Intravitreal triamcinolone acetonide for exudative age related macular degeneration.

AIM: To evaluate the effect of intravitreal triamcinolone acetonide on the visual acuity of patients with exudative age related macular degeneration, to assess the duration of a possible effect, and to evaluate clinical side effects of the treatment. METHODS: The study included 67 patients (71 eyes) who presented with exudative age related macular degeneration of predominantly or total occult type (n = 68) or classic type (n = 3), and who received once, or repeatedly, an intravitreal injection of 25 mg of crystalline triamcinolone acetonide. Mean follow up time was 7.46 (SD 3.54) months (range 3.1-19.57 months). RESULTS: Visual acuity increased significantly (p <0.001) from 0.16 (0.11) to a mean maximum of 0.23 (0.17). Postoperative visual acuity was highest 1-3 months after the injection. 47 (66.2%) eyes gained in maximal visual acuity and 11 (15.5%) eyes lost in visual acuity. Intraocular pressure increased significantly (p <0.001) from 15.1 (3.1) mm Hg at baseline to a maximal value of 23.0 (8.25) mm Hg. At the end of follow up, intraocular pressure again decreased significantly (p<0.001) to 16.8 (4.9) mm Hg. No cases of postoperative infectious endophthalmitis, rhegmatogenous retinal detachment, or proliferative vitreoretinopathy occurred. Owing to a decrease in visual acuity after an initial increase, six patients received a second intravitreal triamcinolone acetonide injection after which visual acuity increased again in three eyes. CONCLUSIONS: Intravitreal injection of 25 mg of crystalline triamcinolone acetonide merits further study for the treatment of exudative age related macular degeneration.

Prevalence and causes of visual field loss in the elderly and associations with impairment in daily functioning: the Rotterdam Study.

OBJECTIVES: To determine the prevalence and causes of visual field loss (VFL) and the association between VFL and indicators of impairment in daily functioning. DESIGN: Population-based cohort study. SETTING: Suburb of Rotterdam, the Netherlands. PARTICIPANTS: Community-dwelling elderly residents (n = 6250). MAIN OUTCOME MEASURE: Visual field loss on suprathreshold static, Goldmann kinetic perimetry, or both. METHODS: Suprathreshold testing of the central visual field was performed on both eyes and repeated if results were abnormal or unreliable. Goldmann perimetry was performed to confirm defects. Causes were determined using ophthalmologic and neurologic examination data and medical records. Impairment was assessed using data from interviews and medical records on disability in daily life, falling, and fractures. RESULTS: The overall prevalence of VFL was 5.6% (3.0% in those aged 55-64 years to 17.0% in those > or =85 years); glaucoma was the leading cause in all age groups. Before age 75 years, other optic nerve diseases and stroke ranked second and third, respectively, as did age-related macular degeneration and retinal vascular occlusive disease, respectively, after this age. Also, after adjustment for visual acuity, VFL was associated with disability, diminished enjoyment of reading and watching television, and a higher risk of incident falling. Risk of incident hip fracture was not increased. CONCLUSIONS: Visual field loss is present in 1 of every 20 community-dwelling elderly people and is associated with impaired daily functioning. Glaucoma is the leading cause in all age groups. Other high-ranking causes, some of which are partly preventable, vary by age.

Regression of neovascular iris vessels by intravitreal injection of crystalline cortisone.

