Faculty Bibliography

PURPOSE: The purpose of this study was to investigate the frequency of glaucoma and related conditions in patients with central serous chorioretinopathy (CSC), a condition associated with increased choroidal thickness. METHODS: A case-control study was conducted. Consecutive patients with CSC examined from January 1, 2006, through July 31, 2008, were compared with a sex- and age-matched control group from the same referral practice seen during the same period for the frequency of glaucoma and related conditions. The charts of the cases and the control subjects were reviewed for diagnosis of glaucoma. RESULTS: In 287 patients with CSC, the mean age was 56.8 years and 207 (72.1%) were men. In the control group of 235, the mean age was 59.5 years and 168 (71.5%) were men. Glaucoma was found in 10 of 287 patients (3.4%) with CSC and in 20 of 235 control subjects (8.5%, P = 0.014, odds ratio = 0.39, 95% confidence interval = 0.16-0.89). The mean intraocular pressures were similar in the two groups. However, the number of patients diagnosed with ocular hypertension (0.3% versus 3.4%, P = 0.0076) and the number of patients using pressure-lowering eye drops (3.8% versus 13.2%, P <or= 0.0001) were significantly less in the CSC group than in the control group. CONCLUSION: Glaucoma and related conditions are less frequent in the CSC group than in the control group. In patients with CSC, increased blood supply to the optic nerve from the choroid may be a contributing factor, but there may be differences in the variances in intraocular pressure that cannot be ruled out

PURPOSE: To characterize reticular pseudodrusen, a potential risk factor for late age-related macular degeneration. DESIGN: Retrospective, observational case series. PARTICIPANTS: Fifty-eight eyes of 33 patients with pseudodrusen (20 female). METHODS: Consecutive patients with reticular pseudodrusen, diagnosed by their typical appearance and distribution using ophthalmoscopy, the blue channel of color fundus photographs, and near infrared images. The patients were imaged by spectral domain optical coherence tomography (SD OCT), and correlations were made between the near infrared images and the SD OCT images. The SD OCT findings in patients with pseudodrusen were compared with previously reported histologic findings of subretinal drusenoid deposits. The histologic specimens were reevaluated with the additional knowledge of the clinical information. MAIN OUTCOME MEASURES: Spectral domain optical coherence tomography and histologic characteristics of pseudodrusen. RESULTS: The mean age of the 33 patients was 81.7 years. The correlating SD OCT scans showed collections of granular hyperreflective material above the retinal pigment epithelium (RPE), in the subretinal space located primarily between the RPE and the boundary between the inner and outer segments of the photoreceptors (IS/OS boundary). In a more advanced stage, this material formed small mounds that broke through the IS/OS boundary. There were no correlates to the deposits seen under the RPE or in the choroid. These findings were similar in character to previously reported histologic characterization of subretinal drusenoid deposits, which had identified the presence of membranous debris, unesterified cholesterol, and complement within the deposits. CONCLUSIONS: Pseudodrusen seen by clinical examination may be subretinal drusenoid deposits seen by histologic examination. This unexpected location suggests that potential pathophysiologic mechanisms on both sides of the RPE need to be taken into account in theories related to the development of age-related macular degeneration. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references

OBJECTIVE: To describe tubular structures found in the outer retina seen in a variety of retinal disorders. METHODS: Sixty-nine eyes of 63 patients were examined with spectral-domain optical coherence tomography. Optical coherence tomography C-scans were correlated with their corresponding B-scans. The prevalence, number, size, and shape of the tubular structures were determined. RESULTS: Branching tubules were identified in the outer retina of 54 patients with age-related macular degeneration and in 9 patients with other diagnoses. The tubules appeared as round or ovoid hyporeflective spaces with hyperreflective borders on the B-scans, measuring 40 to 140 microm high and 40 to 2260 microm wide. Morphologic features ranged from single straight or branching tubules to complex cavitary networks, usually overlying areas of pigment epithelial alteration or subretinal fibrosis. The tubules generally remained stable over time. In a retinal practice specializing in advanced age-related macular degeneration, these structures were identified in 60 of 248 patients (24.2%) seen during a 3-month period. CONCLUSIONS: Degenerating photoreceptors may become arranged in a circular or ovoid fashion during a process we propose to term outer retinal tubulation. These changes are apparently common in advanced diseases affecting the outer retina and retinal pigment epithelium. This observation has practical implications because these findings can be misinterpreted as intraretinal or subretinal fluid, possibly prompting unnecessary interventions

