Search

Purpose: To study the clinicopathologic features of an untreated macular hole in the right eye and a macular hole in the left eye treated by vitrectomy, application of transforming growth factor-beta 2, and gas tamponade., Methods: The patient, a 73-year-old man with bilateral macular holes, was studied clinically before and after surgical treatment of the macular hole in his left eye. The patient's eyes were obtained postmortem and serially step-sectioned through the macula and optic nerve head for electron microscopy., Results: Examination of 1-micron thick plastic-embedded sections through the macula of the right eye disclosed a 0.6-mm macular hole with rounded gliotic margins, a thin epiretinal membrane, and parafoveal cystic changes. Examination of 1-micron thick plastic-embedded sections through the macula of the left eye disclosed a 0.25-mm defect in the fovea, which was bridged by glial cells. The glial cells were continuous with a thin hypocellular epiretinal membrane without contraction features on both sides of the defect. The ultrastructural features of the glial cells were consistent with Mueller cells., Conclusions: Treatment of a macular hole with vitrectomy, transforming growth factor-beta 2, and gas tamponade was followed by complete closure of the macular hole by Mueller cell proliferation.

Purpose: To determine the incidence and timing of increased intraocular pressure in eyes with an idiopathic macular hole treated with bovine transforming growth factor-beta 2 (TGF-beta 2) with different intraocular gas concentrations, recombinant TGF-beta 2, or placebo., Methods: Intraocular pressure was measured preoperatively and two days, two weeks, six weeks, and three months postoperatively in two prospective studies of the treatment of idiopathic macular hole with vitrectomy. Group 1 consisted of 95 eyes treated with bovine TGF-beta 2. Eyes in this group were treated with different concentrations of air and perfluoropropane (C3F8) intraocular gas bubbles. Fifteen eyes were treated with air, 15 eyes with 5% perfluoropropane, 15 eyes with 10% perfluoropropane, and 50 eyes with 16% perfluoropropane. Group 2 consisted of 29 eyes treated with recombinant TGF-beta 2. Twenty-six eyes were treated with placebo in a double-masked, randomized, placebo-controlled study evaluating recombinant TGF-beta 2 with a 16% perfluoropropane intraocular gas bubble., Results: At the two-week examination, the intraocular pressure in Group 1 eyes was > 30 mm Hg in four (26.7%) of 15 eyes treated with air, two (13.3%) of 15 eyes treated with 5% perfluoropropane, one (8.3%) of 12 eyes treated with 10% perfluoropropane, and nine (19.1%) of 47 eyes treated with 16% perfluoropropane. There was no statistically significant difference in the risk of increased intraocular pressure in eyes treated with short-, intermediate-, or long-duration gas tamponade using bovine TGF-beta 2. The intraocular pressure in Group 2 was > 30 mm Hg at the two-week examination in 11 (39.3%) of 28 eyes receiving recombinant TGF-beta 2 compared with one (4.3%) of 23 eyes receiving a placebo (P = .006)., Conclusions: Some eyes develop increased intraocular pressure after vitreous surgery for macular hole, and the increase occurs most frequently between two days and two weeks postoperatively. The risk of increased intraocular pressure is somewhat increased in eyes treated with bovine TGF-beta 2 but is markedly increased in eyes in which recombinant TGF-beta 2 is used as an adjunctive agent for macular hole surgery. Intraocular injection of growth factors produced by similar recombinant DNA techniques may result in potentially dangerous increased intraocular pressure several weeks after surgery. Impurities in the recombinant TGF-beta 2 may explain the relatively high risk of increased intraocular pressure.

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.

Purpose: To evaluate whether vitreous surgery is successful in closing full-thickness traumatic macular holes and whether there is subsequent improvement in visual acuity., Methods: Twelve eyes from 12 consecutive patients with traumatic macular holes underwent vitrectomy, fluid-gas exchange and instillation of bovine or recombinant transforming growth factor (TGF)-beta-2. Three of four eyes underwent repeat vitrectomy with TGF-beta-2 after the initial procedure failed to close the macular hole., Results: Eleven (92%) of 12 eyes had closure of the macular hole. Follow-up ranged from 3 to 33 months. Visual acuity improved by 2 or more lines in 8 (67%) of 12 eyes. Six (50%) of 12 eyes improved to 20/40 or better. All 3 eyes that underwent reoperation had successful closure of the macular hole and achieved 2 or more lines of visual improvement., Conclusion: Treatment of full-thickness traumatic macular holes with vitrectomy, fluid-gas exchange, and TGF-beta-2 may result in successful anatomic closure and visual improvement.

