Samuel R. Pesin

Surgical Management of Subfoveal Choroidal Neovascularization

BACKGROUND Subfoveal choroidal neovascularization (CNV) usually is associated with a poor visual prognosis. Laser photocoagulation of certain subfoveal membranes secondary to age-related macular degeneration (ARMD) appears preferable to observation based on recent Macular Photocoagulation Study (MPS) findings but is associated with decreased vision. The authors explored the use of vitreoretinal surgical techniques as an alternative method of eradicating subfoveal CNV. METHODS After vitrectomy, a small retinotomy technique was used to extract or disconnect from the choroidal circulation subfoveal CNV in 58 eyes. There were 33 eyes with ARMD, 20 eyes with presumed ocular histoplasmosis, and 5 eyes with miscellaneous etiologies. Five eyes also received subfoveal RPE patches. RESULTS With limited follow-up, significant improvement in vision (defined as 2 Snellen lines) was achieved in 7 of 22 eyes with ARMD CNV removal (1 eye 20/20), 0 of 4 eyes with ARMD CNV removal and RPE patches, and 1 of 7 eyes with ARMD CNV disconnection. Significant improvement was achieved in 6 of 16 eyes with presumed ocular histoplasmosis removal and 0 of 4 eyes with presumed ocular histoplasmosis CNV disconnection. In 5 eyes with miscellaneous CNV, 2 improved (20/20 and 20/40). CNV recurred in 29%. CONCLUSIONS Some patients with subfoveal CNV appear to benefit from surgical removal. Only rarely do eyes with ARMD improve. Longer-term follow-up and refined case selection are required before this approach can be widely recommended.

Seven Cases of Trilateral Retinoblastoma

Of 245 consecutive children with retinoblastoma referred to the Oncology Service at the Wills Eye Hospital between January 1974 and August 1988 and followed up for three months to 15 years, seven (3%) developed midline intracranial malignancies consistent with the diagnosis of trilateral retinoblastoma. Six of the seven had bilateral retinoblastoma, and four had a family history of retinoblastoma. The time of diagnosis of retinoblastoma varied between five months after the intracranial tumor was diagnosed and four years before the intracranial tumor was diagnosed. The midline intracranial malignancies were pineal tumors (five cases), suprasellar neuroblastoma (one case), and a parasellar undifferentiated calcified mass (one case). Despite control of the intraocular tumors, five of the seven children have died of the intracranial tumors.

Management of Late-onset Angle-closure Glaucoma Associated with Retinopathy of Prematurity

Late-onset angle-closure glaucoma secondary to retinopathy of prematurity (ROP) occurred in ten eyes of ten patients. The age at presentation ranged from 12 to 45 years (mean, 32 years). Eight eyes had nonneovascular mechanisms for the angle closure while two had neovascular angle closure. Treatment of eyes with this form of secondary angle closure included medical management alone, peripheral iridectomy, trabeculectomy, lensectomy, alloplastic tube shunt implantation, and cilioablative procedures. Three eyes required more than one of these treatments. The choice of therapy was based on the initial intraocular pressure and vision, degree of lens opacity and intumescence, presence of anterior segment neovascularization, and the gonioscopic appearance of the anterior chamber angle. The clinical features of this condition are described and a proposed mechanism and therapeutic approach are presented.

Acute Angle-closure Glaucoma from Spontaneous Massive Hemorrhagic Retinal or Choroidal Detachment: An Updated Diagnostic and Therapeutic Approach

Acute angle-closure glaucoma from a spontaneous massive hemorrhagic retinal or choroidal detachment occurred in five eyes. The source of the hemorrhagic detachment was a disciform macular lesion in all instances. The mechanism for the angle closure is the abrupt forward displacement of the lens-iris diaphragm resulting from the massively detached choroid and retina. Four of the five patients had either systemic hypertension or a primary or anticoagulant-induced clotting disorder. All patients underwent ultrasonographic studies, and one patient had magnetic resonance imaging (MRI) to rule out melanoma. Only one eye required enucleation for pain relief. Glaucoma medication, cyclophotocoagulation, or retrobulbar alcohol controlled the other four eyes. The clinical, ultrasonographic, MRI, and histopathologic features of this rare condition are described, and an updated therapeutic approach is discussed.

Visual Field Loss Caused by Retinal Vascular Occlusion After Vitrectomy Surgery

PURPOSE To report complete superonasal retinal arterial occlusion with resulting temporal visual field loss after uneventful pars plana vitrectomy with gas-fluid exchange. METHOD Case report. RESULTS Superonasal retinal arterial occlusion was observed 12 days after vitrectomy surgery. Within 10 weeks, the artery reperfused, leaving minimal vascular attenuation and mild optic atrophy. CONCLUSIONS Uneventful vitrectomy surgery can be associated with notable peripheral visual field loss caused by arterial occlusion in the immediate postoperative period. Rapid resorption of the intraocular gas and timely postoperative examination may disclose retinal arteriolar occlusion; otherwise, subsequent reperfusion may leave little evidence of the vascular event.