Surgical Management of Bilateral Exudative Retinal Detachment associated with Central Serous Chorioretinopathy

PURPOSE: To report a case of bilateral bullous exudative retinal detachment in central serous chorioretinopathy (CSC) which was attached by vitrectomy and internal drainage of the subretinal fluid. METHODS: A 47-year-old man affected by bilateral atypical CSC with a bullous retinal detachment with subretinal exudate. A fluorescein angiogram (FAG) showed multiple points of leakage and staining of subretinal fibrosis. A tentative diagnosis of Vogt-Koyanagi-Harada (VKH) syndrome was made and the patient was treated with systemic corticosteroids and immunosuppressive agents. However, the subretinal fluid was not absorbed. He was then treated with vitrectomy and internal drainage of subretinal fluid. RESULTS: The retina was attached successfully in both eyes. Visual acuity improved to 20/50 in his left eye but did not improve in the right eye due to subretinal fibrotic scarring and atropic changes on the macula. CONCLUSIONS: Our case suggests that the surgical management of bullous exudative retinal detachment is safe and necessary.

Result of Photodynamic Therapy for Idiopathic Subfoveal Choroidal Neovascularization

PURPOSE: To investigate the factors that affect final vision following photodynamic therapy (PDT) for idiopathic subfoveal choroidal neovascularization (CNV). METHODS: A retrospective review of 16 patients whose eyes were diagnosed as idiopathic subfoveal CNV and were followed up for a minimum of 9 months. Statistical analysis was performed to investigate relationships between sex, age, size of the lesion, and initial vision compared to final vision. RESULTS: In the PDT group (10 eyes), the mean age of the patients was 34 years, mean size of the lesion was 1300 micrometer, mean initial vision was 20/60, and 7 of the 10 patients (70%) showed more than a two-line improvement in vision. Factors affecting final vision were sex (p=0.049), initial vision (p=0.0455), and size of the lesion (p=0.006). In the observation group (6 eyes), the mean age of the patients was 39 years, mean size of the lesion was 575 micrometer, mean initial vision was 20/32, and 5 of the 6 patients (83%) showed more than a two-line improvement in vision. CONCLUSIONS: The prognosis of idiopathic CNV was favorable as was reported in other studies. In the PDT group, statistically significant factors affecting final vision were initial vision, size of the lesion, and sex. However, since the number of patients sampled was insufficient and the average size of the lesions in the female patients was smaller, the size of the lesion seems to be the most important factor.

Quantitative Analysis of Diabetic Macular Edema after Laser Photocoagulation

PURPOSE: Diabetic macular edema is one of major causes leading to visual loss and it is difficult to be quantified. We investigated a volumetric quantification of retinal thickness change before and after focal laser photocoagulation with Heidelberg Retina Tomograph (HRT). METHODS: Ten patients who were diagnosed as diabetic retinopathy with clinically significant macular edema (CSME) in only one eye and treated with focal laser photocoagulation were studied. The opposite eyes which had no CSME were studied as control group. In the eyes which had CSME, the volume above reference plane (VARP) bounded by three consecutive circle centered at the fovea (diameter 1, 2, and 3 mm) were measured. The retinal thickness of control group was also measured with the same method. We performed focal laser photocoagulation for the eyes which had CSME and measured VARP at 1, 2, and 3 months after laser treatment. RESULTS: Three months after laser treatment, the VARP of treated eyes measured in each diameter was significantly decreased, however, there was no significant difference in control group. There was no significant difference in visual acuity change between before and 3 months after laser treatment. CONCLUSION: From the above results, we concluded that HRT could be used to quantify the change of diabetic macular edema before and after laser treatment.

Quantification of Diabetic Macular Edema with Heidelberg Retina Tomograph

Diabetic macular edema is a major cause of visual loss and it is difficult to be quantified.We investigated a method of assessment and volumetric quantification of diabetic macular edema with Heidelberg Retina Tomograph[HRT].Ten normal eyes of control group and 20 eyes with diabetic patients were studied.In 20 diabetic patients, 10 patients had macular edema and 10 patients had no macular edema. Macular edema was defined as any visible macular thickening within a circle centered at the fovea with 6mm in diameter. With HRT, the volumes above reference plane[VARP]bound by three consecutive circles centered at the fovea [diameter, 1, 2, and 3mm ]were measured. Measurements were repeated three times, and mean measurements were used for the analysis. Diabetic eyes with macular edema had statistically greater VARP than diabetic eyes without edema[p0.05]. The sensitivity of HRT was 90%, and the specificity was 100%. The VARP measured using HRT was found to be linearly correlated with visual acuity expressed on a logMAR scale[p<0.05]. From the above results, we concluded that HRT could identify diabetic macular edema by volumetric analysis and indicated a good relationship of volumetric changes with visual acuity.

The Intracho roidal Changes in Harada`s Disease

The intrachoroidal changes in Harada's disease were studied by indocyanine green(ICG)angiography. ICG angiography using confocal laser scanning ophthalmoscope (Heidelberg Retina Angiograph, HRA)and fluorescein angiography were performed in 12 eyes of 6 patients during the acute stage before the initiation of corticosteroid treatment and recovery stage, and the findings were evaluated retrospectively. During the acute stage, early phase HRA images disclosed a dark background fluorescence in all eyes due to the diffuse filling delay and the vague contour of choroidal vessels. In the midphase, Intrachoroidal hyperfluorescence resulting from vascular leakage and scattered hypofluorescent spots were intermingled, and in some eyes patchy hypofluorescence representing focal filling defect was observed. These choroidal changes could be observed before any visible retinal changes appeared. During the recovery stage, choroidal filling was more rapid and choroidal vessels were more clearly visible. However the scattered hypofluorescent spots due to the blockage by the inflammatory precipitates were still observed in small numbers, and in some eyes focal vascular leakage remained. According to these findings, we hypothesize the pathogenesis of Harada`s disease as follows. Severe inflammatory precipitates and vascular leakage can make the choroid edematous with highly viscous fluid. It adds mechanical damage to choroidal vessels already injured by the inflammatory process, leading to reversible circulatory disturbances. The retinal pigment epithelium and the sensory retina may be damaged secondarily.

The Effect of Superficial Temporal Artery Compression on Intraocular Microcirculation

To increase retinal blood flow, we attempted to increase blood flow of ophthalmic artery which in the major vascular supply to the eyeball. The authors evaluated changes in blood flow of ophthalmic artery and retinal capillary after compression of superficial temporal artery. In 5 normal healthy subjects, the superficial temporal artery was compressed for 10seconds and the blood flow was measured with color doppler imaging and Heidelberg Retinal Flowmeter(HRF). After compression, the mean volume of ophthalmic artery was increased by 59.3% and the mean change of diastolic velocity was significantly increased by 29.6%. Systolic velocity did not changing significantly. For evaluation of retinal microcirculation, we measured volume, flow, velocity in retina and optic nerve head. The relative ratio in changes of volume, flow, velocity were 87.9%, 91.5%, 92.6%, in retina respectively and 110.1%, 140.7%, 139.5%, respectively in optic nerve head. These significant changes were not statistically(P>0.05). In 5 diabetic patients with damaged autoregulatory mechanism, the relative ratio in changes of volume, flow, velocity were 114.25%, 118.30%, 117.6%, respectively. These changes were not statistically significant(P>0.05). Our results indicate that the increase of blood flow in ophthalmic artery by compressing superficial temporal artery did not increase retinal blood flow.