Background: Tangential macular traction by the posterior vitreous cortex has been widely accepted as the major causative factor in the development of idiopathic macular holes. Separation of the posterior cortical vitreous should relieve this vitreoretinal traction., Methods: The authors report five patients with idiopathic full-thickness macular hole formation that occurred in the presence of a well-documented pre-existing complete posterior vitreous detachment., Results: Of five eyes, three underwent pars plana vitrectomy and instillation of transforming growth factor-beta. No residual prefoveal cortical vitreous was present at the retinal surface at the time of surgery. Additionally, clinically identifiable epiretinal membranes were present in three of five eyes, but these epiretinal membranes were extremely thin, transparent, induced minimal traction, and did not warrant surgical peeling., Conclusion: It is likely that, in these five patients, some mechanism other than tangential traction by prefoveal vitreous cortex is responsible for idiopathic full-thickness macular hole formation.

Background: Intraoperative peripheral iatrogenic retinal breaks can be a serious complication of vitreous surgery. This study was undertaken to determine whether vitreous surgical techniques used for macular hole surgery were associated with a different incidence or distribution of retinal breaks., Methods: The authors prospectively evaluated a series of 181 consecutive eyes undergoing macular hole surgery. Contemporaneous reporting of intraoperative and postoperative retinal breaks and postoperative retinal detachments was performed. Comparison was made to historic controls of two case series of patients undergoing vitreous surgery for other indications., Results: Of 181 eyes, 10 (5.5%) had 15 intraoperative retinal breaks. Of the 15 breaks, 3 (20%) were in the quadrant near the surgeon's right-hand sclerotomy, 9 (60%) were in the two inferior quadrants, and 11 (73%) were in the two temporal quadrants. By comparison to previously reported case series, tears in our series were less likely to be near the right-hand sclerotomy (P = 0.00055) and more likely to occur in the two inferior retinal quadrants (P = 0.00015) and two temporal retinal quadrants (P = 0.0042). Two patients (1.1%) of 181 had postoperative retinal detachments., Conclusions: Patients undergoing vitreous surgery for macular hole have a similar incidence but different location of iatrogenic retinal breaks when compared with patients undergoing pars plana vitrectomy for other indications. These breaks are not distributed near sclerotomy sites and tend to be in the inferior and temporal retina. This establishes the need for greater intraoperative surveillance in these areas.

Background: The fluorescein angiographic characteristics in eyes with pseudoholes of the macula associated with epiretinal membranes have not been studied extensively., Methods: Stereo photographs and fluorescein angiograms from 83 consecutive eyes of 80 patients with pseudoholes of the macula were evaluated by two independent graders for epiretinal membrane opacity, fluorescence in the base of the pseudohole, and late perifoveal pooling of dye., Results: Hyperfluorescence in synchrony with choroidal fluorescence appeared within the base of the pseudohole in 52 (63%) of the 83 eyes studied. The hyperfluorescence was smaller than the pseudohole in 37 (45%) eyes. Diffuse hyperfluorescence filled the pseudohole in 15 (18%) eyes. No fluorescence was seen in 20 (24%) eyes. Eleven (13%) eyes could not be graded due to coexistent macular disease or media opacity. Fluorescence within the area of pseudohole was less common in eyes with opaque epiretinal membranes than in eyes with visible or transparent epiretinal membranes (P = 0.002). Fluorescence within the area of the pseudohole was also less common in eyes with evidence of macular edema on fluorescein angiography (P < 0.001). The mean visual acuity was better for eyes with hyperfluorescence within the area of the pseudohole than for eyes without hyperfluorescence (P < 0.01)., Conclusion: A common fluorescein angiographic characteristic associated with pseudoholes of the macula is early hyperfluorescence within the area of the pseudohole. This hyperfluorescence coincides with choroidal filling and appears to be a form of transmission defect rather than a blocking of surrounding choroidal fluorescence by the epiretinal membrane. This central hyperfluorescence may result in misdiagnosis of the macular pseudohole as a full-thickness macular hole.

