LEO Clinical Topic Update

Retina, Vitreous, and

Posterior Segment Trauma

H. Michael Lambert, MD
Retina and Vitreous of Texas, PLLC
Houston, Texas

Joseph A. Khawly, MD
Retina and Vitreous of Texas, PLLC
Houston, Texas

This Clinical Topic Update was reviewed by the

Macula Society, the Retina Society, and the Vitreous Society
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Retina, Vitreous, and Posterior Segment Trauma 2

Contents
Introduction 4

Age-Related Macular Degeneration (AMD) 4

Subretinal Choroidal Neovascularization 4

Vitamin Supplementation 5

The Ocular Histoplasmosis Syndrome (OHS) and Idiopathic Neovascularization 6

Idiopathic Macular Hole 6

Diabetic Retinopathy 7

Retinopathy of Prematurity (ROP) 8

Branch Retinal Vein Occlusion 10

Central Retinal Vein Occlusion 10

Retinitis Pigmentosa 11

Retinal Detachment 12

Pneumatic Retinopexy 12

Proliferative Vitreoretinopathy (PVR) 12

Endophthalmitis 13

Posterior Segment Trauma 14

References 15

Related Academy Materials 19

Retina, Vitreous, and Posterior Segment Trauma 3

Introduction

C linical trials and the development of innovative surgical techniques over the
past decade have resulted in an explosion of information about retinal
disease and about the most effective techniques that can be used to fight diseases
of the retina. Laser photocoagulation has been thoroughly evaluated in many
diseases and is now a mainstay of treatment, with the indications for treatment
much clearer. The scope and techniques of surgical therapy have been greatly
extended to include diseases previously considered untreatable and new
techniques and adjuncts to therapy that have facilitated treatment. This Clinical
Topic Update is organized by disease entity and focuses primarily on the results
of the major clinical trials of this period and new therapies under study that
impact the practice of the comprehensive ophthalmologist; it is not meant to be a
comprehensive reference but as a starting point to evaluate what you may want to
review in more detail.

Age-Related Macular Degeneration (AMD)

Subretinal Choroidal Neovascularization

T he efficacy of laser photocoagulation for extra- and juxtafoveal choroidal

neovascular membranes in age-related macular degeneration has been proven
by the Macular Photocoagulation Study (MPS).1−5 The first MPS study
demonstrated the efficacy of laser treatment for well-defined extrafoveal
choroidal neovascular membranes occurring 200–2500 µm from the center of the
foveal avascular zone. After 18 months of follow-up in these patients, 60% of
untreated eyes and 20% of treated eyes had experienced a loss of 6 or more lines
of vision from baseline on a standardized visual acuity chart. The efficacy of
laser photocoagulation diminishes with time and, in fact, 50% of those
membranes treated recur within a 3-year follow-up period. The laser treatment of
juxtafoveal lesions (1–199 µm from the center of the foveal avascular zone) was
also found to be effective for well-defined membranes. At 3 years of follow-up,
58% of untreated eyes had lost more than 6 lines of visual acuity compared with
49% of eyes treated with laser photocoagulation.
The subfoveal arm of the MPS demonstrated the efficacy of the treatment of
subfoveal choroidal neovascularization in age-related macular degeneration.6
Patients randomized to laser treatment had smaller scotomas, slightly better final
visual acuity (20/250 in treated eyes vs. 20/320 in untreated eyes), and slightly
faster reading speeds than those randomized to observation at the 24-month
follow-up visit. Treated patients, however, lost an average of 3 lines of visual
acuity immediately following laser photocoagulation. Visual loss from laser
treatment was greater in patients with better initial visual acuity (5 to 6 lines of
loss when vision was 20/40 to 20/100) and least in patients with poor initial
visual acuity (1 to 2 lines of loss with a pretreatment acuity of 20/200 to 20/320).
Subgroups of the MPS based on the size of the lesion and the patient’s vision
have been identified that may benefit most from conventional laser
photocoagulation.7
A number of authors have reported pilot results of the surgical excision of
subfoveal choroidal neovascular membranes in AMD, the ocular histoplasmosis

