Correlation of quantitative three-dimensional measurements of macular hole size with visual acuity after vitrectomy

· Objective: The purpose of the study was to study the relationship of postoperative visual outcome with anatomical parameters of macular holes using confocal scanning laser tomography and to predict the postoperative visual results. · Design: Cohort study. · Intervention and participants: We evaluated the eyes of 44 patients undergoing macular hole surgery (10 men and 34 women aged 40–76 years, mean 59.1 years). All patients showed idiopathic full-thickness stage 3 macular holes. The duration of symptoms was 1–4 months (mean 2.7 months). · Main outcome measures: The area, volume, mean depth, and maximum depth of the macular holes and the areas of cuff and retinal striae were measured using the Heidelberg Retina Tomograph preoperatively. · Results: All 44 eyes showed closure of the holes and flattening of cuff and retinal striae after vitrectomy and gas tamponade. Postoperative visual acuity was significantly correlated with the area (r=0.822, P<0.0001), volume (r=0.840, P<0.0001), mean depth (r=0.842, P<0.0001), and maximum depth (r=0.831, P<0.0001) of the macular holes, area of cuff (r=0.625, P<0.0001), and area of retinal striae (r=0.648, P<0.0001 ). Multiple regression analysis showed that the combination of the preoperative mean depth of macular holes and logarithm of preoperative visual acuity was the strongest predictor of the postoperative visual acuity. · Conclusions: Postoperative visual results vary significantly with the size of macular holes in patients with stage 3 macular holes of duration 1–4 months. The use of the confocal scanning laser tomography may facilitate the evaluation of macular holes before surgery. Ability to predict the postoperative visual results would be helpful in treating patients with macular holes. Received: 24 July 1998 Revised version received: 30 September 1998 Accepted: 1 October 1998     

Indocyanine green angiography is of value for the diagnosis of chronic central serous chorioretinopathy in elderly patients

Background: Central serous chorioretinopathy is characterized on indocyanine green angiography by areas of transient choroidal hyperfluorescence. These findings are thought to be the consequence of altered permeability of the choroidal vessels. · Methods: The indocyanine green angiograms of 41 patients between 40 and 60 years of age, with central serous chorioretinopathy and of 120 patients above 64 years of age with occult choroidal neovascularization due to age-related macular degeneration were reviewed for the presence of transient indocyanine green leakage. Twelve eyes of 9 patients above 64 years of age with (1) fluorescein leakage of undetermined source corresponding with well-delineated zone(s) of retinal pigmentary changes and (2) transient indocyanine green hyperfluorescence are reported in detail. · Results: Transient indocyanine green hyperfluorescence was seen in all eyes with central serous chorioretinopathy, either typical or chronic, and was seldom seen in occult choroidal neovascularization due to age-related macular degeneration. In the series of chronic serous chorioretinopathy in patients above 64 years of age, four classic choroidal neovascular membranes were found in 12 eyes. Most patients presented multizonal transient choroidal hyperfluorescence in both eyes on indocyanine green angiography. · Conclusion: Transient choroidal hyperfluorescence is suggestive for chronic central serous chorioretinopathy in older patients presenting retinal pigmentary disease with fluorescein leakage of undetermined source. Chronic central serous chorioretinopathy is not uncommonly associated with classic choroidal neovascularization in the elderly. Received: 25 January 1997 Revised version received: 15 September 1997 Accepted: 13 November 1997     

Visual fields after removal of subretinal hemorrhages and neovascular membranes in age-related macular degeneration

