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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.

There is no consensus on whether and when surgical treatment is indicated for combined hamartoma of the retina and retinal pigment epithelium (CHRRPE). We aim to discuss the benefits of surgical intervention and techniques that may improve the outcome. A 24-year-old man experienced progressive visual loss for 6 months in his left eye due to CHRRPE. At presentation, visual acuity was 1.3 LogMAR and fundoscopy revealed extensive tractional pre- and epiretinal membranes, subretinal exudation, and a vasoproliferative tumor in the inferior periphery. A complete vitrectomy was performed, while paying special attention to vitreous shaving at the vitreous base and removal of vitreoschisis-induced vitreous cortex remnants (VCR) from the retinal surface posterior to the vitreous base. Tractional membranes and internal limiting membrane were peeled, and the vasoproliferative tumor was excised. Silicone oil tamponade was removed 11 weeks after surgery. No intra- or postoperative complications occurred. Visual acuity improved to 0.8 LogMAR and remained stable for 48-month follow-up. Vitreoretinal surgery can prevent complications that occur with CHRRPE. In addition, visual function may improve even if the initial visual acuity is low. Timely and complete vitrectomy with extensive membranectomy and detection and removal of VCR is recommended to avoid complications in challenging CHRRPE.

Introduction Radical anterior vitreous base dissection and lensectomy in combination with inferior 180° retinectomy will improve the anatomic success of complex proliferative diabetic vitreoretinopathies (PVR)-related retinal detachment. Our study aims to describe the anatomical and functional results of pars plana vitrectomy with retinotomies and relaxing retinectomies in patients with tractional retinal detachment in advanced PVR. Patients and methods A case series study was conducted on 28 eyes of patients with tractional retinal detachment with severe PVR. Preoperative and postoperative complications and final visual outcomes were recorded. The follow-up period was 12 months. Results Full reattachment rate was reached intraoperatively in 26 (92.9%) eyes, with final complete reattachment success rate in 22 (78.5%) eyes at least 6 months of follow-up. A total of 17 (60.7%) eyes had their best-corrected visual acuity (BCVA) improved at 6 months postoperatively, and reaching a final BCVA of more than or equal to 2/60 at 6 months. The BCVA remained stable in six (21.4%) eyes and declined in five (17.9%) eyes. The complications postoperatively included secondary glaucoma (three eyes), retinal redetachment (four eyes), and hypotony (two eyes). Conclusion Pars plana vitrectomy with relaxing retinotomies and retinectomies is an effective treatment method for complex PVR-related retinal detachment. Improved preoperative visual acuity, lower PVR extension, and silicone oil tamponade use during the early recovery period are essential factors for good anatomical and visual outcomes and a lower rate of complications.

AIM: To compare changes in anterior segment topography and axial length (AL) evaluated with Pentacam and IOL Master after pars plana vitrectomy (PPV) performed with and without vitreous base shaving. METHODS: This prospective study included patients who underwent PPV or phacoemulsification+PPV (Phaco+PPV) for various indications. Patients who underwent total posterior hyaloid detachment and excessive vitreous base shaving with scleral indentation were referred to as complete PPV (c-PPV). The patients whom posterior hyaloid was separated as far as the posterior arcades and vitreous base shaving with scleral depression was not performed were classified as the partial PPV (p-PPV) group. All patients underwent detailed ophthalmologic examinations preoperatively and 1wk, 1, and 3mo postoperatively. Changes in the anterior chamber depth (ACD), anterior chamber volume (ACV), iridocorneal angle (ICA), central corneal thickness (CCT), and keratometric measurements (K(1) and K(2)) were evaluated with Pentacam HR. Changes in the AL measurements were analyzed with IOL Master. RESULTS: A significant increase in ACD was observed in c-PPV cases (P=0.02), but this increase was not significant in the p-PPV group (P=0.053). In contrast, ICA increased significantly in the c-PPV group (P=0.02) but decreased in the p-PPV group (P=0.09). BCVA was significantly improved in the c-PPV group from week 1 (P0.05 for all). CONCLUSION: Incomplete posterior hyaloid excision and not removing the vitreous base in PPV surgeries may create a more stable anterior chamber, thus preventing the downward movement of the lens-iris diaphragm, and may cause ciliary body retraction, thereby reducing ICA. Awareness of these effects can provide some amount of guidance to physicians in selecting the appropriate PPV procedure and preempting surgical complications.

