Vinay A. Shah

Long-term follow-up of idiopathic intracranial hypertension The Iowa experience

Objective: To evaluate recurrent or delayed worsening of papilledema and visual function in patients with idiopathic intracranial hypertension (IIH) followed for more than 10 years. Methods: This is an Institutional Review Board approved retrospective chart review of 410 patients with the diagnosis of IIH evaluated at the University of Iowa Hospitals and Clinics from January 1984 to January 1996. Of the 410 patients, 20 patients with IIH who were followed over 10 years at the neuro-ophthalmology clinic met the inclusion criteria. Three neuro-ophthalmologists independently evaluated and graded the visual field examinations and optic disc stereo-photographs for each follow-up visit (median = 15). Results: Of the 20 patients, 11 demonstrated a stable course of disease without worsening in papilledema or visual field, and 9 patients worsened after a stable course. Of these 9 patients, 6 patients experienced delayed worsening (range: 28 to 135 months from presentation) and 3 patients had recurrence after resolution of papilledema 12 to 78 months from initial resolution of the IIH. Conclusion: Idiopathic intracranial hypertension is a chronic condition that may worsen after a period of stability, warranting long-term follow-up.

Idiopathic macular hole surgery with low-concentration infracyanine green-assisted peeling of the internal limiting membrane.

PURPOSEnTo evaluate the efficacy of pars plana vitrectomy with infracyanine green (IFCG)-assisted internal limiting membrane peeling for the treatment of idiopathic macular hole.nnnDESIGNnProspective, noncomparative interventional case series.nnnMETHODSnThirty-eight consecutive eyes of 35 patients with idiopathic macular hole were included in the study. Patients underwent early treatment diabetic retinopathy (ETDRS) visual acuity examination, dilated ophthalmoscopy, and optical coherence tomography before treatment and during follow-up. Fluorescein angiography was done in selected cases. Patients underwent a three-port pars plana vitrectomy with complete posterior hyaloid and epiretinal membrane removal. The internal limiting membrane (ILM) was stained with 0.5 cc of IFCG (0.5 mg/ml, 308 mOsm) and peeled up to the vascular arcades. Perfluoropropane gas (C(3)F(8)) 10% was used as tamponade.nnnRESULTSnMean follow-up duration was 10 +/- 5 months (range, 3 to 24 months). Six eyes had stage 2 macular hole, 15 eyes stage 3, and 16 eyes stage 4. Overall, 37 of 38 macular holes closed after a single surgery. Median visual acuity was 20/100 (range, 20/400 to 20/50) before surgery and 20/50 (range, 20/640 to 20/25) after surgery. Visual acuity after surgery was 20/50 or better in 24 of 38 (63.1%) eyes. Twenty-five (65.8%) eyes improved by 2 or more lines, nine (23.7%) eyes were stable, and four (10.5%) eyes worsened by 2 or more lines.nnnCONCLUSIONSnThis study suggests that IFCG (0.05%) effectively stains the ILM with apparent safety, and that IFCG-assisted peeling of the ILM may be useful in the treatment of idiopathic macular hole.

Values for macular perimetry using the MP-1 microperimeter in normal subjects.

Purpose: To establish values for the fixation pattern and macular sensitivity to light in healthy subjects using the MP-1 microperimeter (Nideck Technologies, Vigonza, Italy). Method: A prospective study of 37 healthy subjects (age: 19–71 years), approved by the institutional review board. Full-threshold microperimetry of the central 12° of the retina (the macula) was performed prospectively, utilizing 16 points with the MP-1. The fixation stability was simultaneously recorded during microperimetry testing. The relationship between the fixation pattern and light sensitivity with age was calculated using linear regression analysis. Results: Microperimetry was performed on 66 eyes. Total mean sensitivity was 18.33 dB (range: 13.0–19 dB). Mean macular sensitivities at 2°, 4° and 6° as measured by the MP-1 were 18.4 ± 2.0, 18.2 ± 2.3 and 18.2 ± 2.1 dB, respectively. The linear regression analysis revealed a 0.019240, 0.0248 and 0.0285 dB per year age-related decline in mean macular sensitivity at 2°, 4° and 6° from the center of the macula, respectively. The total mean fixation stability values within 2° and 4° were 86 and 96%, respectively. The linear regression analysis also revealed a 0.344% and 0.122% per year decline in age-related fixation stability within 2° and 4°, respectively. There were no statistically significant differences between the median retinal sensitivity or fixation stability values for sex or race in the study. Conclusions: The MP-1 may be a reliable tool to measure macular sensitivity. Among normal healthy subjects, there was a linear decline in light sensitivity with increasing age.

