Daniel Finkelstein

Photocoagulation Treatment of Proliferative Diabetic Retinopathy: The Second Report of Diabetic Retinopathy Study Findings

Data from the Diabetic Retinopathy Study (DRS) show that photocoagulad inhibited the progression of retinopathy. These beneficial effects were noted to some degree in all those stages of diabetic retinopathy which were included in the Study. Some deleterious effects of treatment were also found, including losses of visual acuity and constriction of peripheral visual field. The risk of these harmful effects was considered acceptable in eyes with retinopathy in the moderate or severe retinopathy in the moderate or severe proliferative stage when the risk of severe visual loss without treatment was great. In early proliferative or severe nonproliferative retinopathy, when the risk of severe visual loss without treatment was less, the risks of harmful treatment effects assumed greater importance. In these earlier stages, DRS findings have not led to a clear choice between prompt treatment and deferral of treatment unless and until progression to a more severe stage occurs.

Acute retinal necrosis syndrome.

Six patients with the acute retinal necrosis (ARN) syndrome are described. Ophthalmoscopic examination demonstrated occlusion of peripheral retinal vessels and patchy areas of peripheral retinal whitening spreading rapidly over a period of weeks to markedly decreased vision. In four patients, the disease was bilateral. Histologic examination of vitrectomy specimens from three cases and one enucleated eye revealed chronic granulomatous inflammation. Extensive medical evaluations were noncontributory, with no evidence of compromised immune systems. No patient demonstrated a response to any form of therapy. The etiology is unknown.

Visual hallucinations in patients from an ophthalmology clinic and medical clinic population.

Although visual hallucinations have been associated with patients with visual disorders, no study has specifically examined whether visual hallucinations are indeed more prevalent than in a general medical population. In this study, 127 consecutive visual disorder patients and 100 consecutive general medical patients were screened for complex visual hallucinations. A total of 6.3% of visual disorder patients and 2% of general medical patients had visual hallucinations. Interestingly, the two medical patients with visual hallucinations also had visual disorders. Factors significantly associated with visual hallucinations were female sex (p=.029) and lower cognitive score (p=.001). Data from a previous study of patients with the visual disorder age-related macular degeneration were combined with this study to increase the sample size of visual hallucinators. Factors significantly associated with visual hallucinations in the combined sample were female sex (p=.015), living alone (p=.019), having hearing problems (p=.047), older age (p=.013), and lower cognitive score (p<.001). Implications and future research are discussed.

Experimental Retinal Neovascularization Induced by Intravitreal Tumors

Adult rabbit retinal vessels underwent neovascularization in response to tumor implantation within the vitreous body. The neovascular response was presumably elicited by the tumor angiogenesis factor (TAF). The response of adult retinal vessels to an angiogenic stimulus raises the possibility that a similar substance may cause retinal neovascularization in humans, and that in normal conditions the vitreous may be able to suppress angiogenic activity.

Subretinal Neovascularization Developing After Prophylactic Argon Laser Photocoagulation of Atrophic Macular Scars

Two patients who had lost central vision in one eye due to a histoplasmic disciform macular scar received prophylactic argon laser photocoagulation to one or more atrophic lesions (histo spots) in the second macula in an effort to reduce the risk of developing active neovascularization in the second eye. Despite this prophylactic treatment, both patients developed a choroidal neovascular membrane from the photocoagulation scar.

Ocular Reticulum Cell Sarcoma: Clinicopathologic Correlation of a Case With Multifocal Lesions

A 56-year-old man presented with recalcitrant uveitis with anterior chamber and vitreous cells. He developed small scattered lesions in the macular areas of both eyes, which disappeared in the right eye and evolved to multifocal, discrete, punched-out lesions resembling birdshot retinochoroidopathy in the left eye. Ocular reticulum cell sarcoma (RCS) was suspected but was not confirmed by diagnostic vitrectomy. The patient died 3 years later and was found to have RCS with central nervous system and ocular involvement. The occurrence of tumor cells under the retinal pigment was the apparent cause of the multifocal lesions that disappeared in the right eye and that led to discrete punchedout lesions with no scarring in the left eye.

Clinicopathologic Correlation of Lipidization and Detachment of the Retinal Pigment Epithelium

A 49-year-old woman had a few small drusen-like lesions and one larger area of depigmentation in the right fundus. The pin-point lesions corresponded to single enlarged retinal pigment epithelial cells with lipid accumulation and the larger area represented a small, localized retinal pigment epithelial detachment (soft druse). Lipoidal degeneration of individual retinal pigment epithelial cells may be a mechanism of nodular drusen formation. The soft druse was associated with thickening of the basement membrane of the retinal pigment epithelium.

Cyclic Macular EDEMA

Three patients with macular edema noted that their vision improved during the course of the day. In one patient, a 25-year-old man, visual acuity improved from 20/40 to 20/30; in the second, a 53-year-old woman, it improved from 20/60 to 20/40; in the third, a 30-year-old man, it improved from 20/25 to 20/20. The Rayleigh match showed a wider divergence in color matches to test wavelengths during the morning hours in one patient. The Stiles-Crawford effect was abnormal in all three patients but showed no cyclic pattern. All three patients had difficulty with Arden plates, but no cyclic pattern was apparent. The cyclic change in visual acuity could not be corrected by a change in refraction and may have been the result of a change in the macular edema.

Current concepts in the management of central retinal vein occlusion.

The results of the Central Vein Occlusion Study guide the management of complications of macular edema and neovascularization. Panretinal photocoagulation was shown to be beneficial for eyes with at least 2 hours of iris neovascularization or any angle neovascularization. Grid-pattern laser photocoagulation for perfused macular edema did not show a significant beneficial effect. Recently, several reports have suggested restoring venous outflow by 1) creating a chorioretinal anastomosis, 2) administering recombinant tissue plasminogen activator, 3) cannulating the retinal vein transvitreally, or 4) transecting the posterior scleral ring.

A New Approach to the Problem of Retinal Neovascularization

Tumor cells introduced into the rabbit vitreous produced a form of retinal neovascularization, but only when the tumor cells were in direct contact with the vascularized retina. This contrasted with the production of neovascularization at a distance of several millimeters in other angiogenesis models. An extract of adult rabbit vitreous was found to inhibit the growth of limbal neovascularization induced by tumors implanted in the rabbit corneal stroma. The experimental model of retrolental fibroplasia provides a bioassay to investigate further the apparent inhibitory substances in the vitreous.