视网膜造孔处理无裂孔视网膜下增生牵引性视网膜脱离

目的 观察视网膜造孔取出视网膜下增生膜后,视网膜脱离的复位、造孔愈合及远期视网膜稳定性.方法 3例无裂孔视网膜下增生牵引性视网膜脱离,进行视网膜造孔取出视网膜下增生膜、造孔处眼内激光光凝封闭及玻璃体腔硅油填充.结果 3例(3眼)手术后视野扩大、视力不同程度提高.2周后造孔激光光斑处色素游离.1年后硅油取出,视网膜稳定.结论 视网膜造孔取出视网膜下膜,是处理视网膜下增生牵引性视网膜脱离的较好方法 ,对视网膜损伤较小、脱离视网膜复位有效,但视力的恢复取决于视网膜本身条件.手术操作过程中应避开黄斑区域.     

Treatment of complicated retinal detachment. Intraoperative use of perfluorodecalin]

Perfluorodecalin was injected into the vitreous cavity of 36 eyes during vitreous surgery for complicated retinal detachment. This low-viscosity liquid is immiscible with water, chemically inert and has a high specific gravity. In all cases the posterior retina was flattened without the need for a posterior retinotomy for drainage of subretinal fluid. Injection of the fluid caused stabilization of the retina and improved removal of peripheral epiretinal membranes. In 1 case a retinal break occurred during injection of the liquid and perfluorodecalin entered the subretinal space. In 4 eyes a small mobile droplet of residual perfluorodecalin was observed post-operatively. During follow-up periods of up to 11 months no retinal changes caused by the residual liquid were observed.     

Treatment of a subretinal silicone oil bubble

The passage of a silicone oil bubble under the retina is a rare but severe complication of retinal detachment (RD) surgery. It may cause a permanent detachment and/or migrate with time, decreasing visual function. We present five cases in which the subretinal oil bubble was successfully extracted from the subretinal space by retinotomy. Two cases were rhegmatogenous RD with proliferative vitreoretinopathy, two were post-traumatic RD, and one was a traction detachment in proliferative diabetic retinopathy. The average follow-up was 17 months. In three cases, we were able to remove the silicone oil from the eye. In all cases, visual acuity was improved. Using retinotomy to extract the subretinal oil bubble seems a safe way to manage this complication.     

Vitreoretinal surgery for a subretinal hydatid cyst

PURPOSE: To report the vitreoretinal surgery for management of a subretinal hydatid cyst. METHODS: Conventional pars plana vitrectomy was performed for the removal of a subretinal hydatid cyst and treatment of retinal detachment in the right eye (RE) of a 34-year-old woman. The cyst content was aspirated by a flute needle after retinotomy and cystotomy. The cyst wall was separated from overlying retina and removed. The retina was attached by liquid perfluorocarbon and silicone oil. Postoperatively, the patient was followed for 15 months. RESULTS: After vitreoretinal surgery, the retina RE was attached and recurrence of hydatid disease was not seen in vitreous cavity or subretinal space during the follow-up period. Visual acuity increased from counting fingers to 20/63 at the end of the follow-up time. CONCLUSION: A subretinal hydatid cyst that causes retinal detachment may be treated effectively with vitreoretinal surgery.     

视网膜切开在复杂性视网膜脱离手术中的应用

目的评价视网膜切开在复杂性视网膜脱离手术中的应用价值。方法回顾性总结了1994年7月至1995年12月在我科做视网膜切开手术的连续病例45例46只眼，其中裂孔性视网膜脱离伴增殖性玻璃体视网膜病变（proliferativevitreoretinopathy．PVR）35例35只眼、外伤性PVRS例8只眼、牵引性视网膜脱离2例3只眼。结果平均追踪7个月，内排液组40只眼一次手术成功24只眼占60％，有12只眼再发视网膜脱离做了第二次同样手术，其中同时取视网膜下膜2眼；取视网膜下膜5只眼和视网膜切开减张3只眼中，有6只眼视网膜复位，失败2只眼。视力改善37只眼占80％。结论在复杂性视网膜脱离中，合理选用视网膜切开、眼内排出视网膜下液、取除视网膜下膜和松解缩短、僵硬的视网膜，可提高手术疗效。     

