Three-dimensional topography of the central visual field. Sparing of foveal sensitivity in macular disease

Threshold static perimetry was performed using test object patterns that covered contiguous areas of the central visual field. Computer imaging methods were used to display a three-dimensional surface that was interpolated between the sensitivity values at each of the test object locations. The examinations covered the area out to and including 10 degrees of eccentricity from the point of fixation, corresponding to the same area of the visual field covered by the Amsler grid. The normal visual field surface appears as a high plateau with a smoothly rising level of sensitivity forming a peak at the point of fixation. It was found that in a variety of macular diseases, including those caused by vascular, as well as primary degenerative disorders, central scotomas were characterized by relative sparing of visual sensitivity at the point of fixation. The pattern thus produced was one of a ring-shaped depression within the central 10 degrees of the visual field. This phenomenon was present in 20% of cases with central scotomas resulting from macular disease, but was not found in any eye of 64 patients suffering from central scotomas as a result of optic nerve disease. This pattern of visual field loss may be common, though not frequently recognized. It is proposed that the phenomenon of preservation of foveal sensitivity may be a marker for macular disease, as distinct from central visual field defects arising from optic nerve disease.     

Unilateral double optic nerve head pits with foveo-schisis detachment treated by modified internal limiting membrane peeling technique

A 44-year-old female with a vision of 10/200 in the right eye had double pits in the temporal segment of the optic disc with serous macular detachment. Spectral-domain optical coherence tomography (SD-OCT) confirmed serous retinal detachment, an outer layer hole, and double optic disc pits. The patient underwent pars plana vitrectomy with modified ILM flap surgery involving fovea-sparing internal limiting membrane peeling (FSIP) technique with inverted ILM flap tucking with gas tamponade. Post surgery, the communications between perineural and intraretinal spaces were obliterated with flaps of ILM covering the pits, with reduced serous macular detachment and BCVA of 20/120. FSIP with inverted internal limiting membrane flap tuck can be an effective technique to manage rare cases of double ODP-M.     

Neuronal complications of intravitreal silicone oil: an updated review

Silicone oil (SiO) has a well‐established role as a long‐term endotamponade agent in the management of complicated retinal detachments. Complications of intraocular SiO include keratopathy, glaucoma, cataract and subretinal migration of the oil droplets. SiO tamponade can also lead to a severe optic neuropathy caused by retrolaminar migration. Nevertheless, intracranial migration of the SiO through the optic nerve posterior to the lamina cribrosa to the optic chiasm and brain is uncommon. The mechanism is still under debate, but it has been suggested elevated intraocular pressure, macrophages or optic nerve head anatomical predispositions as potential explanations. Moreover, central scotoma may develop in eyes with SiO not only at the time of oil removal, but also during the period of tamponade. We performed a PubMed search of neuronal complications of silicone oil over a period of 25 years. This review summarizes our current understanding of the specific pathogenic mechanisms of intraocular SiO neuronal side effects, concluding that pre‐existing glaucoma and optic nerve abnormalities are the main risk factors associated with this damage. In their absence, the risk of extraocular SiO penetration is so low that the use of SiO endotamponade in complex retinal detachment patients does not need to be modified. MRI images to assess extraocular SiO migration are only necessary in very few and special cases, such as patients with optic nerve abnormalities and glaucoma.     

特发性旁中心凹毛细血管扩张症的研究

特发性旁中心凹毛细血管扩张症(idiopathic parafoveal telangiectasis,IPT)是一种罕见的眼病。最特征的表现为视网膜透明度下降和视网膜血管异常。因其具有潜在致盲性,又无明确的病因和治疗方法。探索该病的病因、病变机制、检测方法和治疗手段日益成为眼科工作者所关切的问题。     

Histomorphometry of the circular peripapillary arterial ring of Zinn–Haller in normal eyes and eyes with secondary angle‐closure glaucoma

Acta Ophthalmol. 2010: 88: e317–e322

Abstract.