· Background: Surgical removal of subretinal hemorrhaging and membranes in eyes with age- related macular degeneration is feasible from a technical point of view, but no advantage over the spontaneous course of the disease has been proven. Visual acuity usually does not improve much. A realistic aim of surgical intervention may be diminution of the central scotoma size, which has not been studied. · Method: In a prospective study visual fields were measured preoperatively and 6 weeks and 6 months postoperatively in eyes operated on for subretinal hemorrhages and membranes in exudative age-related macular degeneration. The OCTOPUS 1-2-3 program g1x, which tests the visual field of 60° diameter at 59 points, was used. Changes in the total size of areas with sensitivity loss of 10–20 dB (= relative scotoma) and >20 dB (= absolute scotoma) were interpreted as surgical effect. Patients with postoperative retinal detachment or neovascular recurrence were excluded. 30 eyes of 29 patients were enrolled (mean age 75.3 years, 11 male, 18 female) and divided into 3 groups: 14 eyes with massive subretinal hemorrhage of diameters >30°; 12 eyes with hemorrhages of 10°–30°; 4 eyes with mere neovascular membranes < 10°. · Results: (1) The visible area of damage is diminished by surgery (P < 0.01). The reduction for lesions >30° is 80%; for lesions between 10° and 30° the improvement is 43%. For lesions <10° there is no significant change. (2) The absolute scotoma size diminishes in all three groups (P = 0.05). The reductions are 63%, 57% and 21%, respectively. (3) Areas of absolute scotoma do not regain full function but are converted to relative scotoma depth, at best. Therefore, in the >30° group an overall increase (P < 0.01) of the relative scotoma size is observed. (4) The mean sensitivity in the 60° field enhances by 1.6 dB (average over 30 eyes, P = 0.04). (5) Mean preoperative visual acuities were 0.03, 0.12 and 0.17, respectively, with no significant change after surgery. The power of testing is sufficient (0.93) to reject an increase of acuity from 0.12 to 0.2 in group 2. · Conclusion: For hemorrhagic subretinal lesions of diameter >10° a relevant reduction of central scotoma size is achieved by surgery. The final benefit for the patients depends on the frequency of surgical complications and neovascular recurrence. Received: 3 February 1997 Revised version received: 7 May 1997 Accepted: 1 July 1997     

Predictive value of pattern VEP, pattern ERG and hole size in macular hole surgery

· Objective: To describe pattern-reversal visual evoked response (PRVEP) and pattern electroretinogram (PERG) parameters in eyes with macular hole and their value for predicting postoperative visual outcome. · Methods: Prospectively we studied 27 eyes (27 patients) with a full-thickness macular hole. Preoperatively the hole and rim were measured and the PRVEP and PERG were recorded. The preoperative parameters were correlated with postoperative visual outcome. · Results: The macular hole was closed in 26 of 27 eyes. Sixteen eyes (59%) had an increase in visual acuity (VA) of two lines or more, 10 eyes (37%) remained within one line of preoperative VA and 1 eye (4%) had a decrease in VA of two lines. Duration of symptoms was negatively correlated with preoperative VA (R=–0.547, P=0.0038) and postoperative VA (R=–0.519, P=0.0065) and positively correlated with hole area (R=0.533, P=0.0061) and rim area R=0.633, P=0.0009). Only the PRVEP P100 latency of the 10′ check size and the PERG N35 latency were significantly associated with visual outcome (P=0.022 and P=0.042 respectively). · Conclusions: There was no association of either hole or rim size with postoperative visual outcome. Preoperative electrophysiology, however, is useful as a prognostic tool. Utilization is limited to the use of latency parameters of the response and is dependent on the check size of the stimulus. Received: 3 November 1998 Revised version received: 8 January 1999 Accepted: 19 January 1999     

Regional Assessment of Cone System Function Following Uncomplicated Retinal Detachment Surgery

