Sharon Fekrat

Intravitreal triamcinolone acetonide in eyes with cystoid macular edema associated with central retinal vein occlusion.

PURPOSE To evaluate treatment of cystoid macular edema associated with central retinal vein occlusion with intravitreal triamcinolone acetonide. METHODS This study included 10 eyes of nine patients with perfused central retinal vein occlusion with visual acuity of 20/50 or worse. Following baseline evaluation, including best-corrected visual acuity, intraocular pressure (IOP), fluorescein angiography, and volumetric optical coherence tomography (VOCT), triamcinolone acetonide (4 mg in 0.1 ml) was injected into the vitreous cavity. RESULTS Mean duration from the time of diagnosis to the intravitreal injection was 15.4 months. All 10 eyes demonstrated biomicroscopic improvement in cystoid macular edema with corresponding improvement in VOCT measurements from a mean of 4.2 mm(3) preinjection to a mean of 2.6 mm(3) at last follow-up (P <.001). Mean best-corrected visual acuity improved from 58 letters (range, 37-72) at baseline to 78 letters (range, 50-100 letters) at last follow-up (average, 4.8 months). The visual acuity improvement was statistically significant (P =.01). Six eyes (60%) were > or =20/50. There were no significant complications. Three eyes (30%) without previous history of glaucoma required initiation of topical aqueous suppressant therapy for IOP elevation at last follow-up. One eye with a previous history of open-angle glaucoma required a trabeculectomy. CONCLUSIONS Intravitreal injection of triamcinolone acetonide appears to be effective in reducing cystoid macular edema associated with central retinal vein occlusion. This reduction often corresponded to an improvement in visual acuity. Further evaluation is warranted to assess its safety and efficacy in these eyes.

Pars plana vitrectomy, subretinal injection of tissue plasminogen activator, and fluid–gas exchange for displacement of thick submacular hemorrhage in age-related macular degeneration☆

PURPOSE To evaluate a new procedure for displacement of large, thick submacular hemorrhage in patients with age-related macular degeneration. METHODS Retrospective review of 11 eyes of 11 patients with age-related macular degeneration and thick submacular hemorrhage (defined as causing retinal elevation detectable on stereo fundus photographs) treated with vitrectomy, subretinal injection of tissue plasminogen activator (25 or 50 microg), and fluid-gas exchange with postoperative prone positioning. Outcome measures included displacement of hemorrhage from the fovea, best postoperative visual acuity, and final postoperative visual acuity. RESULTS In the 11 affected eyes of 11 patients (seven men and four women; mean age, 76 years), preoperative visual acuity ranged from 20/200 to hand motions. With surgery, subretinal hemorrhage was displaced from the fovea in all 11 cases. Mean postoperative follow-up was 6.5 months (range, 1 to 15 months). Best postoperative visual acuity varied from 20/30 to 5/200, with improvement in nine (82%) cases and no change in two cases. Eight eyes (73%) measured 20/200 or better, with four of these eyes (36%) 20/80 or better. Final postoperative visual acuity ranged from 20/70 to light perception, with improvement in eight (73%) cases, no change in one case, and worsening in two cases. A statistically significant difference was found between preoperative and best postoperative visual acuity (P =.004) but not between preoperative and final visual acuity (P =.16). Hemorrhage recurred in three (27%) eyes, causing severe visual loss in one eye. CONCLUSIONS This technique displaces submacular hemorrhage from the fovea and can improve vision in patients with age-related macular degeneration. However, recurrence of hemorrhage occurred in 27% of eyes and caused severe visual loss in one eye. A randomized, prospective clinical trial is necessary to determine the efficacy of this technique in comparison with other proposed treatments.

