Nathanael Benhamou

Intravitreal triamcinolone for refractory pseudophakic macular edema

PURPOSE To evaluate the efficacy of intravitreal triamcinolone in refractory pseudophakic cystoid macular edema. DESIGN A prospective, interventional case series. METHODS Three eyes of three patients with longstanding pseudophakic cystoid macular edema following uncomplicated cataract surgery, refractory to any medication, were treated with 8 mg of intravitreal triamcinolone. All three eyes were evaluated before injection and throughout follow-up with the Early Treatment Diabetic Retinopathy Studys visual acuity chart, fluorescein angiography, and macular mapping using optical coherence tomography. RESULTS A month after intravitreal triamcinolone injection, a dramatic decrease in macular thickness was noted by optical coherence tomography in all three eyes (from a mean of 502-233 microm). Mean improvement in visual acuity was 3.7 Snellen lines. Two to 4 months after triamcinolone injection, however, the edema recurred in all cases, to the same degree as before the injection, combined with a decrease in vision. Two eyes underwent a second injection of triamcinolone, and macular thickness decreased, but the edema again recurred 3 months after injection. CONCLUSION Intravitreal injection of triamcinolone induces striking regression, within 1 month, of chronic refractory macular edema. This regression appears to be transient, however, even after a second injection.

Adult-onset foveomacular vitelliform dystrophy: a study by optical coherence tomography.

PURPOSE To evaluate the morphology of adult-onset foveomacular vitelliform dystrophy (AFVD) using optical coherence tomography (OCT) and to correlate the OCT findings with those of biomicroscopy and fluorescein angiography (FA). DESIGN Prospective observational case series. METHODS A complete ophthalmologic examination, including visual acuity, fundus biomicroscopy, FA, and OCT was performed in 21 eyes of 14 consecutive patients with AFVD. RESULTS Mean age at presentation was 64 years (range, 39 to 84 years), and best-corrected visual acuity ranged from 20/25 to 20/400 (median 20/50). Sixteen of 21 eyes (11 patients) exhibited late staining of lesions on FA. In these 16 eyes, OCT revealed that AFVD material consists of a hyperreflective structure located between the photoreceptor and the retinal pigment epithelium layers. The retinal pigment epithelium layer was linear and was not elevated, unlike what is observed in retinal pigment epithelium detachment. Five other eyes (x4 patients) without late staining in FA showed, by OCT, a hyperreflective area at the level of the retinal pigment epithelium band, with no material visible between the photoreceptor and retinal pigment epithelium layers. In all 21 eyes, the retina overlying the hyperreflective structure was raised by the pseudovitelliform material and was markedly thinned. CONCLUSIONS Optical coherence tomography is a noninvasive useful tool that provides new information on the morphology of AFVD. It demonstrates, better than biomicroscopy, the location of the yellowish material under the sensory retina but above the retinal pigment epithelium, corresponding angiographically to the late staining. The foveal thinning found by OCT in all cases probably explains the progressive visual loss and possible evolution toward a full-thickness macular hole.

Surgical management of epiretinal membrane in young patients

PURPOSE To report the outcome of epiretinal membrane (ERM) surgery in young patients. DESIGN Interventional case series study. METHOD A retrospective review of 20 young patients who had undergone vitrectomy and epiretinal membrane removal. All patients had a preoperative examination, including fundus biomicroscopy, red free photographs, and fluorescein angiography. RESULTS Nine patients were males and 11 females (age: 7-26 years; mean: 16.3 years). Follow up ranged from 4-96 months (mean: 21.2 months). The 20 patients comprised 13 cases of idiopathic ERM, six cases in which ERM was associated with ocular inflammation and one case of combined hamartoma of the retina and retinal pigment epithelium (RPE). In 13 cases, the ERM was especially white, thick, and opaque, with localized constriction and severe retinal distortion. Final best-corrected visual acuity (VA) was significantly better than preoperatively (20/50 vs. 20/112), (P = 0.0002). Mean improvement in VA was 4.25 lines and 17 patients gained two or more lines. This improvement was better in secondary than idiopathic ERM (6 lines vs. 3.3). During follow up, five cases of recurrence were observed (25%). In another case, postoperative persistent ocular hypertension required filtering surgery. CONCLUSION The characteristics of ERM in young patients are quite different in many cases from those in adults in terms of thickness and adherence. Removal of ERM in young patients is feasible and safe although the membrane may focally adhere strongly to retinal vessels. VA usually improves significantly after surgery, but recurrences are more frequent than in adults.

