A bullous variant of central serous chorioretinopathy treated with oral spironolactone

We report the case of a 39-year-old male patient who presented with visual loss in the right eye for 6 weeks. The best-corrected visual acuity was counting fingers in the right eye and 20/30 in the left eye. The fundus examination demonstrated a right retinal detachment inferiorly extending to the fovea and a left macular serous detachment. After multimodal imaging study, the patient was diagnosed as having a bullous variant of central serous chorioretinopathy and treated with oral spironolactone associated with adjuvant laser photocoagulation. The retinal changes resolved after 6 months. The final visual acuity was 20/20 in both eyes.

PARACENTRAL ACUTE MIDDLE MACULOPATHY AFTER AORTIC ANEURYSM REPAIR

PURPOSE

We report a case of paracentral acute middle maculopathy secondary to cholesterol embolization syndrome after an endovascular aortic aneurism repair (EVAR).

METHODS

Functional and anatomical damage was assessed by Snellen visual acuity, fundoscopy, and optical coherence tomography.

RESULTS

A 67-year-old man presented with sudden vision loss in the right eye for one day with concomitant livedo reticularis in both feet. His medical history included an abdominal EVAR repair three days before the symptoms. The best-corrected visual acuity was 20/40 in the right eye and 20/20 in the left eye. Fundoscopy showed intraarteriolar cholesterol plaques (Hollenhorst) bilaterally, and a localized retinal whitening in the right eye. Optical coherence tomography at the lesion site revealed a hyperreflective band on the level of inner nuclear layer. The patient was referred for imaging and complete systemic evaluation. He was then closely followed up by a vascular team, without additional intervention. Retinal stigma partially regressed at six months with visual improvement.

CONCLUSION

This case describes paracentral acute middle maculopathy as a rare ocular sign of cholesterol embolization in postoperative intraaortic operations. The diagnosis of this complication led to prompt clinical care with a multidisciplinary approach.

Scleral wound healing with cross-link technique using riboflavin and ultraviolet A on rabbit eyes

Purpose

The aim of study was to evaluate the cross-link using riboflavin and ultraviolet A (UVA) for improving scleral wound healing.

Materials and methods

This was an experimental study involving four New Zealand rabbits (eight eyes). Therapy procedure was chosen for the right eye and control procedure for the left one. UVA irradiation of 365 nm with a surface irradiance of 3 mW/cm² and a photosensitizer of riboflavin drops were applied for 30 minutes on the right eye at 2 mm from the limbus. Sclerotomy incision was performed at 2 mm from the limbus in both right (on the cross-link-treated area) and left eye. Then, 30 days after surgery, a morphological analysis and histological staining with hematoxylin–eosin and picrosirius red were performed, and the sclerotomy cicatrization of right and left eyes was compared. The variables investigated were as follows: sclerotomy incision pictures and measurements were made using the ImageJ Software. Scleral thickness was measured (employing the anterior optical coherence tomography and the digital caliper). Collagen fiber density stained with picrosirius red staining was measured using the Image Pro Plus software.

Results

The morphological analysis showed that in all samples, the right eye presented sclerotomy closure, and in two eyes, among them, there were no visible edges of the sclerotomies incision. The left eye presented sclerotomy closure and incision edges. The Image Pro demonstrated a higher density of collagen fibers in the right eye when compared to the one. The statistical analysis was significant when compared to the collagen fiber density in the treated eyes with the control eyes.

Conclusion

The cross-link procedure resulted in a better sclerotomy wound healing.

Endothelial analysis in patients having corneal intrastromal surgery with Cornealring for correction of Keratoconus

PURPOSE

Evaluate corneal endothelium by means of specular microscopy exam in patients with Keratoconus, before and after Cornealring® corneal intrastromal ring surgery.

METHODS

One hundred and two eyes of 67 patients, aged between 12 and 45, with the average age of 27.31 ± 8.15 years, 30 females and 37 males, were selected to be submitted to the implant of Cornealring® corneal ring segments in pre- and post-surgery (six months after the procedure) in the External Diseases and Cornea Ward of the Instituto Panamericano da Visão.

RESULTS

Of the 102 eyes treated, only those that received two rings of equal thickness up to 250 µ showed statistical significance between the initial and final mean number of endothelial cells (P = 0.008), a decrease of 10.1% in the mean coefficient of variation (P = 0.003), and a 9.75% decrease in initial and final hexagonal cell counts. The other eyes receiving rings of other thicknesses showed no statistically significant differences between the mean initial and final SM examinations.

CONCLUSION

A longer segment is necessary for the confirmation or not of the alterations found in this study, particularly regarding the thickness of the ring used, because with the new technologies and the improvement in the result of deep lamellar transplantation, the decrease in the cell count might represent a problem in the indication of this procedure following thick corneal ring implants.

DFPE, partially fluorinated ether: a novel approach for experimental intravitreal tamponade

PURPOSE

To evaluate decafluoro-di-n-pentyl ether (DFPE) as a vitreous tamponade by examining ocular tolerance in rabbits' eyes.

