Craig M. Morgan

Ocular Complications Associated with Retrobulbar Injections

The authors describe six complications, of retrobulbar injections documented by fundus photography and fluorescein angiography. These include (1) injection of corticosteroid into the posterior ciliary arterial circulation resulting in emboli in the vasculature of the choroid and the optic nerve head; (2) injection of corticosteroid into the ophthalmic artery resulting in emboli in both the choroidal and retinal circulations; (3) presumed injection of lidocaine and air into the optic nerve sheath adjacent to the globe with extension anteriorly into the subretinal space and the space between the posterior vitreous and the internal limiting membrane; (4) occlusion of the central retinal artery without an associated retrobulbar hemorrhage; (5) trauma to and partial injection of lidocaine in the central retinal artery with embolization into the retinal circulation; and (6) presumed injection of lidocaine into the optic nerve sheath producing a combined central retinal vein and artery occlusion. Alternative techniques that might decrease the incidence of complications associated with retrobulbar injections are discussed.

Pneumatic retinopexy : a two-year follow-up study of the multicenter clinical trial comparing pneumatic retinopexy with scleral buckling

The authors report 2-year follow-up information on 179 of 198 eyes (90%) enrolled in a previously published multicenter, randomized, controlled clinical trial comparing pneumatic retinopexy (PR) with scleral buckling (SB) for the management of selected retinal detachments. Scleral buckling was compared with PR with regard to redetachment after the initial 6-month follow-up period (1% versus 1%), overall attachment (98% versus 99%), subsequent cataract surgery (18% versus 4%; P less than 0.05), preoperative visual acuity (no significant difference), and final visual acuity of 20/50 or better in eyes with macular detachment for a period of 14 days or less (67% versus 89%; P less than or equal to 0.05). Reoperations after a failed PR attempt did not adversely affect visual outcome. After 2 years, PR continues to compare favorably with SB.

Atrophic Creep of the Retinal Pigment Epithelium after Focal Macular Photocoagulation

To determine if enlargement of laser scars occurs in nonmyopic individuals, the authors retrospectively reviewed 126 consecutive patients with age-related macular degeneration who had been successfully treated with focal macular laser photocoagulation for subretinal neovascularization. Of the 174 laser scars in the study, 122 (70%) increased in size from 50 to 1016 microns (mean, 290 microns) as determined photographically on serial examination ranging from 2 to 81 months. There was no statistically significant difference in the number of scars which increased in size among the three laser wavelengths used. Four (3%) patients lost vision as a result of the scar extending into the fovea. Enlargement of retinal pigment epithelial (RPE) atrophy after focal macular laser photocoagulation may cause significant, delayed visual loss after successful treatment of subretinal neovascularization.

Growth rate of subretinal neovascularization in age related macular degeneration

To determine the growth rate of subretinal neovascularization (SRNV) in age-related macular degeneration (ARMD), 35 pairs of serial fluorescein angiograms from 30 consecutive patients with SRNV who had not been treated with laser photocoagulation were analyzed. The daily growth rate of SRNV measured on consecutive fluorescein angiograms less than 120 days apart ranged from 0 to 74 microns (mean, 18 microns daily). The daily estimated growth rate of SRNV in any one direction ranged from 0 to 37 microns (mean, 9 microns daily). Documented initial slow growth of SRNV in one eye did not preclude a greater subsequent growth rate in the fellow eye. It was not possible to predict reliably the growth rate of SRNV. This reinforces the necessity of prompt evaluation of all subretinal neovascular membranes initially for the purpose of possible laser treatment.

Retinal vasculitis in polyarteritis nodosa.

Although uncommon, a wide variety of ocular manifestations can be seen in polyarteritis nodosa. These occur as a result of the arteritis or secondary to the associated renal induced hypertension. A case of biopsy documented polyarteritis nodosa is reported in which the patient presented with bilateral iritis, vitritis, and a retinal vasculitis involving both the retinal arteries and veins, a feature not described previously. Patients with this potentially fatal disorder may initially present with ocular involvement; thus ophthalmologists should be familiar with the clinical features of this disease.

New Posteriorly Located Retinal Breaks after Pneumatic Retinopexy

Pneumatic retinopexy is a new procedure that is effective in treating many uncomplicated cases of rhegmatogenous retinal detachment (RD). It may be done in the office using a cryoprobe or laser and an expanding gas bubble and for this reason has become popular among RD surgeons. Reports of associated complications are limited. Three patients who had remarkably posterior retinal breaks after pneumatic retinopexy are presented with evidence that these breaks are a direct complication of this procedure. A possible explanation as to the pathogenesis of pneumatic retinopexy-associated posteriorly located retinal tears, as well as suggestions regarding prophylactic measures that may be taken to avoid this complication, are also presented.

Involutional Macular Thinning

We identified a group of 93 patients (102 eyes) with involutional macular thinning which is a condition that predisposes the affected eyes to developing idiopathic macular holes. The fovea in these patients shows specific architectural changes that can be identified on ophthalmoscopy. On follow-up (mean, 50 months), 26 eyes (27%) developed a macular hole compared to 0% in normal fellow eyes (P less than 0.00001). Patients with pigment epithelial window defects on fluorescein angiography (12 of 15 eyes or 80%), or with no posterior vitreous detachment (15 of 34 eyes or 44%) had the highest risk of developing macular holes. There were seven eyes with involutional macular thinning, pigment epithelial window defects on fluorescein angiography and no posterior vitreous detachment; six (86%) developed a macular hole. Macular degeneration, estrogen supplements, cystoid changes (with normal fluorescein angiography), and poor visual acuity did not increase risk. We present a theory for the pathogenesis of idiopathic macular holes.

Limited Choroidal Hemorrhage Mistaken for a Choroidal Melanoma

Considerable progress has been made during the last few years in evaluating patients with suspected choroidal melanomas but difficulties continue to persist. In this report, the authors describe three cases with an unusual localized posterior choroidal hemorrhage, which were thought to be choroidal melanomas and referred for proton beam irradiation. These limited hemorrhagic choroidal detachments presented as a dark brown mass of considerable elevation, but were discrete, well localized, and located posterior to the equator. Fluorescein angiography and ultrasonography may be of some value in differentiating these lesions from choroidal melanomas. Serial observations over time will establish the correct diagnosis.

Linkage of Autosomal Dominant Radial Drusen (Malattia Leventinese) to Chromosome p 16???21

OBJECTIVE To identify the chromosomal location of the gene involved in the pathogenesis of autosomal dominant radial drusen (malattia leventinese). PATIENTS Eighty-six members of four families affected with radial drusen; one family of American origin and three families of Swiss origin. METHODS Family members were clinically examined for the presence of radial drusen. Affected patients and potentially informative spouses were genotyped with short tandem repeat polymorphisms distributed across the autosomal genome. The clinical and genotypic data were subjected to linkage analysis. RESULTS Fifty-six patients were found to be clinically affected. Significant linkage was observed between the disease phenotype and markers known to lie on the short arm of chromosome 2. The maximum two-point lod score (Zmax) observed for all four families combined was 10.5 and was obtained with marker D2S378. Multipoint analysis yielded a Zmax of 12, centered on marker D2S378. The lod-1 confidence interval was 8 cM, while the disease interval defined by observed recombinants was 14 cM. CONCLUSIONS The gene responsible for autosomal dominant radial drusen has been mapped to the short arm of chromosome 2. This is an important step toward actually isolating the disease-causing gene. In addition, this information can be used to evaluate other familial drusen phenotypes such as Doynes macular dystrophy for a possible allelic relationship.