H. Michael Lambert

Pathologic Features of Surgically Excised Subretinal Neovascular Membranes in Age-related Macular Degeneration

The histopathologic features of ten consecutive surgically excised subfoveal neovascular membranes from patients with age-related macular degeneration were examined. Ultrastructural features included the following in decreasing order of frequency: endothelium-lined vascular channels, new collagen, fibrocytes, retinal pigment epithelium, erythrocytes, and myofibroblasts. Chronic inflammatory cells were frequently evident and included macrophages, lymphocytes, and plasma cells. Basal laminar deposit or diffuse drusen were observed in six of the membranes. Photoreceptors and Bruchs membrane were each observed in three of the specimens, but were not associated with decreased postoperative visual acuity. Fibrin was observed in eight membranes, either within the stroma of the membrane or in association with subretinal hemorrhage.

Immunohistochemical and Histochemical Properties of Surgically Excised Subretinal Neovascular Membranes in Age-related Macular Degeneration

The immunohistochemical and histochemical properties of 16 surgically excised subretinal neovascular membranes from 16 patients with age-related macular degeneration were studied. Primary antisera to c-retinaldehyde-binding protein; leukocyte common antigen; factor VIII-related antigen; S-100 protein; glial fibrillary acid protein; muscle-specific actin; neuron-specific enolase; collagen types I, II, III, IV, and V; laminin; and fibronectin were used for immunohistochemical characterization of the membranes. Histochemical staining for lipid and mucopolysaccharide was performed. The results of the staining in conjunction with histologic examination showed the cellular components of the membranes to be composed of retinal pigment epithelium, inflammatory cells, vascular endothelium, glial cells, myofibroblasts, photoreceptor cells, and fibrocytes. The extracellular matrix of the membranes contained collagen types I, III, IV, and V; fibronectin; laminin; mucopolysaccharide; and lipid. These findings are consistent with the concept that subretinal neovascular membranes in age-related macular degeneration are composed of localized intra-Bruchs membrane granulation tissue proliferation associated with diffuse drusen.

Diode-laser Photocoagulation for Zone 1 Threshold Retinopathy of Prematurity

We used the diode-laser indirect ophthalmoscope in the treatment of 17 (30 eyes) infants with zone 1 (a circle centered on the optic disk with a radius of twice the distance from the disk to the fovea) threshold retinopathy of prematurity (at least five continuous or eight cumulative 30-degree sectors [clock hours] of ridge with extraretinal fibrovascular proliferation in the presence of plus disease). Mean follow-up was 31.2 weeks. Two eyes (6.7%) required retreatment of missed areas that had persistent plus disease (enlarged posterior veins and tortuous arterioles). A favorable outcome was attained in 25 eyes (83.3%). Five eyes (16.7%) developed retinal detachments, three of which remained stable at Stage 4A (extrafoveal retinal detachment) and two of which ultimately progressed to Stage 5 (total retinal detachment). Both eyes that went on to Stage 5 had severe posterior pole hemorrhages at the time of treatment. Two eyes that developed retinal detachments (one, stage 4A and one, stage 5) had rhegmatogenous components. Among 14 infants followed up for more than three months, four developed nystagmus, and six developed strabismus. In contrast to cryoablation, diode-laser photoablation of the peripheral retina was found to be an effective treatment for threshold retinopathy of prematurity located in zone 1. Portability and ease of use of the laser system, precision of treatment, and minimal postprocedural adnexal inflammation are further advantages of this therapeutic modality.

Surgical removal of subfoveal choroidal neovascularization in age-related macular degeneration.