Traction exerted on the vitreous base during vitrectomy poses a risk for retinal tears. We aimed to quantify core vitreous traction during vitrectomy using spring return and pneumatic cutters. Juvenile porcine vitreous was vacuum held in a vitreous bath while traction was measured using precision force gauge during vitrectomy. The parameters included were aspiration rate, cut-rate, cutter size, and machine types. An empirical probabilistic model was developed. The traction was proportional to the aspiration rate but insignificantly dependent on the cut-rate. The traction probability was inversely proportional to the exponential function of the traction (p

Mapping the normal eye proteome in healthy persons is essential to unravel the molecular basis of diseases impacting visual health. The vitreous occupies a large portion of the human eye between the lens and the retina and plays a significant role in vitreoretinal diseases as well as maintaining clarity in the visual field, providing nutrition to the lens, and protecting the eye from mechanical shocks. It comprises four distinct anatomical regions, namely the vitreous core, vitreous cortex, vitreous base, and anterior hyaloid. Among these, the vitreous is attached to other substructures in the eye by the vitreous base, which is its strongest point of attachment. Alterations in vitreous substructures have been reported in several vitreoretinal disorders, including vitreomacular traction, vitreoretinopathies, and age-related macular degeneration. There has been limited knowledge on proteomics variations at a resolution of vitreous substructures, including the functionally and pathophysiologically significant vitreous base. We report here new findings on the proteome map of the vitreous base in normal healthy tissue. We employed a global, unbiased proteomic profiling approach resulting in the identification of 6511 proteins. Of these, 302 proteins were involved in metabolic processes essential for energy utilization. Moreover, we identified several structural and nutrient transport proteins. Notably, the identified proteome repertoire indicates that the vitreous base might possess additional physiological functions and may not be a passive structure. This study constitutes the most extensive catalog of vitreous base proteins to our knowledge and offers novel insights as a baseline for future studies on the pathobiology of various eye diseases. These data also invite us to consider a potentially more active functional role for the vitreous base in eye physiology and visual health.

The anterior hyaloid presents a complex anatomy and is involved in accommodation by inducing traction on the vitreous base that may be associated with retinal detachment incidence and recurrence.

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.

To evaluate the association among laser prophylaxis treatment, retinal detachment (RD), and visual acuity (VA) in patients with Stickler syndrome (SS).Retrospective comparative case series.Patients with SS.Patients received extended vitreous base laser (EVBL), nonprotocol laser (NPL), or no laser prophylaxis treatment of any kind.The 2 main outcome measures that were examined in these patients were rates of RD and VA.In this study, 230 eyes of 115 patients were included. Fifty-nine patients were women (51%). The median age at the time of laser prophylaxis treatment was 9.5 years (interquartile range [IQR], 6-13 years), and the median age of patients with RD was 11 years (IQR, 7-18 years). Of the 230 eyes, 92 did not undergo any laser treatment, 9 received NPL treatment, and 129 received EVBL treatment. Of the 129 eyes that underwent EVBL treatment, 4 (3%) had RD, compared with 74 eyes (73%) that had RD and did not receive laser or NPL treatment (P0.001). Eyes that received EVBL treatment had approximately 8 lines better vision, on average, compared with those that did not receive laser or NPL treatment (-0.86 logarithm of the minimum angle of resolution; 95% confidence interval,-1.1 to -0.64; P0.001).Treatment with EVBL seems to reduce the rate of subsequent RD and is associated with better VA in patients with SS.

ObjectiveTo evaluate the technique of peripheral vitreous shaving during vitrectomy, we measured the residual peripheral vitreous using intraoperative optical coherence tomography (iOCT).Methods and AnalysisThis retrospective study included 44 eyes that underwent 25-gauge pars plana vitrectomy with iOCT by a single surgeon. In all cases, the surgery was performed via ocular indentation. Cases in group A were treated with vitreous shaving under slit lamp microscope illumination, whereas cases in group B were treated with vitreous shaving under a wide-angle viewing system. Residual peripheral posterior vitreous-cortex detachment (PVD) was quantified by iOCT.ResultsiOCT image analysis enabled the visualisation of the angle formed between the retina and peripheral PVD around the vitreous base in all cases. After the completion of vitreous shaving, the mean length of the peripheral PVD was shorter in group A (961.7±214.7 µm) compared with group B (1925.3.7 ± 626.1 µm; pConclusioniOCT enabled the quantification of the residual peripheral vitreous after vitreous shaving. The quantification of the residual peripheral vitreous after different shaving procedures will be important for advocating appropriate vitreous shaving in future.

BACKGROUND AND OBJECTIVE: There remains a low but intractable risk of rhegmatogenous retinal detachment (RRD) after surgical repair of macular holes (MHs). The purpose of this study is to identify potential causes for RRDs after MH surgery. PATIENTS AND METHODS: The authors retrospectively examined a single surgeon series of stage 3 MH repair surgeries during a 5-year period. Clinical data, including preoperative, intraoperative, and postoperative evaluations, were reviewed to determine potential causes of RRD. RESULTS: Of the 332 eyes that received MH surgery, 12 (3.6%) developed postoperative RRD. Seven RRD cases exhibited no evident precursor pathology; however, augmented posterior hyaloid adhesions (APHAs) were found intraoperatively and postoperatively. CONCLUSIONS: In MH surgery, APHA increases risk for RRD. During PPV, the vitreous typically separates to the peripheral vitreous base. Some eyes have APHAs near the equator that cannot be elevated, consistent with strong adhesion. The authors believe the high postoperative RRD rate is due to continued hyaloid elevation after surgery. [ Ophthalmic Surg Lasers Imaging Retina. 2019;50:635–638.]

