From the patients who underwent keratoplasty within the last three years we selected 40 out of a total of 121 with the following common features: diameter of the button 7.1 mm, indication for surgery for optical reasons, healing of the button with sufficient clarity, achieving visual acuity of 0.5 or better. In 20 patients we used a running 10/0 nylon suture; in the remaining 20 cases we combined single 8/0 silk sutures with a runing 10/0 prolene suture. No statistically significant difference between the two groups was found when corneal astigmatism was compared to six to eight months postoperatively (at least two months following suture removal). This also applied in respect of the resultant refraction difference. However, in cases of keratoconus the combined suture technique resulted in a lower degree of astigmatism than the running suture technique alone.

The correlation of the topography of certain areas of the fundus, which exhibit relentless progression of microangiopathy (within the framework of general fluctuations in the course of the disease), as well as the degree of predominance of capillary perfusion and permeability disturbances in these respective areas justifies a classification of non-proliferative diabetic retinopathy into three distinct types:(1) pre-maculopathy/maculopathy in non-proliferative diabetic retinopathy (DR),(2) nonproliferative DR, and (3) non-proliferative DR lacking a tendency towards vasoproliferation or maculopathy. These results are based on regular biannual angiographic examinations of six different standard fundus areas in a total of 365 patients with non-proliferative DR. This scheme of classification has prognostic as well as therapeutic consequences.

This paper concerns experience gained by the authors with implants utilized during the past six years at the 1st University Eye Clinic, Vienna, in surgical treatment of 704 cases of rhegmatogenous retinal detachment: in 493 procedures a scleral buckle (silastic sponge in 81%) was applied, in 211 cases an encircling element (a silicon rod 2 mm in diameter in 83%). The subretinal fluid was drained in 52% of the buckling procedures, and in 90% of the encircling procedures. The success rate was 93% in the cases treated by buckling, and 79% following an encircling procedure. Thirty-four cases exhibiting massive periretinal proliferation and three cases with giant ears extending over 180 degrees were treated by retinopexy and indentation of the scleral wall in combination with vitrectomy followed by insufflation of SF6 gas. In 13 of these cases (two of them with giant tears) an anatomical cure was achieved.

In 185 diabetics with proliferative diabetic retinopathy (d.r.) involving both eyes symmetrically we analyzed the indication for photocoagulation in borderline cases in which, despite complications (such as inducement of vitreoretinal retraction), the beneficial effect of photocoagulation outweighs the likelihoood of a spontaneous deleterious course. In stage 2 of proliferative d.r. the risks associated with photocoagulation (i.e., factors likely to cause traction phenomena) were found to be extensive coagulation of intraretinal and preretinal hemorrhages, and coagulation of feeder vessels as well as of fundus areas located behind vitreal hemorrhages. In stage 3, procoagulative risk factors in the morphological picture comprised the existence of several vitreoretinal insertions with tent-shaped traction folds and extensive preretinal and subvitreal hemorrhages.

In 169 out of 409 diabetic patients without any ophthalmoscopically or biomicroscopically visible retinal changes, typical symptoms of diabetic pre-retinopathy were revealed by fluorescein angiography: capillary dilatation (89.3%), capillary occlusion (78.7%), leakage from small blood vessels (54.4%) and arteriovenous shunts (40.8%). No correlation was found between the duration of the diabetes mellitus and the onset of diabetic pre-retinopathy. Juvenile diabetics developed significantly more capillary occlusions, while in diabetics of advanced age capillary occlusions and leakage from small vessels were encountered with almost equal frequency.

Report on 82 consecutive cases in which pars plana vitrectomy was performed because of intravitreal hemorrhage. Postoperative follow-up ranged from 3 to 4 1/2 years. Although an incipient improvement of the visual acuity was achieved in 54%, recurrent hemorrhages as well as progression of the proliferative diabetic retinopathy lead to visual deterioration of blindness in 64% of the eyes.