Effect of glial cell line-derived neurotrophic factor on retinal function after experimental branch retinal vein occlusion

Purpose. The objective of the study was to investigate the effect of glial cell line-derived neurotrophic factor (GDNF) on the multifocal electroretinogram (mfERG) following an induced branch retinal vein occlusion (BRVO) in pigs. Methods. Electrophysiological examination of the retina was performed in 20 pigs with standard and four-frame mfERG 4 weeks after induced BRVO and intravitreal injection of GDNF or vehicle. BRVO was induced by intraocular diathermia of the superior retinal vein. Inner retinal function was measured by analysis of the four-frame mfERG (iN1) and outer retinal function with standard mfERG (P1). Results. In GDNF-treated BRVO eyes, P1 and iN1 amplitudes (P = 0.51 and 0.78) or implicit times (P = 0.08 and 0.99) did not differ from those in healthy fellow eyes. After vehicle injection, P1 and iN1 amplitudes of BRVO eyes were significantly lower than in the healthy fellow eye (P = 0.022 and 0.013). The log ratios of mfERG amplitudes between experimental and healthy fellow eyes were calculated (BRVO/healthy). GDNF improved the ratios of the four-frame mfERG (1.29 [0.88-1.88]) compared with vehicle (0.32 [0.21-0.50], P < 0.001). Equally, GDNF improved the ratios of the standard mfERG; GDNF (0.75 [0.51-1.10]) and vehicle (0.42 [0.27-0.63], P = 0.048). Conclusions. GDNF appears neuroprotective on retinal electrophysiological function after BRVO. The efficacy and safety of GDNF remain to be investigated in primate eyes.     

兔視網膜色素上皮细胞移植的實驗研究

目的 探索用改良的二步法酶法制备视网膜色素上皮(RPE)细胞悬液,经改良的内路法,不经玻璃体切割的情况下进行视网膜下间隙的移植 方法 用酶Ⅰ(含220kU/L透明质酸酶和0.1％的胰蛋白酶)松解视网膜神经上皮细胞与RPE细胞之间的联接,再用酶Ⅱ(含0.25％胰蛋酶)从Bruch膜上离散RPE细胞,制成细胞悬液 用特制的注射针头,通过人为造成的局限性视网膜脱离区将其移植入受体视网膜下间隙 结果 术后2周供体RPE细胞层呈单层排列于受体视网膜下间隙,并存活,未见明显炎症反应 电镜观察,术後7周供体RPE细胞位于受体Bruch膜上并与受体感光细胞外节盘模型成镶嵌关系结论改良的内路法可以将供体RPE细胞成功移植在受体眼视网膜下间隙,并至少存活7周,改良的内路法渴望为视网膜移植的实验室研究提供一条可供借鉴的途径。     

Intraoperative perfluorocarbon liquids in the management of proliferative vitreoretinopathy

Three low-viscosity perfluorocarbon liquids were used intraoperatively for hydrokinetic manipulation of the retina during vitreous surgery for retinal detachment with advanced proliferative vitreoretinopathy. All 23 patients had massive proliferative vitreoretinopathy (Grade D, Retina Society classification), and 16 (69.6%) had Grade D-3 with a closed-funnel configuration. In 21 eyes the retina could be flattened intraoperatively by perfluorocarbon liquids without requiring posterior retinotomy for internal drainage of subretinal fluid. The temporary mechanical fixation of the retina provided by this tool facilitated the removal of epiretinal membranes and release of traction. Fifteen eyes (65.2%) maintained long-term retinal reattachment with follow-up of six months or more. These liquids are useful adjuncts in the management of retinal detachment with severe proliferative vitreoretinopathy.     

