Ferdinando Bottoni

The dynamic healing process of idiopathic macular holes after surgical repair: a spectral-domain optical coherence tomography study.

PURPOSE To analyze progressive changes of the outer retina after vitrectomy for macular hole (MH) repair. METHODS Nineteen consecutive patients underwent vitrectomy for idiopathic MH. Spectral domain optical coherence tomography (SD-OCT) examinations were performed pre- and postoperatively during follow-up visits at 1, 3, 6, 9, and 12 months. Active eye-tracking technology ensured that the same scanning location was identified each time. RESULTS Ten eyes showed a normal external limiting membrane (ELM) at 1 month after surgery and 15 eyes at 3 months. The ELM was already continuous in 79% of the eyes with persistent outer foveal defects during follow-up. No eyes revealed a continuous inner segment/outer segment (IS/OS) line at 1 month, only one eye at 3 months, and 10 eyes at 12 months. No eyes had a disrupted ELM with an intact IS/OS line. Foveal cysts were visible in three eyes at 1 month and in eight eyes during follow-up. The cystic space gradually filled, resulting in a continuous IS/OS line in five of these eyes. Recovery of ELM, IS/OS, and outer nuclear layer (ONL) determined most of visual acuity improvement. The ONL appeared normal in the 10 eyes with an intact IS/OS line at last follow-up. By contrast, it was disrupted in 7 of 9 eyes with a final persistent outer foveal defect. CONCLUSIONS The ELM is the first structure to recover after MH closure. Foveal cysts may develop during follow-up, and in the presence of an intact ONL, they may gradually fill with complete recovery of the IS/OS junction.

Surgical removal of subfoveal choroidal neovascular membranes in high myopia

Abstract · Background: A study was carried out to elucidate the anatomical and functional outcome after surgical excision of subfoveal choroidal neovascular membranes in high myopia. · Methods: Sixty-five patients with high myopia (≥6 diopters), well-defined subfoveal neovascular membranes on fluorescein angiography and preoperative visual acuity ≤20/100 were selected for surgery. A standardized surgical technique was used in all cases, by a single surgeon. The main outcomes assessed were Snellen visual acuity, surgical retinal pigment epithelium defect and postoperative perfusion of the choriocapillaris. Multifactor analysis of variance and chi-square/Fisher’s exact test statistics were used to assess the association between patients’ pre- and postoperative characteristics and outcome measures. · Results: Follow-up ranged from 6 to 48 months (mean 16 months). Mean postoperative visual acuity (0.18) was significantly better than mean preoperative visual acuity (0.09). Visual acuity improved by at least two lines in 29 eyes (45%) and was unchanged in 24 (37%). Overall, 43 eyes (66%) had visual acuity of 20/200 or better and 15 (23%), 20/60 or better. Predictive factors with a significant effect on final visual acuity were mean visual acuity, preoperative status of retinal pigment epithelium and postoperative perfusion of the choriocapillaris. Postoperative perfusion was detected in 31 (48%) of the total 65 eyes and in 12 (67%) of the 18 eyes with normal retinal pigment epithelium at baseline. The mean postoperative retinal pigment epithelium defect was 4.6 times larger than the original neovascular membrane. In selected patients, SLO macular scotometry showed areas of retained retinal sensitivity within the atrophic scar. · Conclusion: The natural history of subfoveal neovascularization in high myopia is rarely visually restorative. By contrast, surgical excision of the membranes is feasible and may restore visual acuity in selected patients. This therapeutic approach merits a formal multicenter clinical trial.

Diagnosis of macular pseudoholes and lamellar macular holes: is optical coherence tomography the “gold standard”?