PURPOSE: To report the clinical outcome of patients who received an intravitreal injection of crystalline triamcinolone acetonide as treatment of neovascular glaucoma. PATIENTS AND METHODS: The study included 14 eyes of 14 patients with secondary neovascular glaucoma attributable to proliferative diabetic retinopathy (n = 9) or ischemic central retinal vein occlusion (n = 5). All patients received an intravitreal injection of 20 mg of crystalline triamcinolone acetonide as the only procedure (n = 4) or in combination with additional procedures, such as goniosynechiolysis (n = 1), phacoemulsification and intraocular lens implantation (n = 2), or transscleral peripheral retinal cryocoagulation (n = 7). Mean follow-up time was 3.10 +/- 2.40 months (median, 3.5 months; range, 0.50-5.7 months). A goniosynechiolysis was carried out in those patients in whom the anterior chamber was circumferentially closed. RESULTS: After surgery, including the first days after surgery, the patients were nearly pain-free. Intraocular pressure was significantly (P < 0.01) reduced from 33.4 +/- 14.5 mm Hg before surgery to 20.7 +/- 8.2 mm Hg at the end of the follow-up period. Postoperative visual acuity (mean, 0.09 +/- 0.07; median, 0.10; range, finger counting to 0.25) was slightly but not significantly (P = 0.31) better than the preoperative values. Degree of rubeosis iridis decreased significantly (P = 0.02) from 2.6 +/- 1.3 relative units to 1.3 +/- 1.2 relative units. When considering only the four patients for whom the intraocular cortisone injection was the only procedure performed, mean intraocular pressure decreased from 26.5 +/- 12.1 mm Hg to 21.75 +/- 11.3 mm Hg. CONCLUSIONS: Intravitreal injection of crystalline cortisone with most of the vehicle removed may be a potentially useful additional tool in the treatment of neovascular glaucoma.

Intravitreal injection of crystalline cortisone as adjunctive treatment of proliferative diabetic retinopathy.

PURPOSE: To report the clinical outcome and complications of intravitreal injections of crystalline cortisone in patients undergoing pars plana vitrectomy for treatment of proliferative diabetic retinopathy. METHODS: The prospective, interventional case series study included 29 consecutive patients (29 eyes) who underwent pars plana vitrectomy for treatment of complicated proliferative diabetic retinopathy associated with central retinal traction detachment. All patients received an intravitreal injection of 15 to 20 mg of crystalline triamcinolone acetonide at the end of surgery, and were operated on by the same surgeon. Mean follow-up time was 1.4 +/- 1.1 months (median, 1 month; range, 0.30 to 4.9 months). RESULTS: At the end of the follow-up period, the retina was attached in 26 of the 29 patients (89.7%). In three of the 29 patients (10.3%), a retinal redetachment had occurred. None of the patients developed iris neovascularization, and the iris neovascularization, present preoperatively in 12 patients, slightly to markedly regressed in all 12 patients. Preoperative and postoperative intraocular pressure values (P =.72) and blood glucose measurements did not vary significantly. A pseudohypopyon consisting of cortisone crystals in the inferior anterior chamber angle was detected in one patient and resolved spontaneously within 4 days. CONCLUSIONS: The present clinical study suggests that intravitreal injection of crystalline cortisone with most of the vehicle removed seems to be well tolerated by eyes undergoing pars plana vitrectomy for treatment of complicated diabetic proliferative retinopathy. In view of the antiphlogistic and antiproliferative effect of cortisone, future randomized clinical trials may be indicated to investigate further the role of intravitreal injection of crystalline cortisone in the treatment of proliferative diabetic retinopathy.

Intravitreal injection of crystalline cortisone as adjunctive treatment of proliferative vitreoretinopathy.

