Fumio Shiraga

Feeder vessel photocoagulation of subfoveal choroidal neovascularization secondary to age-related macular degeneration

PURPOSEnThis study aimed to assess the feasibility of laser photocoagulation of feeder vessels of subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration.nnnPATIENTS AND METHODSnOf 170 consecutive patients with subfoveal CNV secondary to age-related macular degeneration, feeder vessels were detected in 37 patients by means of indocyanine green videoangiography using a scanning laser ophthalmoscope. Dye laser photocoagulation was applied to extrafoveal feeder vessels, with the fovea spared.nnnRESULTSnTwenty-six (70%) of those 37 patients had complete resolution of exudative manifestations. Persistent or worsened manifestations were seen in 11 patients (30%) because of recurrent CNV or persistent CNV. The visual acuity improved or stabilized in 25 patients (68%). Ten patients (27%) had a final visual acuity of 20/40 or better and six patients (16%) had a final visual acuity of 20/50 to 20/100. Significant factors prognostic of the visual outcome of 20/100 or better were small CNV (2 disc areas or smaller, Fishers exact probability test, P = 0.041), the absence of white, fibrous tissue in neovascular membranes (Fishers exact probability test, P = 0.003), and the closest distance of laser burns to the center of the foveal avascular zone (Fishers exact probability test, P = 0.049). Preoperative visual acuity had a significant positive correlation with final visual acuity (Spearmans rank correlation test, P = 0.0076).nnnCONCLUSIONnFeeder vessel photocoagulation should be considered as a treatment option for subfoveal CNV secondary to age-related macular degeneration, because no other treatment method has a better visual outcome.

Risk factors for diabetic choroidopathy in patients with diabetic retinopathy

AbstractPurpose. To identify risk factors for diabetic choroidopathy in patients with type 2 diabetes.n Methods. Forty-five consecutive patients with diabetic retinopathy underwent simultaneous indocyanine green angiography (ICG) and fluorescein angiography using a double detector and confocal scanning laser ophthalmoscopy in both eyes. Choroidal vascular abnormalities were evaluated by comparing the angiographic findings derived from the two methods. We analyzed the association between the presence of abnormal choroidal lesions evident on ICG angiography and several risk factors.n Results. Choroidal abnormalities evident on ICG angiography but not on fluorescein angiography included hypofluorescent spots in 72 eyes (80%) of 40 patients (89%), small hyperfluorescent spots in 61 eyes (68%) of 35 patients (78%), and large hyperfluorescent spots in 32 eyes (36%) of 21 patients (47%). The severity of diabetic retinopathy was significantly associated with the presence of hypofluorescent spots (P=0.002, Cochran–Armitage test) in both eyes and with the small hyperfluorescent spots in the right eyes (P=0.047, Cochran–Armitage test). Glycosylated hemoglobin levels were significantly associated with the large hyperfluorescent spots in the right eyes (P=0.003, Fishers exact probability test), and the treatment regimen was significantly associated with the small hyperfluorescent spots in the left eyes (P=0.048, chi-square test).n Conclusion. These data suggest that risk factors influencing the prevalence of diabetic choroidopathy in patients with type 2 diabetes mellitus may include severity of diabetic retinopathy, degree of diabetic control and treatment regimen.

Autologous Transplantation of the Internal Limiting Membrane for Refractory Macular Holes

