Marta J. Marsh

Scanning Laser Ophthalmoscope Fundus Perimetry After Surgery for Choroidal Neovascularization

PURPOSE Submacular surgery is under investigation for the treatment of subfoveal choroidal neovascularization secondary to age-related macular degeneration, ocular histoplasmosis syndrome, and other causes. The aims of this study were to determine whether the macular area from which choroidal neovascularization was removed surgically remained functional and whether there was any qualitative difference between eyes with different disease conditions or between eyes of younger and older patients. METHODS Our study included 19 patients (19 eyes) with choroidal neovascularization, seven cases caused by age-related macular degeneration and 12 caused by ocular histoplasmosis syndrome, pathologic myopia, or idiopathic causes. All tests were performed at least 6 months after surgical removal of choroidal neovascularization. All patients underwent fundus perimetry with the scanning laser ophthalmoscope for evaluation of dense and relative scotomas and fixation site. RESULTS After submacular surgery in 19 patients, 10 patients (one with age-related macular degeneration and nine with pathologic myopia, ocular histoplasmosis syndrome, or an idiopathic cause of choroidal neovascularization) fixated within an area that ophthalmoscopically and angiographically was an area of retinal pigment epithelial disturbance occupied by choroidal neovascularization preoperatively. Of 12 patients without age-related macular degeneration, seven of eight patients younger than 50 years of age compared with two of four patients 50 years or older fixated within the area of retinal pigment epithelial disturbance. CONCLUSIONS Our data suggest that in patients without age-related macular degeneration who undergo submacular surgery, the surgically disturbed area previously occupied by choroidal neovascularization can remain functional postoperatively. Furthermore, occasionally a patient with age-related macular degeneration undergoing submacular surgery still can fixate in the area from which the choroidal neovascularization was removed.

Phacoemulsification after Retinal Detachment Surgery

PURPOSE Previous studies have documented a 3% to 15.5% risk of retinal redetachment in eyes with prior scleral buckling procedures that later undergo intracapsular or extracapsular cataract extraction. The authors reviewed the records of patients with a history of retinal detachment (RD) surgery and subsequent phacoemulsification to assess the risk of retinal redetachment and the visual outcomes. METHODS Forty-seven eyes of 44 patients with a history of scleral buckling surgery who subsequently underwent phacoemulsification were identified. Features found before, during, and after surgery were reviewed. RESULTS No retinal redetachments occurred on a mean follow-up of 2.3 years. Eyes with RD repair were more myopic than fellow eyes (P=<0.001), had longer axial lengths (P=0.001), had steeper keratometry readings (P=0.03), and had larger differences in K readings between principal meridians (P=0.01). Postoperative visual acuity was 20/40 or better in 72.3% of eyes and 20/80 or worse in 6.4% of eyes. Preexisting macular pathology was responsible for poor outcomes. CONCLUSION The risk of redetachment after phacoemulsification in eyes with previous RD surgery is low. Despite retinal and cataract surgery, these eyes can achieve useful vision.

Guidelines for interpreting retinal photographs and coding findings in the Submacular Surgery Trials (SST): SST report no. 8.