Intracranial hypertension in systemic lupus erythematosus

Purpose: Intracranial hypertension (IH) mimicking pseudotumor cerebri (i.e., idiopathic IH) has been reported in individuals with systemic lupus erythematosus (SLE) since the 1960s. Although various mechanisms have been proposed (e.g., venous thrombosis, medication side effect, and immunologic or inflammatory disease) none have been proven to be causal. Methods: Retrospective chart review of patients with IH and SLE at a single tertiary care institution. Results: In a cohort of IIH patients the percentage of patients in our study with SLE was 1% (4 in 410). Three out of the four patients had serologic evidence for a hypercoagulable state but only one had cerebral venous sinus thrombosis. Two patients had onset or worsening of IH in close temporal relationship to steroid withdrawal. The course, treatment, and prognosis of our patients with SLE and intracranial hypertension did not differ significantly from our clinical experience with IIH or with the published natural history data for IIH. Conclusions: The association of SLE and IH may occur more than by chance alone. Steroid withdrawal in the treatment of the SLE may be a predisposing or precipitating factor in the development of IH in these patients rather than the inflammatory effects of SLE per se. The hypercoagulable state in some patients with SLE may also produce cerebral venous sinus thrombosis as an additional potential mechanism of IH.

Resident Surgical Practice Patterns for Vitreoretinal Surgery in Ophthalmic Training Programs in the United States

PURPOSEnTo assess resident surgical experience in vitreoretinal surgery (VRS) in the United States.nnnDESIGNnAnonymous electronic survey over 2 consecutive years.nnnPARTICIPANTSnA total of 287 third-year ophthalmology residents from US residency programs were included.nnnMETHODSnTo determine the type and amount of surgical experience in VRS. Residents were contacted via e-mail to complete the survey. A series of follow-up e-mails were sent to nonresponders. E-mail correspondence was sent to program directors of the US residency programs to encourage survey participation. An electronic survey instrument (Survey Monkey) was used to distribute the survey and collect the results. Participants were asked about vitrectomy and scleral buckle procedures as primary surgeon and about office procedures (e.g., intravitreal injections and retinal laser procedures). Questions regarding the self-described comfort level of the resident and the Accreditation Council for Graduate Medical Education (ACGME) vitreoretinal requirements for ophthalmology were also included.nnnMAIN OUTCOME MEASURESnVitreoretinal office and surgical procedures.nnnRESULTSnOf the 114 ophthalmology residency programs in the United States, 3 programs declined to participate and 103 of 228 programs (114 programs per year) did not respond to requests during a 2-year period. Of the 287 total respondents, approximately 59.1% had performed vitrectomy and 40.8% had performed a scleral buckle as the primary surgeon. In the survey of office procedures, 96.7% had performed intravitreal injections, 94.8% had performed macular laser therapy, and 99.6% had performed panretinal photocoagulation. In the self-reported resident comfort level section, 59% were fairly comfortable knowing the theoretic steps for VRS and 55.4% were fairly satisfied with VRS training. However, 72% of respondents were unaware of the correct ACGME minimum operative numbers for VRS.nnnCONCLUSIONSnThis self-reported electronic survey of third-year residents suggested that VRS experience at ACGME-accredited programs as primary surgeon was suboptimal for surgeries. A modest majority of residents reported comfort and satisfaction with VRS training for surgery, but a majority was satisfied and had adequate experience with office procedures such as intravitreal injection and laser treatment. Unfortunately, the majority of residents were unaware of the actual numeric ACGME VRS requirements for ophthalmology residency programs.

