J. Arch McNamara

A comparison of laser photocoagulation with cryotherapy for threshold retinopathy of prematurity at 10 years: part 2. Refractive outcome.

OBJECTIVEnTo compare the refractive outcome of eyes treated with cryotherapy for threshold retinopathy of prematurity (ROP) with eyes treated with laser photocoagulation.nnnDESIGNnExtended follow-up of a randomized controlled clinical trial.nnnPARTICIPANTSnOne hundred eighteen eyes from 66 patients were randomly assigned to receive either cryotherapy or laser photocoagulation for threshold ROP. Twenty-five patients (44 eyes treated) were available for follow-up examination 10 years later.nnnINTERVENTIONnCycloplegic autorefraction or retinoscopy was performed. Immersion ultrasound biometry (A-scan) was also performed, and an autokeratometer was used for keratometry. If an A-scan could not be tolerated or the patient was not cooperative, a B-scan through-the-lid biometry was performed. Corneal thickness was measured using optical coherence tomography. MAIN AND SECONDARY OUTCOME MEASURES: Refractive error. In addition, anterior chamber depth, lens thickness, and axial length were measured. Central corneal thickness measurements and keratometric readings were also obtained.nnnRESULTnEyes treated with cryotherapy were significantly more myopic than those treated with laser photocoagulation. When comparing patients with bilateral treatment, the mean spherical equivalent (SE) of eyes treated with laser was -4.48 diopters (D) compared with a mean SE of -7.65 D for eyes treated with cryotherapy (n = 15 pairs of eyes, P = 0.019). Cryotherapy-treated eyes had a mean axial length of 21.7 mm versus 22.9 mm for laser-treated eyes (P = 0.024, n = 12 pairs of eyes). The anterior chamber depth and lens thickness averaged 2.86 mm and 4.33 mm, respectively, in the cryotherapy-treated eyes compared with 3.42 mm and 3.95 mm in the laser-treated eyes (P < 0.001, n = 12 pairs for both measurements). There were no statistical differences in anterior corneal curvature and central corneal thickness between the two treatment modalities. Crystalline lens power bore the strongest correlation to refractive outcomes in both laser-treated (r = 0.885, P < 0.001) and cryotherapy-treated eyes (r = 0.591, P = 0.026). Although keratometric readings were higher than normal values in these eyes, there was no correlation to the degree of myopia.nnnCONCLUSIONSnLaser-treated eyes were significantly less myopic than cyrotherapy-treated eyes. Lens power seemed to be the predominant factor contributing to the excess myopia.

A comparison of laser photocoagulation with cryotherapy for threshold retinopathy of prematurity at 10 years ☆: part 1. Visual function and structural outcome1

OBJECTIVEnTo assess visual and structural outcomes after laser photocoagulation and transscleral cryotherapy for threshold retinopathy of prematurity (ROP) after 10 years.nnnDESIGNnExtended follow-up of a randomized controlled clinical trial.nnnPARTICIPANTSnOne hundred eighteen eyes from 66 patients were randomly assigned to receive either cryotherapy or laser photocoagulation for threshold ROP. Forty-four eyes from 25 patients were examined for 10-year follow-up evaluations.nnnINTERVENTIONnEarly Treatment of Diabetic Retinopathy Study (ETDRS) visual acuity, slit-lamp, and fundus examination; fundus photography; and B-scans (eyes with retinal detachments) were performed. Patients histories were taken to elicit past amblyopia therapy. Based on fundus photographs, independent observers graded the degree of retinal dragging as none, mild, moderate, or severe. MAIN AND SECONDARY OUTCOME MEASURES: Best-corrected ETDRS visual acuity (BCVA). The degree of dragging was determined clinically and photographically. In addition, the presence of strabismus or amblyopia and/or any history of treatment for amblyopia were noted accordingly.nnnRESULTSnEyes treated with laser had a mean BCVA of 20/66 (Snellen equivalent), whereas cryotherapy-treated eyes had a mean BCVA of 20/182 (Snellen equivalent) (P = 0.015, n = 42). Compared with eyes treated with cryotherapy, eyes treated with laser photocoagulation were 5.2 times more likely to have a 20/50 or better BCVA (95% confidence interval, 1.37-19.8, n = 42). Eyes treated with cryotherapy were 7.2 times (95% confidence interval, 1.54-33.6, n = 33) more likely to develop retinal dragging compared with laser treatment. By linear regression analysis, ETDRS visual acuity was inversely proportionate to the degree of retinal dragging in both laser (r = -0.637, P = 0.006) and cryotherapy (r = -0.517, P = 0.040) treated eyes. Among the 21 patients with favorable outcomes in both eyes, 13 had strabismus (62%) and 6 had received amblyopia therapy (29%). Ptosis, loss of cilia, and cortical cataract were among probable treatment-related complications that were noted in this study.nnnCONCLUSIONSnOverall, laser-treated eyes had better structural and functional outcome compared with eyes treated with cryotherapy.

