H. Richard McDonald

Surgical Management of Idiopathic Epiretinal Membranes

The authors reviewed 33 consecutive cases of idiopathic epiretinal membranes removed by vitreous surgical techniques. Visual acuity improved in 79% of surgically treated eyes. In uncomplicated cases, a 47% gain in visual acuity was achieved. Of those eyes that had improved visual acuity post-operatively, 82.5% of the final visual acuity returned by four to eight weeks post-operatively. Eyes with opaque membranes had visual acuity results no worse than those with translucent membranes. Eyes with no pre-operative cystoid edema had better visual acuity results than eyes with cystoid macular edema (CME), although no statistically significant difference was shown. Surgical removal of membranes decreased fluorescein dye leakage in 30% of eyes; while no change in post-operative leakage was noted in 60%, one eye had increased CME post-operatively. Complications included development of nuclear sclerotic cataract, retinal breaks, retinal detachment, and one case of pigment epithelial/retinal burn from the endoilluminator, residual and recurrent membrane formation, and anterior ischemic optic neuropathy.

Vitrectomy for Prevention of Macular Holes: Results of a Randomized Multicenter Clinical Trial

PURPOSE: The purpose of this study is to assess the benefit of vitreous surgery in preventing full-thickness macular holes in patients with impending (stage 1) macular holes. METHODS: A prospective randomized multicenter clinical trial was conducted on patients with full-thickness macular holes in their first eye (stage 3 or 4) and signs and symptoms of stage 1 macular holes in their fellow eye (study eye). The study eye was randomized to vitreous surgery or observation. Outcome was assessed by standardized measurement of visual acuity, detailed clinical examination, fundus photographs, and fluorescein angiography. RESULTS: A full-thickness macular hole developed in 10 (37%) of 27 patients in the vitrectomy group compared with 14 (40%) of 35 patients randomized to observation (P = 0.81). This difference of 3% has a 95% confidence interval of (-21%, 27%). CONCLUSION: The study was terminated because of low recruitment. The authors were unable to prove (or disprove) the benefit of vitreous surgery in patients with stage 1 macular holes. The authors can state, however, that should a beneficial effect from vitrectomy exist, it would probably be minimal. Considering the cost and morbidity of vitreous surgery, a conservative approach for stage 1 macular hole might be appropriate.Purpose: The purpose of this study is to assess the benefit of vitreous surgery in preventing full-thickness macular holes in patients with impending (stage 1) macular holes. Methods: A prospective randomized multicenter clinical trial was conducted on patients with full-thickness macular holes in their first eye (stage 3 or 4) and signs and symptoms of stage 1 macular holes in their fellow eye (study eye). The study eye was randomized to vitreous surgery or observation. Outcome was assessed by standardized measurement of visual acuity, detailed clinical examination, fundus photographs, and fluorescein angiography. Results: A full-thickness macular hole developed in 10 (37%) of 27 patients in the vitrectomy group compared with 14 (40%) of 35 patients randomized to observation ( P = 0.81). This difference of 3% has a 95% confidence interval of (-21%,27%). Conclusion: The study was terminated because of low recruitment. The authors were unable to prove (or disprove) the benefit of vitreous surgery in patients with stage 1 macular holes. The authors can state, however, that should a beneficial effect from vitrectomy exist, it would probably be minimal. Considering the cost and morbidity of vitreous surgery, a conservative approach for stage 1 macular hole might be appropriate.

Traumatic macular hole: observations, pathogenesis, and results of vitrectomy surgery.

PURPOSE To review our experience with vitrectomy surgery techniques for the treatment of traumatic macular holes and the biomicroscopic and surgical findings. DESIGN Retrospective noncomparative, multicenter, case series. PARTICIPANTS AND INTERVENTION Twenty-five patients with traumatic macular hole underwent surgical repair. INTERVENTION Vitrectomy with membrane peeling and gas injection followed by prone positioning for 7 to 14 days. MAIN OUTCOME MEASURES Postoperative evaluation included visual acuity testing, closure of the macular hole, and ocular complications. RESULTS The macular hole was successfully closed in 24 of 25 cases (96%). The visual acuity improved two or more lines in 21 (84%) cases, and 16 (64%) achieved 20/50 or better vision. CONCLUSIONS Vitrectomy surgery can successfully close macular holes associated with trauma and improve vision.