Idiopathic Intracranial Hypertension

Although the cause of IIH remains obscure, loss of visual function is common, and patients may progress to blindness. Diagnosis should adhere to the modified Dandy criteria. Recent case-control studies cast doubt on the validity of many frequently cited conditions associated with IIH. Valid associations include obesity, recent weight gain, female sex, vitamin A intoxication, and steroid withdrawal. Management should include serial perimetry using a sensitive disease-specific strategy so the proper therapy can be selected and visual loss prevented or reversed.

You're Too Old for That

Leber hereditary optic neuropathy (LHON) produces a subacute and typically bilateral but sequential optic neuropathy. LHON is a mitochondrial disease and the most common mutations are at positions 11778, 14484 and 3460. LHON typically presents in young (age 20-40), healthy men but may occur in either sex and at any age. We report a case of LHON in a 72-year-old man and we emphasize the importance of testing for LHON in all cases of unexplained bilateral and sequential optic neuropathy with a ceco-central or central scotoma.

Resident laser in situ keratomileusis surgical training in United States residency programs

&NA; To determine current trends in resident laser in situ keratomileusis (LASIK) training in the United States, a comprehensive survey was sent to the residency coordinator, chairman, or refractive surgery director of all 113 ophthalmology training programs in the U.S. accredited by the Accreditation Council for Graduate Medical Education. The response rate was 64%. Of the respondents, 54% were from programs in which residents performed LASIK surgery, typically as third‐year residents; residents in these programs performed a mean of 4 LASIK surgeries (range 1 to 10 surgeries) during residency. The Visx Star was the most commonly used excimer laser platform and the Hansatome the most commonly used microkeratome. Most programs had 1 attending physician teaching the residents refractive surgery, which was typically performed at the main residency facility. Most programs had significant discounted pricing (>50%) for resident‐performed LASIK.

Spectral Domain Optical Coherence Tomography Findings of Retinal Macroaneurysm.

A 47-year-old healthy male presented to the ophthalmology clinic with complaint of dry eyes. Examination revealed visual acuity 20/20 in both eyes (OU). Anterior segment examination was normal. Fundus examination and fluorescein angiogram findings were consistent with a non-ruptured macroaneurysm. Spectral domain (SD) optical coherence tomography (OCT) (Ophthalmic Technologies, Ontario, Canada) demonstrated a large 215 mu lumen with inferior hyperreflectivity at the area of hemorrhage. There was focal thickening of the retina to encompass the macroaneurysm but no associated retinal edema. The higher resolution afforded by SD OCT may allow more accurate measurement of the size of the aneurysm, making it possible to evaluate prognostically relevant characteristics of the aneurysm such as hemorrhage in the vessel wall or thrombus in the lumen. This may also allow us to possibly intervene earlier in high-risk cases. SD OCT may be of value in management of retinal macroaneurysm.

Spectral domain optical coherence tomography findings of acute branch retinal artery occlusion from calcific embolus

An 82-year-old female presented with sudden painless decrease in vision in the right eye after awakening. She could see the “superior half” of her vision from the right eye only. On examination, best-corrected vision was 20/300 in the right eye and 20/30 in the left eye. The fundus in the right eye revealed recent superotemporal branch retinal artery occlusion (BRAO) with calcified plaque at the disc. Spectral domain optical coherence tomography (OCT) (OTI Ophthalmic Technologies, Inc.), revealed hyperreflectivity and increased thickness of the inner retinal layers of the superior compared to the inferior retina. Imaging at the optic disc revealed the blocked artery containing a highly reflective material. The high reflectivity of the material and underlying optical shadowing could be characterized as calcific emboli.