Surgical management of subfoveal neovascularization in children.

OBJECTIVE: To report the authors' clinical experience with submacular surgery for subfoveal membranes in children and to evaluate the histopathologic findings of membranes in children with various etiologies of choroidal neovascularization. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: Twelve eyes of 12 consecutive children with subfoveal choroidal neovascularization treated by vitrectomy and excision of the choroidal neovascular complex. INTERVENTION: Vitrectomy, excision of the choroidal neovascular complex, and air-fluid exchange. MAIN OUTCOME MEASURES: Visual acuity and recurrence of choroidal neovascular membrane. RESULTS: Preoperative visual acuities ranged from 20/60 to 20/800 (median, 20/300). Postoperative visual acuities ranged from 20/25 to 20/400 (median, 20/80) after an average follow-up of 20 months (range, 7-62 months). Ten of 12 eyes improved from immediate preoperative visual acuity, and four eyes developed recurrence of neovascular membranes over a mean follow-up of 18 months. Histopathologic examination of six excised membranes showed that the most common components of the membranes were retinal pigment epithelium, fibrocytes, vascular endothelium, and collagen. CONCLUSION: Selected eyes of children with subfoveal neovascular membranes and no evidence of membrane regression may benefit from submacular surgery. The histopathologic findings were similar to adult choroidal neovascularization not associated with age-related macular degeneration.     

Surgical treatment of submacular hemorrhage associated with idiopathic polypoidal choroidal vasculopathy.

PURPOSE: To report the visual outcome of surgical treatment of submacular hemorrhage associated with idiopathic polypoidal choroidal vasculopathy. METHODS: Eight eyes of eight consecutive patients with thick submacular hemorrhages associated with idiopathic polypoidal choroidal vasculopathy were treated with pars plana vitrectomy and tissue plasminogen activator-assisted removal of subretinal blood (December 1995 to September 1997) or intravitreal 100% sulfur hexafluoride gas injection without tissue plasminogen activator (October 1997 to March 1998). RESULTS: Postoperatively, laser treatment was performed for active polypoidal lesions outside the foveal avascular zone in four eyes. A retinal pigment epithelial tear was seen outside the foveal avascular zone in three eyes, and one eye developed a retinal detachment. The best-corrected visual acuity improved (by 3 or more lines) or stabilized in seven of the eight eyes. Four eyes had a final best-corrected visual acuity of 20/40 or better, and three eyes had a final best-corrected visual acuity of 20/50 to 20/200. In one eye, the visual acuity decreased from 20/100 to 20/500 because of the development of a subfoveal neovascular membrane. The membrane was excised, and histologic examination showed fibrovascular tissue between the retina and retinal pigment epithelium (type 2 pattern). CONCLUSIONS: Surgical intervention may be of benefit in eyes with submacular hemorrhage associated with idiopathic polypoidal choroidal vasculopathy.     

Foveal translocation with scleral imbrication in patients with myopic neovascular maculopathy

PURPOSE: To report our surgical results of foveal translocation with scleral imbrication in patients with myopic neovascular maculopathy. DESIGN: Noncomparative, interventional, consecutive case series. METHODS: Ten eyes of 10 myopic patients with subfoveal neovascular membranes that had undergone foveal translocation with scleral imbrication were recruited for this retrospective study. Inclusion criteria were myopia 6.0 diopters or greater in refractive error (or axial length 26.5 mm or longer), subfoveal choroidal neovascularization, and preoperative best-corrected visual acuity of 20/100 or worse. None of these eyes had undergone prior laser photocoagulation or submacular surgery. The main outcome measures were surgical complications and postoperative visual function. RESULTS: Postoperatively, visual acuity had improved more than 3 lines in the logarithm of minimum angle of resolution (logMAR) measurement in all eyes. The mean preoperative, postoperative best, and final visual acuity were 0.12, 0.59, and 0.51, respectively. Of the 10 eyes, six achieved a postoperative final visual acuity of 20/40 or better. The mean postoperative foveal displacement was 0.78 disk diameter (range, 0.3--1.3 disk diameter). Two patients underwent a reoperation because of insufficient foveal displacement. Furthermore, one of these two patients required a third operation to reduce an excessive retinal fold involving the fovea induced by the second surgery. Of the 10 patients, two noted transient diplopia. This complaint, however, resolved over time as suppression developed. Although unintentional iatrogenic retinal tears formed intraoperatively in two eyes, these were successfully treated without serious complications. Postoperatively, mild retinal pigment epithelial changes were observed in all cases, but none led to significant deterioration of visual acuity during the follow-up period. All patients but one were followed for a minimum of 6 months. CONCLUSIONS: In eyes with myopic neovascular maculopathy, foveal translocation with scleral imbrication may be useful in improving visual acuity. Further refinements in surgical technique and assessment of the long-term complications will be needed to make this procedure safer and more useful.     

