Management of acute submacular hemorrhage using recombinant tissue plasminogen activator and gas

· Purpose: To assess the effects of intravitreal injection of recombinant tissue plasminogen activator (rTPA) and gas on submacular hemorrhage in age-related macular degeneration (ARMD). · Methods: Eleven consecutive patients (11 eyes) with subretinal hemorrhage due to ARMD involving the fovea with elevation of the neurosensory retina were included in this study. Subretinal hemorrhage occured 12 h to 14 days before onset of therapy. Injection of rTPA through the pars plana in a dose of 50 or 100 μg was performed. Gas instillation (0.2–0.4 ml) followed rTPA injection, either immediately after injection (7 patients) or during the following day (4 patients). · Results: After intravitreal injection of rTPA, subretinal clots were totally or partially liquefied when treatment started up to 3 days after onset of bleeding. In all patients treated with 100 μg rTPA a large exudative retinal detachment of the inferior retina resulted, which reabsorbed spontaneously within 2 weeks. After reattachment of the exudative retinal detachment hyperpigmentation of the retinal pigment epithelium was noted. Temporary opacification of the vitreous was observed between the 2nd and 7th postoperative day in 5 eyes (45.5%). Postoperative visual acuity increased in 5 patients (45.5%). · Conclusion: Intravitreal application of rTPA followed by gas injection is a sufficient and convenient technique for effective removal of freshly formed submacular hemorrhage. Removal is mediated through combined enzymatic (rTPA) and mechanical (gas) effects. This technique offers a quick recovery of vision in eyes with less severe ARMD. Received: 5 January 1998 Revised version received: 25 March 1998 Accepted: 23 June 1998     

Iris pigment epithelial cell translocation in exudative age-related macular degeneration

Background: This prospective, non-controlled pilot study investigates the practicability of IPE translocation and functional outcome in ARMD patients. Removal of submacular choroidal neovascularization (CNV) in age-related macular degeneration (ARMD) is usually associated with RPE damage and poor visual prognosis. Homologous RPE transplants fail to preserve macular function, possibly due to immune rejection. Instead of homologous RPE, we suggest translocating autologous iris pigment epithelium (IPE), building on earlier evidence from animal and in vitro investigations that IPE can substitute RPE functions in the experimental animal. Immunological cell rejection is avoided. Methods: Four eyes with well- defined and eight eyes with ill- defined subfoveal CNV were submitted to operation and followed up for a minimum of 6 months. IPE cells were harvested from a peripheral iridectomy. A vitrectomy was performed. Submacular membranes were removed, and isolated IPE cells were injected into the subretinal space. Examinations included ETDRS visual acuity, fluorescein angiography, and SLO microperimetry. Results: All patients underwent successful surgical removal of CNV and subretinal IPE injection. Compared to preoperative visual acuity (20/400–20/100) no significant change was observed after 6 months (20/320–16/80). A change of more than two ETDRS chart lines was defined as significant. One eye with preoperative ill-defined CNV developed a recurrence, leading to reduced visual acuity. In all patients, postoperative fluorescence angiography revealed early hyperfluorescence (window defect) in the surgically denuded area. Central fixation was demonstrated in 50% of eyes. Conclusions: Preliminary data suggests that IPE translocation in submacular surgery for ARMD can preserve but not improve preoperative visual acuity over 6 months. Functional results are promising compared to submacular membrane extraction alone and RPE transplantation. Continued research on improvement of IPE translocation seems justified. Received: 19 October 1999 Revised: 22 December 1999 Accepted: 16 February 2000     

Surgical removal of subfoveal choroidal neovascularization without removal of posterior hyaloid: a consecutive series in younger patients

