Ippei Takasu

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

PURPOSE This study aimed to assess the feasibility of laser photocoagulation of feeder vessels of subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration. PATIENTS AND METHODS Of 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. RESULTS Twenty-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). CONCLUSION Feeder 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.

Clinical and Angiographic Characteristics of Retinal Manifestations in Cat Scratch Disease

PURPOSE To elucidate clinical and angiographic features of retinal manifestations in cat scratch disease. METHODS Clinical 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. RESULTS A 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. CONCLUSIONS Granuloma with abnormal vascular network as revealed by fluorescein and ICG angiography is characteristic of retinal manifestations in cat scratch disease.

Macular hole surgery with triamcinolone acetonide-assisted internal limiting membrane peeling: One-year results

Purpose: To report the 1-year results of macular hole surgery with triamcinolone acetonide (TA)–assisted internal limiting membrane (ILM) peeling and to compare those with results of indocyanine green (ICG)–assisted ILM peeling. Methods: In a nonrandomized, retrospective, interventional case series, 40 eyes of 39 consecutive patients with idiopathic full-thickness macular holes underwent macular hole surgery with TA-assisted ILM peeling. Surgical results 1 year after surgery, including changes in best-corrected visual acuity (BCVA) and macular hole closure, were evaluated. Moreover, we compared the results for these 40 eyes (TA group) with those for 27 eyes of 27 consecutive patients who had undergone macular hole surgery with 0.25% ICG-assisted ILM peeling (ICG group). Results: In the TA group, macular holes were closed in 39 (98%) of 40 eyes. Mean BCVA ± SD significantly improved from 0.78 ± 0.31 logarithm of the minimal angle of resolution (logMAR) preoperatively to 0.20 ± 0.30 logMAR (P < 0.001). BCVA improved by ≥0.2 logMAR in 37 eyes (93%). BCVA was 20/40 or better in 33 (83%) of 30 eyes. In the ICG group, macular holes were closed in all 27 eyes (100%), and mean BCVA ± SD significantly improved from 0.81 ± 0.4 logMAR preoperatively to 0.34 ± 0.2 logMAR 1 year postoperatively (P < 0.001). BCVA improved by ≥0.2 logMAR in 22 eyes (81%). BCVA was 20/40 or better in 16 (59%) of 27 eyes. Significant differences between groups were seen in mean BCVA 1 year after surgery (P = 0.049) but not in BCVA of 20/40 or better (P = 0.17) or change in BCVA by ≥0.2 logMAR (P = 0.05). Conclusion: TA is useful as an adjuvant for ILM peeling in macular hole surgery, and BCVA 1 year after surgery might be more favorable when compared with ICG-assisted ILM peeling.

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

PURPOSE This 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. DESIGN Consecutive, observational case series. PARTICIPANTS Twenty-six patients with idiopathic subfoveal CNV, of whom six underwent submacular surgery. INTERVENTION Indocyanine green videoangiography with a scanning laser ophthalmoscope. MAIN OUTCOME MEASURES We 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. RESULTS Early 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. CONCLUSIONS Although 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.

Scleral Infolding Combined with Vitrectomy and Gas Tamponade for Retinal Detachment with Macular Holes in Highly Myopic Eyes

PURPOSE To describe the effectiveness of a surgical procedure, scleral infolding combined with vitrectomy and gas tamponade, for retinal detachment caused by macular holes in highly myopic eyes. METHODS In a pilot study, scleral infolding was performed in 5 patients with macular holes, who were selected from 10 consecutive highly myopic patients with retinal detachment caused by macular holes (8 patients) or extramacular posterior-pole holes (2 patients), treated during 1 year at Okayama University Hospital. The patients were all women, 48-77 years of age (mean = 63.4 years), who had been followed-up for 1-2 years. Selection criteria for scleral infolding were either second surgeries for reopening of macular holes (2 patients) or residual retinal detachment around macular holes after complete fluid-air exchange with drainage of subretinal fluid at the initial surgery (3 patients). Following vitrectomy and complete epiretinal membrane removal in the posterior pole, the sclera was shortened by infolding on the temporal side. Three mattress sutures with 5-0 Dacron in each quadrant, 6 sutures in total, were placed at a 7-mm anteroposterior interval with posterior sutures located as deep as possible, near vortex veins. Fluid-gas exchange was then done, with or without endophotocoagulation applied around macular holes. RESULTS After scleral infolding, macular holes were closed, and the retina was totally attached in all 5 patients. The final visual acuity ranged from 20/2000 to 20/70. CONCLUSION Scleral infolding is a simple and effective procedure for treating retinal detachment with macular holes in highly myopic eyes and could be used as an optional procedure of reoperation for a failed initial vitrectomy.

