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BACKGROUND AND OBJECTIVE: The optimal method for surgical management of idiopathic macular holes remains unknown. Adjuvant methods including intraoperative cytokines and postoperative fluid-gas exchange with and without laser have been described. We report on the safety and final results of routine intraoperative autologous plasma-thrombin mixture and postoperative fluid-gas exchange when necessary as an adjunct to the surgical therapy of this disease. PATIENTS AND METHODS: A consecutive series of 114 patients (mean age 66.9 years) with primary idiopathic full thickness Stage II, III, and IV macular holes were primarily treated by vitrectomy, fluid/perfluorocarbon gas exchange, and application of autologous plasma-thrombin mixture to the macular hole. Visible epiretinal membranes were peeled but the normal appearing internal limiting membrane was not routinely stripped. Outcome measures included final Snellen visual acuity, rate of macular hole closure, complications, and number of supplemental procedures performed. RESULTS: Closed at one month, were 110 of 121 (91%) macular holes, including two that underwent repeat fluid/gas exchange and laser within the first two weeks after surgery. At the time of final follow-up (mean: 10.9 months), 110 of 121 (91%) macular holes were closed. This included 8 of 9 eyes that had reopening of the macular hole between one and 21 months successfully treated by repeat fluid-gas exchange and 2 eyes that underwent a second successful pars plana vitrectomy, membrane peeling, and repeat fluid-gas exchange. Overall, 98 of 121 eyes overall (81%) were successfully treated by a single surgery; 94 of 121 (78%) achieved two lines or greater of visual improvement; 83 of 121 (69%) achieved 20/70 or better vision; and 47 eyes (39%) achieved 20/40 or better vision. Complications in this series included infectious endophthalmitis (1 eye), intraoperative retinal break (2 eyes), late retinal detachment (5 eyes), transient mild intraocular pressure elevation (46 eyes), inflammatory response (six eyes), epiretinal membrane (6 eyes), intraretinal hemorrhages (1 eye), and cataract (33 of 99 phakic eyes underwent cataract extraction during the follow-up). CONCLUSION: A combination of intravitreal perfluorocarbon gas and autologous plasma-thrombin mixture (tissue glue) was well tolerated in most patients and did not result in any specific long-term complications. The use of supplemental fluid-gas exchange when necessary improved the final success rate. Further well-controlled and randomized studies will be required to determine the efficacy of this as an adjunct or alternative to other methods of treatment for macular holes.

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PURPOSE: To evaluate the safety and efficacy of transscleral diode laser for retinopexy in rhegmatogenous retinal detachment surgery in a multicenter trial. METHODS: Seventy-two patients with primary rhegmatogenous retinal detachments were enrolled. No patient with chronic detachment, a retinal break greater than 90 degrees, history of uveitis or infectious retinopathy, or proliferative vitreoretinopathy was enrolled. RESULTS: Information from follow-up of 6 months or longer was available on 65 eyes. Retinas were attached at 6 months with a single operation in 58 (89%) of these eyes. Complications included apparent pinpoint breaks in Bruch's membrane in 15 eyes, scleral-thermal effect in 14 eyes, and limited hemorrhage, which was intraretinal in 10 eyes and extended into the vitreous in 3 eyes. In one case, hemorrhage was judged perhaps to have contributed to initial surgical failure. The other complications had no known adverse effects. Complications were significantly associated with the physician's experience in using transscleral laser retinopexy. CONCLUSIONS: In this multicenter study, transscleral diode laser retinopexy served as a safe and effective means of creating chorioretinal adhesion during retinal reattachment surgery. Minor complications were minimized by increasing experience with the technique.

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PURPOSE: To evaluate the safety and efficacy of transscleral diode laser for retinopexy in rhegmatogenous retinal detachment surgery in a multicenter trial. DESIGN: 67 patients with primary rhegmatogenous retinal detachment underwent scleral buckling surgery, using transscleral diode laser for retinopexy, at five study centers. STUDY PARTICIPANTS: 72 patients with primary rhegmatogenous retinal detachments were enrolled. No patient with chronic detachment, a retinal break greater than 90 degrees, history of uveitis or infectious retinopathy, or proliferative vitreoretinopathy was enrolled. Five eyes were excluded because they required additional nonprotocol treatment at the time of surgery (vitrectomy or supplementary cryotherapy due to probe malfunction). MAIN OUTCOME MEASURES: Retinal reattachment at six months after one operation. Secondary measures: visual acuity and complications, including choroidal, retinal, and vitreous hemorrhage, inflammation, and scleral damage. RESULTS: Six months or greater follow-up information was available on 65 eyes. Retinas were attached at 6 months with a single operation in 58 (89%) of these eyes. Complications included apparent pinpoint breaks in Bruch is membrane in 15 eyes, scleral thermal effect in 14 eyes, and limited hemorrhage, which was intraretinal in 10 eyes, and extended into the vitreous in 3 eyes. In one case, hemorrhage was judged to have contributed possibly to initial surgical failure. The other complications had no known adverse effects. Complications were significantly associated with the physicians experience with transscleral laser retinopexy. CONCLUSION: In this multicenter series, transscleral diode laser retinopexy served as a safe and effective means of creating chorioretinal adhesion during retinal reattachment surgery. Minor complications were minimized by increasing experience with the technique.

