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Rhegmatogenous Retinal Detachment: Pathophysiology and Its Implications for Treatment Course

ABSTRACT Contrary to popular dogma, the most important element in the pathogenesis of a rhegmatogenous retinal detachment (RD) is not the break but the vitreoretinal traction that causes the break (i.e., the RD is a vitreogenic pathology). In the presence of vitreous degeneration (syneresis) such dynamic traction is inevitable if the eyeball and/or the head moves: this hypothesis is supported by various clinical observations. Whether in an...

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Vitrectomy for Postoperative Endophthalmitis: Surgical Pearls

Vitrectomy for Postoperative Endophthalmitis: Surgical Pearls ABSTRACT Endophthalmitis is the most devastating postoperative complication following intraocular surgery. Its incidence is low, but it is not zero, even if the most efficient prophylactic measures are employed. The Endophthalmitis Vitrectomy Study (EVS) recommended that surgery be done only in exceptional cases (visual acuity of light perception), but this conclusion can be...

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Prophylactic and Late Chorioretinectomy for Severe Ocular Trauma

Prophylactic and Late Chorioretinectomy for Severe Ocular Trauma ABSTRACT Proliferative vitreoretinopathy (PVR) and the development of full-thickness retinal folds (“PVR stage 0”) are major, sight-threatening complications of severe eye injuries with an incidence that can reach up to 89%. No effective pharmaceutical therapy exists to deal with either complication, and the prognosis of surgery for PVR is usually very poor, both for...

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Diabetic Macular Edema: One Surgery or 30 Injections ?

Diabetic Macular Edema: One Surgery or 30 Injections ? ABSTRACT Diabetes is a disease whose incidence is increasing throughout the entire world. The most common cause of blindness of all the ocular complications of diabetes is macular edema. Today we have numerous treatment options to offer to the patient: corticosteroid and antiVEGF injections into the vitreous cavity as well as certain implants. While most of these medications are...

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Severe Eye Injuries: The Trouble with Being Late

Severe Eye Injuries: The Trouble with Being Late ABSTRACT The “when” is just as an important question in the surgical intervention for eyes with posterior segment injury as is the “what”. Identifying the ideal timing (staging) of vitreoretinal surgery is thus crucial as the most optimal management strategy is selected. Delaying posterior segment surgery beyond two weeks, which is unfortunately too often seen in...

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Rhegmatogenous Retinal Detachment: Basic Concepts and Surgical Strategy for Primary Vitrectomy

Contrary to popular dogma, the most important element in the pathogenesis of a rhegmatogenous retinal detachment (RRD) is not the break but the vitreoretinal traction that causes the break (i.e., the RRD is a vitreogenic pathology). In the presence of vitreous degeneration (syneresis) such dynamic traction is inevitable if the eyeball and/or the head moves: this hypothesis is supported by the clinical observation that a RRD spontaneously...

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Rhegmatogenous Retinal Detachment: Basic Concepts and Surgical Strategy for Primary Vitrectomy

Contrary to popular dogma, the most important element in the pathogenesis of a rhegmatogenous retinal detachment (RRD) is not the break but the vitreoretinal traction that causes the break (i.e., the RRD is a vitreogenic pathology). In the presence of vitreous degeneration (syneresis) such dynamic traction is inevitable if the eyeball and/or the head moves: this hypothesis is supported by the clinical observation that a RRD spontaneously...

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No PVD, No Hope

This 6-year-old boy suffered a rupture due to a fall. He underwent vitrectomy only a few weeks after the trauma because he was not referred on time. Even then, the posterior vitreous could not be detached, and PVR duly developed. During the reoperation a 360º retinectomy was performed, but the PVD could still not be accomplished. The retina redetached under silicone oil, with some proliferation centrally. This time the proliferative...

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Old Intraretinal IOFB: Remove or Face Siderosis?