Retina, Vitreous, and Posterior Segment Trauma 4

 syndrome (OHS), idiopathic neovascularization, and other disease entities.
Although this treatment appears to be promising—especially in OHS, multifocal
choroiditis, and idiopathic neovascularization—multicenter clinical trials, the
Submacular Surgery Trials (SST), are currently under way at multiple clinical
centers to determine the efficacy of this surgical therapy in AMD, idiopathic
neovascularization, and OHS.
The investigations of a surgical approach to treating subfoveal choroidal
neovascularization have been extended, with a renewed interest in macular
translocation. De Juan and Machemer first published discussion of a large
retinotomy approach to these lesions in 1988, but complications limited the
usefulness.8 Machemer then stimulated interest in moving the retina with a 360o
giant retinotomy and entire retinal rotation so that the fovea would be placed over
healthy retinal pigment epithelium.9 Retinal detachments and proliferative
vitreoretinopathy (PVR) limited widespread investigations until de Juan reported
a successful limited macular translocation in 1998. His approach is to detach the
entire temporal retina extending nasally to the optic disc, to remove a
circumferential sliver of sclera in either the superotemporal or inferotemporal
quadrant (more recently to imbricate the sclera with sutures), then to close the
scleral defect, thus effectively shortening the eye. The retina is then reattached
with movement of the fovea of up to 1.5 mm.10 No long-term data on the efficacy
of this procedure are available as of this writing.
Recently, much interest has focused on the treatment of subfoveal choroidal
neovascular membranes using photosensitizing chemicals and a specific laser
that stimulates only structures containing the chemicals. The idea is to treat only
the subfoveal choroidal neovascular membrane, without damaging surrounding
structures as happens with conventional laser treatment. The Treatment of AMD
with Photodynamic Therapy (TAP) investigation using verteporfin has reported
initial 12-month results of a Phase III, randomized, double-masked, placebo-
controlled trial.11 Stable vision (defined as a loss of less than 3 lines of vision on
a standard eye chart) or improved vision was found in 61.2% of verteporfin-
treated patients compared with 46.4% of placebo-administered patients.
Improved vision was found in 16% of verteporfin-treated patients compared with
7% of placebo-treated patients. Retreatment of lesions was common, with an
average of 3.4 treatments in a 12-month period. Lesions for which verteporfin
treatment is effective are those with 50% or greater classic neovascularization. A
similar Phase III clinical trial is under way using another photosensitizing dye,
SnET2, a tin metalloprotease.

Vitamin Supplementation

A study by Newsome and colleagues suggested some efficacy in the use of zinc
supplementation to treat dry AMD, and animal studies have suggested some
benefit to the use of antioxidants in protecting against the degeneration of the
retinal pigment epithelium (RPE)/photoreceptor complex.12 Although this
information is encouraging and has led to many drug companies marketing
vitamins for the eye, as yet there is no good evidence that any of these
supplements are beneficial in AMD. The Age-Related Eye Disease Study
(AREDS), a large, multicenter clinical trial of 4300 patients sponsored by the
National Eye Institute and organized to study the effects of vitamin and mineral
treatment on cataracts and age-related macular degeneration, is under way. Study
results will not be available until study completion midway through the decade.

Retina, Vitreous, and Posterior Segment Trauma 5

The Ocular Histoplasmosis Syndrome (OHS)
and Idiopathic Neovascularization

T he MPS treated patients with extrafoveal choroidal neovascular membranes

in OHS in a similar manner to those with AMD.13 For subretinal choroidal
neovascular membranes that occurred 200 µm or more from the center of the
foveal avascular zone, the risk of losing at least 6 lines of vision was reduced
from 34% to 9% with laser treatment. Similarly, juxtafoveal membranes (1–200
µm from the center of the foveal avascular zone) were proven treatable with laser
photocoagulation; however, there was a higher observed rate of recurrence (52%)
of these membranes. With 3 years of follow-up, 95% of treated eyes had a visual
acuity of 20/200 or better compared with 61% in the untreated group; 67% of
treated eyes had a visual acuity of 20/40 or better compared with 38% of
untreated eyes.13 Idiopathic choroidal neovascular membranes 200 µm or more
from the center of the fovea were also shown to be effectively treated with argon
laser photocoagulation.14
Fine and colleagues performed a pilot study of the photocoagulation of
subfoveal choroidal neovascular membranes in OHS.15 Visual results, which
were similar in the treated and untreated groups, were inconclusive in this very
small pilot study and no further trials are planned.
Surgical excision of subfoveal choroidal neovascular membranes, as
discussed above for AMD, has appeared to be beneficial in OHS and idiopathic
neovascularization in several pilot studies and is currently the subject of a more
extensive study, the Submacular Surgery Trial.

Idiopathic Macular Hole

I n 1988, Gass presented evidence that an idiopathic senile macular hole is

caused by the shrinkage of the vitreous cortex in the foveal area. He described
four stages of macular hole formation, and he indicated a possible role for
vitreous surgery in this disease. In 1995, he updated this classification.16 Stage 1
consists of a yellow spot (stage 1A) or yellow ring (stage 1B) in the fovea with
loss of foveal depression and no evidence of vitreous separation from the foveal
retina. In stage 2, the foveal yellow ring enlarges and an early hole, either
centrally or eccentrically or both, forms with or without vitreofoveal separation.
In stage 3, a fully developed macular hole is present with vitreofoveal separation
and a size of ≥400 µm. Stage 4 is a macular hole with posterior vitreous
separation from the optic disc and macula. A pseudo-operculum may be present
in stages 2–4.
The use of vitrectomy to prevent formation of macular holes in high-risk
patients17–19 and for the treatment of established macular holes, particularly a
pilot study of the treatment of idiopathic macular holes by Kelly and Wendel in
1991,20 stimulated the surgical treatment of these defects by numerous
investigators.
The Vitrectomy for Treatment of Macular Hole Study Group established the
efficacy of cortical vitreous removal, fluid-gas exchange, and prone positioning
for stage 3 and 4 macular holes in a controlled, randomized clinical trial.21 Hole
closure rate was 69% with surgery compared with 4% with observation alone.
Additionally, improvement in visual acuity of 2 lines or greater was seen in 19%