Purpose: To evaluate regional cone system function after uncomplicated retinal detachment (RD) surgery, by recording focal electroretinograms (FERGs) from the central and paracentral regions of the posterior pole. Methods: FERGs in response to either a central (eccentricity: 0–2.25 deg) or a paracentral annular (2.25–9 deg) uniform field, presented on a light adapting background and sinusoidally flickered at 41 Hz (95% modulation depth, 93 cd/m² mean luminance) were recorded from 16 eyes (16 patients) 2 weeks to 420 months following uncomplicated RD surgery (encircling procedure with or without scleral buckling). Pre-operatively, 10 out of 16 eyes had a macular RD. Mean time elapsed from onset of symptoms to surgery was 20 days (range: 5–90 days). Post-operatively, visual acuity ranged 0.1 to 1.0. Eight age-matched normal subjects served as controls. Amplitude and phase of the FERG fundamental harmonic were measured. Results: Compared to control eyes, affected eyes’ central and paracentral FERGs were on average reduced in amplitude (by 40% and 28%, respectively, p<0.01) and delayed in phase (by 70 and 100 degrees, respectively, p<0.01). Eyes with a macular RD did not differ in FERG amplitude or phase from eyes that had a peripheral RD. In individual affected eyes, central, but not paracentral FERG amplitudes were negatively correlated (p=0.05) with time elapsed from onset of symptoms to surgery. Conclusions: Central and paracentral cone system dysfunction may be detected even at lengthy time intervals from retinal reattachment, independent of the presence of a pre-operative macular RD. The extent of central loss appears to be inversely related to RD duration, in agreement with previous reflectometric findings on foveal cone photopigment density [Liem et al., 1994; Ophthalmology 10: 1945-51].     

Aqueous flare in retinitis pigmentosa

· Background: The purpose of this study was to quantify blood-ocular barrier impairment by measuring aqueous flare in retinitis pigmentosa (RP) and to search for clinical correlations. · Methods: Forty-nine patients (94 eyes) with RP and 85 normal controls were examined. Aqueous flare was quantified with the noninvasive laser flare-cell meter (FC-1000, Kowa, Japan). Degrees of cystoid macular edema (CME), vitreous pigment dusting (VPD), intraretinal migration of retinal pigment epithelium, and waxy pallor of the optic nerve head were determined semiquantitatively by biomicroscopy. Data were analyzed using the t-test the Mann-Whitney U-test, the chi-squared test and regression analysis by taking into account the dependency of data from two eyes of the same patients. · Results: Aqueous flare (photon counts/ms) was significantly higher in RP (mean 10.11±3.53) than in normals (3.89±0.94; P<0.001). Clinically significant CME was present in 26% of eyes with RP, being significantly more frequent in autosomal dominant RP (11 of 16 eyes, 69%) than in other variants (17%; P<0.005). Multivariate analysis revealed that CME was most strongly associated with flare values (r=0.84, P<0.01), whereas – after adjusting for CME – correlations between aqueous flare and other clinical findings did not reach significance. · Conclusion: RP eyes show increased aqueous flare values, indicating impairment of blood-ocur barriers. This appears to be associated with CME and with autosomal dominant RP. Received: 27 June 1997 Accepted: 1 October 1997     

The photopic negative response of flash ERG in nonproliferative diabetic retinopathy

Purpose To evaluate with electrophysiological responses and Optical Coherence Tomography (OCT), the short term functional and structural effects at the macula following intravitreal injection of bevacizumab for macular edema. Methods Prospective, non-randomized, interventional case study. In total, 17 eyes of 17 patients with macular edema due to vein occlusions and diabetic retinopathy received intravitreal bevacizumab. All Patients underwent complete ophthalmic examination including Snellen visual acuity testing, Multifocal Electroretinography (mfERG) and Full Field Electroretinography (FERG), OCT scanning at baseline at 1 week and 2 months after intravitreal bevacizumab. Results FERG did not show any change in waveform parameters following intravitreal injection of bevacizumab. Average mfERG macular responses within central 20° showed increased P₁ amplitude (P < 0.05) at 2 months after treatment as compared to the baseline recordings in all subjects. No changes were seen in the implicit time. There was 22% improvement in central retinal thickness (CRT) at 2 months compared to the baseline (P < 001). Conclusion Intravitreal injection bevacizumab resulted in reduction in the central retinal thickness and mild to moderate improvement in the mfERG amplitudes in this short-term study. The visual acuity changes did not directly correlate with the reduced central retinal thickness or improvement in mfERG. The short-term results showed no serious ocular adverse effects. Therefore on short-term follow up the off label drug showed improvement of macular edema secondary to vein occlusion and diabetic retinopathy with no demonstrable toxic effects.     

