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Traumatic optic neuropathy can have varying presentations. Blunt focal trauma can lead to optic nerve avulsion with underlying retinal findings. A case of partial optic nerve avulsion after finger poke injury leading to focal retinal ischemia is reported.Visual acuity, fundus photography with fluorescein angiography, and spectral-domain optical coherence tomography were performed to document the findings in a 16-year-old man who presented after a finger poke injury to the left orbit during a water polo match.On initial presentation, examination revealed decreased visual acuity with a fixed left pupil and afferent pupillary defect by reverse. On slit-lamp examination of the left eye, a hyphema was present. Dilated fundus examination revealed layering vitreous hemorrhage over the posterior pole and an avulsed vitreous base. On follow-up, a gap temporal to the optic nerve head consistent with a partial optic nerve avulsion was noted once the vitreous hemorrhage cleared. Multimodal imaging revealed retinal ischemia temporal to the disc on fluorescein angiography with corresponding changes in the inner retinal layers and retinal nerve fiber layer using spectral-domain optical coherence tomography.Clinicians should have a high suspicion for optic nerve avulsion if a patient presents with new vitreous hemorrhage and afferent pupillary defect after a finger-poke injury. Optic nerve avulsion injury can cause retinal ischemia, likely because of interruption of retinal blood flow as a result of nerve shearing injury. Multimodal imaging can reveal focal retinal injury and aid in proper diagnosis and follow-up.

PURPOSE To describe transcorneal sutureless silicone oil removal using 23-gauge trocars as an alternative surgical technique in an aphakic eye. METHODS We retrospectively evaluated the management of a 50-year-old male patient who had a history of bilateral congenital cataract removal at the age of 5 and developed rhegmatogenous retinal detachment. A 3-port 23-gauge pars plana vitrectomy, removal of the vitreous up to the vitreous base, 60° temporal retinotomy, and anterior flap retinectomy were performed. Silicone oil (1,000 cSt) was selected as a tamponading agent. The patients underwent active silicone oil removal at subsequent surgery 2 months after the initial vitrectomy. RESULTS The silicone oil was successfully extracted from the aphakic eye by using transcorneal 23-gauge trocars. No suture was needed at the corneal wound sites. There were no intraoperative or postoperative complications. CONCLUSION Transcorneal silicone oil removal using 23-gauge trocars can be performed easily with today's modern vitreoretinal surgery systems as an alternative treatment modality.

Purpose To report management of de novo vitreous amyloid opacities after previous pars plana vitrectomy in familial amyloidotic polyneuropathy transthyretin Val30Met. Methods This work is a retrospective observational consecutive case series of five eyes of four patients. Demographic data, transthyretin mutation involved, age at the beginning of disease, duration of disease, treatment (liver transplant or tafamidis), time between vitrectomy and re-intervention, and ophthalmologic changes were evaluated. Surgical re-intervention included phacoemulsification with intraocular lens implantation in phakic eyes, re-vitrectomy as complete as possible with posterior capsulectomy, and internal limiting membrane peeling if wrinkling of internal retinal surface was present. Results All patients had transthyretin Val30Met mutation, and three were women. Mean age of onset of the disease was 52 ± 11.0 years, and average evolution time of the disease was 8 years. Three patients had been submitted to liver transplant 4, 9, and 15 years before. Time between first vitrectomy and surgical re-intervention was longer than 2 years in all cases. Two eyes had amyloid deposits on anterior lens surface and pupillary border with scalloped pupil. Two eyes were phakic. Glaucoma was present in two eyes; one of them had previous trabeculectomy. All cases had vitreous opacities behind posterior lens capsule and at vitreous base area. After re-intervention, no further recurrence was observed (average follow-up of 10 months). Conclusion De novo vitreous amyloid opacities may occur several years after pars plana vitrectomy. Amyloid deposition in vitreous cavity was observed only in strong vitreous adherence locations (behind posterior lens capsule and at vitreous base area). The authors expect that this procedure, an extensive re-vitrectomy associated with posterior capsulectomy, will prevent de novo vitreous amyloid opacities.