Retina, Vitreous, and Posterior Segment Trauma 6

 of operated eyes compared with 5% of control eyes. Visual success in the treated
group may have been limited by cataract formation.
For patients who cannot perform the rigorous prone positioning required with
gas tamponade, silicone oil may prove to be a useful adjunct to macular hole
surgery. In a recent study of silicone oil tamponade to seal macular holes without
position restrictions, hole closure rate was 80% and visual acuity improved an
average of 3.4 lines when the hole sealed.22
Finally, adjuncts used to aid macular hole closure that have been reported in
the literature include autologous serum, plasma, and transforming growth
factor−beta (TGF-beta). A double-masked, randomized trial of autologous
platelet concentrate in surgery for macular holes has recently been completed.23
This group examined stage 3 or 4 macular holes of less than 3 years’ duration. At
1 month, the hole closure rate was 98% in the platelet group and 82% in the
control group. Visual acuity, however, was no different between the two groups
from 1 to 6 months after surgery.
Similarly, although TGF-beta initially appeared to be beneficial in the
treatment of macular holes,24 later studies by Thompson and colleagues showed
no difference between eyes treated with TGF-beta and placebo.25 Improvement in
surgical techniques and understanding of the vitreoretinal interface have greatly
improved the results of this surgery.

Diabetic Retinopathy

T he Early Treatment Diabetic Retinopathy Study (ETDRS) was a multicenter

clinical trial organized to determine the efficacy of laser photocoagulation
and aspirin treatment in reducing the progression of diabetic retinopathy.26–28
Patients with 20/20 or worse vision and clinically significant macular edema
were treated. Clinically significant macular edema was defined as: (1) thickening
of the retina at or within 500 µm of the center of the macula as judged by slit-
lamp biomicroscopy; (2) hard exudates at or within 500 µm of the center of the
macula associated with thickening of the adjacent retina; or (3) a zone or zones of
retinal thickening 1 disc area size or larger, any part of which is within 1 disc
diameter of the center of the macula. In the ETDRS, clinically significant
macular edema was not a fluorescein angiographic diagnosis but a clinical
diagnosis determined on slit-lamp biomicroscopy.
The ETDRS demonstrated that eyes with clinically significant macular
edema benefited from treatment with focal argon laser photocoagulation to areas
of discrete leakage (microaneurysms) as well as from grid laser photocoagulation
to areas of retinal capillary nonperfusion and/or diffuse leakage. Based on the
ETDRS findings, most authorities recommend that patients who develop both
clinically significant macular edema and high-risk proliferative diabetic
retinopathy be treated for the clinically significant macular edema first and, if
possible, that treatment for the proliferative retinopathy with panretinal
photocoagulation be delayed 4 to 6 weeks. If there is marked high-risk
proliferative retinopathy, however, it may be unwise to delay the treatment with
panretinal photocoagulation. Patients with diffuse leakage refractory to laser
therapy have been treated with vitrectomy by several investigators. Although
their results appear promising, a prospective clinical trial of vitrectomy treatment
has not yet been performed.29