PURPOSE: Subfoveal choroidal neovascularization (CNV) remains a common and important cause of visual loss. Previous studies have suggested that submacular surgery may improve or maintain visual acuity, particularly in younger patients. The majority of reported cases included removal of the posterior hyaloid during vitrectomy. The authors present a consecutive series of patients age 55 or younger with subfoveal CNV removal without posterior hyaloid removal. METHODS: Seventeen patients without age-related macular degeneration (ARMD), with subfoveal CNV from choroiditis, presumed ocular histoplasmosis syndrome, myopia, or idiopathic causes, underwent a small retinotomy technique to extract the membranes after vitrectomy without posterior hyaloid removal. RESULTS: Median improvement in visual acuity was from 20/320 to 20/50. Eleven patients (65%) experienced an improvement of three or more lines of Snellen acuity (average 7.5), 4 (23%) were within two lines of preoperative acuity, and 2 (12%) had decreased acuity, with an average follow-up of 12 months (range 3-31). Choroidal neovascularization recurred in six patients (35%). Postoperative retinal detachment, epiretinal proliferation, or macular hole did not occur. CONCLUSIONS: In this series of younger patients with subfoveal CNV not from ARMD, visual acuity was improved in the majority after submacular membrane removal. Omission of removal of the posterior hyaloid did not adversely affect outcome.     

Translocation of iris pigment epithelium in patients with exudative age-related macular degeneration: long-term results

Purpose To report the practicability and efficacy of autologous iris pigment epithelium (IPE) translocation in exudative age-related macular degeneration (ARMD) over 1 year.Methods The consecutive interventional case series included 56 patients with exudative ARMD. During vitrectomy the submacular neovascular membrane (CNV) was removed and IPE cells, harvested from a peripheral iridectomy, were injected into the submacular space. Included were patients with subfoveal occult CNV (11 eyes), classic CNV (10 eyes), mixed CNV (17 eyes), CNV with a pigment epithelial detachment (13 eyes) or CNV with a hemorrhage (5 eyes). Outcome measures were visual acuity, foveal fixation, size of CNV and rate of recurrence based on fluorescence angiographic imaging.Results All patients underwent successful surgical removal of the CNV with consecutive subretinal IPE injection. Visual acuity was better than 20/100 in 19 patients preoperatively and in 18 patients postoperatively. A visual acuity of 20/100 or less was found in 37 patients preoperatively and in 38 patients postoperatively. Mean preoperative visual acuity (1.0±0.3 logMAR units) did not change significantly after 1 year (1.0±0.3 logMAR units). Ten eyes (18%) developed a recurrence. Fixation within the surgically denuded area could be demonstrated in 25 eyes (45%).Conclusions Autologous IPE translocation for ARMD over one year can preserve foveal function on a low level, but cannot improve visual acuity. IPE translocation is technically feasible with a low rate of complications. Continued research seems justified to improve functional outcome.     

Surgical management of subfoveal choroidal neovascularization.

BACKGROUND: Subfoveal choroidal neovascularization (CNV) usually is associated with a poor visual prognosis. Laser photocoagulation of certain subfoveal membranes secondary to age-related macular degeneration (ARMD) appears preferable to observation based on recent Macular Photocoagulation Study (MPS) findings but is associated with decreased vision. The authors explored the use of vitreoretinal surgical techniques as an alternative method of eradicating subfoveal CNV. METHODS: After vitrectomy, a small retinotomy technique was used to extract or disconnect from the choroidal circulation subfoveal CNV in 58 eyes. There were 33 eyes with ARMD, 20 eyes with presumed ocular histoplasmosis, and 5 eyes with miscellaneous etiologies. Five eyes also received subfoveal RPE patches. RESULTS: With limited follow-up, significant improvement in vision (defined as 2 Snellen lines) was achieved in 7 of 22 eyes with ARMD CNV removal (1 eye 20/20), 0 of 4 eyes with ARMD CNV removal and RPE patches, and 1 of 7 eyes with ARMD CNV disconnection. Significant improvement was achieved in 6 of 16 eyes with presumed ocular histoplasmosis removal and 0 of 4 eyes with presumed ocular histoplasmosis CNV disconnection. In 5 eyes with miscellaneous CNV, 2 improved (20/20 and 20/40). CNV recurred in 29%. CONCLUSIONS: Some patients with subfoveal CNV appear to benefit from surgical removal. Only rarely do eyes with ARMD improve. Longer-term follow-up and refined case selection are required before this approach can be widely recommended.     