Purpose To investigate the efficacy of fortified barrier laser (FBL) on the vitreous base in vitrectomy for rhegmatogenous retinal detachment (RRD). Patients and methods This was a retrospective study of patients who underwent vitrectomy for RRD without proliferative vitreoretinopathy. Barrier laser was applied as 3-4 rows surrounding the break at the end of fluid-air exchange. For the FBL, 3-4 rows of laser burn were additionally made about 0.5 clock-hour long adjacent to the break along the posterior border of the vitreous base. The primary outcome was single surgery success rate (SSSR) between two groups: FBL and conventional barrier laser (CBL) groups. Results Overall, 118 eyes were included; 50 eyes in the FBL group and 68 eyes in the CBL group. SSSR was 100% (50/50) in the FBL group and 91.2% (62/68) in the CBL group with a significant difference (p=0.038). Four eyes of the recurrent cases in the CBL group were related to reopening of the break. All eyes achieved reattachment, and no differences were found in postoperative visual acuity at 6 months. Conclusion FBL on the vitreous base was efficacious in improving the anatomical success rate of vitrectomy.

Aim. To refine microanatomy of vitreoretinal interactions in central areas of retina and to obtain additional information on vitreoretinal interactions regarding theoretical possibility of collagen synthesis in the vitreous body of adult humans and mechanisms of vitreoretinal adhesion. Methods. Scanning electron microscopy study was performed in central areas of human retina after removal of vitreous base from its surface. Results. On the surface of retina we found a thin layer of epiretinal vitreous body most strongly bound to the retina. Thickness of paramacular epiretinal vitreous is 3–5 µm and it is formed mainly by thin densely packed fibrils. Its surface layer facing the vitreous cavity consists of the thickest (1 µm) and longest (250 µm) fibrils loosely packed. These fibrils look like “pearl threads” and exhibit signs of newly formed fibrils. Epiretinal layer of the vitreous in the fovea is thinner, its thickness is about 2 µm. Top layer of fibrils is least densely packed with the thickness of the fibrils of about 0.2 µm. The closer to internal limiting membrane, the thinner the fibrils, the denser their packing. The discovered layer can be interpreted as an additional anatomic structural unit of the vitreous body — epiretinal vitreous. Conclusion. We detected indirect signs of lifetime synthesis of newly formed fibrils in the vitreous of adult human; newly formed collagen may be localized in epiretinal vitreous which may be the main binding component providing vitreoretinal adhesion.

Silicone oil (SO) is used mainly when managing complex retinal detachments, commonly with proliferative vitreoretinopathy, as well as a hemostatic agent in proliferative diabetic retinopathy. Combined lens exchange and pars plana vitrectomy remains preferred by many surgeons; however, sequential surgery might be advantageous to minimize the postoperative anterior chamber inflammatory response, particularly in proliferative diabetic retinopathy or retinal detachment. The aim of the study was to evaluate the optimal method of intraocular lens (IOL) calculation in eyes filled with SO. Different techniques are employed for axial length assessment in eyes filled with SO, including preoperative A-scan applanation or immersion biometry, partial coherence interferometry (PCI), or less commonly computed tomography, magnetic resonance imaging, or intraoperative retinoscopy/biometry after SO removal. PCI might provide better refractive outcomes compared to ultrasound measurements, however, the quality of presented evidence is low. Bias in calculation may be a result of limited vitreous base removal during vitrectomy, partial filling of the vitreous chamber with SO and measurements in supine position, macular edema or detachment, selection of an inappropriate IOL calculation formulas and sulcus IOL placement. Clinicians should consider that even when employing optical biometry and correct calculation formulas only a third of eyes filled with silicone oil might achieve ± 1.0 D of target refraction, compared to 97.2% of normal eyes. We would recommend performing optical biometry before the application of SO; if this is impossible, measurement of the second eye or biometry after SO removal is an alternative. Implantation of a convex-plano monofocal polymethyl methacrylate or foldable hydrophobic acrylic IOL with large optic diameter is advised in these patients.

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.