Effect of mitomycin C on aqueous humor flow, flare and intraocular pressure in eyes with glaucoma 2 years after trabeculectomy

· Background: The purpose of this study was to determine the intraocular pressure (IOP), aqueous humor flow, flare and ocular side effects in eyes with a history of hypotony after trabeculectomy with adjunctive mitomycin C (MMC). · Methods: Thirty-six eyes with primary or secondary open-angle glaucoma and IOP ≤8 mmHg during the postoperative period were studied 745±315 days after surgery. MMC (0.2 or 0.5 mg/ml) was applied to the episclera with a cellular sponge. Flare was studied with the Kowa Laser Flare Meter 500. Aqueous humor flow was measured in the afternoon (Fluorotron Master II). IOP, visual fields and best corrected visual acuity were also examined. Twenty-two contralateral eyes without surgical intervention served as controls. · Results: The mean age of patients was 44.5±16.8 years. The mean IOP was significantly lower in the MMC group than in the control group: 9.6±6.4 mmHg vs 18.0±13.6 mmHg at 2 years (P<0.001). Aqueous flow was significantly lower in subjects treated with MMC than in controls (P<0.001). The flare values were significantly higher in the MMC-treated group, with a mean of 12.0±7.7 photon counts/ms, than in the control group, mean 7.9±4.6 photon counts/ms (P<0.019). · Conclusion: Our data suggest that MMC is a useful ocular hypotensive agent which seems to participate in a change in aqueous humor dynamics when applied topically as an aqueous solution. Received: 14 October 1997 Revised version received: 20 February 1998 Accepted: 4 March 1998     

Post-operative inflammation following deep sclerectomy with collagen implant versus standard trabeculectomy

· Background: An investigation was carried out to compare post-operative inflammation following deep sclerectomy with collagen implant (DSCI) versus standard trabeculectomy. · Methods: In this prospective randomized study, 46 eyes of 46 Caucasian patients with medically uncontrolled chronic open-angle glaucoma and without previous glaucoma surgery underwent filtering surgery. Twenty-four eyes underwent DSCI. Twenty-two eyes underwent standard trabeculectomy. Pre- and post-operative flare, measured using laser flare photometry, were compared between the two groups. · Results: In both groups, the mean anterior chamber flare increased on the first post-operative day, then decreased progressively. DSCI was associated with lower flare measurements post-operatively. The difference was statistically significant up to 1 month post-operatively: 16.3±7.8 vs 72.5±38.9 (P<0.001) at 1 day, 7.8±4.6 vs 44.7±29.2 (P<0.001) at 1 week, 5.9±1.6 vs 7.0±2.8 (P=0.012) at 1 month, 6.4±1.8 vs 6.5±1.9 (P=0.77) at 2 months, 5.9±1.8 vs 6.1±1.6 (P=0.65) at 3 months. · Conclusion: Surgically induced inflammation can be reduced with DSCI. This may be due to the lack of iridectomy, irrigation, and penetration of the anterior chamber. Eyes at increased risk of post-operative inflammation, such as those with uveitic or traumatic glaucoma, may benefit from this procedure. Further studies are needed to evaluate the long-term functional and anatomical outcomes of DSCI. Received: 15 September 1997 Revised version received: 28 January 1998 Accepted: 29 January 1998     

Macular function evaluated by focal macular electroretinograms after reduced fluence photodynamic therapy in eyes with polypoidal choroidal vasculopathy