Change in retinal sensitivity due to excision of choroidal neovascularization and its influence on visual acuity outcome

PURPOSE: Excision of choroidal neovascular membranes (CNV) has been attempted as an alternative to photocoagulation for the management of subfoveal CNV. To evaluate functional results of CNV excision, we studied retinal sensitivity in the area corresponding to the CNV (CNV area). METHODS: Static microperimetry using a scanning laser ophthalmoscope was performed on 17 eyes before and after CNV excision. We studied whether CNV excision changed retinal sensitivity in the CNV area. To evaluate the relationship between retinal sensitivity and visual acuity, further testing was performed on nine patients who had subfoveal CNV from age-related macular degeneration (ARMD). RESULTS: Preoperatively, 5 of 17 eyes (29.4%) had retinal sensitivity in the CNV area. Postoperatively, 4 of 17 (23.5%) eyes had retinal sensitivity. Surgery did not significantly change retinal sensitivity in the CNV area (P>0.999). There was a significant correlation between the presence of retinal sensitivity and visual acuity. Postoperative visual acuity of eyes with retinal sensitivity in the CNV area was better than that of the eyes without sensitivity in the patients with subfoveal CNV from ARMD (P = 0.0017). CONCLUSIONS: In most cases, excision of CNV does not improve central retinal sensitivity, and patients have poor visual outcome. In some cases, however, postoperative sensitivity in the bed of CNV is preserved and visual outcome is relatively good. Better or worse preoperative retinal sensitivity does not predict better or worse visual acuity outcome, respectively.     

Macular translocation for surgical management of subfoveal choroidal neovascularizations in patients with AMD: first results

Background: At present no satisfying treatment for subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD) is available. Visual results after successful surgical removal of subfoveal CNV are disappointing. This has been explained by a primary dysfunction of the retinal pigment epithelium (RPE) in the macular region and the surgical trauma to the RPE in patients with AMD. Therefore, Machemer and Steinhorst developed a technique for macular translocation after surgical removal of subfoveal CNV. We report our first experiences with this technique in patients with subfoveal CNV secondary to AMD. · Methods: Seven patients aged between 71 and 83 years with subfoveal CNV were included in the study. Visual acuity of the fellow eyes was below 20/400. All patients underwent pars plana vitrectomy. Retinal detachment was produced by subretinal infusion of balanced salt solution and a 360° retinotomy at the base of the vitreous was performed. After removal of the CNV, retinal rotation and reattachment, the retina bordering the retinotomy was coagulated with endolaser photocoagulation. Silicone oil was used as temporary tamponade. · Results: In all patients the subfoveal CNV was removed and the macula was translocated by a 15°–45° rotation onto functional RPE. The mean duration of follow-up was 11±3 months. Initial visual acuity ranged from 20/80 to hand movements. Final visual acuity was 20/100 to 20/400. Initially all patients complained of tilted vision. During follow-up the rotation of the image regressed and was well tolerated by all patients. Complications included the development of retinal detachment in three patients after silicone oil removal, development of a macula pucker, and a significant increase of lens opacity in the phakic eyes. · Conclusion: In our series rapid improvement of visual function was observed in one patient only, even if the macula appeared ophthalmoscopically and angiographically normal. Vitreoretinal complications occurred frequently during follow-up. Received: 2 February 1998 Revised version received: 6 April 1998 Accepted: 29 April 1998     

Surgical removal of subfoveal choroidal neovascular membranes in high myopia

· Background: A study was carried out to elucidate the anatomical and functional outcome after surgical excision of subfoveal choroidal neovascular membranes in high myopia. · Methods: Sixty-five patients with high myopia (≥6 diopters), well-defined subfoveal neovascular membranes on fluorescein angiography and preoperative visual acuity ≤20/100 were selected for surgery. A standardized surgical technique was used in all cases, by a single surgeon. The main outcomes assessed were Snellen visual acuity, surgical retinal pigment epithelium defect and postoperative perfusion of the choriocapillaris. Multifactor analysis of variance and chi-square/Fisher’s exact test statistics were used to assess the association between patients’ pre- and postoperative characteristics and outcome measures. · Results: Follow-up ranged from 6 to 48 months (mean 16 months). Mean postoperative visual acuity (0.18) was significantly better than mean preoperative visual acuity (0.09). Visual acuity improved by at least two lines in 29 eyes (45%) and was unchanged in 24 (37%). Overall, 43 eyes (66%) had visual acuity of 20/200 or better and 15 (23%), 20/60 or better. Predictive factors with a significant effect on final visual acuity were mean visual acuity, preoperative status of retinal pigment epithelium and postoperative perfusion of the choriocapillaris. Postoperative perfusion was detected in 31 (48%) of the total 65 eyes and in 12 (67%) of the 18 eyes with normal retinal pigment epithelium at baseline. The mean postoperative retinal pigment epithelium defect was 4.6 times larger than the original neovascular membrane. In selected patients, SLO macular scotometry showed areas of retained retinal sensitivity within the atrophic scar. · Conclusion: The natural history of subfoveal neovascularization in high myopia is rarely visually restorative. By contrast, surgical excision of the membranes is feasible and may restore visual acuity in selected patients. This therapeutic approach merits a formal multicenter clinical trial. Received: 27 August 1998 Revised version received: 9 November 1998 Accepted: 10 November 1998     

