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The objective of this study was to evaluate the possibility of analysing quality indicators for uncomplicated primary rhegmatogenous retinal detachment in a hospital department of ophthalmology without the support of a national registry or need to collect data from referring ophthalmological centres.In 2014, we operated 231 consecutive eyes with uncomplicated retinal detachment. Our quality indicators were primary anatomical success, final anatomical success and postoperative endophthalmitis. We reviewed medical records in our university surgical department retrospectively and compared them with medical records from the regional hospitals that had referred most of the operated patients and done their own postoperative examination. Our hypothesis was that any retinal re-detachment and/or serious postoperative complication would be reported back.The medical records at the surgical department revealed primary anatomic success for 91.3% of eyes and final anatomical success of 99.6%. The data from the regional hospitals confirmed that our hypothesis was correct. All patients with adverse outcomes were referred back for reoperation. Patients who were not referred again had an attached retina and showed no signs of endophthalmitis.Our hypothesis that data in the surgical department's medical records would closely reflect those in referring hospitals was borne out. This supports, under current conditions, an effective strategy for analysing chosen quality indicators without relying on a national registry or reviewing records from regional hospitals.

Purpose: To develop a treatment model of rhegmatogenous retinal detachment (RRD) in which the effects of various vitreous tamponades can be explored. Methods: In a primary session, detachment was produced in the right eye of 24 rabbits using vitrectomy, posterior vitreous detachment, retinal break induction, and subretinal injection of viscoelastic solution. The following day, detachments were treated in 16 eyes using SF6 (n = 8) or Healaflow® (HF, a cross-linked hyaluronic acid hydrogel, n = 8) tamponade. Animals were followed for 1 month and thereafter examined macroscopically and morphologically in hematoxylin and eosin-stained sections. Results: Retinal detachment (RD) was successfully treated using repeated surgery. Two HF eyes developed progressive vitritis and were excluded from further evaluation. Enlargement of the initial retinal rupture with concomitant RD was seen in 4/8 SF6 eyes, while all 6 HF eyes displayed an attached retina. Attached areas showed a normal retinal morphology except for in 1 HF eye with extensive degeneration. Conclusions: The RRD repeat vitrectomy model offers a possibility to explore the efficacy and complications of novel potential vitreous tamponades. Gel-based Healaflow® displays excellent anatomic reattachment, however, vitritis and retinal degeneration in some cases warrants further investigation.

Background To report beta‐trace protein (β TP) levels in the subretinal fluid (SRF) of four patients with a macular detachment associated with optic disc pit (ODP). Methods Four patients with a serous retinal detachment involving the macula was operated by pars plana vitrectomy (PPV) with C2F6 gas tamponade and peeling of internal limiting membrane (ILM). Patients with a follow‐up period exceeding one year postoperatively were included in the study. The SRF was drained using a fine cannula without laser photocoagulation, and the samples were analysed using particle‐enhancing nephelometry. The levels of β TP were compared to 20 routine cerebrospinal fluid (CSF) samples. Results In four of the five samples from SRF had relatively low β TP levels, with a mean concentration of 6.6 mg/l (range 2.0 to 23.1 mg/l) compared to 16.0 mg/l (range 6.3‐26.8 mg/l) in CSF. The only SRF sample within the range corresponding to normal CSF was the first sample from patient 4, and the analysis of the renewed aspirate during the second operation was 2.8 mg/l. Postoperatively, the regression of SRF was slow, but regression of SRF in the foveal region took place in all cases; however, visual acuity (VA) was improved in only half of the patients. Conclusion The results from the analysed SRF regarding β TP concentration in these patients indicate that the SRF in ODP is not identical to CSF, as the concentrations of β TP differ.

Background Bacteria in the conjunctiva present a potential risk of vitreous cavity infection during 23-gauge pars plana vitrectomy (PPV). Current preoperative procedures used in Sweden include irrigation with chlorhexidine solution (CHX) 0.05% only and no iodine solutions. We evaluated the bacterial diversity and load before and after this single antibacterial measure. Methods In a prospective, consecutive cohort we investigated bacterial growth in samples from 40 eyes in 39 consecutive individuals subjected to vitrectomy. A conjunctival specimen was collected from each preoperative patient before and after irrigating of eye with CHX, 0.05% solution. Iodine was not used during any part of the surgery. One drop of chloramphenicol was administered prior to surgery. Samples from vitreous cavity were collected at the beginning and end of vitrectomy. All conjunctival specimens were cultured for different species and quantified using colony forming units (CFU). Results There was a significant 82% reduction in the total number of CFUs for all bacteria in all eyes (P < 0.0001), and 90% reduction for coagulase negative staphylococci (CoNS) alone (P = 0.0002). The number of eyes with positive bacterial growth in conjunctival samples decreased from 33 to 18 after irrigation with CHX (P = 0.0023). The most common bacteria prior to surgery were CoNS (70%), Propionibacterium acnes (55%) and Corynebacterium species (36%). No case of post-vitrectomy endophthalmitis was reported during mean follow-up time, which was 4.6 ± 2.3 (range; 1.5 to 9) months. Conclusions Patients undergoing PPV harbored bacteria in conjunctiva capable of causing post-vitrectomy endophthalmitis. Preoperative preparation with CHX significantly reduced the bacterial load in the conjunctival samples subsequently leading to very low inoculation rates in recovered vitreous samples. Thus, CHX used as a single disinfectant agent might be an effective preoperative procedure for eye surgery in Sweden. This is a relatively small study but the results could be a reference for other intraocular surgeries.