Meta-analysis of plasma homocysteine, serum folate, serum vitamin B12, and thermolabile MTHFR genotype as risk factors for retinal vascular occlusive disease

PURPOSE To assess the role of plasma total homocysteine (tHcy) levels, serum folate and vitamin B(12)levels, and homozygosity for the thermolabile methylenetetrahydrofolate reductase genotype (TT) as risk factors for retinal vascular occlusive disease. DESIGN Meta-analysis of literature. METHODS A MEDLINE search was performed to identify all published case-control studies of plasma tHcy levels, serum folate and vitamin B(12) levels, and TT genotype in persons with retinal vascular occlusive disease. Main outcome measures included calculation of plasma tHcy, serum folate, and serum vitamin B(12) standard differences and odds ratios (OR) of TT genotype between cases and controls. RESULTS In total, 614 patients with all types of retinal vein occlusion had higher plasma tHcy levels than 762 control subjects (standard difference, 0.867; 95% confidence interval [CI] = 0.735, 0.999; P <.001). Plasma tHcy levels were also higher in 154 patients with retinal artery occlusion compared with 358 control subjects (standard difference 1.174; 95% CI = 0.947, 1.402; P <.001). Serum folates, but not vitamin B(12) levels, were lower in 287 patients with retinal vascular occlusion than in the same number of control subjects (standard difference, 0.508; 95% CI = 0.340, 0.675; P <.001; and -0.060; 95% CI = -0.024, 0.104; P =.474, respectively). Similar proportions of 690 patients with retinal vein occlusion and 2754 control subjects demonstrated the TT genotype (OR = 1.332; 95% CI = 0.995, 1.783; P =.054) as did 152 patients with retinal artery occlusions and 435 control subjects (OR = 1.716; 95% CI = 0.977, 3.014; P =.060). CONCLUSIONS Retinal vascular occlusion is associated with elevated plasma tHcy levels and low serum folate levels, but not serum vitamin B(12) levels and TT genotype. Until a prospective multicenter trial is undertaken, plasma tHcy levels and serum folate levels should be determined in patients with retinal vascular occlusions, and dietary supplementation with low doses of folate and vitamin B(12) should be considered for affected persons.

Pars planitis ☆: Clinical features and class II HLA associations

OBJECTIVE To describe a cohort of patients with pars planitis followed at a single tertiary care institution, determine the frequency of multiple sclerosis and/or optic neuritis in patients with this disorder, and calculate gene frequencies of human leukocyte antigen (HLA) class II alleles in these patients. DESIGN Fifty-three patients with the diagnosis of pars planitis underwent clinical record review or telephone interview for follow-up or both; 32 of these underwent phlebotomy for analysis of HLA class II alleles. MAIN OUTCOME MEASURES Outcomes included visual acuity, occurrence of multiple sclerosis and/or optic neuritis, and HLA class II gene frequencies. RESULTS With a mean follow-up of 2 years, approximately 90% of patients maintained a visual acuity better than 20/40 in at least one eye. The most frequently encountered ophthalmic complications included cystoid macular edema, cataract, and epiretinal membrane formation. Of 37 patients with pars planitis who had medical or neurologic follow-up evaluations, 6 (16.2%) developed multiple sclerosis. The HLA-DR15 allele, coding for one of the two HLA-DR2 subtypes, was associated with pars planitis (odds ratio = 2.86, 95% confidence interval = 1.42-5.78, P = 0.004). CONCLUSIONS A common immunogenetic predisposition to multiple sclerosis and pars planitis may be associated with the HLA-DR15 allele. This association may represent genetic linkage to the HLA-DR locus or a role for the HLA-DR15 gene product in the pathogenesis of both of these diseases.

Retinal vein occlusion: beyond the acute event.

Retinal vein occlusion is a major cause of vision loss. We provide an overview of the clinical features, pathogenesis, natural history, and management of both branch retinal vein occlusion and central retinal vein occlusion. Several recent multicenter randomized clinical trials have been completed which have changed the approach to this disorder. Management of retinal vein occlusions can be directed at the underlying etiology or the resulting sequelae. Options include surgical intervention, laser photocoagulation, intravitreal pharmacotherapy, and sustained drug delivery devices.