Koichi Nishitsuka, Madoka Nakamura, Katsuhiro Nishi, Hiroyuki Namba, Yutaka Kaneko, Hidetoshi Yamashita Department of Ophthalmology and Visual Sciences, Yamagata University Faculty of Medicine, Yamagata, JapanCorrespondence: Koichi NishitsukaDepartment of Ophthalmology and Visual Sciences, Yamagata University Faculty of Medicine, Yamagata City, JapanTel +81 23-628-5374Fax +81 23-528-5377Email mlc12186@nifty.comPurpose: To compare the surgical outcomes of vitreous surgery for rhegmatogenous retinal detachment (RRD) after two different peripheral vitreous-shaving techniques are performed.Methods: We reviewed 269 eyes with RRD that were treated with a 25-gauge vitrectomy by a single surgeon between June 2015 and May 2020. The exclusion criteria for the proposed air tamponade selection were as follows: more than two weeks since RRD onset, giant retinal tears, a history of complications following cataract surgery, high myopia, and proliferative vitreoretinopathy classified as grade C or higher. We examined the differences in the therapeutic effect between shaving under slit lamp microscope illumination (group A) and shaving under a wide-angle viewing system (group B).Results: A total of 269 eyes were included in this study, with 146 eyes in group A and 123 eyes in group B. The primary anatomical success rates did not differ between group A (97.3%; 142/146 eyes) and group B (97.6%; 120/123 eyes; P = 0.102). However, the surgical time was significantly longer in group A (60.2 ± 17.1 min) than that in group B (46.9 ± 12.6 min) (P < 0.001). The multiple linear regression analysis revealed that surgical time was significantly correlated with using the wide-angle noncontact viewing system for vitreous shaving (adjusted R2 = 0.248; beta [standard partial regression coefficient] = − 0.447, P < 0.001), the number of retinal breaks (beta = 0.182, P = 0.001), and the quadrant of retinal detachment (beta = 0.205, P < 0.001).Conclusion: The surgical outcomes were similar regardless of the shaving procedure performed, and the surgical time was shortened by using the wide-angle noncontact viewing system for vitreous shaving.Keywords: vitrectomy, vitreous base, posterior vitreous-cortex detachment, slit lamp microscope illumination, wide-angle noncontact viewing system

Koichi Nishitsuka, Katsuhiro Nishi, Hiroyuki Namba, Yutaka Kaneko, Hidetoshi Yamashita Department of Ophthalmology and Visual Sciences, Yamagata University Faculty of Medicine, Yamagata, JapanCorrespondence: Koichi NishitsukaDepartment of Ophthalmology and Visual Sciences, Yamagata University Faculty of Medicine, Yamagata City, Yamagata, JapanTel +81 23-628-5374Fax +81 23-528-5377Email mlc12186@nifty.comPurpose: The interaction between the peripheral vitreous and retina is closely associated with the pathogenesis of rhegmatogenous retinal detachment (RRD). This study was conducted to examine the peripheral vitreous and retina in patients with RRD using intraoperative optical coherence tomography (iOCT).Methods: This retrospective study included 50 eyes of 50 patients (mean age 59.42 ± 10.80 years) that underwent vitrectomy using iOCT for treating RRD at the Yamagata University Hospital between September 2015 and September 2016. Each patient underwent 25-gauge pars plana vitrectomy that was performed by a single surgeon. During vitreous shaving with ocular indentation, the iOCT findings of the peripheral vitreous and retina were recorded and analyzed postoperatively.Results: In all patients, iOCT was able to detect the peripheral retina and vitreous around the vitreous base. Peripheral cystoid degeneration was detected on the peripheral retina of 27 eyes (54%). Furthermore, cystoid degeneration was detected around the retinal tear (5 patients), at the detached retinal area (8 patients), and at the attached retinal area (14 patients).Conclusion: iOCT enabled the evaluation of peripheral cystoid degeneration in patients with RRD. Cystoid degeneration might be associated with the pathogenesis of RRD.Keywords: peripheral retinal degeneration, rhegmatogenous retinal detachment, cystoid degeneration, intraoperative optical coherence tomography

The extracellular matrix (ECM) plays a crucial role in all parts of the eye, from maintaining clarity and hydration of the cornea and vitreous to regulating angiogenesis, intraocular pressure maintenance, and vascular signaling. This review focuses on the interactions of the ECM for homeostasis of normal physiologic functions of the cornea, vitreous, retina, retinal pigment epithelium, Bruch’s membrane, and choroid as well as trabecular meshwork, optic nerve, conjunctiva and tenon’s layer as it relates to glaucoma. A variety of pathways and key factors related to ECM in the eye are discussed, including but not limited to those related to transforming growth factor-β, vascular endothelial growth factor, basic-fibroblastic growth factor, connective tissue growth factor, matrix metalloproteinases (including MMP-2 and MMP-9, and MMP-14), collagen IV, fibronectin, elastin, canonical signaling, integrins, and endothelial morphogenesis consistent of cellular activation-tubulogenesis and cellular differentiation-stabilization. Alterations contributing to disease states such as wound healing, diabetes-related complications, Fuchs endothelial corneal dystrophy, angiogenesis, fibrosis, age-related macular degeneration, retinal detachment, and posteriorly inserted vitreous base are also reviewed.