ICG-guided laser photocoagulation of juxtafoveal and extrafoveal occult choroidal neovascularization

· Background: The most common cause of legal blindness in the Western world in people over 50 years of age is age-related macular degeneration (AMD) complicated by choroidal neovascular membranes (CNV). We conducted a prospective pilot study to evaluate the functional and anatomical results of indocyanine green (ICG)-guided laser photocoagulation of juxta- and extrafoveal occult CNV. · Methods: Seventeen consecutive patients (17 eyes) with occult CNV in AMD were included. All showed occult CNV appearing as late-phase fluorescein leakage of undetermined source on fluorescein angiography and as a well-defined hot spot or plaque hyperfluorescence on ICG angiography. Fibrovascular retinal pigment epithelial detachments (PED) and serohemorrhagic PED were excluded. Laser photocoagulation was performed using an argon green laser. The patients had serial follow-up examinations, including fluorescein and ICG angiography, at 15 days and 1, 2, 3, 6, 9 and 12 months after photocoagulation. · Results: At the end of the follow-up, the visual acuity (VA) was stable (within ±3 lines of the initial VA) in 76% (13) of the eyes. A moderate decrease in VA was observed in 24% (4). A complete resolution of exudative signs was observed in 65% (11).  · Conclusion: ICG-guided laser photocoagulation of occult CNV, presenting at baseline examination as late-phase fluorescein leakage of undetermined source and as a well-defined hyperfluorescent lesion on ICG angiography, may constitute a subgroup of occult CNV that benefits from ICG-guided laser photocoagulation. A multicentric randomized controlled clinical study is, however, mandatory to confirm this result. Received: 21 January 1999 Revised version received: 28 April 1999 Accepted: 29 April 1999     

Intravitreal injection of rt-PA and gas in the management of minor submacular haemorrhages secondary to age-related macular degeneration

BACKGROUND: Subfoveal haemorrhage is a serious complication of choroidal neovascularization in age-related macular degeneration (ARMD). Recent studies have demonstrated that intravitreal injections of the fibrinolytic agent recombinant tissue plasminogen activator (rt-PA) and expansile gas may be effective in displacing submacular blood and facilitating visual improvement. However, in most of these studies, this technique has been used for the management of major haemorrhages. The purpose of our study was to investigate the efficacy of treating minor subfoveal haemorrhages with intravitreal rt-PA and pneumatic displacement. PATIENTS AND METHODS: In a prospective study, 25 consecutive eyes of 25 patients with recent ( 14 days showed a comparable outcome (p = 0.017). There were no side effects or complications. CONCLUSIONS: Our findings suggest that intravitreous injections of rt-PA and sulfur hexafluoride are of value for an improved and accelerated visual recovery in ARMD patients with minor subfoveal haemorrhages. Duration of haemorrhage 相似文献   

Photodynamic therapy of subfoveal choroidal neovascularization: clinical and angiographic examples

