Dennis M. Robertson

Prognosis for Central Vision and Anatomic Reattachment in Rhegmatogenous Retinal Detachment with Macula Detached

We analyzed a total of 473 eyes with rhegmatogenous retinal detachment and macular involvement for significant factors relating to anatomic success and a favorable visual outcome of 6/15 (20/50) or better. The overall success rate was 90% (427 of 473 eyes). Visual acuities of 6/15 (20/50) or better postoperatively were present in 37% (174 of 470 eyes). Important factors related to both anatomic success and favorable functional results were preoperative visual acuities of 6/15 (20/50) or better, retinal detachments that were less than total, detachments with tears located at or anterior to the equator, absence of giant retinal tears, absence of either preoperative ocular hypotony (tension less than 5 mm Hg) or ocular hypertension (intraocular pressure greater than 20 mm Hg), detachments managed by nondrainage techniques, a single operation with less than 50 cryoapplications, and noncircumferential buckling. Among the other factors related to favorable visual results were detachments lasting less than one month, a shallowly rather than highly detached macula, the absence of fixed retinal folds, a patient age of less than 60 years, and the absence of postoperative choroidal detachments sufficient to cause glaucoma. We found no statistical relationship between either anatomic success or functional result and the presence of aphakia, demarcation lines, vitreous hemorrhage, detachments of the pars plana epithelium, or predetachment glaucoma being treated.

Direct, Indirect, and Sham Laser Photocoagulation in the Management of Central Serous Chorioretinopathy

The role of argon laser photocoagulation in the management of central serous choriorectinopathy was evaluated in a prospective randomized study of eyes with leaks smaller than 250 microns in diameter in the early frames of the angiogram. Eyes were assigned to Group A when the leak was located in the papillomacular bundle or within 500 microns of the capillary-free zone and to Group B when the leakage site was located outside the papillomacular bundle and more than 500 microns from the capillary-free zone. Thirty eyes in Group A underwent either a sham argon laser treatment or a real argon laser treatment directed to the pigment epithelium under the elevated retina at a site remote from the site of fluorescein dye leakage (indirect laser photocoagulation). Twelve eyes in Group B underwent either a laser treatment directed to the site of fluorescein dye leakage (direct laser photocoagulation) or indirect laser photocoagulation. Compared with indirect photocoagulation, direct laser photocoagulation shortened the duration of central serous chorioretinopathy by approximately two months, a statistically significant difference. When compared to sham treatment, indirect photocoagulation did not significantly alter the duration of central serous chorioretinopathy. During an 18-month interval, the recurrence rate in the eyes treated with sham and indirect laser photocoagulation was 34%, whereas no recurrences were observed in the eyes treated with direct photocoagulation. There were no complications from photocoagulation in any of the eyes.

Retinal detachment in Olmsted County, Minnesota, 1976 through 1995

Abstract Objective To estimate the incidence of rhegmatogenous retinal detachment (RD) in a geographically defined population and to compare the probability of RD in residents after cataract extraction with the probability of RD in residents who did not have cataract extraction. Design Rochester Epidemiology Project databases were used to perform a retrospective population-based incidence study of RD diagnosed between 1976 and 1995 with cohort analyses of the influence of risk factors on the occurrence of RD. Participants The population of Olmsted County, Minnesota, participated. Main outcome measure Incidence rates of RD adjusted to the age and gender distribution of the 1990 U.S. white population were measured. Results Three hundred eleven incident cases of rhegmatogenous RD were identified. The mean annual age- and gender-adjusted incidence rate of rhegmatogenous RD was 17.9 per 100,000 persons (95% confidence interval [CI], 15.9–19.9). For idiopathic rhegmatogenous RD alone, the mean annual age- and gender-adjusted incidence rate was 12.6 (95% CI, 10.9–14.3) per 100,000 persons. Ten years after phacoemulsification and extracapsular cataract extraction, the estimated cumulative probability of RD was 5.5 (95% CI, 3.4–7.6) times as high as would have been expected in a similar group of county residents not undergoing cataract surgery. Conclusions Cataract surgery is associated with a significantly elevated long-term cumulative probability of retinal detachment.

