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Effect of Infusion Air Pressure on Visual Field Defects After Macular Hole Surgery

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Effect of Infusion Air Pressure on Visual Field Defects After Macular Hole Surgery Effect of Infusion Air Pressure on Visual Field Defects After Macular Hole Surgery AKIRA HIRATA, MD, NAOKO YONEMURA, MD, TADASHI HASUMURA, MD, YASUHIRO MURATA, MD, AND AKIRA NEGI, MD ● PURPOSE: A defect in the visual field is one of the ● CONCLUSIONS: The location of the visual field defect serious complications of macular hole surgery. We inves- correlated with the location of the infusion cannula. The tigated the relationship between the occurrence of visual incidence of this visual field defect was influenced field defect and the location of infusion cannula and air strongly by the infusion air pressure. The visual field pressure during fluid–air exchange. defect may be caused by the mechanical damage of air ● METHODS: We studied 100 eyes from 90 patients with infusion. (Am J Ophthalmol 2000;130:611–616. macular holes. All patients underwent preoperative and © 2000 by Elsevier Science Inc. All rights reserved.) postoperative visual field testing. Vitreous surgery was performed in a standard three-port fashion, with surgically ITRECTOMY HAS BEEN USED SUCCESSFULLY FOR induced posterior vitreous detachment, fluid–air exchange, treatment of idiopathic macular holes and such and sulfur hexafluoride gas injection. We analyzed dif- V other diseases as diabetic retinopathy, retinal de- ferences in surgical methods in three groups. In group A, tachment, and epiretinal membrane of the macula. In the the infusion cannula was placed inferotemporally, and treatment of idiopathic macular holes, especially, although the air pressure was set at 50 mm Hg. In group B, the several studies have shown vitrectomy to be effective in producing significant improvement in visual acuity, a variety of complications has been reported during and after See also pp. 653–654. surgery, including retinal breaks,1 rhegmatogenous retinal detachment,2,3 enlarging of the hole, late reopening,2,4 infusion cannula was placed inferonasally, and the air cataract formation,5 and peripheral visual field defect.6–13 pressure was set at 50 mm Hg. In group C, the infusion Visual field defects after vitrectomy, which were first cannula was placed inferotemporally, and the air pressure reported in 1995,6 were relatively unique for macular hole was set at 30 mm Hg. surgery. The incidence varied from 7%13 to 71%8 among ● RESULTS: Eighteen eyes (18%) showed visual field institutions. Although recent studies have shown an asso- defects after vitrectomy. The defect was always located ciation of this complication with fluid–air exchange,14,15 contralateral to the infusion cannula. There was no its mechanism is still unclear. Furthermore, there is no statistically significant difference in the incidence of report in humans regarding the effects of infusion air visual field defects in groups A and B. Decreased air pressure on the occurrence of this complication. pressure reduced the occurrence of visual field defects We report herein the results of a prospective study of visual field defects in 100 eyes of 90 patients operated on ؍ significantly (24% in group A versus 4% in group C, P .011). for idiopathic macular holes. We addressed two issues: the relationship of the incidence of visual field defects with the location of the infusion cannula and the association of Accepted for publication May 23, 2000. incidence of visual field defects on air pressure during From the Department of Ophthalmology, Kumamoto University fluid–air exchange. School of Medicine, Kumamoto, Japan. This work was supported by Grant-in-Aid for Scientific Research 10770939 from the Ministry of Education, Science, Sports and Culture of Japan. A preliminary report of this study was given at the meeting of the METHODS Association for Research in Vision and Ophthalmology 1999 Annual Meeting, Fort Lauderdale, Florida. PROSPECTIVELY, 100 EYES OF 90 CONSECUTIVE PATIENTS Correspondence to Akira Hirata, MD, Department of Ophthalmol- who underwent surgery for idiopathic macular holes and ogy, Kumamoto University School of Medicine, 1-1-1, Honjo, Kum- amoto 860, Japan; fax: ϩ81-96-373-5249; e-mail [email protected]. preoperative and postoperative visual field testing between kumamoto-u.ac.jp January 1996 and May 1999 were included in this study. 0002-9394/00/$20.00 © 2000 BY ELSEVIER SCIENCE INC.ALL RIGHTS RESERVED. 