Planned two-step vitrectomy for extremely large and thick subretinal hematoma.

PURPOSE: To describe a new surgical strategy, planned two-step vitrectomy, for a large and thick subretinal hematoma involving 3 or more quadrants of the fundus. SURGICAL METHODS: In a first-step vitrectomy, a retinotomy was made in the posterior pole, after any vitreous hemorrhage had been removed. Following fluid-gas exchange with no laser photocoagulation around the retinotomy, patients took a face-down position for a few days to a week to facilitate subretinal hemorrhage movement to the vitreous cavity and anterior chamber. In a second-step surgery, the hemorrhage in the vitreous cavity and anterior chamber was washed out. The remaining subretinal hemorrhage was aspirated, and the retina was reattached with fluid-gas exchange and laser photocoagulation around the retinotomy. RESULTS: The planned two-step vitrectomy was performed in 4 consecutive patients with large and thick subretinal hematomas involving 3 or more quadrants seen during a 3-year period. By a face-down position after the first-step vitrectomy, subretinal hemorrhage moved to the vitreous cavity and anterior chamber. The remaining subretinal hemorrhage in a smaller quantity could be easily removed, leading to retinal reattachment in the second-step surgery. CONCLUSIONS: The planned two-step vitrectomy is a safer and more effective procedure for removing a large quantity of subretinal hemorrhage in a shorter period of surgical time, compared with hemorrhage removal in a single vitrectomy.

Scleral infolding combined with vitrectomy and gas tamponade for retinal detachment with macular holes in highly myopic eyes.

PURPOSE: To describe the effectiveness of a surgical procedure, scleral infolding combined with vitrectomy and gas tamponade, for retinal detachment caused by macular holes in highly myopic eyes. METHODS: In a pilot study, scleral infolding was performed in 5 patients with macular holes, who were selected from 10 consecutive highly myopic patients with retinal detachment caused by macular holes (8 patients) or extramacular posterior-pole holes (2 patients), treated during 1 year at Okayama University Hospital. The patients were all women, 48-77 years of age (mean = 63.4 years), who had been followed-up for 1-2 years. Selection criteria for scleral infolding were either second surgeries for reopening of macular holes (2 patients) or residual retinal detachment around macular holes after complete fluid-air exchange with drainage of subretinal fluid at the initial surgery (3 patients). Following vitrectomy and complete epiretinal membrane removal in the posterior pole, the sclera was shortened by infolding on the temporal side. Three mattress sutures with 5-0 Dacron in each quadrant, 6 sutures in total, were placed at a 7-mm anteroposterior interval with posterior sutures located as deep as possible, near vortex veins. Fluid-gas exchange was then done, with or without endophotocoagulation applied around macular holes. RESULTS: After scleral infolding, macular holes were closed, and the retina was totally attached in all 5 patients. The final visual acuity ranged from 20/2000 to 20/70. CONCLUSION: Scleral infolding is a simple and effective procedure for treating retinal detachment with macular holes in highly myopic eyes and could be used as an optional procedure of reoperation for a failed initial vitrectomy.

Evaluation of leukocyte dynamics in choroidal circulation with indocyanine green-stained leukocytes.

PURPOSE: To develop a new method with which to visualize leukocytes moving through the choroidal vessels of pigmented animals and enable the evaluation of leukocyte dynamics in the choroidal microcirculation. METHODS: Pigmented rabbits and monkeys were used in this study. Leukocytes, collected by centrifugal separation of autologous blood, were stained with indocyanine green (ICG) dye. The ICG-stained leukocyte fluid was injected into the vein, and the fundus image was obtained with a scanning laser ophthalmoscope. The image was recorded on videotapes and analyzed with a personal computer-based image analysis system. RESULTS: In pigmented rabbits, fluorescent leukocytes moving in the choroidal circulation were clearly visible for more than 1 hour. In monkeys, distinct fluorescent dots were seen moving approximately 50 to 200 microm in the foveal avascular zone for more than 30 minutes after the injection of the ICG-stained leukocyte fluid. Dim fluorescent dots were seen moving in the fundus. Although the movement of these dim dots was difficult to trace, they seemed to be moving in the choroidal vessels. In the rabbits, the mean flow velocity of leukocytes moving without plugging was 0.48 +/- 0.14 mm/sec in the peripheral choriocapillaris. In the monkeys, the mean flow velocity of distinct fluorescent leukocytes without plugging was 2.45 +/- 0. 48 mm/sec in the posterior choroid. CONCLUSIONS: In pigmented rabbits and monkeys, this method allows visualization of leukocytes passing through the choroidal vessels and provides a new way to investigate, noninvasively and in vivo, leukocyte dynamics in the choroidal microcirculation.

