Moshe Oliver

Age-related Macular Degeneration after Extracapsular Cataract Extraction with Intraocular Lens Implantation

PURPOSE To evaluate the course of age-related maculopathy after cataract surgery. METHODS Included were 47 patients with bilateral, symmetric, early age-related macular degeneration (AMD), documented by fluorescein angiography, who underwent extracapsular cataract extraction with intraocular lens implantation in one eye. The fellow eye served as the control. The patients were retrospectively reviewed or prospectively followed. RESULTS Wet AMD developed in nine eyes (19.1%) that were treated with surgery compared with two fellow eyes (4.3%). It was detected within 3 months of surgery in four (44.4%) of the nine affected eyes and within 6 to 12 months of surgery in four other eyes (44.4%). Progression to wet AMD occurred significantly more often in men than in women (P < 0.05). Soft drusen were found as a significant ocular risk factor (P < 0.05). The final visual outcome was poor in all eyes with such progression. CONCLUSIONS In this study, progression of AMD occurred more often in the surgical eyes compared with the fellow eyes. However, the reasons for the progression of AMD after cataract surgery are still uncertain. Further prospective studies are needed to investigate this observation.

Compliance and Results of Treatment for Amblyopia in Children More Than 8 Years Old

Our prospective study of 350 amblyopic children divided them into three age groups: 2 to 5 1/2 years, 5 1/2 to 8 years, and 8 years and older. Treatment consisted of occlusion of the good eye. Compliance with treatment was analyzed by age group for the whole study population, but visual acuity results were evaluated only in children who complied fully with treatment and who cooperated at the initial visual acuity test with a Snellen chart. Younger children were significantly more compliant than older ones. This was probably the primary reason for the high incidence of treatment failure in older children. Children older than 8 years who complied with treatment showed a marked improvement in visual acuity--one almost as good as that in the younger children. A better initial visual acuity can be taken as a good prognostic sign, especially for this age group. In each group, most of the improvement occurred during the first three months of treatment. Improvement after this period was marginal.

Cystoid macular oedema following cataract extraction in patients with diabetes.

The course of cystoid macular oedema (CMO) following extracapsular cataract extraction with posterior chamber intraocular lens implantation was prospectively studied in 44 eyes of 44 consecutive diabetic patients without preoperative CMO. In 50% of eyes CMO was observed 6 weeks after surgery and in 25% was still present at 1 year. The preoperative presence of diabetic retinopathy significantly affected the postoperative onset and persistence of CMO. CMO occurred postoperatively in only 32% of eyes without pre-existing diabetic retinopathy and in 81% of eyes with pre-existing diabetic retinopathy (p < 0.05). CMO persisted at 1 year after surgery in only 7% of eyes without pre-existing diabetic retinopathy and in 56% of eyes in which diabetic retinopathy persisted (p < 0.01). Angiographic CMO (that is, detectable only on fluorescein angiography) was more common than clinical CMO (detectable on ophthalmoscopic examination as well) in eyes with no pre-existing diabetic retinopathy, whereas clinical CMO was seen more often than angiographic CMO when diabetic retinopathy was present preoperatively (p < 0.01). The course and final visual outcome of angiographic CMO were more favourable than in clinical CMO. Final visual acuity of at least 6/12 was achieved in 86% of eyes with angiographic CMO and in only 33% of eyes with clinical CMO. On the basis of the above findings we believe that cataract extraction should not be recommended for eyes with pre-existing diabetic retinopathy until the vision has deteriorated to at least 6/30-6/60.

Posterior Chamber Lens Implantation in Infants and Juveniles

Extracapsular cataract extraction with posterior chamber intraocular lens implantation was performed in 23 eyes (21 patients) of infants and juveniles. Four children with unilateral infantile cataract were operated on at the age of 3 or younger. Nine older children (11 eyes), all of them with bilateral juvenile cataract, were operated when older than 3. Seven children had traumatic cataracts: surgery was performed at the age of 3 or younger in three of them, and above this age in four. One patient aged 13 had a cataract due to heterochromic iridocyclitis. Final visual acuity results, binocularity, surgical complications and the need for additional surgery for secondary cataract development were analysed in relation to the age at surgery and the type of cataract. A visual acuity of 6/12 or better was achieved in 82.6% of the operated eyes. Stereopsis was found in 47.6% of the patients. Inflammation with fibrinous exudate, aqueous flare and cells in the anterior chamber appeared postoperatively in 57% of eyes, and were more common among the infant age group, but subsided with suitable anti-inflammatory treatment. Opacification of the posterior capsule was found within 3 months of surgery in 43.5% of the eyes, and was more common in the infants. Treatment with Nd-YAG laser was useful in the older children; in infants the opening made by laser in the posterior capsule did not last and a clear visual axis was achieved only after pars plana anterior vitrectomy and posterior central capsulectomy. The final results were excellent in patients with juvenile and traumatic cataracts. In those with unilateral infantile cataracts the results were considered encouraging.

Factors affecting long term results of successfully treated amblyopia: initial visual acuity and type of amblyopia.

