Disease Awareness Among Patients With Age-Related Macular Degeneration: Patterns and Predictors

Purpose: To examine the prevalence and predictors of patient awareness of their disease in adults with age-related macular degeneration (AMD). Methods: This study analyzed 5553 adults 40 years or older in the 2005-2008 National Health and Nutrition Examination Survey who underwent retinal imaging. AMD was determined based on retinal images. Patient awareness of their AMD was assessed by a self-reported AMD diagnosis. Multivariable logistic regression models were constructed to examine the association of patient awareness of their AMD with sociodemographic characteristics and specific AMD lesion types on retinal imaging. Results: AMD was identified in 425 of the adults surveyed (6.5%) (95% confidence interval [CI], 5.5%-7.5%), including 87.7% (95% CI, 82.9%-92.5%) with early AMD and 12.3% (95% CI, 7.5%-17.1%) with late AMD. Among adults with either type of AMD on retinal imaging, 17.5% (95% CI, 13.1%-22.0%) were aware of their disease, which included 11.6% (95% CI, 8.4%-14.9%) with early AMD and 59.2% (95% CI, 43.1%-75.3%) with late AMD (P < .0001). In the same group, those aged 60 years or older (odds ratio [OR], 33.46; 95% CI, 7.67-146.03) and with a best-corrected visual acuity of 20/40 or worse (OR, 4.63; 95% CI, 2.95-7.26) had higher awareness of their AMD diagnosis, whereas Hispanic (OR, 0.28; 95% CI, 0.09-0.88) vs White adults and those who did not speak English at home (OR, 0.05; 95% CI, 0.01-0.41) had lower awareness of their diagnosis. Conclusions: Fewer than 1 in 5 adults with AMD were aware of their personal diagnosis, including fewer than 3 in 5 adults with late AMD. Older adults and those with worse vision were more likely to know they have AMD, whereas Hispanic adults and those who did not speak English at home were less likely. Efforts to increase patients' awareness of their AMD may improve rates of follow-up and prevent vision loss.

Contrast Sensitivity Testing in Age-Related Macular Degeneration Using Motion Diamond Stimulus

Purpose

This study was performed to characterize changes in contrast sensitivity (CS) that occur in patients with age-related macular degeneration (AMD) using a novel test, the motion diamond stimulus (MDS).

Methods

This was a cross-sectional study in which 20 subjects with unilateral exudative AMD (eAMD) and contralateral dry AMD received 3 assessments: the Pelli-Robson (PR) CS Chart, the MDS test, and a visual function questionnaire-25 (VFQ-25). CS results from the PR, and MDS tests were compared across 3 groups: eyes with eAMD vs dry AMD, eAMD vs control, dry AMD vs control. Healthy, undilated eyes from another study served as the control group. Significance was determined using ANOVA analysis for the MDS output parameters (α: overall contrast threshold, β: adaptability of the visual system) and PR logCS. Patients were also administered the VFQ-25 to assess vision-related quality of life.

Results

The ANOVA of the MDS data demonstrated a significant difference in visual function according to the β parameter of the 3 groups, but no significant difference in the α parameter. PR CS results for the 3 groups were significantly different, further supporting the MDS results. Post-hoc analysis showed a significant difference in β and PR log CS between the eAMD and control eyes.

Conclusion

The MDS test is valuable in discerning CS impairments in patients with AMD. It can provide further insight into the visual changes experienced by patients with AMD and has potential to quantify visual function changes that are not found on visual acuity testing alone.

Maculopathy Secondary to Pentosan Polysulfate Use: A Single-Center Experience

AIM

To investigate the prevalence of retinal pathology in patients with a history of exposure to pentosan polysulfate sodium (PPS).

METHODS

Patients exposed to PPS and seen in the ophthalmology clinic at Northwestern University during 1/1/2002 to 1/1/2019 were identified from electronic health records (EHR) by an electronic data warehouse (EDW) search. Visual acuity (VA), reasons for clinic visit, ocular conditions, and duration of exposure to PPS were noted. Chart review was performed for fundus exam findings and ophthalmologic imaging, specifically fundus photography, fundus autofluorescence, and ocular coherence tomography (OCT) images. When OCT or fundus photography was available, studies were evaluated by two independent graders.