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: We studied the progression of cataracts and visual acuity up to 36 months after vitrectomy and instillation of transforming growth factor beta-2 for treatment of full-thickness macular holes., Methods: Sixty-four eyes with idiopathic and two with traumatic macular holes in this prospective consecutive series were divided into the following two groups: 56 phakic eyes were treated with 70, 330, or 1,330 ng of transforming growth factor beta-2 to study the progression of cataracts, and 31 phakic or pseudophakic eyes were treated with 1,330 ng of transforming growth factor beta-2 to study the long-term visual acuity after macular hole surgery., Results: Eyes in the cataract progression study had a mean preoperative nuclear sclerosis grade of 0.4, which increased to 2.4 on final lens examination at a mean of 12.4 months postoperatively. The amount of nuclear sclerosis increased progressively with duration of follow-up, and 16 (76%) of 21 eyes followed up for 24 months or more required cataract extraction. The mean preoperative posterior subcapsular cataract grade was 0.0 and increased only slightly to 0.25 on final lens examination. All eyes had initial successful closure of the macular hole, but the macular hole reopened in two eyes (between six and 12 months and at 19 months) for an overall success rate of 29 (93.5%) of 31 eyes at a mean of 19.5 months. The visual acuity increased two or more Snellen lines in 29 (93.5%) of 31 eyes. The final visual acuity was 20/40 or better in 23 (74%) of 31 eyes and the visual improvement was stable in eyes followed up for three years., Conclusions: Nuclear sclerotic cataracts progress substantially after macular hole surgery with a long-acting intraocular gas tamponade. The visual acuity often decreases 12 or more months after vitrectomy because of cataract progression, but the visual results of vitrectomy and transforming growth factor beta-2 for macular holes are excellent when the cataracts are removed.

Purpose: To compare the effect of a long-acting (16% perfluoropropane [C3F8]) versus a short-acting (air) intraocular gas tamponade on visual outcome and macular hole closure rate after vitrectomy and intravitreal instillation of transforming growth factor-beta 2 (TGF-beta 2) on the macula., Methods: Vitrectomy with removal of the posterior hyaloid fluid-gas exchange with instillation of TGF-beta 2 was performed in 15 eyes treated with air and 37 eyes treated with 16% C3F8 using identical surgical techniques (mean follow-up, 5.6 months)., Results: The macular hole was closed successfully in 36 (97%) of 37 eyes treated with 16% C3F8 and in 8 (53.3%) of 15 eyes treated with air (P = 0.00007). The visual acuity improved by a mean of 3.1 lines on the Early Treatment of Diabetic Retinopathy Study chart for eyes treated with 16% C3F8 and 1.3 lines for eyes treated with air (P = 0.003)., Conclusions: A longer duration intraocular gas tamponade from 16% C3F8 gives a much higher rate of successful closure of macular holes and improved visual acuity using vitrectomy and TGF-beta 2 than does air.

We evaluated the fluorescein angiographic features of full-thickness macular holes before and after vitrectomy, fluid-gas exchange, and instillation of transforming growth factor beta-2 in 43 eyes in a masked fashion to evaluate the angiographic characteristics of macular holes preoperatively and the changes that occur with successful and unsuccessful closure of the macular hole. Hyperfluorescence was present in the base of the macular hole preoperatively in 34 of 43 eyes (79.1%), was questionable in eight of 43 eyes (18.6%), and was definitely absent in only one of 43 eyes (2.3%). The hyperfluorescence in the base of the macular hole disappeared in 19 of 20 eyes (95%) with successful closure of the macular hole (P < .00001) and appeared to be caused by blocked fluorescence at the site of the macular hole. The photographic features of eyes with unsuccessful closure of the macular hole changed little, except that the size of the cuff of neurosensory detachment around the hole increased and was associated with decreased postoperative visual acuity. These angiographic changes support the presence of a glial tissue plug bridging a small defect in the fovea of eyes with successful closure of a macular hole.

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.

Purpose: Vitrectomy with fluid-gas exchange has been shown to close more than one half of full-thickness macular holes, with improvement in visual acuity. By adding the appropriate dose of transforming growth factor-beta 2, a higher success rate has been reported. However, there still remain cases of macular holes that fail to close after vitreous surgery. The current pilot study is designed to determine whether reoperation may have a role in the management of cases that fail after vitreous surgery., Methods: Twelve eyes with persistent full-thickness macular holes that failed to close after an initial vitrectomy underwent reoperation using 1330 ng transforming growth factor-beta 2., Results: After the second operation, closure occurred in 12 (100%) of 12 eyes. Follow-up ranged from 8 to 16 months. Visual acuity also improved by two or more lines in 5 (42%) of 12 patients. Increased nuclear sclerosis occurred in nine (90%) of the ten phakic eyes. Of the five eyes showing visual improvement, four required cataract extraction and intraocular lens implantation., Conclusion: Retreatment of persistent full-thickness macular holes with transforming growth factor-beta 2 appears to have a beneficial effect on both neurosensory retinal flattening and visual outcome.