中心性渗出性脉络膜视网膜病变的相干光断层扫描结果分析

目的 探讨中心性渗出性脉络膜视网膜病变(CEC)黄斑部视网膜下脉络膜新生血管(CNV)患者的相干光断层扫描(OCT)图像特征。方法 对20例(21只眼)CEC连续治疗患者进行OCT检查,并与荧光素眼底血管造影(FFA)和吲哚青绿眼底血管造影(ICGA)结果进行对比;同时对光动力治疗后患者的OCT图像形态变化进行分析,以评价OCT图像特征对CEC患者的临床治疗价值。结果 21只眼中,有16只眼CNV呈类圆形团块状,自视网膜色素上皮层向上突出,位于视网膜神经上皮下间隙,呈强或中等强度反射;5只眼的CNV呈纺锤形或不规则形,亦呈强或中等强度反射,位于色素上皮层平面。21只眼中有9只眼伴有浆液性神经上皮脱离,6只跟伴有出血性色素上皮脱离,14只眼伴有不同程度的视网膜水肿和增厚。17只眼经光动力治疗后,随访3～12个月,平均6个月,FFA检查显示荧光素渗漏消退或减弱的患者,OCT检查均显示CNV团块不同程度退缩,其形态亦发生变化。OCT图像特征与FFA和ICG检查结果有互补性。结论 OCT检查可以确定CEC患者病变中CNV团块的形态、大小及位置。CEC病变中CNV的OCT图像以突出于色素上皮层的类圆形团块为特征,其形态和大小可因治疗和观察时间而变化。     

Factors associated with reduced visual acuity during long-term follow-up of patients with idiopathic central serous chorioretinopathy

PURPOSE: To investigate factors associated with reduced visual acuity during long-term follow-up of patients with idiopathic central serous chorioretinopathy (ICSC). METHODS: Retrospective consecutive case series that included patients with ICSC who were younger than 50 years of age at the time of initial examination and were followed up for > or =3 years. RESULTS: The mean follow-up for 101 involved eyes of 61 patients was 9.8 years (median, 8.0 years). Eyes were stratified into two groups based on visual acuity at the final examination: Group 1, visual acuity of 2040 or better; and Group 2, visual acuity of worse than 2040. Findings identified as potential risk factors for reduced vision at the final follow-up examinations for Group 1 versus Group 2 included the following: macular retinal pigment epithelium atrophy (90.8% versus 96.0%, respectively; P = 0.68); persistent pigment epithelial detachment or persistent subretinal fluid (5.3% versus 28.0%, respectively; P = 0.004); recurrences (39.5% versus 68.0%, respectively; P = 0.020); laser treatment (28.9% versus 32.0%, respectively; P = 0.80); and submacular choroidal neovascularization (0.0 versus 8.0%, respectively; P = 0.059). CONCLUSIONS: Factors associated with reduced visual acuity during long-term follow-up of patients with ICSC included persistent pigment epithelial detachment and/or subretinal fluid, recurrences, and submacular choroidal neovascularization.     

Limited macular translocation for the management of subfoveal choroidal neovascularization after photodynamic therapy

PURPOSE: To report our initial experience of limited macular translocation in patients with subfoveal choroidal neovascularization secondary to age-related macular degeneration following photodynamic therapy with verteporfin. DESIGN: Interventional case series. METHODS: Retrospective review of four eyes of four consecutive patients with subfoveal choroidal neovascularization secondary to age-related macular degeneration who underwent effective limited macular translocation following photodynamic therapy. The mean logarithm of minimal angle of resolution preoperative best-corrected visual acuity was 20/190 (range, 20/150 to 20/200), and in all eyes the visual acuity was 20/150 or worse. The major outcome measures were postoperative visual acuity and complications related to the surgery. RESULTS: The mean postoperative follow-up was 6.75 months (range, 6-8 months). Postoperative best-corrected visual acuity improved by 2 or more Snellen lines of visual acuity in three of four eyes (75%) and remained within 1 line in one of four eyes (25%). The mean postoperative best-corrected visual acuity was 20/100 (range, 20/40 to 20/150), and in two of the four eyes (50%) the visual acuity achieved was 20/100 or better. No complication was observed. CONCLUSIONS: Limited macular translocation may be a viable option in patients who have previously undergone photodynamic therapy.     