RESULTS

A total of 131 patients who were exposed to PPS and seen at the Northwestern Ophthalmology clinic were identified in the EHR. Forty patients of 131 had imaging. Patients with imaging or fundus examination suspicious for PPS maculopathy were placed into the suspect group. Of the 40 patients that had imaging, 5 (12.5%) had features suspicious for PPS maculopathy. Of the remaining 91, 5 (5.4%) had macular pigmentary changes described on fundus exam. Among the 10 patients in the suspect group, the average duration of PPS use was 4.2 years (range 0.3-11.6 years, interquartile range 5.5 years) and the average cumulative dose was 380g (range 29-1092g, interquartile range 132g).

CONCLUSION

A novel drug-induced maculopathy has been associated with PPS use with a distinct clinical constellation that can be accurately identified with multimodal imaging.

Contrast Sensitivity Testing in Retinal Vein Occlusion Using a Novel Stimulus

Purpose

This study evaluated a novel tool known as the motion diamond stimulus (MDS), which utilizes contrast-generated illusory motion in dynamic test regions to determine contrast sensitivity (CS).

Methods

Patients with treated unilateral retinal vein occlusions (RVOs) underwent three assessments: the MDS, the Pelli-Robson (PR), and the National Eye Institute's Visual Function Questionnaire (VFQ-25). The MDS assessment produced two data end points, α and β. The α value represents the overall contrast threshold level and the β value serves to quantify the adaptability of the visual contrast system. The CS parameters from the MDS and log CS PR output values were used to compare RVO eyes (n = 20) to control eyes (n = 20).

Results

The study participants had a mean composite VFQ-25 score of 89.5 ± 10.4 on the VFQ-25. A significant difference was observed between the RVO eyes and the control eyes in PR log CS scores (P value = 0.0001) and in MDS α value (P value = 0.01). No difference in MDS β value was found between the study groups (P value = 0.39).

Conclusions

The results for the MDS assessment's α parameter corroborated the PR scores, suggesting contrast sensitivity threshold impairment in patients with RVO. No significant difference in β value was observed, suggesting that adaptability of the visual system is maintained in treated RVO eyes.

Translational Relevance

Currently, visual complaints cannot be entirely identified by Snellen visual acuity alone. The MDS offers potentially a more complete look at visual function, by including contrast sensitivity and may be able to quantify changes otherwise overlooked in retinal disease progression.

Long-term Outcomes of Treat and Extend Regimen of Anti-vascular Endothelial Growth Factor in Neovascular Age-related Macular Degeneration

Purpose

This study describes the long-term visual and anatomic outcomes of anti-vascular endothelial growth factor (VEGF) treatment using a treat and extend dosing regimen.

Methods

This cross-sectional cohort study consisted of 224 treatment-naïve eyes with neovascular age-related macular degeneration (NV-AMD) from 202 patients that were treated with anti-VEGF agents bevacizumab, ranibizumab, and aflibercept using a treat and extend (TAE) regimen by four physician investigators in a large urban referral center from 2008 to 2015. Subjects were evaluated for visual acuity, injection frequency, and optical coherence tomography (OCT).

Results

Over a seven-year follow-up period (mean 3.4 years), an average 20.2 ± 14.7 injections were administered with 8.4 injections in the first year and 5.5 injections by the seventh year of remaining eyes undergoing treatment. Visual acuity was 0.70 logMAR (20/100 Snellen) at the first visit and 0.67 logMAR (20/93 Snellen) at the final visit, with 74% of eyes maintaining or gaining more than 2 lines of vision. Long-term, 45.1% of eyes achieved 20/50 or better, while 27.1% were 20/200 or worse. Of the treated patients, 61.2% received monotherapy with no difference in visual acuity outcomes or number of injections between the agents used. OCT analysis showed decreased fluid from initial to final follow-up visit: 70.1–15.6% with sub-retinal fluid (SRF) and 47.3–18.8% with intra-retinal fluid (IRF) with no difference between the agents were used.

Conclusion

This study demonstrates that most patients (74%) improve or maintain visual acuity long-term using a TAE model with a significant portion (45.1%) achieving 20/50 or better visual acuity with sustained treatment.