The purpose of this study was to evaluate the macular function by measuring the focal macular electroretinograms (ERGs) recorded before and after reduced fluence photodynamic therapy (RFPDT) in patients with polypoidal choroidal vasculopathy (PCV). Eleven eyes of 11 patients with PCV were studied. Their ages ranged from 62 to 85 years with a mean of 74.7 ± 6.9 years. The exposure time for the RFPDT was reduced to 42 s, so that the total energy of the laser was approximately one-half that of the standard PDT. We measured the visual acuity, foveal thickness, and focal macular ERGs before and after the RFPDT. The follow-up period ranged from 13 to 34 months with a mean of 26 months after the treatment. A significant recovery of vision was seen even at 1 week after the RFPDT (P < 0.005), and the visual acuities improved gradually thereafter (P < 0.0005). The foveal thickness was significantly reduced at 1 week after the treatment (P < 0.005) and then continued to become significantly thinner with time (P < 0.0001). A slight recovery of the a- and b-wave amplitudes was seen postoperatively without a transient reduction in the amplitudes. The b-wave amplitude was significantly larger at 3 months after the treatment than at baseline (P < 0.05). Choroidal hypoperfusion did not develop 3 months postoperatively in the indocyanine green angiograms. Exudative changes recurred in 4 (27%) eyes after 1 year and in 9 (82%) eyes during the follow-up period. RFPDT provided short-term benefits in selected patients with PCV with small lesions. The macular function was retained after RFPDT without a transient decrease in visual function. Further study is needed to determine the long-term efficacy of RFPDT for eyes with PCV.     

Complications of surgery for epiretinal membranes

· Purpose: Surgery has been successful in removing epiretinal membranes (ERM) from the macula, allowing some improvement in vision in 80–90% of patients; however, complications are relatively frequent. We conducted a retrospective study to evaluate the rate of peri- and postoperative complications and their influence on functional outcome of eyes having been operated on for ERM. · Material and methods: Preoperative findings, intraoperative and postoperative complications as final results of 70 consecutive cases of idiopathic or secondary ERM operated on by the same retina surgeon were analyzed. · Results: In all cases the ERMs were succesfully removed from the fovea. The mean visual acuity (VA) increased from 0.34±0.2 to 0.54±0.31 (P<0.05) postoperatively. Idiopathic and secondary ERM both showed significant improvement after surgery. Complications included intraoperative hemorrhage and retinal tears and postoperative progressive nuclear sclerosis, retinal tears causing detachments, macular edema and retinal pigmentary epitheliopathy. Final VA was not significantly different from the mean after complications, apart from when retinal detachments involved the macular area. · Conclusions: Performing surgery for ERM is worthwhile in eyes with major decreased VA and in eyes with metamorphopsia but only moderately reduced vision. Postoperative complications are frequent but can usually be managed successfully. Of them, only retinal detachment has a negative effect on the final functional outcome. Received: 8 July 1997 Accepted: 20 November 1997     

The ocular hypotensive effect of late pregnancy is higher in multigravidae than in primigravidae

· Background: Systemic hypertension and degenerative vascular disease are more common in multigravidae than in primigravidae. The present study investigated whether the known ocular hypotensive effect of late pregnancy is influenced by the number of pregnancies. · Methods: Intraocular pressure (IOP) was measured in normotensive third-trimester primigravidae and multigravidae along with nulligravida controls by means of the Goldmann applanation tonometer. Depending upon the number of previous pregnancies, multigravidae were divided into four subgroups. · Results: The IOP of the pregnant group (primigravidae and multigravidae together) was (mean±SEM) 2.1±0.07 mmHg (P<0.001) lower than in the nulligravida control group. The IOP of nulligravidae was 1.7±0.06 mmHg (P<0.001) and 2.5±0.01 mmHg (P<0.001) higher than in third-trimester primigravidae and multigravidae, respectively. In all subgroups of multigravidae IOP was significantly lower (P<0.02) than in primigravidae. The differences among different subgroups of multigravidae were statistically insignificant. · Conclusions: Gravidity influences IOP and should be taken into account in future research. Received: 14 August 1997 Revised version received: 4 May 1998 Accepted: 26 May 1998     

Short-term efficacy of intravitreal bevacizumab for the treatment of macular edema due to diabetic retinopathy and retinal vein occlusion

