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Special Article |

Surgery as the Primary Management of Proliferative Vitreoretinopathy A History Reflecting My Experiences and Biases FREE

Thomas M. Aaberg Sr, MD, MSPH
[+] Author Affiliations

Author Affiliation: Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia.


Arch Ophthalmol. 2010;128(8):1068-1070. doi:10.1001/archophthalmol.2010.150.
Text Size: A A A
Published online

Although attempts were made ot reattach retinas using proliferative vitreoretinopathy by various techniques before the 1970s, it was the development and subsequent refinement of closed-eye, mechanized pars plana vitrectomy that initiated the rapid rise in the surgical success rate. This article presents a personal history of the milestone accomplishments that facilitated the strong possibility of success that patients with proliferative vitreoretinopathy can now anticipate. Currently, various gasses, chemical compounds, and pharmaceutical agents serve adjunctively to advance surgical techniques with the expectation that they may be the primary curative procedure in the future. As in the past, what is unconventional today may be common tomorrow.

It is with great humility that I extend my sincere appreciation to The Retinal Research Foundation, The Schepens International Society, and Alice McPherson, MD, for inviting me to be the second lecturer to honor the legacy of Charles Schepens, MD.

I first met Dr Schepens while I was in the Howe Laboratory, Massachusetts Eye and Ear Infirmary, during a year of research on aqueous dynamics that preceded my clinical residency. It was apparent that I needed indirect ophthalmoscopy skills to see the peripheral retina in our experimental model in which we cannulated the pars plana. Dr Schepens mentored my improvement in ophthalmoscopic techniques and promoted my joy in seeing the peripheral retinal structures, including elusive retinal tears. These techniques and Dr Schepens' instruction served me well during my subsequent clinical residency, culminating in my career interest in vitreoretinal diseases.

Proliferative vitreoretinopathy (PVR), an enigma to retinal surgeons, had a surgical success rate of about 15% prior to 1970, using external scleral techniques of buckling, resection, or imbrications. Attempts to perform premechanized vitreous surgery were made through limbal and pars plana approaches using vitreous aspiration with or without replacement; the former used saline, donor vitreous, air, gas, silicone oil, or collagen to insufflate the vitreous cavity and strip PVR bands or membranes.112 Simultaneously, vitreoretinal membrane division/cutting was employed using intravitreal knives, punches, scissors, and balloons.1316

Closed-Eye Mechanized Pars Plana Vitrectomy

The 1970s were a decade of both advancement and proliferation of vitrectomy instrumentation, resulting in a doubling of the success rate of PVR surgery to 30%. On April 20, 1970, Robert Machemer, MD, performed his first human closed-eye pars plana vitrectomy with the vitreous infusion suction cutter (written and oral communication, November 1994), profoundly changing ophthalmic surgery and thus helping many patients who were previously considered untreatable. Like other major therapeutic changes in the practice of ophthalmology, vitrectomy, at that time, had detractors as well as advocates, the latter ranging from adamant zeal to remove all portions of the vitreous gel to a more cautious surgical approach. I defended my position in the letter section of Controversies in Ophthalmology,17 stating, “Closed eye vitrectomy represented a true milestone in ophthalmic progress,” but, “The clinician must be on guard as to the future consequences of this surgical therapy.” Dr Schepens presented a cautious contrary view but concluded, “Vitreous surgery is here to stay. . . . remarkable results can be obtained in eyes that would otherwise be doomed.”17 The vitreous infusion suction cutter was a full-function instrument with cutting, aspiration, infusion, cannulated endoillumination, and even diathermy in the early versions, creating a large (about 16-17 gauge) shaft size when fully assembled with the illumination sleeve. Other full-function instrumentation by various independent clinical investigators followed,1823 including a stereotaxic unit.24 The cannula size eventually was reduced by splitting the functions into separate illumination, infusion, and cutting.25

Concurrent equipment submilestones during the aforementioned vitrectomy development were advances in illumination and microscopic visualization of the posterior pole. Early illumination was coaxial and/or aligned slit beam light; both had insufficient light intensity and interfering light reflexes at every intervening tissue optical interface. Most problems were minimized by endoscopic light.26 Microscope modification advances included (1) 2-dimensional horizontal (x-y) foot-controlled movement; (2) variable zoom depth with greater steady-state depth of focus; (3) greater range of magnification27; and (4) wide-angle viewing.28

Each advance facilitated other advances. With improved illumination and visualization, same-gauge auxiliary instruments were developed to be interchangeable through sclerotomy ports with the vitrector such as diathermy, scissors, forceps, pics, extrusion devices, magnets, and more.