Purpose To evaluate the feasibility, advantages, and safety of a novel lutein-based dye for improving identification and removal of the vitreous, internal limiting membrane, and epiretinal membrane during chromovitrectomy in humans. Methods We prospectively evaluated 12 eyes that underwent pars plana vitrectomy using the dye in patients with macular hole, epiretinal membrane, or proliferative diabetic retinopathy/tractional diabetic macular edema. One surgeon performed standard chromovitrectomy and completed a postoperative questionnaire to compare the staining with that of the available dyes. The peeled membranes were evaluated histologically. Follow-up examinations were performed on postoperative Days 1, 7, 30, 90 and 180; best-corrected visual acuity, optical coherence tomography, fluorescein angiography, autofluorescence, and visual fields were performed. Results The green dye was deposited on the posterior pole because of its higher density than balanced saline solution; vigorous dye flushing into the vitreous cavity was unnecessary. The dye stained the posterior hyaloid/vitreous base by deposition onto the vitreous; brilliant blue stained the internal limiting membrane. The epiretinal membrane was poorly stained. The best-corrected visual acuity improved in all eyes without clinical toxicity or toxicity on images/visual fields. Histology showed effective removal of the internal limiting membrane and epiretinal membrane in all eyes. Conclusion The new dye improved intraoperative identification of the internal limiting membrane and the posterior hyaloid/vitreous base during chromovitrectomy.

PURPOSE To evaluate the incidence of retinal redetachment after the removal of silicone oil endotamponade for complicated retinal detachment and identify possible factors affecting outcome. METHODS This is a retrospective review of 173 patients who underwent pars plana vitrectomy with silicone oil tamponade for complex retinal detachment and subsequent removal of silicone oil (ROSO). The outcome factors studied included anatomical success, best-corrected visual acuity and intraocular pressure pre- and post-ROSO. RESULTS Anatomical success was achieved in 167 of the 173 eyes (96.5%) after ROSO. The mean duration of silicone oil tamponade was 70 ± 48 weeks (median, 56 weeks; mode, 48 weeks). The cause for primary retinal detachment was proliferative diabetic retinopathy in 36 (20.8%) and proliferative vitreoretinopathy in 137 of 173 cases (79.2%). Best-corrected visual acuity of greater than 20/100 was achieved in 83 cases (49.4%) at 3 months after ROSO. Levene's test for equality of variances was used to determine the association between previous unsuccessful retinal surgeries and redetachment (P = 0.523) and between duration of endotamponade and anatomical success (P = 0.451). CONCLUSION The incidence of retinal redetachment after ROSO in our study was 3.46%. Aggressive removal of the vitreous base, performing retinotomies, ensuring complete silicone oil filling for adequate tamponade, and argon retinopexy can lead to low complication rates and improved outcomes.

