Ординатура / Офтальмология / Английские материалы / Retinal and Vitreoretinal Diseases and Surgery_Boyd, Cortez, Sabates_2010

A concentration of 1.25-mg/ml ICG under air stains the macular ILM and ERM consistently well facilitating surgery.(62) However, ultra structural findings of the ILM suggest that the cleavage plane may not be exactly at the inner aspect of the ILM but within the innermost retinal layers and that the use of ICG as surgical aid might alter the structure of the retina to some degree.(63) In a series reported by Haritoglou et al using commercially available ICG with a concentration of 0.05% and an osmolarity of 275 mOsm, an improvement of vision was noted in 86% of patients without and 55% of patients with ICG-assisted surgery, and 35% of patients after ICG application presented with a deterioration of visual acuity. Large visual field defects were detected in 7 of 20 patients after ICG staining.(64) However these results are not consistent in other reported series. The results of several studies suggest that ICG toxicity to the retina is dependent on the dye concentration and the osmolarity of the solvent solutions, as well as on the length of dye exposure time and of the vitrectomy endolight illumination. With respect to the safety margins and profile, ICG is therefore a useful surgical tool that is still widely applied, but that may be replaced by more inert and efficient vital dyes.(65-67)

Trypan blue has also been used at concentrations of 0.15,(68) to 0.6 mg/ml in 0.1 mL for 1 min under air for ERM staining.(69) Trypan blue stains both ILM and ERM. However, some toxic effect has been reported following the use of this substance, though it seems to be less toxic than ICG as was demonstrated by Jin et al.(70) A retrospec-

tive study performed by Perrier et al revealed a median preoperative VA of 20/100 vs a mean postoperative VA of 20/60, and 74% of the patients improving their visual acuity by at least two chart lines. No adverse reaction related to trypan blue was observed up to 1 year postoperatively.(71)

Stalmans et al reported on the use of double vital staining in premacular fibrosis to facilitate complete removal of all epiretinal tissue: the epiretinal pucker was removed after staining with trypan blue, whereafter the inner limiting membrane was peeled after staining with infracyanine green.(72)

Dyes such as Evans blue and light green may stain the internal limiting membrane very well, whereas fast green and indigo carmine may be very safe to the retina. Bromophenol blue and Brilliant Blue G (BBG) may be even better novel agents. During the past three years BBG has entered the group of vital dyes for vitreoretinal surgery.(73,74) BBG seems to be an alternative vital staining dye with a good biocompatibility. Comparing the effects with ICG or trypan Blue, BBG exhibits a more favourable safety profile.(75)

The dyes currently used for different steps in chromovitrectomy are: triamcinolone acetonide for vitreous identification; ICG, infracyanine green, and BBG for internal limiting membrane identification; and trypan blue for ERM identification.(76)

Our preferred method is to prepare the vital stain solution in cold 5% Dextrose in order to facilitate its deposit on the retina.

Following injection of the dye near the posterior pole, the infusion port is closed in order to prevent turbulences of the intraocular fluid and the intraocular lights are turned off to prevent phototoxicity to the retina.

Two minutes afterwards, the remnants of the dye are aspirated with the vitrectomy probe. The vital stain facilitates the identification of the borders of the ERM, which are lifted with the aid of a pick or a barbed microvitreoretinal blade which is used to engage the membrane at its edge and elevate it from the retinal surface. The blade is then used to strip away connections to the retina on that side of the membrane where the dissection was initiated. During this initial manoeuvre, a front of elevated membrane is created, taking care not to fragment the membrane by pulling too hard or too long in any one direction. Once an entire side of the membrane has been elevated, Tano forceps or ILM Grieshaber forceps are used to continue the dissection, again elevating the membrane at multiple sites along the advancing edge of residual adhesion. Afterwards, the ERM is dissected until is becomes completely detached from the macular area. It is preferable to grasp the ERM close to the base in order to keep the dissection under control.

Once this advancing edge is close to the fovea, the membrane is grasped so that the fovea can be observed clearly as the membrane is peeled over and free of all macular connections.

In cases of thick and fibrotic ERM, it may be possible to grasp the membrane directly

with an intraocular foreign body forceps and strip it away from the macular surface (Figure 6). Occasionally, no surgical dye is used since a good surgical cleavage plane may exist facilitating the identification of the border of the ERM.

It is not infrequent that macular folds are seen immediately after the ERM dissection (Figure 7b). Small retinal haemorrhages may occur during membrane dissection (Figure 6f). They can be reduced by increasing intraocular pressure, though it is usually not necessary. Xantophyl pigment migrated from the fovea to the membrane can be observed while removing the ERM.

The aetiology of ERM influences the final result. The prognosis of ERM caused by retinal detachment is usually worse than idiopathic cases. In a study evaluating the results of the membrane extraction in retinal detachment or retinal tears, the factors associated with a better postoperative VA included the presence of thin ERM and not detached macula during the previous retinal detachment. 60 to 90% of the cases gained two or more lines VA after surgery, and metamorphopsia decreased or disappeared in 75 to 85% of the cases. The lapse for normalization of visual function may vary from days to months. Final VA is frequently interfered by cataract formation.(77) In a similar report of idiopathic ERM, the factors associated with better postoperative VA included an initial VA of 20/60 or better, short duration of the symptoms of blurred vision, the presence of a thin ERM and the absence of a tractional retinal detachment. Macular folds are reduced following surgery

in 80% of the cases and an almost normal situation is achieved in 30% of the cases. Even though a direct relationship exists between the anatomical and the functional outcome, the latter may be worse in the long standing cases.(78) It has been suggested that eyes with transparent ERM respond better to the surgery than those with opaque membranes.