Purpose: To examine the location and size of the peripapillary arterial circle of Zinn–Haller (PACZH) and its associations with other eye measures in normal eyes and eyes with secondary angle‐closure glaucoma. Methods: The study included 29 human globes enucleated because of malignant choroidal melanoma (n = 19) (control group) or because of secondary angle‐closure glaucoma (n = 10). Anterior–posterior histological sections were morphometrically evaluated. Results: The PACZH was present in all eyes. The glaucoma group and the control group did not vary significantly in the distance from the PACZH to Bruch’s membrane (297 ± 67 versus 270 ± 67 μm; p = 0.29), optic disc border (281 ± 103 versus 391 ± 170 μm; p = 0.07), optic disc centre (1059 ± 191 versus 978 ± 205 μm; p = 0.30) and retrobulbar cerebrospinal fluid space (173 ± 58 versus 172 ± 81 μm; p = 0.97) nor in the minimal PACZH diameter (39 ± 18 versus 36 ± 18 μm; p = 0.74) and maximal PACZH diameter (78 ± 37 versus 65 ± 25 μm; p = 0.36). The PACZH location, measured as distance from Bruch’s membrane, disc border, disc centre and cerebrospinal fluid space, was not significantly associated with axial length (p > 0.39), horizontal globe diameter (p > 0.17) and vertical globe diameter (p > 0.22). Both diameters were statistically independent of axial length (p = 0.72 and p = 0.58, respectively), horizontal globe diameter (p = 0.60 and p = 0.41, respectively) and vertical globe diameter (p = 0.64 and p = 0.52, respectively). All parameters were statistically independent of age (p > 0.10) and gender (p > 0.10). Conclusions: The PACZH was present in all human eyes examined and did not vary significantly in location and diameter between eyes with secondary angle‐closure glaucoma and nonglaucomatous eyes, nor between myopic versus hyperopic eyes.     

Axonal loss occurs early in dominant optic atrophy

Purpose: This study set out to investigate retinal nerve fibre layer (RNFL) thickness and best corrected visual acuity (BCVA) in relation to age in healthy subjects and patients with OPA1 autosomal dominant optic atrophy (DOA). Methods: We carried out a cross‐sectional investigation of RNFL thickness and ganglion cell layer density in 30 healthy subjects and 10 patients with OPA1 DOA using optical coherence tomography (OCT). We then performed a regression analysis of RNFL thickness and BCVA versus age. Results: Both healthy subjects and DOA patients demonstrated a gradual reduction in RNFL thickness with age; the relationship was best described statistically by a model that assumed a constant offset between the two groups. Best corrected VA decreased significantly with age in DOA patients, in whom BCVA was correlated with peripapillary RNFL thickness in the inferior and superior peripapillary quadrants and with total macular thickness at eccentricities of 500–3000 μm. The observations were best described by a constant offset of 41.9 μm separating the two groups and an annual decrease in RNFL thickness of 0.48 μm (p < 0.0001). In patients with DOA, increasing age was associated with decreasing BCVA (p = 0.046). Conclusions: This cross‐sectional study found evidence of comparable age‐related decreases in RNFL thickness in healthy subjects and in DOA patients, where the deficit in DOA patients is best described using a model that assumes the deficit between the groups does not vary with age. The gradual reduction of BCVA with age may be a consequence of a relative deficit in RNFL thickness that is established before the second decade of life.     

正常人黄斑中央凹无血管区域面积分析

目的：运用光学相干断层扫描技术(optical coherence tomography,OCT)血流成像技术测量正常人黄斑中央凹无血管区域(foveal avascular zone,FAZ)面积并分析FAZ面积相关临床特征。

方法：采用横断面研究。用RTVue-100光学相干断层扫描血流成像技术测量健康研究对象的138眼FAZ面积。FAZ面积与相关因素的相关性用单因素和多因素线性回归分析。采用配对t检验比较右眼与左眼FAZ面积的差异。Pearson相关性分析双眼FAZ面积的相关性。

