Kurt A. Gitter

Presumed Macular Choroidal Watershed Vascular Filling, Choroidal Neovascularization, and Systemic Vascular Disease in Patients With Age-related Macular Degeneration

PURPOSE To investigate the possible association of presumed macular choroidal watershed vascular filling (PMWF), choroidal neovascularization, and systemic vascular disease in patients with age-related macular degeneration. METHODS In a retrospective study, we evaluated 74 randomly selected indocyanine green videoangiograms of 74 patients with age-related macular degeneration. We also reviewed the charts of 20 randomly selected, age-matched control patients without age-related macular degeneration, initially referred for uniocular conditions, and subsequently performed indocyanine green videoangiography on their normal fellow eyes. We evaluated these videoangiograms for the presence of PMWF, manifesting as characteristic early choroidal hypofluorescence and its relation to choroidal neovascularization when present. Additionally, the incidence of hypertension, coronary artery disease, peripheral vascular disease, and diabetes mellitus was determined. RESULTS Forty-one (55.4%) of 74 patients with age-related macular degeneration vs three (15.0%) of 20 normal control patients exhibited PMWF on indocyanine green videoangiography (P = .0014). Of the 61 patients with age-related macular degeneration and choroidal neovascularization, 36 (59.0%) exhibited PMWF on videoangiography. Associated choroidal neovascularization arose from the PMWF zone in 33 (91.7%) of these cases. Hypertension was observed in 24 (58.5%) of 41 patients with age-related macular degeneration and PMWF vs nine (27.3%) of 33 patients with age-related macular degeneration who did not exhibit PMWF (P = .007). CONCLUSIONS An increased incidence of PMWF occurs in patients with age-related macular degeneration with a possible predisposition for the development of associated choroidal neovascularization. Additionally, PMWF may be accentuated by associated hypertensive choroidal microvascular insult.

Idiopathic Polypoidal Choroidal Vasculopathy Associated With Retinal Arterial Macroaneurysm And Hypertensive Retinopathy

Background Idiopathic polypoidal choroidal vasculopathy (IPCV), the posterior uveal bleeding syndrome, and multiple recurrent serosanguineous pigment epithelial detachments in black women are a heterogeneous group of related entities seen in elderly hypertensive females. Similar associations are known for retinal arterial macroaneurysm (RAM). Methods This report documents the clinical, fluorescein, and indocyanine green videoangiographic findings of two elderly black female hypertensive patients who presented with IPCV, RAM, and hypertensive retinopathy. Results Clinical, fluorescein, and indocyanine green videoangiographic analysis of these two patients revealed hypertensive retinopathy, RAM, and anomalous polypoidal vascular networks associated with focal “bead-string” constrictions, terminal vascular loops, and polypoidal and pinpoint choroidal nodules. Conclusion Certain subgroups of IPCV and related entities and RAM may be pathophysiologically related as analogous hypertensive insults to the choroidal and retinal vascular beds.

Acute Posterior Multifocal Placoid Pigment Epitheliopathy Associated with an Adenovirus Type 5 Infection

A 19-year-old black man with acute posterior multifocal placoid pigment epitheliopathy had concurrent positive viral cultures and rising antibodies to adenovirus type 5. This finding, considered together with earlier reports of viral-like syndromes accompanying the disease, supports the implication of a respiratory virus as a possible etiologic factor.

Acute leukemia presenting as a unilateral exudative retinal detachment.

The leukemias commonly involve the eyes and adnexae. It is unusual, however, for leukemia to present with visual complaints. Furthermore, there are only rare case reports of leukemic patients presenting with bilateral exudative retinal detachments. We report a unique case of a boy who presented with visual loss due to a unilateral exudative retinal detachment. A systemic evaluation discovered acute lymphocytic leukemia (ALL). There was rapid settling of the exudative detachment and improvement in vision while the patient received chemotherapy and radiotherapy for the ALL.

SURGICAL INTERVENTION FOR COMBINED RETINAL-RETINAL PIGMENT EPITHELIAL HAMARTOMA

A young woman was followed for over 20 years with a macular combined hamartoma of the retina and retinal pigment epithelium. When vision deteriorated due to contracture of an overlying epiretinal membrane, a pars plana vitrectomy with removal of the membrane was performed. Decreased vascular tortuosity and retinal vascular leakage resulted in postoperative improvement of visual acuity. Selected patients with combined retinal and retinal pigment epithelial hamartomas may benefit from removal of epiretinal membranes.

Photocoagulation of Active and Inactive Lesions of Presumed Ocular Histoplasmosis

Argon laser photocoagulation was employed in 27 eyes with presumed ocular histoplasmosis. Thirteen eyes with active macular lesions had stable or improved visual results (72%).

