Scott D. Pendergast

Vitrectomy for diffuse diabetic macular edema associated with a taut premacular posterior hyaloid

PURPOSE To evaluate the role of vitrectomy in eyes with diffuse diabetic macular edema associated with a taut posterior hyaloid. METHODS Records of 55 eyes of 50 patients with diabetic retinopathy and diffuse clinically significant diabetic macular edema who underwent vitrectomy with stripping of the premacular posterior hyaloid were reviewed. In all 55 eyes, diffuse diabetic macular edema was present on contact lens examination and confirmed with fluorescein angiography. On fundus examination, the premacular posterior hyaloid was attached and appeared taut. RESULTS The mean preoperative best-corrected visual acuity was 20/160, and the mean final best-corrected visual acuity was 20/80 (P <.0001, Wilcoxon signed rank test), with 27 (49.1%) of the 55 eyes demonstrating improvement in best-corrected visual acuity of 2 or more lines. Fifty-two (94.5%) of the 55 vitrectomized eyes showed improvement in clinically significant macular edema and in 45 eyes (81.8%) the macular edema resolved completely during a mean period of 4.5 months (range, 1 to 13 months). Eyes with macular ischemia and preoperative best-corrected visual acuity of 20/200 or less tended to respond less favorably to vitrectomy than eyes lacking these characteristics. All eyes had at least 6 months of follow-up after surgery, with a mean follow-up of 23.2 months. CONCLUSION In eyes with persistent diffuse diabetic macular edema with a taut premacular posterior hyaloid face unresponsive to laser therapy, vitrectomy with removal of the posterior hyaloid appears to be beneficial in some cases. Careful selection of eyes with favorable preoperative clinical characteristics may improve surgical outcomes.

Submacular surgery trials randomized pilot trial of laser photocoagulation versus surgery for recurrent choroidal neovascularization secondary to age-related macular degeneration: I. Ophthalmic outcomes. Submacular Surgery Trials Pilot Study report number 1

PURPOSE To report complications and changes in vision during 2 years of follow-up of patients with age-related macular degeneration assigned randomly to surgical removal or to laser photocoagulation of subfoveal recurrent neovascular lesions in a pilot trial designed to test methods, to refine estimates of outcome rates, and to project patient accrual rates for a larger multicenter randomized trial to evaluate submacular surgery. PATIENTS AND METHODS Eligible patients with previous laser photocoagulation of extrafoveal or juxtafoveal choroidal neovascularization secondary to age-related macular degeneration were enrolled at 15 collaborating clinical centers. Assignments to treatment arm were made by personnel at a central coordinating center. Adherence to eligibility criteria and treatment assignment was assessed centrally at a photograph reading center. Patients were examined at 3, 6, 12, and 24 months after treatment for data collection purposes. Outcome measures reported include treatment complications, adverse events, requirements for additional treatment, and 2-year changes in visual acuity from baseline. RESULTS Of 70 patients enrolled, 36 were assigned to laser photocoagulation and 34 to submacular surgery; all were treated as assigned. One patient in each group died before the 2-year examination. Visual acuity was measured at the 2-year examination for 31 of the surviving patients (89%) in the laser arm and for 28 of the surviving patients (85%) in the surgery arm. The 2-year measurements for 36 of the 59 patients (61%) were made by an examiner masked to treatment assignment and to the identity of the study eye. Improvements and losses of visual acuity were observed in both treatment arms; 20 of 31 study eyes (65%) in the laser arm and 14 of 28 study eyes (50%) in the surgery arm had visual acuity 2 years after enrollment that was better than or no more than 1 line worse than the baseline level. Changes in visual acuity and the size of the central macular lesions from baseline to the 2-year examination were similar in the treatment arms. Few serious complications were observed in either arm at the time of initial treatment; serious adverse events were rare. During follow-up, 11 laser-treated eyes and 18 surgically treated eyes had additional intraocular procedures. CONCLUSIONS The data from this pilot trial suggest no reason to prefer submacular surgery over laser photocoagulation for treatment of patients with age-related macular degeneration who have lesions similar to those studied in this pilot trial. Any clinical trial designed to compare submacular surgery with laser photocoagulation in eyes with age-related macular degeneration and subfoveal recurrent neovascular lesions must enroll several hundred patients in order to reach a statistically valid conclusion regarding differences between these two methods of treatment with respect to either changes in visual acuity or complication rates.