Retina, Vitreous, and Posterior Segment Trauma 7

 The ETDRS also demonstrated that aspirin did not prevent the development
of high-risk characteristics of proliferative diabetic retinopathy, reduce the risk of
visual loss, or increase the risk of vitreous hemorrhage. Although no beneficial
effects were found from aspirin therapy, the results suggest that there are no
ocular contraindications to aspirin therapy for the management of other systemic
diseases in diabetic patients.
The Diabetic Retinopathy Vitrectomy Study (DRVS) was a randomized
clinical trial organized to determine the efficacy of early vitrectomy in eyes with
severe vitreous hemorrhage. The data from the DRVS demonstrated that eyes
with recent severe vitreous hemorrhage have a greater chance of recovery of
visual acuity to 20/40 when treated with early vitrectomy.30−34 This is particularly
apparent in type I diabetics (those cases diagnosed at or before 20 years of age,
with the patient taking insulin at the time of randomization). With early
vitrectomy, however, there was also a greater chance of the development of no-
light-perception (NLP) vision earlier, with the vitrectomy-treated group having
significantly more patients than the untreated group with NLP up to 18 months
following vitrectomy. After 18 months, there was no statistical difference
between groups. Similarly, early vitrectomy for patients with severe
neovascularization and severe fibrovascular proliferation was found to be
beneficial. The DRVS took place before the use of endolaser was widely
available, raising the question of how much the adjunctive use of laser therapy
would have improved the results.
The Diabetes Control and Complications Trial (DCCT) reported the results
of intensive treatment and control of blood sugar in diabetes mellitus and its
effect on the progression of diabetic retinopathy, nephropathy, and neuropathy.35
Two cohorts of patients (one group with no retinopathy at baseline and one group
with mild retinopathy at baseline) were randomly assigned either to intensive
insulin treatment, by insulin pump or by multiple daily injections (with close
glucose monitoring), or to conventional therapy with 1 or 2 daily injections. The
goal of the intensive therapy was to maintain preprandial glucose at between 70
and 120 mg/dL, postprandial glucose at less than 180 mg/dL, 3 a.m. glucose at
greater than 65 mg/dL, and a normal hemoglobin A1c.
The data from the DCCT indicated that intensive therapy delayed the onset
and slowed the progression of early retinopathy and decreased the frequency of
progression to severe, sight-threatening retinopathy. Intensive therapy was shown
to reduce the risk of developing proliferative or severe nonproliferative
retinopathy and to decrease the risk of requiring laser surgery by approximately
50%. Patients in the intensive-therapy group had a reduction in the development
of microalbuminuria and neuropathy as well. However, intensively treated
patients also had more weight gain and more frequent hypoglycemic episodes.

Retinopathy of Prematurity (ROP)

T he International Committee for the Classification of the Late Stages of

Retinopathy of Prematurity expanded the initial ROP classification system
described in 1984 to include retinal detachment in 1987.36,37 The term cicatricial
was eliminated and the term retinopathy of prematurity was extended to all
stages of the disease, with the more complete understanding that the major cause
of visual loss in these patients is the traction retinal detachment, which may have

Retina, Vitreous, and Posterior Segment Trauma 8

 exudative features. The new (extended) stages of ROP identified by this
classification are: stage 1: demarcation line; stage 2: ridge; stage 3: ridge with
extraretinal fibrovascular proliferation; stage 4: subtotal retinal detachment (with
substage 4A when the detachment is extrafoveal and substage 4B when the
subtotal retinal detachment involves the fovea); and stage 5: total retinal
detachment. The stage 5 detachment is always funnel shaped and for descriptive
purposes is subdivided into an anterior and a posterior part by the updated
classification system (anterior open or closed and posterior open or closed).
Progressive vascular disease was defined in the first classification of ROP paper
as a condition in which there is increasing dilatation and tortuosity of the
peripheral retinal vessels, iris vascular engorgement, pupillary rigidity, and
vitreous haze. "Plus" disease (a plus sign is added to the ROP classification) is
present when the vascular progression is so marked as to cause posterior venous
enlargement and posterior arteriolar tortuosity. "Plus" disease with zone 1 or
zone 2 ROP may be rapidly progressive.
The Cryotherapy for Retinopathy of Prematurity Cooperative Group (CRYO-
ROP) conducted a randomized clinical trial of the use of peripheral retinal
transscleral cryotherapy to the avascular retina of patients with threshold
disease.38,39 Threshold was reached when the eye had 5 or more contiguous or 8
or more cumulative 30o sectors (clock hours) of stage 3 ROP in zone 1 or zone 2
in the presence of "plus" disease. In the CRYO-ROP trial, 51.4% of control eyes
vs. 31.1% of treated eyes suffered an unfavorable outcome (posterior retinal
detachment, posterior retinal fold, or retrolental tissue obscuring the posterior
pole) with external cryotherapy. The CRYO-ROP therefore recommended the
treatment of both eyes with threshold disease.
Since the CRYO-ROP study was completed, lasers have become available to
treat the peripheral retina of ROP patients, and several groups have reported the
use of laser therapy rather than cryotherapy for threshold ROP. Because a
multicenter clinical trial to test laser therapy was not feasible, the data from three
large studies were combined in a meta-analysis (a statistical method of
summarizing the results of several trials) by the Laser-ROP Study Group. This
study’s results indicate that, statistically, laser therapy is at least as effective as
cryotherapy in treating these eyes.40
Several studies have attempted to keep ROP from occurring in premature
infants at high risk for development of this disease. The Light-ROP study
attempted to prevent ROP by cutting off light to the premature infant’s eyes with
goggles soon after birth. The premise was that light in the pediatric intensive care
unit might stimulate the formation of neovascularization and impede normal
vascular growth. Unfortunately, this approach was not proven to be of benefit.41
Another study, the STOP-ROP study, was conducted at multiple centers to
determine if control of the oxygen given to susceptible premature children can
stop the progression to the severe stages of ROP and stimulate normal retinal
vascularization. Unfortunately, the use of supplemental oxygen at pulse oximetry
saturations of 96% to 99% did not significantly reduce the number of infants
requiring peripheral ablative surgery but also did not cause additional progression
of prethreshold ROP. Supplemental oxygen increased the risk of adverse
pulmonary events, including pneumonia and/or exacerbations of chronic lung
disease, and the need for oxygen, diuretics, and hospitalization at 3 months of
corrected age. Although the relative risk/benefit of supplemental oxygen for each
infant must be individually considered, clinicians need no longer be concerned
that supplemental oxygen will exacerbate active prethreshold ROP.42