Purpose: To evaluate the short-term efficacy of intravitreal bevacizumab injection for the management of macular edema due to diabetic retinopathy and retinal vein occlusion. Methods: Patients with macular edema due to diabetic retinopathy, and retinal vein occlusion were treated with intravitreal bevacizumab and evaluated retrospectively. Standardized ophthalmic evaluation, ETDRS visual acuity measurement, and central macular thickness were performed at baseline and 1 month intervals after injection. Results: There were 23 eyes of 21 patients with macular edema due to diabetic retinopathy (14 eyes of 12 patients), and retinal vein occlusion (9 eyes of 9 patients). The mean baseline logMAR visual acuity and central macular thickness were 0.82 ± 0.27 and 604.71 ± 123.62 μm, respectively, in patients with diabetic retinopathy. There was no statistically significant difference between the mean logMAR visual acuity (P = 0.22) and central retinal thickness (P = 0.16) measurements at baseline and 3 months follow-up. The mean baseline logMAR visual acuity and central macular thickness were 0.94 ± 0.48 and 557 ± 113.9 μm, respectively, in patients with retinal vein occlusion. There was a statistically significant difference between the mean logMAR visual acuity and central retinal thickness measurements at baseline and 3 months follow-up (P < 0.01). Almost all of the eyes (88.8%) regained normal foveal configuration. Conclusions: Although our follow-up period was short and the number of patients were limited to provide specific treatment recommendations, intravitreal bevacizumab seems to be more effective for macular edema due to retinal vein occlusion than diabetic macular edema. The favorable short-term results suggest further study is needed.     

Tamoxifen retinopathy: does it really exist?

· Background: Tamoxifen retinopathy is known to be an adverse effect of high-dose tamoxifen treatment. Evidence of ocular toxicity at lower doses is less convincing: the aim of this study was to assess the prevalence of the above-mentioned retinopathy in a population treated with low-dose tamoxifen. · Methods: One hundred and twenty-nine women treated with low-dose tamoxifen (20 mg/day) were examined. Visual acuity measurement, slit-lamp biomicroscopy and fundus examination were performed. Patients were reexamined after 6–12 months. · Results: Refractile retinal opacities, similar to those previously described as tamoxifen retinopathy, were observed in four patients (prevalence 3.1%; mean duration of therapy 806 days). None of them revealed corneal opacities, papillary and/or macular edema, or visual impairment. The ophthalmoscopic aspect did not change after a mean follow-up of 215 days, although one of these patients had interrupted tamoxifen intake. Statistical analysis (Student’s t-test) did not reveal any difference between patients with and those without refractile retinal opacities as far as age, treatment duration and ERG values were concerned. An early hyperfluorescence, reminescent of cuticular drusen, was demonstrated by fluorescein angiography in all four cases. · Conclusions: The present study would seem to confirm that low-dose tamoxifen may induce retinal toxicity in a low proportion of patients, but we cannot be certain that the refractile retinal opacities observed are really caused by tamoxifen, as differentiation from age-related macular degeneration with cuticular drusen appears nearly impossible. Received: 10 November 1997 Revised version received: 5 January 1998 Accepted: 14 January 1998     

Clinical and optical coherence tomographic findings and outcome of treatment in patients with presumed tuberculous uveitis

Purpose To define the clinical characteristics and optical coherence tomographic (OCT) features, and to assess the outcome of treatment, in patients with presumed tuberculous uveitis (PTU). Methods All patients diagnosed with PTU at King Abdulaziz University Hospital between January 1998 and May 2006 were reviewed. The diagnosis was made when findings were consistent with possible intraocular tuberculosis with no other cause of uveitis suggested by history, symptoms, or ancillary testing, strongly positive tuberculin skin-test results, and response to antituberculous therapy. Results Fifty-one patients (73 eyes) were identified. There were 34 males (66.7%) and 17 females (33.3%) with a mean age of 40.1 ± 11.0 years (range 16–68 years). Fifty-eight eyes (79.5%) had panuveitis and 15 eyes (20.5%) had posterior uveitis at presentation. Clinical manifestations included vitritis (71.2%), macular edema (63%), retinal periphlebitis (35.6%), multifocal choroiditis (20.5%), and granulomatous anterior uveitis (17.9%). All patients received antituberculous therapy and systemic corticosteroids. After a mean follow-up of 18.9 ± 21.9 months (range 6–96 months), all eyes showed resolution of inflammation, with no recurrences, associated with significant improvement in visual acuity (VA) (P = 0.007). There was a significant positive correlation between initial and final VAs (r = 0.7856, P < 0.001). Thirty-one eyes with macular edema were examined at baseline and at follow-up with OCT. There were three patterns of macular edema: diffuse (DME) (28.5%), cystoid (29%), and serous retinal detachment (45.2%). Initial VA of 20/40 or better was significantly associated with central macular thickness (CMT) of 300 μm or less (P = 0.0065) and DME (0.0484). At final follow-up, there was a significant reduction in CMT (P < 0.001) associated with a significant improvement in VA (P = 0.0091). Conclusions Antituberculous therapy combined with systemic corticosteroids leads to resolution of inflammation and elimination of recurrences of PTU. OCT is useful in monitoring the efficacy of treatment in patients with macular edema.     

