Factors affecting anatomical and visual outcome after macular hole surgery: findings from a large prospective UK cohort

ObjectivesTo reassess the definition of a large macular hole, factors predicting hole closure and post-surgery visual recovery.DesignDatabase study of 1483 primary macular hole operations. Eligible operations were primary MH operations treated with a vitrectomy and a gas or air tamponade. Excluded were eyes with a history of retinal detachment, high myopia, previous vitrectomy or trauma.ResultsA higher proportion of operations were performed in eyes from females (71.1%) who were ‘on average’ younger (p < 0.001), with slightly larger holes (p < 0.001) than male patients. Sulfur hexafluoride gas was generally used for smaller holes (p < 0.001). From 1253 operations with a known surgical outcome, successful hole closure was achieved in 1199 (96%) and influenced by smaller holes and complete ILM peeling (p < 0.001), but not post-surgery positioning (p = 0.072). A minimum linear diameter of ~500 μm marked the threshold where the success rate started to decline. From the 1056 successfully closed operations eligible for visual outcome analysis, visual success (defined as visual acuity of 0.30 or better logMAR) was achieved in 488 (46.2%) eyes. At the multivariate level, the factors predicting visual success were better pre-operative VA, smaller hole size, shorter duration of symptoms and the absence of AMD.ConclusionsFemales undergoing primary macular hole surgery tend to be younger and have larger holes than male patients. The definition of a large hole should be changed to around 500 μm, and patients should be operated on early to help achieve a good post-operative VA.Subject terms: Outcomes research, Retinal diseases     

Prediction of visual recovery after scleral buckling of macula-off retinal detachments.

Patients with rhegmatogenous retinal detachments involving the fovea have visual loss that may not be recoverable despite anatomically successful surgery. Few guidelines exist to predict ultimate visual outcome with any certainty. We found that despite macular detachment, a device commonly used to predict visual acuity in cataractous eyes, the Potential Acuity Meter (Mentor O & O, Inc., Norwell, Massachusetts), provided acuity measurements even when Snellen visual acuity levels were poor or unmeasurable. In a study of 50 consecutive patients with clear media, we investigated a possible correlation between postoperative Snellen visual acuity with the preoperative Potential Acuity Meter results. We found that actual visual improvement correlated well with potential visual improvement as determined by Potential Acuity Meter measurements (R = .92). Preoperative assessment of patients with this device was a better predictor of final visual outcome than preoperative Snellen visual acuity, the extent of retinal detachment, or the duration of the retinal detachment by history.     

Optical coherence tomography in the evaluation of incomplete visual acuity recovery after macula-off retinal detachments

PURPOSE: To determine whether pre and/or postoperative optical coherence tomography (OCT) evaluation of the fovea is useful in explaining delayed or incomplete visual acuity recovery after successful surgery for shallow macula-off retinal detachments. METHODS: Prospective study of 16 patients (10 female, 6 male; mean age 53+/-4 years) with a spontaneous rhegmatogenous retinal detachment with peripheral breaks and a shallow elevation of the fovea. Patients were examined by OCT preoperatively and at 1, 6, and 10-12 months after surgery. At 1 month after surgery, fluorescein angiography was also performed. Mean follow-up was 11.0+/-1.0 months. RESULTS: Preoperative OCT images could be classified into four categories according to the extent of retinal edema and presence of foveal depression. The extent of retinal edema in the detached macula did not correlate with preoperative or postoperative vision. In 11 cases, OCT images at 1 month after surgery showed a foveal detachment with residual subretinal fluid that was not visible clinically or on angiography. Long-term persistence of this fluid could be observed in eight cases at 6 months and in one case at 12 months, and was associated with incomplete recovery of visual acuity. CONCLUSIONS: Preoperative OCT of the detached macula can demonstrate widespread retinal edema, the extent of which does not appear to influence final postoperative vision. Delayed and incomplete visual recovery after successful reattachment of the retina may, however, be due to persistent circumscribed subfoveal fluid accumulation that is visible only on OCT not clinically or on fluorescein angiography.     