PURPOSEnTo determine the effectiveness of autologous transplantation of the internal limiting membrane (ILM) for refractory macular holes.nnnDESIGNnProspective, interventional case series.nnnPATIENT AND METHODSnTen eyes of 10 consecutive patients who underwent autologous transplantation of the ILM for the treatment of refractory macular holes were studied. The primary diseases in these patients were large idiopathic macular holes that had existed for more than 1 year (4 eyes), a traumatic macular hole (1 eye), myopic foveoschisis (2 eyes), foveoschisis resulting from pit-macular syndrome (2 eyes), and proliferative diabetic retinopathy (1 eye). Apart from the 5 eyes with idiopathic or traumatic macular holes, macular holes developed in the other 5 eyes after initial vitrectomies with ILM removal. In all eyes, regular macular hole surgery failed to achieve closure. The main outcome measures used in this study were macular hole closure and best-corrected visual acuity (BCVA).nnnRESULTSnMacular holes were closed successfully in 9 eyes (90%) after autologous transplantation of the ILM. The postoperative BCVAs were significantly better than the preoperative BCVAs (P = .007, paired t test). Postoperative BCVAs improved by more than 0.2 logarithm of the minimal angle of resolution units in 8 eyes (80%) and were unchanged in 2 eyes (20%).nnnCONCLUSIONSnAlthough this is a pilot study, the results suggest that autologous transplantation of the ILM may contribute to improved anatomic and visual outcomes in the treatment of refractory macular holes and may warrant further investigation.

Survey of Complications of Indocyanine Green Angiography in Japan

PURPOSEnWe evaluated the safety of indocyanine green for use in fundus angiography.nnnMETHODSnWe sent a questionnaire concerning complications of indocyanine green to 32 institutions in Japan, which were selected on the basis of the client list from the Topcon Company, which manufactures the indocyanine green fundus camera.nnnRESULTSnOphthalmologists at 15 institutions responded, reporting a total of 3,774 indocyanine green angiograms performed on 2,820 patients between June 1984 and September 1992. Before angiography, intradermal or intravenous indocyanine green testing, or both was performed at 13 of 15 institutions. For three patients, the decision was made not to proceed with angiography after positive preangiographic testing. The dosage of indocyanine green used for angiography varied from 25 to 75 mg, depending upon the institution. There were 13 cases of adverse reactions (0.34%), ten of which were mild reactions such as nausea, exanthema, urtication, itchiness, and urgency to defecate, and did not require treatment. Also recorded were one case of pain of the vein, which required treatment, and two cases of hypotension. The two hypotensive patients required treatment for shock.nnnCONCLUSIONSnA comparison of frequency of adverse reactions to indocyanine green with the previously reported frequency of such reactions to fluorescein sodium indicated that indocyanine green is a safe as fluorescein for use in angiography.

Choroidal abnormalities in Behçet disease observed by simultaneous indocyanine green and fluorescein angiography with scanning laser ophthalmoscopy

OBJECTIVEnTo examine choroidopathy in patients with Behçet disease.nnnDESIGNnProspective clinical study.nnnPARTICIPANTSnThirty-three patients (63 eyes) with Behçet disease.nnnINTERVENTIONnPatients underwent simultaneous indocyanine green (ICG) and fluorescein angiography with a double detector of scanning laser ophthalmoscopy.nnnMAIN OUTCOME MEASURESnAngiographic findings recorded on videotapes were evaluated. The relation of angiographic findings with systemic activity and aqueous inflammation was also analyzed.nnnRESULTSnFluorescein angiography showed leakage in varying degrees from retinal vessels in 30 patients (53 eyes, 84%). The ICG angiographic findings were choroidal vascular wall staining in 16 eyes (25%), hyperfluorescent spots in 42 eyes (66%) and hypofluorescent plaques in 22 eyes (35%), both of which were not evident with fluorescein, leakage from choroidal vessels in 3 eyes (5%), and irregular filling of choriocapillaris in 11 eyes (17%). These findings did not have a statistically significant correlation with the presence or absence of aqueous inflammation or oral aphthous ulcerations.nnnCONCLUSIONSnThe patients with Behçet disease showed choroidal abnormalities, which could be revealed only by ICG angiography, but not with funduscopy or fluorescein angiography. Simultaneous ICG and fluorescein angiography would be useful for examining choroidal lesions in Behçet disease.