611 PII S0002-9394(00)00597-3 Informed consent was obtained from all of the patients, age, sex, classification, operation time, preoperative and and the study was carried out in accordance with the postoperative intraocular pressure, and incidence of visual guidelines of the human studies committee of Kumamoto field defects. Postoperative data collected and analyzed University. All patients underwent a preoperative exami- were only for initial surgeries, although four eyes required nation that included visual acuity measurement with best repeated vitrectomy or gas tamponade. Data were tested by correction, applanation tonometry, fundus examination analysis of variance and the Mann-Whitney U test for with contact lenses, and Goldmann peripheral kinetic comparison of the patients’ clinical data and by Fisher visual field examination. Each idiopathic macular hole was exact probability test for detecting the difference in the graded according to the classification proposed by Gass.16 incidence of visual field defects. Results were considered Surgeries were performed with a standard three-port pars significant when P was less than .05. plana vitrectomy under local anesthesia. Briefly, after a core vitrectomy, for stages 2 and 3 macular holes, posterior vitreous detachment was surgically induced with a brush RESULTS backflush needle using active aspiration around the disk and then extended outward to the equator. Vitrectomy was THE CLINICAL FEATURES OF ALL PATIENTS ARE LISTED IN completed, with the vitreous gel removed as far out toward Table 1. At the time of surgery, the macular hole staging the periphery as possible. For stage 4 macular holes, when of the 100 eyes was as follows: 51 eyes were stage 2, 36 were an epiretinal membrane was present around the hole, it stage 3, and 13 were stage 4. After the surgery the macular was peeled off after vitrectomy. Fluid–air exchange was hole ultimately was closed in 90 eyes (90%). Twenty-five performed by passive aspiration using a brush backflush eyes (25%) had an intraocular pressure of 20 mm Hg or needle over the disk with humidified air, as described more 1 day after surgery, but none had an intraocular previously.17 After the fluid–air exchange, side ports were pressure more than 20 mm Hg after the first day. Seventy- immediately plugged with scleral plugs. The side ports and seven of the 90 eyes (85.5%) in which the macular hole the infusion port were then sutured and closed with three was anatomically closed had an improvement in visual bites of running shoelace suture. At the end of surgery, 1.0 acuity of 2 or more lines during a mean follow-up of 16.5 ml of pure sulfur hexafluoride gas was slowly injected into months. In all 100 eyes, postoperative fundus examination the vitreous cavity with a 30-gauge needle to a final was performed when residual gas in the vitreous cavity concentration of 20%. Cataract surgery was combined disappeared, showing no detectable retinal abnormality in with phacoemulsification and aspiration and with intraoc- the retina corresponding to the visual field defect. ular lens implantation in 82 eyes. Of the 100 eyes, 18 eyes (18%) had postoperative To analyze the relationship between the location of the peripheral visual field defects that were not present preop- infusion cannula with the occurrence and location of eratively (Table 1). Patients with 12 of the 18 eyes were visual field defects, the infusion cannula was placed infero- women and ranged in age from 59 to 73 years (mean, 65.2 temporally for 42 eyes (group A) or inferonasally for 12 years). The visual field defect, when present, was evident eyes (group B). Infusion air pressure during fluid–air just after intravitreous gas disappeared, and no progress was exchange was set at 50 mm Hg in both groups. The value detected during the period of follow-up. The clinical of 50 mm Hg for fluid–air exchange had been used during features of the patients with visual field defects were all vitrectomy procedures in our hospital. compared with the features of patients without visual field To test the association of the infusion air-pressure and defects, and the mean age, sex, macular hole stage, the incidence of visual field defect, the air-pressure was set operation time, preoperative and postoperative intraocular at 30 mm Hg with the cannula placed inferotemporally for pressure, and rate of anatomic closure were similar in the the remaining 46 eyes (group C). two groups (Table 1). Patients were instructed to maintain a face-down posi- Forty-two eyes underwent vitrectomy with the infusion tion as much as possible for 14 days. Slit-lamp examination cannula placed inferotemporally and infusion air pressure and applanation tonometry were performed every day until set at 50 mm Hg (group A). Ten eyes of the group (24%) the patient was discharged. Postoperative visual field test- showed visual field defects after surgery (Table 2). The ing was performed when there was no residual gas in the defect, a focal and a triangle-shaped depression, was always vitreous cavity. For each patient, preoperative and postop- observed at a lower temporal quadrant (Figure 1, A and B). erative visual fields were reviewed by three of us (Drs Twelve eyes underwent vitrectomy with the infusion Hirata, Yonemura, and Hasumura). Changes were consid- cannula placed inferonasally with infusion air pressure set at ered significant only when the V4 and I4 isopters were 50 mm Hg (group B). Six eyes of the group (50%) showed indented by the defect. visual field defects after surgery. In contrast to the defects The following data were collected to allow statistical found in group A, the defects in group B were located at the comparison between eyes with visual field defects and lower nasal quadrant (Table 2; Figure 1, C and D).
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