Purpose: To describe the guidelines followed by the Submacular Surgery Trials (SST) Research Group in the interpretation of color fundus photographs and fluorescein angiograms of subfoveal choroidal neovascular lesions evaluated in the SST and to assist ophthalmologists in applying the results of the SST. Methods: Stereoscopic color fundus photographs and fluorescein angiograms of the study eye and nonstudy eye of 1,015 patients with subfoveal choroidal neovascular lesions secondary to age-related macular degeneration, ocular histoplasmosis syndrome, or idiopathic choroidal neovascularization (CNV) were obtained and graded by certified SST fundus photograph readers at the baseline examination in three randomized clinical trials comparing surgery with observation. Adherence to the inclusion and exclusion criteria and ocular features that might affect visual outcome were documented. Stereoscopic color fundus photography and fluorescein angiography were repeated 1 month after randomization for patients assigned to surgery to provide documentation that surgery was performed and to assess compliance with the surgery protocol. Photographs and fluorescein angiograms of both the study eye and the fellow eye in all patients then were obtained 3 months, 6 months, and 12 months after randomization and then annually up to 48 months. The &kgr; statistic was used to evaluate interobserver reliability of photograph gradings. Results: Lesion components at baseline included classic CNV, occult CNV, and features contiguous to CNV, including blood, fibrous tissue, hypofluorescence not corresponding to blood, serous detachment of the retinal pigment epithelium, and prior areas of laser photocoagulation. At follow-up, fluorescein leakage from CNV was assessed peripheral to or within the area of the retinal pigment epithelium abnormality after surgery. The lesion at follow-up could include any of the features identified at baseline as well as retinal pigment epithelium abnormalities, such as mottling of the retinal pigment epithelium with a subtle transition to normal retinal pigment epithelium or a very sharply demarcated, markedly hypopigmented area that was easily distinguished from the surrounding retinal pigment epithelium. &kgr; statistics for interobserver reliability ranged from good (0.47) to excellent (1.00) for features graded at baseline and follow-up. Conclusions: Although some of the definitions essential to the interpretation of the SST are similar to those used in the Macular Photocoagulation Study and randomized clinical trials of photodynamic therapy with verteporfin, this guideline provides new information regarding lesion components at baseline as well as standardized descriptions of lesions after submacular surgery. These descriptions from the SST assist in understanding what lesions were studied, when additional treatment was considered after surgery, and how anatomical results should be interpreted.

Eye care utilisation patterns in a rural county in Ireland: implications for service delivery

AIMS/BACKGROUND This investigation determined eye care utilisation patterns in a rural county in Ireland. Population based estimates of visual impairment and glaucoma were available, so the two studies will optimise planning for eye care services for the county. METHODS Roscommon has a population of 55 000 served by one ophthalmologist and two optometrists. Data were collected on all outpatient visits for all providers for a 3 month period. Information was abstracted on demographics, presenting and final diagnoses. Expected number of visits for glaucoma were calculated using the population structure and rates of glaucoma, and assuming one visit per year per glaucoma patient. RESULTS 1398 patients had a total of 1442 visits in 3 months. A third of the visits were to optometrists, and all but 21 visits were for normal eye examinations or glasses. The majority of children aged less than 16 years, and people older than 60 years were seen by the ophthalmologist. Among children, 81% of all visits were to the ophthalmologist and 92% were classified as a normal examination. Only an estimated 188 visits per year for glaucoma were observed, compared with 1100 expected. CONCLUSION In this rural county, many of the visits to the ophthalmologist were for normal eye examination, particularly among children. Screening algorithms which would free the ophthalmologist to see more complicated problems could be considered. There is an underutilisation of services by glaucoma patients. Reasons for this are described.

Changes in lesion size after submacular surgery for subfoveal choroidal neovascularization in the submacular surgery trials pilot study.

Purpose: To compare the size of subfoveal lesions based on photographic documentation before and after submacular surgery of choroidal neovascularization (CNV) lesions. Methods: Subfoveal lesion sizes at baseline and month 3 follow-up visits for patients assigned to surgery in the Submacular Surgery Trials (SST) Pilot Study were assessed categorically using Macular Photocoagulation Study (MPS) disc area (DA) circles. The Submacular Surgery Trials Pilot Study groups reviewed were as follows: Group N (age-related macular degeneration [AMD]; lesion <50% blood; classic CNV present; size ≤9 MPS DAs); Group R (AMD; prior nonfoveal laser; classic CNV present; size ≤9 MPS DAs); Group B (AMD; lesion ≥50% blood); and Group H (ocular histoplasmosis syndrome or idiopathic; classic CNV present; size ≤9 MPS DAs). Results: Postoperative month 3 lesion size was at least 1 size category smaller than the preoperative lesion size in 6% (4/66) of Group N, 0 (0/31) of Group R, 6% (2/34) of Group H, and 45% (18/40) of Group B eyes. In Group H eyes, there was no size change in 50% (17/34), and enlargement was found in 44% (15/34). For eyes in Groups N and R, approximately one third remained stable (20/66, 30% and 12/31, 39%, respectively), whereas two thirds enlarged by at least 1 category (42/66, 64% and 19/31, 61%, respectively). Conclusions: The change in lesion size after submacular surgery was variable, with a tendency for Group H lesions to remain the same size or larger, Group B lesions to measure smaller, and Group N and Group R lesions to be larger.