AIM: To report on clinical outcome and complications of intravitreal injection of crystalline cortisone in patients undergoing pars plana vitrectomy for treatment of proliferative vitreoretinopathy. METHODS: The study included all 16 patients who underwent pars plana vitrectomy for treatment of proliferative vitreoretinopathy, who received an intravitreal injection of 10-20 mg crystalline triamcinolone acetonide at the end of surgery, and who were operated on by the same surgeon. Most of the vehicle of the solution containing the cortisone crystals was removed before performing the injection. Mean follow up time was 1.64 (SD 2.15) months (median 1. 23 months; range 0.20-9.20 months). The study group was compared with a control group which consisted of 144 patients undergoing pars plana vitrectomy for proliferative vitreoretinopathy performed by the same surgeon. RESULTS: In the study group compared with the control group, intraocular inflammation, as estimated clinically by slit lamp biomicroscopy, was lower, appearance of the fundus upon ophthalmoscopy in the first postoperative week was clearer, and postoperative pain in the first two postoperative days was reduced. Intraocular pressure measured at the end of the first postoperative week did not vary significantly between the groups. A pseudohypopyon consisting of cortisone crystals in the inferior anterior chamber angle was detected in one patient. Postoperative infectious endophthalmitis was not encountered. CONCLUSIONS: This pilot study suggests that intravitreal injection of crystalline cortisone with most of the vehicle removed is not toxic to intraocular structures, reduces postoperative intraocular inflammation, and may be a potentially useful additional tool in the treatment of proliferative vitreoretinopathy.

Ophthalmoscopic evaluation of the optic nerve head.

Optic nerve diseases, such as the glaucomas, lead to changes in the intrapapillary and parapapillary region of the optic nerve head. These changes can be described by the following variables: size and shape of the optic disk; size, shape, and pallor of the neuroretinal rim; size of the optic cup in relation to the area of the disk; configuration and depth of the optic cup; ratios of cup-to-disk diameter and cup-to-disk area; position of the exit of the central retinal vessel trunk on the lamina cribrosa surface; presence and location of splinter-shaped hemorrhages; occurrence, size, configuration, and location of parapapillary chorioretinal atrophy; diffuse and/or focal decrease of the diameter of the retinal arterioles; and visibility of the retinal nerve fiber layer (RNFL). These variables can be assessed semiquantitively by ophthalmoscopy without applying sophisticated techniques. For the early detection of glaucomatous optic nerve damage in ocular hypertensive eyes before the development of visual field loss, the most important variables are neuroretinal rim shape, optic cup size in relation to optic disk size, diffusely or segmentally decreased visibility of the RNFL, occurrence of localized RNFL defects, and presence of disk hemorrhages.

Cataract surgery combined with transpupillary silicone oil removal through planned posterior capsulotomy.

OBJECTIVE: The purpose of the study was to evaluate transpupillary removal of silicone oil combined with cataract surgery in patients after pars plana vitrectomy. DESIGN: A prospective case-control study. PARTICIPANTS: Fifty consecutive patients underwent cataract surgery combined with removal of silicone oil, which had served as intraocular tamponade after pars plana vitrectomy. In 28 patients, silicone oil was removed through a planned posterior capsulotomy, and in 22 patients, silicone oil was removed through pars plana sclerotomies. All patients were operated on by the same surgeon. INTERVENTIONS: Pars plana vitrectomy, cataract surgery, and silicone oil removal were performed. MAIN OUTCOME MEASURES: Frequencies of retinal redetachment, secondary cataract, cystoid macular edema, and vitreous hemorrhage; visual acuity; intraocular pressure; and duration of surgery and visual rehabilitation were measured. RESULTS: Frequencies of postoperative vitreous hemorrhage (1 of 28 [4%] vs. 10 of 22 [45%]) and secondary cataract (0 of 28 vs. 6 of 22 [27%]) were significantly lower (P < 0.05; chi-square test), and duration of surgery and visual rehabilitation were significantly shorter (P < 0.01) for patients with transpupillary silicone oil removal than for patients with drainage of silicone oil through pars plana sclerotomies. Rate of retinal redetachment (4 of 28 [14%] vs. 4 of 22 [18%]), time of retinal redetachment (36 +/- 32 postoperative days vs. 54 +/- 65 days), frequency of dislocated intraocular lenses (1 of 28 vs. 0 of 22), and postoperative visual acuity did not vary significantly between the two groups. Persisting comeal endothelial decompensation and clinically significant cystoid macular edema due to cataract surgery were not observed in any patient. CONCLUSIONS: Silicone oil removal can be combined with cataract surgery. In view of a decreased frequency of postoperative vitreous hemorrhage, reduced rate of secondary cataract, and shorter duration of surgery and visual rehabilitation, transpupillary drainage of silicone oil through a planned posterior capsulotomy compares favorably with removal of silicone oil through pars plana sclerotomies. Retinal redetachment usually occurs within the first 3 postoperative months.