Retina, Vitreous, and Posterior Segment Trauma 9

Branch Retinal Vein Occlusion

T he Branch Vein Occlusion Study (BVOS) was organized to determine the

efficacy of laser photocoagulation in the various complications of branch
retinal vein occlusions.43,44 To examine macular edema secondary to branch
retinal vein occlusion, the study included patients with macular edema that was
present from 3 months to 18 months after the development of the occlusion.
Patients with less than 3 months of branch retinal vein occlusion development
were not included, as many patients with macular edema in the first 3 months
may improve spontaneously. In this study, macular edema was defined by
fluorescein angiography (as opposed to diabetic macular edema which was
defined by slit-lamp biomicroscopy) and the visual criteria for treatment included
patients with 20/40 or worse visual acuity. Candidates for treatment included
patients with persistent macular edema but with perfusion of the foveal
capillaries. Eyes treated with grid laser photocoagulation were more likely to
gain 2 lines of vision (65%) compared with untreated eyes (37%). Treated eyes
were also more likely to have 20/40 or better visual acuity at the 3-year follow-up
examination (60% vs. 34%).
BVOS patients with large areas of retinal capillary nonperfusion were found
to be at significant risk for development of neovascularization. The BVOS
concluded that ischemia alone is not an indication for treatment and that patients
should be observed for the development of neovascularization. Quadrantic laser
photocoagulation to the area of the branch retinal vein occlusion should be
performed in those eyes that develop retinal neovascularization.
Recently, Opremcak and Bruce reported the surgical decompression of
branch retinal vein occlusions by means of vitrectomy and surgical separation of
the tissue sheath connecting the affected artery and vein. Of 15 patients, all
showed clinical improvement and 67% had a significant improvement in visual
acuity following the procedure.45 A national clinical pilot trial at seven centers is
under way to determine the efficacy of this procedure.

Central Retinal Vein Occlusion

T he Central Vein Occlusion Study (CVOS) reported the results of their study
of the efficacy of laser photocoagulation in the treatment of macular edema
related to central retinal vein occlusion, and early panretinal photocoagulation for
the treatment of ischemic central retinal vein occlusions.46,47
The macular edema arm of the CVOS was organized to evaluate the efficacy
of macular grid photocoagulation in preserving or improving central vision in
eyes with macular edema secondary to a central retinal vein occlusion and with a
visual acuity of 20/50 or worse. Similar to the BVOS, treatment was delayed for
at least 3 months following the central retinal vein occlusion to avoid treating
self-limited macular edema (in the BVOS, the untreated macular edema group
actually showed some improvement); inclusion in the CVOS also required
angiographic evidence of edema. Eyes were randomized to macular grid
photocoagulation or to no treatment and were followed at 4-month intervals for 3
years. At no point in the follow-up period was there a statistically significant
difference between treated and untreated eyes. Treatment clearly reduced the
angiographic evidence of macular edema; however, the final median visual

Retina, Vitreous, and Posterior Segment Trauma 10

 acuity in treated eyes was 20/200 vs. 20/160 in control eyes. Macular grid
photocoagulation is therefore not recommended for central retinal vein
occlusion−related macular edema.
The second arm of the CVOS was designed to answer the question of
whether prophylactic panretinal photocoagulation in ischemic central retinal vein
occlusion prevents the development of 2 clock hours of iris neovascularization or
any angle neovascularization (TC-INV/ANV), or whether it is more appropriate
to apply panretinal photocoagulation only when angle neovascularization occurs
(to prevent neovascular glaucoma). Eyes enrolled in the study had had central
retinal vein occlusions for less than 1 year, had at least 10 disc areas of retinal
nonperfusion, and had vision of light perception or better. Study eyes were
randomized to immediate prophylactic panretinal photocoagulation or frequent
close observation. If 2 clock hours of iris neovascularization or any angle
neovascularization occurred, untreated eyes received panretinal photocoagulation
and previously treated eyes received supplemental panretinal photocoagulation.
In both groups, neovascularization of the iris/angle developed less often in
prophylactically treated eyes than in untreated eyes, but the difference was not
statistically significant. The treatment of 2 clock hours of iris neovascularization
or any angle neovascularization was followed by rapid regression in 56% of
untreated eyes and in 22% of previously treated eyes. The development of 2
clock hours of iris neovascularization or any angle neovascularization showed a
statistically significant correlation with both the amount of nonperfused retina
and the extent of retinal hemorrhage; also, males and patients with occlusions of
less than 1-month duration were at higher risk. Prophylactic panretinal
photocoagulation did not totally prevent neovascularization, and prompt
regression of the neovascularization was more likely if no previous treatment had
been done. The CVOS, therefore, recommends careful observation in the early
months with frequent follow-up (including undilated iris exams) for patients
suffering ischemic central retinal vein occlusions, and prompt panretinal
photocoagulation in eyes in which 2 clock hours of iris neovascularization or any
angle neovascularization develops.
A more recent innovation in the treatment of central retinal vein occlusion
and branch retinal vein occlusion is the formation of an anastomosis between the
choroidal circulation and the retina by laser photocoagulation. In 24 patients with
nonischemic central retinal vein occlusions, laser was used to attempt to create a
shunt between the blocked retinal venous system and the choroid. A successful
shunt was created in 8 (33%) patients. A prospective study of this technique is
necessary to determine its efficacy in these patients.48

