Robert C. Watzke

Punctate inner choroidopathy

Ten moderately myopic women had blurred vision, light flashes, or paracentral scotomas associated with small yellow-white lesions of the inner choroid and pigment epithelium. Most lesions had an overlying serous detachment, were hyperfluorescent, and leaked fluorescein during the acute phase. The lesions healed into atrophic scars and became progressively more pigmented with time. Subretinal neovascular membranes later developed from scars in six patients. Vision was usually only minimally affected unless the lesions were subfoveal or unless choroidal neovascular membranes subsequently occurred. Extensive laboratory studies were noncontributory.

Results and Complications of Pneumatic Retinopexy

Fifty-one patients with primary rhegmatogenous retinal detachment (RD) were treated by pneumatic retinopexy. The overall success rate for reattachment with one operation was 63%. Of the 34 phakic eyes, 25 (74%) were reattached; of the 17 aphakic or pseudophakic eyes, seven (41%) were reattached (P less than 0.05). Postoperative complications included the development of new tears (22%), inadequate closure of the original tear, shifting and delayed absorption of subretinal fluid, and opening of previously closed tears. Pneumatic retinopexy is a valuable new technique; however, careful patient selection and postoperative management is required.

Early Loss of Blue-Sensitive Color Vision in Patients With Type I Diabetes

Existing methods for early detection of ocular injury from diabetes have serious limitations. We describe a new method, measuring visual flicker discrimination of the blue-sensitive mechanism of vision. This method is noninvasive, quantitative, and capable of distinguishing two types of impairment. Blueflicker discrimination was measured in 10 adults with type I (insulin-dependent) diabetes for <5 yr. Although no evidence of diabetic changes was detected by careful ophthalmic examination by an experienced ophthalmologist, 12 of 19 eyes (63%) had flicker discrimination scores considered abnormal in comparison with those of a control group, and 8 of 10 subjects (80%) had at least 1 eye with abnormal performance. In all but 2 abnormal eyes the deficit of blue-flicker discrimination was of the “absorptive” type, suggesting increased absorbance or scattering of blue light in the optical media. These data show that a functional impairment of vision can be measured very early in the course of type I diabetes, before visible retinopathy is present, and suggest this test procedure may have both investigative and clinical applications.

Acute Idiopathic Blind Spot Enlargement: A Spectrum of Disease

The authors present a report on their experience with 10 patients with acute idiopathic blind spot enlargement. All had enlarged steep-margined blind spots without accompanying changes in optic disc appearance, significantly diminished visual acuity or color vision. Fluorescein angiography was obtained in eight patients. Five patients had retinal appearance that was either normal or could not be attributed to a known disease entity. Three patients had the multiple evanescent white dot syndrome, one had acute macular neuroretinopathy, and at least one had presumed ocular histoplasmosis. It has been proposed that acute idiopathic blind spot enlargement is a subset of multiple evanescent white dot syndrome. The authors findings suggest that multiple evanescent white dot syndrome and other retinal diseases, some not yet identified, are subsets of acute idiopathic blind spot enlargement.

Morphometric analysis of human retinal pigment epithelium: correlation with age and location

Flat bleached preparations of retinal pigment epithelial (RPE) cells from foveal, temporal posterior pole, and temporal equatorial fundus locations of 20 normal human eyes from donors age ranked from 13 to 96 years were analyzed for density, and 10 were analyzed for area, hexagonality and polymegathism. These factors were related to fundus locations and age. Foveal RPE cells were significantly more dense and more hexagonal in eyes from younger donors. Loss of hexagonality in the fovea, but not elsewhere, was correlated with increasing age. As the eye ages, foveal RPE cells selectively lose unique morphologic characteristics and resemble nonfoveal cells. These morphologic changes resemble other pathologic features of age-related degeneration in their proclivity for the fovea and posterior pole.

Growth Features of Choroidal Neovascular Membranes in Age-related Macular Degeneration+++

The authors studied 80 eyes of patients with choroidal neovascular membranes (CNVMs) associated with age-related macular degeneration between 1982 and 1988. In each case, fluorescein angiography was done on two occasions separated by an interval of 2 days to 11 weeks (average, 13 days) without intervening photocoagulation. Forty-three CNVMs (54%) grew toward the fovea during the interval between fluorescein angiograms, with growth rates ranging from 1 to 24 microns daily (average, 10 microns daily). The CNVM growth was related to the time interval between angiograms (P less than 0.0001), but was not associated with morphologic features of the CNVM. These results reinforce the need for early detection and prompt evaluation of elderly patients with symptoms of CNVMs.