结果：所有研究对象的平均FAZ面积为0.30±0.11mm²。男性研究对象平均FAZ面积为0.29±0.13mm²,而女性为0.31±0.09mm²,男性FAZ面积小于女性FAZ面积,但差异无统计学意义(t=-1.346,P=0.180)。FAZ面积与年龄、性别等临床基本资料无相关性。右眼平均FAZ面积为0.30±0.11mm²,左眼平均FAZ面积为0.30±0.10mm²,双眼差异无统计学意义(P=0.943)。双眼FAZ面积存在很强的相关性。

结论：OCT血流成像技术可清晰观察并定量测量FAZ面积。FAZ面积与老龄、性别等因素无关,双眼FAZ面积呈对称性特征。     

The Radius of Curvature of the Human Foveal Pit

ABSTRACT: The human fovea forms images by reflection (the foveal reflex of ophthalmoscopy) which may be used to determine its curvature “in vivo”. In a population of young people radii of curvature lay between 1.04 and 1.7mm. These values are compatible with histological data on the assumption that the foveal shape approximates a section of a sphere.     

不同类型糖尿病黄斑水肿患者视力与黄斑形态的相关性分析

目的：探讨不同类型糖尿病黄斑水肿（ diabetic macular edema,DME）患者最佳矫正视力与黄斑中心凹形态之间的相关性。方法：采用单中心非随机对照临床回顾性研究。选择2008－07／2014－01在我院眼科门诊就诊和内分泌科要求会诊诊断为DME的62例103眼患者的临床资料。采用糖尿病早期治疗研究（ ETDRS ）视力表检查患者的最佳矫正视力（best corrected visual acuity,BCVA）,所有患者行非接触眼压、裂隙灯、间接检眼镜、荧光素眼底血管造影（fundus fluorescein angiography,FFA）检查,并利用光学相干断层扫描（ optical coherence tomography,OCT）确定黄斑中心1mm直径范围即中心子域平均厚度（ central subfield mean thickness,CSMT）及中心350μm内光感受器内节／外节（ IS／OS）及外界膜（ external limiting membrane,ELM）反射光带的完整性。不同类型临床有意义的糖尿病性黄斑水肿（ clinical significant diabetic macular edema,CSME）的BCVA及CSMT分析采用Kruskal－Wallis秩和检验;DME的4种分型的 BCVA 及 CSMT 组间差异两两比较采用Nemenyi检验;与 BCVA 相关因素分析采用多元回归分析。结果：患者103眼中,局限型DME者47眼（45．6％）,弥漫型DME者35眼（34．0％）,缺血型DME者6眼（5．8％）,增生型DME者15眼（14．6％）。不同类型DME患者的BCVA（H＝69．167,P＜0．01）、CSMT（H＝57．113,P＜0．01）差异均有显著统计学意义。不同类型组间两两比较：局限性和弥漫性（ BCVA：χ2＝14．982, P＜0．01;CSMT：χ2＝14．537,P＜0．01）、局限型与缺血型（ BCVA：χ2＝15．596,P＜0．01;CSMT：χ2＝15．393, P＜0．01）、局限型与增生型（BCVA：χ2＝16．567,P＜0．01;CSMT：χ2＝15．687,P＜0．01）及弥漫型与缺血型之间（ BCVA：χ2＝12．974, P＝0．008;CSMT：χ2＝13．999,P＜0．01）,BCVA和CSMT的差异有统计学意义。多元回归分析患者的 BCVA与 CSMT（ r＝－0．064）、IS／OS及ELM反射光带的完整性（r＝－0．207）、病程（r＝－0．082）、DME水肿类型（r＝－0．160）相关（P＜0．05）;与患者的糖化血红蛋白（r＝－0．885）、眼压（r＝－2．522）、年龄（r＝－1．504）、性别（r＝－0．595）无相关性（P＞0．05）。结论：不同类型DME在形态学和功能学上具有差异。     

糖尿病患者白内障术后黄斑区厚度改变机制的现况研究

近年来,虽然白内障超声乳化术日臻完善,为当今世界治疗白内障的主流术式,但白内障术后并发症仍然存在,始终是困扰术者和患者的一大重要问题.我们发现,有很大一部分老年患者同时患有老年型白内障和糖尿病,因此糖尿病患者白内障手术后相关并发症研究的重要性则日益凸显.本文通过对近年来相关文献进行综述,主要集中概括了糖尿病(diabetes mellitus,DM)患者的视网膜基础,及白内障手术对其产生的后续影响,为早期发现并干预白内障术后黄斑水肿的出现提供了有益的临床参考.     