Diffuse Uveal Melanocytic Proliferation With Primary Vitreoretinal Lymphoma

Importance

Bilateral diffuse uveal melanocytic proliferation is a rare sign of several systemic malignant neoplasms.

Observations

A patient presenting with uveal melanocytic proliferation underwent a detailed physical examination and extensive imaging. No systemic malignant neoplasm was found. Chorioretinal biopsy was performed, and its immunohistochemical results revealed the presence of primary vitreoretinal lymphoma.

Conclusions and Relevance

This patient's results suggest that diffuse uveal melanocytic proliferation may be associated not just with systemic malignant disease, but also with primary intraocular tumors, in this case a primary vitreoretinal lymphoma.

Fundus Autofluorescence Patterns of Submacular Fluid Resolution Following Repair of Macula-Involving Rhegmatogenous Retinal Detachments

BACKGROUND AND OBJECTIVE

Submacular fluid (SMF) can persist for months to years following rhegmatogenous retinal detachment (RD) repair. The authors' objective was to describe fundus autofluorescence (FAF) and optical coherence tomography (OCT) findings associated with the absorption of persistent submacular fluid (SMF) following RD repair.

PATIENTS AND METHODS

Retrospective review of clinical data and FAF and OCT imaging from sequential postoperative visits in a cohort of patients with persistent SMF following RD repair.

RESULTS

In 11 of 13 eyes with persistent SMF, patches of decreased FAF signal corresponded to SMF on OCT. In eight eyes, there was a hypo- to hyperautofluorescence transition at the time of SMF resolution. These areas of increased FAF signal correlated with inner segment/outer segment (IS/OS) junction loss on OCT.

CONCLUSION

FAF imaging can be informative when following SMF after RD repair; a hypo- to hyper-FAF signal transition correlates with SMF resolution and photoreceptor loss. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:1020-1029.].

Retinal Disease in Marfan Syndrome: From the Marfan Eye Consortium of Chicago

BACKGROUND AND OBJECTIVE

To study the prevalence of peripheral retinal disease in patients with Marfan Syndrome (MFS).

PATIENTS AND METHODS

In this observational, cross-sectional case series, patients with MFS were recruited by the Marfan Eye Consortium of Chicago during the National Marfan Foundation's annual conference. Patients underwent a fully dilated exam by vitreoretinal specialists in addition to ultra-widefield fundus photography using a scanning laser ophthalmoscope (Optos 200Tx; Optos PLC, Dunfermline, Scotland, United Kingdom).

RESULTS

Clinical examination revealed posterior segment pathology in 18% of eyes with increased incidence to 70% in patients with a subluxed lens. In six out of 10 subjects in whom the clinical exam was suboptimal (young age, small pupil, and limited cooperation), the Optos provided a superior view of the peripheral retina compared to clinical exam alone.

CONCLUSION

Clinical exam of MFS patients revealed similar posterior segment pathology as noted in previous literature, with improved detection of peripheral retinal disease with the use of ultra-widefield imaging.

Dissociations of the Fluocinolone Acetonide Implant: The Multicenter Uveitis Steroid Treatment (MUST) Trial and Follow-up Study

PURPOSE

To describe fluocinolone acetonide implant dissociations in the Multicenter Uveitis Steroid Treatment (MUST) Trial.

DESIGN

Randomized clinical trial with extended follow-up.

METHODS

Review of data collected on the first implant in the eye(s) of participants. Dissociation was defined as the drug pellet no longer being affixed to the strut and categorized as spontaneous or surgically related.

RESULTS

A total of 250 eyes (146 patients) had at least 1 implant placed. Median follow-up time after implant placement was 6 years (range 0.5-9.2 years). Thirty-four dissociations were reported in 30 participants. There were 22 spontaneous events in 22 participants; 6-year cumulative risk of a spontaneous dissociation was 4.8% (95% confidence interval [CI]: 2.4%-9.1%). The earliest event occurred 4.8 years after placement. Nine of 22 eyes with data had a decline in visual acuity ≥5 letters temporally related to the dissociation. Thirty-nine implant removal surgeries were performed, 33 with replacement. Twelve dissociations were noted during implant removal surgeries in 10 participants (26%, 95% CI 15%-48%); 5 of these eyes had a decline in visual acuity ≥5 letters after surgery. The time from implant placement to removal surgery was longer for the surgeries at which dissociated implants were identified than for those without one (5.7 vs 3.7 years, P < .001). Overall, visual acuity declined 15 or more letters from pre-implant values in 22% of affected eyes; declines were frequently associated with complications of uveitis or its treatment.