Rationale: If a patient is found to have an old, intraretinal, encapsulated IOFB close to the fovea and the eye has full vision, a very difficult dilemma must be faced. Either the IOFB is left in situ or it is to be removed. Leaving it behind saves the patient from all of the possible intraoperative and early postoperative risks, ranging from endophthalmitis to PVR. However, the risk of siderosis will never completely subside, and the...

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Traumatic Cataract – Philosophy and Clinical Practice

Media not available due to technical recording problems. EVRS is very sorry for the inconvenience.   Rationale: Traumatic cataract must not be mindlessly treated as an age-related one. The surgeon must decide preoperatively how to remove the lens without causing additional damage to the already injured eye. The most important two questions to decide are: 1) should vitrectomy instrumentation be utilized and 2) should the lens capsules...

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A Surgeon’s Approach to Prevent PVR

Advantages: Prevention of PVR, whether due to trauma or rhegmatogenous retinal detachment, would eliminate the most common cause of surgical failure. Methods: Destruction using high-powered endodiathermy to destroy the retinal pigment epithelial cells in the area of the injury or retinal break. Effectiveness: In traumatized eyes, the PVR rate dropped from over 65% to below 5%. In RD surgery, the data are still being gathered. Safety: So...

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Patient – Doctor Relationship

In the traditional physician-patient relationship, the physician simply determines which treatment option is the best for the patient’s particular condition. The patient then usually accepts that treatment without questioning it. This type of practicing medicine is, however, unacceptable since it totally disregards not only the patient’s individual needs but also renders him an object, rather than a partner, in the process. In this talk...

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Finally … What to do? Discussion

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DME: 15 Injections or 1 Surgery?

Advantages: The first author has operated on over 600 eyes with DME in the last two decades. Surgery is typically a one-time intervention, unlike intraocular injections. Methods: Complete vitrectomy with detachment of the triamcinolone-marked posterior hyaloid face. This is followed by removal of the internal limiting membrane (ILM), stained by Indocyanine green. While pneumoretinopexy used to be employed earlier, a preoperative...

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Vitrectomy for Rhegmatogenous Retinal Detachment: Why and How

Ferenc Kuhn (Hungary / USA), Zora Ignjatovic (Belgrade, Serbia) Advantages: Even though the retinal break is thought to be the cause of the retinal detachment, the break is secondary to – typically dynamic – vitreoretinal traction. Vitrectomy is the rational approach to treatment by addressing the source, rather than the consequence, as scleral buckling does, however effectively. In addition, other pathologies such as media...

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My Way of Managing Traumatic Retinal Detachments: What, When, How, and Why?

Ferenc Kuhn (Hungary / USA) Advantages: An approach based on a careful analysis of what leads to retinal detachment in the severely injured eye promises results superior to those that simply treat the traumatized globe in a -treat-as-you-go fashion. This review lecture lists the author’s personal pearls and caveats. Methods: Pars plana vitrectomy is almost always necessary if the open-globe injury involves the posterior segment. The...

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Macular Involvement in Terson Syndrome


http://www.evrs.eu/medias/2010/congress/Hemorrhages.flv Ferenc Kuhn (Birmingham, AL, USA) Advantages: Knowing that hemorrhages can severely impact macular function and recognizing the type of macular pathology involved helps the surgeon deal with the macular complications correctly. Methods: Review of the author’s cases over a period exceeding two decades. Effectiveness / Safety:  Removal of the macular hemorrhages is a simple and...

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Expulsive Choroidal Hemorrhage: What Yes and What Never

http://www.evrs.eu/medias/2010/videos/FerencKuhn_VP6_768K.flv Ferenc Kuhn (Birmingham, AL, USA) Advantages: Understanding the pathophysiology of the disease helps preventing the otherwise unavoidable disaster. Methods: Analysis of the literature and the author’s personal experience. Effectiveness / Safety: Prophylaxis and/or proper primary intervention yield results that are far superior to even the best secondary treatment. Take...