Vitreoretinal surgery has undergone remarkable transformations since the first successful pars plana vitrectomy (PPV) was performed by Robert Machemer in 1970. Modern instrumentation and surgical techniques have led to shorter operating times and faster recovery for many patients. This has broadened indications for even lower thresholds of incident visual acuity, but has PPV evolved to the degree to where it can be considered “minimally-invasive?” In the present issue of Retina, Mason et al and Sebag et al describe sutureless, 25-gauge PPV as a successful treatment modality for the management of vitreous floaters associated with posterior vitreous detachment (PVD), myopic vitreopathy, vitreous syneresis, and asteroid hyalosis.[1,2] Both studies report low complications rates and describe a minimalistic approach to surgery that generally involves performing a core vitrectomy, leaving the posterior hyaloid attached in most eyes without pre-existing PVD and preserving the anterior hyaloid face in an attempt to delay cataract formation. More extensive vitreous removal with shaving of the vitreous base is advocated only in cases with retinal breaks. In both of these series, the reported surgical outcomes are favorable. Mason et al retrospectively reviewed 168 eyes of 143 patients undergoing PPV for symptomatic vitreous floaters. Their high surgical success rate was based on 94% of patients rating their experience as a “complete success” and 92% of patients reporting either no symptoms or extremely mild symptoms of floaters after surgery. Complications were relatively few and included 12 eyes (7.1%) with iatrogenic retinal breaks, 2 eyes with transient vitreous hemorrhage, 1 eye with cystoid macular edema, and no eyes with postoperative retinal detachment or endophthalmitis at a mean follow up of 18 months. A visually significant cataract requiring phacoemulsification developed in 9 (16.1%) of the 56 phakic eyes. The authors demonstrated a statistically significant improvement in best corrected visual acuity, which improved from a mean of 20/40 preoperatively to 20/25 postoperatively. In the series by Sebag et al, 76 eyes with symptomatic vitreous floaters underwent PPV. They prospectively evaluated contrast sensitivity in 16 patients and demonstrated a significant improvement using Freiburg Acuity Contrast Testing following surgery. Complete resolution of symptoms was seen in 15/16 (93.8%) patients in this group. Complication rates were retrospectively assessed in 60 patients and were low, with 1 eye (1.7%) developing a macular pucker and no eyes experiencing iatrogenic retinal breaks, vitreous hemorrhage, postoperative retinal detachment or endophthalmitis at a mean follow up of 17.5 months. A visually significant cataract requiring phacoemulsification developed in 8 (23.5%) of the 34 phakic eyes. It is not at all surprising that PPV is successful in resolving symptoms associated with primary vitreous floaters. The most important concern in these patients, however, must be long-term safety. As the authors appropriately emphasize, many of these patients are young, a high percentage are phakic, and nearly all have good preoperative visual acuity, thus there is potential for substantial complications. The excellent surgical outcomes described in these two papers must be contrasted to previous reports in this regard. Two recent large retrospective series out of Europe by De Nie et al and Schulz-Key et al, with longer average follow up of 26.4 and 37 months respectively, report higher complication rates including cataract formation requiring phacoemulsification in 50.0-60.5% of phakic eyes, postoperative retinal detachment in 6.8-10.9% of eyes, and cystoid macular edema in 5.4-5.5% of eyes, some of which was refractory to treatment and resulted in permanent vision loss.[3,4] Other patients lost vision as a result of glaucoma, macular hole formation and photoreceptor disruption. Although patients in these studies underwent primarily 20-gauge and 23-gauge PPV, it is notable that the majority of patients developing retinal detachment did so in a delayed fashion, often years following the original PPV. Tan et al reported a lower retinal detachment rate of 2.5% in a series of mostly 25-gauge PPV cases, but mean follow up was limited to 10.1 months.[5] Additionally, long term data shows an increased risk of open angle glaucoma after pars plana vitrectomy, occurring at a mean of 46 months after surgery in phakic eyes and 18 months in nonphakic eyes.[6] Other rare, but serious risks of PPV include suprachoroidal hemorrhage and endophthalmitis. Furthermore, risks associated with retrobulbar anesthesia should not be dismissed and include vision threatening complications such as retrobulbar hemorrhage, strabismus, and globe perforation as well as life-threatening complications associated with central nervous system spread of anesthesia or adverse reactions to anesthetic agents. Sebag et al suggest that with “modern surgical instrumentation and judicious technique” the risks of surgery can be mitigated and that their study demonstrates that “treating floaters with sutureless 25-gauge vitrectomy without PVD induction can be uniformly safe.” While Mason et al and Sebag et al demonstrate low complication rates in a significant number of eyes, it is important to recognize that these are primarily retrospective studies that are not sufficiently powered to evaluate safety. The authors bring up several other interesting and worthwhile points. Mason et al suggest the following in regards to patients who are bothered by symptomatic vitreous floaters: “From the patient's perspective, the ophthalmologist who has ruled out pathology such as retinal breaks has failed to address their health and quality of life.” Here arises the age-old ethical dilemma of balancing beneficence and non-maleficence. As physicians we have an obligation to acknowledge and to be responsive of patient concerns. On the other hand, we have a commitment to our patients to first do no harm. Is a reduction in contrast sensitivity enough of an indication to support this procedure, when a patient has excellent visual acuity? Additionally, patients with vitreous floaters often improve spontaneously as they gravitate out of the visual axis, as opacities move anteriorly and out of focus with progressive vitreous collapse, or as individuals’ psychophysical attention is no longer stimulated as strongly. Subjecting patients to surgery may place them at unnecessary risk when they may have improved with observation alone. The authors of these studies cite impairment in activities of daily living (Mason et al and Sebag et al), contrast sensitivity (Sebag et al) or well-being (Sebag et al) as the primary inclusion criteria for surgical intervention. It is somewhat surprising, however, that hundreds of patients presenting to these centers, over a short time period, would be impaired to the extent that PPV is required. The potential for severe complications should give patients and surgeons a reason to pause before undertaking this procedure for modest levels of functional impairment. In the case of a patient with symptomatic vitreous floaters, we must seek to understand their degree of impairment and to weigh these concerns against potentially-blinding risks of PPV. As the authors in both studies emphasize, vitreous floaters can have a negative impact on quality of life.[1-5,7-8] In fact, a utility analysis performed by Wagle et al found that patients with floaters were willing to trade away an average of 1.1 out of every 10 years of their remaining life to get rid of their floaters, and were willing to take an 11% risk of death and a 7% risk of blindness to get rid themselves of symptoms associated with vitreous floaters.[7] Previous data also demonstrates, using National Eye Institute Visual Function Questionnaire-39, that general vision, near activities, distance activities, and mental health significantly improve in selected patients undergoing PPV for floaters.[9] But, as Mason et al are careful to point out, only in a minority of patients with symptomatic vitreous floaters will activities of daily living be significantly affected. While PPV should be considered in this small subset of patients, it is important that these patients receive proper informed consent in regards to the risks of PPV. This group of patients might be fertile for abuse. One wonders if this movement will evolve to the point where we see the retina specialist advertising “floaterectomies” on billboards or offering office-based PPV for “simple cases” such as these. Only time will tell. However, we do know that all cases of PPV are associated with potential ocular, anesthetic, and systemic risks. Therefore, retina specialists need to be careful in referring to PPV as “minimally-invasive.” Such language has the potential to trivialize the performance of PPV and does a disservice to our profession and our patients. The overriding principle must be good principles.