AIMS--The study aimed to assess the effect of initial visual acuity and type of amblyopia on the long term results of successfully treated amblyopia. METHODS--The visual acuity of 94 patients, who had been successfully treated for unilateral amblyopia by occlusion of the good eye and followed up to the age of 9 years, was examined 6.4 years, on average, after cessation of treatment. Patients were divided into two groups according to the depth of amblyopia before occlusion therapy was started: those with visual acuity between 20/60 and 20/100 and those with visual acuity of 20/100 or worse. RESULTS--Deterioration of visual acuity was observed in 42% of patients in the first group and in 63% of patients in the second group. Their average deterioration, as measured by the Snellen chart, was 0.58 and 1.54 lines, respectively. The results were also assessed by the division of patients into three groups according to the type of amblyopia: strabismic, strabismic anisometropic, and anisometropic. Deterioration of visual acuity occurred in 46%, 79%, and 36% of patients in these three groups, with an average deterioration on the Snellen chart of 0.70, 2.04, and 0.64 lines, respectively. CONCLUSION--It is concluded that low initial visual acuity and strabismic anisometropic amblyopia are risk factors for deterioration of visual acuity in the long term, following the successful earlier treatment of eyes with amblyopia.

The Course of Age-Related Macular Degeneration Following Bilateral Cataract Surgery

BACKGROUND AND OBJECTIVE Progression of age-related macular degeneration (AMD) following cataract surgery has been described. The aim of this study was to investigate whether an uneventful postoperative maculopathic course in one eye (the first eye) may predict a similar prognosis for the fellow eye (the second eye). PATIENTS AND METHODS Thirty-three patients with bilateral, similar, early AMD (defined by the presence of drusen and/or pigmentary abnormalities on fundal examinations and by the absence of late leakage as documented by fluorescein angiography) who had undergone unilateral cataract surgery, had had a stable postoperative maculopathic course following the first operation, and were scheduled for cataract surgery in the second eye were prospectively observed for at least 1 year after the second operation. The course of maculopathy of the second eye was compared with that of the first eye during the follow-up period of the second eye. RESULTS A total of 9 of the second eyes (27.2%) showed progression to wet AMD. Of these, 1 patient (3%) had progression in both eyes and 8 patients (24.2%) had progression in the second eye only. The conditions of 2 of the first operated on eyes (6.1%) deteriorated (P < .05). Hypertension (P < .05), soft drusen (P < .01), and Nd:YAG laser capsulotomy (P < .05) were risk factors for development of wet AMD. CONCLUSION In this study, 24.2% of the patients with early AMD who underwent bilateral cataract surgery and had an uneventful maculopathic course in the first eye had wet AMD in the second eye. Thus, patients with early AMD and soft drusen undergoing bilateral cataract surgery should be monitored for early detection of progression of maculopathy. Further prospective studies are needed to determine the course of maculopathy following cataract surgery.

The course of diabetic retinopathy following cataract surgery in eyes previously treated by laser photocoagulation

The course of diabetic retinopathy following extracapsular cataract extraction with posterior chamber lens implantation in eyes previously treated by laser photocoagulation for diabetic retinopathy was retrospectively studied in 33 eyes (33 patients). In 20 eyes (61%) there was no change in the retinal status postoperatively. In 13 (39%) there was postoperative progression of diabetic retinopathy compared with the fellow non-operated eye, in which progression occurred in nine eyes (27%). The severity of the preoperative status affected the incidence of progression. Four eyes (12%) developed complications of diabetic retinopathy--that is, rubeosis iridis and vitreous haemorrhage--which regressed after lasering. Cystoid macular oedema developed in 13 eyes (39%) and its incidence varied according to the postoperative course of diabetic retinopathy. The majority of the eyes showed a postoperative improvement in vision.

Factors Affecting Long-Term Results of Successfully Treated Amblyopia: Age at Beginning of Treatment and Age at Cessation of Monitoring

The visual acuity of 104 patients who had previously been successfully treated for unilateral amblyopia by occlusion of the good eye was examined 6.4 years, on average, after cessation of treatment. Three age groups were defined, according to the age at which treatment was started: younger (2 to 5.5 years), middle (5.5 to 8 years) and older (above 8 years). In 55% of the patients, the long-term follow-up examination revealed deterioration of the visual acuity. In patients in whom amblyopia had been monitored at least up to the age of 9 years, the age at which treatment was started did not significantly affect the mean amount of deterioration or the mean visual acuity noted at the long-term follow-up examination.

Development of exudative age-related macular degeneration after cataract surgery

The macular status of patients with findings consistent with early dry age-related macular degeneration (AMD) who underwent an extracapsular cataract extraction with intraocular lens implantation was evaluated by fundoscopy and fluorescent angiography pre-operatively and during the first post-operative year. Five patients who developed the exudative form of AMD, and who represent the problems arising when treating patients with AMD and cataract, are described. Patients who received laser photocoagulation responded with recurrent choroidal neovascularisation. We suggest that patients with signs of age-related changes scheduled for cataract surgery should undergo a thorough pre- and post-operative assessment of their retinal status.

Prophylactic laser photocoagulation in stickler syndrome

The ocular manifestations in a family with Stickler syndrome and the results of laser photocoagulation as preventive treatment for retinal detachment are described. Forty-two family members with Stickler syndrome were retrospectively reviewed; 22 had ocular abnormalities, 22 had myopia and 16 had high myopia. Ten patients had developed retinal detachment and 9 of them were blind in one or both eyes because of irreparable detachment. Only 2 eyes had been operated on successfully. Ten eyes were lasered prophylactically. In eyes with extensive vitreoretinopathy laser burns were applied 360° around the peripheral retina at the border between the pathological and normal retina. Eyes with isolated lesions received focal treatment around the pathological areas. Four eyes received 360° laser photocoagulation and 6 eyes received focal treatment. Of the treated cases, 9 retinas remained attached for a follow-up period ranging from 1 to 15 years. One patient was lost to follow-up, and 5 years later developed retinal detachment in one eye from a new non-lasered lesion. In conclusion, in this particular family the incidence of retinal detachment was significantly higher in non-lasered eyes than in lasered eyes (p<0.025).