Intraoperative Posterior Chamber Irrigation to Enhance Vitreous Cavity Support during Phacoemulsification Cataract Surgery after VitrectomyRead the full article
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The Correlation between Corneal Findings and Disease Severity in Keratoconus per Scheimpflug Corneal Tomography
Purpose. This study aims to correlate the clinical signs of keratoconus (KC) which include superficial apical scarring, Fleischer rings, and Vogt striae with best spectacle-corrected visual acuity (BSCVA) and corneal tomography findings. Patients and methods. A retrospective observational study. 72 consecutive KC patients seen by the senior author over the course of one year were included in this case series. Eyes with pellucid marginal degeneration, postrefractive ectasia, history of a corneal graft, prior corneal collagen cross-linking, intracorneal ring segments or hydrops were excluded from analysis. Subsequently, the final analysis included only treatment-naïve KC eyes with varying degrees of disease severity. Results. BSCVA with manifest refraction was 0.5 logMAR higher in eyes with apical scarring (). Eyes with apical scarring had worse vision than eyes with Fleischer rings alone (0.43 logMAR higher in the former, ). Eyes with apical scarring had higher keratometry readings (K2 = 64.56 ± 12.89 D versus 49.07 ± 6.61 D, ); this was also true for eyes with Fleischer rings compared with ring-free eyes (K2 = 56.23 ± 11.52 D versus 48.91 ± 7.79 D, ) and eyes with Vogt striae (K2 = 56.19 ± 10.27 D versus 50.68 ± 9.21 D, ). Atopic disease was a risk factor for scarring: odds ratio (OR) = 2.87 (). The OR of observing Fleischer rings in KC eyes was 12% per year (). Additionally, each mm of corneal apex displacement from the pupillary center led to a 0.76 logMAR increase in visual acuity (). Conclusion. The presence of apical scarring and Fleischer rings on biomicroscopy can aid the clinician in making the distinction between severe or long-standing disease (respectively). Apical scarring is a sign of advanced disease and is associated with worse BSCVA and tomography findings. Fleischer rings are markers of intermediate disease and their presence correlates with disease duration.
Seven-Year Visual and Anatomical Outcomes of Intravitreal Vascular Endothelial Growth Factor Inhibition for Neovascular Age-Related Macular Degeneration
Purpose. To evaluate 7-year visual and anatomical outcomes of intravitreal injections (IVI) with antivascular endothelial growth factor (anti-VEGF) for neovascular age-related macular degeneration (nAMD) based on a personalized pro re nata (PRN) regimen. Methods. Anonymized data of 124 consecutive eyes in 121 patients with treatment-naïve nAMD were initially collected in 2010. Of those, 45 received anti-VEGF IVI at least every 6months until 2017 in one single center in Austria and hence were retrospectively analyzed. All eyes had been initiated on a loading dose of 3 monthly IVI with different anti-VEGF agents followed by a PRN regimen in the first year. At year 2, monitoring as well as therapeutic intervention could be prolonged every 2weeks up to intervals of 3months without capping treatment. Primary outcome measure was the change of visual acuity (VA) assessed by Early Treatment Diabetic Retinopathy Study charts at 4 meters (ETDRS) in letters—counting every correctly read letter—and converted to Snellen. Secondary outcome measures were number of injections and change of central retinal thickness (CMT) from baseline. Results. Mean baseline VA was 20/63 + 1 (0.63 ± 0.26 ETDRS) and declined to 20/100 + 2 (0.45 ± 0.33) with an overall loss of 9 letters ETDRS after 7years (p = 0.001). An average of 3.5 ± 1.9 IVI was given per year and eye. Mean CMT at baseline was 322 ± 95 μm, decreased by 52 μm to 270 ± 70 μm within the first year, and remained below baseline at year 7 (271 ± 106 μm; ). Conclusions. Our data confirm an absolute vision loss in eyes compromised by nAMD after 7 years of continuous VEGF inhibition. The visual decline was significantly related to baseline VA as well as the number of injections. We suggest following patients thoroughly independent of the initial VA and a greater incentive for the physician to treat.
Amniotic Membrane as a Main Component in Treatments Supporting Healing and Patch Grafts in Corneal Melting and Perforations
Purpose. To report on surgical approaches using amniotic membrane applications and patch grafts in corneal melting and perforations. Anatomical and functional results, including advantages and disadvantages of the interventions, will also be explored. Methods. A five-year retrospective analysis of 189 surgical treatments involving corneal melting with perforation was performed. In one evaluated treatment type, a graft of amniotic membrane, often folded one to three times, was sutured with the epithelial side facing the previously mechanically debrided corneal tissue. A larger monolayer amniotic patch was then sutured, with the epithelial side facing the top of the first membrane, to the perilimbal conjunctiva. For corneal patch grafts, the size-fitting technique of graft trephination was applied, and the donor-recipient junctions were sewn with interrupted sutures. All the procedures were evaluated, noting outcomes and complications of surgery, preoperative and postoperative visual acuities, postoperative intraocular pressures, graft rejection, and other late comorbidities and complications. Results. We performed 119 amniotic membrane applications (63%) and 70 corneal patch grafts (37%). Anatomical reconstruction of the anterior chamber was achieved in 157 eyes, of which 102 eyes (86%) received an amniotic membrane and 55 eyes (79%) were treated with the patch graft technique. In 63 eyes (33%), more than one amnion or graft treatment was necessary to close the corneal perforation. Conclusions. The success of medical and surgical management depends on the cause of corneal melting, and amniotic membrane applications often require further intervention; nevertheless, patch grafts deliver better tectonic reconstruction than amniotic membrane alone.