Floorball - a common cause of sport related eye injury The aim of this study was to survey the incidence and type of sport related to eye injuries with special interest in floorball. A prospective study was conducted December 1st 2013 through November 30th 2014 at the Department of Ophthalmology, Örebro University Hospital. All patients presenting with an acute sports related eye injury were offered to be included. Information was collected from a self-administered questionnaire and from medical journals. During the study period, 49 patients sought care for sports related eye injuries, and 26 (53%) of those were related to floorball. The number of patients who agreed to take part in the study was 38, of which 25 had injuries related to floorball. Among the floorball players, there were two patients where the injury caused permanent vision impairment. None of the floorball players wore eye protection at the time of injury. According to this study, protective eyewear should be recommended when playing floorball, regardless of age or setting.

To investigate whether ultraviolet light (UVA) at 365 nm can inhibit/eliminate Acanthamoeba growth and if riboflavin would potentiate such an association.Acanthamoeba castellanii in a fluid medium with a concentration of approximately 1.7 × 10(4) protozoa/ml were prepared with (0.01 %) and without riboflavin. Exposure of UVA (dose 5.475 J/cm(2)) took place twice, with each illumination period followed by culturing of 10 μl in peptone yeast-extract glucose (PYG) medium for 7 days. Every suspension prepared had a non-exposed control solution. Determination of Acanthamoeba was conducted daily, by count in Burker chamber days 4 through 7 after exposure. Statistical analysis was done by repeated-measurement ANOVA and post-hoc analysis for unpaired samples.The exposure of ultraviolet light resulted in an inhibited growth of Acanthamoeba compared to the non-exposed solutions, with a statistically significant reduction over time (p = 0.0003). The addition of riboflavin did not amplify the effect, and there were no tendencies for an interaction effect between UVA and riboflavin.The antiprotozoal effect of the UVA wavelength, utilized in CXL, is solely mediated by ultraviolet light, and riboflavin does not seem to amplify the antimicrobial efficacy.

Background The aim of this work as to investigate the photochemical interaction used in corneal crosslinking (CXL) as the primary therapy for bacterial keratitis.

To describe 7 eyes with severe infectious keratitis treated using collagen crosslinking (CXL) with riboflavin.Seven eyes of 6 patients with severe infectious keratitis were treated with corneal crosslinking. Three patients were contact lens users. Symptom duration before CXL ranged between 0 and 7 days. Corneal melting was present in all cases. Photodocumentation of the keratitis was carried out and repeated at follow-up. All but 1 patient received topical antibiotic treatment in addition to the CXL treatment. CXL was conducted according to the standardized protocol for keratoconus.In all but 1 eye, patients experienced improvement in symptoms within 24 hours. Two patients reported no symptoms whatsoever at this time. Corneal melting was arrested and complete epithelialization was achieved in all cases. In the 2 eyes with hypopyon, this regressed completely within 2 days after the CXL. Follow-up ranged between 1 and 6 months.Our experience based on the above and other cases suggest that CXL could be an effective tool in battling difficult cases of infectious keratitis. This treatment could present many advantages but will need further investigation.

BACKGROUND Electroporation therapy is a new cancer treatment modality in which a locally applied electrical field enhances cell membrane permeability, allowing greater intracellular accumulation of a chemotherapeutic agent. OBJECTIVE To evaluate the efficacy of electroporation therapy in treating basal cell and squamous cell carcinomas of the skin. MATERIALS AND METHODS Six patients with skin cancer of the head and neck were treated using electroporation therapy with intratumorally injected bleomycin. Orbital growth, facial nerve proximity, or proximity to cartilage of the external meatus complicated four of these tumors. The intention was curative. The follow-up period was 24 months and included biopsies after 8 weeks. RESULTS In four of the six patients, one treatment was enough to eradicate the tumor. In one patient, the tumor persisted even after a second treatment with electroporation therapy. A septal cartilage perforation was the only major complication. The cosmetic results were very satisfactory. One additional recurrence was recorded 6 months after the follow-up period CONCLUSION Electroporation therapy is a promising new cancer treatment that should be further evaluated as an alternative to surgery, especially in complicated skin cancer.