Retinitis Pigmentosa

I n 1993, the results of a national clinical trial were reported that studied 601
patients with retinitis pigmentosa, ages 18 to 49, who were assigned randomly
to treatment combinations of vitamin A and vitamin E as daily supplements.49
Patients were followed for 4 to 6 years, and 95% of those enrolled completed the
study with no adverse side effects observed. The treatment of the retinal
degeneration was monitored by electroretinography (ERG). Progression was
slower on average among patients who took 15,000 IU of vitamin A daily than
among those on other regimens. The results also suggested that the progressive

Retina, Vitreous, and Posterior Segment Trauma 11

 course of the disease might be faster on average among patients taking a daily
supplement of 400 IU of vitamin E vs. those not taking this dose. Rates of loss of
visual field area were consistent with the ERG findings.
The recommendation of this study was that most adult patients with common
forms of retinitis pigmentosa should take a supplement of 15,000 IU of vitamin A
daily under the supervision of their eye care professional and should avoid the
use of high-dose supplements of vitamin E. The recommendations of this
carefully designed and executed study have been quite controversial. The same
volume of the journal that published the study results had an accompanying
editorial and multiple letters to the editor, including letters from members of the
study's data and safety monitoring committee, who disagreed with the universal
application of its treatment recommendations.50−55 Concerns with the study
include the use of the ERG as the measure of effectiveness, the lack of significant
benefit for any measure of visual function, the possibility of long-term adverse
effects of supplemental vitamin A, and statistical evaluation questions. All sides
of this controversy should be reviewed before recommending lifetime treatment
with vitamin A in this disease.

Retinal Detachment
Pneumatic Retinopexy

P neumatic retinopexy was first described as an alternative to scleral buckling

surgery by Hilton and Grizzard in 1986.56 They treated 20 consecutive retinal
detachments that had superior retinal breaks with external cryopexy and a single
transconjunctival injection of gas, achieving a 6-month cure rate of 90%.
Stimulated by these initial results and other studies, the Retinal Detachment
Study Group formed a multicenter randomized trial that compared pneumatic
retinopexy with scleral buckling.57,58 Enrolled eyes included those with retinal
breaks not larger than 1 clock hour or with groups of breaks within 1 clock hour
that were located in the superior 8 clock hours of the retina. When comparing
scleral buckling to pneumatic retinopexy, this study found (at the 6-month
follow-up visit) a single-procedure retinal reattachment rate of 82% vs. 73%,
reattachment with one operation and postoperative laser/cryotherapy of 84% vs.
81%, overall reattachment with reoperations of 98% vs. 99%, final visual acuity
of 20/50 or better in 56% vs. 80%, the development of proliferative
vitreoretinopathy in 5% vs. 3%, and new retinal breaks in 13% vs. 23%. By the
2-year posttreatment visit, redetachment had occurred in 1% vs. 1%, subsequent
cataract surgery had been performed in 18% vs. 4%, and final visual acuity was
20/50 or better in 67% vs. 89%. This study recommended the use of pneumatic
retinopexy as an alternative to scleral buckling for cases meeting the study
criteria.