Prism adaptation response is useful for predicting surgical outcome in selected types of intermittent exotropia

PURPOSEnTo evaluate the prevalence of prism adaptation response in Japanese patients with intermittent exotropia (X [T]) using the prism adaptation test and to assess whether patients with selected types of X [T] benefit from surgical outcome to which prism adaptation response may contribute.nnnMETHODSnIn a prospective study, 128 consecutive patients with X [T] between 1990 and 1995 were enrolled. The prism adaptation test was conducted by neutralizing the angle of deviation for 2 to 3 hours. Patients who showed an increase in exodeviation by 10triangle up or more with the prism adaptation test were defined as having a prism adaptation response. For classification of the pattern of X [T], we chose a value of 15triangle up as the difference between the distance and near measurements.nnnRESULTSnThe percentage of patients in whom the prism adaptation response was observed at near fixation was significantly larger than those at distance fixation [35 (27%) patients versus 10 (8%) patients, P <.05]. Of 35 patients shown to have a prism adaptation response at near fixation, 21 patients (83%) had the basic type of exotropia. Fourteen patients (17%) with the basic type were changed to convergence insufficiency type because of an increase in near deviation and were defined as pseudo basic type. Patients with pseudo basic type had a significantly better surgical outcome compared with that of true basic type, whereas in the convergence insufficiency type, no definite tendency was found between the two subtypes, true and pseudo types.nnnCONCLUSIONnPatients with the pseudo basic type of X [T] in whom a prism adaptation response was demonstrated had a more favorable surgical outcome.

TIMP-1 Production by Human Scleral Fibroblast Decreases in Response to Cyclic Mechanical Stretching

Purpose: The effect of mechanical stretching was examined on cultured scleral fibroblasts of the human eye in order to observe changes in their production of TIMP (tissue inhibitor of metalloproteinase)-1, MMP (matrix metalloproteinase)-1 and -2 in response to physiological strain. Methods: Human scleral fibroblasts were cultured from scleral tissue resected during foveal translocation surgery. The fibroblasts in near confluency were exposed to mechanical stretching of the bottom of a 6-cm Petri dish at the maximum magnitude of 4500 microstrain and at a cycle of 30 s for 72 h. TIMP-1, MMP-1 and MMP-2 levels in the medium following 24, 48 and 72 h of cyclic stretching were measured by enzyme immunoassay. Results: The growth of scleral fibroblasts during the 72-hour period of stretching did not show a significant difference from that of non-stretched control fibroblasts. Scleral fibroblasts in the stretched group produced a significantly smaller amount of TIMP-1 at 72 h after stretching, compared with nonstretched control (p = 0.0353, Student t-test). The levels of MMP-1 and MMP-2 produced by scleral fibroblasts were not significantly different between the stretched group and nonstretched group. Conclusion: The production of TIMP-1 by human scleral fibroblasts was suppressed by cyclic mechanical stretching. Mechanical strain would be one factor to regulate the homeostasis of extracellular matrix in the sclera.

Clinical and Angiographic Characteristics of Retinal Manifestations in Cat Scratch Disease

PURPOSEnTo elucidate clinical and angiographic features of retinal manifestations in cat scratch disease.nnnMETHODSnClinical characteristics as well as fluorescein and indocyanine green (ICG) angiographic features were reviewed in 4 consecutive patients with retinal manifestations caused by serologically confirmed cat scratch disease.nnnRESULTSnA subretinal to intraretinal granuloma at the upper margin of the optic disc was found in 3 patients, while 1 patient developed subretinal to intraretinal granuloma in the midperiphery with serous retinal detachment. Fluorescein angiography revealed the abnormal vascular network of the peripapillary granuloma in the early phase followed by its dye leakage toward the late phase. Indocyanine green angiography demonstrated more clearly the abnormal vascular network with its minimal dye leakage than did fluorescein angiography. In contrast, only the late dye leakage was noted from granuloma of the midperipheral fundus by fluorescein angiography in one patient. Indocyanine green angiography detected no choroidal lesions other than the retinal lesions delineated by fluorescein angiography. The granulomas disappeared in response to a 4-week course of sulfamethoxazole-trimethoprim combined with steroids.nnnCONCLUSIONSnGranuloma with abnormal vascular network as revealed by fluorescein and ICG angiography is characteristic of retinal manifestations in cat scratch disease.

