Ocular side effects associated with peribulbar injections of triamcinolone acetonide for diabetic macular edema.

PURPOSE: To evaluate long-term effects of anterior and posterior peribulbar injections of triamcinolone acetonide on intraocular pressure (IOP) elevation and cataract development. METHODS: This study reports on IOP and cataract progression through 2 years in 96 eyes with diabetic macular edema randomized to focal/grid photocoagulation, 20 mg triamcinolone acetonide anterior injection, anterior injection followed by laser, 40 mg triamcinolone acetonide posterior injection, or posterior injection followed by laser. RESULTS: Intraocular pressure increased from baseline by ≥ 10 mmHg at ≥ 1 visit through 2 years in 2 eyes (8%) in the laser group, 11 eyes (31%) in the anterior groups, and 6 eyes (17%) in the posterior groups. Among phakic eyes at baseline, 0, 5 (17%), and 1 (3%) in the 3 groups, respectively, underwent cataract surgery before the 2-year visit. CONCLUSION: Based on this small randomized trial, it appears that over 2 years, anterior peribulbar triamcinolone acetonide injections are associated with an increased incidence of IOP elevation and an increased risk of cataract development compared with laser or posterior peribulbar injections. The association of posterior injections with IOP elevation is less certain. Although the study involved eyes with diabetic macular edema, the results should be relevant to other conditions treated with peribulbar corticosteroids.

Retinal vascular proliferation as an ocular manifestation of von Hippel-Lindau disease.

OBJECTIVES: To describe the features, natural history, and management of an unusual manifestation of ocular von Hippel-Lindau disease in the form of fine vascular proliferation. METHODS: Case series of 14 patients with definite or presumed von Hippel-Lindau disease. RESULTS: Retinal vascular proliferation consisting of fine superficial vessels was found in 16 eyes of 14 patients with von Hippel-Lindau disease. The lesion was often found in a juxtapapillary location and associated with a fibrovascular component and/or a macular epiretinal membrane. In cases with follow-up (12 patients; mean [SD] follow-up, 10.9 [7.5] years), the lesion was stable in 7 of 13 eyes but showed growth and progression resulting in vision loss in the remainder. In 5 eyes, surgical intervention with pars plana vitrectomy, membrane peel, and excision of the fibrovascular lesion resulted in visual improvement in all of the cases. CONCLUSIONS: Ocular von Hippel-Lindau disease can uncommonly manifest as vascular proliferation that consists of fine, superficial, juxtapapillary vessels that are often associated with fibrovascular proliferation and epiretinal membrane formation. The natural history of this lesion is variable and can result in vision loss from tractional effects in progressive cases. Vision-threatening cases may be successfully managed by surgical excision.

Long-term visual acuity results of treated and untreated radiation retinopathy (an AOS thesis).

PURPOSE: To report ocular findings in eyes with radiation retinopathy and visual acuity (VA) results of photocoagulation for macular edema and proliferative retinopathy. METHODS: This retrospective case series compared VA after photocoagulation treatment and nontreatment of radiation macular edema. Visual outcomes were assessed with regression analyses. RESULTS: Eighty-seven eyes (78 [89.7%] treated with external beam irradiation and 9 treated with local plaques) were studied. Fifty-nine (67.8%) and 28 (32.2%) eyes had nonproliferative and proliferative retinopathy, respectively; macular edema developed in 42 nonproliferative eyes (71.2%) and 24 proliferative eyes (85.7%). Initial VAs (median) were 20/40 and 20/65 for nonproliferative and proliferative eyes, respectively, and final VA was 20/80 and 20/400. Initial VA (median) in eyes with macular edema was 20/50 compared to 20/25 in eyes without edema; final VAs were 20/200 and 20/30. Comparing treated (19 [45.2%]) and untreated (23[54.8%]) macular edema in 42 eyes with nonproliferative retinopathy, initial median VA (20/40 and 20/50) and final VA (20/100 and 20/200) were better in treated eyes. Regression analysis showed significant treatment effect (P = .003) when initial VA (logMAR) and months of follow-up were kept constant; treated eyes had mean final VA (logMAR) 0.36 (95% CI, 0.12-0.60) better than untreated eyes. CONCLUSIONS: The presence of macular edema and proliferation indicates more severe retinopathy and worse visual prognosis than for eyes without macular edema and proliferation. Although these VA results suggest macular photocoagulation is beneficial, eyes with macular edema continue to lose vision despite treatment. Better prevention and treatment methods are needed for radiation retinopathy.

Relationship between optical coherence tomography-measured central retinal thickness and visual acuity in diabetic macular edema.

