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Antibióticos Antituberculosos/efectos adversos , Infección por Mycobacterium avium-intracellulare/tratamiento farmacológico , Rifabutina/efectos adversos , Supuración/inducido químicamente , Tuberculosis Pulmonar/tratamiento farmacológico , Uveítis/inducido químicamente , Anciano , Antibióticos Antituberculosos/uso terapéutico , Femenino , Seronegatividad para VIH , Humanos , Inmunocompetencia , Persona de Mediana Edad , Complejo Mycobacterium avium , Rifabutina/uso terapéutico , Agudeza VisualRESUMEN
Submacular hemorrhages pose a danger to visual acuity. Intervention may help prevent or mitigate severe visual loss. Pneumatic displacement and vitrectomy with direct evacuation are two methods of treating submacular hemorrhages. Tissue plasminogen activator may be an important adjunct to these techniques.
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Fibrinolíticos/uso terapéutico , Activadores Plasminogénicos/uso terapéutico , Hemorragia Retiniana/tratamiento farmacológico , Activador de Tejido Plasminógeno/uso terapéutico , Humanos , Hemorragia Retiniana/patologíaRESUMEN
PURPOSE: To discuss the incidence and to characterize the clinical features of ocular trauma associated with bungee cord injuries. DESIGN: Retrospective case series. PARTICIPANTS: The authors identified 67 subjects (60 males) treated at Wills Eye Hospital for ocular trauma resulting from bungee cords between September 1, 1994, and September 1, 1999. METHODS: The authors reviewed subjects' records from Wills Eye Hospital, records from outside physicians involved in the subjects' care, and conducted telephone interviews when additional information was needed. MAIN OUTCOME MEASURES: Each chart was reviewed for demographic information, mechanism of injury, presenting visual acuity, anterior segment, posterior segment and periocular injuries, medical and surgical intervention, final visual acuity, and length of follow-up. RESULTS: Mean visual acuity on presentation was 20/150. The most common anterior, posterior, and periocular injuries were hyphema (42/67, 63%), commotio retinae (30/55, 55%), and eyelid edema/ecchymosis (40/67, 60%), respectively. Seven subjects (10%) sustained open globe injuries, three (4%) of whom required enucleation. Eighteen subjects (27%) required medical treatment, and 4 subjects (6%) required surgical treatment for increased intraocular pressure. A total of 21 subjects (31%) required some form of surgical intervention. Mean final visual acuity was 20/60, with an average follow-up of 34 weeks. CONCLUSIONS: This series, the largest to date, demonstrates a wide spectrum of serious ocular injuries related to bungee cord use. Medical and surgical treatments are commonly necessary to manage these injuries. We advocate a modification in the design of these cords and appropriate printed warnings directed to the users of bungee cords regarding the potential for severe ocular trauma.
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Cuerpos Extraños en el Ojo/etiología , Lesiones Oculares Penetrantes/etiología , Actividades Recreativas , Goma , Adolescente , Adulto , Niño , Diseño de Equipo , Enucleación del Ojo , Cuerpos Extraños en el Ojo/patología , Cuerpos Extraños en el Ojo/prevención & control , Cuerpos Extraños en el Ojo/cirugía , Lesiones Oculares Penetrantes/patología , Lesiones Oculares Penetrantes/prevención & control , Lesiones Oculares Penetrantes/cirugía , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Oftalmológicos , Estudios Retrospectivos , Agudeza VisualRESUMEN
PURPOSE: To assess the value of patient-initiated second medical opinions (SMO). METHODS: The authors prospectively collected demographic data from 100 consecutive patients. The authors recorded major changes in the patients' care, such as inappropriate surgery recommended, inadequate treatment performed, and appropriate treatment not recommended. The authors also recorded costs incurred or saved by the patients and the third-party payers. RESULTS: In nearly 15 of the cases, the authors had major disagreements with the initial diagnosis or management. Surgery had been recommended in 28 cases. They advised against it in nine. In 72 cases, no surgery had been recommended. They advised and performed it in five. The management of five other patients was not in accordance with that recommended by large clinical trials or was inadequately done. Including the consultation fees, surgery performed or advised against, retinal angiography, and ultrasonography, the 100 SMO cost third-party payers $12,426. If the authors subtract the cost of noncontroversial surgery they recommended and if the patients had paid the consultation fee and had brought along their fluorescein angiograms, third-party payers would have saved $4,079. CONCLUSION: The savings SMO generated by eliminating unnecessary surgery resulted in improved patient care at minimal cost to third-party payers.
