Optic disk pit maculopathy: current management strategies

Introduction

Optic disk pit (ODP) is a rare congenital abnormality of the optic nerve head and can lead to visual impairment when macular detachment occurred. Recent advances in retinal imaging brought new insights into the pathophysiology of the disease, while new therapeutic options have been also described.

Methods

We made a comprehensive search of the literature regarding the current treatment modalities for the treatment of ODP maculopathy.

Results

Although there have been reported some cases of spontaneous resolution, current management of ODP maculopathy involves several surgical approaches. The most commonly used treatment alternative for ODP maculopathy management is vitrectomy, either alone or in combination with other treatment modalities, such as gas tamponade or laser photocoagulation. Other options, such as scleral buckling and inner fenestration, are also used, based on the recent findings about pathophysiology of the disease.

Conclusion

The management of ODP maculopathy remains challenging. Even though there are further advances in the understanding of the disease pathophysiology, the applied treatment is not single and therapeutic modalities differ in the success rate, related to the anatomical and functional results.

Optical Coherence Tomography Study of Vitreoretinal Interface in Full Thickness Macular Hole Associated with Optic Disk Pit Maculopathy

Purpose

To evaluate by optical coherence tomography (OCT) the vitreous involvement in full thickness macular hole associated with optic disk pit maculopathy.

Methods

Two patients with optic disk pit maculopathy and full thickness macular hole underwent OCT for evaluation of vitreous involvement in the pathogenesis of the disease. Fluorescein angiography and fundus photographs were also performed.

Results

OCT documented the presence of vitreous traction at the edge of the full thickness macular hole in the first case and on the elevated macula in the second case. Partial posterior vitreous detachment was also noticed.

Conclusions

Previously unreported OCT findings such as vitreous traction at the edge of the macular hole and on the elevated macula were found. OCT provided evidence for vitreous participation in full thickness macular hole associated with optic disk pit maculopathy. OCT was also able to show that the full thickness macular hole and optic disk pit maculopathy were probably caused by similar vitreous tractional forces. (Eur J Ophthalmol 2007; 17: 272–6)

Complications of intravitreal ocriplasmin for vitreomacular traction and macular hole: a prospective spectral-domain optical coherence tomography study

OBJECTIVE

The purpose of this study was to evaluate the safety of intravitreal ocriplasmin prospectively, reporting potential complications in patients with vitreomacular traction (VMT) alone or associated with macular hole (MH).

MATERIALS AND METHODS

Participants in this prospective, multicenter study, were 24 patients with VMT (17 with VMT alone and seven with MH combined with VMT). All patients were treated with a single ocriplasmin injection and followed-up prospectively at baseline, day 7, 28 and the last examination of the follow-up for each patient (mean ± SD: 64.2 ± 24.4 d, range: 40-145 d). Best-corrected visual acuity (BCVA) was assessed, and spectral-domain optical coherence tomography was performed at each visit while the percentage of resolution of VMT and the association with various potential adverse events were recorded and analyzed.

RESULTS

66.7% of patients presented VMT release at the end of the follow-up, while 28.6% exhibited MH closure. Severe adverse events, such as enlargement of preexisting MH and formation of lamellar MH, were observed in one and four cases, respectively and remained till the end of the follow-up. Moderate adverse events, such as ellipsoid zone disruption and subretinal fluid development, became evident seven days after injection, in four cases. Formation of cystoid macular edema (CME), not evident at baseline, was noticed in three cases at day 28 after injection. Mild adverse events, like vitreous floaters, photopsias, eye pain and foreign body sensation, were noticed at day 7 and resolved till the end of the follow-up.

CONCLUSIONS

Mild and moderate adverse events occurred mainly during the first week of the follow-up, while severe adverse events, such as the lamellar MH formation and CME at day 28 post injection were seen.

Evolution of vitreomacular adhesion to acute vitreofoveal separation with special emphasis on a traction-induced foveal pathology. A prospective study of spectral-domain optical coherence tomography

PURPOSE

To investigate the evolution of vitreomacular adhesion (VMA) to acute vitreofoveal separation with particular emphasis on cases involving the underlying fovea.

METHODS

In this observational case series, of 192 cases in the VMA stage, 51 progressed to acute vitreofoveal separation; this subgroup was divided into those with normal separation (Group I) and those with co-existing macular findings (Group II). All patients were examined using spectral domain-optical coherence tomography (SD-OCT) at regular three-month intervals. We recorded the best-corrected visual acuity (BCVA), the vitreomacular angle of the VMA (nasally and temporally), the horizontal diameter of the VMA, the macular thickness, the integrity of the photoreceptor layer and of the external limiting membrane. The Amsler grid test was used in the intermediate examinations in cases where patients developed symptoms.

RESULTS

Out of the 51 cases in the VMA stage, 45 (88.2%) progressed to normal spontaneous vitreofoveal separation, while six (11.8%) developed findings of the fovea, such as macular thinning (two cases), an anomalous foveal contour (two cases), a macular tissue defect (one case) and vitreous separation from only the temporal side of the VMA in one case. Foveal findings were the same during the follow-up period in all but one case in which improvement was noted. Differences in BCVA between baseline measurements, those made immediately after vitreofoveal separation, and those made during final examination were not statistically significant. For the whole sample of our study (51 cases), the mean observation time at the VMA stage was 21.8 ±10.6 months, while the mean follow-up time after vitreofoveal separation was 9.7 ±4.9 months. In cases that developed incidents from the fovea, the mean observation time from the baseline to the last examination before vitreofoveal separation was 16.5 ±11.2 months and the mean follow-up time from the diagnosis of vitreofoveal separation to the final examination was 8.5 ±4.4 months.