玻璃体腔注射Avastin治疗眼底病400例临床疗效总结

目的:通过对400例眼底病患者520眼经玻璃体腔注射avastin治疗的临床疗效观察,说明玻璃体腔注射avastin对视网膜静脉阻塞(RVO)、糖尿病性视网膜病变(DR)、年龄相关性黄斑变性(ARMD)、中心性浆液性脉络膜视网膜病变(CSC)、视网膜脉络膜新生血管(CNV)等眼底病的治疗能起到重要的作用,并对其副作用作了总结分析统计。方法:对我院门诊确诊为RVO,DR,ARMD,CSC,CNV等眼底病患者400例眼底病患者520眼进行玻璃体腔注射avastin治疗,注射治疗1次/mo,以治疗前后的视力、眼底荧光血管造影(FFA)、眼压、光学相干断层扫描(OCT)作为观察指标,对经玻璃体腔注射avastin治疗的疗效进行分析总结;并对治疗过程当中出现的并发症作了总结、分析。结果:随访时间为3mo～1a,520眼中有467眼(89.8%)视力提高2行以上,眼压正常、视网膜水肿及出血明显吸收,新生血管消退,OCT及FFA指标都有好转;36眼(6.9%)视力稳定,治疗前后视力无变化,但眼底情况都有改善,无新生血管增生加重或眼压升高等并发症的发生;17眼(3.3%)视力下降,其中有13眼(2.5%)从0.2降至0.1,病变稳定;1眼(0.2%)发生了眼内炎,视力从0.6下降至0.2;1眼(0.2%)发生了视网膜中央动脉阻塞(CRAO),视力从0.02变为光感;1眼(0.2%)发生了玻璃体出血;1眼(0.2%)发生了孔源性视网膜脱离,伴有并发症而视力下降的患者中除了1眼(CRAO)外其余在对症治疗后视力均有提高;在所有的治疗眼中发生一过性眼压升高20眼(3.8%),后经降眼压对症治疗后眼压正常。还有1例患者右眼行玻璃体腔注射avastin治疗后3d左眼施行了小梁切除手术,术后切口愈合较一般手术后慢7～10d,眼压相对较低。结论:经玻璃体腔注射avastin治疗视RVO,DR,ARMD,CSC,CNV等眼底病,是一种有效、安全的方法,能提高视力,减轻黄斑和视网膜水肿,促进玻璃体和视网膜下出血的吸收,能有效地消退视网膜和脉络膜新生血管,可以抑制虹膜红变和新生血管性青光眼的发生;对于在治疗过程中出现的并发症也是值得我们去总结、思考的。     

Macular translocation with chorioscleral outfolding: a pilot clinical study

PURPOSE: A new surgical technique to translocate the macula was used to treat patients with subfoveal choroidal neovascularization secondary to age-related macular degeneration (AMD). DESIGN: Prospective, interventional case series. METHODS: Twenty-five eyes of 25 patients underwent macular translocation with either circumferential or radial chorioscleral outfolding using three clip sizes: 2-mm, 3-mm, and 4-mm. Postoperative photocoagulation was performed on only those eyes that had an extrafoveal choroidal neovascular membrane following surgery. RESULTS: The surgery successfully displaced the fovea in 22 (88%) of the eyes. The median postoperative foveal displacement was 1142 microm (range 0 to 3200 microm). Patients who had radial outfolding with 4-mm clips had the greatest displacement of the fovea (range 1644 to 3200 microm median 1977 microm). The fovea was successfully displaced to a location outside the choroidal neovascular membrane in 17 (68%) of the 25 eyes. The best-corrected visual acuity improved in 11 eyes (median, 17 letters), remained unchanged in 4 eyes, and decreased in 10 eyes (median, 12 letters). Visual acuity increased by a median of 2 letters. The final best-corrected visual acuity was 20/64 in 3 eyes; 20/80 in 3 eyes; 20/100 in 4 eyes; 20/126 in 4 eyes; 20/200 in 4 eyes; 20/250 in 4 eyes; and 20/400 in 3 eyes. CONCLUSIONS: Macular translocation with radial chorioscleral outfolding using 4-mm clips resulted in the best foveal displacement and improvement in visual function, and was associated with the least amount of vision loss and complications. Further refinements are needed to make this surgical procedure more predictable, and more research (randomized clinical trials) is needed to determine the role of macular translocation in the treatment of subfoveal choroidal neovascularization in patients with AMD.     