Retinal pigment epithelial cell count, distribution, and correlations in normal human eyes.

PURPOSE: To determine the number of the retinal pigment epithelial cells, their regional distribution, and correlations with general variables in normal human eyes. METHODS: We examined 53 normal human donor eyes from individuals with a mean age of 58.6 +/- 18.8 years and an axial length of less than 27 mm. After opening the globes by a 16-mm corneoscleral trephination, up to 25 biopsy specimens of the retina and retinal pigment epithelium were obtained in four meridians. The retinal pigment epithelial cells and the retinal photoreceptors were counted on photographs taken from the apical retinal pigment epithelial surface and the inner photoreceptor segments. RESULTS: Total number of the retinal pigment epithelial cells was 3,556,290 +/- 490,700 (mean +/- S.D.; range, 2,130,500 to 4,653,200), and it was positively correlated with the number of rods and cones, the total area of the retina, the optic disk size, and the retinal pigment epithelial cell density but was independent of gender. The retinal pigment epithelial cell density decreased significantly (P < .001) from the fovea (4,220 +/- 727 cells/mm2) to the midperiphery (3,002 +/- 460 cells/mm2) and to the outer peripheral fundus regions (1,600 +/- 411 cells/mm2). In the retinal periphery, the retinal pigment epithelial cell density was the highest (P < .01) in the nasal fundus region compared with any other fundus quadrant. The retinal pigment epithelial cell density decreased by about 0.3% per year with increasing age. CONCLUSIONS: These data on the quantitative anatomy of the retinal pigment epithelium may be important for physiology and pathophysiology of the visual process, especially in evaluating the effects of aging.

Retinal photoreceptor density decreases with age.

PURPOSE: To evaluate the effect of age on the density of retinal photoreceptors in humans. METHODS: Fifty-five normal eyes from human donors, with a mean age of 58.7 +/- 19.1 years and an axial length of less than 27 mm, were examined. After opening of the globes by a 16-mm corneoscleral trephination, 25 retinal tissue samples were obtained in four meridians. The photoreceptors were counted on photographs taken from the photoreceptor inner segments after sonographic removal of the outer segments. The cones in the foveal center could not be evaluated. RESULTS: Outside the foveal center, the photoreceptor density decreased significantly with increasing age. In absolute and relative terms, the decline was more marked for the rods (mean rod loss, 236 +/- 63 cells or 0.37% +/- 0.10%/mm2 and year of a mean density of 62.987 rods/mm2) than for the cones (mean cone loss, 5.90 +/- 0.68 cells or 0.18% +/- 0.02%/mm2 and year of a mean density of 3320 +/- 578 cones/mm2). For both cones and rods, the cell loss was more marked at an eccentricity of approximately 5-8 mm than in the retinal periphery at an eccentricity of 14 to 20 mm. There were no significant differences between the superior, inferior, temporal, or nasal meridian nor between women and men. CONCLUSIONS: The photoreceptors decrease in density with increasing age. The annual cell loss of approximately 0.2% to 0.4% is similar to the age-related loss of retinal ganglion cells and pigment epithelium cells. The decline in photoreceptor count affects more rods than cones. It does not prefer special age groups. It is more pronounced at an eccentricity of 5 to 8 mm than in the retinal periphery at an eccentricity of more than 14 mm. It may be important for an age-related decrease in visual functions and for diseases affecting the photoreceptors in elderly patients.

Large optic discs in large eyes, small optic discs in small eyes.