Anatomy and development of the macula: specialisation and the vulnerability to macular degeneration

The central retina in primates is adapted for high acuity vision. The most significant adaptations to neural retina in this respect are: 1. The very high density of cone photoreceptors on the visual axis; 2. The dominance of Midget pathways arising from these cones and 3. The diminishment of retinal blood supply in the macula, and its absence on the visual axis. Restricted blood supply to the part of the retina that has the highest density of neural elements is paradoxical. Inhibition of vascular growth and proliferation is evident during foetal life and results in metabolic stress in ganglion cells and Müller cells, which is resolved during formation of the foveal depression. In this review we argue that at the macula stressed retinal neurons adapt during development to a limited blood supply from the choriocapillaris, which supplies little in excess of metabolic demand of the neural retina under normal conditions. We argue also that while adaptation of the choriocapillaris underlying the foveal region may initially augment the local supply of oxygen and nutrients by diffusion, in the long term these adaptations make the region more vulnerable to age‐related changes, including the accumulation of insoluble material in Bruch's membrane and beneath the retinal pigment epithelium. These changes eventually impact on delivery of oxygen and nutrients to the RPE and outer neural retina because of reduced flow in the choriocapillaris and the increasing barriers to effective diffusion. Both the inflammatory response and the sequelae of oxidative stress are predictable outcomes in this scenario.     

Impact of Reference Center Choice on Adaptive Optics Imaging Cone Mosaic Analysis

PurposeFoveal center marking is a key step in retinal image analysis. We investigated the discordance between the adaptive optics (AO) montage center (AMC) and the foveal pit center (FPC) and its implications for cone mosaic analysis using a commercial flood-illumination AO camera.MethodsThirty eyes of 30 individuals (including 15 healthy and 15 patients with rod–cone dystrophy) were included. Spectral-domain optical coherence tomography was used to determine the FPC, and flood-illumination AO imaging was performed with overlapping image frames to create an AO montage. The AMC was determined by averaging the (0,0) coordinates in the four paracentral overlapping AO image frames. Cone mosaic measurements at various retinal eccentricities were compared between corresponding retinal loci relative to the AMC or FPC.ResultsAMCs were located temporally to the FPCs in 14 of 15 eyes in both groups. The average AMC–FPC discordance was 0.85° among healthy controls and 0.33° among patients with rod-cone dystrophy (P < 0.05). The distance of the AMC from the FPC was a significant determinant of the cone density (β estimate = 218 cells/deg²/deg; 95% confidence interval [CI], 107–330; P < 0.001) and inter-cone distance (β estimate = 0.28 arcmin/deg; 95% CI, 0.15–0.40; P < 0.001), after adjustment for age, sex, axial length, spherical equivalent, eccentricity, and disease status.ConclusionsThere is a marked mismatch between the AMC and FPC in healthy eyes that may be modified by disease process such as rod–cone dystrophy. We recommend users of AO imaging systems carefully align the AO montage with a foveal anatomical landmark, such as the FPC, to ensure precise and reproducible localization of the eccentricities and regions of interest for cone mosaic analysis.     

Effect of the duration of immunomodulatory therapy on the clinical features of recurrent episodes in Vogt–Koyanagi–Harada disease