Background: Visual loss in eyes with full-thickness macular holes has been thought to be due to the absence of retinal function in the area of neurosensory defect as well as loss or reduction of retinal function in the surrounding area of neurosensory retinal detachment. With the advent of surgical techniques to treat macular holes, it is increasingly important to better characterize this visual dysfunction., Methods: Thirty eyes of 30 patients with full-thickness idiopathic macular holes were evaluated with microperimetry using the scanning laser ophthalmoscope to detect and quantitate absolute and relative scotomata within the central 40 degrees of visual field. A log 2 scale of test stimulus intensities was established. Results of microperimetry were compared with best-corrected visual acuities as measured on the logarithmic Early Treatment of Diabetic Retinopathy Study chart as well as duration of symptoms., Results: All 30 eyes showed an absolute scotoma in the area of neurosensory defect as well as surrounding relative scotomata in the area of neurosensory detachment. Best-corrected visual acuity was correlated with the size of the absolute and relative scotomata (P < 0.002). The sizes of the scotomata were correlated with the duration of symptoms of the macular holes (P < 0.05)., Conclusion: Microperimetry using the scanning laser ophthalmoscope demonstrates that the visual loss associated with macular holes is related to the reduction of retinal function in the area of the surrounding neurosensory detachment as well as the absence of retinal function in the area of neurosensory defect. The size of the scotomata, determined by microperimetry, is correlated with the patient's visual acuity as well as the duration of symptoms of the macular hole.

Visual loss in eyes with full-thickness macular holes is thought to be caused by the absence of retinal function in the area of the neurosensory defect as well as reduction in retinal function in the surrounding area of neurosensory retinal detachment. To improve characterization of the visual function of eyes after successful macular hole surgery, we studied six eyes preoperatively and postoperatively with macular microperimetry using the scanning laser ophthalmoscope. Best-corrected visual acuity was improved postoperatively in all eyes. Microperimetry performed preoperatively demonstrated an absolute scotoma that corresponded to the neurosensory defect in all eyes, with surrounding concentric isopters of relative scotomata. No detectable absolute scotoma was found in any eye postoperatively. All eyes showed partial or complete resolution of the surrounding relative scotomata. Improvements in visual acuity after successful macular hole surgery may be related to disappearance of a detectable absolute scotoma as well as improvement in the surrounding retinal function.

Purpose: Surgical techniques for the treatment of macular holes generally include removal of the overlying cortical vitreous and/or epiretinal membranes. The authors demonstrate that by using vitrectomy, posterior hyaloid removal, fluid-gas exchange, and transforming growth factor-beta 2 (TGF-beta 2), a growth factor that modulates the wound healing process, epiretinal membrane peeling can be avoided and the surgical procedure thereby simplified without compromising results., Methods: A total of 24 eyes of 24 patients with stage 2, 3, or 4 full-thickness macular holes were treated. Of 24 patients, 1 was lost to follow-up after suffering a stroke; the remaining 23 (17 females and 6 males) (age range, 11-81 years; mean, 64 years) were followed for 5 to 16 months (mean, 12 months). Preoperative best-corrected visual acuity ranged from 20/50 to 20/400 (mean, 20/125). A standardized vitrectomy was performed with posterior hyaloid removal and, after a near-complete fluid-air exchange, 0.1 ml of a solution containing 1330 ng of TGF-beta 2 was instilled over the macular hole. No attempts were made to peel epiretinal membranes or drain fluid from the macular hole., Results: Of 23 eyes, 22 (96%) had resolution of the surrounding subretinal fluid and flattening of the macular hole (1 patient required a second procedure, in which visual improvement of 20/30 was achieved); 11 (48%) had visual acuities of 20/40 or better, 19 (85%) had visual acuities of 20/60 or better, and 19 (85%) showed an improvement in visual acuity of at least two lines (mean, 3.8 lines). The authors saw no retinal pigment epithelial mottling., Conclusion: The authors' results demonstrate that treatment of macular holes using vitrectomy, fluid-gas exchange, and the instillation of a solution containing TGF-beta 2, without epiretinal membrane peeling, maintains efficacy while simplifying surgery.