A comparison of laser photocoagulation with trans-scleral cryotherapy in the treatment of threshold retinopathy of prematurity,

OBJECTIVEnThe goal of this study was to determine whether there was a significant difference between the visual outcomes of eyes with threshold retinopathy of prematurity (ROP) treated with trans-scleral cryotherapy compared to those treated with laser photocoagulation.nnnDESIGNnExtended follow-up study of a prospective, randomized clinical trial.nnnPARTICIPANTSnFifty-two patients with bilateral threshold ROP participated. Follow-up data were available for 25 of these patients.nnnINTERVENTIONnPatients were randomized to receive cryotherapy in one eye and laser photocoagulation in the other eye.nnnMAIN OUTCOME MEASURESnThe best-corrected visual acuity of each eye was measured. Best-corrected visual acuities of 20/50 or better were classified as good clinical outcomes, whereas those 20/60 or worse were considered poor outcomes. A secondary outcome of this study was the spherical equivalent (SE) of each eyes most recent refraction.nnnRESULTnAt an average follow-up point of 5.8 years (range, 4.3-7.6 years), the odds that an eye treated with laser had a good clinical outcome were 6.91 times greater than for eyes treated with cryotherapy (95% confidence interval, 1.70-28.0; n = 21). Additionally, the laser-treated eyes were less myopic with a mean SE of-3.05 diopters compared to a mean SE of -5.08 diopters for the cryotherapy-treated eyes (P = 0.0072, n = 23).nnnCONCLUSIONnThe authors study suggests that laser photocoagulation for threshold ROP was more likely to result in a good clinical outcome with better final visual acuity and less myopia compared to cryotherapy treatment.

Extracapsular Cataract Extraction with Placement of a Posterior Chamber Lens in Patients with Diabetic Retinopathy

PURPOSEnThe authors evaluated factors that might influence the outcome of extracapsular cataract extraction with placement of a posterior chamber lens in patients with diabetic retinopathy. The factors included patient age and sex, severity of the retinopathy, preoperative laser photocoagulation, vitrectomy, and posterior capsulotomy.nnnMETHODSnThe records of 109 patients who had been examined by the authors before cataract surgery were retrospectively reviewed.nnnRESULTSnThe final visual acuity in only 48% of the eyes was 20/40 or better, and 28% had 20/200 or worse visual acuity. Only 65% had an improvement in visual acuity of two or more Snellen lines. Eyes with preoperative macular edema had a poorer visual outcome than eyes without. Macular edema and ischemia accounted for 70% of the eyes with a final visual acuity of 20/50 or worse. The authors found that age was a strong predictor of final visual acuity and chances of improvement. In patients 63 years of age and younger, 58% had 20/40 or better and 81% had improved visual acuity. In patients 64 years of age and older, only 38% had 20/40 or better and only 54% were improved. Supplementary panretinal photocoagulation was required in 37% of patients who had received it preoperatively. Neovascularization of the iris developed in 6% of patients. Posterior capsulotomy did not cause an increased incidence of neovascularization of the iris or in the development or progression of proliferative retinopathy or macular edema.nnnCONCLUSIONnThe prognosis of patients with diabetic retinopathy about to undergo cataract surgery, even extracapsular cataract extraction with placement of a posterior chamber lens, is guarded.

Extracapsular Cataract Extraction, Posterior Chamber Lens Insertion, and Pars Plana Vitrectomy in One Operation

Extracapsular cataract extraction (ECCE), placement of a posterior chamber intraocular lens (PC IOL), and pars plana vitrectomy were combined in a single operation in 24 patients. Sixteen of these, 11 of whom are diabetic, have had 6 months or more of follow-up. In all cases, excellent visualization of the posterior segment was obtained, and the surgical objectives were achieved. No diabetic patient without preoperative neovascularization of the iris had this complication later. The advantages and disadvantages of alternative techniques are discussed.