METHODS

Thirteen rabbits were divided into 4 groups after mechanical vitrectomy and were followed up to 12 months. The tamponade remained in the eye for 6 months in group 1 (DFPE) and Group 3 (DFPE and silicone oil) and for 12 months in group 2 (DFPE). Group 4 served as control.

RESULTS

In groups 1, 2, and 3, dispersion of the fluid appeared 2 weeks postoperatively. Posterior subcapsular cataracts appeared in rabbits' eyes with large fills of DFPE (>50%). Histologic findings in groups 1 and 2 showed no detectable change in outer nuclear layer thickness. Except for some vacuolations, the inner retina was well preserved in all injected rabbits' eyes. On the electroretinography of injected rabbits' eyes, there was no effect on the a wave amplitude and b wave implicit time, but the b wave amplitude was elevated with statistical significance (P < 0.001) at 1, 3, and 6 months postoperatively but with no statistical significance (P > 0.05) after that period when compared with group 4 and unoperated fellow rabbits' eyes of each group.

CONCLUSION

Decafluoro-di-n-pentyl ether demonstrated minimum adverse effects in retinal rabbits; further studies are needed before clinical use as short-term tamponade.

Comparison of optical aberrations and contrast sensitivity between aspheric and spherical intraocular lenses

PURPOSE

To compare visual acuity, aberrometry, and contrast sensitivity in patients who had a spherical intraocular lens (IOL) (SoFlex SE, Bausch & Lomb) implanted in one eye and an aspheric IOL (SofPort AO, Bausch & Lomb) implanted in the fellow eye during uncomplicated cataract surgery.

METHODS

A prospective, multicenter, double-blind study was performed. Forty patients (80 eyes) underwent bilateral phacoemulsification with implantation of a spherical IOL in one eye and an aspheric IOL in the fellow eye. Postoperatively, visual acuity, aberrometry, and contrast sensitivity tests were performed. Statistical analyses were performed using Student t and Wilcoxon tests, and mixed effects were used for each contrast condition situation.

RESULTS

Thirty-nine patients (30 women, 9 men; 78 eyes) with a mean age of 69.3±6.17 years (range: 51 to 82 years) completed the study. No statistical differences were found regarding visual acuity among eyes. Lower levels of higher order aberrations were achieved in the aspheric group. No statistical difference between groups under photopic conditions was noted. In low spatial frequencies, better performance was observed with the aspheric IOL under mesopic conditions. In high spatial frequencies, the spherical IOL produced better quality of vision. Comparing mesopic conditions with glare, visual performance was statistically better using the aspheric IOL.

CONCLUSIONS

Cataract surgery results cannot be measured by means of visual acuity alone. Quality of vision must be considered, and implantation of IOLs with low levels of spherical aberrations and better contrast sensitivity are preferred. In this study, the aspheric IOL demonstrated better visual function, especially at night, when compared with spherical IOLs.

Comparing the measurement of diurnal fluctuations in intraocular pressure in the same day versus over different days in glaucoma

PURPOSE

To compare the measurement of diurnal fluctuations in intraocular pressure (IOP) in the same day versus over different days in primary open-angle glaucoma.

METHODS

Twenty-five eyes from 25 patients with primary open-angle glaucoma were submitted to a diurnal curve on the same day, 5 measurements, 2.5 hours apart, from 8:00 am to 6:00 pm. For the measurements on different days, we randomly selected one time point from the diurnal curve for each patient. All patients were then instructed to return every 3-7 days to complete all 5 measurements. The maximum, minimum, and IOP fluctuation were compared between the 2 methods.

RESULTS

The IOP fluctuation (maximum-minimum) was similar when we measured the IOP on different days (5.0+/-2.6 mmHg vs 4.0+/-1.2 mmHg, p=0.08). There was no difference regarding the minimum or maximum IOP assessed in the diurnal curve or over different days. There was a high correlation for the maximum IOP (r=0.863, p<0.001) and the minimum IOP (r=0.708, p<0.001) by either method of measuring during the same day or different days, as well as for all measurements (8:00 am: r=0.718, p<0.001; 10:30 am: r=0.479, p=0.01; 1:00 pm: r=0.628, p=0.001; 3:30 pm: r=0.757, p<0.001; and 6:00 pm: r=0.910, p<0.001).

CONCLUSIONS

IOP fluctuation in primary open-angle glaucoma can be assessed using IOP measures on different days, at different time points, which strongly correlate to a diurnal curve.

[Brainstem anesthesia after extraconal retrobulbar block: can it be avoided? Case report]

BACKGROUND AND OBJECTIVES

The CEROF-HC is a public hospital specialized in ophthalmology. Anesthetic blocks for ophthalmic surgeries are common and effective. But the technique is not devoid of risks, and there is the possibility of meningeal perforation and injection of the local anesthetic (LA) in the central nervous system (CNS). The objective of this study was to report a case of brainstem anesthesia as a complication of the ophthalmologic regional anesthesia, stress the importance of preventing this accident, and discuss the treatment.

