Jeffrey K. Luttrull

Long-term safety, high-resolution imaging, and tissue temperature modeling of subvisible diode micropulse photocoagulation for retinovascular macular edema.

Purpose To determine the long-term safety of high-density subvisible diode micropulse photocoagulation (810 nm), compare the clinical findings with computational modeling of tissue hyperthermia and to report results for a subset of eyes treated for diabetic macular edema (ME) documented pre- and postoperatively by spectral-domain optical coherence tomography. Method All eyes treated for ME from diabetic retinopathy (diabetic ME) and branch retinal vein occlusion between April 2000 and January 2010 were reviewed for subvisible diode micropulse laser-induced retinal damage. Therapeutic outcomes were reviewed for a subgroup treated for diabetic ME with pre- and postoperative spectral-domain optical coherence tomography. Laser-induced retinal thermal effects were modeled computationally using Arrhenius formalism. Results A total of 252 eyes (212 diabetic ME, 40 branch retinal vein occlusion) of 181 patients qualified. None of the 168 eyes treated at irradiance <350 W/cm2 and 7 of 84 eyes at ≥590 W/cm2 had retinal damage (P = 0.0001) (follow-up 3–120 months, median, 47). Sixty-two eyes of 48 patients treated for diabetic ME with pre- and postoperative spectral-domain optical coherence tomography with median 12 months follow-up had no retinal injury by infrared, red-free, or fundus autofluorescence photos; fluorescein angiography or indocyanine green angiography; or spectral-domain optical coherence tomography. Central foveal thickness (P = 0.04) and maximum macular thickness decreased (P < 0.0001). Modeling of retinal hyperthermia demonstrates that the sublethal clinical regimen corresponds to Arrhenius integral >0.05, while damage is likely to occur if it exceeds 1. Conclusion Subvisible diode micropulse can effectively treat retinovascular ME without laser-induced retinal damage, consistent with Arrhenius modeling of pulsed hyperthermia.

PARS PLANA IMPLANT AND VITRECTOMY FOR TREATMENT OF NEOVASCULAR GLAUCOMA

Purpose: To evaluate the effectiveness of pars plana implants in the treatment of neovascular glaucoma. Patients and Methods: Twenty‐two consecutive pars plana implant procedures performed for neovascular glaucoma were retrospectively reviewed. Results: Preoperative intraocular pressures ranged from 22 to 80 mmHg (mean 46 mmHg) on a mean of three glaucoma medications. With a mean follow‐up interval of 16 months, final postoperative intraocular pressures ranged 9‐21 mmHg (mean 16) on a mean 0.7 medications. One patient required a second implant to achieve final intraocular pressure control. Visual acuity was stabilized or improved in 19 of 22 cases (86%). Complications included retinal detachment in two cases (9%). Macular pucker, vitreous hemorrhage, hyphema, choroidal hemorrhage, diplopia, and loss of light perception occurred in one case (5%) each. None developed phthisis bulbi. Conclusion: Pars plana drainage tube implants are effective in the treatment of neovascular glaucoma.

Initial experience with pneumatically stented baerveldt implant modified for pars plana insertion for complicated glaucoma

OBJECTIVE To assess the efficacy of pneumatically stented drainage tube implants specially modified for pars plana insertion in the treatment of complicated glaucoma. DESIGN Retrospective, non-comparative case series. PARTICIPANTS 50 consecutive patients with refractory complicated glaucoma nonresponsive to medical treatment. INTERVENTION Baerveldt glaucoma implants modified by Hofmann for pars plana insertion were placed following pars plana vitrectomy and gas-fluid exchange (pneumatically stented implant, or PSI procedure). MAIN OUTCOME MEASURE Reduction of intraocular pressure (IOP) to 21 mmHg or less. RESULTS 31 neovascular and 19 complicated non-neovascular glaucoma eyes in 48 patients referred to a vitreoretinal subspecialty practice, average age 69 years (range 29-91), were followed an average of 18 months (range 3-41). The average preoperative IOP was 44 mmHg (14-78) on an average 3.2 glaucoma medications (range 2-6). The average final postoperative IOP was 14 mmHg (range 5-31) on an average 0.6 glaucoma medications (range 0-3, median 0). The final intraocular pressure was 21 mmHg or less in 47 of 50 (94%) operated eyes. Serious complications related to the procedure occurred in five eyes (10%). CONCLUSIONS Pneumatically stented Baerveldt glaucoma implants modified with the Hofmann elbow to facilitate pars plana insertion are effective in the treatment of complicated glaucoma.

Safety of transfoveal subthreshold diode micropulse laser for fovea-involving diabetic macular edema in eyes with good visual acuity.

