John J. Weiter

Natural history of choroidal neovascularization in degenerative myopia.

We studied 354 eyes with myopic chorioretinal degeneration by means of standard clinical evaluation and fluorescein angiography. The eyes were classified on the basis of the degree of chorioretinal degeneration found in the posterior pole. Lacquer cracks (breaks in Bruchs membrane) were noted in 82% of the 149 eyes with choroidal neovascular membranes (CNM) and in 96% of the 58 eyes with isolated subretinal hemorrhages. These hemorrhages were reabsorbed without adverse visual sequelae in 32 eyes that were followed; in 14 of these eyes that were followed closely, the average time of reabsorption was 6.4 weeks. Seventy eyes with CNM were followed for an average of 40.9 months. In 96% of these eyes the CNM remained stable or regressed, leaving an atrophic, nonexudative scar. This study indicates that CNM in degenerative myopia is usually self-limited.

Infrared imaging of sub-retinal structures in the human ocular fundus

The interaction of infrared light with the human ocular fundus, particularly sub-retinal structures, was studied in vivo. Visible and infra-red wavelengths and a scanning laser ophthalmoscope were used to acquire digital images of the human fundus. The contrast and reflectance of selected retinal and sub-retinal features were computed for a series of wavelengths or modes of imaging. Near infrared light provides better visibility than visible light for sub-retinal features. Sub-retinal deposits appear light and thickened; the optic nerve head, retinal vessels, and choroidal vessels appear dark. Contrast and visibility of features increases with increasing wavelength from 795 to 895 nm. Optimizing the mode of imaging improves the visibility of some structures. This new quantitative basis for near infrared imaging techniques can be applied to a wide range of imaging modalities for the study of pathophysiology and treatment in diseases affecting the retinal pigment epithelium and Bruchs membrane, such as age-related macular degeneration.

Relationship of Senile Macular Degeneration to Ocular Pigmentation

We prospectively evaluated 650 consecutive white patients with senile macular degeneration and compared them to a control group of 363 patients. Ocular pigmentation (iris color and fundus pigmentation) was recorded for each patient, as was hair color (as a child and young adult) and age at evaluation. Patients were from the New England states and Florida. Our most significant finding was that 494 patients with senile macular degeneration (76%) had light-colored irides compared with 145 of the controls (40%). Fundus pigmentation closely corresponded to iris pigmentation (P less than 0.01). Hair color was blond or light brown in 370 of the patients with senile macular degeneration (57%) and in 105 of the controls (29%). Further, there was a tendency for individuals with lightly pigmented irides to have senile macular degeneration at an earlier age than those with dark irides (P less than .01). Thus, increased ocular pigmentation tends to decrease the risk of developing senile macular degeneration.

Classification of retinal pigment epithelial detachments associated with drusen

To understand the natural history of retinal pigment epithelial (RPE) detachments (PEDs) associated with drusen, we retrospectively reviewed 125 PEDs that had not undergone laser treatment over an average follow-up period of 28 months. We identified six types of RPE detachments: pseudo-vitelliform, confluent drusen, serous, vascular, and hemorrhagic lesions as well as PEDs associated with a retinal vascular abnormality. We correlated the type of detachment with visual acuity and anatomic outcome. The poorest results were obtained for PEDs associated with neovascularization (vascular, hemorrhagic, and retinal vascular abnormality types). Eyes presenting with pseudo-vitelliform lesions or confluent drusen had the best visual prognosis and anatomic results. Obvious subretinal new vessels developed in 16 (34%) of the serous PEDs over an average follow-up period of 25 months. Subretinal neovascularization was rare in the pseudo-vitelliform and confluent drusen groups. The proposed classification system may be useful in predicting the natural course of PEDs.

Deep Retinal Vascular Anomalous Complexes in Advanced Age-related Macular Degeneration

PURPOSE The authors describe the clinical characteristics of a group of patients with age-related macular degeneration (AMD), deep retinal vascular anomalous complexes (RVACs), advanced Bruch membrane changes, and severe visual loss. Based on clinical evaluation and imaging studies, the authors hypothesize the cause of such retinal vascular formations. PATIENTS AND METHODS The authors quantified an initial case series of 6 patients and expanded it to 11 patients (14 eyes) with AMD and RVACs diagnosed by fluorescein angiography or slit-lamp examination. Associated pigment epithelial detachments (PEDs) of 13 eyes are described. In addition to the clinical and fluorescein angiography descriptions, infrared imaging and indocyanine green angiography were used to characterize more recently described RVACs and fellow eyes. RESULTS Each study eye had a clearly defined anastomosis connecting the retinal circulation to a vascular complex in the deep retina. The RVACs associated with PEDs assumed a more central location than did typical choroidal neovascularization associated with PEDs. In seven eyes with RVACs, there were clinically recognizable retinovascular findings: intraretinal hemorrhages, telangiectasia, or microaneurysms. Legal blindness occurred in 9 of 11 patients. CONCLUSION These results indicate that retinovascular changes can be associated with nondisciform AMD. The authors speculate that neurodegenerative changes and hypoxia may lead to such changes, the RVAC being a more advanced finding. Closure of an RVAC with photocoagulation is difficult, perhaps because of its higher blood flow. The visual outcome is poor, not only because of the advanced state of the underlying AMD, but also because of the exudative nature of the RVAC.

