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Purpose: To examine the effect of internal limiting membrane (ILM) removal on epiretinal membrane (ERM) surgery by comparing best-corrected visual acuity (BCVA), optical coherence tomography central macular thickness (CMT) changes, ERM recurrence, and need for repeat surgery., Methods: Retrospective study of 251 consecutive patients (251 eyes) who underwent pars plana vitrectomy for idiopathic ERM by a single surgeon with over 1 year of follow-up data. Data were collected preoperatively and postoperatively at 3 months, 1 year, 2 years, and at the last visit. The ILM was not specifically removed in the earlier group of patients and was removed after staining of the ILM in the later group., Results: One hundred and forty eyes (55.8%) did not have an ILM peel (non-ILM group), and 111 eyes (44.2%) did have an ILM peel (ILM group). There were no significant differences between groups in age, gender, preoperative BCVA, preoperative intraocular pressure, preoperative CMT on optical coherence tomography, and cataract status. Total follow-up time for the ILM group was 32.1 months and 45.4 months for the non-ILM group (P = 0.002). Both groups had improvement in BCVA. The ILM group improved by 12 Early Treatment Diabetic Retinopathy Study letters and the non-ILM group improved by 10.5 Early Treatment Diabetic Retinopathy Study letters. There was no significant difference in the final BCVA (P = 0.18) or total change of BCVA (P = 0.48). Cataract status preoperatively did not affect the total change of BCVA, but being phakic at the most recent visit was associated with a slight loss of visual acuity. Both groups had improvement in optical coherence tomography appearance, for the CMT in the ILM group decreased by 83 μm and the CMT in the non-ILM group decreased by 110 μm. There was no significant difference in the final CMT (P = 0.07); however, the non-ILM group tended to have a lower final CMT. Some degree of ERM recurrence was detected by slit-lamp biomicroscopy in 2 eyes (1.8%) of the ILM group and in 32 eyes (22.9%) of the non-ILM group (P ≤ 0.0001). None of the eyes with ILM removal required repeat vitrectomy, whereas 17 eyes (12.1%) of the non-ILM group did require vitrectomy, showing that ILM removal had a significant effect on the need for repeat vitrectomy (P < 0.0001) between non-ILM versus ILM peel groups., Conclusion: The rate of recurrent ERM and need for repeat ERM surgery is lower in eyes where the ILM is removed with the ERM, whereas BCVA and CMT were similar with or without ILM removal. Complete ILM removal around the macula should be considered for the treatment of eyes with idiopathic ERMs to reduce the incidence of ERM recurrences.

Purpose: To identify whether vitrectomy is associated with an increased risk of elevated intraocular pressure (IOP) and to report the incidence of open-angle glaucoma after vitrectomy., Methods: In this retrospective case series of 234 consecutive patients without a history of glaucoma or diabetes undergoing primary unilateral vitrectomy for an idiopathic epiretinal membrane or macular hole with a minimum of 2 years follow-up, mean IOP in operative and fellow eyes were compared at baseline and multiple postoperative times. Eyes were also assessed for the development of open-angle glaucoma., Results: The mean baseline IOP was 14.91 mmHg, and the mean final IOP was 14.6 (P = 0.278) in the operative eyes. Linear regression analysis of IOP in operative eyes from baseline to the final visit found an increase of 0.000047 mmHg per year compared with -0.00027 mmHg per year in the fellow eyes with no significant difference in the slope of the 2 regression lines (P = 0.27). Six vitrectomy eyes were diagnosed with new-onset open-angle glaucoma during a mean follow-up of 4.4 years; however, only one was not also diagnosed with glaucoma or ocular hypertension in the fellow unoperated eye., Conclusion: Vitrectomy does not seem to be correlated with increased risk of IOP elevation or glaucoma development in comparison with fellow control eyes.