Radial optic neurotomy as treatment for central retinal vein occlusion

PURPOSE To review our initial experience with radial optic neurotomy as treatment for retinal vein occlusion. DESIGN Interventional case series. METHODS PATIENT POPULATION five patients (four with central retinal vein occlusion and one with hemiretinal vein occlusion). INTERVENTION Pars plana vitrectomy with radial optic neurotomy was performed in each case. MAIN OUTCOME MEASURES Best-corrected visual acuity, presence of macular edema, perfusion status, and time to venous phase of the angiogram were reviewed retrospectively. RESULTS Mean preoperative visual acuity was 4/200. Preoperatively, the vein occlusion was perfused in one (20%), nonperfused in one (20%), and indeterminate in three (60%). Mean follow-up time was 4.5 months. Mean postoperative visual acuity was 20/400 at last follow-up. Four patients (80%) had improvement in visual acuity and one (20%) worsened. Two patients (40%) improved to 20/80 postoperatively. In four cases (80%), disk congestion improved and intraretinal hemorrhage reabsorbed more quickly than would be expected without treatment. Time to the venous phase of fluorescein angiography improved slightly in three cases (60%) postoperatively. Perfusion status as determined by fluorescein angiography was not significantly altered postoperatively. One patient (20%) had resolution of macular edema postoperatively as shown by volumetric optical coherence tomography. One patient developed choroidovitreal neovascularization and one developed iris neovascularization postoperatively, both of which responded to panretinal photocoagulation. CONCLUSIONS Radial optic neurotomy may improve visual acuity in eyes with central retinal vein occlusion, although choroidovitreal neovascularization from the neurotomy site can occur. Further study is needed to determine its role in the management of central vein occlusion.

The Effect of Oral 13-cis-retinoic Acid on Retinal Redetachment after Surgical Repair in Eyes with Proliferative Vitreoretinopathy

PURPOSE To determine if postoperative oral 13-cis-retinoic acid alters the rate of recurrent retinal detachment in eyes undergoing surgery for proliferative vitreoretinopathy (PVR). METHODS Twenty eyes of 20 adult patients with a detachment due to PVR were identified after retrospective review of the patient records of a single vitreoretinal surgeon (EdJ) over an 18-month period (January 1992-August 1993). All 20 eyes underwent surgical repair using similar techniques. Ten patients received 40 mg oral 13-cis-retinoic acid twice daily for 4 weeks postoperatively (study group). The remaining ten patients did not (control group). The main outcome measure was retinal attachment or detachment. RESULTS No statistically significant differences in preoperative patient characteristics or surgical procedure were present between the groups. Nine of ten eyes in the study group remained attached during a mean follow-up of 8.3 months, whereas four of ten eyes in the control group remained attached (P = 0.061) during a mean follow-up of 9.6 months. The rate of macular pucker was similar between the groups. The one eye in the study group that redetached did not have PVR. Of the six eyes in the control group that detached, four had 6 or more clock hours of PVR. The final visual acuity was better than 20/400 in six study eyes and four control eyes. CONCLUSIONS Despite the small sample size and retrospective nature, the postoperative administration of oral 13-cis-retinoic acid appears to decrease proliferative vitreoretinopathy and increase the rate of retinal attachment after surgical repair. A prospective, randomized, controlled clinical trial is warranted.

Clinicopathologic correlation of an epiretinal membrane associated with a recurrent macular hole.

Purpose To describe the clinicopathologic features of an epiretinal membrane associated with a recurrent, full-thickness idiopathic macular hole and speculate on the mechanism(s) contributing to its recurrence 1 year after initially successful closure of pars plana vitrectomy and gas tamponade (SF6). Methods After fixation of the 2 X 1 mm specimen in a mixture of 1% glutaraldehyde and 4% formaldehyde followed by 2.5% glutaraldehyde, postfixation with osmium tetroxide, and standard dehydration, the specimen was embedded in epoxy resin. Ultrathin sections were stained with uranyl acetate and lead citrate for transmission electron microscopy. Results Ultrastructural examination disclosed a fibrocellular membrane composed of Müller cells and fibrous astrocytes. Native collagen was entrapped in the matrix in some areas. Conclusion Those cells that may lead to the closure of an idiopathic macular hole may also contribute to its recurrence if the reparative process goes awry.