Selection for inferior limited macular translocation on the basis of distance from the fovea to the inferior edge of the subfoveal choroidal neovascularization

PURPOSE To assess the visual outcome of inferior limited macular translocation in eyes selected based on the distance from the fovea to the inferior edge of the subfoveal choroidal neovascularization. DESIGN Interventional case series. METHODS We performed inferior limited macular translocation in 12 consecutive eyes (12 patients) with age-related macular degeneration or polypoidal choroidal vasculopathy, in which the choroidal neovascularization did not extend for more than half of one disk diameter inferior to the fovea. RESULTS In all eyes, the choroidal neovascularization was moved to an extrafoveal location. In seven of the 12 eyes, postoperative vision was 20/40 or better. The visual acuity improved by 2 or more lines in 11 eyes. CONCLUSION Selection for inferior limited macular translocation on the basis of distance from the fovea to the inferior edge of the choroidal neovascularization may be associated with a greater likelihood of visual acuity improvement.

Modified vitreous surgery for symptomatic lamellar macular hole with epiretinal membrane containing macular pigment.

Modified Vitreous Surgery for Symptomatic Lamellar Macular Hole With Epiretinal Membrane Containing Macular Pigment Lamellar macular hole (LMH) was first described by Gass in 1975 as an abortive process of fullthickness macular hole formation that resulted from cystoid macular edema. In contrast, macular pseudoholes (MPHs) were attributable to centripetal contraction of the epiretinal membrane (ERM). Because spectraldomain optical coherence tomography (SD-OCT) is able to show detailed configurations of various macular conditions, this examination can be used to differentiate LMH from MPH. However, Michalewski et al used SD-OCT to demonstrate that MPH may progress to LMH, and because it is an advanced stage of the same non–full-thickness macular disorder, progression of ERM may be the cause of both MPH and LMH. Chen et al hypothesized that both entities may be different manifestations of the same disease. The ERM has been shown to coexist in most of cases with LMH. When ERM coexists with macular edema associated with branch retinal vein occlusion or diabetic retinopathy, or when it occurs after cataract surgery, LMH is secondary. In contrast, when no causative retinal diseases are present, LMH should be referred to as idiopathic. Currently, vitrectomy for LMH remains controversial. Although the natural prognosis for idiopathic LMH is usually good, some patients exhibit a visual acuity decrease that may be amenable to surgical treatment. Because LMH is usually accompanied by typical ERM, surgical treatment regularly includes ERM removal and internal limiting membrane (ILM) peeling with or without gas tamponade. In our surgical experience, LMH is frequently accompanied by ERMcontaining macular pigment, and the ERM appearing to originate from inside the LMH. Because the degree of this migration is on a case-by-case basis, a dehiscence of inner from outer retina is accompanied by a translucent ERM (posterior hyaloid membrane) alone, but not an ERM with macular pigment, in some cases with LMH. Based on the previous findings, we have speculated that ERM may contain not only macular pigment but also some partial retinal tissues. In addition, in 1989, Margherio et al described the concept of preretinal membrane dissection toward the fovea in symptomatic eyes considered to be at high risk for idiopathic macular holes development. Thus, the aim of the current study was to examine a modified surgical method for LMH with ERM containing macular pigment and then to report on the morphologic and functional outcomes of this new surgical procedure.

Transposition of the anterior superior oblique insertion as a treatment for excyclotorsion induced from limited macular translocation.

