Hernando Zegarra

Multiple Recurrent Serosanguineous Retinal Pigment Epithelial Detachments in Black Women

Three middle-aged black women suffered recurrent, multiple, bilateral, asymmetric, serosanguineous retinal pigment epithelial detachments. These involved the posterior fundus with resolution and recurrences producing subretinal hemorrhages, vitreous hemorrhages, retinal pigment epithelial pigmentary mottling, and chorioretinal scars. Fluorescein angiography showed evidence of choroidal neovascular membranes, choroidal serosanguineous leaks, or both. Ocular inflammation was not evident. Systemic laboratory tests were noncontributory. The clinical pattern was not characteristic of any other entity producing serosanguineous retinal pigment epithelial detachments. The origin remains to be defined.

The natural course of central retinal vein occlusion.

Thirty-five patients with central retinal vein occlusion had an extensive medical and laboratory evaluation to identify possible etiologic factors. We describe the natural course of the two forms of retinal venous occlusive disease, hemorrhagic retinopathy and venous stasis retinopathy, by observing a group of 25 untreated patients from one to eight years. Systemic vascular disease was most commonly associated with retinal venous occlusive disease. The visual prognosis is favorable in venous stasis retinopathy and extremely poor in hemorrhagic retinopathy. However, two of ten patients with venous stasis retinopathy developed hemorrhagic retinopathy with poor visual outcome.

Comparison of Pneumatic Retinopexy with Alternative Surgical Techniques

To determine the efficacy of pneumatic retinopexy, the authors conducted a retrospective study of 56 cases of uncomplicated retinal detachments (RDs) treated with this technique (follow-up, 6-18 months). These were compared with 28 similar cases treated with a Lincoff balloon and 78 similar cases treated with a scleral buckle. The long-term success rates for these three groups were 71, 64, and 96%, with the incidence of new breaks being 20, 18, and 1.3% respectively. In aphakic or pseudophakic patients with an absent or ruptured posterior capsule, the success rate for pneumatic retinopexy was only 43%. In phakic and aphakic patients with an intact posterior capsule, the success rate for pneumatic retinopexy improved to 81%. These data suggest that this technique is less effective in aphakic or pseudophakic patients with an absent or ruptured posterior capsule and that careful follow-up to detect new breaks is necessary in all cases. A prospective randomized study is needed to verify these data.

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%).

Macular edema secondary to occulusion of the retinal veins

Occlusion of the central and branch retinal veins causes macular edema by provoking increased venous pressure which is transmitted to the perifoveal capillaries. Damage to the perifoveal capillary endothelium results in leakage with macular edema. The severity of the retinal findings (i.e., macular hemorrhages, macular edema, etc.) is determined by the location, completeness, duration, and evolution of the obstruction (i.e., recanalization of a thrombus). Spontaneous remission of macular edema secondary to either a partial central or branch occlusion carries a relative good visual prognosis. Chronic macular edema secondary to occlusion of either central or branch veins is associated with a relatively poor visual prognosis. In selected cases, paramacular photocoagulation can reverse chronic macular edema and result in visual improvement.

The Acute Retinal Necrosis Syndrome: Possible Herpes Simplex Retinitis

The acute retinal necrosis (ARN) syndrome is a severe necrotic peripheral retinitis with vasculitis and vitritis. It attacks healthy people and carries a poor visual prognosis. Five patients with ARN were seen. Two showed interesting clinical features. One patient developed the ARN syndrome in both eyes but with a 14-year hiatus separating the two episodes, each being preceded by an infectious illness. A second patient had a possible recurrence of the ARN syndrome in the same eye, one year after the original episode. Each episode was preceded by an upper respiratory infection and ipsilateral vesicular skin lesions on the face. Biopsy of one lesion yielded herpes simplex virus (HSV) in culture. These associations, although not definitive, do lend support to the hypothesis that HSV may be the cause of the ARN syndrome.