CONCLUSIONS

VMA, excepting its progression to vitreomacular traction or spontaneous release, in a subset of patients can also cause findings associated with the fovea, concomitantly with vitreofoveal separation. Vitreofoveal separation can induce unilateral anatomic distortion of the fovea accompanied by symptoms, such as metamorphopsia or micropsia.

Spontaneous resolution of vitreomacular traction demonstrated by spectral-domain optical coherence tomography

PURPOSE

To evaluate the natural course of idiopathic vitreomacular traction (VMT) with spectral-domain optical coherence tomography (SDOCT) from the vitreomacular adhesion (VMA) stage to the spontaneous resolution of VMT.

DESIGN

Prospective observational case series.

METHODS

We studied the natural course of idiopathic VMT in 46 eyes (46 patients), divided into those that proceeded to spontaneous VMT resolution (12 cases) and those that remained at the VMT stage (34 cases). All patients were examined with SDOCT at regular 3-month intervals. We recorded the vitreomacular angle of VMA nasally and temporally, the horizontal diameter of VMA, macular thickness, visual acuity, photoreceptor layer, and external limiting membrane.

RESULTS

In the 12 eyes that proceeded to spontaneous resolution, the vitreous adhesion angle had a mean increase of 38 degrees at VMT, compared to the angle at the VMA stage. In the 34 eyes that remained at the VMT stage, the mean angle of traction increased by only 1 degree throughout follow-up. In all 46 patients, the angle at the VMT stage was significantly associated with traction resolution (nasally P = .001, temporally P < .001). The likelihood of resolution was more than 99% lower for patients with a VMT diameter >400 μm compared with that of eyes with a VMT diameter <400 μm. Patients with broad-type VMT remained at the same stage, whereas patients with V-type VMT had 80% probability of resolution.

CONCLUSIONS

Spontaneous VMT resolution is negatively associated with the horizontal adhesion diameter. The strength of the traction exerted by the vitreous on the fovea seems to be positively related to the size of the vitreomacular angle.

Spontaneous closure of lamellar macular holes studied by optical coherence tomography

PURPOSE

To document and study the spontaneous closure of lamellar macular holes (LMH) by optical coherence tomography (OCT).

METHODS

Two women with LMH, 62 and 71 years old, respectively, were followed up with fundoscopy, fundus photography and OCT.

RESULTS

In both patients spontaneous closure of LMH was observed 11 and 21 months after baseline examination, respectively. The foveal thickness in case 1 increased from 84 μm at baseline to 162 μm at the final examination. The foveal thickness in case 2 increased from 48 μm at baseline to 148 μm at the final examination. The foveal contour was also restored in both eyes. The foveal morphology was preserved in both eyes during the follow-up period.

CONCLUSION

In both patients the spontaneous closure of LMH could be attributed to the shrinkage of the hole or the release of the tension on the retinal surface, which followed the complete posterior vitreous detachment and separation of epiretinal membrane from the retina.

Hemodialysis-induced alterations in macular thickness measured by optical coherence tomography in diabetic patients with end-stage renal disease

BACKGROUND/AIMS

To evaluate changes in macular thickness measured by optical coherence tomography (OCT) during a hemodialysis (HD) session in diabetic patients with end-stage renal disease.

METHODS

72 eyes of 36 diabetic patients with and without macular edema were evaluated before and immediately after an HD session. Average and maximum macular thicknesses in the central disk (6 mm in diameter) and total macular volume were measured.

RESULTS

In the eyes with diabetic macular edema, maximum macular thickness within the central disk of 6 mm, and mainly in its peripheral parts, was significantly reduced by 31.18 ± 4.18 μm after HD (p < 0.001). Average macular thickness and total macular volume were also significantly reduced (p = 0.003 and 0.015, respectively). In diabetic eyes without edema, maximum macular thickness decreased significantly by 11.21 ± 1.98 μm after HD (p < 0.001), while average macular thickness and total macular volume decreased slightly (p = 0.034, p = 0.043). Best-corrected visual acuity failed to change. We found a significant association of macular thickness changes with osmolality reduction and the presence of macular edema.

CONCLUSION

HD decreases macular thickness in diabetic patients with macular edema, while there exists a less-pronounced effect in diabetic eyes without edema.

The photoreceptor layer as a prognostic factor for visual acuity in the secondary epiretinal membrane after retinal detachment surgery: imaging analysis by spectral-domain optical coherence tomography

PURPOSE

To study the prognostic factors that influence best-corrected visual acuity (BCVA) outcome in patients with secondary epiretinal membrane (ERM) after retinal detachment surgery.

DESIGN

Retrospective case series.

METHODS

Forty-two patients with ERM were divided into macula-on and macula-off groups based on the macular status before retinal detachment surgery and were studied using the same spectral-domain optical coherence tomography device. Several variables, including the integrity of the external limiting membrane (ELM), the status of the photoreceptor inner segment/outer segment (IS/OS) junction line, and central foveal thickness were evaluated in 17 treated and 25 untreated patients. Linear regression analysis was used to determine the best combination of all variables affecting BCVA.

RESULTS

Final BCVA was significantly better in macula-on and macula-off eyes with intact ELMs and IS/OS junction lines (0.35 ± 0.18 logarithm of the minimal angle of resolution [logMAR] and 0.51 ± 0.17 logMAR, respectively) than in macula-off eyes with disrupted or absent ELMs and IS/OS junction lines (0.83 ± 0.17 logMAR and 1.04 ± 0.05 logMAR, respectively; P < .001, analysis of variance). Final BCVA also was better in the treated group than in the controls (0.55 ± 0.31 logMAR and 0.73 ± 0.26 logMAR, respectively; P = .05, t test). ELM and IS/OS junction line integrity were the main variables significantly affecting the final BCVA outcome (β = 0.42; P = .006, linear regression analysis). Disruption of the ELM and IS/OS junction line was observed in 21 of the 42 cases studied.