In performing routine or complex phacoemulsification (i.e., pupil-dilating devices, capsular staining, zonulopathy requiring capsular tension rings/segments with suturing, iris/scleral sutured IOL), the reader is advised to refer to the appropriate chapters in this textbook. One of the challenges during cataract surgery is dealing with the vitreous gel when it presents itself intraoperatively. Given that the scope of vitreous and lens management cannot be covered in any great detail within one single operative template, this chapter focuses on essential surgical steps one needs to take in managing intraoperative complications when the posterior capsule (PC) is violated (Table 23.1). The farther vitreous travels from the vitreal cavity (categories 1–3, Table 23.1), the greater the traction on the vitreous base with increased risk for a retinal tear or detachment (Arbisser et al., Ophthalmol Clin N Am 19:495-506, 2006; Arbisser, Suppl Cataract Refract Surg Today, 2012). The concepts have been simplified to familiarize the reader in dealing with vitreous. A number of references are provided for further in-depth reading to surgically build upon the basic outline provided in this chapter (Arbisser et al., Ophthalmol Clin N Am 19:495-506, 2006; Arbisser, Suppl Cataract Refract Surg Today 2012; Oetting, http://www.eyerounds.org/tutorials/anterior-vitrectomy/index.htm; Kent, Rev Ophthalmol, 2009). Table 23.1 Classification Intra-operative complication Intervention IOL options 1. Intact anterior hyaloid + broken PC Dispersive OVD over PC tear; cohesive OVD into Berger space; posterior Capsulorrhexis One piece in bag or optic capture in Berger’s space with three piece 2. Vitreous prolapse − vitreous confined to the anterior chamber Keep phaco probe in AC; inject dispersive OVD via side-port to create barrier between vitreous and lens: remove phaco probe; biaxial vitrectomy If anterior capsulorrhexis intact: Sulcus IOL with optic capture. If not, Sulcus IOL 3. Vitreous loss − vitreous has traveled beyond the AC out of the incision Same as (2); avoid sweeping or Wek Cel vitrectomy; use vitrector to sever vitreous from wound; inject Triesence to stain vitreous; perform biaxial vitrectomy If poor visibility; inadequate capsule support or significant zonular dialysis, then AC IOL with PI PC posterior capsule; PI peripheral iridectomy Adapted from Arbisser LB et al. Management of Vitreous Loss and Dropped Nucleus During Cataract Surgery [1, 2]

Thorough preoperative evaluation should be performed including extent of retinal detachment, location of tears, presence of an inverted flap, location of any other peripheral pathology, and presence of preoperative proliferative vitreoretinopathy. Status of the hyaloid (which should be detached in a true giant retinal tear) and lens should also be noted. It is important to clinically differentiate retinal dialysis from a true giant retinal tear, as the management of these entities will be distinct due to the differing relationship of the vitreous base to the posterior aspect of the break. Care is taken to unfurl the inverted posterior tear flap (if present) and in preventing slippage during air exchanges. Rates of proliferative vitreoretinopathy can be high post and preoperatively, and as such silicone oil is often chosen as the tamponade. In phakic patients one can consider concurrent scleral buckle placement with gas tamponade.

The vitreous is a simple structure with only 1–2 questions in basic ophthalmology exams. The most important part to consider when studying the vitreous is its attachment to underlying structures and the spaces formed through these attachments. An example of questions in this regard is to ask about the site of strongest attachment, where the vitreous base, an attachment of vitreous to structures surrounding ora serrata, represents the strongest attachment.

Purpose: To describe a novel technique to visualize vitreous base and the anterior hyaloid during vitrectomy for Rhegmatogenous Retinal Detachment (RRD). Methods: Retrospective, single-center study enrolling all patients who underwent vitrectomy for RRD between June 2015 and June 2018. After core vitrectomy and the necessary additional procedures, endodiathermy was activated near the edge of the peripheral vitreous. This created a heat-induced bubble stream and the bubbles were entangled in the vitreous base and anterior hyaloid. As a result, the vitreous base and anterior hyaloid were visualized and removed. Results: Between June 2015 and June 2018, a total of 210 cases of rhegmatogenous retinal detachment were treated with vitrectomy. Endodiathermy assisted vitreous base shaving and anterior hyaloid removal was used in those cases with a very low incidence of iatrogenic peripheral retinal breaks during vitreous base shaving (2%), and with no case of lens injury related to the technique. We achieved a final anatomical success of 95.2% in the study period after mean number of operations of 1.3 ± 0.2. Endodiathermy near the peripheral vitreous was not associated with any intraoperative or postoperative complications. Conclusion: Endodiathermy assisted vitreous base and anterior hyaloid visualization is a safe adjuvant method that could help in achieving complete and rapid vitreous base shaving and anterior hyaloid removal.