Aim: To assess fundus autofluorescence (AF) for differential diagnosis of macular pseudoholes (MPH) and lamellar macular holes (LMH) evaluated by optical coherence tomography (OCT) as the “gold standard”. Methods: The files on 50 eyes of 46 consecutive patients diagnosed by OCT as having a foveal defect with residual retinal tissue at the bottom were reviewed. Retinal thickness was measured at the foveal centre and 750 μm temporally and nasally to differentiate further MPH and LMH. The corresponding corrected AF images were then evaluated. Eyes with either macular pucker or stage 1a impending macular hole served as controls. Results: OCT measurements allowed the classification of two different profiles: 28 eyes classified with MPH had macular centres and perifoveal retinas that were significantly thicker than the 22 eyes classified with LMH. The corrected value of the foveal AF intensity was not significantly different between the two groups. In addition, the AF did not correlate with the thickness of the retinal tissue at the base of either MPH or LMH eyes. None of the control eyes showed foveal AF. Conclusions: The findings suggest that OCT data must be interpreted with caution when differentiating between MPH and LMH. In this series, the two groups showed similar foveal AF. AF imaging may add useful information to the differential diagnosis of MPH from LMH: the presence of foveal AF is consistent with a loss of foveal tissue and therefore a diagnosis of LMH.

Surgical removal of idiopathic, myopic and age-related subfoveal neovascularization

Abstract• Background: We investigated the functional outcomes of macular surgery for idiopathic, myopic and age-related subfoveal neovascular membranes and looked for preoperative features associated with better final visual acuity (VA). • Methods: We retrospectively studied 61 patients who had undergone macular surgery in our department between October 1992 and September 1994. Follow-up ranged from 5 to 27 months. Of 61 eyes with subfoveal neovascularizations, 6 were idiopathic, 21 had high myopia (-13 D median) and 34 displayed age-related macular degeneration (AMD). Median preoperative VA was 5/200 in AMD, 20/300 in myopia and 20/200 in idiopathic cases. • Results: Four of the six eyes with idiopathic subfoveal neovascularization had VA 20/60 or better after a median follow-up of 18 months. Of the 21 eyes with high moypia, 10 (48%) improved and 13 (62%) were 20/ 200 or greater after a median follow-up of 12 months. Among the 34 eyes with AMD, VA improved in 7 (21%), but only 6 (18%) were 20/ 200 or better after a median follow-up of 7 months. Overall, complications included five retinal detachments, ten cataracts and an increase in size of the retinal pigment epithelium defect over the neovascular membrane of 2.3 + 0.8 times (mean± SD) in idiopathic eyes, 5.9±3.6 times in myopia and 19.5 ± 12.2 times in AMD. Recurrence rates for idiopathic, myopic and age-related neovascular membranes were 33%, 19% and 18% re spectively. Etiology (P=0.035), initial VA in myopic eyes (P=0.026) and initial size of the neovascular membranes in AMD (P=0.025) were preoperative factors with a significant effect on final visual outcome. • Conclusions: Surgical excision of subfoveal neovascular membranes yields different functional results depending on the underlying disease. Severe alteration of the retinal pigment epithelium —Bruchs membrane complex may be responsible for the poor visual outcomes in AMD.

Spectral-domain OCT evaluation of Nd:YAG laser treatment for Valsalva retinopathy

PurposeTo describe the spectral-domain optical coherence tomography (SD-OCT) findings in a patient with a premacular hemorrhage due to Valsalva retinopathy treated with Nd:YAG laser.MethodsSerial SD-OCT examinations were performed before and after Nd:YAG laser treatment to identify the cleavage plane of blood accumulation, as well as the exact location of the areas targeted by the laser spots and the different involvement of the affected retinal layers.ResultsThe SD-OCT scan above the level of settled blood showed that the cleavage plane was located under the internal limiting membrane (ILM). A raster box of 48 horizontal scans centered on the treatment area identified the two spots of ILM targeted by laser. The hyporeflective perforations appeared along an ILM still detached from the underlying retinal layers. Two months after treatment, the blood was completely reabsorbed. The ILM appeared reattached in the previously detached area. Only a mild thickening of the ILM remained visible at the laser-treated spots.ConclusionsSD-OCT evaluation of Nd:YAG laser treatment for Valsalva retinopathy confirmed the cleavage plane of the premacular hemorrhage. In addition, it revealed the exact location of the ILM disruptions caused by the laser spots, and the safety of the procedure, with no involvement of the underlying retinal layers

The effect of simultaneous internal tamponade on fluid compartmentalization and its relationship to cell proliferation.