Background The pathogenesis of rhegmatogenous retinal detachment is complex, and our knowledge of the exact mechanism of vitreoretinal attachment and detachment remains incomplete. Methods We performed a Medline, Ovid, and EMBASE search using search words rhegmatogenous, retinal detachment, vitreous, and retinal adhesion. All appropriate articles were reviewed, and the evidence was compiled. Results Cortical vitreous contains fibrillar collagens type II, V/XI, and IX. The inner limiting membrane of the retina contains collagens type I, IV, VI, and XVIII as well as numerous other glycoproteins and potential adhesion molecules. The distribution and age-related changes in the structure of these molecules play an important role in the formation of a retinal break, which may compromise and disrupt the normal mechanisms of neurosensory retinal adhesion. Conclusion Rhegmatogenous retinal detachment development is intimately related to changes in the fibrillar structure of the aging vitreous culminating in posterior vitreous detachment with regions of persistent and tangential vitreoretinal traction predisposing to retinal tear formation. A complex interplay of factors such as weakening of vitreoretinal adhesion, posterior migration of the vitreous base, and molecular changes at the vitreoretinal interface are important in predisposing to focal areas of vitreoretinal traction precipitating rhegmatogenous retinal detachment. Once formed, the passage of liquefied vitreous through a retinal break may overwhelm normal neurosensory-retinal pigment epithelium adhesion perpetuating and extending detachment and causing visual loss. To understand the molecular events underlying rhegmatogenous retinal detachment so that new therapies can be developed, it is important to appreciate the structural organization of the vitreous, the biology underlying vitreous liquefaction and posterior vitreous detachment, and the mechanisms of vitreoretinal attachment and detachment.

Purpose: To evaluate and compare the performance of several designs of 20-gauge dual port (DP) vitreous cutter tips with a standard 20-gauge single port tip. Methods: Custom 20-gauge pneumatic vitreous DP cutter tips with different sizes and port positions were evaluated through porcine vitreous and water flow rates. Five designed and fabricated DP cutter tips were compared with a normal single port control tip and evaluated by the measurement of water and porcine vitreous flow rates, and surgical examination in enucleated porcine eyes. Results: Some DP tips approached a maximum vitreous and water flow rates, removing water and vitreous faster than the normal control tip. With reference to surgical evaluation, some DP tips performed better than the single port tip for bulk vitrectomy, but none shaved the vitreous base more effectively. Conclusion: The DP cutter system has the potential to increase the flow rates depending on the size and position of the extra port. In the future, the DP cutter may allow the surgeon to perform bulk vitrectomy more efficiently.