CONCLUSIONS

ERM secondary to retinal detachment surgery is accompanied by a high incidence (50%) of IS/OS junction line and ELM disruption. Among the variables studied, the condition of the IS/OS junction layer and the ELM are the main factors that predict final BCVA after ERM peeling.

The significance of the external limiting membrane in the recovery of photoreceptor layer after successful macular hole closure: a study by spectral domain optical coherence tomography

PURPOSE

To evaluate the external limiting membrane (ELM) by spectral domain optical coherence tomography (SDOCT) and its correlation with the inner segment/outer segment (IS/OS) line in patients with successful macular hole surgery.

PROCEDURES

Forty-five eyes were divided into 3 groups according to the interval between surgery and first examination. In the first group the interval was between 6 and 12 months, in group 2 it was >12 months and ≤ 24 months, and in group 3 it was >24 months. The IS/OS and ELM of participants' eyes were postoperatively assessed using SDOCT in 2008 and 12 months later.

RESULTS

A statistically significant association between the integrity of the ELM and the IS/OS junction line was observed in postoperative examinations in all 3 groups. Eyes with a complete IS/OS junction line had an intact ELM. Between the first and the second examinations, a significant improvement in best-corrected visual acuity (BCVA) was noted only in group 1. A positive statistical association was also observed in group 1 between restoration of the IS/OS junction line and improvement in BCVA over follow-up.

CONCLUSIONS

The restoration of the IS/OS junction line is directly related to the integrity of the ELM.

Intravitreal administration of the anti-tumor necrosis factor agent infliximab for neovascular age-related macular degeneration

PURPOSE

To present our preliminary experience on intravitreal administration of an anti-tumor necrosis factor (TNF) monoclonal antibody for neovascular age-related macular degeneration (AMD).

DESIGN

Prospective, noncomparative series of 3 patients previously treated with an anti-vascular endothelial growth factor agent.

METHODS

Two intravitreal injections of 0.05 ml containing infliximab were administered in the first (1 and 2 mg, 2 months apart), second (2 mg each, 2 months apart), and third patient (2 mg each, 3 months apart). Best-corrected visual acuity (BCVA) and central foveal thickness (CFT) were monthly assessed for up to 7 months.

RESULTS

In the first patient, BCVA increased from 20/200 to 20/100 and CFT decreased from 462 to 386 microm, 2 months after the first injection. The condition was further improved after the second injection (BCVA, 20/40; CFT, 210 microm), but recurrence occurred 7 months post-baseline. In the second patient, BCVA increased from 20/200 to 20/70 and CFT decreased from 512 to 420 and 184 microm, 2 and 4 months post-baseline, respectively. In the third patient, clinical improvement was documented after the first injection. A second injection attributable to recurrence resulted in improvement of BCVA from 20/100 to 20/30 and decrease of CFT from 388 to 282 microm, 2 months after the second injection.

CONCLUSIONS

These findings, although insufficient to consider "off-label" treatment with intravitreal infliximab, provide in vivo evidence of a pathogenetic link of locally produced and/or acting TNF to neovascular AMD. A randomized study of consecutive intravitreal injections of infliximab for AMD may be warranted.

Comparison of optical coherence tomography and scanning laser polarimetry in glaucoma, ocular hypertension, and suspected glaucoma

BACKGROUND AND OBJECTIVE

To compare the performance of the newest generation optical coherence topography (OCT) and scanning laser polarimetry with variable corneal compensation (SLP-VCC) in eyes with glaucoma, ocular hypertension, and suspected glaucoma.

PATIENTS AND METHODS

One eye each of 84 patients (30 with glaucoma, 26 with suspected glaucoma, and 28 with ocular hypertension) was included in the study. Retinal nerve fiber layer (RNFL) thickness was measured with both technologies and thickness parameters were compared in the three groups of eyes. The correspondence of RNFL thickness measurements with visual field function was also studied.

RESULTS

Average OCT-RNFL thickness was found to have a statistically significant difference between patients with glaucoma and either suspected glaucoma or ocular hypertension. A statistically significant correlation between the average RNFL thicknesses measured by the two different technologies was shown only in the glaucoma group. A significant correlation with visual field mean deviation was found for superior average RNFL thickness as measured by SLP and for nerve fiber indicator and average and inferior average RNFL thickness as measured by OCT in glaucomatous eyes. Regression analysis indicated nerve fiber indicator to be the most valuable factor in predicting mean deviation.

CONCLUSION

RNFL thickness measurements obtained with OCT and SLP-VCC correlate well only in eyes with more advanced glaucomatous damage. The nerve fiber indicator parameter derived by SLP correlated best with mean deviation.

Vitreous findings in optic disc pit maculopathy based on optical coherence tomography

BACKGROUND

To assess vitreous findings in optic disc pit maculopathy using Optical Coherence Tomography (OCT).

METHODS

Thirty-eight eyes of 38 patients (14-51 years of age) with macular detachment associated with optic disc pit maculopathy were included in the study. The patients were divided into two groups. In group 1, 16 eyes were studied by OCT at presentation and after surgical treatment. In group 2, 22 eyes were examined by OCT only after treatment. In both groups thorough vitreous examination was performed over the macula and the optic disc. All patients were operated by the macular buckling procedure.

