Joseph B. Walsh

Hypertensive Retinopathy: Description, Classification, and Prognosis

In 1898 Marcus Gunn described the changes in retinal vessels noted with hypertension. Arteriolar narrowing, caliber irregularity, alterations of the light reflex, and hiding of the arterial blood column were noted. Arteriovenous crossing changes and capillary bed abnormalities, such as cotton-wool spots, retinal hemorrhages, and retinal edema were also mentioned, as well as blurred discs. In the 83 intervening years, little has been added to the description of hypertensive retinopathy, but our understanding has increased. Retinal vessels respond to elevations of systemic blood pressure by generalized arteriolar constriction. This can lead to arteriolar necrosis, retinal edema, cotton-wool spots, hemorrhage, and disc edema. If the blood pressure is controlled, or slow rising, or if arteriolar sclerosis is present in the retinal arteries, then a picture of arteriolar irregularity will be noted and, depending upon the ability of the retinal vessels to contract, segmental constriction will be seen. In separating hypertensives from nonhypertensives, the most consistent ophthalmoscopic finding is arteriolar narrowing with focal irregularity. In prognosticating for survival, the best method available is the Keith-Wagener-Barker classification. However, the difficulty in separating Groups 1 and 2 of this classification has lead to numerous modifications that make comparisons from one study to another difficult.

Drusen of the optic disc

Although optic disc drusen have been of interest to ophthalmologists for more than 100 years, their etiology and many aspects of their relationship to other clinical conditions remain obscure. They have been clinically observed in 0.3% of the population, although autopsy studies suggest an incidence of 2%. Drusen are seldom accompanied by visual symptoms; however, decreased vision and visual field changes may occur. The historical and epidemiological aspects of drusen are reviewed; clinical and histological features, as well as special diagnostic techniques (ultrasonography and fluorescein angiography) are discussed in detail.

Retinal Fat Emboli as A Sequela to Acute Pancreatitis

A clinical picture of Purtschers retinopathy was observed in three patients with acute pancreatitis. In two patients, fluorescein angiography revealed arteriolar obstruction. Since fat emboli occur in pancreatitis, and since fat emboli may produce the picture of Purtschers retinopathy, we proposed that fat emboli caused the retinal findings in these patients.

Mortality and morbidity in patients with central retinal vein occlusion.

We investigated the risk of mortality and morbidity in 78 patients with central retinal vein occlusion (CRVO) followed for more than 2 years (mean follow-up 7.2 years). Thirteen subjects died at an average of 7.0 years after CRVO. Five subjects developed myocardial infarction at an average of 2.8 years after CRVO, and 1 developed a cerebrovascular accident 3 years after CRVO. Patients with CRVO do not carry a higher risk of mortality and morbidity than matched controls derived from national surveys.

High-resolution ultrasound biomicroscopy of the pars plana and peripheral retina

OBJECTIVE This study aimed to evaluate the ability and role of ultrasound biomicroscopy in imaging the peripheral retina, pars plana, and anterior choroid. DESIGN The study design was a case series. PARTICIPANTS Seventeen eyes of 17 patients with a variety of clinical diagnoses involving the anterior portion of the posterior segment were studied. INTERVENTION High-frequency (50 MHz), high-resolution (50 microns) ultrasound biomicroscopy was performed. RESULTS Ultrasound biomicroscopy was capable of imaging the peripheral retina, pars plana, and anterior choroid. Images had features consistent with known histopathology. Retinoschisis consisted of one thin hyper-reflective echo and could be differentiated from a retinal detachment, which was thicker and formed a bilayered echo. A choroidal effusion could be identified as an echolucent space within the suprachoroidea, whereas a choroidal hemorrhage was moderately echodense. Inflammatory diseases, such as a sarcoid granuloma, pars planitis, and Haradas disease, were characterized by different forms of uveal thickening. A ciliochoroidal nevus was internally hyporeflective and could be measured accurately and localized. CONCLUSIONS Imaging of the peripheral retina, pars plana, and anterior choroid is possible with ultrasound biomicroscopy and may aid in the diagnosis and management of pathology involving this region.