Clinical and angiographic characteristics of retinal manifestations in cat scratch disease.

PURPOSE: To elucidate clinical and angiographic features of retinal manifestations in cat scratch disease. METHODS: Clinical characteristics as well as fluorescein and indocyanine green (ICG) angiographic features were reviewed in 4 consecutive patients with retinal manifestations caused by serologically confirmed cat scratch disease. RESULTS: A subretinal to intraretinal granuloma at the upper margin of the optic disc was found in 3 patients, while 1 patient developed subretinal to intraretinal granuloma in the midperiphery with serous retinal detachment. Fluorescein angiography revealed the abnormal vascular network of the peripapillary granuloma in the early phase followed by its dye leakage toward the late phase. Indocyanine green angiography demonstrated more clearly the abnormal vascular network with its minimal dye leakage than did fluorescein angiography. In contrast, only the late dye leakage was noted from granuloma of the midperipheral fundus by fluorescein angiography in one patient. Indocyanine green angiography detected no choroidal lesions other than the retinal lesions delineated by fluorescein angiography. The granulomas disappeared in response to a 4-week course of sulfamethoxazole-trimethoprim combined with steroids. CONCLUSIONS: Granuloma with abnormal vascular network as revealed by fluorescein and ICG angiography is characteristic of retinal manifestations in cat scratch disease.

Identification of ingrowth site of idiopathic subfoveal choroidal neovascularization by indocyanine green angiography.

PURPOSE: This study aimed to determine whether indocyanine green (ICG) angiography is useful to identify the ingrowth site of idiopathic choroidal neovascularization (CNV), which can predict visual outcomes after surgical removal of idiopathic CNV. DESIGN: Consecutive, observational case series. PARTICIPANTS: Twenty-six patients with idiopathic subfoveal CNV, of whom six underwent submacular surgery. INTERVENTION: Indocyanine green videoangiography with a scanning laser ophthalmoscope. MAIN OUTCOME MEASURES: We studied ICG videoangiographic images of choroidal neovascular membranes from the early phase to the late phase with special attention to abnormal findings, which can indicate the ingrowth site of CNV. RESULTS: Early ICG angiography demonstrated distinct neovascular vessels in 24 of the 26 patients (92%). Hypofluorescent rims continuously or intermittently surrounded neovascular membranes on late ICG angiograms in 21 of the 26 patients (81%). In 22 of the 26 patients (85%), ICG angiography demonstrated hypofluorescent areas within the CNV. These hypofluorescent areas frequently became ring shaped in the middle to late phase of the ICG angiography. In 14 of 16 patients (88%) with CNV larger than half a disc area, the filling of neovascular vessels appeared from the inside of the hypofluorescent areas and branched out toward the surrounding hyperfluorescent membrane in the early phase. In all six patients who underwent surgical removal of CNV, ICG videoangiography showed these hypofluorescent areas from which neovascular vessels emanated. Three of the four surgical patients, in whom hypofluorescent areas or central fluorescent areas surrounded by ring-shaped hypofluorescence were extrafoveal or juxtafoveal, had a best postoperative visual acuity of 20/60 or better. In contrast, both surgical patients with subfoveal hypofluorescent areas had a best postoperative visual acuity of 20/70 or worse. CONCLUSIONS: Although further observations are needed, ICG angiography may be a useful adjunct in the identification of the ingrowth site of idiopathic CNV, which can predict visual outcomes after surgery.