Visual recovery after scleral buckling for macula-off retinal detachments: an optical coherence tomography study

PURPOSE: To assess the postoperative macular reattachment through OCT3 in eyes treated with episcleral surgery due to macula-off rhegmatogenous retinal detachment, as well as to verify if there is a statistically relevant relation between the persistence of a subfoveal detachment and poor postoperative functional recovery. METHODS: Twelve eyes of 12 patients who underwent episcleral surgery due to macula-off rhegmatogenous retinal detachment were enrolled and examined in a prospective study. Exclusion criteria were the following: traumatic retinal detachments, detachment relapses, macular holes, amblyopia, and grade B proliferative vitreoretinopathy or higher. The time period from the onset of subjective symptoms of retinal detachment to retinal surgery ranged from 3 to 7 days. All patients were evaluated in the preoperative and the postoperative period (after 1, 3, and 6 months) through measurement of visual acuity by ETDRS charts, fundus photographs, and macular tomography with OCT3. The postoperative tomography outcomes and the visual acuity were statistically examined using the Mann-Whitney U-test. RESULTS: One month after surgery, despite the macular reattachment assessable ophthalmoscopically and through fundus photographs, the OCT examination showed macular subretinal fluid persistence in 66.6% of cases. After 3 and 6 months, the persistence of such foveal detachment was respectively observed in 41.6% and in 33.3% of cases. Moreover, the macular subretinal fluid persistence in the postoperative period showed a statistically significant relation with poor functional recovery. CONCLUSIONS: Delayed or incomplete visual recovery after episcleral surgery for macula-off retinal detachment may be related to macular subretinal fluid persistence, assessable with tomography and not visible ophthalmoscopically.     

累及黄斑的视网膜脱离术后5a的视功能和光学相干断层扫描的分析

目的:观察累及黄斑区视网膜脱离巩膜扣带术后的黄斑光学相干断层扫描(OCT)图像及术前和术后最佳矫正视力(BCVA)之间的关系的研究。方法:回顾分析5a随访的47例47眼累及黄斑区视网膜脱离患者,并将其分成两组:黄斑脱离≤7d组和>7d组。间接眼底镜行眼底检查,并行TOPCON光学相干断层扫描。结果:患者47例术后5a较术后3mo平均术后BCVA增加1.60±0.02行。≤7d组术后5a的BCVA为0.53,>7d组为0.25,两组之间有显著差异(P=0.008)。≤7d组术后BCVA≥0.4者28例,而>7d组术后BCVA≥0.4者7例(P<0.01)。5a术后随访间接检眼镜检查表明,视网膜脱离均复位。而OCT显示视网膜下液1眼(2%),黄斑区神经上皮层组织堆积1眼(2%),这2例患者术后5a的平均视力只有0.13,明显低于其他45例,术后5a平均BCVA视力为0.54(P=0.025)。术后视网膜较厚组BCVA明显高于视网膜较薄的组,并有统计学差异(P=0.008)。结论:累及黄斑的视网膜脱离时间对术后视力的恢复有很大影响,呈负相关,同时术后视力在较长时间里仍会不同程度的提高,术后视网膜的厚度与术后视力呈正相关性。我们建议对于某些术后复位良好而视力不佳者进行OCT扫描,以便发现视力不佳的原因。本研究对临床预测评估累及黄斑的视网膜脱离复位术后,潜在视功能恢复的情况提供依据。     

Influence of persistent submacular fluid on visual outcome after successful scleral buckle surgery for macula-off retinal detachment