The most important prognostic factors are VA, presence of macular oedema and duration of the condition. Cases with worse VA usually show greater improvement though the final visual acuity is poorer than those cases with better initial VA. Cystoid macular oedema shows resolution in only 10% of the cases. Functional outcome is usually poorer in cases with longer duration and better when surgery is performed within the two years since the symptoms started.(79)

Among the complications of surgery, the most frequently reported are cataracts (40 to 80% in patients older than 60 years of age, especially during the first year after surgery), retinal phototoxicity and toxicity induced by the vital stains, retinal tears and detachment, recurrences of ERM and less frequently en- dophthalmitis.(76,80-83)

The authors have no economical interests in the devices and procedures described.

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Introduction

Classically, the diagnosis of intraocular neoplasies was done through non invasive methods; nevertheless, diverse situations of presentation of intraocular tumors like: previous treatments, systemic implications, unusual clinical presentations or determination of prognosis factors make it necessary to obtain a cytological specimen of the tumor.

Aspirative puncture with a fine needle (FNAB) is a technique that was described and used to obtain cytological specimen from neoplasies, more than 100 years ago. Although it was applied to different tumors, the first report on an aspirative puncture in a solid intraocular tumor was done by

Jakobiec in 1979.(1) At the beginning, it was thought that this technique produced sowing of tumoral cells in the needle tract or it was associated with important intraocular complications. These problems limited its implementation; but nowadays it is known as a safe technique and thus it has been used in more than 200.000 systemic cases with a 25 G diameter or less, without detection of any sowing from the tumor.(2)

Different authors described its use for cytological diagnosis of intraocular tu- mors.(1-3-4) Now there are precise indications to carry out this technique.(5,6) But with the arrival of immunohistochemistry and chromosome studies, the indications to determine important prognosis factors in the evolution of the disease have extended.(7-8-9-10-11)

590

Indications

Classical indications to carry out an aspirative puncture are the following:(5,6)

1.Intraocular tumors that present with differential diagnosis which can not be determined through non invasive methods.

2.Intraocular tumors methastasis suspected in patients where one can not find the primary tumor.

3.Intraocular tumors in immunodepressed patients that have an uncertain diagnosis.

4.Intraocular tumors that require cytological diagnosis confirmation before starting a systemic treatment due to oncological disease, or in order to establish the adequate determination of its stage.

5.In the case the patient requests it before starting a treatment.

6.Determination of prognosis factors (especially the chromosomal ones).

Based on their experience, some authors add another indication like suspicion of growth after treatment of an intraocular melanoma.(12)

Recently, there has been an increase in the use of aspiration puncture with a fine needle previous to the placement of a radioactive plate for braquitherapy in patients

with a clinical diagnosis of posterior uveal melanoma. The goal is to harvest tumor material for histopathological and cytogenetic analysis, i.e. to establish chromosome three

monosomy.(7-8-9-10-11)

Instruments and Surgical

Technique

Different factors have to be taken into account when planning the puncture:

•Type of tumor;

•Size and location;

•Associated retinal detachment;

•Clearness of the media;

•Generally, we use retrobulbar or peribulbar anesthesia.

The access to the lesion is linked to the tumor location (Figure 1 a,b). In the case of iridian lesions we have to approximate through the anterior chamber. We make a puncture with a 25g needle in the tangential limbal sector to the lesion with an inclination of 30 to 45 degrees. The approximation has to be slow, avoiding lesions to the structures. The whole procedure has to be done under strict microscopic control.(5,6,13)

In posterior segment tumors it is important to establish the existence of serous retinal detachment above the lesion, and to locate the tumor before the equator or behind it. A

good maneuver before proceeding with the puncture, is the determination of the size of the tumor with trans - scleral illumination.

If there is no retinal detachment, or scarce sub retinal fluid and the tumor is located posteriorly to the equator, it is convenient to make a transvitreal pars plana approach in a diametrically opposed location to the tumor, having total and constant control through indirect binocular ophthalmoscopy or through surgical microscope and contact magnifying glass. Special care has to be taken when entering the retina, in order no to touch the vessels and to penetrate through the steep

part of the tumor. This procedure is usually done with a 25 gauge needle and a plastic tube connected to a 10 mL syringe, which is then actuated for suction.(5,8)

If there is a considerable serous retinal detachment over the lesion we have to change the approach. A 3 mm scleral hatch is cut at 80% depth and the tumor is entered directly, also with a 25 gauge needle. The whole procedure is done under indirect binocular ophthalmoscopy.(5)

illumination. With this technique you can use 25 to 30 gauge needles connected through a plastic tube to a 10 mL syringe. Enter the tumor directly. After this maneuver, it is mandatory to place a radioactive braquitherapy

plate.(7-8-9-10-11-13-14)

There are reports of biopsies with three port vitrectomy approach with gauge 25.(15)

Complications

Based on the reports from different authorities we noticed that 54% of the patients that had a puncture in the anterior chamber presented with visible hyperemia that resolved in one week without treatment.(5)

The most frequent complications that arose with transvitreal punctures in the posterior segment were: perforation of the retina (between 27 and 60%) without description of a positive evolution of the retinal detachment.(5,7)

In 21 to 24% we observed vitreal hemorrhage that resolved spontaneously.(7,12)

A rare complication was the appearance of a cataract in a patient that presented with diffuse iris melanoma.(13)

It is important to state that there was no tumor recurrence neither in the site of the puncture, nor in the orbital region.(5)

Preparation and Processing of

the Specimen

Once you have the material from the puncture with 25 gauge needle, the attainment of cells is 106 (16), and there has to be a preparation in order to be able to make the cytohistopathological exams (Hematoxiline and Eosin (Figure 2), PAS, Mason Tricromic, immunohistochemistry (Figures 3 a, b, c) and chromosome DNA exams.