The Influence of the Photoreceptor -RPE Complex on the Inner Retina An Explanation for the Beneficial Effects of Photocoagulation

We have measured oxygen consumption in the various retinal layers and have found that the photoreceptor-retinal pigment epithelial (RPE) complex accounts for two thirds of total oxygen consumption. Hence, this complex substantially influences oxygen transport between the choroid and the inner retina. This finding has significant implications in explaining the beneficial effects of panretinal photocoagulation as well as retinal vasculature changes in outer retinal degenerations.

Central sparing in annular macular degeneration

Using fluorescein angiography and monochromatic photography, we measured the size of the central sparing in 45 patients with annular maculopathy (mean +/- S.D., 0.34 +/- 0.15 disk diameter; range, 0.10 to 0.65 disk diameter) and compared it with the size of macular yellow pigment in 40 subjects (mean +/- S.D., 0.31 +/- 0.12 disk diameter; range, 0.1 to 0.5 disk diameter). The close approximation of these values suggested that macular yellow pigment contributed to the annular pattern through a photoprotective mechanism.

Evaluation of micrometric and microdensitometric methods for measuring the width of retinal vessel images on fundus photographs

The width of retinal vessel images on fundus photographs was determined by projection micrometry and microdensitometry. These methods were evaluated on 12 retinal vessels using the negatives of 570-nm monochromatic fundus photographs. For projection micrometry, the intraobserver reproducibility of vessel width measurements was 1.6%–2.9%, depending upon the experience of the observer. Significant interobserver differences in the measured widths were demonstrated. For microdensitometry, three distinct measurement criteria were used. Significant differences in width as measured by the three criteria were found, but there were no interoperator differences for each criterion. The intraoperator reproducibility of vessel width measurements by microdensitometry was 2.1%–2.5%. Significant differences were found in the vessel widths determined by the micrometry and densitometry methods, and results obtained by micrometry are discussed in terms of edge-detection phenomena.

Effect of optic nerve head drusen on nerve fiber layer thickness

OBJECTIVE The purpose of the study was to evaluate the effect of optic nerve head drusen (ONHD) on nerve fiber layer (NFL) thickness by visual field testing, red-free photography of NFL, and optical coherence tomography (OCT). DESIGN The study design was a prospective clinical study. PARTICIPANTS Twenty-three eyes of 15 consecutive patients with ONHD and 27 eyes of 27 age-matched control subjects participated. INTERVENTION Ophthalmologic examination, color and red-free photography, automated Humphrey visual field testing, and OCT were performed. Each of the drusen study eyes were graded on a scale of 0 to III based on the amount of visible ONHD. Grade 0 represented the absence of clinically visible ONHD, and grade III represented an optic nerve head with abundant drusen. MAIN OUTCOME MEASURES Findings from clinical evaluation and color optic nerve head photographs and NFL evaluation by red-free photography, visual fields, and OCT were measured. RESULTS The number of study eyes with visual field defects increased with the higher grade drusen discs, corresponding both with progressively thinner NFL measurements by OCT and NFL loss shown by NFL photography. The NFL evaluation showed NFL thinning by red-free photography in 12 (71%) of 17 eyes with visible drusen (grades I-III discs) and visual field defects in 9 (53%) of 17 eyes in this group. By OCT measurements, the superior and inferior NFLs were significantly thinner in the eyes with visible ONHD compared with those of control eyes in the superior quadrant (P < 0.001) and inferior quadrant (P = 0.004). Compared with grade 0 discs, grades I through III discs showed statistically significant thinning of the NFL superiorly (P < 0.001). No statistical significant thinning of the NFL was seen in grade 0 discs compared with those of control subjects. CONCLUSIONS Optical coherence tomography is able to detect NFL thinning in eyes with ONHD and appears to be a sensitive and early indicator of NFL thinning. Increased numbers of clinically visible ONHD correlated with NFL thinning shown by OCT measurements and both visual field defects and NFL loss seen by red-free photography.

Retinal blood flow alterations associated with scleral buckling and encircling procedures.

The bidirectional laser Doppler technique and monochromatic photography were used to measure the absolute blood flow rate in the major temporal retinal arteries in seven patients following unilateral scleral buckling and encircling procedures, and in two patients before and after removal of scleral buckling elements. In the seven patients who had undergone uncomplicated scleral buckling procedures the arterial flow rates were on average 50% lower (p = 0.01) in the surgically treated eyes than in the contralateral eyes. Removal of scleral buckling elements in two patients produced increases of 73% and 44% in arterial blood flow rates.