Transplantation of autologous retinal pigment epithelium in eyes with foveal neovascularization resulting from age-related macular degeneration: a pilot study.

PURPOSE: To describe the indications, surgical technique, and clinical results of 14 eyes in 13 patients with age-related macular degeneration and foveal choroidal neovascularization, in which subretinal surgery was combined with simultaneous transplantation of autologous retinal pigment epithelial cells. METHODS: Between March 1999 and February 2000, in a prospective study, 14 eyes (13 patients) with age-related macular degeneration underwent subretinal surgery because of foveal choroidal neovascularization with simultaneous transplantation of retinal pigment epithelium harvested from the nasal subretinal area of the same eye. Preoperatively, 1 month postoperatively, 3 months postoperatively and at 3-month intervals thereafter, examinations were performed including best-corrected visual acuity, visual field, biomicroscopy of anterior and posterior segment, tonometry, fluorescein and indocyanine angiographies, autofluorescence, scotometry, and fixation tests. RESULTS: Postoperatively, after median observation of 17 months (range, 12 to 24 months) best-corrected visual acuity was improved 2 or more lines in eight eyes (57.1%), remained the same (+/- 1 line) in five eyes (35%), and decreased by more than 2 lines in one eye (7.1%). Pairwise t test showed significant improvement after 1 month (P = .0031, P = .0062) as well as 1 year (P = .0066, P = .0105). Satisfactory reading vision between Jaeger 1 and 4 was achieved in three eyes (21.2%). No significant intraoperative or postoperative complications occurred in any eye. No recurrence of choroidal neovascularization was observed during the observation period. CONCLUSIONS: In eyes with age-related macular degeneration and foveal choroidal neovascularization, autotransplantation of retinal pigment epithelium was performed in addition to conventional removal of the choroidal neovascularization without significant intraoperative or postoperative complications. Visual acuity improvement of 2 or more lines in 57% of the eyes was achieved. No recurrent choroidal neovascularization formation was observed during the observation period. The results of this pilot study suggest that autologous transplantation of retinal pigment epithelium combined with submacular surgery might be a reasonable treatment option for patients with foveal choroidal neovascularization secondary to age-related macular degeneration.     

Ocular photodynamic therapy in choroidal neovascularization complicating idiopathic central serous chorioretinopathy.

Two consecutive patients with idiopathic central serous chorioretinopathy and decreased vision subsequent to subfoveal choroidal neovascular membranes were treated with photodynamic therapy applied using the protocol of the Treatment of Age-Related Macular Degeneration with Photodynamic Therapy Study Group. Main outcome measures included best-corrected visual acuity, biomicroscopic appearance, and leakage on fluorescein and indocyanine green angiography. Photodynamic therapy offered anatomical, angiographic, and functional improvement. After an initial complete response, the patients required re-treatment at 3 and 4 months, respectively. Cessation of leakage with improvement in visual acuity occurred, but subretinal fibrosis posed a possible limitation for full functional recovery. Although choroidal neovascular membranes complicating idiopathic central serous chorioretinopathy portend a poor visual prognosis, the overall response to photodynamic therapy was favorable.     

Macular translocation for subfoveal choroidal neovascularization in age-related macular degeneration: a prospective study.