PURPOSE To investigate the incidence and risk factors of sclertomy leakage and postoperative hypotony after 23-gauge transconjunctival sutureless vitrectomy. METHODS This was a retrospective study including 322 eyes of 292 patients who underwent 23-gauge transconjunctival sutureless vitrectomy by a single surgeon with minimum follow-up period of 1 month. The incidence and risk factors of intraoperative suture placement for leaking sclerotomies and postoperative hypotony (

PURPOSE To investigate whether an injection of plasmin and sulfur hexafluoride (SF6) can induce posterior vitreous detachment (PVD) without vitrectomy. METHODS One eye each of 15 New Zealand white rabbits was assigned to one of three groups. Eyes in group 1 received a vitreous injection of 1 unit of human plasmin (0.1 mL reconstituted in balanced salt solution) and 0.5 mL of SF6; eyes in group 2 received a vitreous injection of plasmin alone; eyes in group 3 received a vitreous injection of SF6 alone. Seven days after injection, all animals were monitored electroretinographically and killed, and the eyes were enucleated. After fixation, scanning electron microscopy was performed. RESULTS In group 1 eyes, the retinal surface was smooth except for the vitreous base, which showed complete separation of the vitreous cortex from the retina, indicating PVD. In group 2 and 3 eyes, sparse collagen fibers remained on the retinal surface. CONCLUSION Vitreous injection of plasmin combined with SF6 can induce PVD without vitrectomy.

PURPOSE To evaluate the frequency of peripheral vitreoretinal adhesions in the region of the vitreous base by ultrasound examination in relation to axial length of the eye and the age of the patient. Patient gender and the presence of visual symptoms also were considered. METHODS A total of 228 consecutive patients (445 eyes) underwent biometry, ultrasound examination, and biomicroscopic fundus examination. Their medical history also was taken. The patients were divided into three groups according to axial length of the eye ( 26.5 mm) and into three age groups (20-40 years, 41-60 years, and > 60 years). RESULTS No correlations was found between peripheral vitreoretinal adhesions and gender or between peripheral vitreoretinal adhesions and axial length of the eye. A significant correlation was found between peripheral vitreoretinal adhesions and age (P < 0.001). The proportion of adhesions increased with age (P < 0.001). The association between adhesions and presence of symptoms also was significant (P < 0.001). Multivariate analysis showed that only the presence of symptoms independently correlated with adhesions (relative risk, 1.71, 95%; confidence interval, 1.19, 2.46). CONCLUSION Our study shows that peripheral vitreoretinal adhesions, detected by ultrasound, were always associated with the presence of symptoms.

PURPOSE To discover if clinical nontraumatic phakic retinal detachments in the elderly possess characteristics that distinguish them from similar cases in younger persons. METHODS A retrospective study of 100 consecutive cases in patients aged 70 years and older was performed. Recorded data included patient age and sex, type and location of retinal break, extent of detachment, and associated vitreoretinal pathology. RESULTS Approximately 90% of retinal breaks were horseshoe tears, and the majority were located in the superior temporal quadrant. Horseshoe tears confined to the posterior margin of the vitreous base were responsible for retinal detachments in 30% of cases, and an additional 36% of breaks were located anterior to the equator. CONCLUSION The incidence of this type of anterior break is higher than that previously described for phakic retinal detachments, although previous studies have not discussed break types as a function of old age. Anterior horseshoe tears, which cause many phakic retinal detachments in the elderly, may not be caused by acute posterior vitreous detachment, but rather to persistent chronic traction on the vitreous base after posterior vitreous detachment.

Eighteen eyes with examples of clinically important wound-related complications are reported. These include hemorrhage, fibrous ingrowth, and tractional or mechanical problems. Wound hemorrhages may occur early or late and can be the cause of substantial morbidity. Furthermore, intraocular blood is undesirable because it may provoke cataract formation, contribute to the postvitrectomy fibrin syndrome, induce fibrovascular proliferation, and lead to further surgery to remove the blood. Fibroplasia at the wound sites may in some patients contribute to the development of anterior hyaloid fibrovascular proliferation. Fibrous ingrowth may occur early or late and may be self-limited, with few side effects, or florid, with progression to retinal detachment or phthisis bulbi. Dilation of subconjunctival blood vessels entering the incision site suggests the presence of fibrous ingrowth or fibrovascular proliferation occurring in the vitreous base. Tractional or mechanical problems include retinal breaks, which may or may not lead to retinal detachment, and scarring within the vitreous base, which may contribute to the formation of anterior vitreoretinal traction or anterior proliferative vitreoretinopathy.