OBJECTIVE To assess the results of surgical excision of subfoveal choroidal neovascularization (CNV) in patients with age-related macular degeneration (AMD). DESIGN Retrospective, interventional, noncomparative case series. PARTICIPANTS AND INTERVENTION Sixty-four consecutive patients undergoing surgical removal of AMD-related subfoveal CNV were studied. The surgical method included a small retinotomy, subretinal tissue plasminogen activator (t-PA), perfluoro-n-octane, and air-fluid exchange. MAIN OUTCOME MEASURES Final visual acuity was the main outcome measure; surgical complications and recurrence rates were also assessed. RESULTS Preoperative visual acuity ranged from 20/100 to 1/200, with a mean of 20/400. Average follow-up was 19 months. The best acuity achieved after surgery ranged from 20/20 to hand motions, with a mean of 20/200. Final visual acuity ranged from 20/50 to light perception, with a mean of 20/400. Final acuity was improved 3 or more lines in 19 eyes (30%) (median, 5 lines), stable in 27 eyes (42%), and 3 or more lines worse in 18 eyes (28%) (median, 4 lines). Factors associated with greater visual improvement included poorer initial acuity, larger CNV size, and smaller subretinal hemorrhage. Analysis of groups similar to Macular Photocoagulation Study subgroups A through D showed an average improvement of 1 line for group C (visual acuity, 20/200 or worse; CNV larger than 2 disc areas). Other preoperative, intraoperative, and postoperative factors, including recurrence and retinal detachment, did not have a significant effect on final visual outcome. CONCLUSIONS After surgical excision of AMD-related subfoveal CNV, vision improved or stabilized in the majority of patients. Surgery may be of greatest value for patients with poorer vision, larger subfoveal CNV, and minimal hemorrhage. Further evaluation of this technique should be accomplished via completion of a controlled, randomized multicenter study.

Well-defined subfoveal choroidal neovascular membranes in age-related macular degeneration.

PURPOSE The purpose of this study is to correlate the clinical, angiographic and ultrastructural features of well-defined subfoveal neovascular membranes. METHODS Fundus photographs and fluorescein angiograms of five well-defined subfoveal neovascular membranes associated with age-related macular degeneration and exudative retinal detachment were obtained. The subfoveal membranes were surgically excised via the pars plana. The center and peripheral portions of each membrane were evaluated by transmission electron microscopy for cellular and extracellular constituents. RESULTS Each subretinal neovascular membrane was composed of two distinct regions demonstrated by fluorescein angiography. The first component, the core, contained a brighter central area of hyperfluorescent leakage surrounded by a partial or complete cuff of elevated blocked choroidal fluorescence. Results of ultrastructural examination showed that the core was composed of a fibrovascular membrane characterized by endothelium-lined vascular channels with associated retinal pigment epithelium. The second region of the membrane, the rim, is previously unreported and is described in detail. It appeared as a minimally elevated, smooth, subretinal annular rim of hyperfluorescent staining that surrounded the core and was composed of fibrin, photoreceptor outer segments, and macrophages. CONCLUSIONS Well-defined subfoveal neovascular membranes can be appreciated with fluorescein angiography and are composed of a central core of subfoveal choroidal neovascularization surrounded by a peripheral rim composed of fibrin, photoreceptor outer segments, and macrophages.

Linear Nevus Sebaceous Syndrome

The linear nevus sebaceous syndrome is a rare disorder first described in 1962 in two cases by Feuerstein and Mims. As originally described, it consisted of the triad of the characteristic midline facial linear nevus sebaceous of Jadassohn, seizures, and mental retardation. The authors have followed a patient with this syndrome from birth to age 8 and although he does demonstrate several neurologic and ocular abnormalities, he enjoys normal intelligence and has never suffered seizures. The features of this syndrome and several new ocular findings demonstrated in this case are described. Based on our long-term follow-up of this patient and our review of the reported cases to date, the authors suggest that the triad for this disorder should be changed to include the midline facial linear nevus sebaceous of Jadassohn, neurologic abnormalities which may, but not necessarily, include seizures and mental retardation, and ophthalmologic abnormalities.