Surgical treatment of submacular hemorrhage associated with idiopathic polypoidal choroidal vasculopathy.

PURPOSE: To report the visual outcome of surgical treatment of submacular hemorrhage associated with idiopathic polypoidal choroidal vasculopathy. METHODS: Eight eyes of eight consecutive patients with thick submacular hemorrhages associated with idiopathic polypoidal choroidal vasculopathy were treated with pars plana vitrectomy and tissue plasminogen activator-assisted removal of subretinal blood (December 1995 to September 1997) or intravitreal 100% sulfur hexafluoride gas injection without tissue plasminogen activator (October 1997 to March 1998). RESULTS: Postoperatively, laser treatment was performed for active polypoidal lesions outside the foveal avascular zone in four eyes. A retinal pigment epithelial tear was seen outside the foveal avascular zone in three eyes, and one eye developed a retinal detachment. The best-corrected visual acuity improved (by 3 or more lines) or stabilized in seven of the eight eyes. Four eyes had a final best-corrected visual acuity of 20/40 or better, and three eyes had a final best-corrected visual acuity of 20/50 to 20/200. In one eye, the visual acuity decreased from 20/100 to 20/500 because of the development of a subfoveal neovascular membrane. The membrane was excised, and histologic examination showed fibrovascular tissue between the retina and retinal pigment epithelium (type 2 pattern). CONCLUSIONS: Surgical intervention may be of benefit in eyes with submacular hemorrhage associated with idiopathic polypoidal choroidal vasculopathy.

Treatment options In subfoveal choroidal neovascularization secondary to age-related macular degeneration.

Laser photocoagulation of the entire area of the neovascular lesion is the only proven treatment for subfoveal choroidal neovascularization secondary to age-related macular degeneration with a poor natural history. However, there are some limiting factors such as patient eligibility, a significant decline in visual acuity after treatment, and a very low possibility of a final vision of 20/100 or better. Although no large benefit of other treatment modalities, such as indocyanine green videoangiography-guided laser photocoagulation, surgical removal of neovascular membranes, and radiation therapy, has yet been proven, carefully selected patients may be suitable candidates for such treatments. This article reviews the status of treatment modalities for subfoveal choroidal neovascularization secondary to age-related macular degeneration, including laser photocoagulation of the entire area of the neovascular lesion, and discusses factors prognostic of visual outcome in these treatment options.

Feeder vessel photocoagulation of subfoveal choroidal neovascularization secondary to age-related macular degeneration.

PURPOSE: This study aimed to assess the feasibility of laser photocoagulation of feeder vessels of subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration. PATIENTS AND METHODS: Of 170 consecutive patients with subfoveal CNV secondary to age-related macular degeneration, feeder vessels were detected in 37 patients by means of indocyanine green videoangiography using a scanning laser ophthalmoscope. Dye laser photocoagulation was applied to extrafoveal feeder vessels, with the fovea spared. RESULTS: Twenty-six (70%) of those 37 patients had complete resolution of exudative manifestations. Persistent or worsened manifestations were seen in 11 patients (30%) because of recurrent CNV or persistent CNV. The visual acuity improved or stabilized in 25 patients (68%). Ten patients (27%) had a final visual acuity of 20/40 or better and six patients (16%) had a final visual acuity of 20/50 to 20/100. Significant factors prognostic of the visual outcome of 20/100 or better were small CNV (2 disc areas or smaller, Fisher's exact probability test, P = 0.041), the absence of white, fibrous tissue in neovascular membranes (Fisher's exact probability test, P = 0.003), and the closest distance of laser burns to the center of the foveal avascular zone (Fisher's exact probability test, P = 0.049). Preoperative visual acuity had a significant positive correlation with final visual acuity (Spearman's rank correlation test, P = 0.0076). CONCLUSION: Feeder vessel photocoagulation should be considered as a treatment option for subfoveal CNV secondary to age-related macular degeneration, because no other treatment method has a better visual outcome.