CASE REPORT

A female patient, 60 years old, ASA II, with a diagnosis of grade II cataract, was scheduled for a facectomy and implantation of intraocular lens in the right eye. The patient had a past medical history of hypertension and vitrectomy. Physical exam, laboratory and cardiologic exams were normal. An extraconal retrobulbar block was performed with local anesthetic (lidocaine and bupivacaine) and hyaluronidase (total volume of 5 mL). Immediately after, the patient developed apnea and loss of consciousness. She was treated with tracheal intubation and mechanical ventilation, remaining stable. The surgery was performed as planned. Thirty minutes after the intubation, the patient began to move, recovering completely, without deficits.

CONCLUSIONS

Although safe, ophthalmic block is not devoid of risks. The main risk factor is improper anesthetic technique. In the ophthalmic block, the local anesthetic (LA) can reach the CNS by inadvertently puncturing the ophthalmic artery or the meninges that surround the optic nerve, with dispersion to the subarachnoid space. Although rare, it can lead to a severe complication with respiratory arrest that can be fatal if it is not diagnosed promptly. Here we present the possibilities of such a complication, and discuss the nomenclature of anesthetic blocks used in ophthalmology. The importance of the knowledge of this and other complications by the surgical team is paramount, as well as the preparation and adequate monitoring to diagnose and treat immediately this complication to minimize the risks to the patient.

Quality of life in glaucoma patients: Regression analysis and correlation with possible modifiers

PURPOSE

To verify the quality of life in a Brazilian glaucoma population and the influence of possible modifiers (e.g., visual acuity, visual field impairment).

METHODS

Forty-five consecutive patients from CEROF - Federal University of Goias, Brazil were included prospectively in the study. The quality of life was assessed using the Portuguese version of the VFQ. Possible modifiers were evaluated, initially separately with the Spearman's Correlation and then together in a regression model.

RESULTS

The mean age was 59.6 +/- 12.4 years. The mean quality of life score was 79 +/- 15 (range 45-100). Age (r = -0.402, p = 0.006), visual acuity in the better eye (r = -0.497, p = 0.001) and in the worse eye (r = -0.608, p < 0.001), Hodapp-Parrish-Anderson visual field grading scale in the better (r = -0.353, p = 0.01) and worse eye (r = -0.387, p = 0.009), visual field Mean Deviation (MD) in the better (r = 0.355, p = 0.01) and worse eye (r = 0.320, p = 0.04) and ability to perform a visual field test in both eyes (r = -0.397, p = 0.007) were significantly correlated with the quality of life scores. However, only age (younger, better quality of life, p = 0.008) and visual acuity in the better eye (direct relation, p = 0.04) were significant in the regression model (r = 0.633, r(2) = 0.401).

CONCLUSIONS

The VFQ may be a useful tool to assess the quality of life in glaucoma patients. The preliminary results indicate that age and visual acuity in the better eye are the main factors related to the quality of life in these patients.

A randomized, investigator-masked, 4-week study comparing timolol maleate 0.5%, brinzolamide 1%, and brimonidine tartrate 0.2% as adjunctive therapies to travoprost 0.004% in adults with primary open-angle glaucoma or ocular hypertension

OBJECTIVE

The objective of this study was to assess the hypotensive efficacy of timolol maleate 0.5%, brinzolamide 1%, or brimonidine tartrate 0.2% ophthalmic solution, administered in conjunction with travoprost 0.004%, in patients with primary open-angle laucoma (OAG) or ocular hypertension (OHT) whose intraocular pressure (IOP) did not meet the treatment target using travoprost 0.004% monotherapy.

METHODS

This was a randomized, comparative, investigator-masked study. Patients with OAG or OHT treated with travoprost 0.004% monotherapy were randomized to receive 1 of the 3 adjunctive therapies (timolol maleate 0.5%, brinzolamide 1%, or brimonidine tartrate 0.2%), 1 drop BID in each randomized eye, in addition to 1 drop QD of travoprost for a period of 4 weeks. IOP was measured on days 0 (travoprost 0.004%) and 28 (travoprost 0.004% and adjunctive treatment). Adverse events were monitored on days 0 and 28 by patient interview.

RESULTS

Twenty-nine patients with OAG (46 eyes) and 3 patients with OHT (6 eyes), with a total of 52 eligible eyes, completed the study; 28 eyes were from male patients and 24 were from female patients. In addition to continuing travoprost treatment, 20 eyes received timolol, 16 eyes received brinzolamide, and 16 eyes were treated with brimonidine. There were no significant differences among the groups in the mean (SD) IOP at baseline on day 0 (19.0 [4.1], 17.2 [3.5], and 17.0 [3.1] mm Hg, respectively; P=NS). On day 28, the reduction in mean (SD) IOP in eyes treated with brimonidine tartrate 0.2% was significantly smaller (2.3 [1.8] mm Hg vs 3.9 [1.8] mm Hg [P=0.01]) and the mean (SD) percentage reduction in IOP was significantly smaller (13.4% [9.1%] vs 20.2% [7.5%] [P=0.01]) when compared with timolol maleate 0.5%, and likewise when compared with brinzolamide 1% (4.0 [2.1] mm Hg [P=0.02] and 22.7% [8.6%] [P=0.006], respectively). The group treated with brinzolamide was associated with a similar reduction in IOP to timolol (P=NS for both mean [SD] IOP and percentage reduction in IOP compared with timolol monotherapy). Barring the occasional conjunctival hyperemia, which was excluded as an adverse event for the purposes of this study, no adverse events were recorded.