EVALUATION OF PERSISTENCE OF SUBRETINAL NEOVASCULAR MEMBRANES USING DIGITIZED ANGIOGRAPHIC ANALYSIS

A study was conducted using the digitized fluorescein angiogram (DFA) system to evaluate adequacy of coverage of laser treatment for subretinal neovascular membranes (SRNVM) and to confirm that complete coverage lowers the incidence of persistent SRNVMs. Ten consecutive cases were evaluated with the DFA system after undergoing a single laser treatment. Three cases were judged to be adequately treated, and the remaining seven cases were judged to be inadequately treated. The DFA system was then used during photocoagulation in 16 consecutive cases to verify complete coverage of the SRNVM or to indicate the need for photocoagulation augmentation. Despite augmentation, 2 of the 16 cases remained inadequately treated. Overall, the cases that were adequately treated had a 12% (2/17) persistence rate, whereas those that were inadequately treated had a persistence rate of 67% (6/9). The data indicate that adequate coverage of SRNVMs is essential to prevent persistence.

Indocyanine Green Angiography in Stargardt's Flavimaculatus

PURPOSE We studied the indocyanine green videoangiographic characteristics of eyes in patients with Stargardts flavimaculatus and fluorescein angiographic evidence of a dark choroid. METHODS Affected individuals underwent ophthalmic examination and fluorescein angiographic examination. Indocyanine green videoangiography was performed on eight patients with classic Stargardts flavimaculatus. Two additional asymptomatic patients with mild manifestations of Stargardts flavimaculatus, both of whom were related to one patient with the classic phenotype, were also examined with indocyanine green videoangiography. RESULTS Choroidal detail was evident in all patients examined with indocyanine green videoangiography, and varying degrees of choroidal vascular closure were documented in the maculas of eight patients. Retinal pigment epithelial flecks were found to block indocyanine green videoangiographic fluoresence progressively. Late indocyanine green videoangiographic imaes frequently showed retinal pigment epithelial involvement in areas of retina thought to be uninvolved clinically and by fluorescein angiography. Peripapillary crescents of hypofluorescence, which in some patients were not noted clinically or by fluorescein angiography, were observed in all ten patients examined with indocyanine green videoangiography. In one asymptomatic patient, retinal pigment epithelial flecks could be identified only with indocyanine green videoangiography. CONCLUSIONS Indocyanine green videoangiography in conjunction with fluorescein angiography can be a valuable tool in the recognition and further understanding of Stargardts flavimaculatus.

Photocoagulation in Venous Occlusive Disease

Fifty-one eyes with branch or tributary retinal venous occlusive disease underwent photocoagulation (1970-1973) after certain criteria were met: reduced visual acutity, fluorescein angiographic documentation of vessel permeability changes, and either dye leakage into the macula or neovascularization of the retina, or both. Eighty-four percent of the eyes responded to treatment with an improvement or stabilization in visual acuity, a reduction in collateral vessel caliber and permeability, and reduced dye accumlation in the macular area and increased fluorescein transit time. Photocoagulation is an affective means of reducing macular edema resulting from vascular compensatory changes following venous occlusion and decreases the risk of vitreous hemorrhage from sites of retinal neovascularization.

West nile virus occlusive retinal vasculitis.

PURPOSE To report a case of West Nile virus meningoencephalitis presenting with simultaneous chorioretinitis in the right eye and occlusive retinal vasculitis in the left eye. METHODS Case report. Main outcome measures included ocular examination, intravenous fluorescence angiography, indocyanine green, color fundus photography, and serologic testing for West Nile virus. RESULTS A 45-year-old white woman presented with severe loss of vision in the left eye (count fingers at 3 feet) 2 weeks after an episode of hospitalization for fever of unknown origin. Examination showed extensive retinal opacification and edema in the left eye with arteriolar narrowing. Intravenous fluorescence angiography confirmed delayed venous return superiorly, multiple arteriolar occlusions, large area of nonperfusion, and vascular staining and leakage. Indocyanine green highlighted bilateral well-deliniated hypocyanescent choroidal lesions corresponding to the subretinal lesions seen by ophthalmoscopy. Indocyanine green allowed identification of additional lesions that were not initially detected on intravenous fluorescence angiography and ophthalmoscopy. CONCLUSION Occlusive retinal vasculitis is a rare yet important ocular manifestation of West Nile virus infection. It may occur in young patients without diabetes, and unlike West Nile virus chorioretinitis, it is often associated with poor visual outcome.