Retinal function after scleral buckling for recent onset rhegmatogenous retinal detachment: assessment with electroretinography and optical coherence tomography

PURPOSE: To investigate central and peripheral retinal function after scleral buckling surgery for recent onset rhegmatogenous retinal detachment (RD). METHODS: Fifteen phakic patients with rhegmatogenous RD for <1 week underwent scleral buckling surgery. Clinical investigation, optical coherence tomography (OCT), full-field electroretinography (ERG), and multifocal ERG (mfERG) with fundus illumination were performed preoperatively and 6 months postoperatively. RESULTS: Anatomical success was achieved in 14 patients. mfERG amplitudes were reduced preoperatively in detached retina, with significant improvement at follow-up (P = 0.002). Foveal amplitudes improved significantly (P = 0.027). There was no significant difference in postoperative mfERG amplitudes between areas that had been preoperatively detached or attached (P = 0.739). In the subgroup of eight patients in whom the detachment engaged the fovea preoperatively, rod function improved significantly as assessed with full-field ERG (P = 0.008). In these patients, the extent of detachment ranged between 4 clock hours and 6 clock hours, as compared with 2 clock hours and 5 clock hours in the remaining patients. OCT showed subretinal foveal fluid in four patients at follow-up. CONCLUSIONS: In recent onset rhegmatogenous RD, total rod and localized central retinal dysfunction in detached retina can improve significantly after reattachment. mfERG and OCT are suitable tools for further studies of functional outcomes in RD.     

Risk factors for retention of subretinal perfluorocarbon liquid in vitreoretinal surgery

PURPOSE: To analyze factors that may lead to inadvertent subretinal retention of perfluorocarbon liquid (PFCL) after vitreoretinal surgery and compare surgical outcomes and complications associated with these events. DESIGN: Consecutive retrospective study. METHODS: The authors retrospectively reviewed the charts of 72 vitreoretinal surgeries using intraoperative PFCL and its removal through fluid-air exchange and subsequent tamponade. Indications for surgery included trauma, retinal detachment, giant retinal tear, and submacular hemorrhage. Most interventions studied had significant amounts of proliferative vitreoretinopathy and were required after failed or complicated previous vitreoretinal surgery. MAIN OUTCOME MEASURES: Analysis was focused on the occurrence of subretinal retention of PFCL during different surgical procedures and techniques, indications, anatomic and visual results, and complications. RESULTS: At the last follow-up, the retina was completely attached in 97% of eyes treated with PFCL after 1 or 2 vitrectomies. Subretinal PFCL was found in 8 (11.1%) eyes. There was no statistical difference in the retention rate for perfluorodecalin and perfluoro-n-octane. The factor most significantly associated with subretinal retention of PFCL was the presence and large size of a peripheral retinotomy. All cases of subretinal PFCL had a retinotomy of 120 degrees or larger. The average retinotomy size in these cases was 259 degrees . Subretinal PFCL was found in 40% of eyes with a 360 degrees retinotomy. Small and medium-sized retinal breaks were not associated with PFCL retention. Another surgical procedure that correlated significantly with subretinal PFCL was lack of saline rinse during fluid-air exchange. Only 1 of the 23 eyes that were rinsed had subretinal PFCL, although many had large retinotomies. CONCLUSION: Subretinal PFCL retention is most likely to occur in eyes with large peripheral retinotomies, especially if 360 degrees . Saline rinse seems to be useful in the prevention of subretinal PFCL. The presence of subretinal PFCL does not seem to affect visual and anatomic success when located outside the macula, at least during an intermediate period of follow-up.     