· Background: Conventional photocoagulation of subfoveal choroidal neovascularization (CNV) is often accompanied by visual loss due to thermal damage to adjacent retinal structures. Photodynamic therapy (PDT) allows vascular occlusion by selective photochemical destruction of vascular endothelial cells only. In a pilot study we evaluated the use of PDT in CNV. · Methods: In a clinical phase I/II trial, patients with subfoveal CNV were treated with PDT. Benzoporphyrin derivative monoacid ring A (BPD) was used as sensitizer at a drug dose of 6 mg/m² or 12 mg/m². Irradiation was performed via a diode laser emitting at 690 nm coupled into a slit lamp. Safe and maximum tolerated light doses were defined by dose escalation from 25 to 150 J/cm². Photodynamic effects were documented ophthalmoscopically and angiographically. · Results: Sixty-one patients received a single course of BPD-PDT. Preliminary results suggest no damage to retinal structures within the treated area clinically. Retinal perfusion was not altered, while CNV demonstrated immediate absence of fluorescein leakage in the majority of lesions subsequent to PDT. At optimized parameters (6 mg/m² and 50 J/cm²) complete cessation of leakage from classic CNV occurred in 100% of cases at 1 week and in 50% at week 4. In 70–80% of classic CNV, leakage reappeared at week 12, but markedly less than before treatment. · Conclusion: PDT allows temporary absence of leakage from CNV with preservation of visual acuity. The long-term prognosis of CNV secondary to age-related macular degeneration treated with repeated courses of PDT is being evaluated in a phase III trial. Received: 4 March 1997 Revised version received: 8 September 1997 Accepted: 25 September 1997     

Inferior limited macular translocation for subfoveal choroidal neovascularization secondary to age-related macular degeneration: 1-year visual outcome and recurrence report

PURPOSE: To report the 1-year visual outcomes and incidence of persistent and recurrent choroidal neovascularization (CNV) after limited macular translocation (LMT) for subfoveal CNV in patients with age-related macular degeneration (ARMD). DESIGN: Interventional case series. METHODS: Retrospective review of 102 consecutive eyes of 101 patients that had the inferior limited macular translocation procedure for subfoveal choroidal neovascularization secondary to ARMD. The outcome measures were visual acuity at 12 months after surgery, change in visual acuity from baseline, the proportion of eyes with moderate (3 or more lines) or severe (6 or more lines) visual acuity loss, and cumulative incidence of persistent or recurrent CNV and its impact on visual acuity. Cumulative incidence was estimated using Kaplan-Meier survival analysis methods. Association between persistence and recurrence of CNV and the Snellen visual acuity recorded at each follow-up visit was evaluated using the Wilcoxon rank-sum test. RESULTS: Eighty-six (84.3%) of 102 eyes completed the 1-year follow-up. By 12 months postoperatively, 35 (40.7%) of the 86 eyes achieved visual acuity of 20/100 or better while 34 (39.5%) of the 86 eyes experienced 2 or more Snellen lines of visual improvement. In the 52 eyes with effective translocation and complete laser photocoagulation of the CNV complex with sparing of the sensory fovea, the estimated incidence of recurrence was 34.6% at 12 months (95% confidence interval of 21%-48%). Sixty-five percent of the recurrences were subfoveal and caused a decrease in visual acuity. There was a trend toward worse median change in visual acuity in eyes with persistent or recurrent CNV. CONCLUSIONS: Limited macular translocation for the treatment of subfoveal CNV secondary to ARMD is associated with improvement in visual acuity in approximately 39.5% of eyes and enables complete laser photocoagulation of the neovascular complex with sparing of the sensory macula in approximately 60.4% of eyes that complete 1 year follow-up. Persistence and recurrence of CNV are common after LMT and are important causes of vision loss. Further studies are warranted to more precisely evaluate the risks and benefits of LMT in ARMD.     

Surgical removal of submacular choroidal neovascularization: a clinicopathologic study and factors influencing visual outcomes

BACKGROUND AND OBJECTIVE: Clinical and histopathologic characteristics of submacular choroidal neovascular membranes (CNV) are investigated and features predictive of postoperative complications or poorer visual outcome following CNV removal are identified. MATERIALS AND METHODS: Records of patients who underwent submacular CNV removal at Bascom Palmer Eye Institute between 1991 and 1998 are reviewed. RESULTS: At 6 months postoperatively, vision was stable or improved in 19/26 (73%) eyes, with 15/26 (58%) having 20/200 to 20/400 vision. Postoperative retinal detachment occurred more commonly in age-related macular degeneration eyes (AMD) (P <0.05), and CNV recurrence occurred most frequently in presumed ocular histoplasmosis (POHS) eyes (P <0.05). The one eye with an extrafoveal CNV in-growth site had the largest improvement in vision postoperatively. Choroid in the specimen was associated with worse postoperative vision (P = 0.05). CONCLUSION: Submacular CNV removal achieves visual stabilization at the 20/200 to 20/400 level in most eyes. Potential risk factors for postoperative complications or poorer visual outcome include the underlying disease process, subfoveal in-growth site of CNV, and presence of choroid in the specimen.     