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Ocular Traumatology: The Basics

Ferenc Kuhn (Birmingham, AL, USA)   This course covers the basic elements of treating a patient with eye injury. Counseling – the process of communicating with the injured person and his family to achieve maximal cooperation and mutual understanding. Classifying the injury – to make sure that proper information is collected and utilized about the type of trauma encountered. Decision‐making – to decide the optimal route toward...

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Management of Intraretinal IOFBs: My way

http://www.evrs.eu/medias/2008/congress/Management-of-Intraretinal-IOFBs:-My-way.flv Ferenc Kuhn, Adrien Solt Advantages: The “comprehensive” – rather than reflex-based – approach to the management of the injured eye allows to surgeon to carefully plan the operation and aim for the best possible outcome. Methods: The surgical strategy involves consideration of not only the intraocular abnormalities already present,...

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Surgical Prevention of PVR in Serious Ocular Trauma

http://www.evrs.eu/medias/2008/congress/Surgical-Prevention-of-PVR-in-Serious-Ocular-Trauma.flv Ferenc Kuhn, Wolfgang Schrader, Robert Morris, Viktoria Mester Advantages: Prevention of the development of proliferative vitreoretinopathy is crucial in preserving vision in the injured eye. Since pharmacologic methods have largely been unsuccessful, a new surgical approach is attempted. Methods: Prophylactic chorioretinectomy is performed...

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Uveitis – An indication for Vitrectomy?

http://www.evrs.eu/medias/2008/congress/Uveitis-An-indication-for-Vitrectomy.flv Ferenc Kuhn, Adrien Solt Advantages: Timely vitrectomy prevents uveitis-related complications such as retinal detachment; it prevents or treats macular edema; it removes the media opacity; and it dramatically reduces the rate of recurrence and thus the need for systemic uveitis therapy. Methods: Pars plana vitrectomy with or without internal limiting membrane...

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Vitrectomy Session – Hemorrhages

http://www.evrs.eu/medias/2007/videos/vitrectomysession-hemorrhages.flv

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Vitrectomy Session – Peeling

http://www.evrs.eu/medias/2007/videos/vitrectomysession-peeling.flv

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Secondary Glaucoma after Intravitreal Triamcinolone Acetate Injection

Ferenc Kuhn, MD, PhD (Birmingham, AL), Zsuzsanna Szijarto, MD (Pecs, Hungary), Gyongyi Kiss, MD (Pecs, Hungary) PURPOSE: Intravitreal triamcinolone acetate injection has become very popular for treating a variety of conditions ranging from macular edema to age-related macular degeneration. Its complication rate, however, needs to be closely evaluated. METHODS: A prospective study was undertaken to evaluate the postoperative complications of...

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No Light Perception (NLP) Vision After Injury: Don’t Give Up!

http://www.evrs.eu/medias/2006/videos/No-Light-Perception-NLP-Vision-After-Injury:-Don-t-Give-Up.flv Ferenc Kuhn, MD, PhD (Birmingham, AL) SYNOPSIS Over 90% of NLP eyes are enucleated, although vision often could be improved with timely reconstruction. This film is on an 80-year-old lady with an occult rupture after falling. Vision was NLP (confirmed at the slit lamp); the lens was under the conjunctiva and she had a retinal detachment....

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Prognosis of Penetrating Eye Injuries with Posterior Segment Intraocular Foreign Bodies

Zsuzsanna Szijarto, (Pecs, Hungary), Valéria Gaál, MD (Pécs, Hungary), Bálint Kovács, MD, PhD (Pécs, Hungary), Ferenc Kuhn, MD, PhD (Birmingham, AL) PURPOSE: To evaluate the clinical features as well as visual and anatomical outcomes in eyes with posterior segment intraocular foreign body (IOFB) and to identify prognostic factors. METHODS: The records of 28 eyes of 27 patients underwent pars plana vitrectomy (PPV) and IOFB removal...

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No Light Perception Vision After Injury: Don’t Give Up!

No Light Perception Vision After Injury: Don’t Give Up!

