A Three-year Follow-up of Intravitreal Triamcinolone Acetonide Injection and Macular Laser Photocoagulation for Diffuse Diabetic Macular Edema

PURPOSE: To report the three-year outcomes of macular laser photocoagulation following intravitreal injection of triamcinolone acetonide (IVTA) for diffuse diabetic macular edema (DME). METHODS: A prospective, randomized controlled study was completed. Eighty-six eyes of 74 patients with diffuse DME were randomized into two groups. Eyes assigned to the combination group (n = 48) were subjected to macular laser photocoagulation three weeks after IVTA. Eyes in the IVTA group (n = 38) underwent IVTA alone. Central macular thickness was measured by optical coherence tomography, and the number of additional treatments and mean time to recurrence were assessed. RESULTS: Thirty-seven eyes in the combination group and 26 eyes in the IVTA group completed the three-year follow-up. Recurrence of DME after initial treatment was not observed for nine of the 37 (24.3%) eyes in the combination group or for one of the 26 (3.9$) eyes in the IVTA group (p = 0.028). DME was absent for 19.9 months after treatment in the combination group compared to 10.3 months in the IVTA group (p = 0.027). The mean number of additional treatments was 0.92 in the combination group and 1.88 in the IVTA group (p = 0.001). CONCLUSIONS: Results in the subset of subjects who completed the three-year follow-up demonstrated that laser photocoagulation following IVTA is more effective than IVTA monotherapy for diffuse DME. Combination therapy required fewer additional treatments and resulted in a lower recurrence rate than IVTA monotherapy.

A Developmental Mechanism of Spontaneous Reattachment in Rhegmatogenous Retinal Detachment

This retrospective observational case series on eyes from three patients was done to elucidate the developmental mechanism of spontaneous reattachment of rhegmatogenous retinal detachment (SRRRD). The study eyes of each patients showed evidence of retinal break and diffuse retinal pigmentary change. Ultrasound biomicroscopic examination revealed vitreous fibers attached to the area around the retinal break. Posterior vitreous attachment was confirmed in each eye. A thin fibrovascular membrane incompletely sealing the retinal break was noted in one case. We suggest that the vitreous attachment around the retinal break and the sealing of the break with adjacent vitreous fibers seem to be involved in the developmental mechanism of SRRRD.

Estrogen Antagonist and Development of Macular Hole

To describe the clinical and optical coherence tomography (OCT) features of a macular hole (MH) or its precursor lesion in patients treated with systemic antiestrogen agents. We reviewed the medical history of the patient, ophthalmic examination, and both fundus and OCT findings. Three female patients receiving antiestrogen therapy sought treatment for visual disturbance. All of the patients showed foveal cystic changes with outer retinal defect upon OCT. Visual improvement was achieved through surgery for the treatment of MH in two patients. Antiestrogen therapy may result in MH or its precursor lesion, in addition to perifoveal refractile deposits. OCT examination would be helpful for early detection in such cases.

Diabetic Retinopathy and Peripapillary Retinal Thickness

PURPOSE: To assess the diagnostic efficacy of macular and peripapillary retinal thickness measurements for the staging of diabetic retinopathy (DR) and the prediction of disease progression. METHODS: In this prospective study, 149 diabetic patients (149 eyes) and 50 non-diabetic control subjects were included. Baseline optical coherence tomography was employed to measure retinal thickness in the macula (horizontal, vertical, and central) and the peripapillary zone (superior, inferior, nasal, and concentric to the optic disc). Seven baseline parameters were correlated with the DR stages identified by fluorescein angiography. Baseline retinal thickness was compared between groups of patients requiring panretinal photocoagulation (PRP) within 6 months (PRP group) and patients not requiring PRP (No-PRP group). RESULTS: Macular and peripapillary retinal thicknesses in diabetic subjects were significantly greater than that in normal controls (p<0.05). All retinal thickness parameters, and particularly peripapillary circular scans, tended to increase with increasing DR severity (p<0.05). The baseline thicknesses of the peripapillary circular scans were greater in the PRP group than in the no-PRP group (p<0.05). CONCLUSIONS: Peripapillary retinal thickness may prove to be a useful criterion for DR severity and may also serve as an indicator of disease progression.