A retrospective study on 184 eyes of 167 diabetics which had been submitted to a vitrectomy because of various affections of the vitreous body and retina shows, that aphakic eyes, cases suffering from repeated bleeding into the vitreous cavity, and eyes with advanced stages of diabetic retinopathy are mostly preposed to the development of rubeosis iridis. Coincidence of two of these factors was found in more than two thirds of the eyes with post-operative rubeosis iridis. The stage of the diabetic retinopathy was preoperatively determined by means of ultrasonography.

Within the past five years we have performed excision of one quadrant of the ciliary body (pars plicata)(e.c.b.) in 22 eyes with secondary narrow-angle glaucoma. Prior to e.c.b. numerous surgical procedures for glaucoma had been attempted. Sixteen of the eyes were aphakic, six phakic. In nine eyes secondary angle closure was due to rubeosis iridis. The observation period following e.c.b. averaged 27.4 months. The preoperative tensions ranged between 40 and 50 mmHg. In 12 out of 22 eyes e.c.b. alone was sufficient to lower the intraocular pressure permanently; in seven cases local therapy (Timolol, Eppystabil) and/or oral Diamox respectively had to be added. Two eyes became atrophic and blind between one and 1.5 years following e.c.b.

Within the past five years fluorescein angiography of six different fundus areas was performed at intervals of six months on a total of 365 patients exhibiting non-proliferative diabetic retinopathy without diabetic maculopathy. Within that period, diabetic maculopathy was observed to develop in 195 eyes, vasoproliferation in 20 eyes. Within the general scope of fluctuation of the angiographic picture of retinal capillary perfusion disturbance, zones of continuous progression were encountered in 246 eyes. In 183 out of 195 eyes which developed diabetic maculopathy the distinct areas of relentless progression were located 2--6 PD's temporal to the macula; in the total 20 eyes which had advanced to the proliferative stage similar areas were encountered, located nasally 2--6 PD's above and below the optic disk.

Within the past 12 months, 64 intraocular lenses were implanted. Only eyes close to emmetropia and not exhibiting any pathological condition were considered for this type of surgery. The average age of our patients was 76 years. Preoperative medication and surgical procedure are described. Serious postoperative complications have not been observed so far. Striate keratopathy (in 22% of the cases), as well as secondary glaucoma (in 11% of the cases) were restricted to the initial 4-5 postoperative days. In 73% of the cases the postoperative visual acuity was 6/8-6/6. Maculopathy and opacification of the posterior lens capsule left behind were responsible for reduced visual acuity in the remaining cases.

BACKGROUND: The purpose of this study is to evaluate the role, the safety and the effectiveness of intravitreal bevacizumab (IVB) injections as an adjunct to vitrectomy in the management of severe proliferative diabetic retinopathy (PDR). DESIGN: Case-Control Study METHODS: Randomized controlled trial performed on 72 eyes of 68 patients affected by vitreous haemorrhage (VH) and tractional retinal detachment (TRD), which occurred as a consequence of active proliferative diabetic retinopathy (PDR). We randomly assigned eligible patients in a 1: 1: 1 ratio to receive a sham injection or an intravitreal injection of 1.25 mg of bevacizumab, either 7 or 20 days before the vitrectomy. In order to obtain three homogeneous groups of surgical complexity, we assigned to the following preoperative parameters a score from 0 to 3: a) vitreous haemorrhage, b) prior retinal laser-photocoagulation, c) morphological types of retinal detachment such as focal, hammock, central diffuse, table-top. Complete ophthalmic examinations and color fundus photography were performed at baseline and 1, 6, 12, and 24 weeks after the surgery. MAIN OUTCOME MEASURES: Intraoperative management, safety, efficacy of IVB at different time injection as an adjunct to vitrectomy in the management of severe PDR RESULTS: Group A (sham injection): intraoperative bleeding occurred in 19 cases (79.1%), the use of endodiathermy was necessary in 13 patients (54.1%), relaxing retinotomy was performed on one patient (4.1%), and in four cases (16.6%) iatrogenic retinal breaks occurred. The surgical mean time was 84 minutes (SD 12 minutes). Group B (bevacizumab administered 7 days before vitrectomy): intraoperative bleeding occurred in two cases (8.3%) and the use of endodiathermy was necessary in two patients (8.3%). No iatrogenic breaks occurred during the surgery. The surgical mean time was 65 minutes (SD 18 minutes). Group C (bevacizumab administered 20 days before vitrectomy): intraoperative bleeding occurred in three cases (12.5%), the use of endodiathermy was necessary in three patients (1.5%), and an iatrogenic break occurred in one patient (4.1%) while the delamination of fibrovascular tissue was being performed. The surgical mean time was 69 minutes (SD 21 minutes). The average difference in the surgical time was statistically significant between group A and group B (p = 0.025), and between group A and group C (p = 0.031). At the end of the surgery, the retina was completely attached in all eyes. At the 6-month follow-up, we observed the development of tractional retinal detachment (TRD) in one out of 24 patients from group C (4%). CONCLUSIONS: A preoperative intravitreal injection of bevacizumab may represent a new strategy for the surgical treatment of severe PDR by reducing retinal and iris neovascularization: this would make surgery much easier and safer, thus improving the anatomical and functional prognosis. According to our study, the best surgical results are achieved performing the IVB 7 days preoperatively.

