Faculty Bibliography

PURPOSE: To investigate the correlation between visual field (VF) defects in diseases of the acute zonal occult outer retinopathy (AZOOR)-complex and their spectral-domain optical coherence tomographic (OCT) findings. DESIGN: Observational case series. METHODS: Patients with AZOOR, multiple evanescent white dot syndrome (MEWDS), and multifocal choroiditis and panuveitis (MCP) examined in a private practice retinal referral center had threshold VF testing and spectral-domain OCT examination performed using a device capable of obtaining a block of 128 B-scans in a 6 x 6-mm region centered on the optic nerve and macula. The areas of defects in the boundary between the inner segments (IS) and the outer segments (OS) of the photoreceptors, termed the IS/OS boundary, were compared with the VF defects measured. RESULTS: There were 18 evaluable eyes among one patient with MEWDS, two with AZOOR, and seven with MCP. In the 14 eyes with blind spot enlargement [corrected] corresponding IS/OS boundary defects were found in the [corrected] peripapillary region, while no IS/OS boundary defects were found in the four [corrected] eyes without blind spot enlargement. IS/OS boundary defects were seen over chorioretinal scars and areas of neovascularization and no widespread defects were seen [corrected] elsewhere in the fundus. The IS/OS boundary defects showed improvement, as did the blind spot enlargement, spontaneously in the patient with MEWDS and after treatment with immunosuppression in the patients with AZOOR. CONCLUSION: The spectral-domain OCT finding of IS/OS boundary defects, implicating photoreceptor OS perturbation, appears to explain the blind spot enlargement in patients with AZOOR-complex diseases. These defects are not necessarily permanent

OBJECTIVE: To report the results of intravitreous bevacizumab (Avastin) treatment for choroidal neovascularization (CNV) from causes other than age-related macular degeneration (AMD). METHODS: We performed a retrospective analysis of eyes that received intravitreous bevacizumab, 1.25 mg, for subfoveal non-AMD CNV at a referral-based retinal practice. Repeated treatment with intravitreous bevacizumab occurred if there were signs of persistent or recurrent exudation. The main outcome measure was visual acuity (VA). RESULTS: The study included 39 eyes of 36 patients with subfoveal CNV secondary to multifocal choroiditis (n = 12), angioid streaks (n = 11), myopic degeneration (n = 10), idiopathic disease (n = 4), or other disease (n = 2). The median baseline VA was 20/60 (logMAR, 0.48). The mean follow-up was 58.8 weeks, and the mean number of injections per eye was 3.4. After 3-month follow-up, the median VA was 20/30 (logMAR, 0.18) (P = .004 vs baseline). At last follow-up, the median VA was 20/40 (logMAR, 0.30). This remained an improvement compared with baseline (P < .02) but was worse than 3-month follow-up (P < .03). There was no correlation between underlying diagnosis and VA change during follow-up. CONCLUSION: Subfoveal CNV secondary to non-AMD causes treated with intravitreous bevacizumab responded favorably and similarly, despite varying underlying etiologies

PURPOSE: To examine the relationship between visual acuity and morphologic characteristics of macular holes as determined using spectral domain optical coherence tomography (SD OCT). METHODS: A retrospective analysis was performed of eyes with open and closed macular holes at a single, referral-based retina practice. The main outcome measures included best-corrected Snellen visual acuity and SD OCT findings, including the size of the macular hole and the disruption of the junction between inner segments (ISs) and outer segments (OSs) of the photoreceptors. RESULTS: The mean visual acuity for eyes with open (n = 24) and closed (n = 17) macular holes was 20/166 (range, 5/400 to 20/40) and 20/39 (range, 20/80 to 20/25), respectively. The mean macular hole diameter was 859 microm. A disruption of the IS-OS junction was observed in all eyes, and this disruption had a mean diameter of 1,947 microm in eyes with an open macular hole and 626 microm in those with a closed macular hole. There was a negative correlation between both the size of the macular hole (P < 0.001) and the IS-OS disruption (P = 0.01) and visual acuity in eyes with open macular holes. In eyes with closed macular hole, the size of the IS-OS disruption was not correlated with visual acuity (P = 0.82). CONCLUSIONS: The photoreceptor layer appears to be involved for a much larger area than that occupied by the macular hole itself. The abnormality in the IS-OS boundary line may reflect perturbation of a higher level of retinal organization and not an absolute loss of photoreceptor OSs