Purpose: The goal of this study was to see how the availability of ranibizumab affected the referral patterns for low vision (LV) evaluation., Methods: This study used a retrospective review and a comparison of all patients newly referred from retinal Practice 1 (J.T.T., R.N.S.) for LV consultation, from July 2005 to June 2006 (Year 1, preranibizumab) and from July 2006 to June 2007 (Year 2, ranibizumab available), and a retrospective review of patients referred by retinal Practice 2 (M.J.E.) since February 2007., Results: Practice 1: In Year 1, 24 patients with choroidal neovascularization were referred for LV, and in Year 2, only 12 were referred. There was a trend for those patients referred in Year 2 to have worse visual acuity and Pelli-Robson contrast sensitivity than those in Year 1. In Years 1 and 2, 18 and 11 patients with other conditions were referred for LV consultation, respectively. For these patients without choroidal neovascularization, there was no significant difference between groups for visual acuity or contrast sensitivity. Practice 2: The mean best-corrected visual acuity of patients with bilateral choroidal neovascularization referred was 20/145, and no patient had visual acuity > or =20/100., Conclusion: Although the use of antivascular endothelial growth factor agents puts visual acuity in a zone more favorable for successful LV intervention, patients with better acuities may not be referred for LV evaluation despite their residual visual impairments and their scotomas, and despite the fact that without LV intervention, they are having difficulty with reading and other activities of daily living. The frequent visits required for monthly injection, the tendency to wait until a course of therapy is complete before referring patients, and a lesser appreciation for the need for LV intervention in patients with only moderate visual loss may be factors in explaining this.

Purpose: To evaluate the results of vitrectomy for epiretinal membrane in eyes with a preoperative visual acuity of 20/50 or better., Methods: The visual results and complications of vitrectomy for epiretinal membranes were analyzed in a retrospective, consecutive case series of 40 eyes of 40 patients treated by a single surgeon., Results: The mean preoperative visual acuity was 20/50 + 2 (range 20/30 + 1 to 20/50 -3). The mean visual acuity improved to 20/40 + 2 (P = 0.02) by the final examination at a mean of 2.4 years following surgery. The status of the lens at the final examination was correlated with the visual results of surgery. Twenty-one eyes were phakic preoperatively and 14 of these eyes had cataracts removed by the final examination. The mean preoperative visual acuity in 7 eyes which were still phakic at the final examination was 20/50 and this decreased to 20/50 -2 (P = 0.82). The mean preoperative visual acuity was 20/50 + 2 in 33 eyes which were pseudophakic by the final examination and this improved to 20/32 -2 (P = 0.005). There were no other serious complications such as retinal detachment or infectious endophthalmitis., Conclusions: Vitrectomy for epiretinal membranes is safe in eyes with relatively good preoperative visual acuities but cataract surgery is necessary in phakic eyes to achieve long-term visual acuity improvement.

Purpose: To evaluate the results of macular hole surgery in patients over 80 years of age to determine if surgery is beneficial in an elderly patient population., Methods: Twenty consecutive patients over age 80 with idiopathic macular holes and 20 nonconsecutive controls younger than 80 years treated for idiopathic macular holes were compared in a retrospective, consecutive case-control series., Results: The macular hole was closed 3 months after surgery in 19/20 eyes (95%) of patients over age 80 years and 17/20 eyes (85%) of patients under 80 years. The mean preoperative visual acuity was 20/160 in patients over 80 years and 20/160-1 in patients under 80 years. The mean visual acuity at 3 months was 20/63 in eyes of patients over 80 years and 20/80 in eyes of patients under 80 years (P = 0.3). The mean visual acuity was 20/50-2 in eyes of patients over 80 years and 20/63-2 in eyes of patients under 80 years at the final examination (P = 0.403)., Conclusions: Macular hole surgery is beneficial in patients over 80 years of age, with very similar results to those of patients younger than 80 years of age. Age should not be the primary criterion for recommending macular hole surgery.

