Ultra-widefield fundus fluorescein angiography in the diagnosis and management of retinal vasculitis

PurposeTo quantify the additional information provided by ultra-widefield fluorescein angiography, compared with 7-field standard imaging, in patients with retinal vasculitis (RV).Patients and methodsRetrospective case series of 106 patients.ResultsRetinal vascular pathology was identified by UWF FFA, but not by standard ETDRS 7-field area, in 62 patients (58.5%) and in 79 eyes (43.4%). The pathology included active RV (47 eyes, 25.8% of eyes); retinal ischaemia, or infarction (53 eyes, 29.1%); and retinal neovascularization (7 eyes, 3.8%). A change to management was made in 36 patients (34%). Of these, 21 (20% of all patients undergoing angiography) were made after the identification of retinal vascular pathology, which was found only on UWF FFA, outside the ETDRS area.ConclusionUltra-widefield fluorescein angiography has clear advantages over standard multi-field imaging. It is currently the standard method of assessment for RV in this centre.

Electronic retinal implants and artificial vision: journey and present

Retinitis pigmentosa and age-related macular degeneration are two significant causes of severe visual dysfunction. In both, the retinal photoreceptors degenerate, preventing successful conversion of light into electrical energy that is interpreted in the visual cortex as visual function. Artificial vision or visual function began over two centuries ago with the idea of creating artificial light pulses, or phosphenes, through cortical stimulation. The pursuit is now on to improve artificial visual function. Two retinal implants appear the most likely to succeed in the future having undergone multicentre human trials: the Argus II electronic epiretinal device (Second Sight Medical Products, CA, USA) and Alpha-IMS electronic subretinal device (Retina Implant AG, Germany). The trial results to date are encouraging with visual improvement and acceptable safety profiles reported for both devices. At present, the visual function generated by either device does not offer high enough resolution or acuity for a patient to regain a fully functional life. Despite this, both devices not only have the potential, but have actually improved the vision-related quality of life in a significant number of patients implanted. With this in mind, the economic argument is clear. Provided device-life is long enough, its cost should be acceptable for the obtained improvement in the quality of life. The aim of this Review Article is to assist those readers that may be considering offering any of these devices as a treatment for blindness in Retinitis Pigmentosa.

Initial experience with the Pascal photocoagulator: a pilot study of 75 procedures

Background:

The Pascal is a semiautomated photocoagulator that delivers a pattern array of multiple burns in a rapid predetermined sequence with a single foot pedal depression. Each burn is reduced to 10 or 20 ms to achieve this. The authors report their early experience with this system.

Methods:

75 procedures done in 60 patients divided into four groups—group A, patients undergoing panretinal photocoagulation (PRP); group B, patients undergoing focal or modified grid macular laser; group C, patients undergoing macular grid and group D, patients undergoing retinopexy—were retrospectively studied.

Results:

31/34 procedures in group A, 24/26 procedures in group B, 5/7 procedures in group C and all eight patients in group D had successful outcomes. Significantly higher powers were required with the Pascal than with conventional laser (p<0.001) in eyes that underwent PRP and focal/modified grid macular treatment with both systems. Single session PRP was successfully performed in five patients, and five were successfully treated with a macular grid using pattern arrays only. No adverse events were noted.

Conclusion:

Although the shorter pulse duration of the Pascal necessitates the use of a higher power, it is not associated with adverse effects. The results here suggest that the Pascal photocoagulator is safe and effective, and offer several potential advantages related to the brief exposure time.

Retinal pigment epithelium translocation and central visual function in age related macular degeneration: preliminary results

PURPOSE

To test the feasibility of a new surgical technique, and to assess visual function over the translocated retinal pigment epithelium (RPE) cells in patients operated upon for subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD).