Familial exudative vitreoretinopathy ☆: Results of surgical management

OBJECTIVE The purpose of the study was to report the results of surgical management of familial exudative vitreoretinopathy (FEVR). DESIGN The study design was a retrospective clinical study. PARTICIPANTS A consecutive series of 52 eyes of 26 patients with FEVR were studied. INTERVENTION All eyes underwent a complete ocular examination and were graded using a new classification system. Depending on the severity of disease, eyes were treated with peripheral laser photocoagulation, scleral buckling, or vitrectomy. MAIN OUTCOME MEASURES Preoperative and postoperative visual functions and anatomic status of the macula were the main parameters evaluated. RESULTS A total of 40 eyes were treated. Seven eyes required no treatment and five eyes had inoperable retinal detachments. Fifteen eyes were treated with peripheral laser ablation initially and 25 eyes presenting with retinal detachments required vitreoretinal surgery. Of the 15 eyes treated initially with laser, 8 eyes required no further treatment, whereas 7 eyes progressed to retinal detachment requiring vitreoretinal surgery. A total of 32 eyes (including 7 previously lasered eyes) underwent vitreoretinal surgery. Twenty-nine of these 32 eyes had at least 6 months of follow-up. At the last follow-up visit, the macula was attached completely in 18 eyes (62.1%). Visual acuity ranged from 20/25 to light perception, with 10 (34.5%) of the 29 eyes achieving Snellen acuities of 20/100 or better. Two eyes (6.3%) progressed to no light perception. CONCLUSION These data suggest that surgical intervention can be beneficial in selected cases of FEVR.

Visual Field Loss after Macular Hole Surgery

BACKGROUND Vitrectomy has been successfully used for treating idiopathic macular holes. Although macular hole surgery has been successful and is generally regarded as a safe procedure, various complications have been reported. The authors report eight patients with symptomatic peripheral visual field loss occurring after vitrectomy for macular holes. METHODS Over a 3-year period, vitrectomy with removal of the posterior cortical vitreous and fluid-gas exchange was performed on 50 eyes of 47 patients with idiopathic macular holes. Eight patients reported visual field loss postoperatively, and Goldmann visual fields were obtained. The clinical characteristics and outcomes of the group of patients with visual field loss were compared with the group of patients without visual field loss. RESULTS Postoperatively, significant peripheral visual field loss was documented in eight patients. The macular holes were anatomically closed in seven eyes (87.5%) of these patients compared with 37 (88.1%) of 42 eyes in the group of patients with no symptomatic visual field loss. The visual field loss was not associated with age, sex, macular hole stage, postoperative intraocular pressure, or history of hypertension or coronary artery disease. The etiology of visual field loss was unclear in six patients. CONCLUSION Vitrectomy for idiopathic macular holes can result in significant peripheral visual field loss. The etiology of this complication usually is unknown.

Laser treatment in fellow eyes with large drusen: Updated findings from a pilot randomized clinical trial

PURPOSE To update the findings from the Choroidal Neovascularization Prevention Trial (CNVPT) with respect to resolution of drusen, incidence of choroidal neovascularization, and visual function. DESIGN A multicenter, randomized, controlled, pilot clinical trial. PARTICIPANTS The 120 patients enrolled in the CNVPT. Patients had signs of choroidal neovascularization or retinal pigment epithelial detachment in 1 eye and had >/=10 large (>63- micro m) drusen in the contralateral, or fellow, eye. INTERVENTION The fellow eye of 59 patients was assigned randomly to argon green laser treatment consisting of multiple 100- micro m spots at least 750 micro m from the center of the fovea. The fellow eye of the remaining 61 patients was assigned randomly to observation. MAIN OUTCOME MEASURES Change in visual acuity was the primary outcome measure. Incidence of choroidal neovascularization, resolution of drusen, change in contrast threshold, change in critical print size for reading, and incidence of geographic atrophy were secondary outcome measures. RESULTS Throughout 4 years of follow-up, there were no statistically significant differences in change in visual acuity, contrast threshold, critical print size, or incidence of geographic atrophy. With additional follow-up, the large increase in the incidence of choroidal neovascularization observed within 18 months of treatment was maintained; however, by 30 months, the incidence in the two treatment groups was the same. Most drusen resolution in treated eyes occurred within 24 months of the initial treatment. Treated eyes that received higher-intensity laser burns had an increased risk of choroidal neovascularization. Among eyes developing choroidal neovascularization in each treatment group, most lesions (two thirds or more) were composed of occult neovascularization only. CONCLUSIONS Laser treatment as applied in the CNVPT caused an excess risk of choroidal neovascularization in the first year or so after treatment. The increased early incidence of choroidal neovascularization was not associated with either a harmful or beneficial effect in this pilot study.

