Donald A. Frambach

The Spectrum and Burden of Ocular Injury

The authors conducted a hospital-based study to ascertain basic, descriptive epidemiologic information about ocular trauma in an urban setting. Over a 6-month period, 3184 patients presenting to our emergency ward with ocular trauma were studied. Severe injuries totaled 5.1% (ruptured globe, intraocular foreign body, hyphema, orbital/facial fracture) and 94.9% were superficial injuries and contusions. A disproportionate burden of severe ocular injury was borne by those less than 15 years of age. The work place accounted for 48% of all injuries and 50% of ruptured globes. Automobile repair-related tasks were specifically associated with injury. Sports injuries, although accounting for 3.4% of all injuries, were responsible for 60% of hyphemas and 10% of ruptured globes. Annual direct and indirect costs for these ocular injuries are estimated conservatively at

Surgical management of macular holes: a report by the American Academy of Ophthalmology.

5 million and a loss of 60 work years. A large burden of preventable eye trauma is borne by both patients and society.

Vision-threatening Complications of Surgery for Full-thickness Macular Holes

OBJECTIVE The document describes macular hole surgery and examines the available evidence to address questions about the efficacy of the procedure for different stages of macular hole, complications during and after surgery, and modifications to the technique. METHODS A literature search conducted for the years 1968 to 2000 retrieved over 400 citations that matched the search criteria. This information was reviewed by panel members and a methodologist, and it was evaluated for the quality of the evidence presented. RESULTS There are three multicenter, controlled, randomized trials that constitute Level I evidence and compare the value of surgery versus observation for macular hole. There are three multicenter, controlled, randomized trials studying the use of adjuvant therapy in macular hole repair. Postoperative vision of 20/40 or better has been reported in 22% to 49% of patients in randomized trials. The risks of surgical complications include retinal detachment (3%), endophthalmitis (<1%), cataract (>75%), and late reopening the hole (2% to 10%). CONCLUSIONS The evidence does not support surgery for patients with stage 1 holes. Level I evidence supports surgery for stage 2 holes to prevent progression to later stages of the disease and further visual loss. Level I evidence shows that surgery improves the vision in a majority of patients with stage 3 and stage 4 holes. There is no strong evidence that adjuvant therapy used at the time of surgery results in improved surgical outcomes. Patient inconvenience, patient preference, and quality of life issues have not been studied.

Accidental Nd:YAG laser injuries to the macula

OBJECTIVE To study complications of vitrectomy surgery for full-thickness macular holes. DESIGN A multicentered, randomized, controlled clinical trial. PARTICIPANTS Community and university-based ophthalmology clinics. INTERVENTION Standardized macular hole surgery versus observation. MAIN OUTCOME MEASURES Assessment of anatomic and visual outcomes and determination of postoperative complications at 12 months after randomization. RESULTS Posterior segment complications were noted in 39 eyes (41%). The incidence of retinal pigment epithelium (RPE) alteration and retinal detachment (RD) were 33% and 11%, respectively. One RD due to a giant retinal tear resulted in a visual acuity of light perception. Other complications included a reopening of the macular hole in 2 eyes (2%), cystoid macular edema in 1 eye (1%), a choroidal neovascular membrane in 1 eye (1%) and endophthalmitis in 1 eye (1%). Eyes with complications had significantly worse visual acuity outcomes as determined by the Early Treatment Diabetic Retinopathy Study, Word Reading, and Potential Acuity Meter charts (P < 0.01 for all comparisons). Eyes with macular holes greater than 475 microns were more than twice as likely to have complications than eyes with holes less than 475 microns (odds ratio [OR] = 2.2, P = 0.07). Before surgery, the stage of the hole was related to postoperative RPE changes (P < 0.0001) and the occurrence of postoperative RD (P = 0.0002). Intraoperative trauma was related to the occurrence of these complications (P < 0.0001 for RPE changes, P = 0.02 for RDs). Epiretinal membrane removal was related to RPE changes (P = 0.02) but not RDs. CONCLUSIONS The RPE alterations and RDs are common after macular hole surgery and result in significantly reduced postoperative visual acuity. The RPE changes may be related to surgical trauma or light toxicity. Further efforts to reduce complications associated with macular hole surgery are indicated.

Retinopathy of prematurity: evaluation of risk factors.

PURPOSE To study the clinical course of accidental, single-focus Nd:YAG laser injuries to the macula. METHODS We reviewed the clinical course of five eyes (four patients) that sustained macular injuries from a Nd:YAG laser. All patients were examined within 24 hours of injury and were observed without surgical intervention for a mean of 20 months (range, 12 to 32 months). RESULTS A single full-thickness foveal or parafoveal retinal hole was apparent in all eyes either on initial examination or within two weeks of injury. All macular holes were within 650 microns of the foveal center. The mean final visual acuity was 20/60 (range, 20/25 to 20/400) and was related to the distance between the macular hole and the foveal center. None of the eyes developed either subretinal neovascularization or clinically significant epiretinal membrane formation during the study period. CONCLUSIONS Despite initial poor visual acuity in patients who had a full-thickness foveal or parafoveal retinal hole, visual acuity improved without treatment when the site of the laser injury was located outside the foveal center.