CENTRAL RETINAL VEIN OCCLUSION IN YOUNG ADULTS (PAPILLOPHLEBITIS)

We performed a retrospective study of 103 cases of central retinal vein occlusion (CRVO) in young, nondiabetic adults that were followed for at least six months. Of these patients, 64% were men and 36% were women. While visual acuity was usually good, 33 eyes (32%) had a final visual acuity of 20/200 or worse, including 6 eyes (6%) with a final visual acuity of no light perception. Ocular complications included chronic cystoid macular edema, macular pigmentary changes (37%), sheathing of retinal vessels (22%), venous collaterals of the disc (33%), macular hole formation (1%), neovascularization of the disc (1%), retina (1%), and iris (19%), neovascular glaucoma (8%), and vitreous hemorrhage (7%).

Grid Laser Photocoagulation for Macular Edema in Bilateral Juxtafoveal Telangiectasis

OBJECTIVE The purpose of the study is to report the efficacy of laser photocoagulation treatment for macular edema in bilateral juxtafoveal telangiectasis (BJT). DESIGN The study design was a retrospective, clinical study. PARTICIPANTS The authors observed 14 patients with BJT, studying the visual acuities and retinal changes of treated and untreated eyes. MAIN OUTCOME MEASURES Visual acuity, presence of macular edema, and associated retinal findings were measured. RESULTS Of 28 eyes, 10 (8 patients) received 15 laser photocoagulation treatments for macular edema. Neither treated nor untreated eyes had visual improvement of two or more lines. After treatment, five eyes (50%) had increased retinal vascular distortion develop, three (30%) had new draining retinal venules, five (50%) had intraretinal fibrovascular tissues, and four (40%) had retinal and preretinal hemorrhages develop. CONCLUSIONS Grid laser photocoagulation therapy for macular edema in patients with BJT appears to neither improve nor stabilize long-term visual acuity. In addition, treatment is associated with retinal pigment epithelial changes, increased postoperative retinal vascular distortion, postoperative vascularized retinal scars, and postoperative retinal hemorrhages. These changes, however, do not appear to cause a further loss of vision.

Intravitreal Bevacizumab For Previously Treated Choroidal Neovascularization From Age-related Macular Degeneration

Purpose: To report the optical coherence tomography (OCT) findings and visual results in a series of patients treated with intravitreal bevacizumab for choroidal neovascularization (CNV) associated with age-related macular degeneration (AMD), and to determine if a difference in treatment effect exists between previously treated and treatment naïve patients. Methods: A retrospective review of all patients treated with intravitreal bevacizumab for CNV from AMD with visual acuity greater than or equal to 20/320 between September 2005 and February 2006 was performed. OCT data recorded included central macular thickness and the presence or absence of cystic intraretinal fluid, subretinal fluid, or pigment epithelial detachment at the time of the initial injection, at 1-week, 1-month, and 3-month intervals, as well as at the end of follow-up. Visual acuity measurements were recorded using Early Treatment Diabetic Retinopathy Study charts. Any ocular or systemic adverse events were recorded. Statistical analysis was performed to determine if OCT and visual acuity results were significant and to determine if a difference in outcomes existed between previously treated patients and treatment naïve patients. Results: Fifty-four eyes of 51 patients treated with intravitreal bevacizumab for CNV from AMD were identified. A total of 178 injections were performed. Mean number of days of follow-up was 138 with 91% of patients having at least 90 days of follow-up. Seventy percent of patients had undergone previous treatment for CNV. The mean number of intravitreal bevacizumab injections per eye was 3.3. Combined treatment with photodynamic therapy was provided in 20% of cases at the initial intravitreal injection. OCT data for all patients revealed an initial mean thickness of 362 &mgr;m, which was decreased at 1 week to 278 &mgr;m (P = 0.001), 235 &mgr;m at 1 month (P < 0.0001), 238 &mgr;m at 3 months (P = 0.0004), and 244 &mgr;m for the end of follow-up (P < 0.0001). Cystic retinal edema, subretinal fluid, and pigment epithelial detachment resolved in the majority of cases, but pigment epithelial detachment frequently took longer to resolve. Initial mean visual acuity was 20/125 (logMAR 0.8), and final mean visual acuity was 20/100 (logMAR 0.7) (P = 0.03). There was no difference in OCT or visual acuity outcomes (P = 0.62 and P = 0.28, respectively) between previously treated and treatment naïve patients. There was no difference in OCT or visual acuity outcomes (P = 0.67 and P = 0.21, respectively) between patients who received combination therapy and those who received monotherapy with intravitreal bevacizumab. No systemic or ocular adverse events were recorded. Conclusion: Intravitreal bevacizumab for CNV from AMD results in a rapid decrease in OCT-measured retinal thickness in a majority of cases. Visual acuity also improved in this series, suggesting a potential corresponding visual benefit. This series suggests that previously treated and treatment naïve patients have similar outcomes.