Pathogenetic mechanisms in anterior proliferative vitreoretinopathy

A clinicopathologic study of ten consecutive patients (ten eyes) undergoing surgery for rhegmatogenous retinal detachment with anterior proliferative vitreoretinopathy and a subsequent histopathologic, immunohistochemical, and ultrastructural study of ten enucleated eyes with anterior proliferative vitreoretinopathy were performed in order to elucidate relevant pathogenetic mechanisms. Our findings suggest that the pathogenetic evolution of anterior proliferative vitreoretinopathy occurs in three consecutive stages: (1) traction on the ciliary body and peripheral retina induced by fibrocellular contraction of the vitreous base; (2) incorporation of tractionally denuded components of the ciliary body and peripheral retina into the fibrocellular membranes overlying the vitreous base; and (3) proliferation of the incorporated components and fibrovascular ingrowth from the uvea, the retina, or both, into the fibrocellular membranes. Tractional disruption of the epithelium of the ciliary body pars plicata and breakdown of the ciliary blood-aqueous barrier are the principal pathogenetic mechanisms of chronic intractable hypotony and the post-vitrectomy fibrin syndrome in anterior proliferative vitreoretinopathy.

Characteristics after cataract extraction or secondary lens implantation among patients screened for the Endophthalmitis Vitrectomy Study

PURPOSE This report describes the presenting clinical ophthalmic features and historical findings in patients with a clinical diagnosis of endophthalmitis after cataract extraction or secondary lens implant surgery screened for enrollment in the Endophthalmitis Vitrectomy Study (EVS). DESIGN Clinic-based, cross-sectional study. PARTICIPANTS Eight hundred fifty-four patients suspected to have endophthalmitis after cataract extraction or secondary lens implantation. METHODS As part of the screening process for the study, an eye examination, a medical history, and demographic data were recorded in standardized form for all patients with endophthalmitis after cataract extraction or secondary lens implant surgery referred to the clinical centers, regardless of whether the patient met entry criteria. MAIN OUTCOME MEASURES Demographics, presenting signs, and symptoms. RESULTS The median age of individuals presenting with suspected bacterial endophthalmitis was 75 years (range, 9-100 years). Most of those screened (57.7%) were women. Seventy-nine percent of patients sought treatment within 6 weeks of surgery. Blurred vision, conjunctival injection, pain, and lid swelling were the predominant presenting symptoms in order of prevalence. Ocular pain and hypopyon, widely regarded as diagnostic of endophthalmitis, were each absent in 25% of patients. The median hypopyon height, when present, was 1.5 mm. CONCLUSIONS The classic presentation of postoperative endophthalmitis includes reduced vision, conjunctival hyperemia, pain, hypopyon, and lid swelling within days after cataract surgery or secondary lens implantation. These were the prominent clinical findings in the EVS as well. Because pain and hypopyon, although common, were not always present, clinicians must be vigilant in postsurgical monitoring of patients.

Pneumococcal Endophthalmitis Associated with Nasolacrimal Obstruction

Pneumococcal endophthalmitis can be a devastating postoperative infection after cataract extraction or penetrating keratoplasty. Streptococcus pneumoniae was isolated as the causative agent in three of the 124 patients (2%) who were treated for endophthalmitis at our institution between 1984 and 1990. Two of the three patients lost light perception in the affected eye. All three patients had previously unrecognized or untreated chronic nasolacrimal obstruction of varying causes. We studied the role of pneumococcal lacrimal conjunctivitis in the pathogenesis of the postoperative pneumococcal endophthalmitis in these patients.

Examination of Macular Vitreoretinal Interface Disorders With Monochromatic Photography

Monochromatic light accentuates details of different retinal layers because of its variable absorption and reflectance by structures both within and above these layers. Monochromatic photography was used to examine macular vitreoretinal interface abnormalities in 19 patients. Short wavelength photographs (490 nm) provided the best detail of inner retinal abnormalities, including epiretinal membranes, vitreoretinal traction, and the internal surface of confluent macular edema (pseudocyst). Although 540-nm red-free photography provided acceptable photographs, it did not provide optimal detail of inner or deep retinal abnormalities. Longer wavelengths, 585 and 610 nm, best disclosed the extent of deep retinal abnormalities, including the extent of confluent macular edema (pseudocysts) and retinal detachment that surrounded macular holes. The addition of short- and long-wave-length photography to traditional red-free photography may provide better localization, understanding, and documentation of the three-dimensional relationships in macular vitreoretinal interface disorders.