CONCLUSION

Brinzolamide 1% and timolol maleate 0.5% treatment were both associated with a significantly greater reduction in IOP compared with brimonidine 0.2% when administered as a nonfixed adjuvant to travoprost 0.004% in the treatment of patients with OAG and OHT whose IOP was inadequately controlled with travoprost monotherapy. All treatments were well tolerated.

Efficacy of latanoprost or fixed-combination latanoprost-timolol in patients switched from a combination of timolol and a nonprostaglandin medication

PURPOSE

To compare latanoprost with the fixed-combination latanoprost-timolol in glaucoma or ocular hypertension patients switched from a combination glaucoma therapy with timolol and another nonprostaglandin medication.

DESIGN

Prospective randomized clinical trial.

METHODS

Glaucoma or ocular hypertension patients receiving a combined treatment of timolol 0.5% and another nonprostaglandin medication (pilocarpine 4%, alpha-agonist, or a topical carbonic anhydrase inhibitor) underwent a 30-day washout of their medications. A masked observer then measured their intraocular pressure (IOP). The subjects were randomized to either latanoprost or fixed-combination latanoprost-timolol eyedrops to use once daily at 7 am. The IOP was measured again 30 days after the patients started using one of the study drugs by the same examiner at the same time.

MAIN OUTCOME MEASURE

Comparison of the study medications' hypotensive effect.

RESULTS

Fifty-three eyes (28 in the latanoprost group and 25 in the latanoprost-timolol group) from 28 patients were included in the study. The IOP reduction was greater in both study groups compared with the previous combination therapy with timolol and another nonprostaglandin medication in millimeters of mercury (7.7+/-2.3 vs. 5.5+/-2.3, P<0.001, for the latanoprost group; 8.5+/-3.5 vs. 6.3+/-2.7, P<0.001, for the latanoprost-timolol group) and percentage (35.8+/-8.2% vs. 25.6+/-8.9%, P<0.001, for the latanoprost group; 38.6+/-8.7% vs. 28.6+/-9.0%, P<0.001, for the latanoprost-timolol group). There was no statistical difference between latanoprost and fixed-combination latanoprost-timolol in reducing IOP, in either millimeters of mercury (P = 0.3) or percentage (P = 0.2).

CONCLUSIONS

Both latanoprost and fixed-combination latanoprost-timolol may be viable substitutes for timolol and another nonprostaglandin medication in glaucoma or ocular hypertension patients.

A Prospective, Comparative Study between Endoscopic Cyclophotocoagulation and the Ahmed Drainage Implant in Refractory Glaucoma

PURPOSE

To compare endoscopic cyclophotocoagulation (ECP) and the Ahmed drainage implant in the treatment of refractory glaucoma.

METHODS

Sixty-eight eyes of 68 patients with refractory glaucoma were prospectively assigned to either ECP or Ahmed tube shunt implantation. All procedures were performed by a single surgeon. Eyes that were included were pseudophakic with a history of at least one trabeculectomy with antimetabolite, an intraocular pressure (IOP) equal to or above 35 mm Hg on maximum tolerated medical therapy, and a visual acuity better than light perception. Exclusion criteria included eyes that had had previous glaucoma drainage device implantation or a cyclodestructive procedure. Success was defined as an IOP more than 6 mm Hg and less than 21 mm Hg, with or without topical anti-hypertensive therapy.

RESULTS

The mean follow-up was 19.82 +/- 8.35 months and 21.29 +/- 6.42 months, for the Ahmed and ECP groups, respectively (P = 0.4). The preoperative IOP, 41.32 +/- 3.03 mm Hg (Ahmed) and 41.61 +/- 3.42 mm Hg (ECP) (P = 0.5), and the mean postoperative IOP, at 24 months follow-up, 14.73 +/- 6.44 mm Hg (Ahmed) and 14.07 +/- 7.21 mm Hg (ECP) (P = 0.7), were significantly different from baseline in both groups (P < 0.001). Kaplan-Meier survival curve analysis showed a probability of success at 24 months of 70.59% and 73.53% for the Ahmed and ECP groups, respectively (P = 0.7). Complications included choroidal detachment (Ahmed 17.64%, ECP 2.94%), shallow anterior chamber (Ahmed 17.64%, ECP 0.0%), and hyphema (Ahmed 14.7%, ECP 17.64%).

CONCLUSION

There was no difference in the success rate between the Ahmed Glaucoma Valve and ECP in refractory glaucoma. The eyes that underwent Ahmed tube shunt implantation had more complications than those treated with ECP.

Ibopamine provocative test and glaucoma: consideration of factors that may influence the examination

PURPOSE

To evaluate factors that may influence the ibopamine provocative test for the diagnosis of glaucoma.

