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AimTo study the role of internal limiting membrane (ILM) peeling in the prevention of macular epiretinal membrane (ERM) formation following pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD).MethodsIn a randomised trial, patients with macula-off RRD (duration ≤3 months) with proliferative vitreoretinopathy grade ≤C1 and absence of pre-existing maculopathy were recruited from June 2016 to May 2018. Patients were randomised into two groups: group 1 (conventional treatment) underwent PPV alone, while group 2 underwent PPV with macular ILM peeling. The main outcome measures were macular ERM formation (detected on optical coherence tomography), corrected distance visual acuity (CDVA), retinal attachment and central macular thickness (CMT) at last follow-up (minimum 6 months).ResultsSixty patients (30 in each group) completed the required follow-up. The two groups were comparable in sex distribution, age, duration of RRD, baseline CDVA and duration of follow-up (median 15.5 vs 14 months). Macular ERM developed in 20% (n=6) and 0% of eyes in groups 1 and 2, respectively (p=0.002). Retinal reattachment was attained in all eyes. There was no statistical difference in final CDVA between the groups (p=0.43). Dissociated optic nerve fibre layer (DONFL) was found in 0% and 40% (n=12) of eyes in groups 1 and 2, respectively (p=0.0001). However, DONFL did not significantly affect the final CDVA (p=0.84). The final CMT was 266.0±37.5 µm and 270.0±73.7 µm in groups 1 and 2, respectively, with no statistical difference (p=0.62).ConclusionsILM peeling prevents macular ERM formation following PPV for RRD but provides similar visual outcomes as compared with conventional treatment.Trial registration numberCTRI2018/04/012978.

BackgroundAfter idiopathic epiretinal membrane (iERM) removal, it is unclear whether the internal limiting membrane (ILM) should be removed. The objective was to assess if active ILM peeling after iERM removal could induce microscotomas.MethodsThe PEELING study is a national randomised clinical trial. When no spontaneous ILM peeling occurred, patients were randomised either to the ILM peeling or no ILM peeling group. Groups were compared at the month 1 (M1), M6 and M12 visits in terms of microperimetry, best-corrected visual acuity (BCVA) and optical coherence tomography findings. The primary outcome was the difference in microscotoma number between baseline and M6.Results213 patients were included, 101 experienced spontaneous ILM peeling and 100 were randomised to the ILM peeling (n=51) or no ILM peeling group (n=49). The difference in microscotoma number between both groups was significant at M1 (3.9 more microscotomas in ILM peeling group, (0.8;7.0) p=0.0155) but not at M6 (2.1 more microscotomas in ILM peeling group (−0.5;4.7) p=0.1155). Only in the no ILM peeling group, the number of microscotomas significantly decreased and the mean retinal sensitivity significantly improved. The ERM recurred in nine patients in the no ILM peeling group (19.6%) versus zero in the ILM peeling group (p=0.0008): two of them underwent revision surgery. There was no difference in mean BCVA and microperimetry between patients experiencing or not a recurrence at M12.ConclusionSpontaneous ILM peeling is very common. Active ILM peeling prevents anatomical ERM recurrence but may induce retinal impairments and delay visual recovery.Trial Registration NCT02146144.

PurposeTo describe functional and histopathological findings after macular peeling using different dyes.MethodsProspective, randomized, comparative, interventional, and immunohistochemical study. Forty-five eyes from 45 patients with idiopathic epiretinal membrane (ERM) underwent pars plana chromovitrectomy with ERM and inner limiting membrane (ILM) using trypan blue 0.15% + brilliant blue 0.05% + lutein 2% in group 1 (15 eyes), trypan blue 0.15% + brilliant blue 0.025% + polyethylene glycol 3350 4% in group 2 (15 eyes), and indocyanine green 0.05% in group 3 (15 eyes). We evaluated visual acuity (VA) and macular sensitivity (MS) preoperatively, 1, 3, and 6 months after surgery. The expression of glial fibrillary acidic protein (GFAP) and neurofilament protein (NF) was assessed immunohistochemically on the ILMs peeled as markers of glial and neuronal cells.ResultsIn group 1, both mean VA and MS were significantly better at 1 and 3 months after surgery (P < 0.05), whereas no significant difference was found after 6 months. GFAP and NF expression was significantly lower in group 1 (P < 0.05).ConclusionsThe ERM/ILM peeling is thought to rip off the intraretinal tissue, based on the amounts of GFAP and NF in the specimens. The use of lutein dyes reduces iatrogenic stress to the retinal tissue and allows a faster functional recovery in the first 3 months after surgery, suggesting a less iatrogenic adhesion to the retinal tissue.