Electrophysiological abnormalities in age-related macular degeneration

· Background. Results from psychophysical tests indicate that in age-related macular degeneration (ARMD) retinal function is globally impaired. Observations in single ARMD cases showing abnormalities of the electrooculogram (EOG) and electroretinogram (ERG) encouraged us to systematically examine ARMD patients by means of electrophysiological tests to confirm a global retinal dysfunction in ARMD. · Methods. Sixty-six patients with ARMD were examined clinically and by means of EOG, ERG, triple scotopic ERG, and fluorescein angiography (FA). · Results. EOG data were considerably reduced in ARMD. Scotopic a- and b-waves of the ERG were mildly affected. The bright flash response showed reduced b-waves with normal implicit times. The amplitude of the oscillatory potential OP2 was significantly reduced and photopic responses were also pathologic compared with an age-matched control group. Geographic atrophy and pigment epithelium detachment showed specific abnormalities in the ERG, whereas in soft drusen EOG changes were more conspicuous. · Conclusions. In addition to data from psychophysical tests the results from electrophysiological examinations indicated a global reduction of retinal function in ARMD which seemed to be present not only in the macula but also elsewhere in the retina. Received: 3 December 1998 Revised version received: 17 June 1999 Accepted: 17 June 1999     

Use of a macular buckle in the treatment of exudative age-related macular degeneration.

BACKGROUND AND OBJECTIVE: To evaluate a macular buckle for exudative choroidal neovascularization secondary to age-related macular degeneration (ARMD). PATIENTS AND METHODS: Forty-two eyes with choroidal neovascular membranes (CNVM) secondary to ARMD underwent surgical placement of a macular buckle. A Gore-Tex strip (2.0-2.5 mm wide) was button-holed through a 5 mm diameter silicone sponge (9 mm long) and placed behind the macula underneath the CNVM by the same surgeon (Dr Peyman) in all cases. Follow-up ranged from 7-76 months (mean, 20.9 months). RESULTS: Of 12 eyes with classic subfoveal CNVM: 4 (33%) gained 2 or more lines of Snellen visual acuity; 3 (25%) gained 1 line, remained the same, or lost 1 line; and 5 (42%) lost 2 or more lines (range + 6 to - 6 lines). Of 22 eyes with ill-defined subfoveal CNVM: 12 (54%) gained 1 line, remained the same, or lost 1 line; and 10 (46%) lost 2 or more lines (range + 1 to - 8 lines). Eight eyes with ill-defined juxtafoveal CNVM had the following visual acuity outcomes: 5 eyes (62%) maintained the same level of Snellen visual acuity (gained 1, 0, or lost 1 line); and 3 (38%) got worse (lost 2 or more lines of Snellen visual acuity, range + 1 to - 6 lines). Ten eyes (24%) bled subretinally during the follow-up period (average 11.5 months, range 14 days to 27 months), all outside the area of indentation of the macular buckle. CONCLUSIONS: The macular buckle treatment for exudative subretinal choroidal neovascular membranes in ARMD stabilized visual decline and displaced significant subfoveal hemorrhage.     

A randomized controlled clinical trial on the efficacy of radiation therapy in the control of subfoveal choroidal neovascularization in age-related macular degeneration: radiation versus observation