PURPOSE: To report the initial experience and safety profile of 23-gauge pars plana vitrectomy (PPV) in eyes undergoing vitreoretinal surgery. DESIGN: Retrospective, multicenter, consecutive, interventional case series. METHODS: The inclusion criteria for this study included eyes that underwent primary, 23-gauge PPV for various indications including, but not limited to, epiretinal membrane, nonclearing vitreous hemorrhage, idiopathic macular hole, and rhegmatogenous retinal detachment (RD), and postoperative follow-up of at least 12 weeks. Exclusion criteria included history of prior vitrectomy, glaucoma filtration surgery, or administration of gas at expansile concentrations. Main outcome measures included best-corrected Snellen visual acuity (VA), intraocular pressure (IOP), intraoperative complications, and postoperative complications. RESULTS: Ninety-two patients met the inclusion criteria. The overall VA improved from 20/238 (range, 20/25 to hand motions [HM]) preoperatively to 20/82 (range, 20/20 to HM) postoperatively (P <.001). Each surgical indication experienced a statistically significant VA improvement. Intraoperative complications included retinal tears observed in two eyes (2.2%). Sclerotomy sutures were required intraoperatively in two eyes (2.2%). Postoperative complications included postoperative day 1 hypotony in six eyes (6.5%), a retinal tear in one eye (1.1%), and a recurrent RD in one eye (1.1%). No cases of endophthalmitis were observed. CONCLUSIONS: Intraoperative and postoperative complications were rare in this series of 23-gauge vitrectomy. Postoperative day 1 hypotony was the most common complication observed. All cases of postoperative hypotony resolved at postoperative week 1 without intervention. Retinal tear or detachment was an uncommon complication in the intraoperative and postoperative settings. Postoperative endophthalmitis was not noted in this case series.

PURPOSE: To describe the initial experience, effectiveness, and safety profile of 23-gauge instrumentation for a variety of vitreoretinal conditions. DESIGN: Single-center, retrospective, noncomparative, consecutive interventional case series. PARTICIPANTS: Seventy-seven eyes of consecutive patients who underwent 23-gauge transconjunctival vitrectomy surgery by a single surgeon at the Manhattan Eye, Ear, and Throat Hospital from October 2004 through October 2005. INTERVENTION: All patients underwent 3-port 23-gauge vitrectomy using Dutch Ophthalmic Research Corporation instrumentation and an Alcon Accuris Vitrector. MAIN OUTCOME MEASURES: Postoperative visual acuity at months 1 and 3, intraoperative and postoperative complications, and operative time. RESULTS: Mean acuity improved from 20/190 at baseline to 20/108 (P<0.0001) and 20/74 (P<0.0001) at months 1 and 3, respectively. By diagnosis, patients with epiretinal membrane (n = 20) improved from 20/124 to 20/93 (P = 0.0046), macular hole (n = 18) from 20/174 to 20/57 (P = 0.0007), rhegmatogenous retinal detachment (RD)(n = 14) from 20/248 to 20/51 (P = 0.0004), tractional RD (n = 12) from 20/175 to 20/62 (P = 0.0159), nonclearing vitreous hemorrhage (n = 12) from 20/1345 to 20/189 (P = 0.0004), vitreomacular traction (n = 4) from 20/145 to 20/124 (P = 0.7525), and retained lens fragments (n = 4) from 20/308 to 20/140 (P = 0.0972). One patient who underwent diagnostic vitrectomy had stable 20/50 acuity. Two patients had hypotony on postoperative day 1, 1 patient required a sutured sclerotomy intraoperatively, and no patients developed choroidal effusions. No intraoperative tears were noted. Surgical times collected on 17 patients during the final month of the study demonstrated a mean opening time (range) of 103 seconds (70-162), mean closing time of 75 seconds (17-470), and net operating time of 24.1 minutes (7.1-74.6). CONCLUSIONS: Twenty-three-gauge instrumentation is effective for a variety of vitreoretinal surgical indications. The safety profile compared favorably with published rates for 25-gauge systems.