RESULTS

Vitreous abnormalities were found in 28 out of 38 eyes (74%) of both groups. In group 1, 10 of the 16 eyes had vitreous traction on the macula at presentation. The traction started from the optic disc and terminated to the macula. The posterior hyaloid that exerted the traction between the points of adhesion at the optic disc and the macula had a course parallel to the retinal surface in 9 of the 10 cases. Postoperatively, vitreous traction on the macula was not found. Of the remaining 6 eyes 4 had complete or partial posterior vitreous detachment. In group 2, 8 eyes had vitreous strands over the optic disc and 5 eyes posterior vitreous detachment. In the remaining 9 cases no vitreous involvement was noticed.

CONCLUSIONS

OCT was able to detect vitreous abnormalities such as vitreomacular traction, vitreous strands over the optic disc and complete or partial posterior vitreous detachment associated with optic disc pit maculopathy. Our observations support the view that the abnormal vitreous over the macula and optic disc is likely to play a role in the development of macular elevation in cases with optic disc pit. Prospective OCT studies could further assist to better understand the role of vitreous in this disease.

Evolution of retinal pigment epithelium detachment after photodynamic therapy for choroidal neovascularization in age-related macular degeneration

PURPOSE

To report a case of pigment epithelium detachment (PED) which appeared after photodynamic therapy (PDT) and was followed up for 50 months.

METHODS

Case report.

RESULTS

A 71-year-old woman with occult choroidal neovascular membrane due to age-related macular degeneration (ARMD) developed PED 48 hours after PDT. The patient was studied with fluorescein angiography (FA) and optical coherence tomography (OCT). Fluorescein angiographic evidence of PED remained essentially unchanged during the follow-up period of 50 months. Although OCT initially gave clear evidence of PED, in the last 12 months of follow-up the PED appears to have resolved.

CONCLUSIONS

Photodynamic treatment could be involved in the occurrence of PED in occult choroidal neovascular membrane due to ARMD. In this particular case OCT could be considered since it offers useful information in the pretreatment and the post-treatment follow-up period.

Contrast sensitivity in amblyopia: the fellow eye of untreated and successfully treated amblyopes

PURPOSE

We sought to investigate contrast sensitivity on the fellow eyes of amblyopic and successfully treated amblyopic subjects.

METHODS

Contrast sensitivity was tested monocularly on both eyes of 48 amblyopic patients (mean age, 11.51 years) and of 22 successfully treated amblyopic subjects (visual acuity 20/20 in each eye; mean age, 11.22 years). Inclusion criteria were visual acuity in the amblyopic eye 20/40 or better (mild amblyopia) and 20/20 or better in the fellow eye, steady fixation, no signs of congenital, latent or manifest/latent nystagmus on clinical examination. Twenty normal subjects (20 eyes) were used as age-matched controls.

RESULTS

Contrast sensitivity functions from the fellow eye of the 48 amblyopic patients, even those who had never been treated with occlusion therapy before, were significantly decreased (P < 0.001) compared with control subjects. Both the previously amblyopic and the fellow eye of the 22 "cured" amblyopic subjects demonstrated significantly lower values (P < 0.001) compared with control patients.

CONCLUSIONS

We suggest that the nonamblyopic, "normal" eye of amblyopic patients behaves abnormally when evaluated for contrast sensitivity functions. Neither the previously amblyopic nor the fellow eyes of successfully treated subjects were comparable with controls. Occlusion therapy may not be implicated for depressed contrast sensitivity of the fellow eye in amblyopia. The assessment of contrast sensitivity can provide important information on the visual function and the influence of occlusion therapy in amblyopia.

Optical coherence tomography study of tilted optic disk associated with macular detachment

PURPOSE

To describe the macular findings by optical coherence tomography in both eyes of a patient with tilted optic disk and visual decrease.

METHODS

A 35-year-old woman with bilateral tilted optic disk and serous macular detachment was examined by slit-lamp biomicroscopy, fluorescein angiography, indocyanine green angiography and optical coherence tomography (OCT).

RESULTS

Fluorescein angiography demonstrated staining of the temporal rim of the staphyloma adjacent to the optic disk and hyperfluorescence of the diffuse pigmentary changes in the papillomacular area. Leakage points and serous macular detachment were not observed. The existing neurosensory detachment at the fovea became evident only by OCT.

CONCLUSIONS

The existence of subretinal fluid, which became evident only by OCT, supports the view that OCT could further contribute to the study of the asymptomatic pigmentary lesions of the macula that are present in 11% of eyes with tilted optic disk. The reason for the localized macular detachment remains unclear. Dysfunction of the retinal pigment epithelium (RPE) or leakage of the optic disk staphyloma rim could possibly explain the cause of fluid accumulation in the macula.

THE MACULAR BUCKLING PROCEDURE IN THE TREATMENT OF RETINAL DETACHMENT IN HIGHLY MYOPIC EYES WITH MACULAR HOLE AND POSTERIOR STAPHYLOMA

PURPOSE

To evaluate the long-term anatomical and functional results of the macular buckling procedure in myopic macular hole with retinal detachment and posterior staphyloma.

METHODS

Twenty-five consecutive highly myopic eyes with retinal detachment, macular hole, and posterior staphyloma, which were operated between February 1983 and April 1992, were retrospectively studied. The last examination was in June 2002. Follow-up of the 25 patients ranged from 10 years to 19 years (mean, 15 years). Macular buckling with an episcleral sponge was the initial and only procedure. In all operated eyes, anchoring of the sponge was away from the posterior pole. Best-corrected visual acuity was evaluated before and after surgery. The axial length of the eyeball was also measured by A-scan ultrasonography before treatment.