To describe the clinical appearance and the visual outcome of a cohort of patients with vasoproliferative retinal tumours (VPRTs) that were diagnosed and treated between 2002 and 2007 at the University Hospital of Örebro.Nine patients with diagnosed VPRTs were included in a retrospective study. The mean age at the time of diagnosis was 50.2 years (range 7-74 years). Follow-up time ranged between 14 and 83 months (mean 42.6). Nine out of ten eyes received cryotherapy; six eyes were also treated with photocoagulation. One patient was treated with intravitreal injections of ranibizumab (Lucentis(®)) and another was referred for brachytherapy. Because of persisting macular oedema, one eye was treated with intravitreal injection of triamcinolon.Of the treated eyes, one had anterior uveitis, six had macular oedema at baseline and four had an exudative retinal detachment at the time of diagnosis. Seven eyes underwent vitrectomy because of epiretinal membranes. Visual acuity at diagnosis was 0.21 (mean) (range 0.02-0.6) and at latest check-up 0.30 (mean) (range light perception (LP)-1.0), with improvement in six eyes and deterioration in two. Two out of four patients with retinal detachment were successfully treated surgically.VPRTs are benign intraretinal changes. Several complications are associated with this condition. All patients in this study had symptom-giving tumours and six patients (six eyes) already had profound macular oedema at presentation. In these cases, when complications have already developed, the final visual prognosis is poor, thereby making it important to detect these tumours early. The patient who received anti-vascular endothelial growth factor (VEGF; Lucentis) therapy showed a slow improvement and distinct regression in exudations during the follow-up time. However, no increase in visual acuity was seen. At latest examination a peripheral exudative retinal detachment was still observed. Whether anti-VEGF treatment is effective, as either an alternative or complementary therapy, must be established in the future.

Two perfluorocarbon liquids (perfluoro-n-octane and perfluorodecaline) were evaluated as technical aids in vitreoretinal surgery in 42 patients. Perfluorocarbon liquids were found to stabilize the retina and simplify removal of repiretinal membranes, which in many cases permitted the subsequent use of an expanding gas instead of silicone oil at the conclusion of the operation. The infusion of a perfluorocarbon liquids allowed the drainage of subretinal fluid through peripheral retinal breaks obviating the need for a retinotomy in most cases. No difference could be observed between the two types of perfluorocarbon liquids, and there were no adverse effects associated with their use. The retina was centrally attached in 32 eyes (76%) at 3-10 months follow-up.

Metal retinal tacks were used in 18 patients with complicated retinal detachments, such as giant tears (3 cases), severe proliferative vitreoretinopathy (PVR) (7 eyes) and diabetic traction and rhegmatogenous detachment (8 cases). All eyes had undergone vitreous microsurgery, including excision or segmentation of epiretinal membranes, fluid-air (SF6) or silicone oil exchange. Retinal breaks and the cut edges of retinotomies and retinectomies were successfully sealed by metal tacks. Retinal re-attachment was achieved in 9 cases and partial re-attachment in another 5 eyes (follow-up 3–6 months). Retinal tears in diabetic macular detachment associated with extensive epiretinal fibro-vascular membranes were also successfully sealed despite persisting traction. Our first experience indicates that the closing of retinal breaks with metal tacks is a major step forward in retinal re-attachment surgery.

To report the clinical experience and results of using a microsurgical technique to decompress the arteriovenous connection in complicated branch retinal vein occlusion (BRVO) combined with haemorrhage, oedema and ischaemia.We carried out a retrospective, non-randomized, interventional case study of the surgical sheathotomy decompression procedure. We enrolled 12 patients (seven women, five men; median age 64 years) with BRVO and decreased visual acuity (VA) caused by haemorrhage, oedema and ischaemia. The mean duration of thrombosis was 7 months (2-15 months). The patients were examined for pre- and postoperative best corrected VA (BCVA), intraocular pressure (IOP) and fundus photography. Ten patients were examined with fluorescein angiography and eight with ocular coherence tomography (OCT). Postoperative progression of cataract was recorded, as were other complications. The mean follow-up time was 20 months (8-39 months).Best corrected VA had improved in nine patients, was unchanged in one patient and had deteriorated in two patients at the last follow-up. Noted complications were venous haemorrhage at surgery in five patients, retinal detachment in one patient and progression of cataract in four patients.Microsurgical treatment with sheathotomy of BRVO is a technically feasible procedure with few complications. Postoperative increased reperfusion could explain the resolution of macular haemorrhage, oedema and ischaemia, and may improve visual function in patients with this common vascular eye disease.

Vitrectomy requires the substitution of the natural vitreous, as well as tamponading of retinal breaks. Clinically available alternatives such as gas and silicone oil have side effects such as inflammation, secondary glaucoma, cataract, 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.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 Healaflow(®). Clinical evaluation, measurement of intraocular pressure (IOP), and full-field ERG were performed postoperatively. 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 immunohistochemistry.Healaflow(®) was successfully used with standard surgical procedures and remained translucent but did lose most of its viscosity during the postoperative period. One rabbit was lost due to unrelated causes. In two eyes iatrogenic partial retinal detachments were seen, and in two eyes significant cataract developed due to intra-operative complications. ERG-recordings revealed no toxic effect on rod or cone function. Routine microscopy and immunohistochemistry demonstrated normal morphology with some Müller cell activation (up-regulation of glial acidic fibrillary protein, GFAP) compared to unoperated eyes and no significant DNA-fragmentation (TUNEL-assay).Healaflow® did not affect retinal morphology or function negatively during long-term use as a vitreous substitute, making it highly interesting in this setting. An estimated retention time of a few weeks suggests potential for use as a short-term tamponade. Future work will include an increased ratio of cross-linking to prolong the structural integrity of the gel.