PURPOSE: To determine the influences of the extent and duration of persistent submacular fluid on final visual outcome after successful scleral buckle surgery for acute macula-off rhegmatogenous retinal detachment (RD). DESIGN: Prospective observational case series. METHODS: Forty-four consecutive patients (44 eyes) who underwent successful scleral buckle surgery for macula-off rhegmatogenous RD were enrolled patients underwent thorough ophthalmologic tests including best-corrected visual acuity (BCVA) assessments and optical coherence tomography (OCT) at one, three, six, nine, and 12 months postoperatively, until at least six months after the disappearance of subretinal fluid (SRF). Patients with persistent submacular fluid one month after surgery were assigned to group A and those without submacular fluid, to group B. In group A, patients whose submacular fluid disappeared before six months were assigned to group A1; the others, to group A2. The natural course of persistent SRF and associations between the extent and duration of SRF and postoperative BCVA were investigated. RESULTS: Twenty-three eyes (52.3%) were in group A and 21 eyes (47.7%) in group B. Twelve eyes (52.2%) were in group A1 and 11 eyes (47.8%) in group A2. SRF disappeared within 12 months after surgery without reoperation in all patients. No significant differences in final visual acuity (VA) were found among groups A, B, A1, and A2. Final VA was not found to be associated with SRF extent or duration. CONCLUSIONS: The presence and extent of submacular fluid after successful scleral buckle surgery for acute macula-off rhegmatogenous RD did not influence final VA or anatomic attachment.     

Factors affecting visual outcome in herpes zoster ophthalmicus: a prospective study

Purpose: To evaluate visual outcome and factors affecting visual outcome in herpes zoster ophthalmicus (HZO). Methods: A prospective, longitudinal, observational study was undertaken in 64 consecutive patients with HZO presenting within 72 h of rash onset. Patients underwent detailed ophthalmological and dermatological examinations at presentation, with follow up at first, second and fourth weeks and third and sixth months. All patients received both systemic and topical acyclovir. The main outcome measure was best‐corrected visual acuity at 6 months' follow up. Local and systemic factors were correlated with visual outcome using univariate and multivariate analyses. Results: Overall visual outcome was good, with 36/64 (56.3%) patients having a visual acuity of 6/6 or better. Mild visual loss occurred in 22/64 (34.3%), moderate loss in 3/64 (4.7%) and severe loss in 3/64 (4.7%); moderate to severe visual loss was due to severe uveitis (2), neurotrophic keratitis (1) and cataract (3). Increasing age (P = 0.04), positive Hutchinson sign (P = 0.001), absent corneal sensation (P = 0.01), corneal epithelial lesions (P = 0.03) and uveitis (P < 0.001) were significantly associated with visual loss. Uveitis was found to be the best predictor of visual loss in HZO on multivariate analysis. Conclusion: The overall visual outcome is good in HZO patients receiving antiviral therapy. Hutchinson's sign and anterior uveitis were found to be strong predictors of visual loss in HZO. Presence of these predictors calls for close monitoring.     

The effect of duration of macular detachment on results after the scleral buckle repair of primary, macula-off retinal detachments.

PURPOSE: To present a current series that determined the effect of duration of macular detachment (DMD) and patient age on postscleral buckle (SB) visual acuity (VA) and anatomic results. DESIGN: Retrospective, noncomparative, observational case series. PARTICIPANTS: Ninety-four consecutive patients (94 eyes) with primary, uncomplicated, macula-off retinal detachments, a preoperative VA of 20/200 or worse, and a precise history of when macular function was lost. INTERVENTION: Standard explant scleral buckle technique performed by multiple surgeons. MAIN OUTCOME MEASURES: Visual acuity, anatomic reattachment, and proliferative vitreoretinopathy. RESULTS: Visual acuity after SB of 20/40 or better was seen in 71% of eyes with a DMD of 10 days or fewer, 27% of eyes with a DMD of 11 days to 6 weeks, and 14% of eyes with a DMD of more than 6 weeks. Eyes achieved a mean VA after SB of 20/41 after a DMD of 10 days or fewer, 20/121 after a DMD of 11 days to 6 weeks, and 20/178 after a DMD of more than 6 weeks. No decrease in VA was seen within the 1- to 10-day period or the 11 days to 6 week period of DMD. Patients 60 years of age or less achieved a mean VA after SB of 20/47 compared with 20/81 for patients between 61 to 75 years of age and 20 of 96 in patients more than 76 years of age. Duration of macular detachment and patient age had no statistically significant effect on final anatomic reattachment after SB, reoperation rate, or proliferative vitreoretinopathy. CONCLUSIONS: Eyes with primary, uncomplicated, macula-off retinal detachment repaired with SB achieve excellent postoperative VA if repaired within the first 10 days of macular detachment. These results are better than the VA in eyes repaired after 11 days to 6 weeks and more than 6 weeks of macular detachment. Patients 60 years of age and younger obtained better postoperative VA than older patients. Duration of macular detachment and patient age did not significantly effect anatomic outcomes.     