To determine whether the residual free spaces within the vitreous chamber that result after vitreoretinal surgery and internal tamponade may be avoided, and to verify whether such compartmentalization is of real importance in the recurrence of postoperative proliferative vitreoretinopathy (PVR), the use of simultaneous double filling with polydimethylsiloxane (PDMS) and fluorosilicone (FSiO) in the repair of complicated retinal detachment is evaluated in 12 selected cases. Initial retinal reattachment was achieved in all cases. PVR recurred in 10 patients (83%), 6 of whom showed partial retinal detachment. Inferior and superior postoperative residual free spaces were abolished by this procedure, but a new residual fluid space was created, lying horizontally between the bubbles and expanding in a triangular shape nasal to the optic disc and temporal to the macula. Overall, 9 of 10 eyes with PVR after surgery had proliferation involving these areas. These findings support the concept that compartmentalization is of major importance in determining postoperative cell proliferation.

Imaging Protocols in Clinical Studies in Advanced Age-Related Macular Degeneration: Recommendations from Classification of Atrophy Consensus Meetings

PURPOSE To summarize the results of 2 consensus meetings (Classification of Atrophy Meeting [CAM]) on conventional and advanced imaging modalities used to detect and quantify atrophy due to late-stage non-neovascular and neovascular age-related macular degeneration (AMD) and to provide recommendations on the use of these modalities in natural history studies and interventional clinical trials. DESIGN Systematic debate on the relevance of distinct imaging modalities held in 2 consensus meetings. PARTICIPANTS A panel of retina specialists. METHODS During the CAM, a consortium of international experts evaluated the advantages and disadvantages of various imaging modalities on the basis of the collective analysis of a large series of clinical cases. A systematic discussion on the role of each modality in future studies in non-neovascular and neovascular AMD was held. MAIN OUTCOME MEASURES Advantages and disadvantages of current retinal imaging technologies and recommendations for their use in advanced AMD trials. RESULTS Imaging protocols to detect, quantify, and monitor progression of atrophy should include color fundus photography (CFP), confocal fundus autofluorescence (FAF), confocal near-infrared reflectance (NIR), and high-resolution optical coherence tomography volume scans. These images should be acquired at regular intervals throughout the study. In studies of non-neovascular AMD (without evident signs of active or regressed neovascularization [NV] at baseline), CFP may be sufficient at baseline and end-of-study visit. Fluorescein angiography (FA) may become necessary to evaluate for NV at any visit during the study. Indocyanine-green angiography (ICG-A) may be considered at baseline under certain conditions. For studies in patients with neovascular AMD, increased need for visualization of the vasculature must be taken into account. Accordingly, these studies should include FA (recommended at baseline and selected follow-up visits) and ICG-A under certain conditions. CONCLUSIONS A multimodal imaging approach is recommended in clinical studies for the optimal detection and measurement of atrophy and its associated features. Specific validation studies will be necessary to determine the best combination of imaging modalities, and these recommendations will need to be updated as new imaging technologies become available in the future.

Integrated clinical evaluation of Type 2A idiopathic juxtafoveolar retinal telangiectasis

Purpose: To describe spectral high-resolution optical coherence tomography (OCT) findings correlated with fundus autofluorescence (FAF), confocal blue reflectance (CBR), and fluorescein angiography (FA) patterns in patients affected by Type 2A idiopathic juxtafoveolar retinal telangiectasis. Methods: We reviewed OCT, FA, CBR, and FAF images of both eyes from 11 patients affected by Type 2A idiopathic juxtafoveolar retinal telangiectasis. One eye had Stage 2 disease, 13 eyes had Stage 3 disease, 5 eyes had Stage 4 disease, and 3 eyes had Stage 5 disease. All the imaging modalities were obtained with a combined instrument for confocal scanning laser ophthalmoscopy and Spectral-domain OCT. Simultaneous acquisition of OCT images with FA, CBR, and FAF images was achieved with perfect point-to-point correspondence. Results: Increased parafoveal CBR was observed in all but 2 eyes that had Stage 5 disease. A correspondence of hyperautofluorescence on FAF and anatomical localization of the intraretinal cyst was observed in the 16 eyes where the cyst was visible by OCT. All eyes showed some alterations of the plexiform layers. A correspondence between increased CBR and late-phase FA hyperfluorescence occurred in the 4 eyes with focal and oval CBR pattern, whereas none of the 10 eyes with ring-pattern lesions had this correspondence. Patterns of increased CBR corresponded to areas of increased FAF in 94% of eligible eyes. Conclusion: The simultaneous acquisition of Spectral-domain OCT and reference images (FA, FAF, and CBR) with point-to-point correlation may further add to the understanding of morphologic alterations in Type 2A idiopathic juxtafoveolar retinal telangiectasis.