The incidence of retinal detachment in Rochester, Minnesota, 1970-1978.

We studied the incidence of rhegmatogenous retinal detachment in Rochester, Minnesota, for the nine-year period from 1970 through 1978. The age-adjusted rate for idiopathic rhegmatogenous retinal detachment was 10.1 per 100,000 population per year (45 cases). Including 12 cases of aphakic retinal detachments, the age-adjusted incidence was 12.9 per 100,000 population per year. Not surprisingly, the incidence rate increased with age in both sexes. By extrapolation from the Rochester rates, the number of cases per year of idiopathic retinal detachment in the United States would be expected to be about 22,000, and the number of both aphakic and idiopathic phakic cases per year would be expected to approach 28,000.

Changing concepts in the management of choroidal melanoma

PURPOSE To review emerging information related to changing concepts in the management of choroidal melanoma. DESIGN AND METHODS This perspective reviews and discusses selected studies from the past two decades that have influenced management strategies for large, medium, and small-size choroidal melanomas. RESULTS Large choroidal tumors continue to be managed primarily by enucleation. The large tumor trial of the Collaborative Ocular Melanoma Study (COMS) demonstrated neither a positive nor negative effect on 5- and 8-year mortality rates among more than 1000 patients whose eyes containing large choroidal melanomas were randomized to treatment between enucleation alone or enucleation preceded by external radiation. The medium-size tumor trial of the COMS randomized more than 1300 patients between iodine-125 brachytherapy and enucleation. Mortality rates following brachytherapy did not differ from mortality rates following enucleation for up to 12 years after treatment. Iodine-125 has become the most commonly used isotope for brachytherapy in North America. Ten-year follow-up of eyes treated with helium ion and 20 years of experience with proton beam confirm the relative safety and efficacy of these modalities for treatment of choroidal melanoma. Although there is a trend toward earlier treatment of small melanomas, controversy exists regarding the indications for treatment as well as the choice of specific therapy. Recurrences of melanoma after eye-sparing treatment appear to be associated with an increased rate of metastatic disease. Effective adjunctive therapy to prevent or treat melanoma metastasis is lacking. CONCLUSIONS Choroidal melanoma is a lethal tumor. Although evidence suggests that patients with untreated choroidal melanomas have a poorer prognosis than patients who receive treatment, our current treatments are unable to prevent tumor-related deaths for many patients. The use of preoperative external radiation as an adjunct to enucleation for large choroidal melanomas is unsupported by data from the COMS trial. The use of radiation with either brachytherapy or charged particles for the management of medium-size choroidal melanomas is well supported on the basis of long-term follow-up studies. There is a trend toward treatment of smaller choroidal melanomas. Treatment of melanomas should be directed toward minimizing the potential for recurrences as recurrent melanomas are associated with an increased rate of metastatic disease. Gains in our ability to manage choroidal melanoma will likely be modest at best until effective systemic therapies can be identified.

Long-term observation of retinal lesions in tuberous sclerosis.

PURPOSE To obtain long-term photographic follow-up of retinal astrocytic hamartomas in patients with tuberous sclerosis to learn about their stability or possible growth patterns. METHODS Sixteen patients with a confirmed diagnosis of tuberous sclerosis and in whom retinal astrocytic hamartomas were photographed before 1986 at the Mayo Clinic underwent a complete ophthalmic examination, and fundus photographs were taken. The new photographs were compared with previous photographs, and changes in size, character, or number of retinal hamartomas were determined. The minimum follow-up period was five years. RESULTS A total of 37 astrocytic hamartomas were found. Follow-up ranged from almost six years to more than 34 years, with an average of 16 years. Hamartomas in three patients showed progressive or new calcification. In a fourth patient a retinal hamartoma appeared to originate from a site that had been previously photographically documented to be normal. The remaining hamartomas appeared unchanged over the follow-up period. CONCLUSIONS Although most retinal lesions in tuberous sclerosis remain stable, some become calcified over time. Additionally, new lesions may develop from previously normal-appearing retina.