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PURPOSE/METHODS: To evaluate the role of initial visual acuity as a factor for progressive loss of vision or progression to a full-thickness macular hole in eyes with stage I macular holes (tractional foveal detachment without dehiscence). The study population included 35 patients with stage I macular holes with best-corrected visual acuity of 20/25 to 20/80 in one eye, and a full-thickness macular hole in the fellow eye. RESULTS/CONCLUSIONS: Eyes with stage I macular holes with best corrected visual acuity between 20/50 and 20/80 had a 66% (ten of 15 eyes) rate of progression to full-thickness macular hole, whereas eyes with best-corrected visual acuity of between 20/25 and 20/40 had a 30% (six of 20 eyes) risk of progression to full-thickness macular hole. The risk of progression to macular hole is significantly higher in eyes with stage I macular holes with best-corrected visual acuity of 20/50 or worse (P = .03).

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PURPOSE: The purpose of this study is to assess the benefit of vitreous surgery in preventing full-thickness macular holes in patients with impending (stage 1) macular holes. METHODS: A prospective randomized multicenter clinical trial was conducted on patients with full-thickness macular holes in their first eye (stage 3 or 4) and signs and symptoms of stage 1 macular holes in their fellow eye (study eye). The study eye was randomized to vitreous surgery or observation. Outcome was assessed by standardized measurement of visual acuity, detailed clinical examination, fundus photographs, and fluorescein angiography. RESULTS: A full-thickness macular hole developed in 10 (37%) of 27 patients in the vitrectomy group compared with 14 (40%) of 35 patients randomized to observation (P = 0.81). This difference of 3% has a 95% confidence interval of (-21%, 27%). CONCLUSION: The study was terminated because of low recruitment. The authors were unable to prove (or disprove) the benefit of vitreous surgery in patients with stage 1 macular holes. The authors can state, however, that should a beneficial effect from vitrectomy exist, it would probably be minimal. Considering the cost and morbidity of vitreous surgery, a conservative approach for stage 1 macular hole might be appropriate.

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PURPOSE: This study was conducted to determine whether visual outcomes have improved after repair of retinal detachments (RDs) associated with cytomegalovirus (CMV) retinitis, and, if so, whether factors such as earlier intervention and changes in surgical technique have led to these results. METHODS: The authors performed a retrospective review of 35 eyes in 30 immunocompromised patients with CMV retinitis and RD who underwent pars plana vitrectomy with the use of silicone oil injection. Visual and anatomic results in eyes treated between January 1991 and April 1992 (group 1) were compared with eyes treated before January 1991 (group 2). Follow-up was limited due to patient mortality; median follow-up was 4.1 months in group 1 and 2.5 months in group 2. RESULTS: Best-attained postoperative visual acuities were better for group 1 than group 2 eyes, with 71% of group 1 eyes attaining visual acuity of 20/200 or better compared with 17% of group 2 eyes (chi-square1 trend = 12.3; P < 0.001). A similar result was found among eyes with macula-off detachments. Ambulatory visual acuity of 5/200 or better was achieved in 86% of group 1 versus 33% of group 2 eyes. There was a longer interval between diagnosis and surgery in group 2 compared with group 1 (7 versus 3 days); scleral buckling in conjunction with pars plana vitrectomy and silicone oil injection was used in more group 1 eyes. CONCLUSION: Earlier intervention, absence of preoperative optic atrophy, and macular CMV correlate with better postoperative visual acuity results. Pars plana vitrectomy combined with silicone oil for eyes with macula-off RDs can result in improved visual acuity.

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BACKGROUND: The use of laser photocoagulation with sparing of foveal photoreceptors to control exudative age-related macular degeneration (AMD) with subfoveal involvement was investigated. METHODS: Patients with exudative AMD and visual acuity of 20/100 or worse were treated with foveal-sparing laser photocoagulation. The full extent of the choroidal neovascular membrane was treated with laser photocoagulation in addition to any associated retinal pigment epithelial detachment, with sparing of the foveal avascular zone. Three cases in which visual acuity improved dramatically are presented. RESULTS: Laser photocoagulation resulted in control of the exudative process in all patients. The three patients whose cases are presented had dramatic visual improvement. CONCLUSION: Foveal-sparing laser photocoagulation is an alternative treatment modality in patients with exudative AMD involving the fovea. The definitive value of this treatment modality can only be determined by a prospective, randomized, clinical trial.

