Faculty Bibliography

PURPOSE: To describe the optical coherence tomography (OCT) and fluorescein angiography findings in the macula of eyes with chronic central serous chorioretinopathy (CSC) and reduced central vision. METHODS: Using OCT, clinical examination, and fluorescein and indocyanine green (ICG) angiography, the authors examined eight eyes of seven patients with CSC, an attached macula, and reduced central vision of 20/200 or worse. All had a history of chronic CSC with resolution of the subretinal fluid in the macular area and poor vision. RESULTS: Patient ages ranged from 55 to 82 years (mean, 66 years). All eight eyes had some parafoveal, patchy RPE atrophy with corresponding transmission hyperfluorescence (window defect) on fluorescein angiography. Five eyes also had a window defect in the foveal area. With OCT, the foveal area revealed variable areas of cystoid change and atrophy in seven of the eight eyes. In four of these eyes, the cystoid changes were not seen on clinical examination or fluorescein angiography. The seven eyes with cystoid changes imaged with OCT had no intraretinal leakage of fluorescein in the foveal region. The authors categorized these eyes as having cystoid macular degeneration (CMD). One other eye had foveal thinning or atrophy without cystoid changes. CONCLUSIONS: Intraretinal cystoid spaces without intraretinal leakage, or CMD, was a common finding in eyes with chronic CSC and reduced central vision after resolution of subretinal fluid. OCT was useful to establish the presence of CMD and foveal atrophy, even when these changes were not clearly evident on clinical examination or fluorescein angiography. Chronic foveal detachment and antecedent intraretinal leakage were proposed to be the mechanisms for the development of the changes. CMD in conjunction with foveal atrophy was an important clinical finding to account for the poor visual outcome in patients with CSC

PURPOSE: To evaluate the autofluorescence images of patients with nonexudative and the fellow eyes with exudative age-related macular degeneration (AMD). DESIGN: Observational case series. PARTICIPANTS: Fifty-four patients seen in the author's practice. METHODS: A fundus camera-based system for autofluorescence photographs was used, and the wavelengths for the excitation (580 nm) and barrier (695 nm) filters were based on known transmission and autofluorescent characteristics of the ocular media. Patients were also photographed with red-free and infrared monochromatic imaging. The mean levels of autofluorescence were compared between patients without (group 1) and those with exudative AMD. Comparisons were made among patients with exudative AMD, examining the autofluorescence pattern in those without retinal vascular contribution to the exudative process (group 2) to those with retinal vascular contribution (group 3). MAIN OUTCOME MEASURES: Mean amounts and patterns of autofluorescence. RESULTS: A total of 54 patients was evaluated; 18 were in each group. The mean age was 75.4 years, and there was no difference in the mean ages among the groups (P = 0.16). There was no correlation of the autofluorescence measurements and the degree of nuclear sclerosis (P = 0.14). Patients with exudative AMD had more autofluorescence in the fellow eye than did eyes of patients without exudative AMD (P = 0.002). Patients in group 3 were more likely to have focal hyperpigmentation, particularly as imaged by infrared light (P = 0.015), and focal areas of intense autofluorescence (P = 0.001) than were patients in group 2. CONCLUSIONS: By use of this method of autofluorescence imaging, it was determined that the fellow eyes of patients with exudative AMD had larger amounts of autofluorescence than did the eyes of patients without a history of exudative AMD. Patients with retinal vascular anastomosis to the vascular proliferation of exudative AMD were much more likely to have focal areas of intense autofluorescence in their fellow eye that corresponded, for the most part, with focal areas of hyperpigmentation best seen by infrared monochromatic fundus photography. Because the amount of fluorescence is directly related to the amount of lipofuscin, which in turn is related to the cumulative amount of oxidative damage, these findings suggest possible explanations for certain patterns of vessel growth seen in exudative AMD

PURPOSE: To investigate the changes in absolute neutrophil counts in patients with and without pain after verteporfin infusion. DESIGN: Experimental study. METHODS: The absolute neutrophil counts were obtained from the blood samples taken at the beginning of infusion and after the end of verteporfin infusion. RESULTS: Four patients in whom verteporfin infusion-related pain developed had a decrease in the absolute neutrophil counts from a preinfusion mean of 4,589/mm(3) to a postinfusion mean of 1,688/mm(3) while they had pain, as compared with preinfusion and postinfusion counts of 4,912/mm(3) and 4,111/mm(3), respectively, in five control patients having no pain, a difference in proportion that was significant (P =.027). CONCLUSIONS: Patients in this study with verteporfin infusion-associated pain developed neutropenia during infusion, most likely from drug-induced neutrophil margination. It is possible that medications preventing the transient neutropenia may help avert verteporfin infusion-associated pain

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 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