To laser or not?

A 64-year-old male patient presented to the clinic with diminished vision in his right eye for the past 2 years. Examination revealed a best-corrected visual acuity (BCVA) of counting fingers at 1 m with a scarred choroidal neovascular membrane (CNVM) in the right eye while the left eye had a BCVA of 20/20 with a small peripapillary subretinal hemorrhage along with angioid streaks in both eyes. Multimodal imaging revealed the presence of a CNVM in the left eye which was treated with focal thermal laser. Regression was noted on optical coherence tomography angiography at 1 month post-laser, but at 3-month follow-up, exacerbation of the CNVM was observed. Subsequently, four intravitreal ziv-aflibercept injections were given, and scarring of CNVM was noted on OCT. Thermal laser in the background of angioid streaks has worsened the breaks in the Bruch's membrane leading to worsening of the CNVM.

Estrías angioides / No disponible

No disponible

Tratamiento a largo plazo de macroestrías post-laser in situ keratomileusis mediante queratectomía fototerapéutica transepitelial. Caso clínico / Transepithelial phototherapeutic keratectomy to treat chronic laser in situ keratomileusis-flap macrostriae. A case review

Objetivo: Describir el tratamiento a largo plazo de macroestrías en el flap tras laser in situ keratomileusis (LASIK) mediante queratectomía fototerapéutica transepitelial (PTK), a propósito de un caso clínico. Método: Presentamos el caso de un varón de 22 años que presenta macroestrías crónicas en el flap con pérdida de visión en un ojo al que se realiza un tratamiento mediante PTK transepitelial. Resultados: Las estrías y el haze se resuelven completamente con una importante mejoría de la agudeza visual mejor corregida pero con una refracción en el tercer mes de +9,75-4,00×170°. Un año después se implanta una lente fáquica con una agudeza visual final sin corrección de 0,8. Conclusiones: La PTK transepitelial puede resolver las estrías crónicas del flap pero con resultados refractivos variables(AU)

Objective: To describe the use of transepithelial phototherapeutic keratecomy for the long-term treatment of post-laser in situ keratomileusis (LASIK) flap macrostriae. Method: We present the case of a 22 year old male with visual loss in the left eye due to chronic flap macrostriae that was treated with transepithelial PTK. Results: Striae and haze were no longer visible, with a significant improvement of best corrected visual acuity. Refraction in the third month was +9.75-4.00×170°. A phakic intraocular lens was implanted one year later with an uncorrected visual acuity of 0.8. Conclusions: PTK can solve chronic flap striae, but refraction outcome is unpredictable(AU)

[Hyperphosphatemia: an extremely rare cause of angioid streaks]. / L'hyperphosphatémie : une cause rarissime de stries angioïdes.

Angioid streaks are rare lesions of the fundus. They correspond to cracks in the Bruch membrane, which risk choroid neovessel emergence over time. We present the case of a 52-year-old diabetic patient who consulted for a macular syndrome of the left eye. The clinical examination revealed diffuse, bilateral nerve fibers with myelin, but particularly bilateral angioid streaks, complicated on the left by a juxtamacular choroid neovessel. The etiologic assessment revealed idiopathic hyperphosphatemia. We use this observation to discuss the originality of the case, the pathogenic assumption of its etiology, emphasizing the therapeutic difficulties.

[Surgical removal of choroidal neovascularization in angioid streaks].

PURPOSE: All the studies so far on surgical removal of choroidal neovascularization (CNV) in angioid streaks(AS) were conducted on a small number of cases. Therefore, a definitive evaluation of the surgical method was not available. The present study aimed to evaluate this surgical modality. SUBJECTS AND METHOD: We performed surgical removal of foveal CNV accompanied by AS. Eighteen eyes of seventeen patients were available for follow-up of over 12 months. Surgical indications included foveal CNV, fluorescence leakage from the CNV in late-phase fluorescein angiography, and visual acuity of 0.3 or lower. RESULTS: The best visual acuity was improved in 44% and unchanged in 44%. The final visual acuity was improved in 33% and unchanged in 39%. 22% had a preoperative visual acuity of 0.2 or above; and 44% and 17% achieved best and final visual acuity, respectively, of 0.2 or above. Since all cases developed atrophy of the choriocapillaris in the fovea, none of the cases were capable of fixation within atrophy. The fixation point was localized outside atrophy in 56% and fixation was poor in 44%. The diameter of postoperative atrophy of choriocapillaris was significantly greater (p < 0.05) than the preoperative CNV diameter. CNV recurred in 8 eyes(44%), 88% of which occurred within one year. CONCLUSION: Surgical removal of CNV in AS is an effective method to maintain preoperative visual acuity.

[Clinical thinking and decision making in practice. A patient with decreased vision and a skin disorder]. / Klinisch denken en beslissen in de praktijk. Een patiënt met visusdaling en huidafwijkingen.

In a 48-year-old man who suffered from progressive loss of vision in his left eye and metamorphopsia, pseudoxanthoma elasticum was diagnosed. Angioid streaks were observed in both eyes and the skin showed small yellow papules in a linear pattern. The right retina was twice treated by laser coagulation which resulted in temporary regression of neovascularization. Pseudoxanthoma elasticum is a genetic disorder with variable penetrance. There is no treatment. Patients should be told to refrain from contact sports and to avoid using aspirin.