Pattern Dystrophy of the Retinal Pigment Epithelium and Geographic Atrophy of the Macula

PURPOSEnLittle information is available on the long-term course of pattern dystrophies, although some older individuals have been observed with macular atrophy. We sought to evaluate the evolution of symptoms, fundus changes, and physiologic findings by re-examining a family with pattern dystrophy after 20 years.nnnMETHODSnFour patients of seven initially examined were reevaluated 20 years later; two additional affected family members over age 60 were studied for the first time. Patients current ages ranged from 38 to 73 years. Comprehensive ophthalmic examinations were supplemented with fluorescein angiography, dark adaptometry, color vision, electroretinography, and electrooculography.nnnRESULTSnDuring the 20-year interval, visual acuity remained stable and 20/40 or better in all patients. One 62-year-old patient developed paracentral scotomas. All fundi showed evolution of pigmentary changes and increasing atrophy of pigment epithelium and choriocapillaris in the macula. Electro-oculograms were originally subnormal in all patients and changed very little. Electroretinograms, initially normal in two patients, became borderline or mildly subnormal and slightly reduced in the two patients first examined after age 60.nnnCONCLUSIONSnPattern dystrophy in this family was associated with minimal diminution of visual function during a 20-year interval. However, there was electroretinographic evidence of mild diffuse photoreceptor damage in the older patients, and geographic macular atrophy was prominent (suggesting a risk of vision loss in old age). Some cases of atrophic, age-related macular degeneration may represent an evolution of pattern dystrophy.

The Use of Perfluorophenanthrene in the Removal of Intravitreal Lens Fragments

We used perfluorophenanthrene as an aid during pars plana vitrectomy in removing lens fragments dislocated posteriorly into the vitreous cavity. We reviewed the records of all patients (nine patients, nine eyes) referred with dislocated lenses who underwent pars plana vitrectomy with perfluorophenanthrene for removal of the lens material at Wills Eye Hospital from July 1, 1991, through Nov. 30, 1991. The lens was dislocated during cataract extraction in eight eyes. One eye had a history of nonpenetrating trauma and lens dislocation. In one eye a retinal tear was noted intraoperatively and treated. Six eyes had postoperative visual acuity of 20/50 or better. In all eyes the lens was removed without further complications. Perfluorocarbon liquids such as perfluorophenanthrene may enhance current techniques by allowing easier and safer removal of displaced lens fragments through the pars plana.

Visual outcomes after laser photocoagulation for threshold retinopathy of prematurity.

OBJECTIVEnTo determine the long-term visual acuity after diode laser photocoagulation for threshold retinopathy of prematurity.nnnDESIGNnRetrospective, noncomparative case series.nnnINTERVENTIONnPhotocoagulation of the peripheral avascular retina with a diode laser indirect ophthalmoscope.nnnMAIN OUTCOME MEASURESnThe principal outcome evaluated was best-corrected visual acuity (BCVA). The most recent refractions for these eyes were also collected for analysis.nnnPARTICIPANTSnThirty-five infants with threshold retinopathy of prematurity treated with laser photocoagulation from 1991 to 1996.nnnRESULTSnAfter bilateral laser treatment, 14 (56%) of 25 patients who were capable of accurate visual acuity testing had 20/50 or better BCVA in at least 1 eye with 11 (44%) of 25 patients having at least 20/50 BCVA in both eyes. After unilateral treatment, four (40%) of ten had 20/50 or better BCVA in the treated eye while five (50%) of ten laser-treated eyes had a BCVA at least equal to the untreated fellow eye. Compared to eyes with 4 or more diopters (D) of myopia, those with less than 4 D of myopia were 6.4 times more likely to achieve 20/50 or better BCVA (95% confidence interval, 1.7-22.7). The average age at follow-up was 3.7 years.nnnCONCLUSIONSnAfter laser photocoagulation for threshold retinopathy of prematurity, 29 (48%) of 60 eyes had 20/50 or better visual acuity. Eyes with 4 or more D of myopia were significantly less likely to achieve 20/50 or better visual acuity than eyes with less than 4 D of myopia.