· Background: The results of several pilot studies concerning radiation therapy for age-related subfoveal choroidal neovascularization (CNV) have been published recently. Although positive treatment results have been described, it is not known whether this therapy alters the natural course of eyes with neovascular age-related macular degeneration (AMD). A randomized controlled clinical trial was conducted in which radiation therapy was compared with observation in patients with subfoveal neovascular AMD. · Methods: Seventy-four patients with a recent drop in central vision due to subfoveal age-related CNV were randomized to either radiation treatment or observation. Patients with either classic, occult or mixed type CNV were included. Eyes in the treatment group received a radiation dose of 24 Gy in four fractions of 6 Gy. Evaluation of data concerning visual acuity (VA) and fluorescein angiography occurred at 3, 6 and 12 months after inclusion. · Results: At 12 months of follow-up 52.2% of the observation group versus 32.0% of the irradiation group had lost 3 or more lines of VA (P=0.03, log rank test). More severe visual decline, 6 lines or more, was observed in 40.9% of the observation versus 8.8% in the irradiation group (P=0.002 using log rank test). At 12 months 39.6% of the observation group and 20.0% of the treatment group had VA of less than 0.1 (P=0.08, log rank test). The size of the CNV membrane doubled in 25.2% of eyes in the observation group versus 20.0% in the treatment group at 12 months (P=0.5, log rank test). No side effects were observed. · Conclusion: Preservation of VA was significantly better in the treatment group compared with the control group at 12 months. Nevertheless we noted a drop in central vision of 3 or more lines in a substantial proportion of the treatment group. Radiation therapy does not prevent visual loss in all patients with age-related subfoveal CNV, and whether the treatment benefit at 12 months will persist has to be awaited. Received: 26 September 1997 Accepted: 11 November 1997     

Preoperative factors influencing visual outcome following surgical excision of subfoveal choroidal

PURPOSE: To evaluate long-term visual acuity outcomes and the influences of various preoperative factors on visual outcome in patients undergoing surgical removal of choroidal neovascular neovascularization (CNV) caused by age-related macular degeneration (ARMD). METHODS: The authors studied 146 eyes of 146 patients who were followed for at least 1 year after surgical excision of CNV associated with ARMD. Surgical indications included subfoveal active CNV localized mainly above the retinal pigment epithelium (RPE) and a standard Japanese decimal visual acuity of 0.3 or worse. CNV above the RPE was diagnosed by fluorescein angiography, indocyanine green angiography, and optical coherence tomography. CNVs were divided into completely classic CNV or mainly classic CNV. The relationships of the post-operative logarithm of the minimum angle of resolution (logMAR) visual acuity with preoperative logMAR visual acuity, the shortest distance from the center of the foveal avascular zone to the CNV margin, CNV size, and age were analyzed. RESULTS: Final logMAR visual acuity was improved (defined as a logMAR visual acuity increase of 0.2 or more) in 78 eyes (54%), stable in 47 (32%), and worsened in 21 (14%). Stepwise regression identified CNV size as a significant factor influencing final logMAR visual acuity (R2 = 0.213, p<0.0001), while preoperative logMAR visual acuity, shortest distance from the center of the foveal avascular zone to the CNV margin, and age showed no significant correlation with final logMAR visual acuity. Surgical complications included retinal detachment in six eyes (4%), subretinal hematoma in four eyes (2%), macular hole in three (2%), and proliferative vitreoretinopathy in two (1%). CNV recurred postoperatively in 18 eyes (12%). In 92 eyes with completely classic CNV, visual acuity was improved in 57 (62%), stable in 27 (29%), and worsened in 8 (9%). In 54 eyes with mainly classic CNV, visual acuity was improved in 21(39%), stable in 20 (37%), and worsened in 13 (24%). CONCLUSIONS: Surgical excision of CNV for ARMD was effective for completely classic CNV, and better postoperative visual acuity was achieved in cases of small CNV. Given the fact that photodynamic therapy (PDT) has only been used in Japan since 2004, future study should compare PDT and surgical excision in Japanese subjects for relative merits against surgical risk and postoperative complications, to define indications for PDT and surgical excision.     

Angiographic pattern of recurrent choroidal neovascularization in age-related macular degeneration