The balloon-gas procedure: a technique for repair of retinal detachments requiring large volumes of gas.

This report describes the balloon-gas procedure, a technique for obtaining large volumes of intraocular gas. With the balloon-gas procedure a kind of "external fluid-gas exchange" allows for the safe injection of up to 1.0 ml of gas without previous pars plana vitrectomy or surgical drainage of subretinal fluid. From April 1985 to October 1988, in Tübingen, this procedure was utilized in 36 retinal detachments with breaks not suited for scleral buckling: giant tears (nine eyes), large dialyses (seven eyes), posterior breaks (16 eyes), and multiple breaks at different latitudes (four eyes). Follow-up ranged from six to 28 months (average 16 months). Initial retinal reattachment was achieved in 28 eyes (77.8%). Reasons for initial failure were proliferative vitreoretinopathy in six eyes, and a missed break in two. Redetachment occurred in three eyes. All 11 failures were reoperated using segmental sponges (eight eyes) and gas injection (three eyes). Final reattachment was achieved in 29 of the 36 eyes (80.6%), and final failure was due to proliferative vitreoretinopathy in all seven detachments.     

黄斑区脉络膜厚度与孔源性视网膜脱离成功手术复位后视力的相关性

目的 观察黄斑区脉络膜厚度与非高度近视孔源性视网膜脱离(RRD)成功手术复位后视力的相关性.方法 行手术治疗后视网膜均成功复位的非高度近视RRD患者53例53只眼纳入研究.手术前后所有患者双眼同时行最佳矫正视力(BCVA)及频域光相干断层扫描(OCT)检查.取穿过黄斑中心凹横向与纵向的两扫描切面图像进行黄斑中心凹形态分析,并测量黄斑中心凹厚度(CFT)及脉络膜厚度.分析不同黄斑中心凹形态、CFT、脉络膜厚度与患眼手术后BCVA的相关性.根据手术后患眼的脉络膜厚度分为脉络膜厚度≤150.00 μm组及脉络膜厚度＞150.00 μm组,分析两组手术后BCVA提高程度的差异.随访期间观察患眼光感受器内外节连接(IS/OS)及外界膜连接状态,将IS/OS及外界膜中断患眼分为重建及未重建两种状态,对比分析两种状态下手术后BCVA、CFT及脉络膜厚度的差异.结果 末次随访时,患眼平均BCVA为0.52±0.47.频域OCT检查显示,患眼平均CFT为(207.45±63.63) μm,平均脉络膜厚度为(175.46±62.68) μm.患眼手术后BCVA与IS/OS连接形态、脉络膜厚度有明显相关性(r=4.92、4.63,P＜0.05);与手术后外界膜连接状态以及是否存在视网膜下液、视网膜前膜、黄斑水肿和CFT无相关性(r=0.24、1.20、0.30、0.03、0.14,P＞0.05).脉络膜厚度＞150.00 μm组手术后2周～3个月BCVA提高程度较脉络膜厚度≤150.00 μm组更大,差异有统计学意义(t=-2.318,P＜0.05).IS/OS重建及未重建患眼比较,平均BCVA、平均脉络膜厚度间差异有统计学意义(t=-5.253、2.396,P＜0.05);平均CFT间差异无统计学意义(t=1.454,P＞0.05).外界膜重建及未重建患眼比较,平均BCVA、平均脉络膜厚度间差异有统计学意义(t=-5.940、3.563,P＜0.05);平均CFT间差异无统计学意义(t=1.117,P＞0.05).结论 黄斑区脉络膜厚度与非高度近视RRD成功手术复位后BCVA有明显相关性.     