Ferenc Kuhn, MD, PhD (Birmingham, AL) SYNOPSIS Over 90% of NLP eyes are enucleated, although vision often could be improved with timely reconstruction. This film is on an 80-year-old lady with an occult rupture after falling. Vision was NLP (confirmed at the slit lamp); the lens was under the conjunctiva and she had a retinal detachment. Comprehensive reconstruction (wound closure, removal of extruded tissues, vitrectomy, silicone oil...

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Complete and Early Vitrectomy for Eyes with Postoperative Endophthalmitis

Ferenc Kuhn, MD, PhD (Birmingham, AL), Giampaolo Gini, MD (Prato, Italy) PURPOSE: Following recommendations in the Endophthalmitis Vitrectomy Study (EVS), vitrectomy for postoperative endophthalmitis is performed today only if visual acuity drops to light perception. The authors evaluated their results achieved by performing complete and early vitrectomy for these eyes. METHODS: The authors treat their patients with postoperative...

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Comprehensive Reconstruction of a Phthisical, Disorganized Eye after Trauma

http://www.evrs.eu/medias/2006/videos/Comprehensive-Reconstruction-of-a-Phthisical-Disorganized-Eye-after-Trauma.flv Ferenc Kuhn, MD, PhD (Birmingham, AL) SYNOPSIS An 11-year-old boy ruptured an eye that was abandoned after the first, unsuccessful reconstruction. He had LP vision, no pupil (dragged iris), extensive anterior scarring, total retinal detachment with subretinal strands, and severe hypotony. Surgery at 4 months included...

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A frequent cause for retinal detachment occur-ring in open globe injuries is retinal incarceration. The boundary between which cases are operable and which are not has been moved forward as new surgical tech-niques and materials have become available through the years. Aim of this video is to illustrate some of these concepts as we consider a first case in which the boundary of operability has been stretched forward and a second case in which there is a happy ending for a severe injury.

Ferenc Kuhn, MD, PhD (Birmingham, AL) SYNOPSIS Over 90% of NLP eyes are enucleated, although vision often could be improved with timely reconstruction. This film is on an 80-year-old lady with an occult rupture after falling. Vision was NLP (confirmed at the slit lamp); the lens was under the conjunctiva and she had a retinal detachment. Comprehensive reconstruction (wound closure, removal of extruded tissues, vitrectomy, silicone oil...

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Results and Complications of Vitrectomy and Internal Limiting Membrane Removal in the Treatment of Macular Edema

Ferenc Kuhn, Robert Morris, Viktoria Mester, Gyongyi Kiss, Zsuzsanna Szijarto, Balint Kovacs, Beatrix Cser Purpose: To evaluate the results and complications of internal limiting membrane (ILM) removal in the treatment of macular edema. Methods: Retrospective and prospective studies on eyes undergoing vitrectomy with ILM removal for eyes with clinically significant macular edema. Results: Of the 68 eyes, follow-up (average: 9 months) was...

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Clinical Course and Results of Surgical Treatment of Epiretinal Membranes (ERM)

http://www.evrs.eu/medias/2005/congress/Clinical-Course-and-Results-of-Surgical-Treatment-of-Epiretinal- Membranes-(ERM).swf Viktoria Mester, Ferenc Kuhn, Yahya Ali Al Midwahi Purpose: Evaluation of the etiology, incidence, clinical course, and prognosis of surgical cases of epimacular proliferation. Methods: Retrospective review of 52 consecutive patients who underwent pars plana vitrectomy for epimacular proliferation. Results: The common...

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Hemorrhagic Macular Cysts in Terson Syndrome

Ferenc Kuhn, Robert Morris, Viktoria Mester Purpose: To present the incidence, clinical appearance, surgical management, and prognosis of hemorrhagic macular cysts (HMC). Methods: Retrospective case series. Results: The incidence of HMC among patients with Terson syndrome was 42% (15 out of 36). In 11 eyes (73%) the cyst was submembranous (under the internal limiting membrane [ILM]). All cysts were removed without complication, and vision...