Purpose: To determine bacterial eradication using numerous riboflavin concentrations and different ultraviolet light A (UVA) radiant and exposure time in an experimental model. Methods: Dilutions of Staphylococcus epidermidis were mixed with riboflavin at varying concentrations (0.007–0.09%). Effects on bacterial growth were evaluated after 0, 3, 6, 30 and 60 min of UVA exposure (irradiance 30 and 3 mW/cm 2 ). Standard settings of UVA were compared with high-power UVA approach. Different fluid thicknesses of the exposed dilutions were also examined to improve the model. Results: Bacterial eradication (%) was increased after 60 compared with 30 min of UVA exposure for concentrations of 0.03–0.07% but not for 0.09% riboflavin. There was a significant difference between the efficacy between 0.03 and 0.09% and eradication dropped from 80% to 50% (p = 0.01). A correlation could be calculated for the amount of riboflavin at 60 min of UVA and the ability to kill bacteria (p = 0.01). The antibacterial effect was more pronounced when the tested bacterial suspension thickness was reduced. High-power UVA method was less potent in microbial elimination, eradicating only 60% of bacteria after 6 min versus 97–99% after 60 min in the low-power setting, compared with respective controls (p = 0.02). Conclusions: In these in vitro experiments, a longer UVA exposure time in combination with lower riboflavin levels were found to be favourable in killing bacteria as compared to the standard cross-linking settings. Further studies are needed to evaluate the clinical relevance of these findings.

Purpose: To investigate photoreceptor survival in transplantation of non-cultured iris pigment epithelial (IPE) cells to the subretinal space in a prospective experimental study. Methods: Upper iridectomies were carried out in the right eyes of 37 pigmented rabbits. Suspensions of freshly harvested autologous IPE cells (without culturing) were prepared and injected into the subretinal space of the same eye. Follow-up examinations were carried out using ophthalmoscopy and colour fundus photography. The rabbits were killed at 1, 2, 3 and 6 months, respectively, and the eyes examined with light and electron microscopy. Results: On histological examination, the photoreceptor cells were found to be well-preserved in grafted areas at 1–3 months. At 6 months, the photoreceptors generally disclosed a normal nuclear layer and long outer segments when overlying areas with single cells or clusters of transplanted IPE cells. Multilayers of cells in abundance, including native RPE cells and macrophages (stained with RAM 11), particularly under microfolds of the neural retina, were occasionally associated with photoreceptor damage and nuclear drop out from the outer retinal layer. There was no inflammatory response in the choroid and the choriocapillaris remained patent. Conclusion: The experiments show that grafting freshly harvested autologous IPE cells to the subretinal space is feasible and that the photoreceptors generally survive for at least 6 months when overlying the transplanted areas. Multilayers of abundant cells in the subretinal space may induce adverse focal effects on adjacent photoreceptors.

Purpose: To describe a new model for in vitro assessment of novel vitreous substitute candidates. Methods: The biological impact of three vitreous substitute candidates was explored in a retinal explant culture model; a polyalkylimide hydrogel (Bio-Alcamid®), a two component hydrogel of 20 wt.% poly (ethylene glycol) in phosphate buffered saline (PEG) and a cross-linked sodium hyaluronic acid hydrogel (Healaflow®). The gels where applied to explanted adult rat retinas and then kept in culture for 2, 5 and 10 days. Gel-exposed explants were compared with explants incubated under standard tissue culture conditions. Cryosections of the specimens were stained with hematoxylin and eosin, immunohistochemical markers (GFAP, Vimentin, Neurofilament 160, PKC, Rhodopsin) and TUNEL. Results: Explants kept under standard conditions as well as PEG-exposed explants displayed disruption of retinal layers with moderate pyknosis of all neurons. They also displayed moderate labeling of apoptotic cells. Bio-Alcamid®-exposed explants displayed severe thinning and disruption of retinal layers with massive cell death. Healaflow®-treated explants displayed normal retinal lamination with significantly better preservation of retinal neurons compared with control specimens, and almost no signs of apoptosis. Retinas exposed to Healaflow® and retinas kept under standard conditions showed variable labeling of GFAP with generally low expression and some areas of upregulation. PEG-exposed retinas showed increased GFAP labeling and Bio-Alcamid®-exposed retinas showed sparse labeling of GFAP. Conclusions Research into novel vitreous substitutes has important implications for both medical and surgical vitreoretinal disease. The in vitro model presented here provides a method of biocompatibility testing prior to more costly and cumbersome in vivo experiments. The explant culture system imposes reactions within the retina including disruption of layers, cell death and gliosis, and the progression of these reactions can be used for comparison of vitreous substitute candidates. Bio-Alcamid® had strong adverse effects on the retina which is consistent with results of prior in vivo trials. PEG gel elicits reactions similar to the control retinas whereas Healaflow® shows protection from culture-induced trauma indicating favorable biocompatibility., Swedish Research Council, University of Lund. Medical Faculty, Princess Margaret's Foundation for Blind Children, Knut and Alice Wallenberg Foundation, General Sir John Monash Foundation (Scholarship), In Vivo Therapeutics Corporation