视网膜脱离伴前部增生性玻璃体视网膜病变的手术

目的：探讨视网膜脱离中病变严重，伴前部增生性玻璃体视网膜病变（anterior proliferative vitreoretionopalthy,APVR)的手术治疗方法。方法：对57例（57眼）复杂性视网膜脱离伴APVR患者行巩膜环扎，硅胶外加压、玻璃体切除，视网膜前膜分离、切除、视网膜松解性切开、切除、过氟化碳液体注入，眼内排液及硅油眼内填充等,崆春治疗效果。结果：痊愈45例，成功率79％，8眼好转，占14％，4眼无效，占75，术后视力除手术失败者外，均有所提高。结论：运用各种玻璃体视网膜显微手术技术，对APVR的认识和处理能力提高，可以使部分严重，复杂的视网膜脱离复位手术成功率提高。     

Implantation and testing of subretinal film electrodes in domestic pigs

By definition, an electronic subretinal visual prosthesis requires the implantation of stimulation electrodes in the subretinal space of the eye. Polyimide film electrodes with flat contacts were implanted subretinally and used for electrical stimulation in acute experiments in anaesthetised domestic pigs. In two pigs, the film electrode was inserted through a sclerostomy into the vitreous cavity and, subsequently, via a retinotomy into the subretinal space around the posterior pole (ab interno approach). In three other pigs the sclera and pigment epithelium were opened for combined ab interno and transscleral positioning of the subretinal electrode. In all cases, perfluorocarbon liquid (PFCL) was used to establish a close contact between the film electrode and the outer retina. After cranial preparations of three pigs for epidural recording of visual cortex responses, retinal stimulation was performed in one pig with a film electrode implanted ab interno and in two pigs with film electrodes implanted by the ab interno and transscleral procedure. The five subretinal implantations were carried out successfully and each polyimide film electrode tip was positioned beneath the outer retina of the posterior pole. The retina was attached to the stimulation electrode in all cases. Epidural cortical responses to light and electrical stimulation were recorded in three experiments. Initial cortical responses to Ganzfeld light and to electrical stimuli occurred about 40 and 20 ms, respectively, after stimulation onset. The stimulation threshold was approximately 100 microA and, like the cortical response amplitudes, depended both on the correspondence between retinal stimulation and cortical recording sites and on the number of stimulation electrodes used simultaneously. Our results in a domestic pig model demonstrate that polyimide film electrodes can be implanted subretinally and tested by recording cortical responses to electrical stimulation. These findings suggest that the domestic pig could be an appropriate animal model for basic testing of subretinal implants.     

视网膜切开与切除手术临床应用初步报告

目的：探讨视网膜切开及切除在复杂性视网膜脱离，视网膜下手术的临床应用。 方法：对1994年1月至1995年4月行视网膜切开和切除的28例作回顾性分析。 结果：11例视网膜切开内排液，10例视网膜平复，视力提高。7例视网膜下新生血管膜手术切除，4例视功能改善，3例维持不变。视网膜下增殖膜1例，术后因视网膜脱离失败。视网膜切除的9例患者中，巨大裂孔视网膜脱离伴增殖性玻璃体视网膜病变4例，2例在术中无法复位，2例采用过氟化碳压平视网膜加周边僵硬视网膜切除，获得成功；大裂孔视网膜脱离5例均切除僵硬裂边缘后视网膜平复，视力改善。 结论：视网膜切开及切除术有利于视网膜下手术的实施及提高复杂性视网膜脱离的治愈率。 （中华眼底病杂志，1996，12：3-6）       

Modified technique to create retinal detachment during macular translocation surgery

PURPOSE: To report a modified technique for creating total retinal detachment during macular translocation surgery with a 360-degree retinotomy. DESIGN: Interventional case series. METHODS: After vitrectomy, BSS Plus (Alcon, Fort Worth, TX, USA) was injected into the subretinal space with a 39-gauge needle to create a small retinal detachment. The tip of a 20-gauge silicone-tipped needle was then placed in the hole created by the needle, and BSS Plus was injected subretinally at a high flow rate. RESULTS: In 10 eyes (10 patients), we created one iatrogenic retinal hole in seven eyes and two holes in three eyes. The time needed to create total retinal detachment was decreased. CONCLUSIONS: Our technique seems to make creation of a total retinal detachment easier compared with the previous standard procedure and may reduce postoperative complications following macular translocation surgery with a 360-degree retinotomy.     

