Alex E. Jalkh

Natural history of choroidal neovascularization in degenerative myopia.

We studied 354 eyes with myopic chorioretinal degeneration by means of standard clinical evaluation and fluorescein angiography. The eyes were classified on the basis of the degree of chorioretinal degeneration found in the posterior pole. Lacquer cracks (breaks in Bruchs membrane) were noted in 82% of the 149 eyes with choroidal neovascular membranes (CNM) and in 96% of the 58 eyes with isolated subretinal hemorrhages. These hemorrhages were reabsorbed without adverse visual sequelae in 32 eyes that were followed; in 14 of these eyes that were followed closely, the average time of reabsorption was 6.4 weeks. Seventy eyes with CNM were followed for an average of 40.9 months. In 96% of these eyes the CNM remained stable or regressed, leaving an atrophic, nonexudative scar. This study indicates that CNM in degenerative myopia is usually self-limited.

The Role of the Vitreous in Diabetic Macular Edema

The authors assessed retrospectively clinical records of 76 patients (125 eyes) 60 years of age or older with diabetic retinopathy who had undergone a vitreous examination. The groups consisted of 105 eyes (63 patients) with macular edema and 20 eyes (13 patients) without macular edema. Vitreous studies were done using the El Bayadi-Kajiura lens to determine whether or not the posterior vitreous was attached to the retina in the macula. Twenty-one of 105 eyes (20.0%) in the edema group and 11 of 20 eyes (55.0%) in the no-edema group had a detached posterior vitreous. This difference was found to be statistically significant, indicating that diabetic cases without macular edema have a significantly higher rate of posterior vitreous detachment than those with macular edema. This study demonstrates that the vitreous may play a role in diabetic macular edema.

Classification of retinal pigment epithelial detachments associated with drusen

To understand the natural history of retinal pigment epithelial (RPE) detachments (PEDs) associated with drusen, we retrospectively reviewed 125 PEDs that had not undergone laser treatment over an average follow-up period of 28 months. We identified six types of RPE detachments: pseudo-vitelliform, confluent drusen, serous, vascular, and hemorrhagic lesions as well as PEDs associated with a retinal vascular abnormality. We correlated the type of detachment with visual acuity and anatomic outcome. The poorest results were obtained for PEDs associated with neovascularization (vascular, hemorrhagic, and retinal vascular abnormality types). Eyes presenting with pseudo-vitelliform lesions or confluent drusen had the best visual prognosis and anatomic results. Obvious subretinal new vessels developed in 16 (34%) of the serous PEDs over an average follow-up period of 25 months. Subretinal neovascularization was rare in the pseudo-vitelliform and confluent drusen groups. The proposed classification system may be useful in predicting the natural course of PEDs.

Role of the vitreous in cystoid macular edema.

Eyes suffering from various conditions, such as aphakia, diabetic retinopathy, peripheral uveitis, branch vein occlusion, or retinitis pigmentosa, are predisposed to vitreous detachment. When vitreous detachment occurs, the vitreous can remain attached to the macula due to a firm vitreomacular adhesion. This partial posterior vitreous detachment associated with continuous vitreous traction to the macular area can lead to the development of cystoid macular edema. Two types of vitreous traction have been observed: traction with narrow vitreous strand and traction with broad vitreoretinal adhesion. It has been postulated that the posterior vitreous can cause cystoid macular edema by vitreous contraction without vitreous detachment, producing tractional forces at sites of firm vitreoretinal adhesions that are located at the optic disc and macula. Cystoid macular edema is often accompanied by leakage from dilated retinal capillaries at the optic disc.

Biomicroscopic Study of the Vitreous in Macular Breaks

The vitreous in 74 eyes with macular breaks was studied using the El Bayadi-Kajiura preset lens mounted on a slit lamp. Fifteen of the eyes had macular breaks secondary to various causes, and 59 eyes had idiopathic senile macular breaks. Vitreous traction, indicated by the presence of opercula or visible vitreous strands, was present in 29 (49%) of the idiopathic cases. In 17 of 31 eyes without posterior vitreous detachment (PVD), an operculum was seen. In these eyes, intravitreous traction was suspected to be the cause of macular breaks. Opercula were seen attached to the posterior hyaloid membrane in six of the nine eyes with partial PVD. An operculum corresponding to the macular break was observed on the posterior hyaloid membrane in only five of 19 eyes with complete PVD. Of the 15 eyes with macular breaks secondary to various causes, complete PVD was seen in 10 eyes, one of which had an operculum. One eye had no PVD, and four eyes had partial PVD. Opercula were detected in two of the latter eyes. In one eye of the senile group and one eye of the secondary group, partial PVD caused traction at the edges of the macular break, resulting in retinal detachment.