PURPOSE: To evaluate the angiographic characteristics of recurrent choroidal neovascularization (R-CNV) in age-related macular degeneration (AMD). METHODS: A prospective investigation on 107 consecutive patients with exudative AMD and CNV not involving the fovea was conducted. Fluorescein angiography (FA) and indocyanine green angiography (ICGA) were planned before krypton laser treatment, and after 3 weeks, 2, 3, 4, 6, 9, 12, 18, and 24 months from photocoagulation. Laser treatment was FA-guided in eyes with classic CNV, and ICGA-guided in eyes with occult CNV on FA. RESULTS: At baseline on FA, 23.3% had classic CNV, whereas, 76.6% showed occult CNV. On ICGA, CNV assumed a focal and a plaque pattern in 81.3 and 18.6% of cases, respectively. Overall, post-laser CNVs occurred in 56 eyes. FA identified well-defined and ill-defined R-CNV in 25 and 75% of cases, respectively. ICGA identified three different R-CNV patterns: focal, annular, and plaque. Focal R-CNV was defined as a single dot-like hyperfluorescence, which was detected in 69.6% of cases, with subfoveal location in half of them. Annular R-CNV was identified by a hyperfluorescent lesion, partially or completely encircling treated area, which was visible in 19.6% of cases, all with subfoveal involvement. Plaque R-CNV was defined as a hyperfluorescent lesion larger than 1 disc diameter in size, and was seen in 10.7% of cases, all with subfoveal location. CONCLUSIONS: ICGA is able to improve R-CNV visualization identifying three different R-CNV patterns. Focal R-CNV is the most frequent pattern and can be re-treated in half of the cases.     

Patterns of increased in vivo fundus autofluorescence in the junctional zone of geographic atrophy of the retinal pigment epithelium associated with age-related macular degeneration

Purpose: To determine in vivo lipofuscin (LF)-induced topographic variations of fundus autofluorescence in eyes with geographic atrophy (GA) of the retinal pigment epithelium (RPE) associated with age-related macular degeneration (ARMD). · Methods: Fundus autofluorescence was examined with a confocal scanning laser ophthalmoscope (Heidelberg Retina Angiograph) after excitation with an argon laser (488 nm) and detection of the emitted light above 500 nm. Fifty-seven eyes of 38 patients with uni- or multifocal GA associated with ARMD were studied. The findings were compared with 43 eyes with GA secondary to other etiologies, including juvenile macular dystrophies. · Results: An increased autofluorescence outside the GA was observed in 47 (82.5%) of 57 eyes with GA associated with ARMD in contrast to 4 (9.3%) of 43 eyes with GA of other causes (P<0.001). Three different patterns were noted: a continuous band at the margin with variable peripheral extension in 36 eyes (76.6%), a diffusely increased autofluorescence at the entire posterior pole in 6 eyes (12.8%), and small focal spots of increased autofluorescence in the junctional zone in 3 eyes (6.4%). Of 19 patients with bilateral GA, 17 (89.5%) had an identical pattern in both eyes. · Conclusions: The different patterns of autofluorescence in the presence of GA associated with ARMD may reflect variable forms of reactive changes in the surrounding RPE cells, and may indicate the extend of compromised RPE secondary to ageing changes in the outer retina, Bruch’s membrane and choriocapillaris. Since GA spreads over time, increased LF accumulation in the junctional zone may precede cell death and may, therefore, be of prognostic value. Knowledge of the topographic variation in LF accumulation is important because heterogeneity may reflect underlying differences in cell kinetics, metabolism and biochemistry.     

Large submacular hemorrhages after verteporfin therapy

PURPOSE: To report the occurrence of large submacular hemorrhages after photodynamic therapy with verteporfin in age-related macular degeneration patients with subfoveal choroidal neovascularization (CNV) composed of occult with no classic CNV in whom the hemorrhage precluded determining if additional therapy should be given within 3 months after initiation of treatment. DESIGN: Retrospective, noncomparative case series. METHODS: The records of all age-related macular degeneration patients who received verteporfin therapy for subfoveal lesions composed of occult with no classic CNV between February and July 2001 at The Wilmer Eye Institute were reviewed. Subjects who reported either having undergone a procedure to remove intraocular blood before a month 3 follow-up visit, or who had submacular hemorrhage at the month 3 visit that was severe enough to preclude determining if additional verteporfin therapy should be given were identified. RESULTS: Fifty-five eyes of 52 patients were reviewed. Five eyes (9% [95% confidence interval, 1.4%-16.6%]) developed submacular hemorrhage that precluded determining if additional verteporfin therapy should be given. Visual acuity 3 months after documentation of the hemorrhage decreased a median of 8.5 lines compared with pretreatment acuity. CONCLUSIONS: Even in the absence of acute severe visual acuity decrease, submacular hemorrhage after verteporfin therapy can be associated with severe vision loss and preclude determining if additional therapy should be given.