玻璃体切除和硅油填充手术后视网膜再脱离及其治疗

目的：探讨玻璃体切除和硅油填充手术手视网膜再脱离的治疗。 方法：回顾总结增殖性玻璃体视网膜病变（proliferative vitreorinapthy PVR）5例5只眼和外伤性PVR3例3只眼的视网膜脱离手术后再脱离的治疗效果。治疗方法为经睫状体平坦部闭合式玻璃体切除、膜剥离、视网膜切开、内排溶剂化物、硅油填充，2只眼加视网膜下膜剥离取出。 结果：术后视网膜解剖复位6只眼，2只眼下方仍有浅脱离，术后视力提高6只眼，不变2只眼。 结论：视网膜再脱离的原因与增殖性视网膜前膜和下膜形成有关，治疗原则为玻璃体切除、解除增殖膜的牵引和充分地液/油交换. （中华眼底病杂志，1996，12：13-15）     

Delayed absorption of subretinal fluid after scleral buckling procedures.

Delayed absorption of subretinal fluid beyond six weeks after surgical repair for rhegmatogenous retinal detachment was recognized in 39 of 575 consecutive cases of scleral buckling. The most common preoperative condition was large clumps of cells on the undersurface of the detached retina (subretinal precipitates). Approximately one in four patients in whom precipitates are seen preoperatively will have fluid persisting beyond six weeks from surgical repair to complete absorption. A second relatively common condition associated with delayed fluid absorption that could be recognized before operation was long-standing peripheral (usually inferior) retinal detachment, which typically spared the macula, was associated with demarcation lines, and was caused by round atrophic holes with or without associated lattice degeneration. An analysis of subretinal fluid protein concentrations in 39 cases showed a positive relationship between protein concentration and duration of detachment. Pigment-laden macrophages in the subretinal space, possibly originating from the retinal epithelium, were common.     

Management of subretinal foreign bodies with a cannulated extrusion needle

We treated two patients who had nonmagnetic subretinal foreign bodies (metallic pellet and lens nucleus fragment) in the presence of a retinal detachment and a distant retinal break. After the pars plana vitrectomy, the soft, flexible tip of the cannulated extrusion needle was used to push the foreign object gently away from the posterior pole toward the retinal break where it was grasped and removed from the eye. This technique for subretinal foreign body removal is preferable to creating a large posterior retinotomy overlying the foreign body because of the potential risks of further macular trauma, hemorrhage, or proliferation of periretinal membranes from the retinotomy site.     

The spatial resolution of the porcine multifocal electroretinogram for detection of laser‐induced retinal lesions

Purpose: This study aimed to investigate the spatial resolution of a porcine multifocal electroretinogram (mfERG) protocol by testing its ability to detect laser‐induced retinal lesions. Furthermore, we wanted to describe time‐dependent changes in implicit time and amplitude of the different mfERG peaks after laser‐induced retinal damage. Methods: Three pigs underwent a three‐port pars plana vitrectomy, followed by laser photocoagulation of different lesion sizes within the visual streak. In an additional six non‐vitrectomized pigs, we studied changes in mfERG signals with time after a uniform laser photocoagulation within the visual streak. The animals were evaluated with mfERG 1 and 6 weeks after treatment. After the last mfERG examination, selected eyes were processed for histological examination. Results: The size of the smallest lesion detected was approximately 1/4 of the longest diameter of the optic disc (LDOD) measured in pixels. When analysing the uniform lesions we found that signals deriving from the centre of the laser lesions were characterized by a significant reduction in the amplitude of all three peaks after 1 week of observation. After 6 weeks, the amplitudes of P1 and N2 were still significantly reduced. The implicit times were unaffected by laser treatment in the acute phase. After 6 weeks only P1 was significantly delayed. Conclusion: We have determined the spatial resolution of the mfERG in the porcine retina to be smaller than or equal to the area of two adjacent hexagons, corresponding to a width of approximately 288 pixels or 1.2 mm. Laser lesions of uniform size resulted in a significant reduction of the amplitudes 1 and 6 weeks after treatment.     