PURPOSE To evaluate the transposition of the anterior superior oblique insertion as a treatment for cyclovertical diplopia accompanied by an awareness of tilted image perceived with the affected eye induced from limited macular translocation (LMT). DESIGN Observational case series. METHODS Transposition of the anterior part of the superior oblique tendon combined with or without vertical muscle surgery on the affected eye was retrospectively studied in seven patients. Clinical outcome was assessed for binocular and monocular vision. A successful result was defined as restoration of single binocular vision (SBV) at distance and near examined with the Bagolini test with disappearance of a tilted image perceived in the affected eye. RESULTS Six of seven patients (86%) became unaware of tilted image, and three patients (43%) obtained successful results after the strabismus surgery. Of these three patients with successful results, one (33%) patient recognized metamorphopsia, whereas two (67%) of the three patients with unfavorable results reported metamorphopsia. Patients with successful results showed a visual acuity of 20/25 or better in the affected eye and a significantly smaller difference in visual acuity between the two eyes than those patients with unfavorable surgical results (0.133 logarithm of the minimal angle of resolution for SBV(+) vs 0.675 logarithm of the minimal angle of resolution for SBV(-); P =.0255). CONCLUSIONS The relatively low success for restoration of SBV indicates that strabismus surgery is recommended for patients whose difference in visual acuity between the two eyes is small and who have a high level visual acuity of the affected eye.

Treatment Options in Subfoveal Choroidal Neovascularization Secondary to Age-Related Macular Degeneration

Laser photocoagulation of the entire area of the neovascular lesion is the only proven treatment for subfoveal choroidal neovascularization secondary to age-related macular degeneration with a poor natural history. However, there are some limiting factors such as patient eligibility, a significant decline in visual acuity after treatment, and a very low possibility of a final vision of 20/100 or better. Although no large benefit of other treatment modalities, such as indocyanine green videoangiography-guided laser photocoagulation, surgical removal of neovascular membranes, and radiation therapy, has yet been proven, carefully selected patients may be suitable candidates for such treatments. This article reviews the status of treatment modalities for subfoveal choroidal neovascularization secondary to age-related macular degeneration, including laser photocoagulation of the entire area of the neovascular lesion, and discusses factors prognostic of visual outcome in these treatment options.

Evaluation of the Dynamics of Choroidal Circulation in Experimental Acute Hypertension Using Indocyanine Green-stained Leukocytes

PURPOSE To evaluate the dynamics of choroidal circulation in experimental acute hypertension, using the indocyanine green leukocyte angiography (ILA) method, which the authors have developed for the evaluation of leukocyte dynamics in choroidal circulation. METHODS Japan White rabbits were used in the present study. Leukocytes were collected by centrifugal separation of the autologous blood, and were stained with indocyanine green (ICG) dye. The ICG-stained leukocyte fluid was injected into an ear vein, and fundus images were obtained by infrared laser and a scanning laser ophthalmoscope. Experimental acute hypertension was induced by the intravenous drip injection of angiotensin II (AII). RESULTS The fluorescent dots rapidly moved in choroidal arteries at a decreasing velocity, passed very slowly through choroidal capillaries and drained into choroidal veins. Under normal blood pressure, the mean leukocyte velocities in arteries, capillaries and veins were 8.63+/-1.68, 0.52+/-0.07, and 6.96+/-2.20 mm/s, respectively. On the other hand, the respective mean velocities in acute hypertension induced by AII were 13.50+/-1.82, 0.81+/-0.09, and 10.54+/-3.91 mm/s. Besides flow velocity, no change in leukocyte dynamics was observed. CONCLUSIONS Under the condition of acute hypertension induced by AII, leukocytes moved faster in the total choroidal circulation (from arteries to veins) compared to their velocity under the condition of normal blood pressure. Blood velocities might increase in the total choroidal circulation at an early stage in acute hypertension induced by AII, resulting in increased choroidal blood flow. ILA makes it possible to evaluate the changes in choroidal circulation under various pathologic conditions.