CONCLUSION

There is an increasing risk of dissociation of Retisert implants during follow-up; the risk is greater with removal/exchange surgeries, but the risk of both spontaneous and surgically related events increases with longevity of the implants. In 22% of affected eyes visual acuity declined by 15 letters. In the context of eyes with moderate to severe uveitis for years, this rate is not unexpected.

Quantification of Change in Pigment Epithelial Detachment Volume and Morphology After Transition to Intravitreal Aflibercept in Eyes With Recalcitrant Neovascular AMD: 18-Month Results

BACKGROUND AND OBJECTIVE

To quantitatively evaluate the change in pigment epithelial detachment (PED) morphology on spectral-domain optical coherence tomography (SD-OCT) 18 months after the transition to intravitreal aflibercept in patients with neovascular age-related macular degeneration (AMD) with PED recalcitrant to monthly intravitreal bevacizumab or ranibizumab.

PATIENTS AND METHODS

Retrospective case series examining patients with neovascular AMD who had a persistent fibrovascular or serous PED on SD-OCT. PED volume was calculated by manually outlining the PED on individual OCT slices of the raster scan and multiplying by the pixel dimensions.

RESULTS

Eleven eyes of 10 patients who had received an average of 25.7 ± 20.1 (range: 6 to 70) prior bevacizumab or ranibizumab injections over a period of 26.6 ± 19.8 months (range: 4 to 63) were included. PED volume decreased with aflibercept from 0.687 ± 0.837 mm(3) to 0.562 ± 0.705 mm(3) (P = .02), a decrease of 19% ± 12.27%.

CONCLUSION

After 18 months of aflibercept, recalcitrant PED volumes were reduced by 19% while preserving visual acuity in eyes with neovascular AMD.

Long-term Outcomes of Cytomegalovirus Retinitis in the Era of Modern Antiretroviral Therapy: Results from a United States Cohort

PURPOSE

To describe the long-term outcomes of patients with cytomegalovirus (CMV) retinitis and AIDS in the modern era of combination antiretroviral therapy.

DESIGN

Prospective, observational cohort study.

PARTICIPANTS

Patients with AIDS and CMV retinitis.

METHODS

Immune recovery, defined as a CD4+ T-cell count >100 cells/μl for ≥3 months.

MAIN OUTCOME MEASURES

Mortality, visual impairment (visual acuity <20/40), and blindness (visual acuity ≤20/200) on logarithmic visual acuity charts and loss of visual field on quantitative Goldmann perimetry.

RESULTS

Patients without immune recovery had a mortality of 44.4/100 person-years (PYs) and a median survival of 13.5 months after the diagnosis of CMV retinitis, whereas those with immune recovery had a mortality of 2.7/100 PYs (P < 0.001) and an estimated median survival of 27.0 years after the diagnosis of CMV retinitis. The rates of bilateral visual impairment and blindness were 0.9 and 0.4/100 PYs, respectively, and were similar between those with and without immune recovery. Among those with immune recovery, the rate of visual field loss was approximately 1% of the normal field per year, whereas among those without immune recovery it was approximately 7% of the normal field per year.

CONCLUSIONS

Among persons with CMV retinitis and AIDS, if there is immune recovery, long-term survival is likely, whereas if there is no immune recovery, the mortality rate is substantial. Although higher than the rates in the population not infected by human immunodeficiency virus, the rates of bilateral visual impairment and blindness are low, especially when compared with rates in the era before modern antiretroviral therapy.

Risk of cataract in persons with cytomegalovirus retinitis and the acquired immune deficiency syndrome

OBJECTIVE

To evaluate cataract risk in eyes of patients with AIDS and cytomegalovirus (CMV) retinitis and to identify risk factors.

DESIGN

Prospective cohort study.

PARTICIPANTS

Patients with AIDS and CMV retinitis.

