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Vitreoretinal surgery for idiopathic epiretinal membranes
Published in A Peyman MD Gholam, A Meffert MD Stephen, D Conway MD FACS Mandi, Chiasson Trisha, Vitreoretinal Surgical Techniques, 2019
H Richard McDonald, Robert N Johnson, Robert N Johnson, Everett Ai, J Michael Jumper, Arthur D Fu
Approximately 90% of eyes with idiopathic ERM have a posterior vitreous detachment. Eyes with the vitreomacular traction syndrome may have an ERM in association with persistent vitreomacular adhesion.27,52 In eyes without a posterior vitreous detachment, the vitreous is separated from the posterior pole and the posterior hyaloid face is stripped anteriorly. Increased visualization of residual vitreous cortex with the use of intravitreous triamcinolone has been described.53 Although some surgeons have left the peeled epiretinal membrane within the vitreous cavity without removal of vitreous,54 most perform some degree of vitrectomy. However, no aggressive attempts are made to strip the vitreous cortex anteriorly to the posterior vitreous base insertion if tenacious adhesions are present.
Common Vitreoretinal Procedures
Published in Pradeep Venkatesh, Handbook of Vitreoretinal Surgery, 2023
Posterior vitreous detachment is a natural outcome of the senescent changes occurring with the vitreous humor. It is characterized by a clean, complete, and uncomplicated separation of the posterior hyaloid face of the vitreous from the ILM. Complications at the periphery of the retina such as retinal haemorrhage and retinal tear following complicated PVD are well recognized. These complications result from the strong attachment of the vitreous to the retina at the vitreous base. Posteriorly, the hyaloid is firmly attached to the margins of the optic disc, fovea, and blood vessels. VMT is also a form of complicated PVD in which the posterior hyaloid fails to separate from attachments at the foveal region, causing subtle tractional changes. Unlike EMM, in which retinal distortion results from static forces, VMT causes retinal changes owing to dynamic traction. Hence, the clinical course, characteristics, management approach, outcomes, and prognosis are different [see section on idiopathic EMM]. VMT is usually a diagnosis that is confirmed only after OCT imaging and has been classified as primary [without other pathology] and concurrent [with other pathology like vascular occlusion]. Based on the size of attachment on 2D OCT scan, it is termed focal and diffuse, when less than and greater than 1500 µm, respectively. It is termed vitreomacular traction syndrome [VMTS] when there is also associated ERM. Ultramicroscopic imaging of the vitreomacular cone resected at surgery has revealed the uniform presence of fibrocellular proliferation along the surface of the inner retina and posterior surface of the hyaloid. This proliferation is also thought to contribute to the strong adherence between the fovea and hyaloid in patients with VMT. Tractional CME, tractional DME, and myopic foveoschisis [see section on MTM] are considered as variants of VMT. It is important to note that fluorescein angiographic leakage is absent in tractional CME. Unlike in classic VMT, wherein the area of attachment is broad based, in tractional CME, it is very focal and narrow. Tractional CME has two further subtypes, one with shallow neurosensory separation and one without. Spontaneous separation of vitreomacular adhesion [VMA, or mere attachment of partially separated hyaloid to the fovea without any structural and functional changes in the retina] during follow-up has been observed in about one third of patients and so these patients need only follow-up. On the other hand, spontaneous release of VMT is considered infrequent.
The current status of biological treatment for uveitis
Published in Expert Review of Clinical Immunology, 2020
Carla Gaggiano, Jurgen Sota, Stefano Gentileschi, Valeria Caggiano, Salvatore Grosso, Gian Marco Tosi, Bruno Frediani, Luca Cantarini, Claudia Fabiani
Tocilizumab has shown promising results, arising as an alternative choice for the treatment of different forms of NIU, including severe refractory cases and UME [128–132]. The STOP-Uveitis study, a multicenter, randomized, open-label clinical trial, evaluated the safety, tolerability, and bioactivity of two doses of TCZ (4 mg/kg/4 weeks and 8 mg/kg/4 weeks) in 37 patients with intermediate, posterior, or panuveitis. Primary and secondary outcome measures were analyzed after 6 months of treatment, disclosing a favorable effect of TCZ on visual acuity, vitreous haze and central macular thickness, with an acceptable safety profile with both regimens [133]. Later after, the same authors observed that the absence of vitreomacular adhesion (VMA) or the development of posterior vitreous detachment in eyes with VMA had a beneficial effect on visual outcome of subjects receiving TCZ [134]. A single-center prospective interventional study aimed at evaluating efficacy and safety of TCZ in the treatment of refractory BD-related uveitis is currently recruiting patients and it is expected to end in 2020 (ClinicalTrials.gov Identifier: NCT03554161).
Emerging drugs for the treatment of diabetic retinopathy
Published in Expert Opinion on Emerging Drugs, 2020
Elio Striglia, Andrea Caccioppo, Niccolò Castellino, Michele Reibaldi, Massimo Porta
LP has been for years the only available treatment for DR and still represents a therapeutic option of pivotal importance for the treatment of peripheral retina complicated by ischemia and retinal proliferation. It aims to stabilize visual acuity. In DME, focal or grid laser treatment is applied directly to localized microaneurysms and intraretinal vascular abnormalities. In the last decade LP of the macula for the treatment of DME was overshadowed by the advent of intravitreal injections of anti-VEGF and corticosteroids in the management of DME. Relative indications for macular laser include the vasogenic subform of DME which is characterized by the clinical identification of focally grouped microaneurysms and leaking capillaries. Laser has been shown effective even in eyes with DME and persistent vitreomacular adhesion. In contrast, when DME is associated with vitreomacular traction, vitrectomy is needed [11].
The Impact of Epiretinal Membrane in Neovascular Age-Related Macular Degeneration Treatment: A Spectral-Domain Optical Coherence Tomography Study
Published in Seminars in Ophthalmology, 2018
Irini Chatziralli, Panagiotis Stavrakas, George Theodossiadis, Konstantinos Ananikas, Eleni Dimitriou, Panagiotis Theodossiadis
In patients with AMD, vitreoretinal interface (VRI) alterations, such as posterior vitreous detachment (PVD), vitreomacular adhesion (VMA), and vitreomacular traction (VMT), have been reported in previous studies.8,9 Epiretinal membrane (ERM) refers to the formation of a thin layer along the inner retinal surface, which is the result of fibroglial proliferation on the retinal surface and mainly at the macular area.10 The coexistence of ERM and nAMD has been reported to be 26%, using spectral domain-optical coherence tomography (SD-OCT),11 but in clinical trials patients with AMD and co-existent ERM were generally excluded.5–7 In the literature, there are a limited number of studies dealing with AMD and coexistent ERM, which were retrospective with variable short-term follow-up.12–14 In light of this, the purpose of this prospective study was to evaluate the impact of ERM presence on anatomical and functional results in patients with wet AMD treated with intravitreal anti-VEGF injections.