METHODS

Two Ibopamine (3,4 di-isobutyrylester of N-methyldopamine) 2% eyedrops were instilled 5 minutes apart in one eye selected at random in both glaucoma and normal subjects. The intraocular pressure (IOP) was assessed prior to the drops and 30, 60 and 180 minutes after instillation. The test was considered positive when there was an IOP increase of greater than 4 mmHg at any one of the timepoints. The amount of IOP change was compared to the severity of glaucomatous visual field loss and to the types of medical treatment.

RESULTS

The sensitivity (glaucoma patients with a positive result) and specificity (normal individuals with a negative result) of the Ibopamine test was 87 and 95%, respectively. Glaucoma patients using prostaglandin analogues did not have a significant IOP elevation.

CONCLUSION

The Ibopamine provocative test may be an auxiliary test in glaucoma diagnosis. Concurrent use of prostaglandin analogues reduces the test's sensitivity.

Interventions in pseudophakic rhegmatogenous retinal detachment

With refinement of vitrectomy techniques over the past 30 years, the treatment of rhegmatogenous retinal detachment (RRD) has transitioned from the almost exclusive use of extraocular techniques to the present time in which intraocular interventions are available and, in some practices, enjoy almost exclusive use for primary repair of RRD. Except for those situations in which a retinal detachment is associated with obvious immediate complications related to the cataract surgery, the considerations for the treatment of pseudophakic RRD are quite similar to those of phakic RRD. The current options are: use of an extraocular buckling device, vitrectomy-related procedures, intraocular gas injection with associated retinopexy, and combinations of these. Disagreement on the ideal intervention for pseudophakic retinal detachment is not uncommon and particularly so in those RRDs which lie somewhere in the spectrum between complex and simple. As is so often the case in the surgical treatment of disease, there may not be one ideal technique for a particular type of RRD; but knowledge of alternatives logically increases the likelihood of a successful result. The goal of this paper is to outline the clinical factors shown to be of importance in deciding which technique will have the greatest chance at not only achieving retinal re-attachment but also in optimizing long-term vision.

Identifying live nematodes in diffuse unilateral subacute neuroretinitis by using the scanning laser ophthalmoscope

OBJECTIVE

To describe use of the scanning laser ophthalmoscope (SLO) to identify live nematodes in patients with diffuse unilateral subacute neuroretinitis.

METHODS

Infrared, red, and blue illumination (780, 633, and 488 nm, respectively) in an SLO were used to image and evaluate functional retinal status in patients with late-stage diffuse unilateral subacute neuroretinitis. An examination to identify live nematodes was performed in the affected eyes.

RESULTS

Using blue illumination, the ocular fundus appeared dark and provided a high-contrast background for the white image of the worm. The red laser was used to perform red-on-red perimetry. We also used perimetry stimulus to stimulate the worm's movement and pinpoint its location. We precisely defined the relation between the fixation point and the worm to plan accurate laser treatment. The infrared laser is safe and comfortable for prolonged examination. Using the SLO, several physicians simultaneously visualized the ocular fundus. Video output from the SLO provided temporal information, excellent for enhancing detection of worms, which was displayed dynamically on video.

CONCLUSIONS

Although examination with a fundus contact lens by skilled ophthalmologists is the method of choice, the SLO provides a new examination modality with distinct advantages for identifying live worms in young patients with diffuse unilateral subacute neuroretinitis.

Biomicroscopic study of the vitreous in eyes with macular pucker after retinal detachment surgery

The posterior vitreous condition of 43 eyes with macular pucker following retinal detachment surgery was studied using the El Bayadi-Kajiura preset lens mounted on a slit lamp. The posterior vitreous was found to be attached in one eye (2%), completely detached in 29 eyes (68%), and partially detached with residual vitreoretinal adhesion to the macular area in 13 eyes (30%). Macular pucker with partial posterior vitreous detachment was significantly more frequent (P less than .05) in eyes with refractive errors of -4 diopters or less. That condition was also accompanied by a higher incidence of dye leakage in the macular area by fluorescein angiography, a shorter time lapse between retinal detachment surgery and development of macular pucker, and a worse visual outcome than was found in eyes with complete posterior vitreous detachment.

Photofield mapping in the evaluation and management of subretinal neovascularization

Photofield mapping is a useful method for classifying subretinal neovascularization based on its area and location. Careful central field mapping is performed to delineate scotomata during evaluation of patients with subretinal new vessels. A photofield map is then constructed by projecting 35 mm fundus photographs and angiograms onto an appropriately-oriented central visual field map. The composite map (photofield) documents the location and relationship of scotomata, subretinal neovascularization, foveal avascular zone, and retinal blood vessels. The areas of subretinal neovascularization and scotomata are measured in square millimeters with a planimeter. The distance between their closest edge and the center of the foveal avascular zone is measured in millimeters. This method permits quantitative comparison of results with different photocoagulation protocols and instrumentation. Such comparative analysis may help improve the technique and instrumentation used in laser photocoagulation of subretinal neovascularization.