PURPOSE:: To determine safety and efficacy of intravitreal triamcinolone acetonide (IVTA) for refractory clinically significant diabetic macular edema (DME). DESIGN:: Prospective, randomized, dose-escalation pilot study comparing single injection of 2 mg versus 4 mg doses of IVTA. METHODS:: Inclusion criteria included clinically significant DME persisting >/=3 months after maximal laser treatment and visual acuity </=20/40. Best-corrected ETDRS vision, intraocular pressure, presence of DME, and fluorescein angiography (FA) were evaluated at 3 months and 6 months after injection. RESULTS:: Mean change in visual acuity at 3 months compared to baseline was 7.1 letters (P = 0.01) in the 2 mg group and 12.5 letters in the 4 mg group (P < 0.0001). However, there was not a significant difference in visual improvement between the 2 mg and 4 mg dose groups (P = 0.11). Vision improved >15 letters at 3 months in 23% (3/13) of 2 mg group and in 33% (5/15) of 4 mg group (P = 0.69), and 0% (0/11) and 21% (3/14) at 6 months, respectively (P = 0.23). Visual improvement was more likely in cystoid-type DME than diffuse DME. Intraocular pressure rise of >/=10 mmHg occurred in 19% (3/16) of 2 mg group and 41% (7/17) of 4 mg group. CONCLUSIONS:: Both doses of IVTA were well tolerated and had significant positive effects on refractory DME for short term. There were consistent trends throughout the study that suggest that a 4 mg IVTA may be more effective than a 2 mg dose. The benefit of IVTA was greater for cystoid-type DME

PURPOSE: To investigate the characteristics of fundus autofluorescence in birdshot chorioretinopathy (BSCR). DESIGN: Retrospective, observational case series. PARTICIPANTS: Sixteen eyes of 8 consecutive patients with BSCR (3 men, 5 women). METHODS: Color and autofluorescence photography and optical coherence tomograms of patients with BSCR seen in a referral practice were evaluated. MAIN OUTCOME MEASURES: Autofluorescent characteristics in BSCR. RESULTS: The 8 patients ranged in age from 35 to 73 years (mean, 56.9 years). Of the 16 eyes, 11 eyes (69%) of 6 patients had retinal pigment epithelium (RPE) atrophy as evidenced by hypoautofluorescent regions. Some of the hypoautofluorescent areas corresponded to the hypopigmented birdshot lesions, but the others did not necessarily show a correspondence. Eight eyes (50%) of 4 patients showed linear hypoautofluorescent streaks along the retinal vessels, most of which corresponded to visible changes at the level of the RPE. Placoid hypoautofluorescence in the macula was seen in 6 eyes (38%) of 3 patients and was correlated significantly with best-corrected visual acuity of 20/50 or less (P<0.05). CONCLUSIONS: Autofluorescence photography demonstrated the RPE atrophy, which was hard to see by other means of investigation. The areas of RPE atrophy did not necessarily correspond to the hypopigmented lesions, which suggested that both the choroid and the RPE can be affected independently. Retinal pigment epithelium atrophy in the macula may be an important cause of poor central visual acuity in eyes with BSCR

PURPOSE: To investigate the autofluorescence findings associated with multifocal choroiditis and panuveits (MCP), a condition that has marked potential to affect the retinal pigment epithelium (RPE). DESIGN: Observational case series. METHODS: This is a retrospective review of consecutive patients with MCP examined in a retinal referral practice. Each patient was given a comprehensive examination including fundus photographs, angiographic studies, and autofluorescence photography with an excitation filter with the bandpass wavelengths of 535 to 585 nm and a barrier filter with a bandpass of 615 to 715 nm. Integrative analysis was performed of the ocular imaging to ascertain abnormalities caused by the disease. RESULTS: Thirty-six eyes of 18 consecutive patients were evaluated. The mean duration of symptoms was 86.2 months and the mean visual acuity was 20/50. Of the 36 eyes, 23 had choroidal neovascularization (CNV). Chorioretinal hypoautofluorescent spots >or= 125 microns usually, but not always, had the clinically evident correlate of a punched-out scar visible by color fundus photography. Chorioretinal hypoautofluorescent spots less than 125 microns, which could number in the hundreds, typically were not visible by color fundus photography. All chorioretinal scars visible by color fundus photography were visible by autofluorescence photography. During follow-up many patients developed new clinically evident chorioretinal scars, which were presaged in earlier autofluorescence photographs. CNV had a hyperautofluorescent boundary, making it readily visible. CONCLUSIONS: Patients with MCP have much more widespread involvement of the RPE than would be suspected by other means of imaging. Autofluorescence photography supplies information about inflammatory damage and secondary CNV in a noninvasive manner