RESULTS

Twenty-two of 25 eyes were successfully treated with a single procedure. In the remaining three eyes, retinal reattachment was obtained after a second buckling operation, which was considered necessary due to loosing of the sponge fixation sutures in two cases and the location of the hole beside the buckle in one case. The mean overall visual acuity was improved after treatment.

CONCLUSIONS

The macular buckling procedure with anchoring of the sponge away from the posterior segment provided efficient scleral indentation of long duration for closure of the macular hole and retinal reattachment.

Evolution of a retinoma case in 21 years

A 35-year-old man was observed during a 21-year period with fundus color photography, fluorescein angiography, and B-scan ultrasonography for a presumed retinoma detected in his left eye during routine ophthalmoscopy in 1982. The patient was a carrier of the 13q14 retinoblastoma gene. His retinal lesion remained stable during the follow-up period without signs of malignant transformation. Retinomas are most commonly observed in patients with retinoblastoma and their relatives. In this case, none of the patient's parents, siblings, or children had evidence of a retinal tumor. Photographic documentation of the nonprogressive nature of this presumed retinoma is provided and demonstrates the absence of growth.

Optical coherence tomography appearance of "drusenoid" pigment epithelial detachment

A case of bilateral "drusenoid" pigment epithelial detachment that was studied with fundus fluorescein angiography and optical coherence tomography is described. Fundus fluorescein angiography depicted staining of the drusen without any sign of pooling of the dye, whereas optical coherence tomography displayed detachment of the retinal pigment epithelium. These findings remained unchanged during a 10-month period.

Optic nerve cyst associated with optic disk pits

PURPOSE

To report a case with two optic disk pits which were associated with an optic nerve cyst in the same eye.

METHODS

Observational case report.

RESULTS

A 47-year-old patient noted visual impairment in the right eye. On examination the best corrected visual acuity in the right eye was 20/80 and in the left eye was 20/20. Biomicroscopy revealed, in the right eye, a very pale optic disk with two optic disk pits without macular elevation. Magnetic resonance imaging (MRI) revealed a well circumscribed 6 x 6-mm(2) round cystic lesion within the right optic nerve sheath adjacent to the temporal aspect of the right optic nerve at its retrobulbar segment, which compressed and displaced the nerve.

CONCLUSIONS

In the case of an extremely pale optic disk with congenital pits and visual impairment without macular detachment, radiological examination is indicated in order to exclude the possibility of coexisting optic nerve anomalies.

Infliximab for chronic cystoid macular edema associated with uveitis

PURPOSE

To assess the efficacy of the anti-TNF monoclonal antibody infliximab in uveitis patients without clinically evident ocular inflammation and impaired visual acuity because of chronic cystoid macular edema (CME).

DESIGN

Prospective, noncomparative, interventional case series.

METHODS

Patients with refractory CME (14 eyes, mean duration of 14 months), associated with intermediate uveitis (n = 6), Adamantiades-Behcet disease (n = 2), adult-type vascular pseudotumor (n = 1), and HLAB27+-related uveitis (n = 1) received an intravenous infliximab infusion (5 mg/kg); five patients were retreated after 1 month.

RESULTS

Macular thickness, measured by ocular coherence tomography, was reduced from 428 +/- 138 microm to 219 +/- 51 microm at 2 months postbaseline (P = .0001), while visual acuity increased from 0.41 +/- 0.18 to 0.83 +/- 0.17 (P < .00001). Anatomic and functional improvement was sustained at 6 months in all. No ocular or extra-ocular side effects were noted.

CONCLUSION

These promising results suggest that TNF may play an important pathogenetic role in chronic CME, thus, a controlled trial is warranted.

Assessing hydroxychloroquine toxicity by the multifocal ERG

Twenty patients on Plaquenil treatment were evaluated for retinal toxicity using the (EOG) and the mfERG. Group 1 comprises 15 patients (30 eyes) with normal EOG. From these patients 11 (22 eyes) showed normal RRD of mfERG in area 1 and area 2. The rest four patients (8 eyes) the RRD were reduced. Six months after interruption of HC, the mfERG improved in three cases. Group 2 comprises 5 patients (10 eyes) with subnormal EOG. Four (8 eyes) of these showed a decrease of RRD of the mfERG in area 1 and 2. In the rest one (2 eyes) the RRD were normal. Six months after interruption of HC the mfERG and the EOG improved in 2 cases. These results postulate that the mfERG may be used as an alternative method, perhaps more sensitive, for the detection of the HC retinopathy and the follow up of the patients on hydroxychloroquine.

A preliminary assessment of macular function by MF-ERG in myopic eyes with CNV with complete response to photodynamic therapy

PURPOSE

To evaluate by multifocal electroretinogram (MF-ERG) macular function before and after photodynamic therapy (PDT) in myopic eyes with choroidal neovascularization (CNV).

PATIENTS AND METHODS

Ten eyes with classic subfoveal CNV due to pathologic myopia were studied with MF-ERG before and after PDT in order to evaluate the results of PDT with verteporfin. The post-treatment follow-up was 6 months. Visual acuity testing, ophthalmic examinations, fluorescein and indocyanine green angiograms, and MF-ERG recordings were used to evaluate the results of PDT with verteporfin. The post-treatment period was 6 months.

RESULTS

Before treatment, the electrical response densities in the foveal and perifoveal areas were apparently decreased in all patients. Six months after treatment, the mean retinal response densities in the same areas were found to be higher than before treatment.

CONCLUSIONS

MF-ERG evaluates objectively the macular function in myopic eyes with CNV. After successful PDT, the electrical activity of the foveal and parafoveal areas is higher than before treatment. This finding postulates the efficacy of PDT in the treatment of CNV.