Role of the Vitreous in Idiopathic Preretinal Macular Fibrosis

Of 250 eyes with idiopathic preretinal macular fibrosis, 56 had no posterior vitreous detachment (Group 1), ten had partial posterior vitreous detachments without vitreous traction to the macula (Group 2), 29 had partial posterior vitreous detachments with vitreous traction to the macula (Group 3), and 155 had complete posterior vitreous detachments (Group 4). There were significantly more eyes with visual acuities of 20/60 or worse, cystoid macular changes, or macular fluorescein leakage in Group 3 than in Group 1 or Group 4. Thus, the presence of vitreous traction to the macula was associated with worse anatomic and functional findings.

Retinal Circulatory Changes after Scleral Buckling Procedures

The noninvasive laser Doppler technique was used to study retinal circulatory characteristics in five patients who underwent uncomplicated scleral buckling procedures. In each patient, the systolic/diastolic variation of the red blood cell speed in the retinal arteries (flow pulsatility ratio) was lower in the eye that had received an intrascleral implant and an encircling band than in the fellow eye. In one patient, an increase in flow pulsatility ratio accompanied an increase in retinal blood flow after removal of the scleral buckling elements. In another patient, the flow pulsatility ratio in the eye that had received a solid implant and an encircling band was less than the ratio in the fellow eye that had received an absorbable implant alone. Our results indicated that reduced retinal blood flow may be common after scleral buckling procedures, and may be a significant factor in otherwise inexplicable postoperative complications.

Retinal Detachment after Cataract Surgery: Surgical Results

The authors studied the results obtained by the Retina Associates in 376 eyes of 361 patients operated on for retinal detachment associated with aphakia or pseudophakia with a postoperative follow-up of at least 6 months. All eyes underwent scleral buckling. The series included 103 eyes with aphakia, 17 eyes with iris-fixated intraocular lens, 111 eyes with anterior chamber (AC) IOL, and 145 eyes with posterior chamber (PC) IOL. The overall success rate for retinal detachment was 93%, without significant difference among the different groups. The aphakia and PC IOL groups had significantly higher prevalence (63% and 60%, respectively) of visual acuity equal to or better than 20/40 compared with the AC IOL group (33%). The prevalence of postoperative corneal edema in the AC IOL group was significantly higher than in the aphakia and PC IOL groups. Preoperative vitreous hemorrhage, large retinal breaks, posterior retinal breaks, total retinal detachment, proliferative vitreoretinopathy, and the need for performing a closed vitrectomy were significant factors in predicting ultimate failure.

Characterization of Functional Changes in Macular Holes and Cysts

Precise characterization of functional loss in small retinal lesions is difficult with conventional techniques. Using the scanning laser ophthalmoscope, the authors evaluated functional changes and fixation behavior in 26 eyes with macular holes and 15 eyes with macular cysts. A dense scotoma was present over all macular holes; 24 had no detectable functional alteration at the margins of the hole, and fixation was above the horizontal meridian in all eyes. Nine eyes with cysts had no detectable functional loss over the cyst. Only two eyes had small areas of dense scotoma within the cyst area, and four had areas of relative scotoma. Fixation was central in all eyes. Characterization of functional changes is helpful in differentiating holes from cysts. Photocoagulation at the margin of the holes may result in further functional damage.

Unusual Central Chorioretinitis as the First Manifestation of Early Secondary Syphilis

Three young, otherwise healthy patients had a similar picture of unilateral central chorioretinitis associated with severe visual loss. Fluorescein angiography disclosed diffuse leakage under the neurosensory retina in the posterior pole, associated with multifocal areas of staining along the retinal vessels. Systemic examination showed a positive fluorescent treponemal antibody absorption test and a sharp increase in VDRL titers, indicative of active secondary syphilis. The patients responded dramatically to penicillin treatment, with visual recovery and resolution of the fundus lesions.