Intraocular Solutions and Gases

During the first decade of closed-eye vitrectomy, little was known about the tolerance of the eye for infused liquids, particularly for the volume and duration of early vitrectomy infusions that compounded the patients' debilitating ocular conditions such as diabetes, sickle cell, trauma, and multiple previous surgeries. Vitrectomy surgeons thus noted while using the basic saline or lactated Ringer solutions that were available (or variants thereof) that the corneas and lenses lost clarity during surgery and, postoperatively, the corneas were thickened for a considerable period of time. Eyes of diabetic patients that developed intraoperative cataract necessitating concurrent lensectomy then had a greater risk of postoperative rubeosis irides.

A great advance that eventually saved the vision of many postoperative patients occurred when Henry Edelhauser, PhD, developed the prototype glutathione bicarbonate ringers solution with osmolarity, buffering capacity, and pH compatible with the aqueous humor.29

Further research by Haimann and Edelhauser et al30 showed that the eyes of persons with diabetes, invariably accustomed to higher preoperative intraocular aqueous glucose levels (hence higher osmolarity), maintained intraoperative lens clarity better when adding additional dextrose to the irrigating solution.

Retina surgeons had used air for many years for intravitreal tamponade of retinal holes and to maintain proper retinal alignment. Air had been used intraoperatively during vitrectomy in the late 1970s but was not practical until automated air injection in the early 1980s. Because air dissipates quickly from the vitreous cavity, vitreoretinal surgeons were also excited by studies in the mid 1970s that demonstrated the ability of sulfur hexafluoride gas to expand and persist for many days in the eye.31 This was followed by other gaseous compounds such as perfluoropropane, which expanded and persisted even longer.32,33 Surgery in an air-filled eye had greater interface surface tension than a fluid-filled eye so tangential traction in a fluid-filled eye could be severed and maintained postoperatively with an air-gas exchange at the conclusion of surgery. Thus, the therapeutic armamentarium of the surgeon expanded, albeit with some risk.

Intraocular Laser

Endocoagulation initially used a xenon light source but was ineffective in an air-filled eye, so it was soon replaced by intraocular laser. This dramatically altered the technical capabilities of the vitreoretinal surgeon, permitting intraoperative treatment of retinal holes and demarcation of intractable anterior disease in air-filled eyes. These capabilities allowed success in some eyes that would otherwise have failed and increased the overall rate of surgical success in PVR to 63%.3436

Sustained Retinal Tamponade

Silicone oil has been used since the previtrectomy 1960s when Cibis37 used it as a substance to separate preretinal tractional membranes and afford long-term retinal tamponade. Except for the surgical tenacity of Scott38 and a few others who continued to use silicone oil, it was rarely used in the early 1970s. It's renewed interest came as an adjunct to pars plana vitrectomy techniques,3941 leading to a randomized clinical trial comparing silicone oil to long-acting gas as a retinal tamponade in PVR.42,43

During this time, 2 further advances occurred: (1) recognition of the significance of proliferation in or about the posterior insertion of the vitreous base, ie, the anterior component of PVR,35,36 and (2) developing clinical experience with perfluorocarbon liquids; a variety were available but perfluoro-N-octane became the most clinically used to reposition the mobilized retina after membrane dissection.44 By understanding the mechanisms and significance of periretinal membrane proliferation and developing the surgical corrections, the success rate of PVR surgery rose to 78% by 198735 and currently is even higher.