PURPOSE: To conduct a prospective study of macular translocation in patients with subfoveal choroidal neovascularization secondary to age-related macular degeneration. METHODS: In 10 eyes of 10 patients with subfoveal choroidal neovascularization and best-corrected visual acuity ranging from 20/50 to 20/800 (median, 20/111), the fovea was relocated by means of scleral imbrication, intentional retinal detachment with small posterior retinotomies, and partial fluid-air exchange. In two eyes, the choroidal neovascular membranes were removed at the time of macular translocation; in seven eyes they were photocoagulated in the postoperative period; and in one eye the membrane was removed during reoperation to unfold a macular fold. RESULTS: All 10 eyes were followed up for 6 months. The median postoperative foveal displacement was 1286 microm (range, 114 to 1,919 microm). In three eyes (30%), a foveal fold formed postoperatively requiring reoperation, with one of these eyes requiring a second reoperation for a rhegmatogenous retinal detachment. Best-corrected visual acuity improved in four eyes (median, 10.5 letters) and decreased in six eyes (median, 14.5 letters). The median change in visual acuity was a decrease of 5 letters. The final best-corrected visual acuity was 20/80 in two eyes, 20/126 in one eye, 20/160 in four eyes, 20/200 in one eye, 20/250 in one eye, and 20/640 in one eye. CONCLUSIONS: Our initial experience with limited macular translocation suggests that this surgical technique is unpredictable. However, in patients with subfoveal choroidal neovascularization from age-related macular degeneration, it offers the potential for improving visual function and may be associated with less loss of vision than the disease itself, if allowed to progress. Further refinements in surgical indications and technique are needed to make this procedure safer, more predictable, and more beneficial.     

The natural history of pigment epithelial detachment associated with central serous chorioretinopathy

PURPOSE: To determine the visual outcome of retinal pigment epithelial detachment (PED) associated with central serous chorioretinopathy (CSC), to further characterize the natural history of these lesions, and to provide a review of previous reports. PARTICIPANTS: Data for 340 consecutive patients with a diagnosis of CSC from January 2001 through December 2004 were retrospectively reviewed. Patients with CSC combined with angiographic evidence of PED were included in the study. MAIN OUTCOME MEASURES: Age, sex, use of corticosteroid medications, presenting visual acuity, and final visual acuity were recorded. Lesion characteristics including location, number of lesions, and laterality were recorded. Clinical outcome measures included resolution or persistence of the PED, progression to retinal pigmentary atrophy, or development of choroidal neovascularization. Fluorescein angiograms were obtained if available. RESULTS: Thirty-four (9%) of 319 patients with angiographic evidence of CSC were diagnosed with PED over a mean follow-up of 49 months (range, 12-165 months; median, 36 months). Mean age of the patients was 47 years (range, 32-69 years; median, 48 years), most of whom were males (68%). Mean initial visual acuity was 20/32 (range, 20/13 to 20/400; median, 20/30). PEDs were commonly unilateral (88%), unifocal (76%), and extrafoveal (82%). Overall mean final visual acuity was 20/25 (range, 20/13 to 20/250; median, 20/25) for all patients. Mean visual acuity for the group of patients with subfoveal PED (18%) was 20/50 (range, 20/25 to 20/250; median, 20/50). Complete resolution of the PED occurred in 65% of patients, with resultant mean visual acuity of 20/25 (range, 20/13 to 20/250; median, 20/25). In this group, localized retinal pigment epithelial atrophy developed in 86%, with mean final visual acuity of 20/25 (range, 20/13 to 20/250; median, 20/25). Persistent PED was observed in 35% of patients, resulting in mean visual acuity of 20/25. There were no cases of choroidal neovascularization. CONCLUSIONS: CSC with associated retinal PED may be seen and generally has a good visual prognosis. The most frequent outcome is resolution with retinal pigment epithelial atrophy. Subfoveal PED occurs less commonly and may have a poorer visual prognosis.     

黄斑下脉络膜新生血管膜的手术治疗及随访观察

目的探讨黄斑下脉络膜新生血管膜手术治疗后的远期效果。方法经睫状体平部行闭路式玻璃体切除术后，切开视网膜，取出黄斑下脉络膜新生血管膜瘢痕组织。７例（７只眼）手术前、后均行视力、矫正视力、眼底及眼底血管荧光素造影检查，并进行长期随诊观察。结果随诊观察１年以上，６只眼黄斑下脉络膜新生血管膜消失，１只眼脉络膜新生血管膜复发。６只眼手术后视力均有不同程度增进，其中２只眼视力提高到０．５以上；１只眼视力减退，黄斑机化组织形成；１只眼发生继发性黄斑前膜。结论黄斑下脉络膜新生血管膜手术切除后，大多数眼视力有所提高，视力提高大小与黄斑下脉络膜新生血管膜瘢痕组织对色素上皮及神经上皮的损害程度有关，手术操作对色素上皮及神经上皮的影响亦有一定关系。     