Background/aimsTo compare the visual outcome in early versus deferred surgery in patients with idiopathic epiretinal membrane (ERM) and good presenting visual acuity and mild symptoms.MethodsThis study is a randomised clinical trial. 53 eyes of 53 patients with symptomatic ERM and best-corrected visual acuity (BCVA) at presentation ≥65 early treatment diabetic retinopathy study (ETDRS) letters were randomised to immediate surgery (20 eyes) or to watchful waiting (33 eyes) for 1 year. Primary end-point was BCVA after 12 months. Secondary end-points were central macular thickness and the number of patients that crossed over from the watchful waiting arm to the surgery arm due to deteriorated symptoms.ResultsMean BCVA after 12 months in the watchful waiting group (81 letters) were not significantly different from patients undergoing immediate surgery (82.5 letters, p=0.647). During 1 year of follow-up, eight patients in the watchful waiting group (24%) crossed over to surgery and these patients gained a mean of 3.1 letters (SEM 1.38). Patients randomised to immediate surgery gained approximately one line. Watchful waiting patients who remained without surgery were stable. The visual acuity gain after surgery is slow and gradual until 9 months postoperatively. There were no serious complications such as retinal detachment or infectious endophthalmitis.ConclusionsVitrectomy for early symptomatic ERM is beneficial in preserving excellent vision. A watchful waiting approach with 1 year of follow-up is safe in the sense that this group does not lose five ETDRS letters in waiting. Deferral of surgery by regular monitoring of patients is a safe approach.Trial registration numbersH-C-2008-026 and NCT00902629.

Aim:To determine the effect of internal limiting membrane (ILM) peeling on anatomical and functional success rates in stage 2 and 3 idiopathic macular hole surgery (MHS).Methods:Randomised clinical trial of stage 2 and 3 idiopathic macular hole without visible epiretinal fibrosis and with less than 1 year’s duration of symptoms. Eyes were randomised to (1) vitrectomy alone without retinal surface manipulation, (2) vitrectomy plus 0.05% isotonic Indocyanine Green (ICG)-assisted ILM peeling or (3) vitrectomy plus 0.15% Trypan Blue (TB)-assisted ILM peeling. Main outcomes were hole closure after 3 and 12 months and best-corrected visual acuity after 12 months.Results:78 eyes were enrolled. Primary closure rates were significantly higher with ILM peeling than without peeling for both stage 2 holes (ICG peeling 100%, non-peeling 55%, p = 0.014) and for stage 3 holes (ICG peeling 91%, TB peeling 89%, non-peeling 36%, p<0.001). Visual outcomes in eyes with primary hole closure were not significantly different between the groups.Conclusions:Dye-assisted ILM peeling was associated with significantly higher closure rates than non-peeling in both stage 2 and 3 MHS. Intraoperative ILM staining with 0.05% isotonic ICG was not associated with a significantly different visual outcome than non-peeling or TB peeling in eyes with primary hole closure.Trial registration number:NCT00302328.

PurposeTo compare the 27G versus 25G vitrectomy in patients with epiretinal membrane (ERM).Patients and methodsSixty pseudophakic eyes of 60 consecutive patients treated by pars plana vitrectomy (PPV) using 27G (30 eyes) or 25G (30 eyes) were prospectively evaluated including eye’s inflammation, surgery time, ERM + ILM removal time and complications. Additionally, 1, 3, 7, 14, 30, 90 and 180 days after PPV, the following were estimated: intraocular pressure (IOP), sclerotomy wound closure time, distance best corrected visual acuity (DBCVA), foveal macular thickness (FMT) and surgically induced astigmatism (SIA).ResultsThe eye’s inflammation resolved within 30 days after surgery in both groups. The surgery and ERM + ILM times were longer in the 27G group (p ≤ 0.02). The most common postoperative complication was hypotony in both groups, more common in 25G group (23.3% vs. 10% of eyes). In 27G group, the mean IOP prior to 180 days postoperatively was higher (p < 0.05) and the sclerotomy wound closure time was shorter (p < 0.001). Mean DBCVA values (7, 14, 30 days after surgery) were significantly better in 27G group (p < 0.001). The mean FMT values were similarly and significantly reduced in both groups 1 day postoperatively (p < 0.05) as compared to preoperative values and then stabilized during follow-up. Mean SIA was lower in 27G group 30, 90 and 180 days after surgery (p < 0.001).ConclusionThe use of 27G PPV in patients with ERM significantly reduced sclerotomy wound closure time and surgically induced astigmatism, better stabilized intraocular pressure and allowed to achieve faster visual acuity improvement, as compared to 25G PPV.

Aim:To compare the sutureless 23-gauge system with a standard 20-gauge system in pars plana vitrectomy.Methods:60 patients in two randomised groups were included in this prospective clinical trial. Pars plana vitrectomy with either 23- or 20-gauge instruments was performed. The main outcome measures were postoperative conjunctival injection and pain. Secondary outcome parameters were time of surgery, intraocular pressure, visual acuity and complications.Results:Conjunctival injection (p = 0.0003) and postoperative pain (p = 0.01) were significantly reduced following 23-gauge vitrectomy compared with the 20-gauge procedure. Opening (p = 0.006) and closure times (p<0.00001) were significantly shorter, and vitrectomy time (p = 0.001) significantly longer in the 23-gauge system compared with 20-gauge vitrectomy. However, retinal manipulation and overall surgery times did not differ significantly between both groups. The same applies for eye pressure, distance and reading acuity. Regarding complications, two choroidal haemorrhages and one flat serous choroidal detachment occurred in the 23-gauge group.Conclusion:The 23-gauge system for pars plana vitrectomy offers significantly higher patient comfort during the early postoperative period. Time of surgery is almost equal—a shorter time for wound closure is neutralised by a longer vitrectomy time in the 23-gauge group.