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.     

Subretinal fibrosis and choroidal neovascularization in Vogt-Koyanagi-Harada syndrome

· Background: To describe clinical findings of subretinal fibrosis and choroidal neovascularization in patients with Vogt-Koyanagi- Harada (VKH) syndrome. · Methods: We retrospectively reviewed 75 medical records of patients with VKH seen at the National Eye Institute, Bethesda, Maryland between 1978 and 1996. Recorded data included age, gender, race, duration of disease, extraocular manifestations, best-corrected visual acuity, slit-lamp biomicroscopy, retinal examination, retinal photographs and fluorescein angiograms. We sought features that correlated with the visual outcome. · Results: Thirty of 75 (40%) patients developed subretinal fibrosis. Eleven patients (14.7%) had choroidal neovascularization. Presence of subretinal fibrosis was associated with a longer duration of the disease (42.6 vs 19.1 months, P=0.07). Patients with subretinal fibrosis had worse visual acuity than those without subretinal fibrosis (26.2 vs 57.3 ETDRS letters read, P<0.001) after adjusting for duration of disease (P=0.021), degree of vitreous haze (P=0.074), and use of immunosuppressive therapy (P=0.008). · Conclusions: Presence of subretinal fibrosis in patients with VKH is associated with a poor visual prognosis. The diagnosis of choroidal neovascularization and subretinal fibrosis presents a challenge in the management of this disease. Received: 10 June 1999 Revised version received: 4 August 1999 Accepted: 10 August 1999     

Subtype lesions of neovascular age-related macular degeneration in Chinese patients

Purpose To identify the subtype frequency and clinical features of neovascular age-related macular degeneration (AMD) in Chinese patients. Methods From January 2003 to August 2006, we investigated prospectively 155 newly diagnosed patients with presumed neovascular AMD. Fundus fluorescein angiography (FFA) and indocyanine green angiography (ICGA) were performed in both eyes of all patients. Subtype frequency and clinical features were recorded according to their angiograms. Results Three subtypes of lesion were noted, which were polypoidal choroidal vasculopathy (PCV), retinal angiomatous proliferation (RAP) and mixed lesions. Of the 155 patients, 105 (67.7%) had choroidal neovascularization (CNV) of the typical type seen in AMD, 38 (24.5%) had PCV and seven (4.5%) had RAP. In five (3.2%) additional cases, mixed lesions were noted. In 38 cases (47 eyes) with PCV, the rates of subfoveal, juxtafoveal and extrafoveal lesion were respectively 29.8% (14 eyes), 8.5% (four eyes), and 61.7% (29 eyes), compared with 75.6%, 14.6% and 9.8% for CNV lesion (P < 0.01). The percentage of subfoveal lesion in PCV group was significantly lower than that in the CNV group (P < 0.01). The location of the RAP lesion was subfoveal in two (28.6%) eyes, juxtafoveal in three (42.9%) eyes and extrafoveal in two (28.6%) eyes. The five eyes with mixed lesions were all PCV coexisting with CNV at the same eye, and in all of the five cases, CNV was subfoveal while PCV was extrafoveal. Conclusions In this hospital-based study, PCV accounts for 24.5% of neovascular AMD and is the most common subtype, RAP is less frequent (4.5%), and mixed lesions are much less common in Chinese patients. PCV is least likely to involve the fovea in neovascular AMD. The authors have no proprietary interest. This study was supported by the Natural Science Foundation of Guangdong Province (grant no. 04009333) and the Research Fund of Guangdong Bureau of Chinese Medicine (grant no.20030086).     