Aging of vitreous involves a degenerative process where glycosaminoglycans (GAGs) dissociate from collagen and the gel disintegrates into fluid adjacent to which collagen fibrils adhere to each other and cross-link [1–4]. In most eyes this process is accompanied by dehiscence at the vitreoretinal interface progressing to posterior vitreous detachment and nothing more happens [see chapter II.C. Vitreous aging and posterior vitreous detachment]. In several pathologic conditions, vitreous is hazy due to hemorrhage and/or cell proliferation forming membranes that contract, leading to traction retinal detachment [see chapters III.J. Cell proliferation at the vitreo-retinal interface in proliferative vitreo-retinopathy and related disorders; III.L. Proliferative diabetic vitreo-retinopathy]. Vitreoretinal surgery for these conditions includes complete removal of the vitreous gel (Figure I.F-1), removal of pre- and subretinal membranes, and injection of a tamponade such as silicone oil or expanding gases. All the presently used intravitreal tamponade substances carry different side effects making them unsuitable for permanent or long-standing use. Many authors [5–9] have suggested an ideal single artificial vitreous gel covering all needs, but no gel has yet been found to fit these demands [10].

Purpose: To investigate the cellular morphology in the subretinal space following transplantation of iris pigment epithelial (IPE) cells from the same eye. Methods: Following an iridectomy, fresh IPE cells were prepared and no culturing performed. After pars plana vitrectomy, a suspension of autologous IPE cells was injected into the subretinal space in 37 rabbits. The grafts were monitored by ophthalmoscopy and colour fundus photography. Rabbits were sacrificed at 1, 2, 3 and 6 months, respectively, and the eyes examined with light and electron microscopy. Results: The grafted area retained the same configuration over 6 months but then appeared less pigmented. At 1‐3 months, the IPE formed one or more contiguous layers on top of native RPE. At 6 months, cells compatible with grafted IPE were present in the subretinal space, often forming monolayer-like chains integrating with the native RPE. Depigmented cells of presumed IPE origin were seen and frequently in association with abundant melanin granules located in the apical portion of adjacent RPE cells. In such areas, large macrophage-like cells were observed. Conclusion: Transplanted IPE cells survived for up to 6 months in the subretinal space. Our observations suggest a scenario of remodelling of the cellular layers in the subretinal space over time where grafted IPE cells formed a compound layer with the native RPE. Transplantation of autologous IPE cells may have a potential as a treatment modality in selected cases of age-related macular degeneration.

A dysfunction of the retinal pigment epithelium (RPE) is the main cause for the development of age-related macular degeneration (ARMD) and visual loss in elderly people. For about 10 years experimental and clinical attempts to transplant RPE cells have been performed. The aims of this study were to elucidate the long term results of RPE allografts, to develop an atraumatic transplantation technique, and to explore the cellular response to RPE allografts, melanin granules, and autologous IPE cells.Surgery was performed on rabbits with a follow-up period of up to six months. After a pars plan vitrectomy, a subretinal bleb was created into which a suspension of RPE/IPE donor cells or melanin granules was injected. Pigmented RPE donor cells or preparations of melanin granules were implanted subretinally in albino rabbits. Pigmented rabbits were used in IPE transplantation. The eyes were monitored with ophthalmoscopy, fundus photography, light microscopy, electron microscopy and immunohistochemistry.Transplantation of suspensions of fresh pigmented RPE cells to the subretinal space in rabbits is feasible and induces virtually no complications when an atraumatic surgical procedure is used. The allograft forms a monolayer in conjunction with the native RPE and persists almost intact up to three months. At six months after transplantation, there was a cellular response exhibiting multilayers of cells, such as RPE and macrophages. Damage to adjacent photoreceptors in combination with melanin granules in the subretinal space indicates graft failure. No infiltration of lymphocytes was seen. Whether the cellular response was due to immunological or non-immunological mechanisms could not be determined from this experiment.Cyclosporine (CsA) could not prevent disintegration of the RPE transplant and graft failure. CsA was not capable of promoting graft survival as compared to the controls. The transplant seems to be disrupted either by immunological mechanisms that are not inhibited by CsA, or by non-immunologic events.Implantation of melanin granules to the subretinal space of albino rabbits induces a considerable phagocytic cellular response involving the host’s RPE, macrophages and glial cells. The migration of pigment-laden cells into the neural retina was frequently associated with focal photoreceptor damage. The cellular response was identical to that ensuing RPE cell transplantation. These findings support the concept that non-immunological events have a considerable influence on the outcome.In order to evaluate the impact of non-immunological mechanisms, a technique of transplanting fresh autologous IPE cells to the subretinal space of the same eye was developed. Grafted IPE cells were seen to survive for six months. There was a remodeling of the compound cellular layers in the subretinal space over time where grafted IPE cells joined the native RPE cells. The cellular response that developed exhibited macrophages, but no lymphocytes, and was in this respect similar to that observed following RPE transplantation.In RPE allografts, the photoreceptors appeared normal on light microscopy at three months, but at six months, the photoreceptors overlying the transplants generally exhibited pathological changes. In autologous IPE grafts, on the other hand, the photoreceptors displayed normal outer segment length and outer nuclear layer on top of grafted IPE cells. Focally, multilayers of both grafted IPE and RPE cells, together with macrophages, induce damage to adjacent photoreceptors as observed at 6 months. Cellular multilayers in the subretinal space, irrespective of genesis, are likely to have adverse effects on photoreceptors. The experiments using autologous IPE grafts show that non-immunogenic mechanisms have a decisive impact on the outcome of the transplant in the subretinal space.