Delayed macular choriocapillary circulation in age-related macular degeneration

AbstractObjectives: The purpose of this study was to determine what risk factors play a role in the development of retinopathy of prematurity (ROP). Study design: Data were collected on 157 infants born and cared for in one institution between January 1991 and July 1994. Initially we evaluated all children enrolled in the study to determine potential risk factors for the development of ROP. We subsequently compared multiple variables for ROP positive singletons with ROP positive twins to determine ROP risk factors for each group and to determine if one group was more susceptible to a given risk factor. Results: Of the 157 infants examined, 72 infants (46%) developed ROP. Infants who developed ROP had a lower gestational age, a lower birth weight, a higher number of days on oxygen/ventilator. more days in the intensive care unit (ICU), a greater need for steroids and a higher incidence of sepsis when compared to infants who did not develop ROP. There was no significant difference noted between singleton and twin gestation infants that developed ROP when comparing gestational age, weight, ventilator time or length of ICU stay. Total number of days on oxygen therapy was higher in the singleton group and this difference did reach statistical significance. Conclusions: Several risk factors are associated with a higher incidence of ROP. These variables may not be independent risk factors but may be a sign of the increased severity of illness associated with those infants who are born earlier with a lower birth weight. Multiple gestational births do not appear to increase the risk of developing ROP when compared to a similar group of singleton birth infants.

A photogrammetric method to measure fluid movement across isolated frog retinal pigment epithelium.

Purpose. To investigate the macular choriocapillary circulation (MCC) in eyes with age-related macular degeneration (ARMD) and to correlate these findings with the associated clinical and angiographic drusen characteristics. Methods. Scanning laser ophthalmoscope fluorescein videoangiography was performed on 34 eyes with age-related macular degeneration and eight age-matched normal volunteers. Drusen characteristics were assessed using the Wisconsin age-related maculopathy grading scale. Results. A delayed macular choriocapillary circulation (DMCC) was defined as a macular choriocapillary filling time greater than 3 standard deviations from the normal mean (greater than 5 seconds). Nine (26%) of the 34 eyes with ARMD were found to have a DMCC. After age adjustment, eyes with DMCC were more likely to have geographic atrophy of the retinal pigment epithelium (p = 0.003) or choroidal neovascularization (p = 0.07) than were eyes with a normal MCC. Regional differences in choriocapillary filling times were present in the eyes with a DMCC, including nasal-to-temporal, central-to-peripheral, and inferior-to-superior gradients of progressively less choriocapillary filling delay. The DMCC correlated with the location, number, size, confluence, and fluorescein staining characteristics of the associated drusen. Conclusion. DMCC occurs in some eyes with ARMD. This finding may not only assist in defining eyes at risk for progressive disease but may also help to elucidate the pathogenesis of age-related macular degeneration.

Intraocular Pressure Increase Associated With Epsilon-Aminocaproic Acid Therapy for Traumatic Hyphema

Bullfrog retinal pigment epithelium (RPE)/choroid explants were mounted in an Ussing chamber modified so that the side bathing the choroid was completely sealed. Net fluid movement across the RPE and into or out of the sealed side of the chamber forced the tissue to assume a convex or concave shape. Photogrammetry was used to measure this tissue bowing by analyzing the displacement of the image produced on the RPE surface by an off-axis laser. Under baseline conditions, measured net fluid movements were always in the retina-to-choroid direction with a mean of 7.6 microliter cm-2 h-1. Potential artifacts from a variety of sources have been examined and shown to be insignificant.

Choroidal hypoperfusion after surgical excision of subfoveal neovascular membranes in age-related macular degeneration

We treated five patients receiving epsilon-aminocaproic acid who demonstrated sudden and accelerated clot dissolution with accompanying increases in intraocular pressure 24 to 96 hours after discontinuing treatment. All of these patients required additional ocular hypotensive medications and one patient required anterior chamber washout for persistently increased intraocular pressure. These findings suggest that certain patients with hyphema may be at risk for significant intraocular pressure increases following cessation of epsilon-aminocaproic acid therapy.

Stereoscopic Photography With a Scanning Laser Ophthalmoscope

Purpose. To study the choroidal circulation after surgical excision of subfoveal choroidal neovascular membranes (SFCNVM) in age-related macular degeneration (ARMD). Methods. Twelve eyes of eleven patients with ARMD that underwent surgical excision of SFCNVMs were evaluated with stereoscopic color fundus photography, stereoscopic fluorescein angiography (FA) and scanning laser ophthalmoscope-indocyanine green videoangiography (SLO-ICGv). The patients were followed for a mean of 7.9 months (range 2 to 14 months). Results. Preoperatively, all eyes had angiographic evidence of a SFCNVM, with SLO-ICGv showing the presence of a choriocapillary blush. Postoperatively, stereoscopic color fundus photographs documented that the bed of the surgical excision was characterized by an absence of visible retinal pigment epithelial (RPE) pigmentation in all eyes. Stereoscopic FA of the excision bed revealed choriocapillary hypofluorescence with visible dye perfusion in the underlying medium and large choroidal vessels in all eyes. SLO-ICGv of the excision bed disclosed the presence of perfused medium and large choroidal vessels, but a marked choroidal hypofluorescence with loss of the choriocapillary and small choroidal vascular filling within the excision bed in eleven of the twelve eyes. Conclusion. Our results indicate that both choriocapillary and small choroidal vascular filling is frequently abnormal or absent in the bed of surgically excised subfoveal neovascular membranes in ARMD. This finding, which may represent either pathologic or iatrogenic choriocapillary and small choroidal vascular atrophy or occlusion with preservation of perfusion in the underlying medium and large choroidal vessels, may influence structural and visual recovery after submacular surgery for ARMD, despite RPE transplantation or regeneration.