PURPOSE: The purpose of the study was to evaluate the choroidal thickness in patients with central serous chorioretinopathy, a disease attributed to increased choroidal vascular hyperpermeability. METHODS: Patients with central serous chorioretinopathy underwent enhanced depth imaging spectral-domain optical coherence tomography, which was obtained by positioning a spectral-domain optical coherence tomography device close enough to the eye to acquire an inverted image. Seven sections, each comprising 100 averaged scans, were obtained within a 5 degrees x 30 degrees rectangle to encompass the macula. The subfoveal choroidal thickness was measured from the outer border of the retinal pigment epithelium to the inner scleral border. RESULTS: The mean age of subjects undergoing enhanced depth imaging spectral-domain optical coherence tomography was 59.3 years (standard deviation, 15.8 years). Seventeen of 19 patients (89.5%) were men, and 12 (63.2%) patients had bilateral clinical disease. The choroidal thickness measured in 28 eligible eyes of the 19 patients was 505 microm (standard deviation, 124 microm), which was significantly greater than the choroidal thickness in normal eyes (P < or = 0.001). CONCLUSION: Enhanced depth imaging spectral-domain optical coherence tomography demonstrated a very thick choroid in patients with central serous chorioretinopathy. This finding provides additional evidence that central serous chorioretinopathy may be caused by increased hydrostatic pressure in the choroid

PURPOSE: To measure macular choroidal thickness (CT) in highly myopic eyes using enhanced depth imaging optical coherence tomography (OCT). DESIGN: Retrospective, observational case series. METHODS: Enhanced depth imaging OCT images were obtained in highly myopic eyes (> or =6 diopters [D]). Images of CT were obtained by positioning a spectral-domain OCT device close enough to the eye to acquire an inverted image. CT was measured from the outer border of the retinal pigment epithelium to the inner scleral border at 1000-mum intervals of a horizontal section from 3 mm temporal to the fovea to 3 mm nasal to the fovea. Statistical analysis was performed to evaluate CT at each location and to correlate CT with age and refractive error. RESULTS: The mean age of the 31 patients (55 eyes) was 59.7 years (+/- 17.6 years; range, 24 to 90 years), and the mean refractive error was -11.9 D (+/- 3.7 D). The mean subfoveal CT was 93.2 microm (+/- 62.5 microm) and was correlated negatively with age (P = .006), refractive error (P < .001), and history of choroidal neovascularization (P = .013). Regression analysis suggested that subfoveal CT decreased by 12.7 mum for each decade of life and by 8.7 microm for each D of myopia. CONCLUSIONS: The choroid in highly myopic eyes is very thin and undergoes further thinning with increasing age and degree of myopia. Abnormalities of the choroid may play a role in the pathogenesis of myopic degeneration

PURPOSE: To study patients with neovascular age-related macular degeneration (AMD) who experienced a macular hemorrhage after stabilization with intravitreal antivascular endothelial growth factor (anti-VEGF) agents to improve current treatment regimens and prevent disease progression. METHODS: Retrospective chart review of six patients. The main outcome measures included time between last intravitreal anti-VEGF treatment and date of hemorrhage, time between last office visit and date of hemorrhage, and visual acuity before and after hemorrhage. RESULTS: Three of 6 eyes had a macular hemorrhage within 4 weeks of a stable examination. One eye had optical coherence tomography (OCT) that demonstrated no fluid 1 day before the macular hemorrhage. The average time between the date of the last injection and macular hemorrhage was 16.8 weeks (range, 7.3-28.9 weeks). The average time between the last stable examination and an event was 4.2 weeks (range, 1 day to 7.3 weeks). Three of six patients had a persistent decline in vision after the hemorrhage. Among the 4 patients, who had better than 20/200 vision before the macular hemorrhage, 2 dropped to 20/200 or worse. CONCLUSION: Sight-threatening macular hemorrhages from AMD can occur within days to weeks after a stable examination and absence of fluid on OCT. Regimens that treat 'as needed' based on clinical findings and OCT may not be appropriate for certain patients

Choroidal neovascularization (CNV) is typically characterized as an invasion of blood vessels, but it is important to recognize concurrent inflammatory and mesenchymal cell infiltration. A two component model of CNV can be thought to be composed of a vascular component and an extravascular component. Macular damage is possible through either. Given the redundancy and complex interaction among biologic systems involved in the production of CNV, it is likely that a monotherapeutic approach will not be fully effective. The vascular component of CNV arises through the orchestrated interaction of a number of growth factors such as vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF), which maintains pericyte viability. The vascular component of CNV can be selectively targeted with anti-VEGF and anti-PDGF drugs or nonselectively with such modalities as ionizing radiation. The extravascular component can be targeted selectively by inhibiting specific cytokines such as tumor necrosis factor alpha or nonselectively with antiinflammatory drugs such as corticosteroids