Consensus Definition for Atrophy Associated with Age-Related Macular Degeneration on OCT Classification of Atrophy Report 3

PURPOSE To develop consensus terminology and criteria for defining atrophy based on OCT findings in the setting of age-related macular degeneration (AMD). DESIGN Consensus meeting. PARTICIPANTS Panel of retina specialists, image reading center experts, retinal histologists, and optics engineers. METHODS As part of the Classification of Atrophy Meetings (CAM) program, an international group of experts surveyed the existing literature, performed a masked analysis of longitudinal multimodal imaging for a series of eyes with AMD, and reviewed the results of this analysis to define areas of agreement and disagreement. Through consensus discussions at 3 meetings over 12 months, a classification system based on OCT was proposed for atrophy secondary to AMD. Specific criteria were defined to establish the presence of atrophy. MAIN OUTCOME MEASURES A consensus classification system for atrophy and OCT-based criteria to identify atrophy. RESULTS OCT was proposed as the reference standard or base imaging method to diagnose and stage atrophy. Other methods, including fundus autofluorescence, near-infrared reflectance, and color imaging, provided complementary and confirmatory information. Recognizing that photoreceptor atrophy can occur without retinal pigment epithelium (RPE) atrophy and that atrophy can undergo an evolution of different stages, 4 terms and histologic candidates were proposed: complete RPE and outer retinal atrophy (cRORA), incomplete RPE and outer retinal atrophy, complete outer retinal atrophy, and incomplete outer retinal atrophy. Specific OCT criteria to diagnose cRORA were proposed: (1) a region of hypertransmission of at least 250 μm in diameter, (2) a zone of attenuation or disruption of the RPE of at least 250 μm in diameter, (3) evidence of overlying photoreceptor degeneration, and (4) absence of scrolled RPE or other signs of an RPE tear. CONCLUSIONS A classification system and criteria for OCT-defined atrophy in the setting of AMD has been proposed based on an international consensus. This classification is a more complete representation of changes that occur in AMD than can be detected using color fundus photography alone. Longitudinal information is required to validate the implied risk of vision loss associated with these terms. This system will enable such future studies to be undertaken using consistent definitions.

Clinical application of digital indocyanine green videoangiography in senile macular degeneration

Digital indocyanine green videoangiography (ICGV) was done in 34 eyes of 24 patients with aging macular degeneration (AMD), including drusen, either alone (6 eyes) or in association with other AMD changes (9 eyes), geographic atrophy of the retinal pigment epithelium (2 eyes), well-defined choroidal neovascularization (CNV; 3 eyes), occult CNV (12 eyes) and recurrent CNV (11 eyes). Of the 11 eyes with soft drusen, 10 showed abnormal fluorescence in the late ICGV picture. ICGV of the 4 eyes with hard drusen showed no abnormality. The geographic atrophy of the retinal pigment epithelium and choriocapillaris remained hypofluorescent with sharply demarcated boundaries throughout the study. ICGV confirmed the presence of CNV in all 3 eyes with well-defined CNV and in 11 of the 12 eyes with occult CNV Additionally, all but 1 eye with primary occult CNV and 6 of the 8 eyes with recurrent occult CNV could be reclassified in this study as having well-defined CNV Overall, ICGV yielded additional information in 17 of the 20 eyes with primary and recurrent occult CNV Its clinical importance for the evaluation of early stages of AMD has still to be confirmed by future investigations. ICGV is recommended as a diagnostic examination in eyes with CNV poorly defined by fluorescein angiography.