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Derivación y Consulta/economía , Derivación y Consulta/estadística & datos numéricos , Enfermedades de la Retina/economía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Costo de Enfermedad , Costos y Análisis de Costo , Femenino , Costos de la Atención en Salud , Humanos , Lactante , Reembolso de Seguro de Salud/economía , Masculino , Persona de Mediana Edad , Oftalmología/economía , Pennsylvania , Estudios Prospectivos , Enfermedades de la Retina/diagnóstico , Enfermedades de la Retina/cirugíaRESUMEN
OBJECTIVE: To describe the clinical features, association with von Hippel-Lindau (VHL) disease and visual acuity outcomes of patients with a juxtapapillary capillary hemangioma. DESIGN: Retrospective observational case series. PARTICIPANTS: Seventy-two eyes of 68 patients identified with a juxtapapillary capillary hemangioma. Follow-up data of at least 6 months duration were available for 60 eyes. METHODS: A retrospective chart review of patients diagnosed with a juxtapapillary capillary hemangioma examined at four medical centers. MAIN OUTCOME MEASURES: Age at diagnosis, visual acuity (VA) at first examination and at last follow-up, tumor growth pattern and location, associated clinical features, type of treatment, association with VHL, and presence of peripheral hemangiomas were recorded for each patient. RESULTS: On initial examination, VA was >/=20/40 in 43 of 70 eyes (61%) and was >/=20/200 in 60 eyes (86%). At an average follow-up of 5.4 years (range, 0.5-19 years), VA of >/=20/40 was achieved in 21 eyes (35%) and >/=20/200 in 33 eyes (55%). Patients with VHL had poorer initial VA (48% vs. 70% with VA >/=20/40, and 74% vs. 93% with VA >/=20/200) and final VA (26% vs. 41% with VA >/=20/40, and 39% vs. 65% with VA >/=20/200) compared with patients without VHL. Patients with VHL more commonly were seen at an earlier age (average, 20 vs. 44 years, P: < 0.001), with bilateral (17% vs. 0%), and/or peripheral (39% vs. 0%) (P: < 0.001) tumors that more often had an endophytic growth pattern (63% vs. 22%, P: = 0.001) compared with patients without VHL. Patients selected for laser treatment generally had poorer initial (52% vs. 74% with VA >/=20/40, 79% vs. 96% with VA >/=20/200) and final VAs (18% vs. 56% with VA >/=20/40, 45% vs. 67% with VA >/=20/200) compared with patients not treated with laser. CONCLUSIONS: On long-term follow-up of patients with a juxtapapillary capillary hemangioma, the VA generally worsens. Patients with VHL and a juxtapapillary hemangioma more often present at a younger age, have tumors with an endophytic growth pattern, and have bilateral, multiple tumors. Treatment with laser photocoagulation results in variable VA outcomes.
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Hemangioma Capilar/patología , Disco Óptico/patología , Neoplasias del Nervio Óptico/patología , Agudeza Visual , Adolescente , Adulto , Anciano , Niño , Preescolar , Femenino , Angiografía con Fluoresceína , Estudios de Seguimiento , Hemangioma Capilar/complicaciones , Hemangioma Capilar/cirugía , Humanos , Coagulación con Láser , Masculino , Persona de Mediana Edad , Disco Óptico/cirugía , Neoplasias del Nervio Óptico/complicaciones , Neoplasias del Nervio Óptico/cirugía , Estudios Retrospectivos , Enfermedad de von Hippel-Lindau/complicacionesRESUMEN
Photodynamic therapy is a relatively selective form of treatment for choroidal neovascularization. Unlike standard laser photocoagulation, photodynamic therapy can close choroidal neovascularization with minimal or no detectable damage to surrounding tissues. Therefore, it allows the clinician to treat subfoveal choroidal neovascularization without immediately adversely affecting central visual function. Several dyes for photodynamic therapy have been under various stages of formal clinical investigation. There is now mounting evidence that shows that photodynamic therapy with at least one of these dyes can significantly reduce the risk of visual loss in eyes with subfoveal choroidal neovascularization from age-related macular degeneration. This form of treatment promises to have a major, favorable impact on public health in areas of the world in which age-related macular degeneration is common.
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Neovascularización Coroidal/tratamiento farmacológico , Fotoquimioterapia , Fármacos Fotosensibilizantes/uso terapéutico , Coroides/patología , Neovascularización Coroidal/etiología , Humanos , Degeneración Macular/complicaciones , Soluciones Oftálmicas , Fotoquimioterapia/métodos , Fotoquimioterapia/tendencias , Retina/patología , Resultado del TratamientoRESUMEN
OBJECTIVE: To compare visual outcomes between cases of acute postoperative endophthalmitis that did or did not receive intravitreal steroids. DESIGN: Retrospective nonrandomized comparative trial. PARTICIPANTS: Fifty-seven patients with postoperative endophthalmitis. INTERVENTION: Thirty-one patients with postoperative endophthalmitis resulting from cataract extraction received both intravitreal antibiotics and steroids, whereas the remaining 26 received only intravitreal antibiotics. MAIN OUTCOME MEASURES: Improvement in visual acuity. RESULTS: Multivariate logistic regression was used to analyze the variables that potentially influence a three-line visual acuity improvement. The mean baseline visual acuities of both groups were comparable. The use of intravitreal steroids reduced the probability of developing a three-line improvement in visual acuity (odds ratio [OR] = 0.287; 95% confidence interval [CI] [0.072-0.852]). On the basis of logistic regression analysis using our multivariate model, gender, baseline visual acuity, and pars plana vitrectomy were not significantly associated with visual outcome differences between the two groups. CONCLUSIONS: Patients who received intravitreal steroids had a significantly reduced likelihood of obtaining a three-line improvement in visual acuity. At a minimum our study provides no support for their use and, therefore, steroids may not be efficacious for acute endophthalmitis related to cataract extraction.