Purpose: To evaluate the visual and anatomic results of macular hole surgery in eyes that have had symptoms of a macular hole for 2 years or longer., Methods: Fifty-one eyes with chronic macular holes (> or = 2 years' duration) were treated in a retrospective analysis of the results of vitrectomy, 16% perfluoropropane gas tamponade, and one of three adjunctive agents (bovine transforming growth factor beta-2, recombinant transforming growth factor beta-2, or autologous platelet extract). Of 51 eyes, 45 (88.2%) were examined 3 months after surgery. Visual acuity of these 45 eyes was measured preoperatively and 3 months postoperatively using the Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity chart. Twenty-eight eyes (62.2%) had no prior vitrectomy and 17 eyes (37.8%) had a prior vitrectomy for the macular hole that failed., Results: The macular holes had a mean duration of 3.7 years and were successfully closed in 32 of 51 total eyes (62.7%) and 32 of 45 eyes (71.1%) that were examined 3 months after surgery. The mean preoperative visual acuity was 20/100 -2 and the mean visual acuity at 3 months was 20/80 for a mean gain of 6.6 ETDRS letters (+ 1.3 lines). Of 45 eyes, 17 (37.8%) were 20/63 or better 3 months after surgery; 21 (46.7%) gained 2 or more ETDRS lines. There was no statistically significant difference in macular hole closure (P = 0.311) or visual acuity change (P = 0.095) in eyes with or without prior vitreous surgery. Eyes with macular holes between 2-2.99 years experienced a somewhat better anatomic and functional result overall than eyes with macular hole from 3-14 years, duration, but the visual acuity change was not statistically significant (P = 0.187). There was substantial variability in visual improvement among eyes with successful closure of the chronic macular hole., Conclusions: Macular holes of > or = 2 years' duration may be more difficult to close successfully than are more recent macular holes, and the visual improvement appears to be less favorable. Many eyes with chronic macular holes in our study gained substantial visual acuity, so vitreous surgery can be considered in selected eyes with chronic macular holes based on visual needs.

Purpose: The authors determined the anatomic and visual success rates of vitrectomy in patients who have failed previous macular hole surgery., Methods: Standardized Early Treatment Diabetic Retinopathy Study (ETDRS)-style best-corrected visual acuity was measured in each patient pre- and postoperatively. Surgery was performed at two centers using a standardized protocol, as previously reported, using 1330 ng bovine-derived transforming growth factor-beta 2 (TGF-beta 2) and 16% perfluoropropane internal gas tamponade. Endpoint analyses were conducted for anatomic closure of the hole, visual improvement of three or more ETDRS lines, and final visual acuity of > or = 20/63 and > or = 20/40., Results: Forty-eight failing macular hole surgery were reoperated. The anatomic results showed closure of the hole in 40 (83%) cases at the end of the mean follow-up interval of 7.4 months. The visual acuity improved in greater than or equal to three lines in 52%, was > or = 20/63 in 54%, and was > or = 20/40 in 25% of reoperated eyes. The only factor associated with a better final visual acuity was preoperative visual acuity better than 20/80. Nuclear sclerosis leading to cataract extraction was observed in 13 (30%) of 43 initially phakic eyes., Conclusions: Macular hole closure was induced in this subset of reoperated patients. Visual improvement occurred often, although in a lower percentage than has been reported for primary surgical eyes. Repeat vitrectomy should be considered in patients with persistent macular hole after failure of primary surgery.

Purpose: The authors compare the success of macular hole surgery with a short duration tamponade using 5% perfluoropropane (C3F8), intermediate duration tamponade using 10% C3F8, or a long duration tamponade using 16% C3F8 in a prospective consecutive clinical trial at two institutions., Methods: Vitrectomy and fluid-gas exchange was performed in 29 eyes treated with 5% C3F8 and 1 week of prone positioning, 30 eyes treated with 10% C3F8 and 2 weeks of prone positioning, and 90 eyes treated with 16% C3F8 and 2 weeks of prone positioning 90% of time, followed by 2 weeks of prone positioning 50% of time., Results: The macular hole was closed successfully in 19 of 29 eyes (65.6%) treated with 5% C3F8, 19 of 30 eyes (63.3%) treated with 10% C3F8, and 85 of 90 eyes (94.4%) treated with 16% C3F8 at 3 months (P = 0.00017 for 5% vs. 16% C3F8, P = 0.00006 for 10% vs. 16% C3F8). The visual acuity improvements measured by refraction using the Early Treatment Diabetic Retinopathy Study (ETDRS) acuity charts paralleled the success of macular hole closure. The acuity improved a mean improvement of + 9.6 ETDRS letters for eyes treated with 5% C3F8, + 6.4 ETDRS letters for eyes treated with 10% C3F8, and + 13.1 ETDRS letters in eyes treated in 16% C3F8., Conclusions: A long duration intraocular gas tamponade with 16% C3F8 gives a substantially higher success rate for macular hole surgery than a short (5% C3F8) or intermediate duration (10% C3F8) intraocular gas tamponade.

