Lon S. Poliner

Management of submacular hemorrhage with intravitreous tissue plasminogen activator injection and pneumatic displacement

OBJECTIVE To investigate the efficacy and safety of treating thick submacular hemorrhages with intravitreous tissue plasminogen activator (tPA) and pneumatic displacement. DESIGN Retrospective, noncomparative case series. PARTICIPANTS From 5 participating centers, 15 eligible patients had acute (<3 weeks) thick subretinal hemorrhage involving the center of the macula in eyes with pre-existing good visual acuity. Hemorrhages were secondary to age-related macular degeneration in 13 eyes and macroaneurysm and trauma in 1 eye each. METHODS The authors reviewed the medical records of 15 consecutive patients who received intravitreous injection of commercial tPA solution (25-100 microg in 0.1-0.2 ml) and expansile gas (0.3-0.4 ml of perfluoropropane or sulfur hexafluoride) for thrombolysis and displacement of submacular hemorrhage. After surgery, patients maintained prone positioning for 1 to 5 days (typically, 24 hours). MAIN OUTCOME MEASURES Degree of blood displacement from under the fovea, best postoperative visual acuity, final postoperative visual acuity, and surgical complications. RESULTS In 15 (100%) of 15 eyes, the procedure resulted in complete displacement of thick submacular hemorrhage out of the foveal area. Best postprocedure visual acuity improved by 2 lines or greater in 14 (93%) of 15 eyes. After a mean follow-up of 10.5 months (range, 4-19 months), final visual acuity improved by 2 lines or greater in 10 (67%) of 15 eyes and measured 20/80 or better in 6 (40%) of 15 eyes. Complications included breakthrough vitreous hemorrhage in three eyes and endophthalmitis in one eye. Four eyes developed recurrent hemorrhage 1 to 3 months after treatment, three of which were retreated with the same procedure. CONCLUSIONS Intravitreous injection of tPA and gas followed by brief prone positioning is effective in displacing thick submacular blood and facilitating visual improvement in most patients. The rate of serious complications appears low. Final visual outcomes are limited by progression of the underlying macular disease in many patients.

Macular hole surgery without face-down positioning. A pilot study

Purpose: To investigate whether postoperative face‐down positioning is necessary for successful macular hole repair. Background: Although never proven, face‐down positioning is strongly considered an important maneuver to achieve macular hole closure. Face‐down posturing is inconvenient, and for patients with physical or mental limitations, weeks of face‐down positioning may be an impossible task. A gas bubble that completely fills the vitreous cavity will tamponade a macular hole despite head position and may close a macular hole as effectively as a partial gas fill with face‐down positioning. If face‐down positioning were not necessary, more patients would be eligible to benefit from this surgery. Methods: Thirty‐three consecutive eyes in 31 patients aged 65‐79 years with Stage II, III, or IV full‐thickness macular holes underwent macular hole surgery with a complete 15% C3F8 vitreous fill. Hole duration varied from 1 month to 10 years; in 21% of eyes, (seven of 33) holes had been present for more than 1 year. All phakic eyes (n = 25) had cataract extraction with intraocular lens insertion when macular hole surgery was done. No patients were positioned face down. Results: The follow‐up period was 6‐40 months; 73% of the patients have been observed for more than 1 year. Preoperative hole duration did not affect hole closure rate. The success rate after one surgery was 79% (26 of 33 eyes), and with additional vitrectomy surgery, the total success rate was 85% (28 of 33 eyes). Forty‐eight percent of eyes attained visual acuity of 20/50. Eighty percent of eyes with preoperative acuity of > 20/100 attained > 20/50 acuity. Significant complications included iris incarceration into the cataract wound during a postoperative fluid‐gas exchange (one eye), posterior synechiae (four eyes), intraocular lens capture (two eyes), elevated intraocular pressure (three eyes), and retinal detachment (three eyes). Most of these problems can be avoided or reduced. Conclusion: This pilot study suggests that successful macular hole closure is possible without face‐down positioning. This technique may be an alternative for patients with macular holes in pseudophakic eyes who are unable to assume face‐down posturing. Combining cataract surgery with this technique for macular hole repair is reasonable for phakic patients who cannot maintain prone positioning. Major disadvantages of combined surgery include the morbidity of the second procedure and removal of a visually insignificant cataract. This approach should be considered for those patients unable to tolerate face‐down positioning.

Pneumatic retinopexy : a two-year follow-up study of the multicenter clinical trial comparing pneumatic retinopexy with scleral buckling

The authors report 2-year follow-up information on 179 of 198 eyes (90%) enrolled in a previously published multicenter, randomized, controlled clinical trial comparing pneumatic retinopexy (PR) with scleral buckling (SB) for the management of selected retinal detachments. Scleral buckling was compared with PR with regard to redetachment after the initial 6-month follow-up period (1% versus 1%), overall attachment (98% versus 99%), subsequent cataract surgery (18% versus 4%; P less than 0.05), preoperative visual acuity (no significant difference), and final visual acuity of 20/50 or better in eyes with macular detachment for a period of 14 days or less (67% versus 89%; P less than or equal to 0.05). Reoperations after a failed PR attempt did not adversely affect visual outcome. After 2 years, PR continues to compare favorably with SB.