Optical coherence tomography findings in the macula after treatment of rhegmatogenous retinal detachments with spared macula preoperatively

PURPOSE

To present the postoperative optical coherence tomography (OCT) findings of the macula in rhegmatogenous retinal detachment with spared macula preoperatively.

METHODS

Eleven of 46 patients who underwent surgery for rhegmatogenous retinal detachment had an uninvolved macula preoperatively. Scleral buckling without intravitreous gas injection was the operation used in all eyes. All 11 patients were examined before and after treatment with slit-lamp biomicroscopy, indirect ophthalmoscopy, fundus photography, fluorescein angiography, and OCT.

RESULTS

In 3 of the 11 patients with rhegmatogenous retinal detachment and uninvolved macula preoperatively, fluid was identified with OCT in the macula after successful treatment. OCT showed that the fluid gradually diminished and finally disappeared 5 to 7 months after the scleral buckling procedure. The fluid in the macula became visible with slit-lamp biomicroscopy in only one of the three patients.

CONCLUSION

Subretinal fluid in a preoperatively uninvolved macula can be found after successful treatment of rhegmatogenous retinal detachment. If the fluid is located in the fovea, the visual acuity decreases and does not reach the preoperative levels. OCT identifies the presence of fluid and contributes to the study of the fluid's evolution.

Retinal hemorrhage after photodynamic therapy in patients with subfoveal choroidal neovascularization caused by age-related macular degeneration

PURPOSE

To report the frequency and the evolution of the extensive retinal hemorrhages that can appear within 48 h after the application of photodynamic therapy.

METHODS

Two hundred and fifteen individual eyes of 194 consecutive patients with subfoveal choroidal neovascularization (CNV) due to age-related macular degeneration who underwent photodynamic treatment were included in the study. The visual acuity was measured before and after treatment. Color and red-free photographs were taken. Fluorescein angiography and optical coherence tomography (OCT) were also performed in order to describe the macular hemorrhages.

RESULTS

Four out of 215 eyes developed macular hemorrhage within 48 h after the photodynamic therapy. Before treatment one of the four patients had classic CNV, one predominantly classic and two patients occult CNV without any classic component. In all four cases, the hemorrhage after photodynamic therapy (PDT) was extensive, it extended beyond the arcades and it was not absorbed during the follow-up period, which ranged from 11 to 21 months. The greatest linear dimension of the hemorrhage was extremely high (>12,000 microm).

CONCLUSION

Extensive macular hemorrhage was observed in 1.86% of the studied cases. The hemorrhage was not related to the type of the CNV lesion before treatment. The size and the appearance of hemorrhage within 48 h after treatment support the view that the hemorrhage is a direct consequence of the photodynamic therapy and not related to the natural course of the disease.

Evaluation of successful macular hole surgery by optical coherence tomography and multifocal electroretinography

PURPOSE

To evaluate successful macular hole surgery using optical coherence tomography (OCT) and multifocal electroretinography (MFERG).

DESIGN

Interventional case series.

METHODS

In a prospective study, 20 eyes of 20 patients with successful surgery for stage II, III, or IV idiopathic macular hole were evaluated by best-corrected visual acuity (BCVA), ocular examination, OCT, and MFERG preoperatively and 1, 3, 6, and 12 months postoperatively. For statistical analysis, the paired t test and nonparametric methods were used, as well as the Spearman analysis.

RESULTS

Postoperatively, all 20 eyes of 20 patients had anatomic closure of the macular hole confirmed by OCT. The center of the fovea, measured by OCT from the retinal pigment epithelium to the inner retinal surface, had a mean +/- SD thickness of 116.5 +/- 30.9 microm (range, 68-175 microm) 1 year postoperatively. Best-corrected visual acuity significantly improved (preoperative mean +/- standard deviation [SD] value, 0.131 +/- 0.081 and 1 year postoperative mean +/- SD value, 0.407 +/- 0.193). Multifocal electroretinography values area 1 (0-2.8 degrees) and area 2 (2.8-9 degrees from the center of the fovea) significantly improved (preoperative mean +/- SD values 3.10 +/- 1.334 nV/deg(2) and 3.573 +/- 1.545 nV/deg(2), respectively, and 1 year postoperative +/- SD mean values, 5.53 +/- 1.208 nV/deg(2) and 4.748 +/- 1.404 nV/deg(2), respectively). The thickness of the fovea, measured by OCT, significantly correlated with the BCVA 1 year postoperatively. One year postoperative MFERG values areas 1 and 2 were not correlated with 12-month BCVA and OCT findings.

CONCLUSIONS

Twelve months postoperatively BCVA and MFERG values significantly improved in this series of eyes with successful macular hole surgery. Optical coherence tomography findings were correlated to BCVA, but MFERG values were not correlated to BCVA and OCT findings, 1 year postoperatively.

Retinal disorders in preeclampsia studied with optical coherence tomography

PURPOSE

To report optical coherence tomography (OCT) of retinal disorders in preeclampsia.

DESIGN

Observational case report.

METHODS

A 24-year-old woman developed hypertension (190/100 mm Hg), proteinuria, and generalized edema in the 34th week of pregnancy. Soon after undergoing a cesarean section, she noted severe impairment of vision in both eyes.

RESULTS

Ten days after delivery, OCT showed a diffuse intraretinal edema that was still present but in a minor degree 2 months later. Eight months after delivery, macular edema had resolved, but the highly reflective band of retinal pigment epithelium (RPE) and choriocapillaris was thickened with focal elevations corresponding to the Elschnig spots.

CONCLUSION

In the acute phase of preeclampsia, OCT revealed a diffuse increase in macular thickness. Two months after delivery, macular edema still existed but in a minor degree. Eight months after the first examination, OCT depicted restoration of the contour of the fovea. Moreover, OCT showed the characteristic RPE focal elevations and abnormalities corresponding to the Elschnig spots.

