TISSUE PLASMINOGEN ACTIVATOR FOR SUBFOVEAL HEMORRHAGE DUE TO AGE-RELATED MACULAR DEGENERATION: Comparison of 3 Treatment Modalities.

PURPOSE: To analyze and compare the effects of three common treatment modalities for a thick subfoveal hemorrhage due to exudative age-related macular degeneration on final visual acuity and the size of the final subretinal scar. DESIGN: Retrospective case series. SETTING: Single-site, tertiary referral center. PATIENTS: Thirty-nine patients with exudative age-related macular degeneration and acute SMH greater than 250 µm. INTERVENTION: Patients received vitrectomy with a subretinal tissue plasminogen activator (tPA) injection, pneumatic displacement (PD) with intravitreal tPA, or PD without tPA within 2 weeks of presentation. MAIN OUTCOME MEASURE: Functional outcome was determined by Snellen visual acuity. Anatomical outcome was determined as the final disciform scar size. RESULTS: Treatment groups did not differ in age, sex, initial visual acuity, the initial area of the thick subfoveal hemorrhage, follow-up duration, lens status, duration of exudative age-related macular degeneration, previous intravitreal bevacizumab injections, or time from last given injection to the acute thick subfoveal hemorrhage. Final visual acuity improved significantly in both the vitrectomy and subretinal tPA injection group (P < 0.001), and the intravitreal tPA injection group (P = 0.002) but not with PD alone. Patients treated with subretinal tPA achieved 40% ± 54% reduction in final scar area, in contrast to 27% ± 35% decrease in patients treated with intravitreal tPA (P = 0.001). CONCLUSION: Treatment with tPA improves the functional and anatomical outcomes in patients with thick subfoveal hemorrhage due to subfoveal choroidal neovascular membrane secondary to exudative age-related macular degeneration and was superior to PD without tPA. Vitrectomy with subretinal tPA injection reduced the final disciform scar compared with PD with or without intravitreal tPA.

UNTREATED OBSTRUCTIVE SLEEP APNEA HINDERS RESPONSE TO BEVACIZUMAB IN AGE-RELATED MACULAR DEGENERATION.

PURPOSE: To compare functional and anatomical responses to intravitreal bevacizumab in patients with exudative age-related macular degeneration (AMD) between two groups of patients with obstructive sleep apnea (OSA) with and without treatment with continuous positive airway pressure therapy. METHODS: Patients with OSA were categorized into 2 groups: 18 untreated and 20 treated with continuous positive airway pressure therapy. All patients had exudative AMD and received treatment with intravitreal bevacizumab. Central retinal thickness was plotted against time to assess anatomical response. Logarithm of the minimum angle of resolution visual acuity changes determined functional effect. Total number of intravitreal injections administered was assessed. RESULTS: Treated OSA group received 8 ± 7 total injections; untreated OSA group received 16 ± 4 injections (P < 0.05). Treated OSA group achieved statistically significant better visual acuity (logarithm of the minimum angle of resolution, 0.3 ± 0.24, 20/40), as opposed to the untreated group (logarithm of the minimum angle of resolution, 0.7 ± 0.41; P < 0.05). Central retinal thickness improved in the treated OSA group compared with the untreated group: 358 ± 95 µm to 254 ± 45 µm and 350 ± 75 µm to 322 ± 105 µm, respectively (P < 0.05, 20/100). CONCLUSION: Untreated OSA hinders the response of exudative AMD to intravitreal bevacizumab. Treatment of OSA with continuous positive airway pressure therapy yields a subsequent anatomical response and functional improvement while requiring significantly less injections. Identifying and treating underlying OSA earlier in patients with exudative AMD may yield better functional outcomes.

Mathematical analysis of specific anatomic foveal configurations predisposing to the formation of macular holes.

PURPOSE: To mathematically analyze and to clinically describe specific anatomic foveal configurations predisposing to the formation of macular holes in comparison with normal foveal anatomy. METHODS: In a retrospective observational case-control series, a total of 3882 optical coherence tomography (OCT) foveal thickness maps were analyzed; 96 foveal maps were identified before the formation of macular holes. Maps were analyzed using several anatomic measurements including: retinal thickness, foveal slope, and length of foveal depression. The mathematical analog of the foveal configuration was analyzed using automated symbolic regression software and the equation to describe the mathematical relationship in a 0.083 fit was derived for premacular hole foveas compared with normal age-matched foveas. RESULTS: Premacular hole anatomic configuration was found to be significantly different from normal foveal anatomy for maximal slope (P < 0.05) and for central length of foveal depression (P < 0.05). The mathematical regression function followed a first-order cosine curve of level 12 complexity for normal fovea compared with a complex sine curve of level 30 complexity function for premacular hole fovea. Normal foveas had higher symmetry (0.86 ± 0.1, P = 0.03) along the midline, whereas premacular hole foveas had steeper maximal slopes (40 ± 18°, P = 0.01); 75% of these patients had similar foveal configuration in the fellow eye and 50% developed bilateral macular holes. CONCLUSIONS: Premacular hole foveal configurations are significantly different from normal foveal configurations. Suspicious macular configurations are easy to recognize on OCT scans and may allow early diagnosis, follow-up, and better management of macular hole-prone patients.

Primary retinal detachment repair: comparison of 1-year outcomes of four surgical techniques.

PURPOSE: To compare functional and anatomical outcomes of modern methods of repair of primary retinal detachment. MATERIALS AND METHODS: Retrospective interventional comparative case series. A total of 1,226 patients with primary retinal detachment were included in the study. All patients completed 1-year follow-up and were divided into 4 groups: 322 patients underwent scleral buckling surgery, 442 patients underwent pars plana vitrectomy surgery, 316 patients underwent a combination of scleral buckling and vitrectomy surgery, and 56 patients underwent pneumatic retinopexy surgery for the primary repair of retinal detachment. Reattachment success rates, pre- and postoperative visual acuity, complications, and change in refractive error were reviewed. RESULTS: Initial success rate for retinal reattachment was 86% for scleral buckling only, 90% for vitrectomy only, 94% for the combination of scleral buckling and vitrectomy, and 63% for pneumatic retinopexy surgery. Although patients undergoing pneumatic retinopexy had a lower initial success rate, there was no statistically significant difference in initial reattachment rates between the other three groups. There was no statistically significant difference in final visual acuity between the four groups. Complication rates varied among the techniques used. CONCLUSION: Postoperative visual acuity at 1 year did not differ among the various techniques used to repair primary rhegmatogenous retinal detachments. However, scleral buckling, vitrectomy, or a combination of both resulted in an initially better anatomical success rate and fewer operative procedures than pneumatic retinopexy.