Background Macular hole retinal detachment (MHRD) occurs most commonly in high myopia and causes severe visual impairment and greatly reduces the quality of life. The aim of this study is to evaluate the efficacy and safety of inverted internal limiting membrane insertion combined with air tamponade in the treatment of MHRD in high myopia, and also to compare the treatment efficacy with that of the conventional “vitrectomy plus internal limiting membrane peeling plus silicone oil tamponade” method for high myopia-associated MHRD. Methods/design In this clinical trial, 38 patients with MHRD in high myopia will be randomly assigned to two groups (Group 1: standard 3-port 23-gauge pars plana vitrectomy plus internal limiting membrane peeling plus air-fluid exchange plus silicone oil infusion; Group 2: standard 3-port 23-gauge pars plana vitrectomy plus internal limiting membrane peeling plus inverted internal limiting membrane insertion plus air-fluid exchange). The primary outcome is macular hole closure rate in 3 months after the initial surgery. The secondary outcomes are best corrected visual acuity (BCVA), reattachment rate of retinal detachment, and postoperative complication rate. Discussion The study results may help to evaluate the efficacy and safety of inverted internal limiting membrane insertion combined with air tamponade in the treatment of MHRD in high myopia, and also compare the efficacy of the new treatment with the conventional “vitrectomy plus internal limiting membrane peeling plus silicone oil tamponade” method. This trial may provide a novel surgical treatment for MHRD in high myopia with more effectiveness and less pain. Trial registration ClinicalTrials.gov, NCT03383731 . Registered on 19 December 2017. Retrospectively registered.

Background To evaluate the potential efficacy and safety of inner limiting membrane (ILM) staining with brilliant blue G (BBG) under air infusion. Methods 63 patients, treated by one surgeon with macular hole or idiopathic epiretinal membrane were evaluated prospectively. BBG was applied under air infusion in 38 patients (group 1), and injected into the vitreous cavity in 25 (group 2). Main outcome measures were the chromaticity difference between the stained ILM and the unstained underlying retina, anatomical–functional outcomes and complications of the surgery. Chromaticity difference was measured by an objective and quantitative analysis method to describe colour contrast strengths as they are perceived by the human eye. Anatomical and functional outcomes were assessed using optical coherence tomography (OCT), visual field analyses (VFA) and multifocal electroretinography (mfERG). Results CIELAB scores showed a significantly superior contrast for group 1 (16.72±2.36) than group 2 (10.34±1.29) (p<0.001). Visual acuity had increased in 28 eyes and remained stable in 10 eyes in group 1. In group 2, visual acuity had improved in 17 patients and remained unchanged in 8 patients. Based on postoperative OCT, anatomical success rate was 100%. During the follow-up period, mfERG and VFA demonstrated no case of BBG toxicity in either group. Cataract progression was the main postoperative complication (six eyes in group 1 and four eyes in group 2) and did not show a significant difference between the groups (p=0.45). Conclusions BBG under air infusion yields a significantly higher contrast staining and easy peeling of ILM associated with anatomical and functional improvement and no retinal toxicity after macular surgery.

Purpose To evaluate whether the status of the external limiting membrane (ELM) or inner segment/outer segment junction (IS/OS) improves after intravitreal injection of ranibizumab for age-related macular degeneration (AMD). We also evaluated whether the pre-operative values of these parameters are associated with the visual prognosis. Methods This was a hospital-based, cross-sectional study. Seventy-six eyes of 76 treatment-naive AMD patients who received three monthly intravitreal injections of ranibizumab followed for more than 6 months with additional as-needed injections were investigated. Spectral domain OCT was used to evaluate the length of ELM, IS/OS, and foveal thickness pre- and post-operatively. Changes of ELM and IS/OS length were evaluated postoperatively. Correlation coefficients between pre-operative parameters and post-operative visual acuity were also analyzed. Results Significant changes were noted in mean logMAR (0.66 to 0.53), foveal thickness (231.1 to 151.1 μm), and IS/OS length (514.9 to 832.3 μm) after the treatment. ELM length did not improve significantly (1,312.4 to 1,376.7 μm). Restoration of IS/OS occured where ELM is retained. Although pre-operative ELM length, IS/OS length, and foveal thickness showed correlation with post-operative logMAR ( R  = –0.51, –0.39, and 0.46, respectively), the most powerful predictive factor for visual prognosis was pre-operative logMAR ( R  = 0.77, p  < 0.001). Conclusions IS/OS status improves in response to anti-VEGF therapy but ELM seems to have less plasticity. The status of IS/OS and ELM can be used as prognostic factors but the predictive power is inferior to that of baseline visual acuity.