Factors influencing improvement of visual field after trans-sphenoidal resection of pituitary macroadenomas: a retrospective cohort study

AIM: To investigate the influencing factors of visual field improvement after trans-sphenoidal resection of pituitary macroadenomas. METHODS: This retrospective cohort study included 201 patients (366 eyes) with visual field defect induced by pituitary macroadenomas. All of them were treated with trans-sphenoidal surgery. Ophthalmologic evaluation, best-corrected visual acuity (BCVA), and visual field examination were performed before and 3mo after surgery. BCVA, visual field defect index mean deviation (MD), duration of symptoms, age, sex, and volume of tumors were compared. Expression of vascular endothelial growth factor (VEGF) and Ki-67 of tumor tissue were detected by immunohistochemical technique. RESULTS: The mean age of patients was 44.23±1.29y. Ninety-three patients were female and 108 were male. The mean tumor volume was 14.36±6.23 cm3. The mean duration of preoperative symptoms was 11.50±0.88mo. Mean preoperative MD was -17.50±0.82 dB. Mean Preoperative visual acuity was 0.64±0.04. Postoperative visual field improved in 270 (73.77%) eyes, unchanged in 96 (26.23%) eyes. Multivariate logistic regression displayed that the factors independently influencing visual field improvement were young age (OR=1.71, 95%CI: 1.325-2.387, P=0.013), low preoperative MD absolute value (OR=1.277, 95%CI: 1.205-1.355, P<0.001), small volume of tumor (OR=1.458, 95%CI: 1.060-4.289, P<0.001), low expression of VEGF in tumor tissue (OR=1.554, 95%CI: 1.089-2.457, P=0.022), and low expression of Ki-67 in tumor tissue (OR=1.552, 95%CI: 1.161-2.847, P=0.026). CONCLUSION: After pituitary macroadenomas trans-sphenoidal resection, the independent influencing factors of the visual fields recovery were low preoperative MD absolute value, young age, small volume of tumor, and expression levels of VEGF/ Ki-67.     

A comparison of using digitally assisted vitreoretinal surgery during repair of rhegmatogenous retinal detachments to the conventional analog microscope: A prospective interventional study

International Ophthalmology - To compare outcomes and complications of pars plana vitrectomy (PPV) using a three-dimensional heads-up visualisation system (digitally assisted vitreoretinal system,...     

Ocular findings in Norwegian patients with ataxia-telangiectasia: a 5 year prospective cohort study

PURPOSE: To describe the outcome of ophthalmologic examination of 10 Norwegian children with ataxia-telangiectasia (AT) followed through 5 years. METHODS: Ten Norwegian patients with AT aged 2-22 years (three females, seven males) were examined. The diagnosis was confirmed clinically as well as with molecular genetic studies. Conventional ophthalmologic examination was performed and supplemented by photographs of the conjunctiva, video recordings and registration of eye motility in five consecutive years. Additionally conjunctival biopsies were performed at the end of the follow-up period. RESULTS: General ataxia was usually detected when the child started to walk. All children over the age of 4 years had abnormal saccade movements, a form of ocular motor apraxia. Conjunctival telangiectasias were mostly visible at 4-5 years, primarily within the palpebral fissure. Immunohistochemical examination of conjunctival biopsies showed an increased number of cross-sections of blood vessels and neurons surrounded by glial tissue. There was a tendency to slightly earlier onset of conjunctival telangiectasias in the patients homozygous for a founder mutation compared with the other patients. CONCLUSION: The diagnosis of AT can be supported at preschool age by the onset of ocular motor apraxia and conjunctival telangiectasias. The findings become more prominent with age. The conjunctival telangiectasias seem to appear slightly earlier in the patients who are homozygous for a Norwegian founder mutation than in the rest of the patients.     