Background: Air travel is known to be potentially hazardous for patients with intraocular gas bubbles, and the external pressure changes associated with hyperbaric oxygen therapy and scuba diving could be similarly dangerous., Methods: Rabbits with a perfluoropropane/air gas mixture filling approximately 60% of the vitreous cavity of the right eye were exposed to 3 different hyperbaric pressure profiles to an equivalent depth of 33 feet. The first group were a control group and were not exposed to hyperbaric pressures. The second group remained at an equivalent depth of 33 feet for 30 minutes, and the third group remained at 33 feet for 1 minute. Both groups ascended to normal atmospheric pressure at a rate of 1 foot per minute. The fourth group remained at 33 feet for 1 minute and then ascended at a rate of 0.2 feet per minute., Results: In all eyes with an intraocular gas bubble, intraocular pressure dropped to zero when the atmospheric pressure was increased, and rose to more than 50 mmHg when the atmospheric pressure was returned to normal. Pressures in excess of 50 mmHg were sustained for 10 minutes or longer in each rabbit exposed to one of the hyperbaric profiles. No significant intraocular pressure changes were observed in eyes without an intraocular gas bubble or eyes not exposed to hyperbaric pressure., Conclusion: Marked elevation in intraocular pressure occurs as a result of hyperbaric exposure in eyes with an intraocular gas bubble. Hyperbaric exposure is therefore not advisable for patients with intraocular gas bubbles.

Purpose: Vitreous fluid that remains trapped in the peripheral vitreous cavity after vitrectomy with fluid-air exchange can result in a smaller than desired intravitreal gas bubble size. To evaluate the effectiveness of a single fluid-air exchange in dehydrating the vitreous cavity, we measured the rate and volume of posterior vitreous fluid migration after an initial fluid-air exchange., Methods: Thirty-eight eyes undergoing vitrectomy for macular hole closure had measurements of posterior vitreous fluid accumulation at either 5, 10, 15, or 20 minutes after fluid-air exchange., Results: An average of 0.38 ml of fluid accumulated posteriorly within 10 minutes after the initial fluid-air exchange compared to 0.22 ml that accumulated after 5 minutes (P = 0.0003). A mean of 0.04 ml accumulated during each 5-minute interval between 10 and 20 minutes after the initial fluid-air exchange., Conclusion: Fluid composing 10% of the vitreous volume may migrate and accumulate posteriorly within 10 minutes of an apparently complete fluid-air exchange. Fluid aspiration after a 10-minute wait after the initial fluid-air exchange helps maximize vitreous cavity dehydration and should be employed when a large gas bubble is required after vitrectomy.

Purpose: A technique for managing giant retinal tears without proliferative vitreoretinopathy (PVR) is presented, and visual outcome, anatomic reattachment, and postoperative complications are discussed., Methods: A total of 25 consecutive cases of retinal detachment from giant retinal tears in eyes without PVR that had not previously undergone surgery were reviewed. A surgical technique combining pars plana vitrectomy, perfluoro-octane, and fluid-gas exchange was used. Scleral buckling was performed in 23 (92%) of 25 eyes, and pars plana lensectomy was performed in 11 (69%) of the 16 phakic eyes. A minimum follow-up period of 6 months was documented in each case., Results: Of the 25 eyes, redetachment occurred in 3 (12%) after the initial procedure, and further surgery was necessary to successfully reattach the retina. A total of 9 secondary procedures were performed in 7 (28%) of the 25 eyes. Final retinal reattachment was achieved in all 25 eyes. Final Snellen visual acuity was 20/80 or better in 18 (72%) patients and 20/200 or better in 21 (84%) patients., Conclusion: The anatomic and visual results of this method of surgical treatment of giant retinal tears without PVR compare favorably to those achieved with techniques that use a nonbuckling approach, but with reduced ocular morbidity.