Retinal detachment secondary to proliferative vitreoretinopathy (PVR) is often precipitated by traction on the retina from preretinal membranes and traction on the vitreous base. Contraction and proliferation of retinal pigment epithelial (RPE) cells appear to play an important role in the pathogenesis of PVR. Contraction of collagen gels by human RPE cells was evaluated as a model of tractional forces on the vitreous gel. The area of collagen gels with admixed RPE cells in 15-mm wells was measured daily. The collagen gels contracted to less than 50% of original area in 89% of wells. Colchicine (0.01-1 microM) inhibited RPE-induced collagen gel contraction, whereas 1 ng/ml of transforming growth factor-beta enhanced it. Potential stimulators or inhibitors of RPE-mediated gel contraction can be tested using this model.

Retinal detachment was studied in a rabbit model of penetrating ocular injury with retinal laceration. The injury was an 8 mm perforation through the sclera, choroid, and retina with vitreous loss and incarceration. When the injury was located at the equator of the globe, the rate of retinal detachment was 16%, but if located at the ora serrata, the rate was 78%. The higher rate of retinal detachment following injuries located at the ora serrata is probably due to the involvement of the vitreous base.

The types and locations of retinal tears associated with 268 pseudophakic retinal detachments were studied as a function of the time at which they occurred following cataract surgery. Retinal detachments occurring more than two years following cataract extraction were significantly more likely to have their most posterior retinal break located at the posterior margin of the vitreous base than at or behind the equator. This distribution of tears was not observed in detachments occurring within six months of cataract surgery, with equatorial tears being significantly more common in early onset detachments than in those occurring after two years. The anterior tears which cause most retinal detachments long after cataract extraction are due to persistent chronic traction upon the vitreous base rather than to acute posterior vitreous detachment. RETINA 9:181-186, 1989

A case of advanced pigmentary retinal degeneration is described. Posterior subcapsular cataract and a remnant of the anterior hyaloid system on the posterior lens surface were found. Extensive dispersion of pigment and organization of the vitreous base were present. Gliosis was seen in the retina, and no photoreceptors were evident. The retinal blood vessel walls were extensively hyalinized, with cell debris and deposition of basement-membrane-like material, which may have originated from perivascular pigment-laden cells of pigment epithelial origin. The pigment epithelium showed extensive proliferation in clumps. Pigmented retinal pigment epithelium (RPE) cells without lipofuscin, migrating nonpigmented RPE cells, and macrophages with large lysosomal bodies could be identified in each clump. An abundance of extracellular basement-membrane-like material or mucopolysaccharide was seen in the retina and adjacent to the RPE. This material probably originated from the abnormal RPE. Abnormalities of the large and small choroidal vessels are present.

Idiopathic retinal dialyses accounted for 1.8% of 1,789 eyes with rhegmatogenous retinal detachments diagnosed in two institutions over the 6-year period from 1972 through 1977. These detachments characteristically occur in the inferotemporal quadrant of young adult eyes and often are associated with demarcation lines, retinal cysts, peripheral microcystoid degeneration, and yellow-white vitreous opacities. This study provides additional evidence that a distinct type of retinal detachment secondary to nontraumatic retinal dialyses exists. The authors believe that these dialyses probably are secondary to a developmental abnormality of the inferotemporal periphery of the retina and vitreous base. Trauma may precipitate these dialyses but is not the primary cause.

Using a new temporary keratoprosthesis in an eye with an opaque cornea and a proliferative vitreoretinopathy, a pars plana vitrectomy combined with a silicone oil injection was successfully performed. The new keratoprosthesis is made of silicone rubber and is fixed to the threphined corneal bed with four 10-0 nylon sutures. It permits an excellent view of the intraocular structures and allows vitreoretinal surgery even in the region of the pars plana and vitreous base. It is replaced by a corneal graft at the end of the vitrectomy.