Purpose: To determine the long-term RPE allograft survival in the subretinal space using suspensions of RPE cells and atraurnatic transplantation surgery.Methods: Nineteen albino rabbits were trans ...

Operative treatment for macular holes often includes the filling of the eye with air or expanding gas. It is considered important for the patients to maintain the face-down position as much as possible during the first two weeks immediately postoperatively. The patients usually realise the importance of the procedure, but may find it difficult to comply to the instructions because of boredom, with few activities adapted for the face-down position. Specially adapted mattresses with a hole cut for the face allow reading, for example, and television sets may be placed on the floor with the screen pointing upwards. Walking, however, presents a problem for these patients.

Response to : evaluation of combined riboflavin and ultraviolet A as an alternative treatment for keratitis

To investigate inter-reader agreement on five severity levels of central vascular changes (none, mild, moderate, severe pre-plus disease, plus disease) and aggressive posterior retinopathy of prematurity (ROP), and to see whether an unintended shift in indication for treatment occurred.Four international ROP readers participated. Before the grading of the photographs, the readers were informed that a high proportion of advanced ROP cases were included. In total, 243 photographs/948 quadrants were available from 136 infants. As a standard series of photographs was available, grading was performed under optimised conditions.The four readers agreed on the quadrant scores of only 70 (7.38%) of the 948 quadrants--that is, on 1, 5, 15, 4 and 45 quadrants for scores 0, 1, 2, 3 and 4, respectively. The mean scores differed systematically between the readers (permutation test, p0.0001). Agreement on presence of aggressive posterior ROP from all four readers was not obtained for any of the photographs. Readers scored plus disease in at least two quadrants in 95.5% of the eyes for which treatment was indicated. All four readers agreed on the scoring of indication for treatment for 195 eyes (80.2%); however, treatment was only recommended in 18 (7.4%) eyes. One reader was found to differ systematically from the others in indicating treatment (Rasch analysis; p=0.0001). Finally, a significant shift in indication for treatment occurred between birth period 2000-2002 and 2003-2006 (Mann-Whitney rank sum test, p0.001).Inter-reader agreement on central vascular changes is poor, especially when based on more than two rating categories. The subjective nature of diagnosing such vascular changes possibly resulted in earlier treatment of preterm infants in Denmark over the entire study period (1997-2006). The recent increased incidence of treated infants in Denmark is, at least in part, explained by a significant shift in indication for treatment.

The aim of this study was to employ an experimental protocol for in vivo evaluation of sols of 5 wt.\% poly(ethylene glycol) (PEG) in phosphate buffered saline (PBS) as artificial vitreous substitutes. A 20 gauge pars plana vitrectomy and posterior vitreous detachment were performed in the right eye of 8 pigmented rabbits. Approximately 1 mL of the viscoelastic PEG sols were then injected into the vitreous space of 6 eyes. PEG with an average molecular weight of 300,000 g mol(-1) and 400,000 g mol(-1) was used in 2 and 4 eyes respectively. Two eyes received balanced salt solution (BSS) and served as controls. Full-field electroretinography (ERG) and intraocular pressure (IOP, palpation) was measured pre-and post-operatively at regular intervals up to 41 days. The rabbits were sacrificed and the eyes were examined by retinal photography, gross macroscopic examination and histology. The viscoelastic sols were successfully injected and remained translucent throughout the postoperative period, with some inferior formation of precipitates. None of the eyes displayed IOP elevation postoperatively, but in 3 of the PEG sol injected eyes, transient hypotony was noted. One eye sustained a retinal detachment during surgery and another 2 in the postoperative period. ERG recordings confirmed preservation of retinal function in 3 out of 4 eyes injected with 400,000 g mol(-1) PEG. Histological examination revealed upregulation of glial acidic fibrillary protein (GFAP) in Müller cells in PEG sol injected eyes, but normal overall morphology in eyes with attached retinas. The viscosity of the sol was not retained throughout the postoperative period, indicating the demand for polymer crosslinking to increase residence time. The results provide promising preliminary results of the use of PEG hydrogels as a vitreous substitute.