Central Photoreceptor Viability and Prediction of Visual Outcome in Patients with Idiopathic Macular Holes

PURPOSE: To identify the correlation between preoperative optical coherence tomography (OCT) features and postoperative visual outcomes in eyes with idiopathic macular holes (MHs). METHODS: Data from 55 eyes with idiopathic MHs which had been sealed by vitrectomy were retrospectively reviewed. Correlation analysis was conducted between postoperative visual acuity (V(postop), logarithm of the minimum angle of resolution [logMAR]) and preoperative factors, including four OCT parameters: the anticipated length (A) devoid of photoreceptors after hole closure, MH height (B), MH size (C), and the grading (D) of the viability of detached photoreceptors. Additionally, the formula for the prediction of visual outcome was deduced. RESULTS: V(postop) was determined to be significantly correlated with the preoperative visual acuity (V(preop)) and OCT parameters A, C, and D (p<0.001). Based on the correlation, the formula for the prediction of V(postop) was derived from the most accurate regression analysis: V(postop)=0.248xV(preop)+1.1x10(-6)xA(2)-0.121xD+0.19. CONCLUSIONS: The length and viability of detached photoreceptors are significant preoperative OCT features for predicting visual prognosis. This suggests that, regardless of the MH size and symptom duration, active surgical intervention should be encouraged, particularly if the MH exhibits good viability in the detached photoreceptor layer.

Comparison of the Normal Visual Fields Between the Goldmann and Humphrey Kinetic Perimetries

PURPOSE: To show Humphrey automated kinetic perimetry can be substituted for Goldmann perimetry, which has been used in the field of disability evaluation field, the differences of normal visual fields between two perimetries were evaluated. METHODS: Goldmann and Humphrey automated kinetic perimetries were performed simultaneously in 70 eyes of 35 normal healthy Koreans who had no specific ophthalmologic disease at 12 meridians; 0degrees, 30degrees, 60degrees, 90degrees, 120degrees, 150degrees, 180degrees, 210degrees, 240degrees, 270degrees, 300degrees, and 330degrees. The mean values of field in each case were compared. In addition, the corrected values were obtained through the calculation of the difference in the two maximal fields. RESULTS: The visual fields of Humphrey and Goldmann kinetic perimetries showed a similar oval shape, but the fields of Goldmann were statistically significantly wider than the Humphrey fields. As the values of Humphrey were compared with the original data of Goldmann, all values of the visual field were narrow. CONCLUSIONS: The visual fields by Humphrey automated kinetic perimetry were smaller than those by Goldmann perimetry. Therefore, if Humphrey kinetic perimetry is used for the evaluation of visual disability, the visual field should be evaluated after the correction.

The Short-term Effect of Triple Therapy for Diabetic Macular Edema With Vitreomacular Traction

PURPOSE: To evaluate the short-term effect and safety of a triple therapy on diabetic macular edema (DME) with vitreomacular traction. METHODS: Twenty four eyes from 24 subjects, diagnosed with DME with vitreomacular traction, were subjected to vitrectomy. Intravitreal triamcinolone acetonide injection and macular laser photocoagulation were conducted sequentially at one and 14 days after vitrectomy. Best corrected visual acuity (BCVA) and central macular thickness (CMT) were recorded before surgery and at three and six months after triple therapy. RESULTS: The mean (+/-standard deviation [SD]) logarithm of the minimum angle of resolution BCVAs before, three, and six months after the triple therapy were 0.77+/-0.38, 0.48+/-0.27, and 0.47+/-0.36, respectively. The mean (+/-SD) CMTs before, three, and six months after the triple therapy were 407.9+/-127.1 micrometer, 272.4+/-104.6 micrometer, and 263.5+/-131.2 micrometer, respectively. The changes in BCVA at three and six months from treatment were statistically significant. Macular thickness decreased significantly at 3 and 6 months postoperatively. CONCLUSIONS: Triple therapy is a good therapeutic option for diabetic macular edema with vitreomacular traction to improve visual acuity and macular thickness.

Retinal Angiomatous Proliferation and Intravitreal Bevacizumab Injection

PURPOSE: To evaluate the short-term efficacy and safety of intravitreal bevacizumab injection (IVBI) in patients with retinal angiomatous proliferation (RAP). METHODS: Seven eyes of 5 patients with RAP were included in this study. All of the eyes evidenced stage 2 RAP lesions, except for one eye with a stage 3 lesion. IVBI (1.25 mg/0.05 cc) were conducted at 4 or 6-week intervals. Complete ocular examinations, angiographic results and optical coherence tomographic findings before and after the IVBI were analyzed at baseline and upon the follow-up visits. RESULTS: Seven eyes were studied in 5 patients who had undergone IVBI. Partial (3 eyes) or complete (4 eyes) regression of RAP was noted after IVBI in all of the studied eyes. Visual acuity improved in 5 of the eyes, and was stable in 2 of the eyes. One eye evidenced severe intraocular inflammation after IVBI and a subsequent development of new RAP, which was controlled with vitrectomy and repeat IVBI. CONCLUSIONS: This treatment was effective over 6 months, stabilizing or improving visual acuity and reducing angiographic leakage. These short-term results suggest that IVBI may constitute a promising therapeutic option, particularly in the early stages of RAP.