Optical coherence tomography in optic disk pit maculopathy treated by the macular buckling procedure

PURPOSE

To report optical coherence tomography in optic disk pit maculopathy treated with macular scleral buckling procedure.

METHODS

Twenty six eyes (26 patients) with optic disk pit maculopathy were treated with macular buckling procedure and evaluated with optical coherence tomography. In group 1, five eyes were evaluated with optical coherence tomography before and after macular buckling procedure. In group 2, 21 eyes were evaluated with optical coherence tomography after macular buckling procedure. With optical coherence tomography, cross-sectional, horizontal retinal images were obtained through the fovea and optic disk pit.

RESULTS

In group 1, four of five eyes showed absorption of intraretinal fluid 7 to 9 months after macular buckling procedure. After absorption of fluid, retinal thickness in the foveal center ranged from 128 to 178 microm. In one eye the channel from optic disk to fovea reopened and fluid reappeared. In group 2, 20 of 21 eyes showed absorption of intraretinal schisis and subretinal fluid after macular buckling procedure. After absorption of fluid, retinal thickness in the foveal center ranged from 119 to 216 microm.

CONCLUSIONS

In optic disk pit maculopathy, optical coherence tomography enabled morphologic assessment of the retina before and after macular buckling procedure. In the successfully treated cases the permanent closure of the connection between the optic disk pit and the intraretinal schisis was demonstrated. Eventual disappearance of schisis and subretinal fluid was depicted. It was also proved that the thickness of the macula returned to normal and visual acuity improved.

Hemostatic effects of SF6 after diabetic vitrectomy for vitreous hemorrhage

PURPOSE

To investigate the hemostatic effects of SF6 gas in preventing postoperative vitreous hemorrhage in diabetic vitrectomy.

METHODS

A prospective, randomized study of 33 diabetic eyes with vitreous hemorrhage, treated by vitrectomy. In 17 of our cases SF6 20% was injected into the eye at the end of the operation, while in 16 cases BSS remained in the vitreous cavity.

RESULTS

The incidence of vitreous hemorrhage recurrence was 17.6% for the SF6 group and 12.5% for the BSS group (statistically not significant). Progression of lens opacities was observed in 23.5% of the SF6 group, and in 18.8% of the BSS group (statistically not significant, with a higher incidence in the SF6 group).

CONCLUSIONS

SF6 gas did not show hemostatic effects in the cases studied. Furthermore, it may have contributed to cataract progression. Therefore we suggest that the use of SF6 is not recommended as a treatment modality in preventing new vitreous hemorrhage after diabetic vitrectomy.

Recurrent vitreous hemorrhages due to combined pigment epithelial and retinal hamartoma: natural course and indocyanine green angiographic findings

We report the clinical and angiographic features as well as the natural course of an optic disk and juxtapapillary combined pigment epithelial and retinal hamartoma in a 23-year-old white girl. The patient presented 3 episodes of recurrent vitreous hemorrhages in the first 4 years of follow-up, which were spontaneously and totally absorbed. During the last 6 years, she was absolutely free of any ocular symptom. The tumor did not show any growth during the 10 years of follow-up. The digital indocyanine green angiography, which was normal in the early frames, revealed a mild, patchy hyperfluorescence corresponding to the tumor location in the late phase.

Combined clear cornea phacoemulsification and trabecular aspiration in the treatment of pseudoexfoliative glaucoma associated with cataract

BACKGROUND

In the present prospective randomized study the effectiveness and safety of trabecular aspiration combined with clear cornea phacoemulsification (phaco) was compared to clear cornea phaco alone in patients with pseudoexfoliation (PEX) glaucoma and visually disabling cataract.

METHODS

Twenty-seven patients suffering from visually significant cataract (visual acuity < 5 Snellen lines) and PEX glaucoma were randomly assigned to either phaco combined with trabecular aspiration (14 eyes of 14 patients) or phaco alone (13 eyes of 13 patients). Inclusion criteria for glaucoma were IOP < or = 22 mmHg under treatment with up to two antiglaucomatous agents, excluding pilocarpine 4%, and no previous surgery or laser trabeculoplasty treatment. Clear cornea phaco with foldable acrylic intraocular lens (IOL) implantation was carried out in all patients uneventfully. Trabecular aspiration was performed using a special probe in the inferior 180 deg of the angle after IOL implantation.

RESULTS

Follow-up duration ranged from 12 to 18 months. In the combined procedure group there was a statistically significant decrease in postoperative IOP during the whole follow-up period (P < 0.01), while in 9 of the 14 patients the IOP was controlled without medications at the last examination. In the phaco alone group a statistically significant decrease in postoperative IOP was recorded at 9 and 12 months after surgery (P < 0.05), while in 4 of the 13 patients the IOP was controlled without medications at the last examination. Comparing the two groups, a statistically significantly lower number of medications was being used in the combined procedure group at the last recorded examination (P < 0.05).

CONCLUSIONS

It seems that the combined clear cornea phaco and trabecular aspiration procedure in cases of PEX glaucoma associated with cataract is a safe and effective method. This technique controls IOP more effectively and with fewer postoperative medications than clear cornea phaco alone.

Cystoid macular edema in a patient with acquired immunodeficiency syndrome and past ocular history of cytomegalovirus retinitis after initiation of protease inhibitors

PURPOSE

To describe a patient with acquired immunodeficiency syndrome (AIDS) who presented with cystoid macular edema (CME) which was not associated with active cytomegalovirus (CMV) retinitis or AIDS-related microvasculopathy.