The optic disc area, varying interindividually by a factor of 1:7, is correlated with the count of the retinal ganglion cell axons and photoreceptors. This study evaluated whether the variations in the disc size are additionally correlated with those of the coronary diameters of the globe. Fifty-three normal human donor eyes with a mean age of 54.2 +/- 19.6 years were included in the study. After performing a 16-mm corneoscleral trephination, the globes were fixed and the horizontal and vertical diameters of the globes were measured. We cut the globes into meridional slices sticking together at the posterior fundus region. The areas of the whole retina and the optic disc were planimetrically evaluated on photographs with a millimeter scale aligned. We found that the horizontal and vertical diameters of the globe were correlated with the optic disc size and the retinal surface area. Eyes with long horizontal and vertical diameters had a larger optic disc and a larger retinal surface area than eyes with short diameters. The results suggest the combination of large optic discs in large eyes and of small optic discs in small eyes. Taking into account the relatively low correlation coefficients of 0.3 and 0.4, the study also suggests the existence of other not-evaluated factors influencing the occurrence of large optic discs. The results go along with the reported association between a large optic disc area and a large cornea size.(ABSTRACT TRUNCATED AT 250 WORDS)

Calculation of size and location of autologous ipsilateral rotating keratoplasty.

BACKGROUND: Autologous ipsilateral rotating keratoplasty is a special form of keratoplasty in which a nonprogressive opacification of the centre of the cornea is rotated towards the limbus and the clear peripheral cornea is rotated into the optical axis of the eye. This study was performed to find an equation for calculating the best size and location of the trephine for this special kind of keratoplasty. METHODS: Geometrical calculations were used to derive the formula. RESULTS: We arrived at the following equation for the best diameter of the trephine: diameter(trephine) = 3/4 diameter(cornea)-1/2e(e = preoperative distance between corneal centre and nearest edge of opacity covering corneal centre). The postoperative diameter of the optical zone is: 2 x diameter(trephine)-diameter(cornea). A postoperative clear optical zone of half the corneal diameter is achieved if the opacity just touches but does not extend beyond the corneal centre. For a postoperative optical zone of at least 30% (40%) of the corneal diameter, the opacity is preoperatively not allowed to extend beyond the corneal centre for more than 20% (10%) of the corneal diameter. CONCLUSION: This equation can be used for calculating the optimum size and location of the trephine for autologous ipsilateral rotational keratoplasty. For that purpose it is advisable to take photographs preoperatively.

Retinal photoreceptor count, retinal surface area, and optic disc size in normal human eyes.

PURPOSE: The optic disc area of normal human eyes shows an interindividual variability of 1:7. This study evaluated whether the variation in the optic nerve head size is correlated with a variability in the retinal photoreceptor count and the retinal surface area. METHODS: Forty-six normal human donor eyes with an axial length of less than 26 mm were examined. The corneoscleral button, lens, and vitreous body were removed. The remaining cup of the eye was cut into orange slice-like pieces. Up to 25 retinal biopsies were taken from areas arranged in increasing distance from and concentric to the fovea. The photoreceptor outer segments were sonographically removed. The photoreceptor inner segments were counted on photographs taken from the outer side of the retina. RESULTS: The count of the rods (mean +/- standard deviation: 57,447,000 +/- 10,481,000), the count of the cones (3,246,000 +/- 618,000), the optic disc size, and the retinal surface area (1204 +/- 184 mm2) were significantly (P < 0.05) and positively correlated with each other. CONCLUSIONS: The results indicate that eyes with large optic nerve heads as compared with eyes with small optic discs may have a higher count of rods and cones and a larger retinal surface area. It corresponds with the positive correlation between the optic nerve fiber count and the optic disc size. Taking into account a loss of photoreceptors in glaucoma as recently reported, it may point toward a higher anatomic reserve capacity in glaucomatous eyes with large optic discs than in eyes with small optic nerve heads.