Vitreoschisis and retinal detachment: New insight in proliferative vitreoretinopathy

Purpose To assess the occurrence of peripheral vitreoschisis-induced vitreous cortex remnants (p-VCRs) in primary rhegmatogenous retinal detachment (RD) and investigate whether the presence of p-VCRs results in a greater risk of RD recurrence, secondary to Proliferative Vitreoretinopathy (PVR) development after pars plana vitrectomy (PPV). Methods Patients who underwent PPV for primary rhegmatogenous RD between January 2016 and December 2018 were included. The presence of residual p-VCRs was confirmed intraoperatively using triamcinolone acetonide (TA). Patients with p-VCRs were divided into two groups: Group A comprised of patients who underwent PPV without p-VCR removal, while Group B included patients who underwent PPV with p-VCR removal. Results Four hundred-thirteen eyes with evidence of p-VCR were analyzed. Two-hundred-twenty-three eyes underwent PPV without VCR removal (Group A), while 190 eyes underwent PPV with p-VCR removal (Group B). Primary anatomical success was 91.5% in the Group A and 95.4% in the group B. Retinal re-detachment due to PVR occurred in 17 (7.6%) eyes in Group A and in four (2.1%) eyes in Group B within the first 3 months (p = 0.01). Among group A, in 11 eyes, there was a diffuse posterior PVR grade C, while six eyes were focal PVR grade C. In Group B, we observed four retinal re-detachment due to focal PVR grade C. Conclusion The presence of p-VCRs seems to be associated with a higher incidence of PVR development and might also result in more complex RD recurrence, this suggests the need for more aggressive VCRs removal during the first surgery.

Surgery for Combined Hamartoma of the Retina and Retinal Pigment Epithelium

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.

A simple new technique for the induction of residual posterior vitreous cortex removal and membrane peeling

AIM: To describe a quick, cost-effective alternative to using a scraper to remove the residual posterior vitreous cortex and create an inner limiting membrane (ILM) flap during vitrectomy. METHODS: The surgical technique and a retrospective interventional single-center series of cases were described. A hook was made on the tip of a conventional syringe needle (outer diameter, 0.6 mm; 23 gauge) by bending the needle against a plate. We used this hook to remove the residual posterior vitreous cortex and create an ILM flap during vitrectomy. The efficacy and safety of using this instrument in ophthalmological procedures for a variety of vitreoretinal disorders were evaluated. RESULTS: The hook was effective for removing focal or diffuse residual posterior vitreous cortex in eyes with rhegmatogenous retinal detachment, proliferative diabetic retinopathy, and pathological myopia. It was also successfully used to make a free edge of the ILM and help strip the epiretinal membrane. There were no serious complications associated with using the hook in delicate ophthalmological procedures. CONCLUSION: The hook, made by bending a conventional needle, is a simple and cost-effective instrument for removing residual posterior vitreous vortex and to create epiretinal and ILM flaps during vitrectomy in eyes with various vitreoretinal diseases.

Quantification of the peripheral vitreous after vitreous shaving using intraoperative optical coherence tomography

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; p<0.01).ConclusioniOCT 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.

Anatomic and Topographic Vitreous and Vitreoretinal Interface Features in Proliferative Diabetic Vitreoretinopathy

The role of the vitreous body and vitreomacular interface (VMI) is key in many processes including proliferative diabetic retinopathy (PDR). In PDR patients, the VMI changes can significantly influence the emergence and progression of the disease. There are multiple factors at work in the VMI including taut posterior cortical layers, vitreoschisis, posterior vitreous detachment (PVD), and vitreous adhesions. But there is no general consensus about their role in proliferative complications. Further understanding the VMI relationship in a case of PDR is warranted in order to design better treatments, to arrest and possibly even reverse progression of PDR. Today there is no imaging techniques to determine normal vitreous and VMI interactions in different PDR stages intraoperatively. Purpose: to analyze intraoperative vitreous and vitreoretinal interface features during chromovitrectomy in patients with A-C stages of PDR. Patients and methods. Seventy-four diabetic patients (74 eyes) were included. We performed standard 25 Gauge pars plana vitrectomy using Vitreocontrast for vitreous and vitreoretinal interface (VRI) visualization. Intravitreal “Vitreocontrast” suspension is the most favored agent of those studied and it is increasingly used as an adjunct during surgery to delaminate fine tissue planes and pockets of formed vitreous and VRI structures that may not be visible with routine operative illumination systems, or using modern vital dyes. Results. “Vitreocontrast” suspension allows to visualize posterior cortex changes during different stages of PDR. We investigated vitreous and VRI anatomy, topography and structure and determined safety of retrociliary and equatorial cisterns walls in 97 % in stage A of PDR, 95 % in stage B and in 82 % of stage C. In 3–5–18 % cases, correspondently, we determined disorganization of some vitreous cisterns. In 94 % cases of PDR A and 96 % cases of PDR B we visualized preretinal vitreous layer in a central macular zone, within the boundaries of vascular arcades. It has specific topography and strong adhesion to the internal retinal membrane. It’s the first time when this new vitreous cortex layer was revealed. The presence of this layer is the result of a strong vitreomacular adhesion that causes the posterior vitreous cortex split as it attempts to detach from the inner retinal surface. Such outermost layer remains attached to the macula and can induce further proliferation process. On a stage B of PDR this area correspond with multiple vitreoschisis, on a stage C of PDR — with fibrovascular membrane. The complete PVD was revealed in 61 cases. Conclusion. In this article we analyze the results of surgical treatment in 74 patients with A-C stages of proliferative diabetic retinopathy. Newer imaging technique with new dye — suspension “Vitreocontrast” allows to detect sensitive relationships of vitreous and VRI in each stage of the disease. The role of vitreous body in this process gives us a reason to consider it as an important object for further research. Moreover, the understanding of their relations in different stages of PDR enables to develop optimal surgical approach on each stage of PDR.