Zeon Lee

VITRECTOMY FOR DIABETIC CYSTOID MACULAR EDEMA

PURPOSE We evaluated visual outcomes following vitrectomy for diabetic cystoid macular edema. METHODS Visual outcomes and factors possibly influencing final visual acuity were assessed and documented retrospectively in 45 eyes of 40 patients, all of whom were followed up for at least 6 months postoperatively. RESULTS Compared with the preoperative logarithm of the minimum angle of resolution (logMAR) visual acuity, final logMAR visual acuity improved 0.2 or more in 51% of the eyes, was unchanged in 47%, and decreased 0.2 or more in 2%. A final postoperative visual acuity of 0.5 or better was achieved in 38%. Preoperative visual acuity and the extent of the cystoid space on fluorescein angiography were significantly related to final visual acuity. A final postoperative visual acuity of 0.5 or better was noted in 8% of eyes with a preoperative visual acuity below 0.1, in 50% of eyes with a preoperative visual acuity of 0.1 or better, in 71% of eyes with a cystoid space smaller than 5 disc areas, and in 20% of eyes with a cystoid space of 5 disc areas or more. The state of the posterior vitreous membrane did not influence final visual acuity. There were no complications that decreased visual acuity. CONCLUSIONS We conclude that diabetic cystoid macular edema is a good indication for vitrectomy, regardless of the state of the posterior vitreous membrane. A preoperative visual acuity of 0.1 or better and/or a cystoid space smaller than 5 disc areas may be indications for surgery aimed at achieving a final postoperative visual acuity of 0.5 or better.

Surgical removal of choroidal neovascularization in angioid streaks

PurposeAll the studies so far on surgical removal of choroidal neovascularization (CNV) in angioid streaks (AS) were conducted on a small number of cases. Therefore, a definitive evaluation of the surgical method was not available. The present study aimed to evaluate this surgical modality.Subjects and MethodWe performed surgical removal of foveal CNV accompanied by AS. Eighteen eyes of seventeen patients were available for follow-up of over 12 months. Surgical indications included foveal CNV, fluorescence leakage from the CNV in late-phase fluorescein angiography, and visual acuity of 0.3 or lower.ResultsThe best visual acuity was improved in 44% and unchanged in 44%. The final visual acuity was improved in 33% and unchanged in 39%. 22% had a preoperative visual acuity of 0.2 or above; and 44% and 17% achieved best and final visual acuity, respectively, of 0.2 or above. Since all cases developed atrophy of the choriocapillaris in the fovea, none of the cases were capable of fixation within atrophy. The fixation point was localized outside atrophy in 56% and fixation was poor in 44%. The diameter of postoperative atrophy of choriocapillaris was significantly greater (p ≪ 0.05) than the preoperative CNV diameter. CNV recurred in 8 eyes (44%), 88% of which occurred within one year.ConclusionsSurgical removal of CNV in AS is an effective method to maintain preoperative visual acuity. Nippon Ganka Gakkai Zasshi (J Jpn Ophthalmol Soc 107:440–444, 2003)

The subclassification and long-term prognosis of preproliferative diabetic retinopathy

PURPOSE We followed up 54 patients (95 eyes) with preproliferative diabetic retinopathy (PPDR) for at least 2 years, and then evaluated the proportion developing proliferative diabetic retinopathy (PDR), and the period from diagnosis of PPDR until the development of PDR. METHODS We divided the 95 eyes affected by PPDR into 75 eyes with mild-type and 20 eyes with moderate-type based on our previously proposed subclassification, and evaluated long-term (2 or more years) prognosis. RESULTS The proportion developing PDR was 24% in mild-type and 60% in moderate-type. The average period from diagnosis of PPDR until the development of PDR was 6 years and 5 months in mild-type, 2 years in moderate-type. The cumulative occurrence rates of PDR at 2, 5, and 10 years were estimated to be 0%, 14%, and 39% in mild-type and 35%, 58%, and 79% in moderate-type, respectively. The proportion developing PDR was significantly higher and the average period until PDR development significantly shorter in moderate than in mild-type. In mild-type eyes, the rate of progression to moderate-type was 56% and further progression from moderate-type to PDR occurred in 43%. CONCLUSION The above results again confirm the usefulness of our subclassification, and also provide valuable information about the long-term prognosis of PPDR.