Retinal Pigment Epitheliopathy after Macular Hole Surgery

BACKGROUND Full-thickness idiopathic macular holes were previously considered untreatable, but surgical intervention has been proposed to collapse the hole and improve vision. This study evaluates the fluorescein angiographic changes that occur after macular hole surgery. METHODS Sixteen patients with stage III idiopathic macular holes underwent pars plana vitrectomy, removal of the posterior hyaloid, peeling of fine epiretinal sheets along the edges of the holes, and fluid-gas exchange. Preoperative fluorescein angiograms were performed, and best-corrected preoperative visual acuity was 20/200 or less in all eyes. RESULTS Postoperatively, the macular hole disappeared in 12 eyes (75%). In all 12 eyes, retinal pigment epithelial swelling was present, with a unique fluorescein angiographic appearance. This pattern slowly resolved over months, with gradual visual improvement but residual retinal pigment epithelial mottling. Systemic and periocular steroids had no significant impact on the process. CONCLUSION The combination of prolonged intraocular gas contact and light exposure exceeding threshold for an already compromised macula appears to be responsible for this pigmentary pattern. Depending on the severity of the pigment epithelial alteration, this unique pattern may portend a guarded visual prognosis in affected patients undergoing successful macular hole repair.

Interferon Alpha-2a for Subfoveal Neovascularization in Age-related Macular Degeneration

BACKGROUND The current study is a prospective randomized clinical trial to determine the effect of interferon alpha-2a on eyes with subfoveal subretinal neovascularization secondary to age-related macular degeneration (AMD). METHODS Twenty eyes of 19 patients with subfoveal neovascularization secondary to AMD were prospectively evaluated. Ten eyes were randomized to subcutaneous interferon alpha-2a (3 million units/m2) every other day for 8 weeks, whereas 10 eyes were randomized to observation alone as controls. Fluorescein angiography, best-corrected visual acuity tests, and macular visual field assessments were performed, and all eyes were followed for a minimum of 6 months. RESULTS At the 2-month follow-up visit, the interferon group manifested somewhat slower neovascular growth than controls, but the results were not statistically significant. At the 6-month follow-up visit, there was no difference in visual acuity, average macular sensitivities, or extent of neovascularization. The rate of neovascular progression was significantly related to the extent of previous macular photocoagulation in both groups. CONCLUSION Though the rate of neovascular progression was slowed during the second month of interferon treatment, the effect did not persist once interferon was discontinued. No long-term benefit appeared to be present. Unfortunately, lengthening the time of administration, increasing the dosage, or increasing the frequency of administration would likely give rise to unacceptable side effects.

Scatter macular photocoagulation for subfoveal neovascular membranes in age-related macular degeneration. A pilot study

Forty eyes with age-related macular degeneration and a choroidal neovascular membrane involving the entire foveal avascular zone were enrolled in a pilot study to evaluate an unconventional photocoagulation technique that was postulated to stimulate inhibitors of neovascularization. Eighteen (45%) eyes were treated with extrafoveal scatter macular photocoagulation, and 22 (55%) eyes were treated with this type of photocoagulation and focal extrafoveal ablation of the choroidal neovascular membrane. The eyes were followed for at least 1 year and up to 4 years (average, 2.4 years). One to 7 months after treatment, approximately 45% of the membranes treated with each technique did not leak fluorescein during angiography. The absence of leakage was associated with better visual acuity, but this difference was not statistically significant. At the beginning of the study, the visual acuity was 20/200 or better in 32 eyes (80%) and 20/80 or better in 11 (28%). At the conclusion of the study, the visual acuity was 20/200 or better in 21 eyes (53%) and 20/80 or better in 7 (18%). After treatment, 24 eyes (60%) had the same or better (plus or minus two lines) visual acuities. Compared with eyes in natural history studies, those treated with scatter macular photocoagulation had less visual loss from baseline but did not recover acuity of 20/100 or better more frequently. There was no difference in results between these two methods of treatment.

Transparency overlay. A rapid method to assess retinal pathologic changes.

Many ocular disorders are managed with the aid of serial photography to detect, document, and measure change. The authors developed a method of field mapping that is a clinically useful, rapid, and inexpensive way to assess changes in retinal anatomy using recently released Polaroid 691 transparency film. This transparency film allows the pretreatment fluorescein angiogram and the posttreatment black-and-white or color transparency images to be enlarged and compared without the use of additional photographic enlargers or projectors.