Neodymium: YAG laser vitreolysis for treatment and prophylaxis of cystoid macular oedema

Eighteen eyes with vitreous strands adherent to the corneoscleral wound of previous cataract surgery were treated with neodymium: YAG laser to achieve vitreolysis. Twelve eyes were treated for management of cystoid macular oedema (CMO group) and six eyes were treated for prophylaxis of possible CMO (prophylactic group). In the CMO group, visual acuity improved two or more Snellen lines in 10 eyes (83.3%) and seven eyes had a post–laser visual acuity of 20/40 or better (one eye had a pre–treatment visual acuity of 20/40 or better). In the prophylactic group, visual acuity was either maintained at the pre–treatment level or improved in five eyes (83.3%) eighteen months after laser treatment. This procedure was complicated by retinal detachment in one case and elevation of intraocular pressure over 10 mmHg in another case.     

特发性黄斑裂孔治疗进展

特发性黄斑裂孔(idiopathic macular hole,IMH)是指原因不明、发生于黄斑区域视网膜神经上皮层的全层组织缺损。早期直径较小的IMH可以进行观察随访,玻璃体切割术联合视网膜内界膜(internal limiting membrane,ILM)剥除术是目前主要的治疗方法,ILM手术方式的不断改进和创新,使IMH的治疗方法多样化、成熟化。目前药物玻璃体溶解术(pharmacological vitreolysis)、气体玻璃体溶解术(pneumatic vitreplysis)的应用对IMH的预防及治疗有着广阔的前景。本文就IMH的治疗方法作一综述。     

Vitreomacular traction syndrome: a comparison of treatment with intravitreal plasmin enzyme vs spontaneous vitreous separation without treatment

Purpose

To evaluate the effects of intravitreal autologous plasmin enzyme (APE) in patients with focal vitreomacular traction (VMT).

Methods

APE was obtained by incubation of patient-derived purified plasminogen with streptokinase, and intravitreally injected 5–12 days later. Twenty-four hours after injection, in case of incomplete VMT release, a pars plana vitrectomy was performed. The hyaloid internal limiting membrane adherence and removal of the posterior hyaloid were intraoperatively evaluated.

Results

Thirteen patients were recruited. During preparation of APE, five patients had spontaneous release of VMT. Eight patients received APE injection (2 IU). In five patients, spontaneous resolution of VMT occurred before APE administration. Twenty-four hours after injection, persistence of VMT was detected in all the eight treated patients. Best-corrected visual acuity was 0.51±0.37 LogMAR at baseline, improving to 0.23±0.14 LogMAR at 6 months (P=0.002). Foveal thickness was 464±180 μm at baseline, reducing to 246±59 μm at 6 months (P<0.001). Hyaloid was intraoperatively judged ‘partially detached'' in seven cases and ‘totally detached'' in one case. Hyaloid peeling was evaluated ‘easy'' in six eyes and ‘very easy'' in two eyes.

Conclusions

In the current study, there was a large percentage of spontaneous resolution of VMT before an APE administration. A single intravitreal APE injection seems insufficient to induce a complete posterior vitreous detachment in these patients.     

The vitreomacular interface in retinal vein occlusion

Purpose: To evaluate the posterior vitreous adhesion status in patients with a history of central or branch retinal vein occlusion and to compare the results with the natural time‐course of posterior vitreous detachment in healthy age‐related controls. Methods: A retrospective chart review in terms of the posterior vitreous adhesion status was performed in 132 patients (133 eyes) with a history of a central (CRVO) or branch (BRVO) retinal vein occlusion. All patients underwent vitrectomy. Based on the operation reports, the vitreous adhesion status was classified as attached, partially detached or completely detached. The results were compared to the natural time‐course of posterior vitreous detachment development in healthy age‐related controls. Results: Eighty‐one eyes met the inclusion and exclusion criteria. Fifty‐two eyes (64%) had a history of CRVO and 29 eyes (36%) a history of BRVO, respectively. In the CRVO group, the posterior vitreous was attached in 47 eyes (90%) and completely detached in five eyes (10%). In the BRVO group, the posterior vitreous was attached in 27 eyes (93%), partially detached in 1 eye (3%) and completely detached in another eye (3%). A subdivision into age classes and a comparison with healthy age‐related controls [data by Weber‐Krause & Eckardt (1997) Ophthalmologe, 94, 619–623] showed in patients between 65 and 69 years of age an attached posterior vitreous cortex in 72% in healthy eyes, in 100% in CRVO (p = 0.109) and in 89% in BRVO (p = 0.440), in patients between 70 and 79 years of age an attached posterior vitreous cortex in 56% in healthy eyes, in 86% in CRVO (p = 0.010) and in 100% in BRVO (p = 0.038) and in patients between 80 and 89 years of age an attached posterior vitreous cortex in 43% in healthy eyes, in 100% in CRVO (p = 0.191) and in 67% in BRVO (p = 0.582) (Fisher’s exact t‐test). Conclusion: In patients with a history of CRVO or BRVO, the posterior vitreous cortex stays attached more frequently in all age groups in comparison with the healthy age‐related controls.     

Current and future pharmacological intervention for diabetic retinopathy

Diabetic retinopathy (DR) is a potentially visually devastating complication of chronic hyperglycaemia. Prospective, randomised clinical trials have delineated the standard prevention protocols, including intensive glycaemic, blood pressure, and lipid control, and laser photocoagulation treatment for neovascularisation and clinically significant macular oedema. However, despite these interventions, vision loss from DR still occurs at an alarming rate. Researchers have directed their efforts towards better understanding the specific biological and chemical changes occurring in DR to develop more targeted pharmacological prevention and treatment strategies. This review of diabetic retinopathy will primarily detail the therapies in development at present, including aldose reductase inhibitors, advanced glycosylation end product inhibitors, antioxidants, supplemental oxygen, growth factor modulators including vascular endothelial growth factor inhibitors and protein kinase C inhibitors, extracellular matrix modifiers including corticosteroids, and vitreous modulators. The experimental therapies alter several different pathways that lead to DR. Future research will further delineate these pathways, and therapy is likely to involve arresting several different promoters of DR.     