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Vitrectomy for Optic Pit-Related Retinal Detachment

Ferenc Kuhn, Robert Morris, Viktoria Mester Purpose: To present an effective intraocular approach for the treatment of eyes with optic pitrelated retinal detachment. Methods: Retrospective case series. Results: Twenty-one eyes underwent pre- or intraoperative laser (L) at the disc margin, complete vitrectomy (V), including separation and removal of the posterior hyaloid face, and gas tamponade (G) with postoperative positioning “LVG...

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The FILMS Procedure for ILM Atraumatic Removal

Ferenc Kuhn, Robert Morris, C. Douglas Witherspoon We have introduced a new method of ILM detachment: Fluidic Internal Limiting Membrane Separation. The technique involves using a specially designed, sharp microcannula, which is inserted under the ILM. Once the cannula is in place, the surgeon utilizes the vitrectomy machine’s pump to gently inject viscoelastic material under the ILM, mimicking of what occurs in eyes with subILM...

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Internal Limiting Membrane Removal Indications and Techniques

Ferenc Kuhn, Robert Morris, Viktoria Mester, Gyongyi Kiss, Purpose: To present the rationale, indications, and techniques of internal limiting membrane (ILM) removal. Methods: Analysis of personal experience and videotape demonstration. Results: Surface traction relief is the primary reason for ILM peeling. A long list of indications for ILM removal exist today, including its original condition (hemorrhagic macular cyst in eyes with Terson...

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Phacoemulsification on Previously Vitrectomized Eyes for Macular Disease

Zsuzsanna Szijártó, B. Haszonits, Á. Patzkó, F. Kuhn, B. Kovács Purpose: To analyse the results of cataract extraction by phacoemulsification on previously vitrectomized eyes for macular disease. Methods: Phacoemulsification (phaco) and intraocular lens (IOL) implantation were performed on 143 vitrectomized eyes in the last 10 years at our department, 23 eyes were vitrectomized for macular disease. Intraoperative and postoperative...

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Internal Limiting Membrane Removal for Severe Macular Edema

Ferenc Kuhn, Robert Morris, Viktoria Mester, Gyongyi Kiss, Zsuzsanna Szijarto, Balint Kovacs, Beatrix Cser Purpose: To evaluate the results and complications of internal limiting membrane (ILM) removal in the treatment of macular edema. Methods: Retrospective and prospective studies on eyes undergoing vitrectomy with ILM removal for eyes with clinically significant macular edema. Results: Of the 68 eyes, follow-up (average: 9 months) was...

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The Significance and Impact of Standardization: The Classification of PVR

Ferenc Kuhn*, Robert Morris Birmingham, USA Goal: To determine the impact and efficacy of the PVR classification systems. Methods: Literature analysis prior to and following the publication of the classifications of PVR. Results: Before the first PVR classification system was designed, and especially before the advent of pars plana vitrectomy, there was little understanding of the pathophysiology and clinical significance of intravitreal...

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Nocere

Ferenc Kuhn Birmingham, USA The patient in this videofilm had several potential risk factors for postoperative PVR development: pseudophakic retinal detachment in a myopic eye; young age; severe peripheral retinal degeneration; and physician by profession. During careful vitrectomy, multiple breaks developed in the temporal retinal periphery, which had advanced and widespread lattice degeneration, as opposed to a healthy retina nasally. Did...

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Counseling in Ocular Trauma

Robert Morris*, Don Fletcher, Ferenc Kuhn, Margaret Harrill United States Since vision provides man’s primary means of orientation to his environment, sight threatening eye injuries typically induce massive anxiety. The urgent and unexpected nature of eye injuries challenges us to achieve the rapport or necessary for initial informed consent and continued partnership during treatment. We review counseling concepts, including use of...

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Ocular Trauma Management: A Logic-Based Approach

Ferenc Kuhn, M.D*, Ph.D, Viktoria Mester, M.D., Robert Morris, M.D., Judit Lang, M.D. United States Goal: To help resolve the controversy over the timing for surgery in patients with intraocular foreign bodies – an example of how logic-based thinking can help the ophthalmologist in decision-making. Method: A logic-based, critical analysis of the literature. Results: Most patients who develop endophthalmitis do so by the time they...