The residual epiretinal membrane after vitrectomy for macular hole

· Background: We retrospectively observed idiopathic macular holes in 63 eyes using a scanning laser ophthalmoscope, in order to study the relation between postoperative epiretinal membranes and closure of macular holes following vitrectomy. · Methods: The eyes were classified into three groups based on the degree of the postoperative epiretinal membranes. Group I consisted of 23 eyes with no epiretinal membrane remaining on the retina after vitrectomy. Group II consisted of 20 eyes in which epiretinal membranes were observed on the retina, but separate from the edge of the macular hole. Group III consisted of 20 eyes in which epiretinal membranes were observed at the edge of the macular hole. Using these three groups, we studied how postoperative epiretinal membranes were related to the closure of macular holes. · Results: All macular holes (100%) in groups I and II were closed following vitrectomy. In group III, 5 (25.0%) of 20 eyes had complete closure and 13 eyes (65.0%) had incomplete closure of the macular hole, while 2 eyes (10.0%) had re-opening of initially closed macular holes several months after vitrectomy. · Conclusion: Residual postoperative epiretinal membranes at the edge of macular hole are responsible for primary failure of vitrectomy. Removal of epiretinal tissues around the macular hole is important for macular hole to be closed following vitrectomy. Received: 7 July 1998 Revised version received: 7 October 1998 Accepted: 22 October 1998     

The effect of acetazolamide on passive and active transport of fluorescein across the blood-retina barrier in retinitis pigmentosa complicated by macular oedema

· Background: The carbonic anhydrase inhibitor acetazolamide (AZM) reduces macular oedema in some patients with retinitis pigmentosa. To better understand the oedema-reducing effect of AZM, the effect of AZM on passive permeability and active transport of fluorescein across the blood-retina barrier was studied in patients with retinitis pigmentosa and varying degrees of macular oedema. · Method: The selection of patients was based on an introductory examination including vitreous fluorometry for qualitative assessment of the vitreous. Macular oedema was graded by fluorescein angiographic leakage. The effect of AZM on the transport properties of the blood-retina barrier was determined by differential spectrofluorometry, in a randomised, double-masked, cross-over study, comprising 2 weeks’ treatment with AZM (500 mg/day) and 2 weeks’ treatment with placebo. The penetration ratio, defined as the ratio between vitreous concentration 3 mm in front of the retina and the plasma integral, was determined for fluorescein and its metabolite fluorescein glucuronide at 30–60 min and at 120 min after fluorescein injection. Passive permeability and unidirectional permeability in the direction vitreous to blood, due to outward active transport of fluorescein, were determined in those cases where the curves for vitreous concentration of fluorescein could be fitted to a mathematical model. Visual acuity was tested by use of ETDRS standard logarithmic charts. · Results: Twenty-two patients volunteered to participate in the study. Signs of significant vitreous detachment/liquefaction caused the exclusion of ten patients after the introductory examination. Nine patients with approximately intact vitreous and varying degrees of oedema completed the cross-over study. AZM treatment was related to a decrease in the penetration ratio of 21% for fluorescein (P=0.01) and of 22% for fluorescein glucuronide (P=0.004). Passive permeability and unidirectional permeability were determined in seven patients. AZM caused a decrease of 27% in the passive permeability of fluorescein (from 1.1×10¹ nm/s, P=0.031), and a 95% increase in unidirectional permeability of fluorescein (from 1.2×10² nm/s, P=0.047). AZM led to a reduction in the grade of macular oedema as determined by fluorescein angiography in three out of seven patients. Only small improvements (≤5 letters) in visual acuity were noted. · Conclusion: The present study indicates that the oedema-reducing effect of AZM is due to decreased leakage and stimulated active transport across the blood-retina barrier. Received: 9 February 1998 Revised version received: 20 April 1998 Accepted: 21 April 1998