PURPOSE: To determine the incidence of endophthalmitis following intravitreal injection of anti-vascular endothelial growth factor (VEGF) agents. DESIGN: A retrospective interventional case series. METHODS: A total of 10,254 intravitreal anti-VEGF injections (406 pegaptanib, 3,501 bevacizumab, and 6,347 ranibizumab) were performed from January 5, 2005 to October 18, 2007. The number of the injections was determined from the injection log books and billing records. The injections were performed as an office based procedure with use of povidone-iodine as a part of preinjection preparation. Preinjection antibiotics, eye drape, or surgical attire were not used. The main outcome measures were the incidence of suspected and proven endophthalmitis. RESULTS: There were three cases of suspected endophthalmitis, one case following bevacizumab injection and two cases following ranibizumab injection. There was no case of culture-proven endophthalmitis. All three patients regained their preinjection visual acuity. The incidence of suspected endophthalmitis was 0.029% (95% confidence interval, 0.006% to 0.085%). There was no difference in the incidence of endophthalmitis between ranibizumab and bevacizumab injections (P = .6). CONCLUSIONS: Although there is no consensus regarding the intravitreal injection procedure technique, the incidence of suspected endophthalmitis was very low in a large series of injected patients in a community setting and the incidence compares favorably with that reported in clinical trials where much more extensive preinjection preparation was mandated. We found no difference in the endophthalmitis risk of patients receiving bevacizumab as compared with ranibizumab

PURPOSE: To delineate the 3-dimensional (3-D) relationship in vitreomacular traction (VMT) and idiopathic epiretinal membrane (ERM). DESIGN: Observational case series. METHODS: Forty-eight evaluable eyes of 35 patients with VMT or idiopathic ERM were investigated with spectral-domain (SD) optical coherence tomography (OCT). VMT was defined as focal if the diameter of the vitreous attachment was 1500 microm or less and broad if it was more than 1500 microm. The 3-D OCT representation of vitreomacular interface abnormalities was evaluated. RESULTS: Focal VMT was seen in five eyes. Broad VMT was seen in seven eyes. Of these 12 eyes, concurrent ERMs under the detached vitreous were seen in 10 eyes and zones of hyperreflectivity affecting the adjacent detached posterior hyaloid face were seen in 11 eyes. Eyes with focal VMT showed a foveal cavitation, whereas eyes with broad VMT had more widespread cystoid macular edema. Idiopathic ERM was seen in 36 eyes; 30 had complete posterior vitreous detachment (PVD), five had partial PVD associated with attached posterior hyaloid at some peripheral portion of the ERM, and one had no PVD. CONCLUSIONS: The SD OCT with 3-D image reconstruction provided unprecedented visualization of VMT and idiopathic ERM. The vitreous attachment to the macula can be subclassified into two subgroups, each having specific induced alterations in retinal anatomy. Most of the eyes with VMT had concurrent ERM, whereas several eyes with idiopathic ERM had attachment of the vitreous to some portion of the ERM, which suggests there is significant overlap between VMT and idiopathic ERM

Fundus autofluorescence (FAF) imaging is a novel imaging method that allows topographic mapping of lipofuscin distribution in the retinal pigment epithelium cell monolayer as well as of other fluorophores that may occur with disease in the outer retina and the subneurosensory space. Excessive accumulation of lipofuscin granules in the lysosomal compartment of retinal pigment epithelium cells represents a common downstream pathogenetic pathway in various hereditary and complex retinal diseases, including age-related macular degeneration. FAF imaging has been shown to be useful with regard to understanding of pathophysiologic mechanisms, diagnostics, phenotype-genotype correlation, identification of predictive markers for disease progression, and monitoring of novel therapies. FAF imaging gives information above and beyond that obtained by conventional imaging methods, such as fundus photography, fluorescein angiography, and optical coherence tomography. Its clinical value coupled with its simple, efficient, and noninvasive nature is increasingly appreciated. This review summarizes basic principles and FAF findings in various retinal diseases