Purpose: To evaluate the duration of immunomodulatory therapy (corticosteroids, immunosuppressive drugs) with regard to the rate of relapses and clinical features (exudative retinal detachment or anterior uveitis) in inflammatory episodes of Vogt–Koyanagi–Harada disease. Methods: Data of all 42 patients diagnosed with acute uveitis associated with VKH disease during the period of January 2005 to December 2008 at the Pitié‐Salpêtrière Hospital or at the Lariboisière Hospital in Paris, France were extracted by chart review. Results: There were 31 patients (73.8%) with episodes of recurrence and were included in the study. At the first recurrence, 81% (13 patients) of exudative retinal detachments (ERD) were associated with an initial immunomodulatory treatment conducted ≤6 months (3.76 months ± 2.67). Conversely, an initial treatment duration of >6 months was associated with anterior uveitis signs for 66% of patients (eight patients) with anterior first recurrence (p = 0.0061). On second episode of recurrence, 75% of patients (three patients) who developed exudative retinal detachment had been managed by immunomodulatory therapy for ≤6 months with the total duration of immunomodulatory treatment ≤6 months during previous inflammatory episodes. Conversely, all 16 patients who presented anterior uveitis with additional manifestations (optic disc oedema, macular oedema, vitritis and/or ‘Sunset glow’ fundus) have been treated for more than 6 months or treated during the initial occurrence lasting more than 9 months (p = 0.0035). Conclusions: The duration of systemic corticosteroids (and/or immunosuppressive drug therapy) for ≤6 months at first and second recurrence was associated with features of further exudative retinal detachment instead of anterior uveitis in VKH disease.     

Foveal Differentiation and Inner Retinal Displacement Are Arrested in Extremely Premature Infants

PurposeChildren with a history of prematurity often have poorly developed foveae but when during development foveal differences arise. We hypothesize that the course of foveal development is altered from the time of preterm birth.MethodsEyes of 102 preterm infants undergoing retinopathy of prematurity screening examinations in the STudy of Eye imaging in Premature infantS (BabySTEPS) ({"type":"clinical-trial","attrs":{"text":"NCT02887157","term_id":"NCT02887157"}}NCT02887157) were serially imaged between 30 and 42 weeks postmenstrual age (PMA) using handheld optical coherence tomography systems. Total retinal thickness, inner retinal layer (IRL) thickness, and outer retinal layer (ORL) thickness were measured at the foveal center and parafovea. Foveal put depth, IRL thickness, and ORL thickness were compared between infants born at different gestational ages using mixed effects models.ResultsFoveal pit depth and IRL thickness were inversely related to gestational age; on average, the most premature infants had the thickest IRL and shallowest pits at all PMAs. Differences were evident by 30 weeks PMA and persisted through 42 weeks PMA. The foveal pits of the most premature infants did not progressively deepen, and the IRLs did not continue to thin with increasing chronological age.ConclusionsFoveation in extremely preterm infants is arrested from the earliest observed ages and fails to progress through term equivalent age. The developmental displacement of the IRL from the foveal center into the parafovea does not occur normally after preterm birth. These observations suggest that foveal hypoplasia seen in children with history of prematurity is due to disturbances in foveal development that manifest within weeks of birth.     

近视眼LASIK后黄斑区视网膜厚度变化的研究

目的 探讨准分子激光角膜原位磨镶术（exdmer laser insitu keratomileusis LASIK）对近视眼黄斑区视网膜厚度的影响及其影响因素。方法 随机选择接受LASIK手术矫正视力≥1．0近视眼患者25例49眼，根据术前屈光度数分为二组：中轻度近视组：≤6．00D，17眼；高度近视组：＞6．00D，32眼。采用Zeiss-Humphrey光学相干断层成像仪（Optical Coherence Tomography OCT）第三代观察近视眼LASIK术前，术后1d、3d、1w、1m眼底黄斑区变化，并测量以黄斑中心凹为中心3mm半径内的视网膜平均厚度，以地形图分9个区域显示。结果 25例49眼近视患者LASIK术后1d、3d黄斑中心凹（A1）视网膜平均厚度同术前比较有增加，差别具有统计学意义（P＜0．05；P＜0．01），近视眼术后1w、1m黄斑中心凹视网膜平均厚度同术前比较差别无统计学意义（P＞0．05）：除黄斑中心凹（A1区）外的近视眼黄斑部各区（A2-A9）视网膜平均厚度术后同术前比较差别无统计学意义（P＞0．05）。高度近视眼组术后1d、3d、1w黄斑中心凹（A1区）视网膜平均厚度均高于术前，差异具有统计学意义（P＜0．05；P＜0．01；P＜0．05），高度近视眼组术后1m黄斑中心凹视网膜平均厚度同术前比较差异无统计学意义（P＞0．05）；中轻度近视组术后观察各时期与术前比较差异无统计学意义（P＞0．05）。高度近视眼LASIK术后黄斑中心凹视网膜平均厚度的增加与术前屈光状态、激光切削时间呈正相关。结论 近视眼LASIK术后出现的黄斑中心凹视网膜水肿主要发生在高度近视眼，与术前屈光度数大、激光切削时间长有关。高度近视眼LASIK术后出现的黄斑中心凹水肿是轻微的，可逆的，未影响视力，在1m内消退。     