Anticipated Pharmacologic/Immunologic Milestones for PVR

Thirty three years ago, Dr Schepens aptly stated, “The greatest limiting factor of vitreous surgery cannot be overcome . . . the continuing growth of new formed tissue . . . in instances of massive preretinal retraction . . . the control of such regrowth will certainly require considerable research work.”17 Such research continues, and headway is being made.

Because initial surgical reattachment of primary retinal detachments can now usually be achieved, prevention of cellular migration, adhesion, and proliferation, ie, PVR, should be targeted. Risk factors for subsequent PVR are known and should be the template for determining candidate eyes for preventative treatment in primary retinal detachment and as an adjunct at the time of PVR surgery to prevent reoccurrence.45,46

Several of the many known cytokines are prospects for pharmacologic inhibition and/or modification to prevent cellular proliferation. Inhibition of cellular migration and adhesion may be inhibited by plasma fibrin and fibronectin in the early assembly of a provisional extracellular matrix and/or inhibition of a subsequent matrix of collagen and cellular/fibronectin. Several laboratories are working on these pathways4547 as well as the best delivery systems for PVR therapeutic/prophylactic agents.48

I conclude that while epidemiologic and therapeutic evidence suggests pharmacologic/immunologic treatment is necessary, at present, surgery is still the primary management of PVR.

Correspondence: Thomas M. Aaberg Sr, MD, MSPH, Department of Ophthalmology, Emory University School of Medicine, 1365 B. Clifton Rd NE, Ste 4400, Atlanta, GA 30322 (ophttma@emory.edu).

Submitted for Publication: February 26, 2010; final revision received February 26, 2010; accepted April 8, 2010.

Financial Disclosure: None reported.

Funding/Support: This study was supported by Retinal Research Foundation and the Schepens International Society.

Additional Contributions: I gratefully acknowledge the financial support of the Retinal Research Foundation and the Schepens International Society and the assistance of Patricia Bennett.