OBJECTIVE: To compare optical coherence tomography (OCT)-measured retinal thickness and visual acuity in eyes with diabetic macular edema (DME) both before and after macular laser photocoagulation. DESIGN: Cross-sectional and longitudinal study. PARTICIPANTS: Two hundred ten patients (251 eyes) with DME enrolled in a randomized clinical trial of laser techniques. METHODS: Retinal thickness was measured with OCT and visual acuity was measured with the electronic Early Treatment of Diabetic Retinopathy procedure. MAIN OUTCOME MEASURES: Optical coherence tomography-measured center point thickness and visual acuity. RESULTS: The correlation coefficients for visual acuity versus OCT center point thickness were 0.52 at baseline and 0.49, 0.36, and 0.38 at 3.5, 8, and 12 months after laser photocoagulation. The slope of the best fit line to the baseline data was approximately 4.4 letters (95% confidence interval, 3.5-5.3) of better of visual acuity for every 100-mum decrease in center point thickness at baseline with no important difference at follow-up visits. Approximately one third of the variation in visual acuity could be predicted by a linear regression model that incorporated OCT center point thickness, age, hemoglobin A1C, and severity of fluorescein leakage. The correlation between change in visual acuity and change in OCT center point thickening 3.5 months after laser treatment was 0.44, with no important difference at the other follow-up times. A subset of eyes showed paradoxical improvements in visual acuity with increased center point thickening (7%-17% at the 3 time points) or paradoxical worsening of visual acuity with a decrease in center point thickening (18%-26% at the 3 time points). CONCLUSIONS: There is modest correlation between OCT-measured center point thickness and visual acuity, and modest correlation of changes in retinal thickening and visual acuity after focal laser treatment for DME. However, a wide range of visual acuity may be observed for a given degree of retinal edema. Thus, although OCT measurements of retinal thickness represent an important tool in clinical evaluation, they cannot substitute reliably as a surrogate for visual acuity at a given point in time. This study does not address whether short-term changes on OCT are predictive of long-term effects on visual acuity.

Diurnal variation in retinal thickening measurement by optical coherence tomography in center-involved diabetic macular edema.

OBJECTIVE: To evaluate diurnal variation in retinal thickness measured with optical coherence tomography (OCT) in patients with center-involved diabetic macular edema. METHODS: Serial OCT3 measurements were performed in 156 eyes of 96 subjects with clinically diagnosed diabetic macular edema and OCT central subfield retinal thickness of 225 microm or greater at 8 am. Central subfield thickness was measured from OCT3 retinal thickness maps at 6 points over a single day between 8 am and 4 pm. A change in central subfield thickening (observed thickness minus mean normal thickness) of at least 25% and of at least 50 microm at 2 consecutive points or between 8 am and 4 pm was considered to have met the composite outcome threshold. RESULTS: At 8 am, the mean central subfield thickness was 368 microm and the mean visual acuity was 66 letters (approximately 20/50). The mean change in relative central subfield retinal thickening between 8 am and 4 pm was a decrease of 6% (95% confidence interval, -9% to -3%) and the mean absolute change was a decrease of 13 microm (95% CI, -17 to -8). The absolute change was significantly greater in retinas that were thicker at 8 am (P<.001) but the relative change was not (P = .14). The composite threshold of reduction in central subfield thickening (as defined above) was observed in 5 eyes of 4 subjects (3% of eyes; 95% CI, 1% to 8%) while 2 eyes of 2 subjects (1%; 95% CI, 0% to 5%) had an increase in central subfield thickening of this same magnitude. The maximum decrease was observed at 4 pm in all 5 eyes. CONCLUSION: Although on average there are slight decreases in retinal thickening during the day, most eyes with diabetic macular edema have little meaningful change in OCT central subfield thickening between 8 am and 4 pm.

Optical coherence tomography of bilateral posterior microphthalmos with papillomacular fold and novel features of retinoschisis and dialysis.

PURPOSE: To report a case of retinoschisis and dialysis associated with bilateral posterior microphthalmos and papillomacular fold. DESIGN: Observational case series. METHODS: Complete ophthalmologic examination of three of five siblings presenting with bilateral posterior microphthalmos and papillomacular fold. Optical coherence tomography (OCT) data are presented to confirm the abnormal anatomy. RESULTS: All subjects have bilateral elevated horizontal papillomacular retinal fold with cystoid macular edema and shallow subretinal fluid. Optical coherence tomography was consistent with our examinations. One subject, a 13-year-old Hispanic, initially presented with retinoschisis in the superotemporal quadrant of the left retina that developed 9 years later into a retinal dialysis without subretinal fluid. The right eye of this same patient developed retinoschisis in the far superotemporal retinal periphery during 9 years of observation. CONCLUSION: Retinoschisis and dialysis may occur in patients with posterior microphthalmos with papillomacular fold. Optical coherence tomography may be helpful in assessing these patients.

Subluxation of transscleral sutured posterior chamber intraocular lens (TSIOL).

PURPOSE: To evaluate factors related to late-onset transscleral sutured posterior chamber intraocular lens (TSIOL) subluxation. METHODS: Retrospective observational case series. Analysis of subluxated TSIOLs in seven eyes from seven patients treated between May 1999 and May 2001. RESULTS: Mean age at the time of TSIOL surgery was 33 +/- 6 years. Mean time from TSIOL surgery to its subluxation was 78 +/- 19 months. Initial diagnoses requiring TSIOL surgeries were previous history of trauma and Marfan syndrome. Subluxation of TSIOLs was associated with blunt trauma in three eyes, whereas the other four eyes experienced spontaneous lens dislocation. CONCLUSION: Subluxation of TSIOL is not uncommon in younger patients with history of trauma or Marfan syndrome.