Howard Schatz

Idiopathic Macular Holes

We monitored 132 patients (148 eyes) with idiopathic, full-thickness macular holes for a mean of 52 months. Ninety-six of the patients were women and 61 were in their 60s. The initial sizes of the macular holes correlated highly with initial visual acuity (P less than .0001). Although most macular holes enlarged during the study, long-term visual acuity was stable. Although these patients had a significantly (P less than .05) higher prevalence of cardiovascular disease, the incidences of hysterectomies and estrogen supplements were not unusually high. Seventy-one patients had some type of pigment epithelial disease (P less than .05).

Atrophic Macular Degeneration

The authors studied 50 eyes with atrophic (dry) macular degeneration (geographic atrophy of age-related macular degeneration [GAMD], in 50 consecutive patients for 2 to 6 years (average, 3.4 years). There were 35 women and 15 men ranging in age from 60 to 89 years (average, 73 years). The areas of atrophy tended to follow the disappearance or flattening of soft drusen, pigment epithelial detachment, or reticular mottling of the retinal pigment epithelium. The atrophic areas were multifocal in 20 of the 50 eyes. Atrophy of the retinal pigment epithelium was followed by atrophy of the choriocapillaris. The atrophic areas tended to expand (average rate in one direction, 139 microns per year) and cause gradual loss of central visual acuity. The rate of significant visual loss (from 20/50 or better to 20/100 or worse) was 8% of eyes per year. There was a tendency toward resistance of the spread of atrophy into the fovea. The atrophy tended to expand faster in patients under age 75 and slower in patients aged 75 and over. Subretinal neovascularization developed in ten of the 50 eyes.

Visual Loss Following Panretinal Photocoagulation for Proliferative Diabetic Retinopathy

We reviewed the preoperative, postoperative, and follow-up examinations, fundus photographs, and fluorescein angiograms of 175 eyes of 134 patients with proliferative diabetic retinopathy treated with panretinal photocoagulation. Forty-four (25%) of these eyes lost two or more lines of vision by the time of the last follow-up examination. Follow-ups ranged from 3 to 48 months, with a median follow-up of 15 months. The most common cause of decreased visual acuity was chronic macular edema that had developed following laser treatment, occurring in 14 (8%) eyes. The causes of visual loss following panretinal photocoagulation are discussed.

Idiopathic retinal vasculitis, aneurysms, and neuro-retinitis

Purpose: The authors describe the clinical feature of ten patients with a new syndrome characterized by the presence of retinal vasculitis, multiple macroaneurysms, neuro-retinitis, and peripheral capillary nonperfusion. Methods: The authors evaluated ten patients identified to have clinical features compatible with the syndrome of idiopathic retinal vasculitis, aneurysms and neuroretinitis (IRVAN). Clinical examination findings, sequential fundus photographs (when available), fluorescein angiograms, systemic investigations, response to therapy, and visual outcomes were reviewed. Results: Seven eyes of four patients sustained a marked decrease in visual acuity of 20/200 or worse. Visual loss was due to a combination of an exudative maculopathy and sequelae of retinal ischemia. Capillary nonperfusion was seen in all ten patients and was severe enough to warrant panretinal laser photocoagulation in six patients. Systemic investigations were uniformly noncontributory. Oral prednisone appears to have little beneficial effects on patients with this disorder. Conclusions: Patients with IRVAN have characteristic retinal features that readily identify this syndrome. An increased awareness of this rare syndrome may help to identify sight-threatening complications at an earlier stage. The authors caution against extensive medical investigations. Ophthalmology 1995;102:1089-1097

Recurrent Multifocal Choroiditis

The authors examined 11 young adult, moderately myopic female patients who presented with visual loss secondary to a newly described disorder consisting of multiple small discrete lesions at the level of the retinal pigment epithelium and choriocapillaris. The condition appears to be inflammatory and occurs primarily in the macula and posterior pole. Disc edema and a mild vitritis may be present. The condition was bilateral in five patients, although the fellow eye was asymptomatic in each case. Multiple recurrences are common, with new sites developing adjacent to old ones. Four of the 11 patients had subretinal neovascularization develop from parafoveal lesions. The inflammatory lesions, as well as the subretinal neovascularization, regressed with corticosteroid treatment, and most patients recovered excellent visual acuity. Systemic laboratory studies were noncontributory.

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.

Atrophic Creep of the Retinal Pigment Epithelium after Focal Macular Photocoagulation

To determine if enlargement of laser scars occurs in nonmyopic individuals, the authors retrospectively reviewed 126 consecutive patients with age-related macular degeneration who had been successfully treated with focal macular laser photocoagulation for subretinal neovascularization. Of the 174 laser scars in the study, 122 (70%) increased in size from 50 to 1016 microns (mean, 290 microns) as determined photographically on serial examination ranging from 2 to 81 months. There was no statistically significant difference in the number of scars which increased in size among the three laser wavelengths used. Four (3%) patients lost vision as a result of the scar extending into the fovea. Enlargement of retinal pigment epithelial (RPE) atrophy after focal macular laser photocoagulation may cause significant, delayed visual loss after successful treatment of subretinal neovascularization.

Adult-onset foveomacular pigment epithelial dystrophy.

Thirty-three pateints had adult-onset foveomacular dystrophy. The macular lesions typically resulted in a mild to moderate decrease in vision and appeared as small, yellow, bilateral, slightly elevated, pigment epithelial lesions with areas of hyperpigmentation. The characteristic finding on fluorescein angiography was a ring of hyperfluorescence surrounding an area of hypofluorescence. The electro-oculograms were either normal or slightly subnormal in most cases. This dystrophy appears to have an autosomal dominant transmission.

Retinal Toxicity Secondary to intraocular Gentamicin Injection

The authors present five cases of severe retinal ischemia associated with gentamicin injection. In three of the cases massive doses of gentamicin were erroneously injected into the eye; in two of the cases the authors presume that gentamicin toxicity occurred. The sequence of clinical findings was similar in all five cases. The prominent findings included early superficial and intraretinal hemorrhages, opaque and edematous retina, cotton-wool infarcts, arteriolar narrowing, and venous beading. Fluorescein angiography revealed severe retinal vascular nonperfusion. Chronic findings included rubeosis irides, neovascular glaucoma, retinal pigmentary degeneration, and optic atrophy. Of the documented cases of massive intraocular gentamicin injection, two patients had no light perception (NLP) vision and one had bare light perception. Of the two cases of presumed gentamicin toxicity, one had 20/400 vision and one had count fingers vision. Strict precautions are necessary to prevent the catastrophic events resulting from inadvertent gentamicin injection; such precautions should include precise labeling of all injectable solutions on the surgical field, waiting to draw up injectable antibiotics until the time they are needed, and drawing up injectable antibiotics under direct physician observation. All intravitreal injections should be performed slowly, in the anterior vitreous, with the needle bevel up.

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%).