Incidence and Risk Factors of Iatrogenic Retinal Breaks: 20-Gauge versus 25-Gauge Vitrectomy for Idiopathic Macular Hole Repair
Purpose. We compared the incidences of iatrogenic retinal breaks and postoperative retinal detachment between eyes that underwent 20-gauge vitrectomy and those that underwent 25-gauge vitrectomy for idiopathic macular hole repair. Methods. This retrospective nonrandomized consecutive observational case series included 185 eyes of 183 patients (130 eyes of 129 patients and 55 eyes of 54 patients in the 20- and 25-gauge groups, respectively). We assessed the relationship between the incidence of retinal breaks and postoperative retinal detachment and related this to posterior vitreous detachment and lattice degeneration. Results. The incidences of iatrogenic retinal breaks were 36.9% and 12.7% in the 20-gauge and 25-gauge groups, respectively. These groups did not differ in their respective frequencies of posterior vitreous detachment (the 20-gauge group: 31.5% and the 25-gauge group: 27.3%) and lattice degeneration (the 20-gauge group: 14.6% and the 25-gauge group: 7.3%). Among eyes without lattice degeneration, the 20-gauge group showed a higher incidence of iatrogenic retinal breaks than the 25-gauge group. However, among the eyes with lattice degeneration, the frequency of retinal breaks did not differ between the two surgery types, and four cases of postoperative retinal detachment were reported in both groups. Conclusions. The incidence of retinal breaks related to idiopathic macular hole surgery is higher among patients undergoing 20-gauge vitrectomy than among those undergoing 25-gauge vitrectomy. Posterior vitreous detachment and lattice degeneration are associated with considerably increased incidences of retinal break.
Intravitreal Injections for Macular Edema Secondary to Retinal Vein Occlusion: Long-Term Functional and Anatomic Outcomes
Purpose. To report the long-term visual and anatomic outcomes of intravitreal injections for macular edema (ME) secondary to retinal vein occlusion (RVO) in a real-life clinical setting. Design. Retrospective interventional case series. Methods. A total of 223 consecutive eyes with ME secondary to RVO, treated with the first three intravitreal Ranibizumab or dexamethasone injections between August 2008 and September 2018, were enrolled in the study. Subsequent retreatment was guided by best-corrected visual acuity (BCVA) and central macular thickness (CMT) measurements, aimed at achieving macular fluid regression and BCVA stability. BCVA and CMT were recorded at baseline and at subsequent annual time points. The mean number of injections administered each year and the incidence of adverse events were recorded. Results. The mean BCVA and CMT at baseline were 0.79 logMar (SD 0.71) and 615.7 μm (SD 257.5), respectively. The mean follow-up (FU) period was 47.8 months (min 12–max 120). At 12 months, the mean BCVA and CMT had significantly improved to 0.62 logMar (SD 0.68; ) and 401.04 μm (SD 183.8; ). Improvements remained significant at the final FU visit. Eyes with BRVO and nonischemic RVO showed significantly better visual outcomes when compared to eyes with CRVO and ischemic RVO, over the entire FU period. An average of 4.08 (SD 2.1) Ranibizumab and 1.5 (SD 0.6) Ozurdex injections were administered over the first 12 months. The number of injections decreased thereafter progressively. One eye with CRVO developed endophthalmitis and one with BRVO developed an intraocular pressure increase that was refractory to topical medications and ultimately treated with trabeculectomy. Conclusion. Intravitreal Ranibizumab and/or dexamethasone injections were found to be effective at inducing a long-lasting improvement of BCVA and CMT in a real-life clinical setting. A safety profile similar to that already well-established in Ranibizumab and dexamethasone treatment was observed, as well as a steady decrease in the number of intraocular injections required. The results support intravitreal treatments for BRVO and CRVO in patient populations with similar characteristics in similar settings.
Clinical Investigation into Posterior Capsule Rupture in Phacoemulsification Operations Performed by Surgery Trainees
This retrospective cohort study investigated the occurrence rate, correlative factors, and prognosis of posterior capsule rupture (PCR) in phacoemulsification operations conducted by surgery trainees. This study assessed the first 200 phacoemulsification surgeries performed by six surgery trainees between August 2016 and December 2018. Cases were divided into two groups depending on whether they fell within the first 100 surgeries performed by a trainee (first 100 cases group) or the last 100 surgeries (last 100 cases group). The following clinical data were analyzed: the occurrence rate of PCR, whether this complication arose in the phaco or irrigation/aspiration (IA) phase, the occurrence of vitreous loss, retinal detachment, and dropped nucleus, the site of intraocular lens (IOL) implantation, and postoperative visual acuity. Thirty-nine of the 1200 cases (3.25%) experienced PCR. The occurrence rates of PCR and vitreous loss were higher in the first 100 cases group than in the last 100 cases group ( and ). PCR occurred more frequently in the phaco phase in the first 100 cases group and in the IA phase in the last 100 cases group (). There was no difference between the two groups in terms of site of IOL implantation, the occurrence of retinal detachment or dropped nucleus, and postoperative visual acuity. With a supervising surgeon and the selection of suitable cases, the occurrence rate of PCR in phacoemulsification operations performed by surgery trainees could be controlled to the desired level. The phase in which PCR most frequently occurred and the likelihood of vitreous loss differed depending on the level of surgical experience of the trainees. It is a lengthy process for surgery trainees to reach the stage at which they can manage PCR and complex cataract surgery independently.