Previous studies of treatment of full-thickness macular holes have effected resolution of the surrounding subretinal fluid cuff in 58%-71% of cases. An initial report has found 330 ng and 1,330 ng transforming growth factor-beta 2 to be successful in effecting resolution of the surrounding subretinal fluid cuff in 100% of cases. A randomized, masked, controlled, prospective, multicenter study of 90 patients with full-thickness macular holes was performed to assess the efficacy of the local application of TGF-beta 2 at the time of vitrectomy surgery. Eligibility criteria included: (1) best corrected visual acuity of 20/80 or worse; (2) duration of macular hole for less than 1 year; and (3) absence of other ocular disorders that might interfere with vision. Patients were evenly randomized to receive placebo, 660 ng transforming growth factor-beta 2, or 1,330 ng transforming growth factor-beta 2. The treatment assignment was unmasked at the examination 3 months after treatment only if the macular hole failed to close. If the initial treatment had been placebo, patients were offered crossover to 1,330 ng transforming growth factor-beta 2 during a reoperation. It can be deduced that resolution of the subretinal fluid cuff occurred in 16 of 30 placebo-treated eyes, 53 of 58 eyes treated with transforming growth factor-beta 2, and in 9 of 13 cases (69%) initially treated with placebo that subsequently underwent repeat surgery under the crossover option.(ABSTRACT TRUNCATED AT 250 WORDS)

The current two-dimensional (2D) retinal drawing chart is an azimuth equidistant representation of the retina. The distortion produced by this chart was analyzed and compared to other 2D projections, such as stereographic, equal area, and orthographic maps of the retina. Circumferential distortion was calculated for lesions at varying distances from the macula using the azimuth equidistant retinal map and was found to increase exponentially as a function of the distance from the macula. Circumferential distortion was 57.1% at the equator, 88.5% 3 mm anterior to the equator, and 137.8% 6 mm anterior to the equator. A three-dimensional (3D) model of the retinal surface was created using 3D computer assisted design (CAD) software. This 3D model was able to represent retinal lesions such that their true size, shape, location, and orientation were all conserved. Retinal lesions could be viewed from multiple angles and examined in cross section. The use of 3D CAD software coupled with ultrasound or magnetic resonance imaging data has the potential to represent retinal lesions more accurately than current methods.

The authors prospectively studied 67 eyes of 64 patients undergoing pars plana vitrectomy without a scleral buckle to determine the effect of surgery on postoperative corneal curvature. An average of 1 D of against-the-rule astigmatism was induced in the immediate postoperative period. This astigmatic change spontaneously regressed to less than 0.15 D by the 7th postoperative week. Pars plana vitrectomy does not induce clinically significant corneal astigmatism.

A 62-year-old man was noted on routine examination to have a dark lesion in the peripheral fundus of the right eye and a corresponding dark scleral mass. The lesion was initially suspected to be a choroidal melanoma with extrascleral extension. The patient denied having ocular trauma. Orbital x-rays and ultrasonography, however, demonstrated the lesion to be an occult transcleral metallic foreign body. An occult foreign body should be considered in the differential diagnosis of a small choroidal or ciliary body melanoma with extrascleral extension.

We derived a formula to compare the chord length and scleral arc length, when using calipers to measure the distance for suture placement, during retinal reattachment surgery. The scleral arc length is slightly longer than the chord length (caliper setting). The difference is 0.16 mm (2.0%) for an 8mm caliper setting, 0.31 mm (3.1%) for a 10 mm setting, and 0.74 mm (5.7%) for a 13 mm setting. The difference in the chord and arc length is small, but the surgeon can select a slightly reduced caliper setting, if more precise estimation of the arc length is desired.

Retinal pigment epithelial (RPE) cells were obtained from human cadaver eyes and grown to confluence in 16 mm wells. A sterile intact rabbit vitreous body was isolated and placed on the RPE monolayer. RPE cells with fibrocyte-like morphology appeared over the RPE monolayer within 4 to 6 days. These rapidly proliferating cells were observed to extend cellular processes and migrate into the vitreous body. Migration of the RPE cells progressed over 20 to 40 days, at which time bipolar RPE cells were found in multiple layers of the vitreous body. The contractile properties of the migrating RPE cells were evident as 24% of vitreous bodies contracted into a dense cellular gel. This study provides a model of migration of RPE cells in the vitreous and allows study of the interaction of RPE with the intact vitreous gel.