To evaluate polyalkylimide as a possible vitreous tamponading agent. A 20-gauge pars plana vitrectomy and posterior vitreous detachment were performed in the right eye of six pigmented rabbits. Approximately 1 ml of viscoelastic gel, polyalkylimide (Bio-AlcamidA (R)) was thereafter injected into the vitreous space. Full-field ERG and intraocular pressure (IOP, Tonopen) was measured pre-and postoperatively at regular intervals up to 28 days. At day 6 or 28, the rabbits were sacrificed and the eyes were examined macroscopically, photographed, and prepared for histological examination with routine microscopy. The viscoelastic hydrogel was successfully injected, and remained translucent with preserved gel properties throughout the postoperative period. The postoperative IOP was unchanged compared to preoperative values. Five of six eyes displayed retinal edema or pigmentary changes centrally while the periphery appeared intact. ERG recordings showed a radical decrease in rod- and cone-derived B-wave amplitudes. Histological examination confirmed varying degrees of edema combined with neuronal cell death within the retinal layers in the central part of the fundus, while the peripheral part appeared intact. Polyalkylimide displays favourable physical properties when used as a vitreous tamponade. However, the hydrogel causes functional and morphological retinal damage when in direct contact with the inner retina. Possible pathological mechanisms include osmotic imbalance and direct toxic effects, and modification of biochemical properties is warranted before clinical use will be possible.

Purpose: Floaters caused by degenerative or postoperative changes in the vitreous can interfere with all aspects of visual functioning. The aim of this study is to report the longterm outcome of pars plana vitrectomy (PPV) for persistent vitreous opacities. Methods: In a retrospective, non-randomized, interventional case study we reviewed all cases of vitreous floaters that were vitrectomized at our department between 1997 and 2006. Patient complaints and satisfaction were assessed by a questionnaire administered at the end of follow-up. Results: Seventy-three consecutive cases were included (61 patients). Mean Snellen best corrected visual acuity (BCVA) before surgery was 0.81. Overall, 85% of patients complained of severe or very severe difficulty caused by floaters. A total of 42% of eyes were pseudophakic, four of which were operated with combined PPV and phacoemulsification. Mean follow-up time was 37 months. Of the phakic eyes, 60% were operated for cataract during follow-up. One retinal detachment (RD) occurred immediately postoperatively (1.3%) and another four eyes developed RD during longterm follow-up 24–44 months after PPV (5.5% of cases). Postoperative BCVA remained mostly unchanged. Overall, 88% of patients were satisfied with the results of the operation. Conclusions: Some patients make considerable complaints as a result of vitreous opacities and their distress does not correlate with visual acuity. Vitrectomy is a safe and effective procedure with which to help these patients. Patients should be informed about the risk of cataract progression, unexpected inflammatory reaction and an increased risk for RD several years after PPV (5.5%).

Background: Age-related macular degeneration (AMD) is associated with degeneration and subsequent loss of the retinal pigment epithelium (RPE). Transplantation of allogeneic RPE cells seems to induce graft rejection. Therefore, autotransplantation was suggested. Iris pigment epithelial cells (IPE) are embryologically similar to RPE.

Purpose: To compare the visual outcome after surgical removal of subfoveal choroidal neovascularization (CNV) in patients younger and older than 50 years of age. Methods: Patient records from all Swedish centers performing submacular CNV surgery were reviewed and 90 patients treated between 1992–1999 with a follow-up of 6 months or more were included. The results obtained in 49 patients aged 51–89 years (median=72 years) with neovascular disease caused by age-related macular degeneration (AMD) were compared with the outcome of 41 patients aged 6–49 years (median=36 years) with CNV secondary to non-AMD causes. The main outcome measure was the improvement or deterioration in visual acuity (standardized in logMAR units) at 6 months following surgery. Secondary endpoints were recurrent CNV and surgical complications. Results: The level of preoperative visual acuity was not significantly different between younger patients with CNV associated with non-AMD and older patients with visual loss due to AMD (p=0.069). However, visual acuity at 6 months after surgery was better (p=0.0042) in younger patients (median improvement=0.19 logMAR) than in older patients (median improvement=0.0 log MAR). Marked visual improvement (>1 log MAR unit) was seen in 29% of non-AMD patients 50 years. Conclusion: Surgical removal of submacular CNV does not appear to improve visual acuity in patients > 50 years of age. However, it may be beneficial for younger patients where a substantial improvement of visual acuity is seen in a subset of these patients. Further studies are required to assess the long-term outcome.

Tinted sodium hyaluronate (Healon® Yellow) was used during posterior segment surgery mainly for the dissection of epiretinal membranes in cases of proliferative diabetic retinopathy and macular pucker. The yellow color facilitated injecting the viscoelastic substance under the membranes and simplified its removal at the end of surgery.