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Posteriorly dislocated lens and IOL: Why vitrectomy?

Ferenc Kuhn, Hungary/Birmingham, USA Viktoria Mester, Hungary Observation or various types of surgical intervention have been recommended for eyes with lens material or intraocular lens luxated into the vitreous cavity. This presentation discusses the principles of an optimal treatment approach and reviews two series of patients treated by the authors.

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Traumatic Cataract: an Indication for the Vitreoretinal Surgeon

Ferenc Kuhn, Pecs, Hungary/Birmingham, USA Viktoria Mester, Pecs, Hungary Synopsis: To show the difficulties in the preoperative evaluation of eyes with lens trauma and demonstrate the advantages of and potential problems with various treatment options. Objective: To enable surgeons making the correct preoperative and intraoperative decisions when treating patients with traumatic cataract and to facilitate early visual...

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Indirect Ophthalmoscope Laser Cerclage Prophylaxis against Pseudophakic Retinal Detachment

Robert Morris, Birmingham, USA Ferenc Kuhn, Hungary/Birmingham, USA C. Douglas Witherspoon, Terry Moore, Birmingham, USA Suzanne Nelson, Birmingham, USA Indirect ophthalmoscopic laser delivery has dramatically altered our ability to prevent rhegmatogenous retinal detachment (RRD) in certain high risk eyes. By applying bilateral treatment, we have been able to reduce the RRD rate in the fellow eye to 0% from greater than 20% (p<0.00001)...

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Expulsive Choroidal Hemorrhage: What Not to Do?

Ferenc Kuhn, MD, Hungary/Birmingham, USA Robert Morris, Birmingham, USA This videofilm shows two surgeons who have been unprepared to respond to the occurrence of an intraoperative expulsive choroidal hemorrhage; the results were disastrous. The message is obvious: an intervention plan must be in place before the surgeon opens the eye.

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Expulsive Choroidal Hemorrhage: is this a Problem no More?

Ferenc Kuhn, Hungary/Birmingham, USA Robert Morris Birmingham, USA Viktoria Mester, Hungary With current cataract removal techniques, the risk of an intraoperative expulsive choroidal hemorrhage is much lower – but it is still not zero. This presentation discusses the precautions surgeons should take to minimize the risk and the steps that need to be taken should such a hemorrhage occur.

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Silicone Oil Implantation for Postoperative Endophthalmitis

Ferenc Kuhn Hungary/Birmingham, USA If complete vitrectomy has been achieved, there are certain advantages to implanting silicone oil in eyes with advanced postoperative (and especially with posttraumatic) endophthalmitis. This videofilm shows the techniques and outcomes of this still controversial operation.

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The Postero-Anterior (P/A) Vitrectomy Technique

Ferenc Kuhn1,2 ,Viktória Mester2,3, Robert Morris1 1Birmingham, AL, USA 2Pécs, Hungary 3Abu Dhabi, UAE Purpose: To determine whether a new, P/A vitrectomy technique offers advantages over the traditional antero-posterior approach. Methods: In the last few years, we employed a different technique for vitreous removal: our initial step of surgery is detaching the posterior cortical hyaloid. Actual removal of the vitreous follows, with as...

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Primary Vitrectomy (PPV) for Non Complicated Rhegmatogenous Retinal Detachment (RD)

Ferenc Kuhn, M.D., Ph.D.,1,2 Viktória Mester, M.D.,2,3 Robert Morris, M.D.1 1Helen Keller Foundation, Birmingham, AL, USA 2Department of Ophthalmology, University of Pécs, Hungary 3Department of Ophthalmology, Mafraq Hospital, Abu Dhabi, UAE Purpose: To evaluate whether primary PPV is an acceptable alternative to treat eyes with noncomplicated rhegmatogenous RD. Methods: Comparing two approaches (external: cryopexy and scleral buckling...

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