Background: Retinal pigment epithelial (RPE) cells are a major component of contractile cellular membranes in proliferative vitreoretinopathy (PVR). Displacement of viable RPE cells into the vitreous cavity is necessary for membrane formation. This study examines the effect of cryotherapy during surgery for giant retinal tears on the dispersion of viable cells into the vitreous cavity., Methods: A total of seven eyes undergoing vitrectomy and retinal reattachment surgery were studied. Vitreous fluid from three eyes was aspirated immediately after cryotherapy; fluid from four eyes was aspirated after scleral indentation with the cryoprobe, but without cryotherapy. Colonies of pigmented cells routinely grew in flasks inoculated with fluid from eyes treated with cryotherapy. In contrast, flasks inoculated with fluid from eyes not treated with cryotherapy contained significantly fewer viable cells., Conclusion: Cryotherapy performed during retinal reattachment surgery in eyes with giant retinal tears is likely to enhance intravitreal dispersion of viable RPE cells. The findings in this study suggest that possible harmful effects of cryotherapy should be evaluated further and that alternative methods of creating a chorioretinal adhesion should be considered in cases with an especially high risk of PVR.

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)

Background: Full-thickness macular holes generally cause a significant reduction in visual acuity, due in part to a rim of surrounding neurosensory retinal detachment and retinal thickening. Recent studies have suggested that flattening of this narrow rim of neurosensory detachment can result in improved visual acuity. However, the ability to flatten the neurosensory detachment is limited using current surgical techniques., Methods: Transforming growth factor-beta 2 (TGF-beta 2) is a recently discovered potent stimulator of wound healing. The authors, therefore, performed a prospective randomized study of 60 patients to determine if the local application of TGF-beta 2 to the edge of the macular hole can reproducibly induce flattening of the surrounding neurosensory detachment. The results of a study designed to determine the effect of a pars plana vitrectomy, fluid-gas exchange, and intravitreal instillation of TGF-beta 2 in eyes with a full-thickness macular hole and reduced visual acuity are reported., Results: After treatment, visual acuity improved 2 lines or more in 5 of 11 eyes treated with 70 ng, in 4 of 12 eyes treated with 330 ng, and in 10 of 11 eyes treated with 1330 ng of TGF-beta 2. In some eyes, hyaluronic acid was added. In these cases, visual acuity improved 2 lines or more in 0 of 9 eyes treated with 70 ng TGF-beta 2, in 2 of 8 eyes treated with 330 ng, and in 4 of 9 eyes treated with 1330 ng., Conclusion: Logistic regression analysis demonstrated a statistically significant beneficial effect of TGF-beta 2 on visual improvement (P = 0.003).

Giant retinal tears complicated by proliferative vitreoretinopathy (PVR) pose one of the more complex problems in vitreoretinal surgery. The authors developed a technique using perfluoro-octane, a temporary vitreous substitute that is heavier than water, combined with vitrectomy, scleral buckling, fluid-gas exchange, and direct manipulation of the retina to treat these cases. Ten eyes with giant retinal tears and grade D-1 PVR or worse were treated. In all eyes, the retina was successfully reattached at the end of surgery. Nine of the ten retinas remained attached after 6 months of follow-up. Five eyes required a total of six reoperations for epiretinal membrane formation without retinal detachment. The one eye in which the retina did not remain reattached developed severe recurrent PVR and iris neovascularization. Visual acuity improved in 8 of 10 eyes. Final visual acuity was 20/400 or better in 8 of 10 eyes, and 20/80 or better in 4 eyes.

To determine the current incidence and outcome of iatrogenic retinal breaks occurring during pars plana vitrectomy, the authors reviewed 404 consecutive operations done on eyes without preexisting retinal breaks. Thirteen eyes had 14 iatrogenic peripheral retinal breaks. Three other eyes had both peripheral breaks and posterior breaks. Twenty-five eyes had 43 posterior breaks. The incidence of peripheral breaks was 4% and of posterior breaks was 6%. Patients with proliferative diabetic retinopathy had a higher incidence of iatrogenic retinal breaks than those with other diagnoses. Peripheral breaks occurred most commonly just posterior to the site of insertion of the vitrectomy probe. Although six eyes required reoperation, 33 of 38 eyes had a successful anatomic outcome.

