Faculty Bibliography

PURPOSE: To review and update techniques of posterior segment ophthalmic fundus imaging. DESIGN: Literature review and collective experience of the authors. METHODS: This perspective includes sections on digital imaging, fundus autofluorescence, ultrasonography, angiography, and optical coherence tomography (OCT) -ophthalmoscopy written by leading clinicians and researchers in these areas. RESULTS: Digital angiography has become the new standard in the ophthalmic community based upon improved technology which has enhanced resolution, processing time, and ease of image duplication, manipulation, and transmission. A relatively new imaging technique, fundus autofluorescence, highlights lipofuscin deposits and improves our understanding of the metabolic status of the retinal pigment epithelium. Diagnostic ultrasonography continues to be a major adjunct to ocular evaluation where advances now allow for exceptional versatility and portability. High speed angiographic techniques provide detailed visualization of choroidal perfusion which improves our understanding of both normal and pathologic vascular phenomenon. Advances in high-resolution OCT currently under development promise an even more detailed fundus representation. The integration of the scanning laser ophthalmoscope and OCT has produced a dynamic new instrument, the OCT ophthalmoscope, which simultaneously images the fundus in numerous ways with point to point correlation. CONCLUSIONS: Ophthalmic imaging technology has revolutionized fundus examination. Currently available systems have contributed significantly to our understanding of the pathophysiology and treatment of various retinal diseases. Future advances promise near histologic resolution of retinal structures as well as real-time image manipulation and instantaneous transmission world-wide

PURPOSE: To report the detection of intraretinal silicone oil vacuoles after the use of a silicone oil tamponade for macular hole surgery with internal limiting membrane (ILM) peeling. DESIGN: Observational case report. METHODS: A 57-year-old woman with a recurrent macular hole in the left eye underwent macular hole surgery with ILM peeling and silicone oil tamponade. After early silicone oil emulsification was detected, the silicone oil was removed. RESULTS: Follow-up ophthalmoscopic examination and optical coherence tomography imaging revealed intraretinal silicone oil vacuoles in the area of ILM peeling. CONCLUSIONS: Internal limiting membrane defects may facilitate the entry of silicone oil into the retina, leading to accumulation of oil vacuoles. The use of silicone oil in macular hole surgery with ILM peeling may complicate the postoperative outcome

PURPOSE: To examine combined photodynamic therapy (PDT) with verteporfin and intravitreal triamcinolone acetonide for choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). DESIGN: Noncomparative case series. PARTICIPANTS: Twenty-six eyes of 26 patients with CNV secondary to AMD. Thirteen with CNV, without restriction to type, were not treated with prior PDT and were called the Newly Treated group. Thirteen patients with prior PDT therapy who experienced visual loss during treatment with PDT alone comprised the remainder and were termed the Prior PDT group. METHODS: Patients with CNV were treated with PDT immediately followed by an intravitreal injection of 4 mg of triamcinolone acetonide. Visual acuity was measured by Early Treatment Diabetic Retinopathy Study protocol refraction. Need for retreatment was based on fluorescein angiographic evidence of leakage at 3-month follow-up intervals. MAIN OUTCOME MEASURES: Visual acuity and retreatment rate. RESULTS: Of the 13 patients in the Newly Treated group the mean visual acuity change at 3 months was an improvement of 1.9 lines, and 4 (30.8%) had an improvement of at least 3 lines. Two patients (15.4%) required retreatment at 3 months. At the 6-month follow-up, available for 12 patients in the Newly Treated group, the mean visual acuity change from baseline was an improvement of 2.4 lines, 4 patients (33%) had an improvement of at least 3 lines and 1 patient required retreatment. At both time points the visual acuity was significantly greater than at baseline (P = 0.023 and P = 0.007, at the 3-month and 6-month time points, Wilcoxon signed ranks test) for patients in the Newly Treated group. Among the 13 patients in the Prior PDT group, the mean change in visual acuity from baseline at the 3-month follow-up was 0.31 lines and 1 patient (7.7%) had an improvement of at least 3 lines. Six-month follow-up was available for 11 patients in the Prior PDT group and the mean change from baseline visual acuity was 0.1 lines and 1 patient (9.1%) experienced an improvement of 3 or more lines. No patient in the Prior PDT group required retreatment at 3 or 6 months. At the 3-month and 6-month time points the visual acuity was not significantly different than the baseline acuity in the Prior PDT group. No patient in either group at any time point experienced a loss of visual acuity of 3 or more lines. Five patients (19.2%), 3 in the Newly Treated group and 2 in the Prior PDT group, required monodrop therapy to control their intraocular pressure. No patient developed endophthalmitis. CONCLUSION: Although the number of patients in this pilot study was limited, the improvement of acuity and the lack of fluorescein leakage in these patients suggest combination therapy with PDT and intravitreal triamcinolone acetonide, particularly when used as first-line therapy, merits further investigation

PURPOSE: To evaluate the premacular vitreous zone of liquefaction (the posterior precortical vitreous pocket [PPVP]) using contact B-scan ultrasonography and to compare the size of the observed PPVP in fellow eyes with posterior vitreous detachment (PVD) as compared with fellow eyes with macular holes. METHODS: Patients with a fellow eye having a PVD or macular hole but not having a PVD in the examined eye were evaluated with contact B-scan ultrasonography to measure the PPVP. RESULTS: The mean age +/- SD of the 19 patients was 63.9 +/- 7.8 years. There were 13 patients in the PVD group and 6 in the macular hole group. All patients in the macular hole group had a vitreous detachment in the macular region of the eye with the macular hole. There was no difference in the mean age (P = 0.44, independent samples t test) or mean refractive error (P = 0.56) of the two groups. The PPVP was seen to be round to ovoid in shape with a mean anteroposterior dimension of 8.4 mm and a mean horizontal dimension of 9.2 mm for all patients. The mean anteroposterior measurement was 7.6 mm in the PVD group versus 10.3 mm in the macular hole group, a difference that was significant (P = 0.004, independent samples t test). In a similar manner, the mean horizontal dimension was 8.2 mm in the PVD group and 11.1 mm in the macular hole group, a difference that was significant (P = 0.031). CONCLUSIONS: The PPVP was larger in fellow eyes in the macular hole group. The larger PPVP would be expected to cause a greater degree of force concentration and a more pronounced shifting of the direction of the force vector for anteroposterior tensile stress to one being more tangential to the surface of the retina in these patients

PURPOSE: To report optical coherence tomography findings in nicotinic acid maculopathy. DESIGN: Observational case report. METHOD: The patient was examined with ophthalmoscopy, fluorescein angiography, and optical coherence tomography. RESULTS: A 71-year-old man presented with bilateral decreased visual acuity with metamorphopsia. Optical coherence tomography demonstrated cystoid spaces in the outer plexiform layer and inner nuclear layer. Fluorescein angiography did not show leakage. Two weeks after stopping the nicotinic acid, the cystoid spaces resolved. CONCLUSIONS: Niacin maculopathy causes cystoid spaces in the inner nuclear and outer plexiform layers that resolve with discontinuation of the drug