MATERIALS AND METHODS

Six patients presenting previously untreated exudative AMD underwent surgical excision of the subfoveal CNV with RPE translocation and were followed from 1 to 10.5 months. The surgery consisted of a standard three port pars plana vitrectomy (TPPPV), excision of the CNV and RPE translocation. Pre and post-operative ocular examination included best-corrected visual acuity measurement, fundus color stereo photography and fundus fluorescein angiography. Optical coherence tomography (OCT) and confocal laser scanning ophthalmoscopy (cLSO) were performed post-operatively. A cross fixation target and a single-point flashing light were projected on different areas of the posterior pole using a cLSO. Photopic 10-2 perimetry, photopic fine matrix mapping, cLSO microperimetry were also performed pre and post-operatively in four patients. OCT cross-sectional scans and cLSO RPE autofluorescence were recorded to detect the presence of viable translocated RPE. Visual acuity, fixation, photopic 10-2 perimetry, photopic fine matrix mapping and cLSO microperimetry were tested for the presence of central visual function.

RESULTS

RPE could be effectively translocated at the time of CNV removal from the edge of the RPE defect to a subfoveal location. OCT showed the translocated RPE as an area of increased optical reflectivity with optical shadowing external to it. cLSO showed autofluorescence of the translocated RPE. The cross fixation target was seen when projected on the translocated RPE. During eccentric fixation, the patients could see a flashing point-target projected on the translocated RPE. Photopic 10-2 perimetry, photopic fine matrix mapping and cLSO microperimetry showed presence of central visual function.

CONCLUSIONS

The authors propose that translocation of RPE at the time of CNV removal, from the edge of the RPE defect to a subfoveal location, may have a role in the surgical management of AMD.

Polypoidal choroidal vasculopathy in exudative and haemorrhagic pigment epithelial detachments

AIMS

To determine the prevalence of polypoidal choroidopathy in consecutive patients presenting with large haemorrhagic and exudative neurosensory retinal and retinal pigment epithelial detachments (PEDs) of over 2 mm in diameter in the absence of drusen.

METHODS

40 patients were identified over a 5 month period of which 29 had haemorrhagic detachments, and 11 had purely exudative detachments. All had indocyanine green (ICG) angiography, and the presence was sought of large blood vessels in the choroid associated with localised dilated terminals that filled slowly and leaked ICG.

RESULTS

In 34 cases (85%) there was an appearance consistent with previous descriptions of idiopathic polypoidal choroidal vasculopathy. Of the six without polypoidal lesions the disorder was attributed to choroidal neovascularisation in four, chorioretinitis in one, and a fibrovascular PED in one. Of those with polypoidal lesions 20 (65%) were female, the mean age was 65.4 years (range 44-88), and 25 (74%) were white, seven (20%) black, and two (6%) east Asian. Eight had a history of hypertension. Visual acuity varied from 6/6 to counting fingers in the involved eye (mean 6/24). Bilateral polypoidal choroidal lesions were demonstrated in 16 patients (47%). The predominant location for these lesions was the macular region in 23 patients (68%). Polypoidal vasculopathy was found in 16 patients (47%) who had a previous diagnosis of age related macular disease (AMD). No patients had evidence of intraocular inflammation.

CONCLUSIONS

In a largely white patient population a high proportion of patients with haemorrhagic and exudative PEDs has evidence of polypoidal lesions on ICG angiography.

Micropulse laser in the treatment of diabetic macular edema

The micropulse laser is a new development in laser therapy. Micropulsing is frequent short pulses of subthreshold intensity applied to retinal lesions. It has been shown to be effective in diabetic macular edema, branch vein occlusion, and drusen. Although the initial landmark studies showed it to be effective, the exact parameters have not been established. This article illustrates the current state of its use.

Ocular manifestations of diabetes mellitus

The ocular complications of diabetes mellitus are numerous and include retinopathy, cataract, uveitis, and neurophthalmic disorders. A review of the current literature shows that the emphasis has changed from the laser and surgical management of pre-existent retinopathy to the development of cohesive multidisciplinary screening and education programs, and to a better understanding of the cellular and molecular mechanisms that underlie disease. The role of associated and potentially modifiable systemic factors is also now recognized. Early intervention with systemic and local therapies may soon provide hope for the better management of diabetic eye disease.