Giant retinal tears with foreshortened and stiffened retina secondary to advanced proliferative vitreoretinopathy (PVR) pose a complex problem for the retinal surgeon. In the past, tractional forces on the retina in these eyes have been counteracted temporarily by retinal sutures, retinal incarceration, or retinal tacks, often combined with fluid-gas exchange in the prone position. These techniques are complex and add multiple additional maneuvers to the surgical procedure. The current report describes the use of a simple, stepwise fluid-gas exchange technique with the patient in the supine position in which the expanding gas bubble traps the edge of the stiffened and foreshortened retina against the pigment epithelium. Long-term counteraction of tractional forces was achieved by the use of intraocular silicone oil. Using this technique, 18 of 19 eyes with giant retinal tears and PVR Grade D1 to D3 could be successfully reattached. Four of these successfully reattached eyes had 360 degrees giant retinal tears. The most common and significant complication in our series was the recurrence of periretinal membranes. All 18 eyes that were initially reattached suffered the recurrence of significant periretinal membranes. Four of those 18 eyes developed recurrent interior traction detachments on to four months postoperatively.

In 18 eyes of 17 patients, we treated retinal detachment caused by a giant retinal tear by unfolding and repositioning the retina with a cannulated extrusion needle. After pars plana vitrectomy, a fluid-gas exchange was performed with the patient in the supine position. Using the cannulated extrusion needle to drain subretinal fluid posterior to the giant retinal tear, the retinal flap was manipulated into the correct anatomic position. With this technique, 18 of 18 eyes with retinal detachment caused by a giant retinal tear were successfully reattached intraoperatively. Although eight of these eyes subsequently redetached and required additional surgical procedures, 16 of 18 eyes remain attached with a mean follow-up of 11 months.

We performed pars plana vitrectomy in 15 patients with physical changes and visual loss believed to indicate impending macular hole formation. Twelve (80%) of 15 eyes have not progressed to macular holes during a minimum follow-up period of 15 months (average, 26 months). In these 12 patients final vision was within one line of the preoperative vision in four eyes, improved two or more lines in five eyes, and was two lines worse in three eyes. Decreased vision in all three eyes was the result of progressive lenticular nuclear sclerosis. A thin sheet of cortical vitreous fibers was sometimes found intraoperatively on the surface of the retina, despite an apparent complete posterior vitreous detachment.

The authors report the occurrence of new retinal breaks in the immediate postoperative period following pars plana vitrectomy and intravitreal infusion of silicone oil for advanced proliferative vitreoretinopathy (PVR). This postoperative complication is important to recognize in light of the renewed interest in the use of silicone oil for the treatment of PVR.

Transforming growth factor beta (TGF-beta) stimulates fibrosis. We studied its possible role as a bioactive substance for inducing localized chorioretinal wound healing along the edge of a retinal tear. The TGF-beta was applied to induced retinal tears that were examined histopathologically. One day after surgery, neither control nor TGF-beta-treated eyes developed chorioretinal wound healing. Four days, two weeks, and two months after surgery, the control eyes still had not developed chorioretinal wound healing. In contrast, the edges of the retinal tear treated with TGF-beta were adherent to the underlying Bruch's membrane via localized fibrous tissue without apparent effects elsewhere. These results demonstrate intraocular in vivo bioactivity of TGF-beta and suggest that TGF-beta may have a potential role as an alternative means for inducing a chorioretinal adhesion in the treatment of retinal tears.

The location of retinal breaks found on preoperative examination was studied in 68 eyes of 68 patients with recurrent retinal detachment and proliferative vitreoretinopathy. Twelve eyes had 23 open breaks that were known to exist previously, no open break was detected in 18 eyes, and 72 new or previously unidentified breaks were found in 41 eyes. Forty-seven (65.3%) of the 72 breaks were located on previous buckles, and 31 of these were on the posterior slope of the buckle. Twenty-nine (40.2%) of all new or previously unidentified breaks were on the border of a cryopexy-induced chorioretinal scar, and of these, 25 breaks (86%) were on the posterior slope of the buckle. Our results indicate that the retina that borders chorioretinal scars is vulnerable and prone to develop retinal tears secondary to traction from preretinal membranes. The vicinity of cryopexy-induced scars should be closely observed for retinal breaks in cases of recurrent retinal detachment with proliferative vitreoretinopathy.