Preclinical evaluation and intraoperative human retinal imaging with a high-resolution microscope-integrated spectral domain optical coherence tomography device

Purpose: The authors have recently developed a high-resolution microscope-integrated spectral domain optical coherence tomography (MIOCT) device designed to enable OCT acquisition simultaneous with surgical maneuvers. The purpose of this report is to describe translation of this device from preclinical testing into human intraoperative imaging. Methods: Before human imaging, surgical conditions were fully simulated for extensive preclinical MIOCT evaluation in a custom model eye system. Microscope-integrated spectral domain OCT images were then acquired in normal human volunteers and during vitreoretinal surgery in patients who consented to participate in a prospective institutional review board–approved study. Microscope-integrated spectral domain OCT images were obtained before and at pauses in surgical maneuvers and were compared based on predetermined diagnostic criteria to images obtained with a high-resolution spectral domain research handheld OCT system (HHOCT; Bioptigen, Inc) at the same time point. Cohorts of five consecutive patients were imaged. Successful end points were predefined, including ≥80% correlation in identification of pathology between MIOCT and HHOCT in ≥80% of the patients. Results: Microscope-integrated spectral domain OCT was favorably evaluated by study surgeons and scrub nurses, all of whom responded that they would consider participating in human intraoperative imaging trials. The preclinical evaluation identified significant improvements that were made before MIOCT use during human surgery. The MIOCT transition into clinical human research was smooth. Microscope-integrated spectral domain OCT imaging in normal human volunteers demonstrated high resolution comparable to tabletop scanners. In the operating room, after an initial learning curve, surgeons successfully acquired human macular MIOCT images before and after surgical maneuvers. Microscope-integrated spectral domain OCT imaging confirmed preoperative diagnoses, such as full-thickness macular hole and vitreomacular traction, and demonstrated postsurgical changes in retinal morphology. Two cohorts of five patients were imaged. In the second cohort, the predefined end points were exceeded with ≥80% correlation between microscope-mounted OCT and HHOCT imaging in 100% of the patients. Conclusion: This report describes high-resolution MIOCT imaging using the prototype device in human eyes during vitreoretinal surgery, with successful achievement of predefined end points for imaging. Further refinements and investigations will be directed toward fully integrating MIOCT with vitreoretinal and other ocular surgery to image surgical maneuvers in real time.

The effect of arteriovenous sheathotomy on cystoid macular oedema secondary to branch retinal vein occlusion

Background: Arteriovenous (AV) sheathotomy, a potential treatment for branch retinal vein occlusion (BVO), surgically separates retinal vessels at an AV crossing. Relief of the aetiological obstruction, with resolution of cystoid macular oedema (CMO), may result in improved visual acuity. Methods: A retrospective review of consecutive cases of AV sheathotomy for BVO was undertaken. Eyes were categorised as having resolution (group 1), reduction (group 2), or persistence (group 3) of CMO. Intergroup comparisons were made with regard to preoperative, intraoperative, and postoperative parameters. Preoperative and postoperative visual acuities were compared within each group. Results: Of the 27 eyes identified, eight (29.6%) had resolution, 14 (51.8%) had reduction, and five (18.6%) had persistence of CMO. Median preoperative visual acuity was similar in all groups (1.0, 1.0, 1.3, respectively; p = 0.29). Overall median follow up was 12.0 months (Q1 = 12.0, Q2 = 22.5). Eyes in group 1 had significantly better median postoperative visual acuity than eyes in groups 2 and 3 (0.6, 1.0, 2.0 respectively; p = 0.01). A significantly higher proportion of eyes in group 1 had visual acuity improvement compared with eyes in the other groups (87.5% v 35.7% and 20.0%; p = 0.03). Median postoperative visual acuity was significantly better than median preoperative visual acuity in group 1 eyes only (p = 0.02). A higher percentage of group 1 eyes had evidence of postoperative retinal perfusion (83.0% v 21.43% and 40.0%; p  =  0.16). Postoperative retinal detachment occurred in three eyes (11.1%). Conclusion: Complete resolution of CMO after AV sheathotomy occurred in one third of patients, and postoperative vision improved significantly in this group. However, in the majority of cases, despite an improvement in CMO, there was no improvement in vision after AV sheathotomy.