Chronic Central Serous Chorioretinopathy: Photodynamic Therapy

PURPOSE: To evaluate the clinical results of photodynamic therapy (PDT) using verteporfin in patients with chronic central serous chorioretinopathy (CSC). METHODS: A retrospective study in a clinical practice setting of eight eyes (eight patients) with chronic CSC. The point of dye leakage on the fluorescein angiogram (FA) was too close to the fovea to treat these patients with focal laser treatment. Additionally, choroidal vascular hyperpermeability was observed with indocyanine green angiogram (ICGA). Patients were treated with verteporfin PDT and evaluated for visual acuity, complications, change in centralmacular thickness with the optical coherence tomogram (OCT), and recurrence. RESULTS: Pre-PDT visual acuity improved from 0.46 (0.04~0.7) to 0.82 (0.15~1.2) with an average of 15.2 months follow-up post-treatment (p=0.011). The mean central macular thickness also reduced from 283 micrometer to 135.5 micrometer. Central macular exudation resolved completely in all eyes. There was no recurrence after PDT. CONCLUSIONS: PDT with verteporfin appeared to be a beneficial treatment option for patients with chronic CSC.

Circumscribed Choroidal Hemangioma: a Report of 7 Cases

PURPOSE: To report the clinical features and management of circumscribed choroidal hemangioma. METHODS: Seven patients with circumscribed choroidal hemangioma were reviewed retrospectively. One eye having a small tumor without subretinal fluid was observed. Four eyes with large tumors around the posterior pole were treated with laser photocoagulation or/and transpupillary thermotherapy. Stereotactic radiosurgery with a gamma knife was applied in 2 eyes with large tumors on the peripheral retina. RESULTS: In all cases, the retinal detachment showed complete resolution. Tumor thickness was decreased in 2 cases treated with stereotactic radiosurgery. Visual acuity was either improved or unchanged in 6 eyes and decreased in one eye after treatment. CONCLUSIONS: Circumscribed choroidal hemangioma is a rare intraocular tumor. These tumors can be treated with variable modalities based on their size, location, and subretinal fluid. They have a favorable prognosis. Stereotactic radiotherapy is a reasonable treatment alternative for large symptomatic choroidal hemangiomas.

Visual Prognosis of Culture-Proven Bacterial Endophthalmitis

PURPOSE: To evaluate the factors contributing to the visual outcome of patients with culture-proven bacterial endophthalmitis. METHODS: We reviewed medical records of all eyes with infectious endophthalmitis between January 1996 and June 2005. The causative bacteria were identified in 18 of 90 eyes, for which we evaluated their clinical features and factors influencing their visual prognosis. RESULTS: Bacterial endophthalmitis occurred after cataract surgery in 6 of 18 eyes, after trabeculectomy or glaucoma implant surgery in 4 eyes, after trauma in 3 eyes, after intravitreal triamcinolone injection in 1 eye, and after endogenous endophthalmitis in 4 eyes. The culture results were similar between gram positive and gram negative organisms. Final vision was 0.1 or better in 6 of the 18 eyes. Final visual acuities showed statistically significant correlation with causative organisms (p=0.018). CONCLUSIONS: For effective management of bacterial endophthalmitis and prediction of prognosis, we recommend thorough bacterial culture. Also, further investigation with a large population is needed.

Results of Deep Lamellar Endothelial Keratoplasty (DLEK)

PURPOSE: To evaluate the clinical results of deep lamellar endothelial keratoplasty (DLEK) surgery in patients with bullous keratopathy. METHODS: Seven eyes of 7 patients diagnosed with bullous keratopathy were evaluated for pre- and postoperative visual acuity, refractive error, astigmatism, and corneal topographic results. Specular microscopy and corneal pachymetry was performed in order to evaluate the corneal endothelial cell status. Postoperative complications such as graft rejection, infection, glaucoma, and graft dislocation were also evaluated. RESULTS: Preoperative visual acuity improved from 0.006 (CF ~ 0.02) to 0.4 (0.1 ~ 0.5) at an average of 1.2+/-0.18 years of follow-up. Manifest refraction, topographic astigmatism, corneal endothelial cell density, and central corneal thickness at the final visit were 1.21+/-0.73D, 2.1+/-0.70D, 1304+/-682 cells/mm2, and 504+/-128 micrometer respectively. Two eyes (28.6%) developed graft rejection, one of which recovered after intensive steroid treatment. However, one patient (14.3%) underwent penetrating keratoplasty due to graft failure at 6 months postoperatively. Seven of 7 eyes were noted to have graft dislocation, all of which were repositioned and attached after air injection or suture. CONCLUSIONS: DLEK surgery is an effective alternative to conventional penetrating keratoplasty for bullous keratopathy patients because of fast visual recovery and low incidence of postoperative astigmatism.