Abnormal Glucose Metabolism and Parafoveal Telangiectasia

Parafoveal telangiectasia is a microvascular abnormality of the macula that may be developmental or acquired. Twenty-eight patients with this condition and normal fasting blood glucose levels underwent ophthalmologic evaluation and glucose tolerance testing. Bilateral telangiectasia was more frequently associated with laboratory evidence of abnormal glucose metabolism than unilateral disease (five of eight cases vs six of 17 cases). In five of our patients, results of glucose tolerance testing were consistent with diabetes even though fasting blood glucose levels were normal. Right-angle venules, which have been reported to be an important sign of bilateral disease, were also found in unilateral telangiectasia. Unilateral telangiectasia occurs in females as well as males. Glucose tolerance testing should be performed in all patients who have bilateral parafoveal telangiectasia.

Acute Macular Outer Retinopathy (AMOR): A Reappraisal of Acute Macular Neuroretinopathy Using Multimodality Diagnostic Testing

mone deficiencies). Radiation therapy greatly increases the lifelong risk of secondary malignant neoplasms (glioblastoma multiforme, malignant astrocytoma, meningioma, bone and soft-tissue sarcoma, and malignant melanoma) in children with TRB who are already predisposed to secondary cancers owing to their germline RB1 mutations. Treatment of TRB using the Toronto Protocol and intrathecal topotecan combined with cytarabine, followed by consolidation with autologous peripheral stem cell transplant after supralethal chemotherapy avoids the need for radiation therapy and, in some instances, extends survival.

Long-term juxtafoveal retinal telangiectasia.

Purpose: To determine the long-term natural history of idiopathic juxtafoveal telangiectasia (IJRT). Methods: Record review in 2 university-based and 2 private vitreoretinal practices sought patients with IJRT documented by color photographs and fluorescein angiograms (FAs) during the period January 1, 1980, to December 31, 1993. Patients then had repeated examinations and FAs. Results: Twenty patients with IJRT in 32 eyes had follow-up examinations. Fifteen patients had color photographs and FAs, and one had color photographs alone. Follow-up varied from 10 years to 21 years (average, 15 years). Six eyes were treated by laser photocoagulation at onset. Twenty-four of the 26 untreated eyes lost vision as measured by Snellen testing. Visual loss and morphologic progression depended on IJRT type. Six of 8 untreated eyes with type IA IJRT lost vision by ≥3 lines (Snellen), 4 to 20/70 or worse. Vision loss was caused by progressive telangiectatic changes and intraretinal edema. Fifteen of 20 initially untreated eyes with type IIA IJRT developed either central retinal pigment epithelium membranes or subretinal neovascularization with loss of vision to 20/80 or less. Conclusion: IJRT prognosis depends on type and clinical features. Long-term prognosis for central vision is poor.

Clinical features and natural history of the acute idiopathic enlarged blind spot syndrome

OBJECTIVEnTo study the clinical pattern and natural history of patients with the symptom of an enlarged blind spot.nnnDESIGNnA retrospective case series. Twenty-one patients were collected from a neuro-ophthalmologic practice during the period January 14, 1983, to July 1, 1996, and four consecutive patients were added from three vitreoretinal practices during the period April 14, 1986, to June 7, 1999.nnnPARTICIPANTSnTwenty-six eyes of 25 patients were studied at onset and at repeat visits from 1 year and 7 months to 15 years and 6 months later.nnnMETHODSnThe first visit was composed of a complete neuro-ophthalmologic examination with fundus photos and fluorescein angiography in 12 of the 26 eyes. Follow-up examination consisted of an interval history, ophthalmologic examination, visual fields, fundus photographs, fluorescein angiograms in eight eyes, indocyanine green angiograms in seven eyes, and multifocal electroretinograms (mfERG) in both eyes of seven patients.nnnMAIN OUTCOME MEASURESnThe major outcome measures were onset and long-term visual field characteristics, disc and peripapillary features, association with other chorioretinal diseases, and mfERG features.nnnRESULTSnTwenty-one eyes had clinical features of chorioretinal syndromes, which are usually associated with an enlarged blind spot. Five eyes were examined too late after onset to expect such features. The visual field defect regressed in all but 12 eyes but never to an unequivocally normal-sized blind spot. Four of the 12 had chorioretinal scarring that corresponded to the permanent field defect. Twenty-one of 26 eyes had peripapillary scarring. The peripapillary scarring appeared the same no matter what the associated chorioretinal disease or type or size of field defect was. mfERG testing of seven patients at follow-up revealed first-order and second-order abnormalities long after clinical recovery, abnormalities that were bilateral even when the clinical signs had been unilateral.nnnCONCLUSIONSnIf an eye with an enlarged blind spot is examined within 2 weeks of onset, signs of a chorioretinal disease will usually be present. Beyond that period, signs such as disc congestion, disc staining, peripapillary retinitis, foveal changes, and peripheral retinal spots may not be present. Although the patient usually becomes asymptomatic, the blind spot is slightly and permanently enlarged, and there is usually peripapillary disc scarring. mfERG testing indicates that retinal damage is more widespread, bilateral, and permanent than the visual field and clinical features would indicate. Chorioretinal syndromes that are associated with a temporal field defect have some features in common and others that are distinctive.