Background
Postoperative vitreous cavity haemorrhage (POVCH) is a significant complication following vitrectomy for proliferative diabetic retinopathy (PDR). It delays visual recovery and can make further treatment difficult if the view of the fundus is significantly obscured. A number of interventions to reduce the incidence of POVCH have been proposed, including the perioperative use of anti-vascular endothelial growth factor (anti-VEGF). Anti-VEGFs reduce vascular proliferation and the vascularity of neovascular tissue, which is often the source of bleeding following vitrectomy.

Objectives
This updated review aimed to summarise the effects of anti-VEGF use to reduce the occurrence of POVCH after vitrectomy surgery for PDR.

Search methods
We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 4), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to May 2015), PubMed (January 1966 to May 2015), EMBASE (January 1980 to May 2015), Latin American and Caribbean Health Sciences (LILACS) (January 1982 to May 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 26 May 2015.

Selection criteria
We included all randomised controlled trials (RCTs) and quasi-RCTs that looked at the use of anti-VEGFs and the incidence of POVCH in people undergoing vitrectomy for PDR.

Data collection and analysis
Both review authors independently assessed and extracted the data. We used standard methodological procedures expected by Cochrane.

The primary outcomes of the review were the incidence of early and late POVCH following perioperative anti-VEGF administration. Secondary outcomes included best-corrected visual acuity at six months following surgery, the incidence of vitreous cavity washout or revision vitrectomy at six months, adverse effects of intervention (cataract, iris rubeosis and rubeotic glaucoma, retinal detachment, increased inflammation and systemic side effects), quality of life measures performed at least six months following vitrectomy, and density of POVCH.

Main results
The current review included 12 RCTs that looked at the pre- or intraoperative use of intravitreal bevacizumab to prevent postoperative vitreous haemorrhage during pars plana vitrectomy for complications of PDR. The studies were conducted in a variety of countries (three from Iran, two from Italy, two from Egypt, and the remaining from South Korea, USA, Mexico, Pakistan, and Japan). The inclusion criteria for entry into the studies were standard complications of proliferative retinopathy: non-clearing vitreous haemorrhage, tractional retinal detachment involving the macula, or combined tractional rhegmatogenous detachment. The included studies randomised a total of 654 eyes. The average age of the participants was 54 years.

We identified methodological issues in all included studies. Risk of bias was highest for masking of participants and investigators (four studies were an 'open label' design), and a number of studies were unclear when describing randomisation methods and sequence allocation.

Participants receiving intravitreal bevacizumab in addition to pars plana vitrectomy were less likely to experience early POVCH (grade 2) compared to people undergoing pars plana vitrectomy alone (risk ratio (RR) 0.28, 95% confidence interval (CI) 0.08 to 0.96, 2 studies, 144 eyes, high-quality evidence). This corresponds to an absolute effect of 130 fewer people (95% CI 167 fewer to 7 fewer) with early POVCH per 1000 people when treated with intravitreal bevacizumab. We saw similar results for all grades of POVCH (RR 0.35, 95% CI 0.23 to 0.53, 9 studies, 512 eyes) and when excluding cases where assessment of outcome was impossible due to presence of silicone oil (RR 0.34, 95% CI 0.19 to 0.60, 6 studies, 302 eyes).

The effect of pre- or intraoperative intravitreal bevacizumab on the incidence of late postoperative haemorrhage was uncertain (RR 0.72, 95% CI 0.30 to 1.72, 3 studies, 196 eyes, low-quality evidence). The absolute effect was 55 fewer people (95% CI 138 fewer to 143 more) with late POVCH per 1000 people when treated with intravitreal bevacizumab. This outcome was rarer and was only reported in a few studies. We are currently unable to provide an estimate of the effect of intravitreal bevacizumab on postoperative visual acuity due to significant study heterogeneity.

No local or systemic complications of intravitreal bevacizumab were reported by the RCTs. The risk of postoperative retinal detachment was lower in the participants treated with pre- or intraoperative bevacizumab (RR 0.46, 95% CI 0.19 to 1.08, 7 studies, 372 participants, low-quality evidence); the absolute effect was 49 fewer people (95% CI:73 fewer to 8 more) with postoperative retinal detachment per 1000 people when treated with intravitreal bevacizumab.

Authors' conclusions
The use of pre- or intraoperative bevacizumab lowers the incidence of early POVCH. The reported complications from its use appear to be low. Futher randomised studies that look at other anti-VEGF medications are ongoing and will strengthen the current review findings, giving both surgeons and patients evidence to guide treatment choices in the management of proliferative retinopathy.

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Anti-vascular endothelial growth factor for prevention of postoperative vitreous cavity haemorrhage after vitrectomy for proliferative diabetic retinopathy.