Purpose: To determine the safety of transfoveal subthreshold diode micropulse laser for fovea-involving diabetic macular edema. Methods: The records of all patients treated with transfoveal subthreshold diode micropulse laser for fovea-involving diabetic macular edema in two retina clinics were reviewed. The eligibility included fovea-involving diabetic macular edema by spectral domain optical coherence tomography and pretreatment visual acuity of 20/40 or better. Results: Thirty-nine eyes of 27 patients aged 50 years to 87 years (mean, 69 years) were included. Postoperative follow-up ranged from 3 months to 36 months (mean, 11 months). Fourteen patients were insulin dependent, and 19 had nonproliferative retinopathy. The preoperative visual acuity was 20/20 (10 eyes), 20/25 (10 eyes), 20/30 (8 eyes), and 20/40 (11 eyes). No eye had evidence of laser-induced macular damage by any imaging means postoperatively. There were no adverse treatment effects. Logarithm of the minimum angle of resolution visual acuity was improved on average of 0.03 units at 4 months to 7 months of follow-up (P = 0.0449, paired t-test) and otherwise stable. The central foveal thickness was improved at 4 months to 7 months (P = 0.05, paired t-test) and 8 months to 12 months, postoperatively (P = 0.04, mixed model accounting). Maximum macular thickness was improved at 4 months to 7 months postoperatively (P = 0.01, paired t-test and mixed model accounting). Conclusion: In a small retrospective series, transfoveal subthreshold diode micropulse laser was safe and effective for the treatment of fovea-involving diabetic macular edema in eyes with good preoperative visual acuity that were not the candidates for conventional photocoagulation or intravitreal injection. Further study is warranted.

LASER RESENSITIZATION OF MEDICALLY UNRESPONSIVE NEOVASCULAR AGE-RELATED MACULAR DEGENERATION: Efficacy and Implications.

Purpose: Drug tolerance is the most common cause of treatment failure in neovascular age-related macular degeneration. “Low-intensity/high-density” subthreshold diode micropulse laser (SDM) has been reported effective for a number of retinal disorders without adverse effects. It has been proposed that SDM normalizes retinal pigment epithelial function. On this basis, it has been postulated that SDM treatment might restore responsiveness to anti–vascular endothelial growth factor drugs in drug-tolerant eyes. Methods: Subthreshold diode micropulse laser treatment was performed in consecutive eyes unresponsive to all anti–vascular endothelial growth factor drugs, including at least three consecutive ineffective aflibercept injections. Monthly aflibercept was resumed 1 month after SDM treatment. Results: Thirteen eyes of 12 patients, aged 73 to 97 years (average, 84 years), receiving 16 to 67 (average, 34) anti–vascular endothelial growth factor injections before SDM treatment were included and followed for 3 months to 7 months (average, 5 months) after SDM treatment. After SDM treatment and resumption of aflibercept, 92% (12 of 13) of eyes improved, with complete resolution of macular exudation in 69% (9 of 13). Visual acuity remained unchanged. Central and maximum macular thicknesses significantly improved. Conclusion: Subthreshold diode micropulse laser treatment restored drug response in drug-tolerant eyes with neovascular age-related macular degeneration. Based on these findings, a theory of SDM action is proposed, suggesting a wider role for SDM as retinal reparative/protective therapy.

Prolongation of choroidal hypofluorescence following combined verteporfin photodynamic therapy and intravitreal triamcinolone acetonide injection.

Purpose: To determine the incidence and effect of persistent/prolonged choroidal hypofluorescence (PCH) following combined verteporfin photodynamic therapy and intravitreal triamcinolone acetate injection (PDT + IVTA) for age-related subfoveal choroidal neovascularization (CNVM). Method: A retrospective review of all patients undergoing PDT + IVTA for CNVM from December 2003 through November 2004 was performed. Included patients underwent intravenous fundus fluorescein angiography (FA) preoperatively and 1 week and 3 months following PDT. FA presence of persistent choroidal hypofluorescence (PCH) 3 months postoperatively was graded in each eye by comparison with the 1 week postoperative FA. Twenty-seven eyes treated with PDT alone before December 2003 served as controls. Results: A total of 53 eyes of 46 patients were identified for study. At 3 months post treatment, PCH was noted in 37/53 eyes (70%) receiving PDT + IVTA combination therapy compared to only 3/27 (11%) control eyes treated with PDT alone (P < 0.0001; Fisher two-tailed exact test). Conclusion: The findings suggest that IVTA prolongs the native PDT effect manifest by post treatment FA CH. This phenomenon may reflect a mechanism by which IVTA enhances the effectiveness of PDT. Further study is necessary to confirm and elucidate this possible association.

LOW-INTENSITY/HIGH-DENSITY SUBTHRESHOLD DIODE MICROPULSE LASER FOR CENTRAL SEROUS CHORIORETINOPATHY.