zur Nedden  M The curative value of aspiration of the vitreous. Arch Ophthalmol 1928;57109
Landegger  GP Clinical experiences with vitreous replacements. Am J Ophthalmol 1950;33 (6) 915- 921
PubMed
O’Malley  CC A case of bilateral vitreous opacities in a boy improved by vitreous extraction. Trans Ophthalmol Soc U K 1954;74599
Grafton  EG  JrGuyton  JS The value of injecting saline into the vitreous as an adjunct to diathermy operations for retinal detachment. Am J Ophthalmol 1948;31 (3) 299- 303
PubMed
Posner  A Intra-vitreal injection of saline in retinal detachment surgery. EENT Monthly 1953;32656
Rohmer  L Effets des injections d’air sterilize dans le vitre contre le decollement de la retine. Arch Ophtalmol (Paris) 1912;32257
Arruga  MH Decollement retinien, l’urgence operatoire, l’injection d’air les grandes desinsertions. Bull Soc Franc. Ophtalmol 1936;49288
Rosengren  B Cases of retinal detachment treated with diathermy and injection of air into the vitreous body [abstract]. Acta Ophthalmol (Copenh) 1938;16177
Rosengren  B 300 cases operated upon for retinal detachment. Acta Ophthalmol (Copenh) 1952;30 (1) 117- 122
PubMed
Cutler  NL Transplantation of human vitreous [abstract]. Arch Ophthalmol 1948;39419- 424
Shafer  DM The treatment of retinal detachment by vitreous implant. Ophthalmology (Rochester) 1957;61194
Cibis  PABecker  BOkun  RECanaan  S The use of liquid silicone in retinal reattachment surgery. Arch Ophthalmol 1968;68590- 599
Link to Article
Aaberg  TMMachemer  R Vitreous band surgery: instrumentation and technique. Arch Ophthalmol 1972;87 (5) 542- 544
PubMed Link to Article
Neubauer  H Der amagnetische intraoculare Fremdkoerper. Sautter  HEntwicklung und Forschritt in der Augenheilkunde. Stuttgart, Germany Enke Verlag1963;
Couvillion  GCFreeman  HMSchepens  CL Vitreous surgery V: modification of the vitreous scissors. Arch Ophthalmol 1970;83 (6) 722- 723
PubMed Link to Article
Freeman  HMSchepens  CLCouvillion  GC Current management of giant retinal breaks. Trans Am Acad Ophthalmol Otolanryngol 1970;74 (1) 59- 74
PubMed
Aaberg  TMSchepens  CL Pars plana vitrectomy and the vitreous: can we violate it and go unpunished? Brockhurst  RJBoruchoff  SAHutchinson  BTLessell  SControversies in Ophthalmology. Philadelphia, PA WB Saunders Co1977;478- 513
Douvas  NG The cataract roto-extractor. Trans Am Acad Ophthalmol Otolanryngol 1973;77 (6) 792- 800
PubMed
Peyman  GADodich  NA Experimental vitrectomy: instrumentation and surgical technique. Arch Ophthalmol 1971;86 (5) 548- 551
PubMed Link to Article
Hennig  JFaulborn  JBernhard  F An apparatus for vitreous surgery in the treatment of severe ocular injuries [in German]. Klin Monbl Augenheilkd 1972;161 (1) 107- 109
PubMed
Tolentino  FIBanko  ASchepens  CL  et al.  Vitreous surgery XII: new instrumentation for vitrectomy. Arch Ophthalmol 1975;93 (8) 677- 672
PubMed Link to Article
Klöti  R Vitrektomie I: ein neues instrument fuer die hintere vitrektomie. Albrecht von Graefes Arch Klin Exp Ophthalmol 1973;187161- 170
PubMed Link to Article
Federman  JLCook  KBross  R  et al.  Intraocular microsurgery I: new instrumentation (SITE). Ophthalmic Surg 1976;7 (1) 82- 87
PubMed
Kreiger  AEStraatsma  BRGriffin  JRStorm  FKSmiley  EH A vitrectomy instrument in stereotatic intraocular surgery. Am J Ophthalmol 1973;76 (4) 527- 532
PubMed
O’Malley  CHeintz  RM Vitrectomy via the pars plana: a new instrument system. Trans Pac Coast Otoophthalmol Soc Annu Meet 1972;53121- 137
PubMed
Parel  JMMachemer  RAumayr  W A new concept for vitreous surgery IV: improvements in instrumentation and illumination. Am J Ophthalmol 1974;77 (1) 6- 12
PubMed