Prognostic factors for clinical outcomes in patients with Vogt–Koyanagi–Harada disease treated with high‐dose corticosteroids

Purpose: To determine prognostic factors in patients with Vogt–Koyanagi–Harada (VKH) disease who were treated with high‐dose corticosteroids. Methods: Retrospective analysis of 87 patients (174 eyes). Results: At presentation, there were 53 patients with initial‐onset acute VKH disease and 34 patients with chronic recurrent VKH disease. Chronic recurrent presentation was significantly associated with more severe anterior segment inflammation at presentation as indicated by presence of mutton‐fat keratic precipitates, anterior chamber reaction ≥2+, iris nodules and posterior synechiae (p < 0.001 for all comparisons), less exudative retinal detachment at presentation (p < 0.001), more complications during the follow‐up period (p < 0.001) and a worse visual outcome (p < 0.001). The use of immunomodulatory therapy (cyclosporine and mycophenolate mofetil) as first‐line therapy significantly reduced the development of complications in the whole study group (p = 0.006) and in initial‐onset acute group (p = 0.024) and improved visual outcome in the whole study group (p = 0.004) and in chronic recurrent group (p = 0.024). In the whole study group, final visual acuity of 20/20 was significantly associated with good initial visual acuity of >20/200 [odds ratio = 4.25; 95% Confidence interval (CI) = 1.53–11.89] and age older than 16 years was significantly associated with the development of complications (odds ratio = 3.15; 95% CI = 1.04–9.48). Conclusions: Chronic recurrent VKH disease is significantly associated with more severe anterior segment inflammation and less exudative retinal detachment at presentation, more ocular complications and a worse visual outcome than initial‐onset acute VKH disease. Use of immunomodulatory therapy significantly improved the clinical outcomes.     

改良的黄斑中心凹下全氟化碳残留取出术的临床应用

目的 评价改良的视网膜黄斑中心凹下全氟化碳(perfluorocarbon liquid,PFCL)残留取出术的临床疗效.方法 对15例(15眼)中心凹视网膜下PFCL残留的患者行手术治疗.术中使用自制26G针头于PFCL小泡上缘先垂直视网膜再斜向PFCL小泡中心进行穿刺造口,最后使用笛针缓慢将视网膜下PFCL取出.术后随访1-12个月,观察最佳矫正视力(best corrected visual acuity,BCVA)、OCT下中心凹内界膜与色素上皮层间(ILM-RPE)厚度.结果 患眼术后1～12个月视力较术前提高(F =40.09,P＜0.01),ILM-RPE厚度减少(F=130.15,P＜0.01).各时间段前后时间点BCVA和ILM-RPE厚度比较,术后1个月与术前、术后3个月与术后1个月、术后6个月与术后3个月相比差异均有统计学意义(均为P＜0.05),而术后12个月与术后6个月相比差异均无统计学意义(均为P＞0.05),患眼视力和ILM-RPE厚度于术后6个月趋于稳定.术后12个月BCVA (LogMAR):最佳0.22,最差0.82,视力较术前改善14眼(93.33％),1眼视力维持.有2眼术后12个月仍有不同程度的视物变形.术后4.5个月出现并发性白内障1例,已行超声乳化吸出并人工晶状体植入术.结论 该手术方式治疗术后6个月患者视力及中心凹视网膜ILM-RPE厚度趋于稳定,此手术治疗黄斑中心凹视网膜下PFCL残留有效.