Natural history of choroidal neovascularization in degenerative myopia

We studied 354 eyes with myopic chorioretinal degeneration by means of standard clinical evaluation and fluorescein angiography. The eyes were classified on the basis of the degree of chorioretinal degeneration found in the posterior pole. Lacquer cracks (breaks in Bruch's membrane) were noted in 82% of the 149 eyes with choroidal neovascular membranes (CNM) and in 96% of the 58 eyes with isolated subretinal hemorrhages. These hemorrhages were reabsorbed without adverse visual sequelae in 32 eyes that were followed; in 14 of these eyes that were followed closely, the average time of reabsorption was 6.4 weeks. Seventy eyes with CNM were followed for an average of 40.9 months. In 96% of these eyes the CNM remained stable or regressed, leaving an atrophic, nonexudative scar. This study indicates that CNM in degenerative myopia is usually self-limited.

Retinal pigment epithelium decompensation. I. Clinical features and natural course

We studied 97 eyes (73 patients) that showed a sharp contrast between the grossly normal appearance of the posterior pole by funduscopy and the fluorescein angiography findings of multiple patches of retinal pigment epithelium (RPE) transmission defect in the early transit, associated with focal areas of RPE staining in the late transit. The staining was located primarily at the superior edge of the RPE defect (63 eyes). The average age of the patients was 52.2 years at the time of diagnosis, and the ratio of men to women was 3.5 to 1. Ocular histories were unremarkable, except for 27 eyes with documented central serous retinopathy. Thirty-two consecutive eyes have been followed for an average of 3.9 years, and 30 of those eyes have shown visual deterioration.

Retinal pigment epithelium decompensation. II. Laser treatment

Forty-one of 97 eyes with retinal pigment epithelium decompensation (RPED) were treated with monochromatic green argon laser photocoagulation to the focal area of RPE staining detected in the late fluorescein transit. Nineteen eyes were treated because of progressive visual deterioration. The other 22 eyes already had visual acuities of 20/50 or worse. Vision stabilized or improved in 34 eyes (82.9%) after an average of 1.6 years following treatment, compared with improvement in only 5 of 56 untreated eyes after an average follow-up period of 2.1 years. After an average follow-up of 7.1 years, 12 of 97 eyes with RPED developed choroidal neovascularization (9 spontaneously and 3 after photocoagulation) in the area where late RPE staining had been observed.

A- and B-scan characteristics of shifting fluid level

A shifting fluid level (SFL) was detected by A- and B-scans in 155 eyes. All eyes had a hemorrhage into the vitreous. In 129 of the 155 eyes (83%) the vitreous hemorrhage resulted from proliferative diabetic retinopathy. In 11 (7%) and seven eyes (5%), respectively, the hemorrhage was a complication of closed vitrectomy and scleral buckling procedures. In eight eyes (5%), the hemorrhage resulted from severe penetrating ocular trauma. The SFL was characterized by a high-amplitude echo on A-scan, and straight horizontal or vertical linear echo on horizontal or vertical B-scan, respectively. It showed a typical shift toward the most posterior portion of the globe when the eye was moved in the different positions of gaze. The SFL was overlying the retina in 150 eyes (97%) and was suspected to be subretinal in five eyes (3%). SFL represented a layer of sedimented red blood cells on the surface of the retina or choroid.

Surgical treatments of proliferative vitreoretinopathy

Four hundred ten eyes with retinal detachment and proliferative vitreoretinopathy underwent closed vitrectomy with membrane peeling, scleral buckling, and intraocular air injection. The retina was reattached in 243 eyes (59.3%). Useful vision was attained in 223 eyes. The preoperative proliferative vitreoretinopathy was clinically graded in six groups of increasing severity (C-1, C-2, C-3, D-1, D-2, D-3). From grades C-2 to D-3, a significant trend related a decreased rate of retinal reattachment with increased severity. However, grade C-1 showed a significantly lower success rate than did grade C-2. Scleral buckling alone may be the treatment of choice in grade C-1 eyes. Grade D-3 eyes had the worst anatomic and functional results. Preoperatively, there was a significant relationship between increasing severity of proliferative vitreoretinopathy and frequency of aphakia, and aphakic eyes showed a significantly lower rate of retinal reattachment than did phakic eyes.

Negative-lens field expander for patients with concentric field constriction

An oversized, negative-power spectacle lens may be used as a field expander to improve mobility and general orientation ability of patients with peripheral field loss but intact central vision. The device is inexpensive and simple to use for brief spotting periods.

Chronic macular edema in retinal branch vein occlusion: role of laser photocoagulation

We used the monochromatic green argon laser to treat 41 eyes with retinal branch vein occlusion (RBVO) and decreased vision because of chronic macular edema of at least six months duration after the onset of RBVO. The average follow-up period after treatment was 19 months. Cystoid macular edema (CME) occurred in 34 eyes and noncystoid macular edema in seven eyes. In eyes with chronic CME we decreased intracapillary pressure in the portion of the macula drained by the occluded vein by segmental retinal arteriolar narrowing using photocoagulation to the retinal arterioles that perfused the involved portion of the macula. Partial or complete resolution of macular edema occurred in 27 eyes. Vision improved in 19 eyes and was stabilized in seven eyes. In eyes with chronic noncystoid macular edema treatment consisted of focal closure of leaking microaneurysms and retinal telangiectasias with photocoagulation. Closure of these leaking vessels associated with partial or complete resorption of hard exudates that had accumulated in the macula secondary to the leakage occurred in six of the seven photocoagulated eyes. Vision improved in four eyes and was stabilized in two eyes.