Parel  JMMachemer  RAumayr  W A new concept for vitreous surgery V: an automated operating microscope. Am J Ophthalmol 1974;77 (2) 161- 168
PubMed
Spitznas  M A binocular indirect ophthalmomicroscope (BIOM) for non-contact wide-angle vitreous surgery. Graefes Arch Clin Exp Ophthalmol 1987;225 (1) 13- 15
PubMed Link to Article
Edelhauser  HFVan Horn  DLHyndiuk  RA Schultz  RO Intraocular irrigating solutions: their effect on corneal endothelium. Arch Ophthalmol 1975;93 (8) 648- 657
PubMed Link to Article
Haimann  MHAbrams  GWEdelhauser  HFHatchell  DL Effect of intraocular irrigating solutions on lens clarity in normal and diabetic rabbits. Am J Ophthalmol 1982;94 (5) 594- 605
PubMed
Abrams  GWEdelhauser  HFAaberg  TMHamilton  LH Dynamics of intravitreal sulfur hexafluoride gas. Invest Ophthalmol 1974;13 (11) 863- 868
PubMed
Vygantas  CMPeyman  GADaily  MJEricson  ES Octafluorocyclobutane and other gasses for vitreous replacement. Arch Ophthalmol 1973;90 (3) 235- 236
PubMed Link to Article
Lincoff  AHaft  DLiggett  PReifer  C Intravitreal expansion of perfluorocarbon bubble. Arch Ophthalmol 1980;98 (9) 1646
PubMed Link to Article
Parke  DW  IIAaberg  TM Intraocular argon laser photocoagulation in the management of severe proliferative vitreoretinopathy. Am J Ophthalmol 1984;97 (4) 434- 443
PubMed
Aaberg  TM Management of anterior and posterior proliferative vitreoretinopathy: XLV Edward Jackson Memorial Lecture. Am J Ophthalmol 1988;106 (5) 519- 532
PubMed Link to Article
Lewis  HAaberg  TM Anterior proliferative vitreoretinopathy. Am J Ophthalmol 1988;105 (3) 277- 284
PubMed Link to Article
Cibis  P  Vitreoretinal Pathology and Surgery in Retinal Detachment.   St Louis, MO CV Mosby1965;
Scott  JD Treatment of the detached immobile retina. Trans Ophthalmol Soc U K 1972;92351- 357
PubMed
Haut  JUllern  MChatellier  PHCedah  A Resultata de 200 cas d’injection intra-oculaire de silicone associee a la vitrectomie. Bull Mem Soc Fr Ophtalmol 1979;91180- 184
Zivojnović  RMertens  DABaarsma  GS Fluid silicon in detachment for surgery [in German]. Klin Monbl Augenheilkd 1981;179 (1) 17- 22
PubMed Link to Article
Leaver  PKGrey  RHBGarner  A Silicone oil injection in the treatment of massive pre-retinal retraction II: late complications in 93 eyes. Br J Ophthalmol 1979;63 (5) 361- 367
PubMed Link to Article
Silicone Study Group, Vitrectomy with silicone oil or sulphur hexafluoride gas in eyes with severe proliferative vitreoretinopathy: results of a randomized clinical trial: Silicone Study Report 1. Arch Ophthalmol 1992;110 (6) 770- 779
PubMed Link to Article
Silicone Study Group, Silicone Study Report 3: vitrectomy with silicone oil or perfluoropropane gas in eyes with severe proliferative vitreoretinopathy: results of a randomized clinical trial. Retina 1993;13 (4) 279- 284
PubMed Link to Article
Chang  SSparrow  JIwamoto  TGershbein  ARoss  ROrtiz  R Experimental studies of tolerance to intravitreal perfluoro-N-octane liquid. Retina 1991;11 (4) 367- 374
PubMed Link to Article
Pastor  JC Proliferative vitreoretinopathy: an overview. Surv Ophthalmol 1998;43 (1) 3- 18
PubMed Link to Article
Pastor  JCde la Rúa  ERMartín  F Proliferative vitreoretinopathy: risk factors and pathobiology. Prog Retin Eye Res 2002;21 (1) 127- 144
PubMed Link to Article
Chang  YCKao  YHHu  DNTsai  LYWu  WC All-trans retinoic acid remodels extracellular matrix and suppresses laminin-enhanced contractibility of cultured human retinal pigment epithelial cells [published December 9, 2008]. Exp Eye Res 2009;88 (5) 900- 909
PubMed Link to Article
Zhang  GFeng  XWabner  K  et al.  Intraocular nanoparticle delivery: a pilot study using an aerosol during pars plana vitrectomy. Invest Ophthalmol Vis Sci 2007;48 (11) 5243- 5249
PubMed Link to Article