Ophthalmic Features of Necrobiotic Xanthogranuloma with Paraproteinemia

Necrobiotic xanthogranuloma of the skin is associated with paraproteinemia and, often, with plasma proliferative disorders, including multiple myeloma. Other commonly recognized systemic abnormalities include hepatosplenomegaly, a highly increased erythrocyte sedimentation rate, and leukopenia. Fifteen of 16 patients (seven men and nine women with a mean age of 54 years) with this condition had ophthalmic manifestations. Thirteen patients had lesions affecting the skin of the eyelids and periorbital tissue; on casual examination these lesions resembled plane xanthoma. Unlike plane xanthoma, however, the lesions of necrobiotic xanthogranuloma were almost always indurated. Further, the lesions frequently became inflamed, leading to superficial ulceration. Deeper lesions occasionally involved the orbit. Yellow lesions were sometimes visible in the episcleral tissues where they were associated with recurrent symptoms of scleritis and episcleritis. Biopsy specimens of the skin lesions disclosed a distinctive pattern of subepidermal granulomatous masses with focal aggregates of histiocytes and giant cells surrounded by hyaline necrobiosis. Surgical excision of the eyelid lesions was often followed by recurrence and increased activity of the lesions. Low-dose chemotherapy is likely to produce a favorable response, with regard to both the skin lesions and the paraprotein abnormalities.

Second nonocular tumors in survivors of heritable retinoblastoma and prior radiation therapy

PURPOSE The principal objectives of this study were to estimate the incidence of second tumors among children treated for heritable retinoblastoma during a 50-year period and to investigate the relationship between these tumors and previous radiation therapy. METHODS The records of all retinoblastoma patients examined at the Mayo Clinic from 1941 through 1990 were retrospectively reviewed. The therapeutic modality used to manage the tumor, the occurrence of any second malignancy, and current follow-up on all patients were evaluated. RESULTS Eighty-two (46%) of 180 children with retinoblastoma had bilateral tumors (76 patients) or unilateral disease and a positive family history (six patients) and were followed for an average of 21.8 years (range, 1 month to 53 years). The Kaplan-Meier estimates of second nonocular tumors among the 82 patients with heritable retinoblastoma were 12% at 10 years, 16% at 25 years, and 30% at 40 years. Although 14 of the 15 patients who developed second malignancies had received radiation therapy, only four of the malignancies occurred within the field of irradiation. CONCLUSIONS The relatively low incidence of second tumors among long-term survivors of heritable retinoblastoma in this series of patients occurred predominantly outside the field of irradiation. The variable incidence of second nonocular malignancies in previous reports may reflect variations in radiation technique and dosage.

Ocular Surgery on Patients Receiving Long-Term Warfarin Therapy

We analyzed data of 50 patients receiving long-term warfarin sodium therapy who underwent ocular surgery between 1982 and 1986. The frequency of hemorrhagic and thrombotic complications was compared in patients in whom anticoagulants were continued, those in whom the anticoagulants were discontinued in the perioperative period, and a group of matched control patients. There were six perioperative hemorrhagic complications in the warfarin-treated group (12%) compared to none in the control group. This difference was significant (P less than .03). However, no significant difference in hemorrhagic complications was seen between patients in whom warfarin sodium was continued and those in whom it was discontinued.

Long-Term Follow-Up of Occlusion of the Central Retinal Vein in Young Adults

We did a long-term follow-up study of 42 patients aged 40 years and younger who had occlusion of the central retinal vein in order to learn its course and determine the frequency of related systemic disorders. Two groups of venous occlusion (complete and incomplete) were delineated by initial ocular findings. Final visual prognosis could not be predicted by the severity of the venous occlusion at the time of diagnosis. The presence of anomalous disk vessels closely correlated with a favorable prognosis in patients who had complete occlusion of the central retinal vein. None of the patients with incomplete central vein occlusion developed neovascular glucoma; three (14%) of the 21 patients with complete venous occlusion developed neovascular glucoma, which resulted in enucleation. Significant associated systemic maladies included cardiovascular disease and diabetes mellitus. An apparent correlation exists between occlusion of the central retinal vein and early death.