Background Recurrent retinal detachment (RD) is still a widespread event despite the therapeutic options available. Proliferative vitreoretinopoathy (PVR) is one of the main causes of redetachment. Little is known about the use of endoscopy-assisted vitrectomy (E-PPV) in complex recurrent RD with PVR. The purpose of this study was to identify the potential advantages of E-PPV in complex RD with PVR compared with pars plana vitrectomy (PPV) alone. Methods Single-center, retrospective, observational, descriptive study. The medical records of 293 patients were reviewed. Patients who underwent PPV for complex rhegmatogenous RD and associated PVR between 2009 and 2017 were included. Patients with diabetic tractional RD, trauma, uveitis or detachment postendophthalmitis were excluded. After 2013, an endoscopic visualization system was used in a nonrandomized fashion at the surgeon’s discretion. Outcome measures (reattachment rate, number of surgeries, lens status, PVR stage, intraocular pressure, phthisis rate) were compared between the E-PPV and PPV-only groups with independent samples t-tests (continuous variables) and Fisher’s exact test (categorical variables), as well as time-adjusted analyses. Postoperative time to retinal redetachment was assessed with Kaplan–Meier survival analysis. Results One hundred one eyes from 100 patients met the inclusion criteria. The mean participant age was 63.3 years old (95% CI 60.4–66.1 years), without a significant difference between groups. E-PPV was performed in 36.6% (n = 37) of eyes, and 63.4% (n = 64) underwent PPV only. The mean follow-up was significantly longer in the PPV-only group (31.9 vs. 21.1 months; p = 0.021). Upon adjustment for follow-up duration, the mean number of surgeries was significantly lower in the PPV-only group (2.6 vs. 4.3 number of surgeries; p 0.05). Conclusions Compared to PPV alone, endoscopy-assisted vitrectomy seems to be advantageous in achieving better reattachment rates in complex RD with advanced PVR. Endoscopic visualization allows a thorough examination and extensive anterior PVR and vitreous base dissection.

Purpose We describe a modified injection technique that adheres a sustained-release dexamethasone intravitreal implant (Ozurdex®) to the vitreous base. Observations This modified technique was applied after removal of a prior dislocated Ozurdex® that migrated into the anterior chamber in one patient, and also on another patient bothered by perception of a large floater induced by a free-floating Ozurdex® in the vitreous cavity previously inserted with the conventional technique. The main feature of this new technique consisted of altering the conventional “bevel-up” orientation of the insertion needle tip towards the vitreous cavity to the modified “bevel-down” orientation of the needle tip directed towards the pars plana and vitreous base, for the purpose of adhering a portion of or the entire dexamethasone implant to the vitreous base. Neither patient developed postoperative complications with this technique. Conclusions and importance This modified insertion technique allows adherence of Ozurdex® to the vitreous base and avoids adverse effects associated with a free-floating Ozurdex®, such as its migration into the anterior chamber, or visual disturbance associated with movement of the implant., Highlights • For conventional injection of sustained-release dexamethasone implant (Ozurdex®), needle tip is maintained in bevel-up position (facing vitreous cavity) before its insertion and after subsequent insertion and intraocular implant release. • For modified technique, needle-tip is first directed in conventional bevel-up position before insertion and re-directed in bevel-down position towards eye-wall after insertion. • Alternatively, needle is already in bevel-down position before its insertion, and maintained in same position after insertion with subsequent release and adherence of implant at vitreous base.

To determine the preoperative factors associated with selecting scleral buckling (SB) or pars plana vitrectomy (PPV) to treat rhegmatogenous retinal detachments (RRDs) in the era of microincision vitrectomy surgery. A nationwide, multicenter, observational study in the Japan Retinal Detachment Registry was done. From February 2016 to March 2017, 3446 cases were registered, and 3219 among them were analyzed. The factors related to the patient or surgeon were selected; the surgeon’s factor included years of experience, number of cases registered, and current activity. The odds ratio (OR) for factors associated with SB or PPV was estimated by a mixed logistic regression model. SB was selected in 24.2% (779/3219), PPV was in 71.5% (2238/3219), and PPV+SB was in 6.3% (202/3219). Multivariate analysis showed that age [< 70 years old, OR 4.27, 95% confidence interval (CI) 2.34–7.79, P < 0.001], visual acuity [1.0+ (OR 7.41, 95% CI 3.47–15.82, P < 0.001)], pseudo-phakia (OR 4.83, 95%CI 2.11-10.56, P < 0.001), retinal tear (OR 6.92, 95% CI 4.83–9.92, P < 0.001), breaks at/near the vitreous base (OR 8.07, 95% CI 3.50–18.62, P < 0.001), 90+° retinal tear (OR 108.24, 95% CI 7.44–1574.34, P < 0.001), and number of breaks 4+ (OR 3.15, 95% CI 1.95–5.09, P < 0.001), were significantly associated with selecting PPV over SB. The surgeons’ activity defined as the number of cases experienced during the registry period was related to the selection of PPV (OR 3.83, 95% CI 2.11–6.93, P < 0.001). The choice of PPV for the RRD was associated not only with patients’ preoperative factors but also the surgeon’s activity. Active surgeons selected PPV more than SB.