Figures

Tables

References

zur Nedden  M The curative value of aspiration of the vitreous. Arch Ophthalmol 1928;57109
Landegger  GP Clinical experiences with vitreous replacements. Am J Ophthalmol 1950;33 (6) 915- 921
PubMed
O’Malley  CC A case of bilateral vitreous opacities in a boy improved by vitreous extraction. Trans Ophthalmol Soc U K 1954;74599
Grafton  EG  JrGuyton  JS The value of injecting saline into the vitreous as an adjunct to diathermy operations for retinal detachment. Am J Ophthalmol 1948;31 (3) 299- 303
PubMed
Posner  A Intra-vitreal injection of saline in retinal detachment surgery. EENT Monthly 1953;32656
Rohmer  L Effets des injections d’air sterilize dans le vitre contre le decollement de la retine. Arch Ophtalmol (Paris) 1912;32257
Arruga  MH Decollement retinien, l’urgence operatoire, l’injection d’air les grandes desinsertions. Bull Soc Franc. Ophtalmol 1936;49288
Rosengren  B Cases of retinal detachment treated with diathermy and injection of air into the vitreous body [abstract]. Acta Ophthalmol (Copenh) 1938;16177
Rosengren  B 300 cases operated upon for retinal detachment. Acta Ophthalmol (Copenh) 1952;30 (1) 117- 122
PubMed
Cutler  NL Transplantation of human vitreous [abstract]. Arch Ophthalmol 1948;39419- 424
Shafer  DM The treatment of retinal detachment by vitreous implant. Ophthalmology (Rochester) 1957;61194
Cibis  PABecker  BOkun  RECanaan  S The use of liquid silicone in retinal reattachment surgery. Arch Ophthalmol 1968;68590- 599
Link to Article
Aaberg  TMMachemer  R Vitreous band surgery: instrumentation and technique. Arch Ophthalmol 1972;87 (5) 542- 544
PubMed Link to Article
Neubauer  H Der amagnetische intraoculare Fremdkoerper. Sautter  HEntwicklung und Forschritt in der Augenheilkunde. Stuttgart, Germany Enke Verlag1963;
Couvillion  GCFreeman  HMSchepens  CL Vitreous surgery V: modification of the vitreous scissors. Arch Ophthalmol 1970;83 (6) 722- 723
PubMed Link to Article
Freeman  HMSchepens  CLCouvillion  GC Current management of giant retinal breaks. Trans Am Acad Ophthalmol Otolanryngol 1970;74 (1) 59- 74
PubMed
Aaberg  TMSchepens  CL Pars plana vitrectomy and the vitreous: can we violate it and go unpunished? Brockhurst  RJBoruchoff  SAHutchinson  BTLessell  SControversies in Ophthalmology. Philadelphia, PA WB Saunders Co1977;478- 513
Douvas  NG The cataract roto-extractor. Trans Am Acad Ophthalmol Otolanryngol 1973;77 (6) 792- 800
PubMed
Peyman  GADodich  NA Experimental vitrectomy: instrumentation and surgical technique. Arch Ophthalmol 1971;86 (5) 548- 551
PubMed Link to Article
Hennig  JFaulborn  JBernhard  F An apparatus for vitreous surgery in the treatment of severe ocular injuries [in German]. Klin Monbl Augenheilkd 1972;161 (1) 107- 109
PubMed
Tolentino  FIBanko  ASchepens  CL  et al.  Vitreous surgery XII: new instrumentation for vitrectomy. Arch Ophthalmol 1975;93 (8) 677- 672
PubMed Link to Article
Klöti  R Vitrektomie I: ein neues instrument fuer die hintere vitrektomie. Albrecht von Graefes Arch Klin Exp Ophthalmol 1973;187161- 170
PubMed Link to Article
Federman  JLCook  KBross  R  et al.  Intraocular microsurgery I: new instrumentation (SITE). Ophthalmic Surg 1976;7 (1) 82- 87
PubMed
Kreiger  AEStraatsma  BRGriffin  JRStorm  FKSmiley  EH A vitrectomy instrument in stereotatic intraocular surgery. Am J Ophthalmol 1973;76 (4) 527- 532
PubMed
O’Malley  CHeintz  RM Vitrectomy via the pars plana: a new instrument system. Trans Pac Coast Otoophthalmol Soc Annu Meet 1972;53121- 137
PubMed
Parel  JMMachemer  RAumayr  W A new concept for vitreous surgery IV: improvements in instrumentation and illumination. Am J Ophthalmol 1974;77 (1) 6- 12
PubMed
Parel  JMMachemer  RAumayr  W A new concept for vitreous surgery V: an automated operating microscope. Am J Ophthalmol 1974;77 (2) 161- 168