METHOD

A 32-year-old man with AIDS and a past ocular history of inactive CMV retinitis was placed on protease inhibitors when his CD4+ T lymphocyte counts dropped to 8 cells/mm3. Three months later, after his CD4+ T lymphocyte counts had increased to 196 cells/mm3 he complained of micropsia and metamorphopsia in his right eye of 1 week duration. The patient had a complete ocular examination including fluorescein angiography (FA).

RESULTS

Visual acuity (VA) was 7/10 OD. Fundus examination revealed CME and inactive CMV retinitis, and FA demonstrated CME and a hot disc. Two transseptal injections of corticosteroids were administered 2 weeks apart in the right eye as treatment of the CME. The patient reported gradual visual improvement and 6 weeks later, his VA was 10/10(-2). CME had resolved clinically and angiographically.

CONCLUSIONS

CME in our case is associated with inactive CMV retinitis and gradually increasing number of CD4+ T lymphocytes after initiation of treatment with protease inhibitors. It may be amenable to regional administration of corticosteroids without reactivation of retinitis.

Cyst formation in optic disc pit maculopathy

PURPOSE

To evaluate the presence and the evolution of cyst formation in optic disc pit maculopathy.

METHODS

In this prospective study, 18 cases with optic disc pit maculopathy were studied. Five of them showed cyst formation in the fovea at the initial examination. The fundus findings were documented with slit-lamp biomicroscopy, indirect ophthalmoscopy, and stereoscopic photography of the posterior pole. All 5 patients were treated with a macular scleral buckle procedure.

RESULTS

The presence of cysts in the elevated macula depends on the grade of the disease. Cyst formation can develop not only in the later stage of the disease but also quite early. In all 5 patients cyst formation gradually decreased and finally disappeared after the surgical procedure.

CONCLUSIONS

Cyst formation is an entity which accompanies the macular detachment associated with optic disc pit. The development of the cysts has been noticed after the establishment of the schisis-like separation and before or in conjunction with the formation of a lamellar macular hole which usually accompanies the optic disc pit maculopathy.

The macular buckling technique in the treatment of optic disk pit maculopathy

In 1988 we introduced the macular buckling procedure for the treatment of optic disk pit maculopathy and we have been applying it since then. The surgery consists of a scleral sponge fixation of 7.5 x 5.5 mm at the posterior pole of the globe corresponding to the macula along the vertical axis of the 12 to 6 o'clock meridian. No additional treatment of any kind (laser, diathermy, or cryotherapy) is used. The correct positioning of the sponge during the surgery is monitored by B-scan ultrasonography. Within the first week after surgery, indocyanine green angiography (ICG) is used to evaluate the choroidal circulation. During the same period, magnetic resonance imaging (MRI) of the orbit is performed to determine the sponge position in relation to the optic nerve. We analyze the results of 23 eyes with optic disk pit maculopathy that underwent surgery with the macular buckling technique between November 1988 and December 1998. In 20 of them the macula and the surrounding area of the retina became completely flat. No recurrence was noted in the successfully treated patients in the follow-up period, which ranged from 9 months to 10 years. Visual acuity was improved by 1 to 7 Snellen lines in 18 of the 23 patients. An improvement in visual field indices was also recorded. The sponge positioning between the temporal part of the optic disk and the macula acts mechanically and seems to provide a barrier that prevents the flow of the fluid from the pit toward the macula.

Optical coherence tomography in the study of the Goldmann-Favre syndrome

PURPOSE

To report a case of Goldmann-Favre syndrome with special emphasis on the optical coherence tomography findings.

METHODS

In a 23-year-old white man with an 8-year history of visual impairment in both eyes and night blindness, vertical and horizontal optical coherence tomography images were obtained through the macula and through the retinoschisis located at the temporal side of the macula.

RESULTS

Optical coherence tomography showed in the left eye a clear loss of the inner retinal layer at the fovea and the formation of inner and outer retinal layer holes in the temporally located retinoschisis. The outer retinal layer hole had rolled edges.

CONCLUSION

In Goldmann-Favre syndrome, optical coherence tomography demonstrated confluent macular cystoid changes and retinoschisis in both eyes. In the left eye, a lamellar macular hole and retinoschisis with inner retinal layer and outer retinal layer holes were observed. The outer retinal layer hole had rolled edges.

Visual field improvement after treatment of optic disk pit maculopathy with the macular buckling procedure

PURPOSE

To evaluate visual field changes in 18 of 21 patients with unilateral optic disk pit maculopathy who were successfully treated with the macular buckling procedure.

METHODS

In this prospective study, visual field examination with the Humphrey analyzer (programs 30-2 and 10-2) was recorded before treatment, repeated 1 month after the operation, and repeated every 6 months thereafter. All 18 patients were treated with the macular buckling procedure. The operation consisted of fixation of a silastic sponge explant at the posterior pole corresponding to the macula.

RESULTS

In 18 eyes included in the study and successfully treated, an improvement in visual field indices was recorded. The mean deviation improved from -7.75+/-3.15 (program 30-2) and -10.19+/-3.66 (program 10-2) decibels before surgery to -6.25+/-2.61 (P<0.0001) and -8.56+/-3.13 (P<0.0001) decibels at the last examination, respectively. No additional visual field defect was induced in any of the 18 eyes after treatment. Also, the majority of the eyes (16/18) gained from 1 to 7 Snellen lines of visual acuity (P<0.0001).

CONCLUSION

Improvement of central and peripheral visual field (within 30 degrees of fixation) was recorded after the treatment of optic disk pit maculopathy with the macular buckling procedure. This technique seems to be effective for treatment of the disease with good anatomic and functional results.