A 13‑year‑old child diagnosed with neurofibromatosis type 1 who on a routine control presented with rhegmatogenous retinal detachment associated to dialysis of the ora serrata in the left eye (OS). There were no clinical signs or history of contuse ocular trauma. Neurofibromatosis produces alterations in fibroblasts of the cortex of the vitreous base. This results in deficient production of the collagen fibers that anchor the vitreous base to the pars plana and the peripheral neurosensory retina. Thus, suboptimal function of the fibroblasts explains spontaneous avulsion of the vitreous base. Such avulsion in turn is related to dialysis of the ora serrata.

Purpose. To evaluate whether limited vitrectomy is as effective as complete vitrectomy in eyes with epiretinal membrane (ERM) and to compare the surgical times and rates of complications. Methods. In this multicentre European study, data of eyes with ERM that underwent vitrectomy from January 2017 to July 2018 were analyzed retrospectively. In the limited vitrectomy group, a posterior vitreous detachment (PVD) was induced up till the equator as opposed to complete PVD induction till the vitreous base in the comparison group. Incidence of iatrogenic retinal breaks, retinal detachment, surgical time, and visual outcomes were compared between groups. Results. We included 139 eyes in the analysis with a mean age being 72.2 ± 6.9 years. In this, sixty-five eyes (47%) underwent limited vitrectomy and 74 eyes (53%) underwent complete vitrectomy. Iatrogenic retinal tears were seen in both groups (5% in limited vitrectomy versus 7% in complete vitrectomy, p = 0.49 ). Retinal detachment occurred in 2 eyes in the limited vitrectomy group (3%) compared to none in the complete vitrectomy group ( p = 0.22 ). Best-corrected visual acuity (BCVA) and central macular thickness improved significantly with no intergroup differences ( p = 0.18 ). Surgical time was significantly shorter in the limited vitrectomy group with 91% surgeries taking less than 1 hour compared to 71% in the complete vitrectomy group ( p < 0.001 ). Conclusion. A limited vitrectomy is a time-efficient and effective surgical procedure for removal of epiretinal membrane with no additional complications.

Context: Anatomical and visual outcomes of phacoemulsification and 23-gauge (23G) pars plana vitrectomy (PPV) assisted with perfluorocarbon liquid (PFCL) and 27-gauge twin-chandelier endoillumination for primary rhegmatogenous retinal detachment (RRD). Aims: This study aims to determine the anatomical and visual outcomes of phacoemulsification and 23G PPV for primary RRD assisted with 27-gauge (27G) transconjunctival twin-chandelier endoillumination and bimanual vitreous base shaving under PFCL. Settings and Design: A prospective single tertiary center cohort study of 65 consecutive eyes by a single surgeon between August 2013 and June 2014. Subjects and Methods: The primary outcome measure was the primary retinal reattachment rate. The secondary outcome measure was best-corrected visual acuity (BCVA). All patients were reviewed postoperatively up to 4 months. Statistical Analysis Used: Chi-squared, Student's t-test, and one-way ANOVA test were used in this study. Results: At 4 months, overall retinal reattachment was 83.1% with a single operation and 87.7% with a second surgery. After exclusion of the proliferative vitreoretinopathy (PVR) cases, the primary retinal reattachment rate improved to 93.9% and secondary retinal reattachment rate was 98.0%. The mean BCVA improved from logMAR 1.06–0.83 (P = 0.002). PVR (P = 0.0001), silicone oil tamponade (P = 0.002), macula-off RD (P = 0.12), location of RRD (P = 0.09), and delay of more than 7 days for surgery (P = 0.09) were associated with a higher redetachment rate. The main postoperative complications were small bubbles of PFCL in the posterior segment (18.5%) and subretinal PFCL (3.1%). Conclusions: Chandelier endoillumination and PFCL-assisted 23G PPV with phacoemulsification has reattachment rates and visual outcomes similar to the current standard of RRD repair of different complexities. This surgical technique can be considered an alternative method of repairing RRD, with some advantages.