Absence of herpesvirus DNA by polymerase chain reaction in ocular fluids obtained from immunocompetent patients.

Objective: To assess the prevalence of herpesvirus DNA in ocular fluids obtained from healthy patients undergoing vitreoretinal surgery. Background: Polymerase chain reaction (PCR) has been used to detect herpesvirus DNA in patients with acute retinal necrosis and cytomegalovirus retinitis. Little is known regarding the prevalence of detectable herpesvirus DNA in ocular fluids collected from healthy seropositive patients with no clinical evidence of viral retinitis. Methods: Seventy‐five intraocular specimens (35 aqueous and 40 vitreous samples) were collected from 75 patients undergoing scleral buckling or vitrectomy. Using a PCR‐based assay, the authors tested each specimen for the presence of herpesvirus genome DNA with primers specific for cytomegalovirus, Epstein‐Barr virus, herpes simplex virus types 1 and 2, and varicella zoster virus. Serologic testing for immunoglobulin G (IgG) and IgM levels corre‐sponding to each of the herpesviruses was also performed. Results: Of the 75 samples tested, none was found to harbor herpesvirus DNA. The assay did not give false‐positive results in patients with active intraocular inflammation. The sensitivity of the assay was 0.08 infection‐forming units for cytomegalovirus, 0.6 tissue culture infectious doses for herpes simplex virus, 0.5 infected‐cell equivalents for Epstein‐Barr virus, and 0.03 focus‐forming units for varicella zoster virus. The percentage of patients with positive herpesvirus serology ranged from 86% to 100% and was consistent with rates observed in the general population. Conclusions: The prevalence of herpesvirus DNA detectable by PCR techniques in ocular fluids appears to be quite low despite the high proportion of patients who tested positive for herpesvirus antibodies. Therefore, a positive result obtained in a patient presenting with vitreoretinal inflammation should be regarded as significant.

Removal of optic disc stalks during diabetic vitrectomy.

Background The morphologic features and clinical consequences of removing residual optic disc stalks during vitrectomy for complications of diabetic retinopathy have not been described. Methods Twenty-four residual optic disc stalks that were surgically removed from eyes with proliferative diabetic retinopathy and dense nonclearing vitreous hemorrhage and/ortraction retinal detachment were studied histologically using conventional hematoxylin and eosin staining as well as a modified Glees staining technique. Results Histologic examination demonstrated that 79% of the specimens consisted of vascularized glial tissue with an infiltrate of mononuclear cells and 21% consisted of glial membranes devoid of vasculature. Axons were identified in 33% of all tissues studied. Intraoperative hemorrhage occurred in three eyes with strongly adherent optic disc stalks and was controlled with transient elevation of the intraocular pressure. The presence of axons in the removed optic disc stalks was not correlated with a decreased final postoperative visual acuity (median time to follow-up 21 months). Conclusions Residual optic disc stalks removed during vitrectomy for proliferative diabetic retinopathy frequently contained axons. The presence of axons does not portend an unfavorable postoperative visual outcome.

Double Choroidal Malignant Melanoma in an Eye With Apparent Clinical RegressionDavid apple and milton boniuk, editors

Multicentric melanomas in the same eye are rare, with few cases substantiated by histology and serial sectioning. We report a patient with two documented choroidal malignant melanomas in one eye. The initial tumor spontaneously decreased in size for over 2 years before a second tumor appeared in a noncontiguous location in the same eye. After enucleation, serial sections showed that the two lesions were independent choroidal melanomas. We review the literature regarding multiple, independent intraocular choroidal malignant melanomas.

Ocular findings in cutis marmorata telangiectatica congenita. Bilateral exudative vitreoretinopathy.

Background: Cutis marmorata telangiectatica congenita is a rare, cutaneous, reticulated, vascular anomaly characterized by congenital persistent cutis marmorata, telangiectasis, and phlebectasis. While systemic abnormalities frequently are associated with cutis marmorata telangiectatica congenita, ophthalmic abnormalities are quite rare and include congenital glaucoma and congenital, bilateral, total retinal detachments with secondary glaucoma. Methods: The authors report a case of bilateral, tractional retinal detachments associated with peripheral fibrovascular proliferation simulating familial exudative vitreoretinopathy in a female child with cutis marmorata telangiectatica congenita. Molecular genetic analysis of the Norries disease gene was performed. Results: After vitrectomy, the posterior poles of both eyes were reattached successfully. No abnormalities of the Norries disease gene were identified. Conclusion: Bilateral exudative vitreoretinopathy is a rare ophthalmic manifestation associated with cutis marmorata telangiectatica congenita.