Reoperations and visual results after failed pneumatic retinopexy

A single pneumatic retinopexy (PR) procedure failed to achieve permanent retinal reattachment in 23 (23%) of 101 cases of simple primary retinal detachment (RD). In 12 (16%) of 76 cases that were phakic or had an intact posterior capsule, a single PR failed compared with 11 (44%) of 25 cases without an intact posterior capsule. A total of 27 reoperations including eight repeat PRs (5 of which were successful) was required to achieve permanent retinal reattachment. Comparison of the final visual acuity and change from preoperative to final visual acuity between the initially failed and the successful cases demonstrated that initial failure of PR does not adversely affect the visual outcome. In all cases, the retina remained reattached at latest follow-up.

Laser treatment in fellow eyes with large drusen: Updated findings from a pilot randomized clinical trial

PURPOSE To update the findings from the Choroidal Neovascularization Prevention Trial (CNVPT) with respect to resolution of drusen, incidence of choroidal neovascularization, and visual function. DESIGN A multicenter, randomized, controlled, pilot clinical trial. PARTICIPANTS The 120 patients enrolled in the CNVPT. Patients had signs of choroidal neovascularization or retinal pigment epithelial detachment in 1 eye and had >/=10 large (>63- micro m) drusen in the contralateral, or fellow, eye. INTERVENTION The fellow eye of 59 patients was assigned randomly to argon green laser treatment consisting of multiple 100- micro m spots at least 750 micro m from the center of the fovea. The fellow eye of the remaining 61 patients was assigned randomly to observation. MAIN OUTCOME MEASURES Change in visual acuity was the primary outcome measure. Incidence of choroidal neovascularization, resolution of drusen, change in contrast threshold, change in critical print size for reading, and incidence of geographic atrophy were secondary outcome measures. RESULTS Throughout 4 years of follow-up, there were no statistically significant differences in change in visual acuity, contrast threshold, critical print size, or incidence of geographic atrophy. With additional follow-up, the large increase in the incidence of choroidal neovascularization observed within 18 months of treatment was maintained; however, by 30 months, the incidence in the two treatment groups was the same. Most drusen resolution in treated eyes occurred within 24 months of the initial treatment. Treated eyes that received higher-intensity laser burns had an increased risk of choroidal neovascularization. Among eyes developing choroidal neovascularization in each treatment group, most lesions (two thirds or more) were composed of occult neovascularization only. CONCLUSIONS Laser treatment as applied in the CNVPT caused an excess risk of choroidal neovascularization in the first year or so after treatment. The increased early incidence of choroidal neovascularization was not associated with either a harmful or beneficial effect in this pilot study.

PARTIAL OCCLUSION OF THE CENTRAL RETINAL VEIN

Twenty-three untreated patients (14 men and nine women ranging in age from 31 to 74 years) with partial occlusion of the central retinal vein were followed up prospectively for a minimum of 12 months. Seventeen had systemic vascular disease. At the conclusion of the study, 12 patients had visual acuities of 20/40 or better and eight had visual acuities of 20/100 or worse. Eleven patients had complete resolution of the retinopathy and had final visual acuities of 20/30 or better. Five eyes progressed to complete occlusion with final visual acuities of 20/300 or less. Seven eyes had chronic macular edema and visual acuities ranging from 20/40 to 20/200. One eye with background diabetic retinopathy developed optic disk neovascularization. None of the patients developed neovascular glaucoma.

Nanophthalmic uveal effusion.

A nanophthalmic patient with hypermetropia, shortened anterior-posterior axial length, and thickened choroid presented with a choroidal detachment and nonrhegmatogenous retinal detachment (NRRD). He underwent partial thickness, 5 x 7 mm, sclerectomies and 1-2 mm central sclerostomies 9.5 mm posterior to the limbus, specifically avoiding vortex veins. Complete resolution of the retinal and choroidal detachments occurred in spite of postoperative ultrasonograms demonstrating residual choroidal-scleral thickening. The effectiveness of this technique in our patient, in light of recent studies demonstrating histochemical and microscopic abnormalities in nanophthalmic sclera, suggests impairment of trans-scleral protein transport as the primary pathophysiologic mechanism in nanophthalmic uveal effusion.