Purpose: To review the results of low-intensity/high-density subthreshold micropulse laser (SDM) for treatment of central serous chorioretinopathy. Method: The records of all patients treated in a retinal subspecialty practice with SDM for central serous chorioretinopathy were reviewed. Results: Eleven consecutive eyes of 11 patients treated between October 2011 and April 2014 were identified for study, 9 men and 2 women, aged 30 to 55 (mean = 46). Symptom duration before treatment ranged 1 month to 7 months (mean = 3.6 months) and after treatment with SDM laser, follow-up ranged 1 month to 45 months (mean = 14). Preoperative visual acuities ranged 20/20 to 20/100 (mean = 20/37) and postoperative visual acuities were 20/15 to 20/40 (mean = 20/24) (P = 0.01, paired t-test). Maximum retinal thickness ranged 314 &mgr;m to 893 &mgr;m (mean = 508) preoperatively and 222 &mgr;m to 365 &mgr;m (mean = 250) postoperatively for an average 258 &mgr;m reduction in retinal thickness (P = 0.002, paired t-test). Subretinal fluid was eliminated in all eyes by 3 months after treatment (mean = 1.3 months). The number of SDM laser spot applications ranged 295 to 1431 per treatment session (mean = 772). One eye required retreatment, but for a new leakage locus 4 months after initial treatment. There were no adverse treatment effects. Conclusion: An SDM laser seems to be safe and effective for the treatment of central serous chorioretinopathy. As advocated in the literature, a higher treatment density and larger treatment area, as reported in this article, may improve clinical results.

Chronic Serous Macular Detachments and Visual Disturbance Complicating Consecutive Cases of Symptomatic Vitreomacular Adhesion With Macular Hole Treated With Ocriplasmin.

Two consecutive cases of symptomatic vitreomacular adhesion with macular hole were treated with intravitreal ocriplasmin. Both were complicated by long-term visual symptoms and chronic serous foveal detachments lasting 17 months post-treatment. These findings suggest direct and long-lasting effects of ocriplasmin on the retinal pigment epithelium and/or outer retina. Patients treated with ocriplasmin should be cautioned that the side effects of even successful drug treatment may prolong visual recovery compared to vitrectomy.

Vitrectomy After Anti-Vegf Therapy for Epiretinal Membranes Coincident with Age-Related Subfoveal Choroidal Neovascularization

BACKGROUND AND OBJECTIVE To report the visual acuity results in a small case series of eyes undergoing membrane peeling for epiretinal membrane presenting with age-related subfoveal choroidal neovascularization. PATIENTS AND METHODS Retrospective chart review of all eyes undergoing vitrectomy with epiretinal membrane peeling after intravitreal anti-vascular endothelial growth factor injection treatment for age-related subfoveal choroidal neovascularization presenting between February 2005 and January 2007 to a private vitreoretinal subspecialty practice. RESULTS Four eyes of four patients observed for 10-23 months (median = 20.5 months) were identified. All eyes presented with an angiographically ill-defined choroidal neovascular membrane and epiretinal membrane by optical coherence tomography. After anti-vascular endothelial growth factor therapy, visual acuity improved 1 to 5 Snellen lines (median = 2 lines). After vitrectomy, visual acuity further improved 1 to 6 lines (median = 2 lines). Final visual acuity was unchanged in 1 eye and improved in 3 eyes, with an overall improvement of 0 to 7 Snellen lines (median = 3.5 lines) after 5 to 14 months (median = 8 months) of follow-up following the vitrectomy. CONCLUSION In selected eyes presenting with epiretinal membrane and age-related subfoveal choroidal neovascularization after anti-vascular endothelial growth factor therapy, pars plana vitrectomy with membrane peeling may offer further improvement in visual acuity.

Concentric ring scanning laser ophthalmoscope artifacts and dysphotopsia in diffractive multifocal pseudophakia.

A 67-year-old woman had decreased visual acuity in her left eye and disturbing concentric ring dysphotopsias after bilateral implantation of ReSTOR (SN60D3; Alcon Laboratories, Inc., Fort Worth, TX) diffractive multifocal intraocular lenses (IOLs). Monochromatic (820-nm infrared and 488-nm red-free) scanning laser ophthalmoscopy (SLO) documented central retinal concentric ring patterns resembling the patients drawings of her dysphotopsia, prompting investigation of the relationship of these phenomena. Similar SLO findings were present in four eyes of three additional ReSTOR pseudophakes without dysphotopsia, but absent in monofocal pseudophakes or phakic individuals. Optical analysis shows that concentric ring SLO imaging artifacts can be caused by coherent reflection of monochromatic laser radiation off the diffractive optical element on the IOLs anterior surface, whereas concentric ring dysphotopsias are due to diffraction or projection of broad spectrum light sources in ordinary environments. Thus, the IOLs diffractive optics is the origin of both concentric ring dysphotopsia and SLO artifacts, but diffraction or projection causes the visual phenomenon, whereas coherent reflection produces the imaging anomaly.