PURPOSE: Report of anatomic and functional results of retinal detachment with giant retinal tear. PATIENTS AND METHODS: Retrospective study of 23 cases of retinal detachment resulting from retinal tear of 90 degrees or more: five had a history of ocular trauma, 14 had myopia, and six had no risk for giant retinal tear. Episcleral surgery was performed on cases of giant retinal tear less than 180 degrees , with no advanced proliferative vitreoretinopathy and no inversion of the retinal flap. A vitrectomy was performed on other cases. Scleral buckle was associated with vitrectomy in cases of advanced vitreoretinopathy. RESULTS: The degree of success in the primary surgery was 50% in vitreoretinal surgery, 75% in vitreoretinal surgery with an encircling scleral buckle, and 86.4% in episcleral surgery. Of the seven failed cases, six patients underwent second-intention surgery: vitrectomy in four cases (primary surgery: the first case, episcleral surgery; the next two cases, vitrectomy; and in the fourth, vitrectomy with an encircling scleral buckle). In the last two cases, vitrectomy with scleral buckle was used (the primary surgery in both cases was vitreoretinal surgery). The final success rate was 78.2%, and the average follow-up was 32 months. Through the last test, postsurgery acute vision improved in 16 cases. CONCLUSION: Vitrectomy is often recommended to repair retinal detachment with giant retinal tear. However, episcleral surgery can be used if the giant tear is less than 180 degrees , the proliferative vitreoretinopathy is not advanced, and the retina flap is not inverted. The scleral buckle must be associated with the vitrectomy in cases of inferior giant retinal tear even if the proliferative vitreoretinopathy is not advanced.

We report an unusual case of isolated bilateral microspherophakia with giant retinal tear and rhegmatogenous retinal detachment in a 10-year-old boy. Uneventful vitreoretinal surgery was performed in both eyes.

BACKGROUND: To evaluate the surgical results of scleral buckling alone on eyes with retinal detachment with giant retinal tears of less than 120 degrees, without inverted flap or proliferative vitreoretinopathy, and vitrectomy combined with scleral buckling with or without intraoperative usage of perfluorocarbon liquid (PFCL) in complicated cases. METHODS: Retrospectively, we reviewed giant retinal tear cases treated at Chang Gung Memorial Hospital, Kaohsiung, Taiwan between January 1, 1989 and August 31,2000. The surgical techniques consisted of standard three-port pars plana vitrectomy combined with scleral buckling in complicated cases, PFCL used intraoperatively in later cases, and scleral buckling alone in minor cases. RESULTS: A total of 47 consecutive eyes with giant retinal tears with retinal detachment in 45 patients with no previous history of ocular penetrating injury or vitreoretinal operations were enrolled in this study. The follow-up period was at least three months for all patients. Thirty-four eyes (72.3%) had giant retinal tears of less than 180 degrees, 12 eyes (25.5%) had tears between 180 degrees and 270 degrees, and one eye had two giant retinal tears. Scleral buckling combined with vitrectomy was performed in 36 complicated eyes (76.6%), PFCL was used intraoperatively later in 24 eyes, and scleral buckling was used alone in 11 minor cases (23.4%). Thirty eyes (63.8%) gained reattachment after the first surgery. Altogether, the retinas of 38 of 47 eyes (80.9%) remained attached at the last follow-up examination. CONCLUSION: In minor cases of giant retinal tear, scleral buckling alone without vitrectomy may be considered the primary surgical procedure. In complicated cases, using PFCL intraoperatively not only affords many advantages during surgery, but also raises the retinal reattachment rate.