METHODS

Patients 13 years of age and older were enrolled between 1998 and 2008. Demographic and clinical characteristics, slit-lamp biomicroscopy findings, and dilated ophthalmoscopy results were documented at quarterly visits. Cataract status was determined at the initial visit (prevalence) and at follow-up visits (incidence).

MAIN OUTCOME MEASURES

For cataract, a high grade of lens opacity by biomicroscopy to which best-corrected visual acuity worse than 20/40 was attributed. Eyes that had undergone cataract surgery before enrollment or between visits also were counted as having cataract.

RESULTS

Seven hundred twenty-nine eyes of 489 patients diagnosed with CMV retinitis were evaluated. Higher prevalence was observed for patients with bilateral versus unilateral CMV retinitis (adjusted odds ratio [aOR], 2.74; 95% confidence interval [CI], 1.76-4.26) and, among unilateral CMV retinitis cases, for eyes with retinitis versus without retinitis (15% vs. 1.4%; P<0.0001). The age-adjusted prevalence of cataract among CMV retinitis cases was higher than that in a population-based sample (P<0.0001). Cataract prevalence increased with age (aOR, 11.77; 95% CI, 2.28-60.65 for age ≥ 60 years vs. younger than 40 years) and longer duration of retinitis (aOR, 1.36; 95% CI, 1.20-1.54 per year). Among eyes with CMV retinitis initially free of cataract, the cataract incidence was 8.1%/eye-year (95% CI, 6.7%-10.0%). Prior retinal detachment was associated with higher cataract risk (if repaired with silicone oil: adjusted hazard ratio [aHR], 10.37; 95% CI, 6.51-16.52; otherwise: aHR, 2.90; 95% CI, 1.73-4.87). Large CMV retinitis lesions also were associated with higher risk of cataract (for involvement of 25-49% retinal area: aHR, 2.30; 95% CI, 1.51-3.50; for ≥ 50% involvement: aHR, 3.63; 95% CI, 2.18-6.04), each with respect to ≤ 24% involvement, as were anterior segment inflammation (aHR, 2.27; 95% CI, 1.59-3.25) and contralateral cataract (aHR, 2.52; 95% CI, 1.74-3.66).

CONCLUSIONS

Cytomegalovirus retinitis is associated with a high absolute and relative risk of cataract. Among several risk factors, large retinal lesion size and use of silicone oil in retinal detachment repair are potentially modifiable, albeit not in all cases. Cataract is likely to be an increasingly important cause of visual morbidity in this population.

Association between abnormal contrast sensitivity and mortality among people with acquired immunodeficiency syndrome

PURPOSE

To investigate the relationship between contrast sensitivity (CS) and mortality among people with acquired immunodeficiency syndrome (AIDS); and to explore the hypothesis that abnormal CS is a marker of systemic, life-threatening microvascular disease.

DESIGN

Longitudinal, observational cohort study.

METHODS

We evaluated 3395 eyes of 1706 individuals enrolled in the Longitudinal Study of the Complications of AIDS (1998-2008). CS was evaluated as a risk factor for death, and was compared to the presence of systemic diseases characterized by microvasculopathy (diabetes, cardiovascular disease, stroke, renal disease) and to laboratory markers of those diseases. Abnormal CS was defined as logCS <1.5 (lower 2.5th percentile for a normal control population).

RESULTS

CS was abnormal in 284 of 1691 (16.8%) study participants at enrollment. There was a positive relationship between the presence of abnormal CS at study entry and mortality (relative risk 2.0, 95% confidence interval 1.7-2.3, P < .0001). Abnormal CS was related to the presence of cardiovascular disease, stroke, and renal disease (all P values <or= .01), but abnormal CS remained associated with death even after adjustment for these diseases and for other known predictors of death among people with AIDS. Diseases characterized by microvasculopathy were more often identified as causes of death among individuals with abnormal CS than among those with normal CS, although the strength of the association was moderate (P = .06).

CONCLUSIONS

Abnormal CS among people with AIDS is associated with increased mortality, and is independent of other risk factors for death that are monitored routinely. The relationship may indicate life-threatening microvascular disease in other organs.

Photodynamic Therapy for Focal Retinal Pigment Epithelial Leaks Secondary to Central Serous Chorioretinopathy

PURPOSE

To report the use of photodynamic therapy with verteporfin as a treatment for patients with focal retinal pigment epithelial leaks secondary to central serous chorioretinopathy (CSC).