Pterygia are noncancerous growths of conjunctiva that may require surgical removal because of discomfort, cosmesis, or obstruction of vision. Pterygia often recur after excision. The major goal of pterygium treatment is avoiding recurrence, but complication rates and cosmetic results are also considered. Despite the number of techniques available, there is no consensus on the best procedure. Even the best techniques carry risk of recurrence and complications. In this review, different surgical techniques, graft attachment methods, and adjuvant therapies in current use are discussed. Also discussed are newer techniques that early studies have shown to be promising, but require more investigation before becoming a recommended treatment. The review is intended to provide an overview of the current research to inform surgeons with regard to their decisions and aid researchers in hypothesis generation.

Surgical Management of Pterygium

The musculoskeletal conditions most commonly associated with diabetes are discussed below. One or more pathogenic mechanisms may be implicated in an association of a musculoskeletal condition with diabetes. Some rheumatological conditions are exclusive to diabetes whilst others occur more frequently in the diabetic population compared with non-diabetics. Whilst some musculoskeletal conditions may be managed conventionally when associated with diabetes, others may require special considerations. There is a preponderance of rheumatological manifestations of diabetes in the upper limb, although some conditions occur throughout the skeletal system.

Musculoskeletal manifestations of diabetes mellitus.

The main treatment for pterygium is surgical removal. However, pterygium surgery is concerned with high rates of postoperative recurrence. Predicting factors of recurrence are not fully understood, yet, but they probably depend on a multitude of patient-related, clinical, and/or surgical factors. Several adjuvant treatments have been proposed to reduce postoperative pterygium recurrence, including different antimetabolites, antiangiogenetic factors, and radiation therapy. The purpose of this review is to collect the current evidence regarding application and limits of different therapeutic approaches for preventing postoperative recurrence of pterygium, giving insights and perspectives for better management of this disease. In the light of the current evidence, pterygium surgery cannot disregard wound coverage with conjunctival autografting or rotational flap combined with adjuvant treatments. The rotational flap technique is associated with shorter surgical time rates and prevents graft displacement and necrosis, given its vascular pedicle. Amniotic membrane may still be reserved in case of great conjunctival defects or insufficient conjunctiva. Repeated subconjunctival antivascular endothelial growth factor injections can be considered as an effective and safe adjuvant treatment. Moreover, management of postoperative pain is crucial. Innovative treatment strategies will probably target different molecular pathways, considering recent findings regarding pterygium pathogenesis, to improve better understanding and develop universally shared guidelines. Great importance shall be dedicated to the identification of novel molecular biomarkers and favoring factors of recurrence, in order to achieve a customized surgical treatment for each patient and obtain maximal reduction of postoperative recurrence.

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How to minimize pterygium recurrence rates: clinical perspectives

Intravitreal injection of expansile perfluoropropane (c(3)f(8)) for the treatment of vitreomacular traction.

Background and objective To evaluate the safety and efficacy of intraoperative subconjunctival bevacizumab as an adjunctive treatment after surgical excision of primary pterygium. Patients and methods This was a randomized prospective clinical study. Group 1 (21 eyes) underwent pterygium excision with conjunctivo-limbal autograft. Group 2 (20 eyes) received subconjunctival 1.25 mg/0.05 mL of bevacizumab at the end of the surgery. Results There were no statistically significant differences regarding age, sex, laterality, or dimensions of the pterygia or grafts between the two groups (P > .05, 95% confidence interval). After 8 months of follow-up, two eyes in group 1 and four eyes in group 2 had recurrent pterygia. One patient in group 2 had lost graft. The difference in recurrence rate between the two groups did not reach statistical significance (P = 0.4, 95% confidence interval). Conclusion Intraoperative subconjunctival bevacizumab following primary pterygium surgical excision is not helpful and possibly harmful. Larger studies are needed.

Intraoperative subconjunctival bevacizumab as an adjunctive treatment in primary pterygium: a preliminary report.

Purpose: To assess preoperative factors associated with postoperative posterior vitreous detachment (PVD) following intravitreal autologous plasmin injection in diabetic macular edema associated with vitreomacular traction. Methods: Twenty-five eyes with diabetic macular edema associated with vitreomacular traction as documented with optical coherence tomography were included. Approximately 0.2 IU/0.2 ml of autologous plasmin was injected intravitreally. Condition of the posterior vitreous face (degree of detachment, thickness, reflectivity, and diameter of attached vitreous base) was evaluated preoperatively and postoperatively up to 3 months. Results: PVD was achieved in ten eyes (41.7%). There was a significant difference (P = 0.03) in mean posterior vitreous face thickness between the eyes with PVD and the eyes with failed PVD. There was a significant cor relation between PVD and both posterior vitreous face thickness (P < 0.03%) and degree of posterior vitreous face reflectivity (P = 0.002). Conclusion: In diabetic eyes with vitreomacular traction, the prediction of PVD after plasmin injection is governed by the condition of posterior vitreous face; mainly posterior vitreous face thickness and reflectivity. Eyes with thinner, less reflective posterior vitreous face are more likely to develop PVD.