Background: In some retinal diseases and following transplantation of retinal pigment epithelium (RPE), melanin granules are liberated to the subretinal space. Our aim was to investigate the cellular response to implanted extracellular melanin. Methods: After pars plana vitrectomy, 17 albino rabbits received a suspension of melanin granules in the subretinal space. Postoperative examination included ophthalmoscopy, color fundus photography, histology using monoclonal antibodies identifying RPE cells (AE1/3), macrophages (RAM 11), B-lymphocytes (CD20) and T-lymphocytes (CD45), and electron microscopy. The follow-up time was 2 weeks, 4 weeks and 6 months. Results: On fundus photographs, the layer of melanin showed focal attenuation with lighter areas at 6 months. Melanin granules were phagocytosed by RPE cells and macrophages at 2 weeks, as identified by monoclonal antibodies. In areas where an abundance of melanin was present, multilayers of macrophages were seen associated with considerable photoreceptor damage. Pigment-laden cells invaded the neural retina. The cellular infiltration of the retina was focal, and when it involved the outer nuclear layer the photoreceptor damage was severe. Electron microscopy demonstrated the presence of melanosomes intracellularly in Muller glia. The process of phagocytosis and removal of melanin granules from the subretinal space was slow and not completed at 6 months. Conclusion: Our experiments show that implantation of melanin granules in the subretinal space of albino rabbits may induce a considerable phagocytic cellular response featuring the host’s RPE, macrophages and glial cells. The migration of pigment-laden cells into the neural retina was associated with focal photoreceptor damage.

Purpose: Macular pucker patients were re-examined 16–90 months after surgery (mean 72 months) to evaluate visual acuity, metamorphopsia, and complications, with particular reference to cataract development. Surgery had been performed on 48 eyes in 46 patients, 31 eyes having a primary, and 17 eyes a secondary macular pucker. Results: At the 6-month control 65% of the eyes with a primary macular pucker and 35% of the eyes with a secondary macular pucker exhibited an improved visual acuity defined as doubling or more of the visual angle. At the last control 57% of the primary group and 33% of the secondary group had a visual acuity which still exceeded the preoperative value. At the final examination a cataract progression was observed in 22/28 (79%) of the primary group and 8/14 (57%) of the secondary group. In the primary group 11% and in the secondary group 36% of the eyes suffered a retinal detachment. All cases were successfully treated and none were followed by visual deterioration. Conclusion: The improvement in visual quality after macular pucker surgery appears to be long-standing, if not permanent, especially in primary cases. In those eyes in which a decrease in visual acuity is observed, the most frequent cause is cataract development.

Healon®, a viscoelastic preparation of Sodium hyaluronate, has been reported effective in posterior segment surgery for dissection of epiretinal membranes, i.e. proliferative diabetic retinopathy and macular pucker. A more viscous substance might be more effective for this kind of surgery. Therefore, a new Sodium hyaluronate preparation Healon® GV with a ten times greater viscosity at rest than Healon®, was tested in and open clinical study. Twenty-four patients of both sexes and not younger than 18 years were enrolled. The follow-up time was three months. The main indications for using Healon® GV were: to separate membranes from the retina, to stop bleeding and to reposition a detached retina. 0.2–0.5 ml of Healon® GV was injected through a 27 gauge bent cannula and at close of surgery irrigated out of the eye. Postoperatively the patients were monitored concerning intraocular pressure, vitreous clarity, anterior chamber flare and visual acuity. Healon® GV was found to make the surgical procedure simpler and safer. No inflammatory reaction and no increase of IOP was observed.

Between 1987–89 fifteen premature infants with severe retinopathy of prematurity (ROP), at the age of ten months or less, were admitted as outpatients to the Department of Ophthalmology at the Orebro Medical Center Hospital. Initial examination of the infants showed that 6 eyes had stage 3+, 3 eyes had stage 4 B and 21 eyes had stage 5 ROP. All 15 infants were born at gestational week 24–28 (mean value 26) and had a birth weight between 600 and 1310 g (mean 907 g). For stage 3+ cryotherapy was performed. For stage 4 B and 5 buckling procedure and vitreous surgery was performed in an attempt to re-attach the retina. The children were followed 2–5.5 years. Postoperatively, the retinas of all eyes in stage 3+ and 4B were attached. Four retinas out of seventeen stage 5 eyes were later found to be centrally re-attached. One eye with stage 3+ and four eyes with stage 5 were not treated at all. At follow-up of stage 3+ and 4B, visual acuity was measurable in all eyes; in stage 5 only two out of four eyes with anatomically reattached retinas had perception of light.

A dysfunction of the retinal pigment epithelium (RPE) is the main cause for the development of age-related macular degeneration (ARMD) and visual loss in elderly people. For about 10 years experime ...

In eyes with retinal detachment and a horseshoe break, vitreous traction on the retina has been relieved by severing the flap of the break with the aid of the Q-switched Nd:YAG laser. The retina often flattens in eyes with shallow retinal detachment after this treatment; the breaks then can be sealed off with argon laser. In cases of retinal detachment treated with expanding gas, fewer recurrences were observed when vitreous traction had been relieved by Nd:YAG laser treatment.