to AS-OCT for identifying vitreous incarceration.

PURPOSE. The purpose of this study was to report a novel model for comparing mechanical resistance to intraocular pressure (IOP) increases with 23-gauge (23G) and 25G transconjunctival sutureless vitrectomy (TSV) sclerotomies in the immediate postoperative period using an experimental model of a vitrectomized eye. METHODS. This was a prospective, experimental, randomized, and observer-masked experimental study in which TSV 23G and 25G oblique sclerotomies, performed in same cadaveric pig eye, were subject to an increase in IOP. Mechanical resistance was determined by the resistance to intraocular fluid leak through the sclerotomy. The simultaneous use of the different sclerotomy diameters in the same eye avoided interindividual scleral resistance differences. RESULTS. This animal model allowed comparison of the effect of different sclerotomy diameters (23G and 25G) on incisional mechanical resistance. One hundred twenty eyes were included. In 60.7% of cases, the 23G sclerotomy first allowed intraocular fluid escape (leaked; P 0.02). When comparing opening pressure values, 23G sclerotomies leaked at significantly lower pressure levels than 25G sclerotomies (P 0.0001); 53% of the 25G incisions but only 16% of 23G incisions opened at pressure levels greater than 120 mm Hg. CONCLUSIONS. Oblique 23G sutureless sclerotomies offer less mechanical resistance to increases in IOP than do 25G sclerotomies. This animal model may become the basis for future studies to evaluate the advantages of using other types of incision or other surgical tools on sclerotomy closure capacity. (Invest Ophthalmol Vis Sci. 2011;52:4080‐4084) DOI:10.1167/ iovs.10-6812

Javier Benitez-Herreros,1 Lorenzo Lopez-Guajardo,1,2 Cristina Camara-Gonzalez,1 Aurora Perez-Crespo,1 Agustin Silva-Mato,3 Miguel A Teus1,2 1Department of Ophthalmology, University Hospital Príncipe de Asturias, Madrid, Spain; 2Department of Surgery, Medical and Social Sciences, Faculty of Medicine, Alcalá University, Madrid, Spain; 3Department of Health and Sociomedical Sciences, Alcalá University, Madrid, Spain Purpose: To evaluate the influence of sclerotomy use during vitrectomy (vitreous cutter, illumination probe, or infusion-line entrance) on postoperative vitreous incarceration using an experimental model of vitrectomized eye. Materials and methods: Experimental, randomized, and observer-masked study in which 23-gauge transconjunctival sutureless vitrectomy was performed in cadaveric pig eyes. Postoperative incisional vitreous entrapment was evaluated by direct visualization. No vitreous incarceration was classified as grade 0 (G0), thin vitreous entrapment was classified as grade 1 (G1), and thick vitreous strands as grade 2 (G2). Results: A total of 46 eyes were included. Vitreous incarceration was detected in 91.3% (43.5% G1, 47.8% G2) of the sclerotomies used by the vitreous cutter probe, 95.7% (45.7% G1, 50% G2) of the illumination-pipe entrances, and 93.5% (45.7% G1, 47.8% G2) of the infusion-line incisions. No statistical differences were found when comparing incisional vitreous incarceration after vitrectomy according to sclerotomy use. Conclusion: Different manipulation of the sclerotomies, depending on their use, does not seem to influence postvitrectomy vitreous entrapment in our experimental model. Keywords: vitrectomy, vitreous incarceration, direct visualization, sclerotomy use, experimental model

PURPOSE To evaluate the effect of the cannula removal technique on postoperative vitreous incarceration using an experimental model of vitrectomized eye. METHODS In a prospective, experimental, randomized, and observer-masked study, 118 cadaveric pig eyes were vitrectomized through 23-gauge transconjunctival sclerotomies. Once vitrectomy was finished, one of the superior cannulas was extracted with the illumination probe inserted through it, and the other cannula was removed with a cannula plug inserted. Postoperative incisional vitreous entrapment was evaluated by direct visualization. No vitreous incarceration was classified as grade 0 (G0), thin vitreous entrapment was classified as grade 1 (G1), and thick vitreous strands as grade 2 (G2). RESULTS Considering the sclerotomies whose cannulas were extracted with the light probe inside, vitreous incarceration was detected in 93.2% (73.7% G1, 19.5% G2) of the incisions. In turn, vitreous entrapment was observed in 95.8% (43.2% G1, 52.6% G2) of the entry sites whose cannulas were extracted with the plug inserted. Statistical analysis showed significant differences when comparing postvitrectomy vitreous incarceration grades in sclerotomies according to the cannula extraction technique (P < 0.0001). CONCLUSIONS Interposing the light probe through the cannula during its removal reduces vitreous incarceration grade in our experimental model. This simple maneuver may decrease complications related to vitreous entrapment, such as peripheral retinal tears and acute endophthalmitis.

To develop an injection technique that reduces drug loss occurring due to reflux and consequent subconjunctival bleb formation after standard intravitreal pegaptanib injection.Prospective interventional case series report. The 27-gauge needle is inserted obliquely via pars plana to create a valved wound. The rate of subconjunctival bleb formation is evaluated performing ultrasound biomicroscopy, (1/2)h after intravitreal drug delivery comparing standard (straight)with this new described injection technique (oblique) using Fisher's exact test.Eyes on which oblique injection technique was performed developed significantly less subconjunctival bleb than those treated with the standard technique. The rate of injection-related complications (retinal detachment, vitreous haemorrhage, traumatic cataract, and endophthalmitis) in our small series was similar between both groups.The use of this technique can result in reduced drug loss after intravitreal pegaptanib injection. Larger studies are needed to determine if the rate of complications associated with intravitreal injections, especially endophthalmitis, is lowered with this technique.

Purpose To study 25-gauge sclerotomy healing process in vivo with ultrasound biomicroscopy (UBM) in direct and oblique incisions. Design Prospective interventional case series report. Methods At our institution, we performed UBM studies on 53 sclerotomies during the first 30 days after 25-gauge vitrectomy, looking for conjunctival bleb development, sclerotomy healing signs, and vitreous incarceration in the wound. Results Echographical healing signs were completed in 77% of patients by day 15 with no differences between direct and oblique sclerotomies. By day 30, all but one sclerotomy were closed. Conjunctival blebs developed over 64% of direct sclerotomies, and 25% of oblique (P = .0059), but all resolved spontaneously by day 15. Vitreous incarceration appeared in 72% of sclerotomies. Conclusions Twenty-five gauge sclerotomies heal by day 15 in most cases with no difference between direct and oblique sclerotomy construction. Conjunctival blebs developed more frequently over direct than oblique sclerotomies.