Pseudophakic rhegmatogenous retinal detachment in a large Asian tertiary eye centre: a cohort study

Background: To determine the incidence and identify risk factors for the development of rhegmatogenous retinal detachment in patients who had cataract surgery at the Singapore National Eye Centre between 2001 and 2003. Design: Retrospective case–control study. Participants: All patients who had cataract surgery between 2001 and 2003 and subsequently retinal detachment surgery in the same eye, between 2001 and June 2008, at Singapore National Eye Centre. Methods: Review of case records. Main Outcome Measures: Incidence of posterior capsular rupture and retinal detachment. Results: Thirty‐nine eyes, out of 24 846 cataract operations performed between 2001 and 2003, developed rhegmatogenous retinal detachment in the follow‐up period from 2001 to 2008 (cumulative incidence 0.16%, 95% confidence interval 0.11–0.21%). Of the 508 eyes with posterior capsular rupture during cataract surgery, nine developed retinal detachment (cumulative incidence 1.77%, 95% confidence interval 0.87–3.23%). Men were more likely to develop retinal detachment (P < 0.001). On Kaplan–Meier survival analysis, younger patients had a higher probability of retinal detachment in comparison with older subjects (P < 0.001). Similarly, eyes with posterior capsular rupture during surgery had shorter interval duration to retinal detachment, compared with eyes that did not (P = 0.002). When compared with patients more than 70 years of age, younger patients had significantly higher hazard ratios of retinal detachment (hazard ratio 19.7, 95% confidence interval 3.6–107.3, P < 0.05). Conclusion: The incidence of pseudophakic retinal detachment in our institution is low. Posterior capsular rupture during surgery, men and younger age at time of surgery increases the risk of developing retinal detachment, and careful observation for the occurrence of retinal detachment may be warranted in these groups of patients.     

Bilateral midperipheral large drusen and retinal pigment epithelial detachments associated with multifocal areas of choroidal neovascularization: a histopathologic study

PURPOSE: The ocular histopathologic features of a patient with bilateral multiple midperipheral areas of choroidal vascularization, large drusen, and detachments of the retinal pigment epithelium (RPE) are presented. METHODS: The eyes were obtained at autopsy and fixed in 4% buffered formaldehyde. Serial sections through the macula area and inferior segments were prepared. Light as well as electron microscopy was performed. RESULTS: Microscopic examination disclosed numerous large drusen measuring up to 200 micro m in height and 280 micro m in diameter and areas of serous RPE detachments in the midperiphery of both eyes. Some of the large drusen had choroidal vascularization. Areas of sub-RPE neovascularization that measured up to 6.5 mm in diameter were present in the midperiphery of both eyes. The choroidal origin for neovascularization was evident in 10 areas. A 1-mm area of hemorrhagic detachment of the RPE contiguous with choroidal neovascularization (CNV) was present in the immediate postequatorial area temporally in the left eye. No drusen, basal deposit, or CNV was present in the macular area. CONCLUSION: Multifocal midperipheral RPE detachments and CNV can occur in the absence of significant age-related macular disease.     

Pneumatic retinopexy for the repair of retinal detachments: a comprehensive review (1986-2007)

Pneumatic retinopexy has become an important surgical technique in the modern era of retinal surgical management for retinal detachments. It is primarily indicated for uncomplicated retinal detachments with retinal breaks involving the superior 8 clock hours of the fundus, although more complex retinal detachments may be successfully managed with this technique on a selected basis. Qualified candidates must be willing to maintain a specific head posture for five or more days for optimal outcome with pneumatic retinopexy. Basic surgical steps of pneumatic retinopexy include retinopexy of retinal breaks with cryotherapy or laser, intraocular gas injection before or after retinopexy, and maintenance of proper head posture by the patient for the required time period after surgery. Phakic eyes fared better than nonphakic eyes for pneumatic retinopexy, with the single-operation successes of 71-84% for the former and 41-67% for the latter. Despite lower single-operation successes with pneumatic retinopexy in comparison to sclera buckling, the multicenter pneumatic retinopexy trial and other published reports have shown that the final anatomical and visual outcomes are not disadvantaged by the initial pneumatic retinopexy. An extensive discussion of complications associated with pneumatic retinopexy is presented. In addition, a key feature of this review is a comprehensive update in the outcome of pneumatic retinopexy in published reports from 1986 to the present in chronological order not available in the current literature. This comprehensive summary shows updated average surgical outcomes for the 4,138 eyes in the 21-year period to be similar to previous reports: single-operation successes (74.4%), final operation successes (96.1%), new retinal breaks (11.7%), and proliferative vitreoretinopathy (5.2%).