Multimodal evaluation of foveal sparing in patients with geographicatrophy due to age-related macular degeneration.

Purpose: To compare the ability of spectral domain optical coherence tomography (SD-OCT), blue light fundus autofluorescence (FAF), and near-infrared fundus autofluorescence (NIR-FAF) to evaluate foveal involvement in geographic atrophy as a result of age-related macular degeneration. Methods: All consecutive patients with geographic atrophy underwent FAF (excitation &lgr; = 488 nm; emission &lgr; > 500 nm), NIR-FAF (excitation &lgr; = 787 nm; emission &lgr; > 800 nm), and simultaneous SD-OCT scanning (Spectralis HRA + OCT; Heidelberg Engineering). Two readers independently graded foveal involvement on FAF, NIR-FAF, and SD-OCT and measured the width of foveal sparing. In eyes with an intergrader agreement of foveal sparing by at least one among FAF, NIR-FAF, and SD-OCT, microperimetry (Spectral OCT/SLO; OPKO-OTI) was analyzed. Results: A total of 158 eyes (83 patients; 53 women, 30 men, mean age 69.2 ± 4.8 years) with geographic atrophy were included. Spectral domain OCT showed the highest intergrader agreement of foveal involvement (k = k′ = 0.8, P = 0.001 vs. k = k′ = 0.7, P = 0.01 for NIR-FAF and k = k′ = 0.5, P = 0.01 for FAF). In 74 eyes (46.8%) foveal sparing was present according to interobserver agreement. Width of the foveal sparing was larger on SD-OCT than on NIR-FAF and FAF (1,334 ± 943 &mgr;m vs. 1,228 ± 912 &mgr;m, P < 0.001 and 1,201 ± 922 &mgr;m, P < 0.001, respectively). Retinal fixation was predominantly central and stable in 97.3% of eyes with foveal sparing. Conclusion: Spectral domain OCT is an appropriate imaging modality for evaluating the presence and extent of foveal sparing, followed by NIR-FAF and FAF.

Imaging analysis with optical coherence tomography: relevance for submacular surgery in high myopia and in multifocal choroiditis.

Purpose To classify the preoperative and postoperative optical coherence tomography (OCT) findings for subfoveal choroidal neovascularization (CNV) related to high myopia and multifocal choroiditis (MFC) and to correlate these findings with surgical outcome. Methods Ten consecutive patients presenting with subfoveal CNV related to either MFC or degenerative myopia were evaluated. Each patient underwent a biomicroscopic examination, fluorescein and indocyanine green angiographies, as well as OCT before and after surgical removal of CNV. Four different parameters were considered in the analysis of all OCT scans: tissue reflectivity, location of the CNV band, presence or absence of a separation zone, and reflectivity underneath the retinal pigment epithelium (RPE) band. Results For all six eyes with MFC, OCT showed a hyperreflective band anterior to the RPE with a separation zone and an optically clear zone underneath the RPE. Visual acuity improved in all six eyes. For the degenerative myopia group (4 eyes), OCT revealed findings similar to those observed for MFC for 1 eye, which had a favorable postoperative outcome. The remaining three myopic eyes with different OCT patterns had poor postoperative outcomes. Conclusion Optical coherence tomography can provide preoperative clues for submacular surgery. Eyes with CNV located anterior to and separated from the RPE that have an “optically clear zone” underneath are the best candidates for surgical removal. Such a feature was correlated with a good postoperative outcome.