Role of the vitreous in cystoid macular edema

Eyes suffering from various conditions, such as aphakia, diabetic retinopathy, peripheral uveitis, branch vein occlusion, or retinitis pigmentosa, are predisposed to vitreous detachment. When vitreous detachment occurs, the vitreous can remain attached to the macula due to a firm vitreomacular adhesion. This partial posterior vitreous detachment associated with continuous vitreous traction to the macular area can lead to the development of cystoid macular edema. Two types of vitreous traction have been observed: traction with narrow vitreous strand and traction with broad vitreoretinal adhesion. It has been postulated that the posterior vitreous can cause cystoid macular edema by vitreous contraction without vitreous detachment, producing tractional forces at sites of firm vitreoretinal adhesions that are located at the optic disc and macula. Cystoid macular edema is often accompanied by leakage from dilated retinal capillaries at the optic disc.

Immersion A- and B-scan ultrasonography. Its use in preoperative evaluation of diabetic vitreous hemorrhage

Immersion A- and B-scan ultrasonography was performed before vitreous surgery in 256 eyes with diabetic vitreous hemorrhage. Of 32 eyes with vitreous hemorrhage without vitreous traction (group 1), 28 (88%) showed useful postoperative vision. Of 87 eyes with vitreous traction without tractional retinal detachment (group 2), 69 (79%) had useful postoperative vision. Eyes with tractional retinal detachments were classified as follows: X-shaped detachment with narrow vitreoretinal adhesions (group 3, 75 eyes), and H-shaped detachment with broad vitreoretinal adhesions (group 4, 62 eyes). Useful postoperative vision returned in 43 eyes in group 3 (57%) and in only 14 eyes in group 4 (23%), a statistically significant difference. Visual improvement was greater in groups 1 and 2 than in groups 3 and 4. Postoperative functional results were worse when the macular area was the site of vitreoretinal adhesion and traction.

Bilateral choroidal osteoma with subretinal neovascularization

Choroidal osteoma is a rare entity, reported previously mainly in females. We report a case of bilateral choroidal osteoma in a 15-year-old boy. Ultrasonography and computerized tomography findings were key to establishing the diagnosis. During two years' follow-up, there was observable growth in the tumor size. Leakage from subretinal neovascular tufts covering the tumor caused visual deterioration. Photocoagulation of the subretinal new vessels was performed twice, with limited success, but the value of this treatment in choroidal osteomas needs further study.

Manifestations of Whipple's disease in the posterior segment of the eye

Ocular manifestations of Whipple's disease result from CNS involvement, direct intraocular involvement, or both. Ocular signs caused by CNS involvement occurred in 30 of the 34 patients with ocular manifestations described in the literature. In only four of the 34 cases were ocular manifestations due solely to intraocular involvement. Two cases reported herein had unique intraocular involvement, manifested as diffuse chorioretinal inflammation. Fluorescein angiography showed diffuse vasculitis, with hemorrhages, exudates, retinal capillary occlusion in the perifoveal and midperipheral areas, capillary dilation at the optic disc, and choroidal folds. Proper antibiotic treatment resulted in ocular and systemic recovery. Follow-up is mandatory because of possible recurrences, which may start with intraocular signs, followed by systemic manifestations. Some cases progress to fetal CNS involvement. Therefore, when intraocular signs recur in treated patients, antibiotic therapy should be restarted or dose should be increased.

Vitreous floaters

The vitreous changes in 148 eyes with sudden onset of floaters were evaluated biomicroscopically and documented photographically using an El Bayadi-Kajiura aspherical preset lens mounted on a photo slit lamp. Posterior vitreous detachment (PVD) was found in 83% of the eyes. In those eyes, the primary causes of floaters were prepapillary glial tissue on the posterior hyaloid membrane and minimal vitreous hemorrhage. In eyes with no PVD, intravitreous fiber-like opacities corresponding to the patient's symptoms were present in the posterior vitreous cavity near the retina. These opacities were found on the plicated membranes of Cloquet's canal, or were associated with liquefaction of the gel. The symptoms of patients 50 years of age or older were related to the acute onset of PVD in 95% of the cases. The complaint of multiple small floaters was frequently associated with vitreous hemorrhage and retinal breaks.

Biomicroscopic study of the vitreous in macular breaks

The vitreous in 74 eyes with macular breaks was studied using the El Bayadi-Kajiura preset lens mounted on a slit lamp. Fifteen of the eyes had macular breaks secondary to various causes, and 59 eyes had idiopathic senile macular breaks. Vitreous traction, indicated by the presence of opercula or visible vitreous strands, was present in 29 (49%) of the idiopathic cases. In 17 of 31 eyes without posterior vitreous detachment (PVD), an operculum was seen. In these eyes, intravitreous traction was suspected to be the cause of macular breaks. Opercula were seen attached to the posterior hyaloid membrane in six of the nine eyes with partial PVD. An operculum corresponding to the macular break was observed on the posterior hyaloid membrane in only five of 19 eyes with complete PVD. Of the 15 eyes with macular breaks secondary to various causes, complete PVD was seen in 10 eyes, one of which had an operculum. One eye had no PVD, and four eyes had partial PVD. Opercula were detected in two of the latter eyes. In one eye of the senile group and one eye of the secondary group, partial PVD caused traction at the edges of the macular break, resulting in retinal detachment.