DESIGN

Noncomparative, nonrandomized, retrospective interventional case series.

PARTICIPANTS

Nine eyes of 9 symptomatic patients with acute focal retinal pigment epithelial leaks secondary to CSC, confirmed with fluorescein angiography, evaluated at 1 of 3 referral retina practices.

METHODS

Patients were treated with photodynamic therapy using verteporfin. Best-corrected visual acuity (VA) was recorded at presentation and follow-up visits.

MAIN OUTCOME MEASURES

Resolution of neurosensory detachment, status of fluorescein leakage, and VA.

RESULTS

Neurosensory detachment and fluorescein leakage resolved in all patients within 1 month. Visual acuity improved from 1 to 6 lines in 7 eyes and remained unchanged in 2. At 6 months, there was a statistically significant improvement in mean VA (P = 0.012, Wilcoxon signed ranks test), and mean VA improved from 20/80 to 20/40. No patient lost vision or suffered any treatment-related complications.

CONCLUSION

The treatment of acute CSC with photodynamic therapy may result in prompt resolution of neurosensory detachment and fluorescein leakage, which can be associated with rapidly improved vision. Although this case series is limited in follow-up and number of patients, the encouraging results and lack of visually significant complications suggest that further investigation is warranted.

Rhegmatogenous retinal detachments in children: risk factors and surgical outcomes

PURPOSE

To describe the presenting features and surgical outcomes in a series of children with rhegmatogenous retinal detachments.

DESIGN

Retrospective, noncomparative, interventional case series.

PARTICIPANTS

Thirty-nine eyes of 34 children 18 years of age or younger undergoing surgery for rhegmatogenous retinal detachment.

METHODS

Patients were identified by chart review at two affiliated tertiary care centers. Risk factors for retinal detachment were classified into four categories: (1). congenital or developmental structural ocular abnormalities, (2). trauma, (3). previous ophthalmologic surgery, and (4). preceding uveitis.

RESULTS

Median age was 10 years, and 79% of patients were boys. Nine patients (26%) had bilateral retinal detachment at presentation, or experienced a detachment in their second eye before their nineteenth birthday. Every eye had at least one risk factor for retinal detachment, and more than half had risk factors in two or more categories. Structural abnormalities were most common (56%). Fifty-one percent of eyes underwent previous surgery, 36% experienced trauma, and 15% had uveitis. Detachments tended to be complex. Median follow-up was 24 months. Retinal reattachment was achieved in 79% of eyes; however, visual recovery was modest. Median preoperative and postoperative visual acuities were counting fingers and 20/400, respectively. Predictors of a poor visual outcome were: unmeasurable or light perception-only preoperative vision (P = 0.0001), macula-off retinal detachment (P = 0.01), the need for vitrectomy surgery (P = 0.01), the presence of proliferative vitreoretinopathy grade C or worse (P = 0.02), and the use of silicone oil (P = 0.02).

CONCLUSIONS

Predisposing factors in pediatric retinal detachments, particularly congenital and developmental structural abnormalities, may be more common than previously reported. Modern vitreoretinal surgical techniques can help achieve retinal reattachment in most cases. Many factors contribute to the limited visual recovery in this patient population. Predictors of visual outcomes are similar to those observed in adults. Inability of the clinician to determine confidently the preoperative visual acuity is a newly identified predictor of poor visual outcomes.

A newly recognized maculopathy: benign symmetric oval-shaped foveal depigmentation

PURPOSE

To characterize a newly recognized maculopathy, benign foveal depigmentation.

METHODS

Three patients with unusual foveal depigmentation were prospectively studied.

RESULTS

The patients were referred with a diagnosis of Stargardt's macular dystrophy. Ophthalmic examination revealed discrete, bilateral, symmetric, oval foveal depigmentation. This appeared to be at the level of the retinal pigment epithelium. These patients were followed for up to ten years with stable vision and no change in lesion size.

CONCLUSIONS

Benign foveal depigmentation is a maculopathy which has discrete, bilateral, symmetric, horizontally oval foveal depigmentation at the level of the retinal pigment epithelium. This appears to be visually benign.