Purpose To determine the impact of total pars plana vitrectomies (PPVs) with peripheral shaving of the vitreous base on the rates of postoperative complications in patients with aphakic, snap-on type I Boston keratoprostheses (KPros). Design Retrospective, consecutive case series. Participants A total of 48 eyes in 46 patients with implantation of aphakic, snap-on type 1 Boston KPros performed at a tertiary care facility between January 1, 2007, and December 31, 2013, were included. Methods The cumulative incidences of postoperative complications were compared between patients who underwent total PPVs with shaving of the vitreous base (n = 22) and those who had partial PPVs or anterior vitrectomies (AVs) at the time of KPro implantation (n = 26). Main Outcome Measures Rates of complications between patients who underwent total PPVs and partial PPVs or AVs. Results The rate of total postoperative complications was lower in the total PPV group ( P = 0.018, log-rank test). In particular, eyes that underwent total PPVs had lower rates of retroprosthetic membranes (RPMs) requiring intervention ( P = 0.049) and less vision loss due to glaucoma progression ( P = 0.046). There was also a trend for fewer corneal melts ( P = 0.060) and less sight-threatening complications ( P = 0.051) in the total vitrectomy group. There was no difference in the rates of KPro extrusion ( P = 0.41), endophthalmitis or vitritis ( P = 0.15), retinal detachments ( P = 0.76), cystoid macular edema ( P = 0.83), or timing of complications between the 2 groups. The mean preoperative and postoperative visual acuities were similar between the 2 groups ( P = 0.97). The mean follow-up was 49±22 months. Conclusions Eyes that underwent total PPVs during implantation of aphakic, snap-on, type I Boston KPros had less postoperative complications than eyes with partial PPVs or AVs during the average 4 years of follow-up.

Background: Partial posterior hyaloidectomy is suggested to minimize traction on the vitreous base and thus reduce the risk of iatrogenic breaks in patients with macular hole and epiretinal membrane. Aims: To evaluate the safety and efficacy of limited vitrectomy in patients with macular hole. Study Design: Retrospective cohort study. Methods: Fifty-two consecutive patients who underwent macular hole surgery without complete peripheral vitreous removal were included in the study. The improvement in visual acuity, the incidence of retinal breaks and detachment, anatomical results, and intraoperative and postoperative complications of this technique were evaluated. Results: The median visual acuity was 0.2 (0.1-0.4) before surgery and 0.5 (0.3-0.6) after surgery (p

Purpose To investigate the efficacy of fortified barrier laser (FBL) on the vitreous base in vitrectomy for rhegmatogenous retinal detachment (RRD). Patients and methods This was a retrospective study of patients who underwent vitrectomy for RRD without proliferative vitreoretinopathy. Barrier laser was applied as 3–4 rows surrounding the break at the end of fluid-air exchange. For the FBL, 3–4 rows of laser burn were additionally made about 0.5 clock-hour long adjacent to the break along the posterior border of the vitreous base. The primary outcome was single surgery success rate (SSSR) between two groups: FBL and conventional barrier laser (CBL) groups. Results Overall, 118 eyes were included; 50 eyes in the FBL group and 68 eyes in the CBL group. SSSR was 100% (50/50) in the FBL group and 91.2% (62/68) in the CBL group with a significant difference (p=0.038). Four eyes of the recurrent cases in the CBL group were related to reopening of the break. All eyes achieved reattachment, and no differences were found in postoperative visual acuity at 6 months. Conclusion FBL on the vitreous base was efficacious in improving the anatomical success rate of vitrectomy.

PurposeTo evaluate outcomes of small-gauge pars plana vitrectomy (PPV) for the treatment of rhegmatogenous retinal detachment (RD) without scleral-depressed shaving of the vitreous base.MethodsRetrospective, consecutive case series. Surgical technique included small-gauge PPV (25G, 23G, 25G+ or 27G) and wide-angle vitrectomy viewing system in all cases. No cases were excluded based on the level of complexity of RD. Outcome measures were retinal reattachment rates and Snellen visual acuity (best-corrected visual activity [BCVA]).Results312 eyes of 301 patients, mean age 60.8 years, and mean follow-up 23.1 months. Baseline characteristics included macula-off RD in 207 (66%) eyes, psudophakia in 124 (40%) eyes, high myopia in 74 (24%) eyes and giant retinal tear in 14 (5%) eyes. The retina was reattached with one procedure in 296 (95%) eyes. Final retinal reattachment was achieved in 310 (99%) eyes. The BCVA at baseline was >20/40 in 76 (24%) eyes, 20/50–20/100 in 48 (15%) eyes, 20/200–20/400 in 46 (15%) eyes and 20/40 in 168 (54%) eyes, 20/50–20/100 in 60 (19%) eyes, 20/200–20/400 in 49 (16%) eyes and ConclusionSmall-gauge PPV without scleral-depressed vitreous base shaving can be associated with good anatomical and visual outcomes. Case selection based on the complexity of RD may not be required when considering small-gauge PPV.