A flexible infusion micro-cannula for subretinal surgery.

Injection of fluids or drugs into the subretinal space is often necessary during subretinal surgery. The authors have developed a flexible micro-cannula for subretinal surgery that can be used for submacular injection of drugs or for atraumatic hydrodissection of the retina. The novel features of the soft tip include reduced diameter (200 microns), increased length, and material selection for resistance to tip buckling. The authors have used this cannula following pars plana vitrectomy for 14 patients with subfoveal choroidal neovascularization secondary to age-related macular degeneration (13 patients) and angioid streaks (1 patient). The cannula creates a relatively atraumatic retinotomy and allows an efficient, controlled injection of subretinal fluid. This micro-cannula seems to be a valuable tool for the subretinal infusion of fluids or drugs.

Laser treatment of choroidal neovascularization in patients with angioid streaks.

The benefit of laser photocoagulation to choroidal neovascularization secondary to angioid streaks remains controversial. To further expand our knowledge, we reviewed the records of 20 patients (24 eyes) with classic (well-defined) choroidal neovascularization secondary to angioid streaks, who were treated with laser between 1982 and 1991 at the Retinal Vascular Center of the Wilmer Institute. The choroidal neovascularization was extrafoveal in 18 (75%), juxtafoveal in two, subfoveal in three, and indeterminate in one eye. Seventeen of the 24 fellow eyes (71%) had a disciform scar or choroidal neovascularization, or both. Follow-up ranged from three months to nine years (mean, 3.5 years; median, two years). Lines of visual acuity change averaged -2.5 at three, -2.6 at six, -2.4 at 12, and -4.8 lines at 24 months. Choroidal neovascularization persisted in five of 24 eyes and recurred in nine of the remaining 19 eyes at risk. When the fellow eye had choroidal neovascularization, scar, or both, at the time of treatment, the rate of persistence or recurrence was 65% vs 33% if the fellow eye had no choroidal neovascularization, scar, or both. An average of four lines of visual acuity was lost when fellow eyes had choroidal neovascularization, scar, or both, vs one line when the fellow eye had no choroidal neovascularization or scar. Laser photocoagulation of choroidal neovascularization in patients with angioid streaks can result in closure of the choroidal neovascularization and stabilization of visual acuity.

A long-term follow-up study of laser coagulation of neovascular membranes in angioid streaks.

We treated 30 eyes (24 patients) with angioid streaks and neovascular membranes using light coagulation. Of 30 eyes, 16 showed either ameliorated or unchanged visual acuity. Twelve of the remaining 14 eyes retained a visual acuity of 20/200 or better. In 11 patients, the fellow untreated eye showed central macular degeneration with loss of central vision. The follow-up period ranged from two months to 16 years (mean, 3.4 years).

Angioid streaks.

Angioid streaks are often associated with a systemic condition, most frequently pseudoxanthoma elasticum, Paget's disease of the bone, or one of the sickle hemoglobinopathies. The clinical manifestations of angioid streaks and those three systemic conditions are reviewed. A diagnostic survey is suggested for patients discovered to have angioid streaks with no known systemic disease. The results of such a survey in 50 patients are presented. In addition, separate studies of patients with Paget's disease of the bone (50 patients) and of the sickle hemoglobinopathies (100 patients) are described, and the characteristics of patients with angioid streaks as well as the incidence of streaks in these conditions is reviewed. The histopathologic and fluorescein angiographic characteristics of angioid streaks, as well as the possible benefit of photocoagulation for complications of angioid streaks is discussed.

Laser treatment of choroidal neovascular membranes in angioid streaks.

Eight patients with active extrafoveal choroidal neovascular membranes related to angioid streaks were studied. One eye of each of four patients was treated with argon laser. Two patients received bilateral treatment. Four patients received multiple treatments at different times for recurrence of neovascular membranes. Two patients were not treated. The visual acuity of the treated eyes remained the same or improved posttreatment, with one exception. The majority of untreated eyes lost vision. The vast majority of the treated eyes showed a marked improvement in central visual field posttreatment, whereas the untreated eyes remained the same or lost considerably more central visual field. In one to four years after treatment, recurrences of the neovascular membranes occurred in four of the treated eyes demonstrating that these cases must be followed indefinitely. Carefully selected cases appear to benefit from complete obliteration of choroidal neovascularization by argon laser photocoagulation.

Argon laser treatment in complications of angioid streaks.

Five patients with subretinal neovascular complications of angioid streaks were treated with the argon laser. One patient, additionally had a central retinal vein occlusion with preretinal neovascularization. In four out of five cases we obliterated the subretinal neovascular membranes with ensuing improvement of visual acuity. In a follow-up period of 14 months on the average, the treatment appeared to be successful.

Neovascularization after argon laser photocoagulation of macular lesions.

In three patients treated for macular degeneration with argon laser photocoagulation choroidal neovascularization occurred four to six weeks later at the photocoagulation site. Two of the patients were treated for angioid streaks of the macular region, the third patient was treated for disciform macular degeneration. Argon laser photocoagulation also induced neovascularization experimentally in pigmented rabbits.