Vitrectomy in Eyes with Peripheral Retinal Angioma Associated with Traction Macular Detachment

PURPOSE Peripheral angiomas have been associated with epiretinal membranes and traction retinal detachment. The authors investigated the timing, results, and complications of vitreous surgery to remove the retinal traction and treat the peripheral vascular tumor. METHODS The authors reviewed the results of ten eyes that had undergone vitrectomy for macular pucker and/or traction retinal detachment. These eyes had either preoperative or intraoperative treatment of the peripheral tumor. RESULTS Patients were followed 4 to 95 months. Six eyes had nonfamilial peripheral acquired retinal hemangioma, three had von Hippel angiomas, and one had multiple large peripheral retinal angiomas associated with extensive retinal telangiectasis. Four eyes received cryotherapy and/or laser photocoagulation 2 to 3 months before surgery. In the remaining six eyes, initial treatment to the peripheral angioma was performed at the time of vitreous surgery. At final follow-up, all eyes were attached without retinal traction. Vision improved in all eyes; six (60%) achieved 20/50 or better visual acuity. Complications included recurrent epiretinal membrane (n=3); nonregressed angiomas (n=3); increased nuclear sclerosis (n=2); and retinal detachment (n=1). CONCLUSION Vitreous surgery, when applied to epiretinal membranes or traction retinal detachments associated with peripheral vascular tumors, has a good chance of improving vision. Treatment of the hemangioma, before or during vitrectomy, usually results in tumor regression.

Central Serous Chonoretinopathy Occurring in Patients 60 Years of Age and Older

The authors report on 13 eyes in 13 patients, 60 years of age or older, with idiopathic central serous chorioretinopathy, a condition that typically presents in adults between the ages of 30 and 50 years. In older patients, this condition can easily be mistaken for macular degeneration with subretinal neovascularization. None of the patients in this series had soft drusen, geographic atrophy, or subretinal neovascularization, signs of age-related macular degeneration or other retinal or macular disease. Subretinal nea vascularization was not seen either at the time of initial diagnosis or during follow-up. The clinical, biomicroscopic, and fluorescein angiographic characteristics of this entity are described. The clinical course of 7 of these 13 eyes that underwent laser photocoagulation treatment is also described.

Emerging concepts in the management of acute retinal necrosis

Acute retinal necrosis (ARN), also known as Kirisawa-type uveitis, is an uncommon condition caused by infection of the retina by one of the herpes family of viruses, most typically varicella zoster virus or herpes simplex virus and less commonly cytomegalovirus. Clinical diagnosis can be challenging and is often aided by PCR-based analysis of ocular fluids. Treatment typically involves extended use of one or more antiviral agents. Long term retinal detachment risk is high. We review the literature on ARN and present an approach to the diagnosis and management of this serious condition.

Subretinal fibrosis in central serous chorioretinopathy

PURPOSE To report unusual and heretofore unreported visually damaging manifestations of severe central serous chorioretinopathy. METHODS Case studies. RESULTS Each of six male patients (average age, 40 years) had a form of severe central serous chorioretinopathy with at least one eye containing fibrin in the subretinal space that then developed into a subretinal fibrotic scar. Scar formation was followed by a tenting up of the macula, vascularization of the fibrosis (subretinal neovascularization), or a retinal pigment epithelial rip. Four of the seven eyes with subretinal fibrosis had severe visual loss (20/400 or worse). CONCLUSION Subretinal fibrin and other extracellular matrix molecules appear to stimulate the retinal pigment epithelium to undergo fibrous metaplasia, which results in subretinal fibrotic scar formation and other sequelae, all of which can lead to severe visual loss.