纤溶酶和透明质酸酶药物性玻璃体切割术的发生机制

目的研究纤溶酶联合透明质酸酶诱导药物性玻璃体切割术的发生机制。方法新西兰白兔24只,分为6组,采用玻璃体腔内注射药物0．1mL。A、B、c组分别注射纤溶酶4、2、1μmol／L;D组：纤溶酶1μmol／L＋透明质酸酶20μmol／L;E组：透明质酸酶20μmol／L;F组：BSS溶液0．1mL为对照组。7d后免疫胶体金电镜技术检测玻璃体视网膜界面层粘连蛋白（LN）、纤维连接蛋白（FN）抗体分布。另取7只白兔（14只眼）进行纤溶酶活性测定,组1：一侧眼玻璃体腔内注射纤溶酶1μmol／L＋透明质酸酶20μmol／L;组2：对侧眼玻璃体腔内注射纤溶酶1μmol／L。结果免疫胶体金电镜检测视网膜内界膜表面LN、FN显示,A、B、C、D组与对照组比较LN数量减少,差异均有统计学意义（P〈0．01）,E组与对照组比较LN数量减少,差异无统计学意义（P〉0．05）。FN免疫胶体金电镜结果与LN相似。纤溶酶1μmol／L组在药物注射后1h内维持最大纤溶酶活性,此后酶活性逐渐下降,12h后酶活性消失,D组纤溶酶活性曲线和C组走向基本一致。结论药物性玻璃体切割术的实质是溶解玻璃体视网膜界面的LN、FN等分子胶而发生玻璃体后脱离（PVD）,透明质酸酶联合纤溶酶可显著提高PVD的效果,提示合理诱发PVD的药物应既能解除玻璃体视网膜界面之间的粘连,又能液化玻璃体。     

Diabetic macular edema: Current management 2013

Diabetic retinopathy (DR) is the leading cause of vision loss of working-age adults, and diabetic macular edema (DME) is the most frequent cause of vision loss related to diabetes. The Wisconsin Epidemiologic Study of Diabetic Retinopathy found the 14-year incidence of DME in type 1 diabetics to be 26%. Similarly the Diabetes Control and Complications Trial reported that 27% of type 1 diabetic patients develop DME within 9 years of onset. The most common type of diabetes, type 2, is strongly associated with obesity and a sedentary lifestyle. An even higher incidence of macular edema has been reported in older patients with type 2 diabetes. Within the last 5 years, the use of intravitreal corticosteroids and intravitreal anti-vascular endothelial growth factor (VEGF) agents have come into clinical practice for the management of DME and several recent randomized clinical trials have shown improved effectiveness of ranibizumab compared to focal/grid laser. In this theme issue, we discuss the classification of DR and the treatment options currently available for the treatment of DME including corticosteroids, anti-VEGF agents, combined therapy, enzymatic vitrectomy (vitreolysis), and new therapies.     

Ultra Q-YAG玻璃体消融术治疗飞蚊症的临床初步观察

目的：研究 Ultra Q-YAG 玻璃体消融术治疗不同年龄段临床有症状飞蚊症患者的疗效及安全性。
　　方法：回顾性队列研究。对2014-09/2015-05在北京爱尔英智眼科医院临床确诊为玻璃体混浊的患者263例340眼纳入研究,所有患者均行视力、眼压、裂隙灯、散瞳查眼底、B 超检查,并记录玻璃体混浊物的形态,排除眼底病变。根据患者年龄分为两组：A 组(<30岁)78例82眼,玻璃体混浊的形态多为细点、丝状、网状;B 组(>45岁)185例258眼,玻璃体混浊的形态多为 Weiss 环,半透明絮状或致密纤维膜状。均排除外伤与眼内病变所致混浊,30~45岁患者由于混浊因素不典型被剔除。所有患者均由同一有经验医师行 YAG 玻璃体消融术( Ellex Medical Lasers),对比分析治疗后1mo 飞蚊症状缓解情况。
　　结果：行问卷调查,根据患者问卷得分将术后症状改善程度分为基本无改善(1~2分)、部分改善(3~5分)、显著改善(6~10分)。1mo 后 A 组无改善9眼(11.0%),部分改善57眼(69.5%),显著改善16眼(19.5%);B 组无改善0眼,部分改善23眼(8.9%),显著改善235眼(91.1%);所有患者无1例并发症发生。
　　结论：YAG 玻璃体消融术治疗飞蚊症安全有效。对于年龄<30岁年龄组的飞蚊症患者,有改善但显著改善的几率不高。而对于年龄>45岁年龄组,因玻璃体后脱离导致的玻璃体混浊,患者效果更佳。     

激光玻璃体松解术治疗Weiss环是否必要

YAG激光玻璃体松解术治疗Weiss环是通过激光汽化作用将Weiss环分解,消除患者眼前黑影症状的一种治疗手段。该技术产生于上世纪九十年代,有一定疗效,也可产生严重并发症。目前临床上对于此种治疗方法的应用有较多争议。本期刊出了一篇相关论著性文章,其结果可供读者参考。本文中三位眼底病专业医师针对YAG激光玻璃体松解术治疗Weiss环是否必要及疗效进行了讨论。