Initial experience of inferior limited macular translocation for subfoveal choroidal neovascularization resulting from causes other than age-related macular degeneration

PURPOSE: To report our initial experience of inferior limited macular translocation in patients with subfoveal choroidal neovascularization resulting from causes other than age-related macular degeneration. METHODS: We conducted a retrospective study of 23 eyes of 22 patients with choroidal neovascularization involving the foveal center secondary to pathologic myopia (11 eyes), ocular histoplasmosis syndrome (four eyes), angioid streaks (four eyes), idiopathic neovascularization (three eyes), and multifocal choroiditis (one eye), in which the fovea was moved inferiorly by means of limited macular translocation surgery. The mean preoperative best-corrected visual acuity was 20/150, and in five of 23 eyes (21.7%) the visual acuity was 20/80 or better. The major outcome measures were preoperative and postoperative visual acuity, postoperative foveal displacement, and complications related to the surgery. RESULTS: The mean postoperative follow-up was 10.82 months (range, 6 to 18 months). Postoperative best-corrected visual acuity improved by 2 or more Snellen lines of visual acuity in 11 of 23 eyes (47.82%), remained within 1 line in seven of 23 eyes (30.43%), and worsened 2 or more lines of vision in five of 23 eyes (21.74%). The mean postoperative best-corrected visual acuity was 20/100, and in 12 of the 23 eyes (52.17%) the visual acuity achieved was 20/80 or better. Retinal detachment was the most frequent complication and occurred in six eyes (26%). CONCLUSIONS: Our initial experience with limited macular translocation shows that this treatment modality offers the potential to improve visual function in some eyes with subfoveal choroidal neovascularization secondary to myopia, ocular histoplasmosis syndrome, angioid streaks, idiopathic neovascularization, and multifocal choroiditis. Although longer and more complete follow-up is needed, the results of this initial series warrant further studies to define the precise role of macular translocation in the management of these conditions.     

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.     

massive peripapillary subretinal neovascularization: an indication for submacular surgery

PURPOSE: To describe the course and outcome of three consecutive patients with massive peripapillary subretinal neovascularization secondary to ocular histoplasmosis syndrome managed with submacular surgery. METHODS: Three eyes of three consecutive patients with progressive and massive peripapillary subretinal neovascularization secondary to ocular histoplasmosis syndrome were treated with submacular surgery and followed up for a mean of 41 months (range, 11-59 months). The main outcomes were surgical complications, visual acuity, and subretinal membrane recurrence. RESULTS: Visual acuity improved in each patient from counting fingers, 20/25, and 20/400 preoperatively to 20/50, 20/20, and 20/20, respectively, at the last follow-up visit. With respect to complications, Patient 3 was found to have an operculated retinal tear approximately 1 month postoperatively, which was successfully treated with argon laser retinopexy. There were no cases of visually significant cataract, rhegmatogenous retinal detachment, or recurrent choroidal neovascularization in any of the operated eyes during the period of follow-up. CONCLUSIONS: Submacular surgery proved safe and beneficial in this small series of young patients with massive peripapillary subretinal neovascularization secondary to ocular histoplasmosis syndrome and should be considered in this relatively uncommon clinical presentation.     

Central serous chorioretinopathy.