Proliferative Vitreoretinopathy (PVR)

Great strides have been taken in the treatment of proliferative vitreoretinopathy, a

complication seen in approximately 8% to 10% of patients with retinal
detachments. An updated classification of PVR includes a more anatomic
description of the disease59 and is summarized in the current Basic and Clinical

Retina, Vitreous, and Posterior Segment Trauma 12

 Science Course, Section 12, Retina and Vitreous (see Related Academy
Materials).
Progress has been made in the treatment of the anterior proliferative
vitreoretinopathy subset of this disorder as well. Contraction of the anterior
vitreous in both the circumferential and anterior/posterior directions was
recognized in the late 1980s.60 Identification of this contraction in the anterior
vitreous is essential for attaining high success rates in treatment. Careful
dissection of vitreous and vitreous membranes anteriorly can relieve the anterior
traction on the retina, thus allowing the retina to settle posteriorly.
The use of perfluorocarbon liquids has greatly facilitated the treatment of
PVR.61 Perfluorocarbon liquids are heavier-than-water fluids that, when injected
posteriorly, can flatten the retina from posterior to anterior, greatly facilitating
the treatment of detached retinas in PVR, giant retinal tears, and the like. Clinical
trials are under way to obtain FDA approval for the use of perfluorocarbon
liquids in patients with these problems.
Various intraocular tamponades have been used to achieve retinal
reattachment following complicated vitrectomy for PVR. The Silicone Study was
organized to compare the effectiveness and complications of silicone oil, sulfur
hexafluoride gas, and perfluoropropane gas as tamponading agents.62,63 Silicone
oil was found to be superior to sulfur hexafluoride gas and effectively equivalent
to perfluoropropane gas in the repair of retinal detachments complicated by
severe PVR.

Endophthalmitis

T he Endophthalmitis Vitrectomy Study (EVS) was organized to determine the

role of immediate pars plana vitrectomy in the management of
endophthalmitis occurring after cataract surgery or secondary intraocular lens
implantation and the role of IV antibiotics in the management of
endophthalmitis.64 Patients enrolled in this multicenter clinical trial had clinical
evidence of bacterial endophthalmitis and a visual acuity of less than 20/50 but at
least light perception. The involved eye had either a hypopyon or enough
clouding of the anterior chamber or vitreous media to obscure clear visualization
of some part of the second-order retinal arterioles; a cornea or anterior chamber
clear enough to visualize some part of the iris; and a cornea clear enough to allow
pars plana vitrectomy. The 420 patients in the study were randomized to either
immediate vitrectomy or vitreous tap/biopsy (tap with needle or biopsy with
vitrector) and further randomized to either IV antibiotics or no IV antibiotic
treatment. After final evaluation and visual acuity measurement at 9 to 12
months, it was found that: (1) there was no difference in final vision or media
clarity, whether or not systemic antibiotics were used; (2) patients presenting
with hand motion or better vision did equally well whether they had immediate
vitrectomy or immediate vitreous tap/biopsy; and (3) patients who presented with
light-perception-only vision had much better visual results with immediate
vitrectomy than with immediate vitreous tap/biopsy (they were three times more
likely to achieve 20/40 final visual acuity, twice as likely to achieve 20/100 final
vision, and less than half as likely to incur severe vision loss).
The EVS concluded that in patients with hand motion or better vision,
routine immediate vitrectomy was of no additional benefit in patients who met

Retina, Vitreous, and Posterior Segment Trauma 13

 the EVS entry criteria; however, immediate vitrectomy was substantially more
beneficial for patients presenting with light-perception-only vision. There was no
difference in final visual acuity or media clarity with or without the use of the
intravenous antibiotics studied in the EVS.

Posterior Segment Trauma

M ost ophthalmologists would agree that the advent of pars plana vitreous
surgery 25 years ago has led to the salvage of many eyes that would
otherwise have been lost to ocular trauma. Specifically, vitreous surgery is an
essential component in the management of intravitreal foreign bodies, traumatic
retinal detachments, trauma-associated endophthalmitis, and penetrating ocular
trauma. Although reported many years ago, one of the most important
experimental studies concerning ocular trauma is from Cleary and Ryan
regarding the timing of vitrectomy in the setting of penetrating ocular trauma and
vitreous hemorrhage.65−67 They performed vitrectomy at 1 and 14 days after a
standard scleral injury was given experimentally and blood was injected
intravitreally. Although there was no difference in the rate of development of
retinal detachment in the two groups, the vitrectomy performed at 14 days was
technically easier because posterior hyaloid dissection was easier to perform at
that time.
Recently, a standardized nomenclature for ocular trauma has been
proposed.68 Universal definitions of eye trauma have been established in this
nomenclature, which should lead to a common international language, improving
accuracy in both clinical and experimental practice. A rupture is defined as a
full-thickness wound of the eye wall caused by a blunt object; a laceration is a
full-thickness wound caused by a sharp object. A penetrating injury is a single
laceration of the eye wall and a perforating injury is two full-thickness
lacerations (entrance and exit) of the eye wall. Terms such as “double
penetrating” and “double perforating” have no place in the new classification
system. The classifications for retinopathy of prematurity and proliferative
vitreoretinopathy led to a common language and improved communication
among ophthalmologists. It is hoped that this system will do the same for ocular
trauma.

Retina, Vitreous, and Posterior Segment Trauma 14

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Ophthalmology 1992;99:753−759.