A grading system for iris neovascularization. Prognostic implications for treatment.

A retrospective study of 34 eyes of 30 patients who had neovascularization of the anterior segment and who received panretinal photocoagulation (PRP) and/or panretinal cryotherapy was performed. The eyes were all classified preoperatively and postoperatively as to the grade of neovascularization of the iris and the anterior chamber angle according to the system devised by Weiss and Gold. The grading system of Weiss and Gold was useful in predicting the response to treatment of iris neovascularization. Almost all eyes in angle grades 0 through 2 did well. Eyes with angle grade 3 had an intermediate response. Eyes in angle grade 4 almost uniformly did poorly. Eyes with iris neovascularization secondary to central retinal vein occlusion (CRVO) or hemiretinal branch vein occlusion (HBVO) had a more rapidly progressive disease than that of eyes with rubeosis secondary to diabetes alone. The patients with the most advanced rubeosis initially, however, were those diabetics with ischemic-type CRVO.

Arteriovenous Anastomoses of the Retina

The authors reviewed the clinical findings in 13 patients followed at Montefiore Medical Center and in 85 cases described in the literature with primary arteriovenous communication of the retina (AVCR). The characteristics of AVCR include: young age at detection; both sexes affected; detected on routine examination, and less frequently after decreased vision or referral after diagnosing systemic arteriovenous communication (AVC); unilateral involvement; single or multiple sites in the same fundus; and predilection for the papillomacular area and the superotemporal quadrant. Vision correlated inversely with the grade of AVCR. The presence of concomitant systemic AVC correlated directly with the grade of AVCR. It is concluded that grade I AVCR and the majority of grade II AVCR represent isolated retinal vascular anomalies, and there is no need for extensive search for systemic AVC if these patients remain asymptomatic.

Transscleral diode laser retinopexy in retinal detachment surgery: results of a multicenter trial.

Purpose: To evaluate the safety and efficacy of transscleral diode laser for retinopexy in rhegmatogenous retinal detachment surgery in a multicenter trial. Methods: Seventy‐two patients with primary rhegmatogenous retinal detachments were enrolled. No patient with chronic detachment, a retinal break greater than 90°, history of uveitis or infectious retinopathy, or proliferative vitreoretinopathy was enrolled. Results: Information from follow‐up of 6 months or longer was available on 65 eyes. Retinas were attached at 6 months with a single operation in 58 (89%) of these eyes. Complications included apparent pinpoint breaks in Bruchs membrane in 15 eyes, scleral‐thermal effect in 14 eyes, and limited hemorrhage, which was intraretinal in 10 eyes and extended into the vitreous in 3 eyes. In one case, hemorrhage was judged perhaps to have contributed to initial surgical failure. The other complications had no known adverse effects. Complications were significantly associated with the physicians experience in using transscleral laser retinopexy. Conclusions: In this multicenter study, transscleral diode laser retinopexy served as a safe and effective means of creating chorioretinal adhesion during retinal reattachment surgery. Minor complications were minimized by increasing experience with the technique.

Purtscher's retinopathy in acute pancreatitis

A patient who became blind following an episode of alcohol-induced pancreatitis is described. The clinical appearance of this patients retinal changes corresponds most closely to post-traumatic (Purtschers) retinopathy. The etiology of the retinopathy is best explained by retinal vascular occlusion due either to fat embolism or thrombosis.

Cotton-Wool Spots as a Sign in Leptospirosis (Weil's Disease)

A 44-year-old black male presented with fever, myalgia and weakness. He had elevated blood urea nitrogen, creatine phosphokinase and serum glutamic-oxaloacetic transaminase. During the first 6 days of this undiagnosed illness azotemia increased, a pericardial friction rub occurred, and hematuria was present. On the 7th day bilateral subconjunctival hemorrhages, anterior uveitis, and peripapillary cotton-wool spots were noted. This combination of findings suggested leptospirosis, which was subsequently confirmed by specific antibody titers. Therapeutic response was achieved with high-dose systemic steroids.