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We reexamined 96 patients with macular holes or cysts. The mean follow-up period was 4.7 years. Of 19 eyes with macular cysts, only two (10.5%) showed progression to a macular hole. In 15 (79%) of those 19 eyes, the cyst disappeared. Of 80 patients with a macular hole or cyst in one eye and a normal fellow eye, a hole developed in the fellow eye in only one patient (1.2%) and a cyst developed in the fellow eye in only two patients (2.5%). Of 66 eyes with a stage 3 full-thickness macular hole, three eyes (5%) showed resolution without any sign of a hole. Our results suggest a favorable prognosis for normal fellow eyes of patients with macular holes or cysts and for eyes with cysts. Eyes with full-thickness macular holes have a less favorable prognosis, although their natural history may not be as poor as previously thought.

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Retinal detachments are a recognized complication of cytomegalovirus retinitis. In a series of 145 patients with cytomegalovirus retinitis, 38 (26%) developed retinal detachments. The cumulative probability of a retinal detachment 1 year after the diagnosis of cytomegalovirus retinitis was 50%. Detachments were associated with increased size of the cytomegalovirus lesion and with lesions extending anteriorly up to the ora serrata. Treatment with an anticytomegalovirus drug appeared to delay the time to detachment. Median survival time after the diagnosis of retinal detachment was 9 months. In our study, vitrectomy with silicone oil as the initial surgical procedure was the most effective approach. Successful anatomic reattachment of the retina was achieved in 70% of patients undergoing this procedure. Despite the success of surgery, the visual outcome was disappointing, with only 20% of eyes achieving a final visual acuity of 5/200 or better.

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We evaluated the occurrence or progression of nuclear sclerosis of the crystalline lens in 100 eyes after vitrectomy for removal of idiopathic epiretinal membranes causing macular pucker. The follow-up period ranged from six to 99 months (average, 29 months). Visually significant nuclear sclerosis was present preoperatively in three of the operated on eyes and four of the fellow eyes. The rate of occurrence or progression of visually significant nuclear sclerosis was far greater in the operated on eyes (P less than .0001). Of 100 patients, 80 operated on eyes and 24 fellow eyes had visually significant nuclear sclerosis or had undergone previous cataract extraction at the conclusion of the study. Different concentrations of glucose in the intraocular irrigating solution did not affect occurrence of later nuclear sclerosis. Patients older than 50 years of age had a far greater incidence of later nuclear sclerosis than patients younger than 50 years of age (P = .0003). Nuclear sclerosis may be caused by altered lens metabolism after removal of part of the vitreous gel, since nuclear sclerosis also occurs in other conditions associated with vitreous liquefaction.

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Recurrent rhegmatogenous retinal detachment sometimes occurs following scleral buckling surgery in the absence of advanced proliferative vitreoretinopathy (grade C-2 or greater). Such detachments can occur because: 1) the scleral buckle is not properly positioned beneath the original break; 2) the buckle is not high enough; 3) the break is elevated off the buckle due to progressive vitreous traction; 4) there are new breaks; and 5) chorioretinal adhesion is insufficient. Techniques that may be useful for reattaching the retina in these cases include: 1) adding scleral buckling material to augment the original buckle; 2) modifying the existing buckle without adding new material; 3) replacing the original buckle with other material; 4) re-treating inadequately closed breaks; and 5) combinations of these four techniques. Vitrectomy may be avoided in many cases.

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The pathogenesis of idiopathic macular holes and cysts is currently debated. The authors studied the histopathologic features of 41 specimens. Of 22 full-thickness holes, 16 (73%) had epiretinal membranes (ERMs), 15 (68%) had cystoid macular edema (CME), and 3 (17%) were sealed by fibroglial and retinal pigment epithelial hyperplasia. Photoreceptors were variably degenerated, for a mean of 480 microns (range, 200-750 microns) from the hole margins. Of 12 lamellar macular holes, 6 (50%) had an ERM exhibiting tangential traction on the internal limiting membrane. Cystoid macular edema was present in five (71%) of seven macular cysts, and an ERM was noted in only one (14%). The authors' results suggest that ERM tangential traction may play a role in the pathogenesis of lamellar macular holes. Macular holes often have associated ERMs and CME, which may be potentially reversible.

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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.

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Four eyes underwent vitrectomy and epiretinal membrane dissection for tractional retinal detachment (RD) or macular pucker associated with Candida chorioretinitis. The epiretinal membranes were vascularized and, in three of four eyes, were associated with full-thickness retinal scars, presumably at the site of previous active Candida chorioretinitis. The epiretinal membranes were successfully removed in all four cases. Visual results depended on the degree of macular pathology and the presence and location of a full-thickness retinal scar.

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Control of intraoperative hemorrhage is critical during vitreoretinal surgery for penetrating ocular injuries. Methods to control bleeding include: (1) raising the intraocular pressure, (2) intraocular diathermy, (3) fluid/gas exchange, (4) choice of irrigating solution, (5) addition of thrombin to the infusion solution, (6) endophotocoagulation, (7) silicone oil injection, (8) sodium hyaluronate injection. A combination of these various methods will almost always control bleeding in each case.

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