Peter A. Nixon

Branch Retinal Artery Occlusion: Visual Prognosis

PURPOSE To evaluate the visual prognosis in eyes with branch retinal artery occlusion (BRAO). DESIGN Retrospective, observational, consecutive case series. METHODS Retrospective medical record review of 52 consecutive eyes of 52 patients with BRAO seen at two vitreoretinal practices in Birmingham, Alabama. Only eyes with decreased central macular perfusion on fluorescein angiography (FA) were included. Eyes with anterior segment or optic nerve disease, lack of retinal whitening or a delay in arterial filling on FA, central retinal artery occlusion, and cilioretinal artery occlusion were excluded. The main outcome measure was presenting best-corrected visual acuity (BCVA) and its relationship to final BCVA. RESULTS On presentation, 54% of eyes with BRAO had BCVA of 20/40 or better. At the mean 14-month visit, 60% of all eyes had visual acuity (VA) of 20/40 or better. VAs of 20/40 or better were retained by 89% of eyes with baseline BCVA of 20/40 or better. Only 14% of eyes with 20/100 or worse BCVA improved to 20/40 or better. Neither visible emboli (P > or = .244) nor the region of macular involvement (P = .142) were significant with respect to visual improvement. CONCLUSIONS Visual prognosis after BRAO seems to be correlated to presenting VA. Eyes with initial VA of 20/40 or better usually remained at 20/40 or better. Individuals with poor VA of 20/100 or worse generally did not show the significant improvement reported in previous studies.

Trans-luminal Nd: YAG laser embolysis for branch retinal artery occlusion

Purpose: To evaluate the clinical efficacy of transluminal YAG laser embolysis (TYE) for patients with severe vision loss secondary to a newly diagnosed branch retinal artery occlusion (BRAO) with visible emboli. Methods: Five eyes of five patients with acute, severe vision loss secondary to a branch retinal artery occlusion with visible emboli and retinal whitening were prospectively examined, enrolled, and underwent visual acuity testing, ophthalmic examination, color photography, and fluorescein angiography. Each patient was offered TYE and the potential risks of the treatment were explained. Follow-up examinations were undertaken postprocedure day 1 and subsequent follow-up depended on the clinical course. Results: In our five patients baseline best-corrected visual acuity (BCVA) was found to be 5/400, count fingers at 3 feet, count fingers at 5 feet, 20/800, and 20/200. All five of our patients showed improvement in BCVA 1 day after TYE. Fluorescein angiography showed immediate and dramatic restoration in flow past the obstructed arteriole in all patients. Patient 2 developed subretinal hemorrhage, which after vitrectomy and associated procedures the acuity improved to 20/25 at 22 days after the TYE. Final BCVA was 20/30, 20/25, 20/40, 20/30, and 20/40. Conclusion: TYE is a treatment modality to be considered in patients with BRAO who present acutely with severe vision loss and a visible embolus. The risks of TYE must be weighed against the possibility of severe and permanent loss of vision secondary to BRAO.

INTRAVITREAL SULFUR HEXAFLUORIDE INJECTION FOR THE TREATMENT OF VITREOMACULAR TRACTION SYNDROME.

Purpose: Vitreomacular traction (VMT) syndrome can cause symptomatic metamorphopsia and decreased visual acuity. Although it is typically treated with vitrectomy or intravitreal ocriplasmin injection, these procedures can be invasive and costly. The purpose of this retrospective, consecutive case series was to evaluate the efficacy of intravitreal expansile sulfur hexafluoride gas injection for the treatment of symptomatic VMT syndrome. Methods: Nine eyes of 9 patients with symptomatic VMT syndrome on spectral domain optical coherence tomography received an intravitreal injection of 0.3 mL of 100% sulfur hexafluoride. The primary outcome was the number of eyes with release of VMT on spectral domain optical coherence tomography at 1 month after treatment. Secondary outcomes included change in visual acuity and central subfield thickness 1 month after treatment. Results: Five patients (55.6%) had release of VMT on spectral domain optical coherence tomography by 1 month after injection. Two patients who had Stage I macular holes before injection had closure of the macular holes. Mean visual acuity at 1 month improved slightly after injection by 0.09 logMAR units, although this change was not statistically significant (P = 0.15). Central subfield thickness on spectral domain optical coherence tomography decreased by an average of 35.3 microns after injection (P = 0.004). All eyes with release of VMT had pretreatment vitreomacular adhesion of less than 521 microns and none had epiretinal membranes. One patient (11.1%) developed a peripheral retinal hole at 1 month after injection. Conclusion: Intravitreal injection of expansile sulfur hexafluoride gas is a low-cost and minimally invasive alternative for the treatment of symptomatic VMT syndrome. Further study is warranted.

Combined rhegmatogenous and traction detachment associated with vasoproliferative tumor secondary to sickle cell retinopathy

Purpose To report the surgical management of a combined rhegmatogenous and traction retinal detachment associated with a vasoproliferative tumor secondary to sickle cell retinopathy. Observations A 29 year old man from Ghana presented with unilateral vision loss, ischemic retina and sea fan neovascularization in both eyes and a retinal detachment nearby a vasoproliferative tumor (VPT) in the left eye. Hemoglobin electrophoresis led to the diagnosis of sickle cell disease. The patient underwent vitrectomy with scleral buckle surgery, resection of the tumor, and removal of subretinal membranes in the left eye. Laser photocoagulation was targeted to areas of ischemic retina in both eyes. Conclusions and Importance: To our knowledge, this is the first report of a combined rhegmatogenous and traction retinal detachment associated with a VPT in sickle cell retinopathy managed by modern vitrectomy techniques. Prompt recognition of the condition and surgical management addressing both rhegmatogenous and tractional components can lead to improved outcome.