BACKGROUND: Central serous chorioretinopathy is a condition typically affecting young adults between 25 and 50 years of age. It is predominating in type A personality trait men. Central serous chorioretinopathy is defined clinically as a detachment of the sensory retina that is commonly unilateral but can also be bilateral. Laser photocoagulation has been used widely with central serous chorioretinopathy to prevent recurrence and to speed recovery time. Photodynamic therapy is emerging as a potential treatment for chronic central serous chorioretinopathy. The prognosis for resolution and visual recovery for patients with central serous chorioretinopathy is excellent. Approximately 95% of patients with central serous chorioretinopathy will recover to a final visual acuity of 20/30. CASE REPORTS: Patient 1 was a 57-year-old man who reported to the clinic with a complaint of central scotoma involving the left eye. He also had a decrease in best-corrected visual acuity of 20/30 in the left eye. Idiopathic central serous chorioretinopathy was diagnosed, and observation was the management choice. At the 6-month follow-up, the patient's left eye visual acuity had returned to 20/20. Patient 2 was a 63-year-old man who reported to the clinic with decreased central vision of the left eye. His best-corrected visual acuity in that eye was 20/40. This was an unusual case because of the patient's age and the risk of macular degeneration. With fluorescein angiography and optical coherence tomography, the diagnosis of central serous chorioretinopathy was confirmed. At the 10-month follow-up the patient's acuity had returned to 20/20 in the left eye. Patient 3 was a 59-year-old man who reported to the clinic with decreased vision in the left eye. His best-corrected visual acuity was 20/60 in that eye. He is a kidney transplant recipient and was taking 60 mg of prednisone. The patient was found to have steroid-induced central serous chorioretinopathy. Observation was the management of choice for several months without resolution. Focal laser photocoagulation was performed at the 6-month follow-up, which did not help, and his ultimate visual acuity in the left eye was 20/400. He returned to the clinic 3 years later with the same complaint in his right eye. The patient was again found to have steroid-induced central serous chorioretinopathy but in the right eye, with a best-corrected visual acuity of 20/30. Because of the failure of photocoagulation in the left eye, observation was the chosen management option. The central serous chorioretinopathy did not resolve, and because of this it was decided that the patient's nephrologist be contacted to suggest a decrease in the patient's oral prednisone dose. The nephrologist decreased his prednisone from 60 mg daily to 5 mg daily. With this change, the patient's visual acuity stabilized at 20/25. The central serous chorioretinopathy was still present but without subjective visual complaints. CONCLUSION: Central serous chorioretinopathy is a condition that normally affects type A personality trait men. Also, patients taking any type of corticosteroids must be watched closely for the development of central serous chorioretinopathy. There is no good course for treatment, with observation being the best management choice. Photodynamic therapy may become the treatment choice for patients with chronic central serous chorioretinopathy, but more studies on the use of photodynamic therapy need to be completed.     

Limited macular translocation for the management of subfoveal retinal pigment epithelial loss after submacular surgery

PURPOSE: To report a case of subfoveal retinal pigment epithelial (retinal pigment epithelium) loss after submacular surgery managed successfully by limited macular translocation. METHODS: Case report. RESULTS: A 28-year-old woman presented with a visual acuity of 20/100 caused by subfoveal choroidal neovas-cularization secondary to ocular histoplasmosis syndrome. Submacular resection of the choroidal neovascularization was complicated by inadvertent retinal pigment epithelium loss from beneath the foveal center. She underwent limited macular translocation 5 days after the initial surgery and had successful displacement of the fovea to an area inferior to the retinal pigment epithelium defect. Her visual acuity was 20/60 4 months postoperatively. CONCLUSION: This report demonstrates the feasibility of using limited macular translocation for the management of eyes with central retinal pigment epithelium defect after submacular surgery and extends the clinical indications for limited macular translocation.     

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     

Results of intravitreal tissue plasminogen activator and expansile gas injection for submacular haemorrhage in Thais

PURPOSE: To study the results of intravitreal tissue plasminogen activator (tPA) and expansile gas injection for submacular haemorrhage in Thai patients. METHODS: The medical records of Thai patients who presented with submacular haemorrhage between January 1998 and December 2002 were reviewed. The inclusion criteria were acute onset of bleeding (<1 month), treatment with intravitreal injection of tPA solution (50-100 mug in 0.1 ml) and expansile gas (0.3-0.4 ml of 100% perfluoropropane or sulphur hexafluoride), and at least 6 months of follow-up. Our main outcome measures were best final postoperative visual acuity and surgical complications. RESULTS: A total of 19 eyes of 19 patients completed the inclusion criteria with a mean duration of 13.1 days. The causes of haemorrhage were age-related macular degeneration in 15 eyes (78.9%), idiopathic choroidal neovascularization in two eyes (10.5%), and traumatic, and valsalva retinopathy in one eye each (5.2%). After a mean follow-up of 13 months (range 6-39 months), postoperative visual acuity improved two lines or greater in 12 eyes (63.2%), stabilized in six eyes (31.6%) and worsened in one (5.2%). The final visual acuity measured 20/63 or better in 10 eyes (52.6%). The surgical complications were breakthrough vitreous haemorrhage (three eyes) and cataracts (three eyes), and two had retinal detachments. CONCLUSION: The treatment of submacular haemorrhage with intravitreal injection of tPA and expansile gas improved visual acuity in more than half of the patients. In all, 10 in 19 eyes demonstrated final visual acuity at a functional level.