TIMP-1 and TIMP-2 levels in vitreous and subretinal fluid.

To understand the role of tissue inhibitors of metalloproteinase-1 and -2 (TIMP-1 and TIMP-2) in intraocular diseases, levels of TIMP-1 and TIMP-2 were measured by enzyme immunoassay in 47 patients with various ocular diseases: in subretinal fluid of 7 patients with rhegmatogenous retinal detachment and in vitreous of 12 patients with proliferative diabetic retinopathy, 4 with proliferative vitreoretinopathy, 2 with vitreous hemorrhage due to branch retinal vein occlusion, 12 with idiopathic macular hole, 3 with retinal detachment due to high-myopic macular hole, 4 with macular epiretinal membrane, and 3 with choroidal neovascular membrane due to age-related macular degeneration. TIMP-1 levels were significantly higher in subretinal fluid than in vitreous fluid with any diseases (P < 0.0001, Mann-Whitney U test). TIMP-1 levels in vitreous fluid of the eyes with proliferative diabetic retinopathy and proliferative vitreoretinopathy were higher than those in vitreous with other diseases (P < 0.0001). In contrast, TIMP-2 levels were not elevated in the subretinal fluid and vitreous. TIMP-1, but not TIMP-2, was secreted into the subretinal space in rhegmatogenous retinal detachment, and also into the vitreous in eyes with proliferative disease, suggesting that TIMP-1 would play a specific role in the process of these diseases.

Identification of ingrowth site of idiopathic subfoveal choroidal neovascularization by indocyanine green angiography

PURPOSEnThis study aimed to determine whether indocyanine green (ICG) angiography is useful to identify the ingrowth site of idiopathic choroidal neovascularization (CNV), which can predict visual outcomes after surgical removal of idiopathic CNV.nnnDESIGNnConsecutive, observational case series.nnnPARTICIPANTSnTwenty-six patients with idiopathic subfoveal CNV, of whom six underwent submacular surgery.nnnINTERVENTIONnIndocyanine green videoangiography with a scanning laser ophthalmoscope.nnnMAIN OUTCOME MEASURESnWe studied ICG videoangiographic images of choroidal neovascular membranes from the early phase to the late phase with special attention to abnormal findings, which can indicate the ingrowth site of CNV.nnnRESULTSnEarly ICG angiography demonstrated distinct neovascular vessels in 24 of the 26 patients (92%). Hypofluorescent rims continuously or intermittently surrounded neovascular membranes on late ICG angiograms in 21 of the 26 patients (81%). In 22 of the 26 patients (85%), ICG angiography demonstrated hypofluorescent areas within the CNV. These hypofluorescent areas frequently became ring shaped in the middle to late phase of the ICG angiography. In 14 of 16 patients (88%) with CNV larger than half a disc area, the filling of neovascular vessels appeared from the inside of the hypofluorescent areas and branched out toward the surrounding hyperfluorescent membrane in the early phase. In all six patients who underwent surgical removal of CNV, ICG videoangiography showed these hypofluorescent areas from which neovascular vessels emanated. Three of the four surgical patients, in whom hypofluorescent areas or central fluorescent areas surrounded by ring-shaped hypofluorescence were extrafoveal or juxtafoveal, had a best postoperative visual acuity of 20/60 or better. In contrast, both surgical patients with subfoveal hypofluorescent areas had a best postoperative visual acuity of 20/70 or worse.nnnCONCLUSIONSnAlthough further observations are needed, ICG angiography may be a useful adjunct in the identification of the ingrowth site of idiopathic CNV, which can predict visual outcomes after surgery.