AIM: To compare characteristics, management, and outcome of two groups of patients with primary rhegmatogenous retinal detachment (RRD) presenting to the same vitreoretinal unit approximately 20 years apart. METHODS: 124 patients in 1979-80 and 126 cases in 1999 were compared. RESULTS: More cases were pseudophakic and fewer aphakic in 1999 than 1979-80. More cases of giant retinal tear and fewer dialyses were operated on in 1999. Vitrectomy was a primary procedure in 63% of cases in 1999 but only 1% in 1979-80. Anatomical success rates were statistically similar: 79.8% primary and 88.8% final success in 1979-80, and 84% primary and 93.6% final success in 1999. CONCLUSION: Surgical management of primary RRD has changed greatly in 20 years. Success rates have changed little, despite availability of differing surgical techniques.

PURPOSE: To evaluate the indication for endoscopic vitreoretinal surgery in proliferative diabetic retinopathy (PDR). METHODS: Chart review of consecutive cases of vitreoretinal surgery for PDR performed by one of the authors (Y.L.F.) over a 2-year period. RESULTS: Endoscopic vitreoretinal surgery was performed in 8 of 41 (19.5%) eyes. The surgical indications were small pupil (3), hyphema (3), pseudophakia with fibrotic posterior capsule (1), and pars plana neovascularization with anterior tractional retinal detachment (6). CONCLUSION: Endoscopic vitreoretinal surgery, by enhancing the visualization of the retroirideal space, is a useful technique in PDR with opaque ocular media and/or neovascularization of the pars plana and ciliary body.

PURPOSE: We compared the surgical results of vitrectomy and scleral buckling for uncomplicated superior retinal detachment caused by flap tears. SUBJECTS AND METHODS: Included in the study were 225 phakic eyes of 225 patients undergoing primary surgery from January 1990 to December of 1996 for superior retinal detachment caused by flap tears; all eyes had been followed for longer than six months after surgery. The choice of procedures was based on each surgeon's preference. The cases were evaluated retrospectively and the surgical outcome and the rate of complications compared between the two groups of eyes. RESULTS: Initial and final anatomical success rate were 92% and 100% after each procedure. Redetachment after the first procedure was due to new retinal breaks in 5 eyes, reopening of original breaks in 2 eyes of vitrectomy cases, and malpositioned buckle in 11 eyes of scleral buckling cases. Proliferative vitreoretinopathy occurred in 3 eyes of vitrectomy cases. CONCLUSION: Primary vitrectomy was as successful as scleral buckling for superior rhegmatogenous retinal detachment. Although a high incidence of postoperative cataract formation was a major drawback, vitrectomy had some advantages over to scleral buckling.

PURPOSE: In the United Kingdom the majority of vitreoretinal (VR) surgery is performed under general anaesthesia (GA). The aim of this study was to demonstrate the scope of local anaesthesia (LA) for VR surgery, to measure the acceptance of LA to patients and surgeons and to compare the surgical outcomes, complication rates and duration of the surgical procedures under LA and GA. METHODS: A case-control study was undertaken to compare 100 cases performed under LA with 100 matched cases performed under GA. The matching of cases was based on multiple criteria such as configuration and complexity of retinal detachment, the involvement of the macula, the number and site of retinal tears, presence and severity of proliferative vitreoretinopathy, experience of the surgeon and the type of the surgical procedure. A clinical audit was also carried out on 65 successive patients using a questionnaire to determine the acceptability of LA to patients and surgeons. RESULTS: Anatomical and visual success rates, and intra-operative and post-operative complications, were similar in cases carried out under LA and GA. The mean duration of the surgery (excluding anaesthetic time) was significantly shorter for LA than GA procedures (p < 0.001). The acceptance for LA was high for both patients and the operating surgeons. CONCLUSIONS: We found that VR surgery can be safely and efficiently performed under LA. Adoption of LA has increased our throughput.