PubMed
Spitznas  M A binocular indirect ophthalmomicroscope (BIOM) for non-contact wide-angle vitreous surgery. Graefes Arch Clin Exp Ophthalmol 1987;225 (1) 13- 15
PubMed Link to Article
Edelhauser  HFVan Horn  DLHyndiuk  RA Schultz  RO Intraocular irrigating solutions: their effect on corneal endothelium. Arch Ophthalmol 1975;93 (8) 648- 657
PubMed Link to Article
Haimann  MHAbrams  GWEdelhauser  HFHatchell  DL Effect of intraocular irrigating solutions on lens clarity in normal and diabetic rabbits. Am J Ophthalmol 1982;94 (5) 594- 605
PubMed
Abrams  GWEdelhauser  HFAaberg  TMHamilton  LH Dynamics of intravitreal sulfur hexafluoride gas. Invest Ophthalmol 1974;13 (11) 863- 868
PubMed
Vygantas  CMPeyman  GADaily  MJEricson  ES Octafluorocyclobutane and other gasses for vitreous replacement. Arch Ophthalmol 1973;90 (3) 235- 236
PubMed Link to Article
Lincoff  AHaft  DLiggett  PReifer  C Intravitreal expansion of perfluorocarbon bubble. Arch Ophthalmol 1980;98 (9) 1646
PubMed Link to Article
Parke  DW  IIAaberg  TM Intraocular argon laser photocoagulation in the management of severe proliferative vitreoretinopathy. Am J Ophthalmol 1984;97 (4) 434- 443
PubMed
Aaberg  TM Management of anterior and posterior proliferative vitreoretinopathy: XLV Edward Jackson Memorial Lecture. Am J Ophthalmol 1988;106 (5) 519- 532
PubMed Link to Article
Lewis  HAaberg  TM Anterior proliferative vitreoretinopathy. Am J Ophthalmol 1988;105 (3) 277- 284
PubMed Link to Article
Cibis  P  Vitreoretinal Pathology and Surgery in Retinal Detachment.   St Louis, MO CV Mosby1965;
Scott  JD Treatment of the detached immobile retina. Trans Ophthalmol Soc U K 1972;92351- 357
PubMed
Haut  JUllern  MChatellier  PHCedah  A Resultata de 200 cas d’injection intra-oculaire de silicone associee a la vitrectomie. Bull Mem Soc Fr Ophtalmol 1979;91180- 184
Zivojnović  RMertens  DABaarsma  GS Fluid silicon in detachment for surgery [in German]. Klin Monbl Augenheilkd 1981;179 (1) 17- 22
PubMed Link to Article
Leaver  PKGrey  RHBGarner  A Silicone oil injection in the treatment of massive pre-retinal retraction II: late complications in 93 eyes. Br J Ophthalmol 1979;63 (5) 361- 367
PubMed Link to Article
Silicone Study Group, Vitrectomy with silicone oil or sulphur hexafluoride gas in eyes with severe proliferative vitreoretinopathy: results of a randomized clinical trial: Silicone Study Report 1. Arch Ophthalmol 1992;110 (6) 770- 779
PubMed Link to Article
Silicone Study Group, Silicone Study Report 3: vitrectomy with silicone oil or perfluoropropane gas in eyes with severe proliferative vitreoretinopathy: results of a randomized clinical trial. Retina 1993;13 (4) 279- 284
PubMed Link to Article
Chang  SSparrow  JIwamoto  TGershbein  ARoss  ROrtiz  R Experimental studies of tolerance to intravitreal perfluoro-N-octane liquid. Retina 1991;11 (4) 367- 374
PubMed Link to Article
Pastor  JC Proliferative vitreoretinopathy: an overview. Surv Ophthalmol 1998;43 (1) 3- 18
PubMed Link to Article
Pastor  JCde la Rúa  ERMartín  F Proliferative vitreoretinopathy: risk factors and pathobiology. Prog Retin Eye Res 2002;21 (1) 127- 144
PubMed Link to Article
Chang  YCKao  YHHu  DNTsai  LYWu  WC All-trans retinoic acid remodels extracellular matrix and suppresses laminin-enhanced contractibility of cultured human retinal pigment epithelial cells [published December 9, 2008]. Exp Eye Res 2009;88 (5) 900- 909
PubMed Link to Article
Zhang  GFeng  XWabner  K  et al.  Intraocular nanoparticle delivery: a pilot study using an aerosol during pars plana vitrectomy. Invest Ophthalmol Vis Sci 2007;48 (11) 5243- 5249
PubMed Link to Article

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Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

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