Predictability of vitreous detachment following intravitreal plasmin injection in diabetic macular edema associated with vitreomacular traction.

Objectives. To study the fitting and the visual rehabilitation obtained with a corneoscleral contact lens, namely, Rose K2 XL in patients with irregular cornea. Methods. This prospective study included 36 eyes of 36 patients with irregular cornea fitted with Rose K2 XL. Refractive and visual outcomes and mesopic and aberrometric parameters of fitted eyes were assessed at 2 weeks, 3 months, and 6 months after the initial lens use. Objective and subjective parameters of patient satisfaction and lens comfort were noted. Causes of lens discontinuation and complications were also recorded. Results. Average logMAR VA improved significantly from 0.95 ± 0.09 without correction to 0.04 ± 0.05 six months after lens wear. Similarly, mesopic and aberrometric measures were significantly improved. Statistical analysis of the subjective patients’ responses showed a significant acceptance of the lens by most of them. At the end of follow-up, the mean wearing time was 9.9 ± 2.9 hours per day. The most common cause of wearing discontinuation was persistent discomfort (16.7%) and high lens expenses(16.7%). Self-assessed questionnaire showed statistically significant improvement in nearly all measured subjective parameters. Conclusion. Rose K2 XL lenses provide patients with irregular cornea with both quantitative and qualitative optimal visual function with high degree of patient comfort and satisfaction.

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Fitting Tips and Visual Rehabilitation of Irregular Cornea with a New Design of Corneoscleral Contact Lens: Objective and Subjective Evaluation.

Objective To evaluate the use of perforated punctal plugs with adjuvant application of mitomycin-C in the management of acquired external punctal stenosis grades 0 and 1. Methods This is a prospective interventional case series including 30 eyes of 30 patients with acquired external punctal stenosis of the lower punctum of grades 0 and 1 presenting with epiphora. They were examined to exclude other causes of lacrimation and epiphora: Slit-lamp assessment of the stenosed punctum and grading was done, probing was done to exclude associated canalicular stenosis, and syringing was done to exclude nasolacrimal duct obstruction. For all cases, dilatation was done, followed by application of mitomycin-C, and perforated punctal plugs were then inserted. Plugs were removed after 6 months, and anatomical and functional success were assessed and followed during and for 6 months after removal of the plugs. Results The study included 30 patients with acquired external punctal stenosis: 9 males (30%) and 21 females (70%) with a mean age of 62.83 ± 8.3 years. Punctal stenosis grade 0 (no punctum) occurred in 9 cases (30%), and grade 1 (the punctum is covered by a membrane) occurred in 21 cases (70%). Six months after removal of the plugs, epiphora improved in 93.3% of patients, and fluorescein dye disappearance test results improved in 90% of patients; 6.7% of cases had early extrusion of the plug, and 3.3% had granuloma formation. Conclusions Application of perforated punctal plugs combined with mitomycin-C is a simple and efficient technique in the management of tight acquired external punctal stenosis.

Perforated punctal plugs with adjuvant use of mitomycin-C in management of acquired external punctal stenosis grades 0 and 1.

Deep friction massage (DFM) has long been proven to be effective in treatment of some tendinopathies. The aim of our study was to evaluate the efficacy of this physical modality in the treatment of plantar fasciitis in comparison with local steroid injection. Sixty patients were assigned into 2 groups through a computer-based randomization table and completed the treatment and follow-up assessments; thirty in group I received 40 mg local triamcinolone injection and thirty in group II received 7 sessions of DFM. Demographic data showed a statistically insignificant difference in age, female to male ratio, and body mass index (BMI) in both groups. The mean for age was 39.42 years in group I and 41.32 years in group II (P = 0.86); the female to male ratio was 3:1 in group I and 2.75:1 in group II, and the mean for BMI was 32.41 in group I and 33.31 in group II (P = 0.51). At 2 and 6 weeks follow-up, DFM led to less improvement in pain and function compared to local steroid injection (P = 0.001 and 0.002 for pain and P = 0.001 and 0.001 for function respectively at both time points of follow-up). This study revealed that deep friction massage is not effective as a single method in treatment of the plantar fasciitis. However, it can be used as an adjuvant physical modality. Further, large scale studies are needed to support this observation. Pan African Clinical Trial Registry PACTR202004672785790. Date of registration 16 April 2020, “retrospectively registered.”

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Mohamed M. Elwan

Papers

Intraoperative subconjunctival bevacizumab as an adjunctive treatment in primary pterygium: a preliminary report.

Predictability of vitreous detachment following intravitreal plasmin injection in diabetic macular edema associated with vitreomacular traction.

Fitting Tips and Visual Rehabilitation of Irregular Cornea with a New Design of Corneoscleral Contact Lens: Objective and Subjective Evaluation.

Perforated punctal plugs with adjuvant use of mitomycin-C in management of acquired external punctal stenosis grades 0 and 1.

Deep friction massage versus local steroid injection for treatment of plantar fasciitis: a randomized controlled trial