Idiopathic polypoidal choroidal vasculopathy of the macula

OBJECTIVE

The authors evaluated the clinical, fluorescein, and indocyanine green (ICG) angiographic characteristics of the macular variant of idiopathic polypoidal choroidal vasculopathy (IPCV).

DESIGN

Observational case series.

PARTICIPANTS

The records, photographs, and fluorescein and ICG angiograms of eight eyes of seven patients with IPCV lesions confined to the macula were reviewed.

MAIN OUTCOME MEASURES

The visual acuity, fundus examination, fluorescein and ICG angiographic characteristics, and clinical course were compared.

RESULTS

All patients demonstrated polypoidal lesions arising from macular choroidal vessels on ICG angiography. One patient had bilateral lesions. These lesions appeared hyperfluorescent in the early phases of both fluorescein and ICG angiography. Late-phase leakage was seen in cases associated with subretinal fluid or exudate. None of these patients demonstrated polypoidal lesions arising from the peripapillary choroidal circulation or peripapillary choroidal neovascularization. Three eyes with polypoidal lesions that were associated with subretinal fluid and exudates were treated with photocoagulation. Five eyes were not treated. Final visual acuity ranged from 20/20 to hand motions. Severe visual loss was associated with vitreous and subretinal hemorrhage, but this resolved without permanent severe visual loss in several cases.

CONCLUSIONS

In the macular variant of IPCV, ICG and fluorescein angiography demonstrate characteristic macular polypoidal lesions without evidence of peripapillary lesions. The vascular origin of these polypoidal lesions appears to be the macular choroidal circulation. This is distinguished from classic IPCV, in which lesions appear to arise from the peripapillary choroidal circulation. Visual prognosis appears to be good, with most patients retaining visual acuity of 20/80 or better. If subretinal fluid or exudates reduce visual acuity, photocoagulation should be considered.

Unifocal helioid choroiditis

OBJECTIVE

To report a previously undescribed clinical entity involving an unusual inflammatory lesion of the choroid.

PATIENTS

Six young, healthy patients experienced acute unilateral visual loss secondary to unifocal choroiditis in the macula.

RESULTS

All patients exhibited a solitary, elevated, yellow-white active focus of choroiditis with overlying subretinal fluid and in some cases subretinal hemorrhaging. The lesions were approximately 1 disc diameter in size and, on follow-up, showed minimal growth, then gradual resolution of the subretinal fluid. No other signs of ocular inflammation were noted, except in 1 patient who had anterior chamber and vitreous inflammation. In the 3 patients with prolonged follow-up, elevated white plaquelike lesions persisted with little change over time. Relapses were seen, and some permanent visual loss occurred in 1 of the 3 patients. Systemic evaluations revealed no definitive etiology.

CONCLUSIONS

To our knowledge, these patients exhibit an undescribed clinical entity, separable from previously established choroidal disorders. The cause of the lesions remains uncertain. We call this entity "unifocal helioid choroiditis."

Repair of retinal detachments due to herpes varicella-zoster virus retinitis in patients with acquired immune deficiency syndrome

PURPOSE

The authors characterize surgical techniques and report results for repair of retinal detachments due to varicella-zoster retinitis in patients with acquired immune deficiency syndrome (AIDS).

BACKGROUND

Varicella-zoster virus (VZV) retinitis is a distinctly aggressive infection in patients with AIDS. Retinal detachments occur in the majority of such patients, and contribute to their poor visual prognosis.

METHODS

A case series of five eyes in four patients with AIDS and retinal detachments due to VZV retinitis is presented, highlighting surgical technique and results. Pars plana vitrectomy, silicone oil tamponade, and endolaser photocoagulation were used in all cases.

RESULTS

Apparent contraction of the necrotic retina was observed, requiring large relaxing retinectomies to achieve retinal attachment in three of the five eyes. Follow up after surgery was 4, 6, 15, 29, and 30 months. Four eyes maintained ambulatory vision and the retinas remained attached.

CONCLUSION

Vitrectomy with silicone oil tamponade may be used to preserve ambulatory vision in carefully selected patients with AIDS and retinal detachments due to VZV retinitis. Relaxing retinectomy is a useful technique to achieve and maintain retinal attachment.