Choroidal neovascularization in fellow eyes of patients with advanced senile macular degeneration. Role of laser photocoagulation

Choroidal neovascularization in fellow eyes of patients with advanced disciform macular scars usually has an unfavorable prognosis. Fifty-two such fellow eyes were treated, using the monochromatic green argon laser. The neovascular membranes were foveal in 24 eyes, juxtafoveal in ten eyes, and perifoveal in 18 eyes. Complete closure of the choroidal new vessels after treatment was seen in 46 eyes. Only one eye in the foveal group and five eyes in the juxtafoveal group had residual new vessels. After an average follow-up period of 16 months, improvement or stabilization of vision was seen in 36 eyes--18 eyes in the foveal group, four in the juxtafoveal group, and 14 in the perifoveal group. In view of the rewarding anatomical and functional results, photocoagulation, using the monochromatic green argon laser, should be considered in these high-risk eyes. Treatment of foveal neovascular membranes seems to be indicated if the visual acuity is 20/70 or worse.

Management of choroidal neovascularization within the foveal avascular zone in senile macular degeneration

After fluorescein angiography, central visual field testing, and photofield mapping, 94 eyes with senile macular degeneration and foveal choroidal new vessels (distance of 200 micron or less from the center of the foveal avascular zone) were treated with the monochromatic green argon laser. By the end of the follow-up period (average follow-up, 15 months), the new vessels were closed in 88 eyes and visual acuity was stabilized or improved in 70 eyes. These 70 eyes included 68 of 80 eyes with preoperative visual acuities of 20/70 or worse and only two of 14 eyes with preoperative visual acuities of 20/60 or better. Visual acuity was stabilized or improved in 55 of 62 eyes in which the foveal edge of the choroidal new vessels was within the margins of the pretreatment scotoma and in only 15 of 32 eyes with foveal edges extending beyond the scotoma margins.

Diffuse choroidal thickening detected by ultrasonography in various ocular disorders

Diffusely thickened choroid was detected ultrasonically in 207 eyes in various conditions, including: following intraocular surgery (108 eyes), trauma (8 eyes), phthisis bulbi (52 eyes), endophthalmitis (12 eyes), and nanophthalmos (27 eyes). Diffusely thickened choroid was seen by A-scan as a widening of the echo pattern originating from the posterior coats of the eye and by B-scan as a curvilinear echo giving a double contour to the globe. Although B-scan characteristics of thickened choroid consisted of a smooth curvilinear echo in 196 eyes, this echo was irregular with multiple angulations in 11 eyes that had phthisis bulbi. The mechanisms suspected of choroidal thickening were ocular hypotony (sudden or chronic, 154 eyes), impaired drainage in the vortex system (41 eyes), and severe intraocular inflammation (12 eyes).

Ultrasonographic findings in eyes with giant retinal tears and opaque media

A preoperative diagnosis of giant retinal tear was suspected as a result of ultrasonography in six eyes with opaque media, and the diagnosis was then confirmed during surgery. All eyes showed a discontinuity in the high amplitude linear retinal echo, representing the location of a retinal tear involving more than one retinal quadrant. In five eyes there was a double linear echo attached to the optic nerve. The linear echo that was discontinuous with the contour of the globe corresponded to the inverted posterior flap of the giant retinal tear. The linear echo that was continuous with the contour of the globe represented detached retina. The preoperative discovery of a giant retinal tear by ultrasonography in eyes with opaque media influences the subsequent management of the patient.

Macular photocoagulation. Optimal wavelength selection

Relative merits of different laser wavelengths for macular photocoagulation are analyzed in terms of light scattering and light absorption in hemoglobin, melanin, and macular xanthophyll. Disadvantages of inner retinal damage in the macula caused by the blue-green argon photocoagulators in standard clinical use are discussed, along with advantages of argon green and krypton yellow light. Results of treatment of subretinal neovascularization in disciform macular degeneration are presented. A repetitive treatment, close follow-up protocol was employed with the objectives of closing neovasculature and preserving central visual field. In 74 successive patients treated with monochromatic argon green radiation, neovasculature was closed in 93%, central visual field loss was reduced or stabilized in 76%, and visual acuity was improved or stabilized in 70%. Results were analyzed in terms of location and size of the neovascular membrane, and it was found that best results were obtained with neovascularization farther than 600 microns from the foveola and smaller than 2 mm2. In 17 patients with neovascular membranes more than 600 microns from the foveola, neovasculature was closed in 100%, central visual field loss was reduced or stabilized in 94%, and visual acuity was improved or stabilized in 88%. Similar results were obtained with monochromatic krypton yellow radiation.