Subclassification of Preproliferative Diabetic Retinopathy and Glycemic Control: Relationship Between Mean Hemoglobin A1C Value and Development of Proliferative Diabetic Retinopathy

PURPOSE We evaluated the relationship between long-term glycemic control and the proportion of patients developing proliferative diabetic retinopathy (PDR) among cases with mild type preproliferative diabetic retinopathy (PPDR). METHODS The relationship was evaluated between the mean hemoglobin A1C (HbA1C) value during a period of at least 2 years and the proportion of patients developing PDR among cases with mild type PPDR, based on our previously proposed subclassification. RESULTS During follow-up, 27% of the total PPDR cases developed PDR. The mean HbA1C value in those patients who had developed PDR was 9.4% and was significantly higher than the 7.6% in those who had not developed PDR. The proportion developing PDR was 48% of the cases with a mean HbA1C value of 8.6% or more. By comparison, the proportion developing PDR was 8% among those with a mean HbA1C value below 8.6%. The proportion developing PDR was estimated to approximately double with each 1% increase in the mean HbA1C value. The cumulative occurrence rates of PDR at 2, 5, and 10 years were estimated to be 5%, 28%, and 60% in cases with a mean HbA1C value of 8.6% or more, and 0%, 7%, and 14% in those with a mean HbA1C value below 8.6%, respectively. CONCLUSION Stricter systemic and ophthalmological control is indicated for cases with a mean HbA1C value exceeding 8.6%.

Response to 'photodynamic therapy for polypoidal choroidal vasculopathy'

Dear Editor, In our study, maximum GLD was 6000 μm including the fovea in eyes with PCV. There are several disadvantages associated with PDT, as you mentioned. In addition, transformation from PCV into polypoidal CNVor secondary CNV development under the retina after PDT during the follow-up study may have been related to PDT. Furthermore, eyes with good visual acuity cannot undergo PDT. Anti-VEGF drugs are useful for absorbing exudation in eyes with PCV, whether or not polypoidal lesions regress [in our recent study, causative polypoidal lesions disappeared on ICGA in 15% of 26 eyes with visual acuity of 0.6 or more after three treatments with ranibizumab, and mean visual acuity improved from log MAR 0.11 to 0.03 (P< 0.001)]. Therefore, PCV patients with good visual acuity are thought to have a good indication for ranibizumab monotherapy. However, the Everest study showed that the disappearance rate of polypoidal lesions on ICGA was significantly better with PDT alone and PDT plus ranibizumab than with ranibizumab monotherapy (personal communication). Persistent polypoidal lesions may result in recurrent exudation and/or hemorrhage, such that several re-treatments will be needed for recurrent exudation over an extended period. Therefore, PDT is needed in cases with visual acuity of 0.5 or less. These cases, especially, respond well to PDT, as we have shown in this study. PCV manifests in various ways, e.g., as a small network with one polypoidal lesion or a large network with multiple polypoidal lesions. In the near future, we plan to choose the best modality based on clinical manifestation.

Preproliferative Diabetic Retinopathy Subclassification and Glycemic Control: Relationship Between Mean Hemoglobin A1C Value and Development of Proliferative Diabetic Retinopathy

PURPOSE We evaluated the relationship between long-term glycemic control and the proportion of patients developing proliferative diabetic retinopathy(PDR) in cases of mild preproliferative diabetic retinopathy(PPDR). MATERIALS AND METHODS We evaluated the relationship between the mean hemoglobin A1C (HbA1C) value during a period of at least 2 years and the proportion of patients developing PDR in cases of mild PPDR, based on our previously proposed subclassification. RESULTS During follow-up, 27% of all cases developed PDR. The mean HbA1C value in these cases was 9.4%, which was significantly higher than the 7.6% in cases which had not developed PDR. The proportion of patients developing PDR was 48% in cases with a mean HbA1C value 8.6% or more. In contrast, the proportion was 8% in cases with a mean HbA1C value below 8.6%. It was estimated that the proportion of patients developing PDR will approximately double if the mean HbA1C value increases by one percent. The cumulative occurrence rates of PDR at two, 5, and 10 years were estimated to be 5, 28, and 60% in cases with a mean HbA1C value 8.6% or more and 0, 7, and 10% in cases with a mean HbA1C value below 8.6%, respectively. CONCLUSION Based on the above results, we conclude that more strict systemic and ophthalmological control is indicated for patients with a mean HbA1C value exceeding 8.6%.