玻璃体视网膜手术治疗晚期大泡状视网膜脱离的临床疗效观察

目的 观察玻璃体视网膜手术治疗晚期大泡状视网膜脱离的疗效。 方法 回顾分析经裂隙灯显微镜、三面镜及间接检眼镜、B型超声以及荧光素眼底血管造影检查确诊，无法进行有效激光光凝而行玻璃体视网膜手术治疗的晚期大泡状视网膜脱离患者7例9只眼的临床资料。所有患眼均在局部麻醉下巩膜穿刺放出视网膜下液后，行睫状体扁平部的闭合式三切口玻璃体切割手术。去除玻璃体及后皮质，视网膜内引流 ，吸出视网膜下液体，激光光凝封闭视网膜切开处和渗出区，气液交换后注入眼内填充物。 手术后随访3个月～8年，平均随访时间47个月。 结果 随访期内视网膜均复位。1只眼在手术后2年复查时因视网膜前增生膜牵引形成一裂孔，并有一硅油泡进入视网膜下造成局部视网膜脱离而行第二次手术治疗，手术后随访1年视网膜平复。8只眼手术后视力较手术前有不同程度提高，1只眼手术后视力无改变。 结论 晚期严重大泡状视网膜脱离患者行玻璃体视网膜手术治疗能安全有效地促进视网膜复位，挽救患眼的部分视力。 （中华眼底病杂志，2006，22：299-301）     

Compound subretinal prostheses with extra-ocular parts designed for human trials: successful long-term implantation in pigs

Background Subretinal implants aim to replace photoreceptor function in patients suffering from degenerative retinal disease like retinitis pigmentosa by topically applying electrical stimuli in the subretinal space. This study—as a last step before upcoming human trials—explored a newly developed surgical technique for permanent implantation of complex subretinal implants with extra-ocular parts. Methods The implant consisted of a microphotodiode array (MPDA) with 1,550 electrodes and a 4×4 array of gold electrodes for direct electrical stimulation; both were mounted onto a polyimide foil for transscleral placement into the subretinal space. The foil carried connection lanes to a silicone cable that was implanted under the skin and led to a stimulator box in the animal’s neck. Surgery was performed in 11 domestic pigs. Improved vitreo-retinal surgical technique consisted of a 180° peripheral retinotomy and use of diathermy to penetrate the choroid in order to avoid choroidal haemorrhage. Subretinal forceps were used to place the implant safely onto the retinal pigment epithelium before the retina was flattened, peripheral laser photocoagulation was applied and the eye was filled with silicon oil. The implant was stabilized by a scleral fixation patch, use of a metal clamp with bone screws on the animal’s skull and a tissue ring under the animal’s skin in the neck. Behaviour was observed in the freely moving animals after direct subretinal electrical stimulation and funduscopy, optical coherence tomography, fluorescein angiography and histology were performed. Results All implants were successfully placed subretinally. In three animals a proliferative vitreo-retinopathy was observed after approximately 2 weeks. Otherwise, funduscopy and OCT demonstrated complete retinal attachment and FA showed no retinal vascular abnormalities over and around the implant. The animals showed clear behavioural reactions to electrical stimulation over the whole examination period. Histological examination failed to show any voltage-induced alteration in the cellular architecture of the retina overlying the stimulation electrodes. Conclusions This study demonstrates the feasibility of a new surgical procedure for highly safe and controlled implantation of complex subretinal devices with extra-ocular parts. The new implant design proved to be safely implantable in free-moving pigs for an observation period of 4 weeks.