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 30. Diabetic Retinopathy Vitrectomy Study Research Group. Two-year course of
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32. Diabetic Retinopathy Vitrectomy Study Research Group. Early vitrectomy
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44. Branch Vein Occlusion Study Group. Argon laser photocoagulation for
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 45. Opremcak EM, Bruce RA. Surgical decompression of branch retinal vein
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56. Hilton GF, Grizzard WS. Pneumatic retinopexy: a two-step outpatient
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57. Tornambe PE, Hilton GF, Retinal Detachment Study Group. Pneumatic
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1989;96:772−784.
58. Tornambe PE, Hilton GF, Brinton DE, et al. Pneumatic retinopexy: a two-
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 62. Silicone Study Group. Vitrectomy with silicone oil or sulfur hexafluoride gas
in eyes with severe proliferative vitreoretinopathy: results of a randomized
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63. Silicone Study Group. Vitrectomy with silicone oil or perfluoropropane gas
in eyes with severe proliferative vitreoretinopathy: results of a randomized
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Related Academy Materials

Academy Statements
Age-Related Macular Degeneration. Preferred Practice Pattern. 1998.
Diabetic Retinopathy. Preferred Practice Pattern. 1998.
Eye Care for People with Diabetes Mellitus. Information Statement. 1999.
Indocyanine Green Angiography. Ophthalmic Procedures Assessment. 1998.
Laser Surgery. Policy Statement. 1996.
Management of Posterior Vitreous Detachment, Retinal Breaks, and Lattice
Degeneration. Preferred Practice Pattern. 1998.
Repair of Rhegmatogenous Retinal Detachments. Ophthalmic Procedures
Assessment. 1995.

Basic and Clinical Science Course

Retina and Vitreous. Section 12. Updated annually.

Focal Points: Clinical Modules for Ophthalmologists

Bressler SB. Age-Related Macular Degeneration. Vol XIII, Module 2. 1995.
Capone A Jr. Macular Surface Disorders. Vol XIV, Module 4. 1996.
Doft BH. Managing Infectious Endophthalmitis: Results of the Endophthalmitis
Vitrectomy Study. Vol XV, Module 3. 1997.
Finkelstein D, Clarkson JG, Hillis A. Branch and Central Vein Occlusions. Vol
XV, Module 9. 1997.
Haller JA. Retinal Detachment. Vol XVI, Module 5. 1998.

Retina, Vitreous, and Posterior Segment Trauma 19

 Ip MS, Duker JS. Advances in Posterior Segment Imaging Techniques. Vol
XVII, Module 7. 1999.
Mieler WF. Systemic Therapeutic Agents and Retinal Toxicity. Vol XV, Module
12. 1997.
Smiddy WE, Flynn HW Jr. Managing Retained Lens Fragments and Dislocated
Posterior Chamber IOLs after Cataract Surgery. Vol XIV, Module 7. 1996.
Tiedeman JS. Retinal Breaks, Holes, and Tears. Vol XIV, Module 3. 1996.
Vinger PF. Athletic Eye Injuries and Appropriate Protection. Vol XV, Module 8.
1997.

Monographs
Berkow JW, Flower RW, Orth DH, et al. Fluorescein and Indocyanine Green
Angiography:Technique and Interpretation. Ophthalmology Monograph 5. 1997.
Flynn HW, Smiddy WE. Diabetes and Ocular Disease. Ophthalmology
Monograph 14. 2000.
Folk JC, Pulido JS. Laser Photocoagulation of the Retina and Choroid.
Ophthalmology Monograph 11. 1997.
Hilton GF, McLean EB, Brinton DA. Retinal Detachment: Principles and
Practice. Ophthalmology Monograph 1. 1995.

Multimedia
Lambert HM, Barr CC, Dieckert JP, et al. Retina. LEO Clinical Update Course
on CD-ROM. 1998.
ProVision Interactive. Volume 2: Retina and Glaucoma. 1998.

Self-Assessment
Lane SS, Skuta GL, eds. ProVision: Preferred Responses in Ophthalmology.
Series 3. 1999.
Skuta GL, ed. ProVision: Preferred Responses in Ophthalmology. Series 2. 1996.

Videotapes
DRSR Group, ETDRSR Group. Management of Diabetic Retinopathy for the
Primary Care Physician. Clinical Skills Series. 1999.
DRSR Group, ETDRSR Group, DRVSR Group. Evaluation and Treatment of
Diabetic Retinopathy. Clinical Skills Series. 1999.
ETDRSR Group. Photocoagulation for Diabetic Macular Edema. Clinical Skills
Series. 1997.
Kelly MP. Basic Techniques of Fluorescein Angiography. Clinical Skills Series.
1999.
King LP. Passive Controlled Needle Evacuation of Subretinal Fluid. Annual
Meeting Series. 1995.

Retina, Vitreous, and Posterior Segment Trauma 20