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Extracción de Catarata/efectos adversos , Dexametasona/uso terapéutico , Endoftalmitis/tratamiento farmacológico , Glucocorticoides/uso terapéutico , Agudeza Visual , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Amicacina/uso terapéutico , Quimioterapia Combinada , Endoftalmitis/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Vancomicina/uso terapéutico , Vitrectomía , Cuerpo Vítreo/efectos de los fármacosAsunto(s)
Ceguera/etiología , Ojo/irrigación sanguínea , Arteria Oftálmica/fisiopatología , Arteria Retiniana/fisiopatología , Curvatura de la Esclerótica/efectos adversos , Adulto , Ceguera/fisiopatología , Velocidad del Flujo Sanguíneo , Presión Sanguínea , Femenino , Frecuencia Cardíaca , Humanos , Presión Intraocular , Arteria Oftálmica/diagnóstico por imagen , Arteria Retiniana/diagnóstico por imagen , Desprendimiento de Retina/cirugía , Ultrasonografía Doppler en Color , Agudeza VisualRESUMEN
Recent developments in the clinical application of indocyanine green angiography have mainly concerned refining its role as an adjunct to fluorescein angiography in detecting and guiding the treatment of choroidal neovascularization. We now have a better understanding of the different patterns of abnormal hyperfluorescence seen with indocyanine green angiography in eyes with both wet and dry forms of macular degeneration. In exudative cases, the success rate of laser treatment guided by indocyanine green angiographic findings can vary considerably, and it is now known which angiographic presentations are not as likely to benefit. In dry macular degeneration, indocyanine green angiography appears to add clinically useful information, such as helping to identify plaques in fellow eyes with choroidal neovasculrization or watershed zones that may be predictive of future exudative transformation. In certain circumstances, indocyanine green angiography can be valuable in detecting choroidal neovascularization in other macular diseases or in helping to diagnose other choroidal conditions, especially when the clinical presentation is atypical, such as central serous chorioretinopathy in elderly patients.
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Neovascularización Coroidal/diagnóstico , Angiografía con Fluoresceína , Colorantes Fluorescentes , Verde de Indocianina , Degeneración Macular/diagnóstico , Neovascularización Coroidal/etiología , Fondo de Ojo , Humanos , Degeneración Macular/complicaciones , Epitelio Pigmentado Ocular/patologíaRESUMEN
OBJECTIVE: To investigate the efficacy and safety of treating thick submacular hemorrhages with intravitreous tissue plasminogen activator (tPA) and pneumatic displacement. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: From 5 participating centers, 15 eligible patients had acute (<3 weeks) thick subretinal hemorrhage involving the center of the macula in eyes with pre-existing good visual acuity. Hemorrhages were secondary to age-related macular degeneration in 13 eyes and macroaneurysm and trauma in 1 eye each. METHODS: The authors reviewed the medical records of 15 consecutive patients who received intravitreous injection of commercial tPA solution (25-100 microg in 0.1-0.2 ml) and expansile gas (0.3-0.4 ml of perfluoropropane or sulfur hexafluoride) for thrombolysis and displacement of submacular hemorrhage. After surgery, patients maintained prone positioning for 1 to 5 days (typically, 24 hours). MAIN OUTCOME MEASURES: Degree of blood displacement from under the fovea, best postoperative visual acuity, final postoperative visual acuity, and surgical complications. RESULTS: In 15 (100%) of 15 eyes, the procedure resulted in complete displacement of thick submacular hemorrhage out of the foveal area. Best postprocedure visual acuity improved by 2 lines or greater in 14 (93%) of 15 eyes. After a mean follow-up of 10.5 months (range, 4-19 months), final visual acuity improved by 2 lines or greater in 10 (67%) of 15 eyes and measured 20/80 or better in 6 (40%) of 15 eyes. Complications included breakthrough vitreous hemorrhage in three eyes and endophthalmitis in one eye. Four eyes developed recurrent hemorrhage 1 to 3 months after treatment, three of which were retreated with the same procedure. CONCLUSIONS: Intravitreous injection of tPA and gas followed by brief prone positioning is effective in displacing thick submacular blood and facilitating visual improvement in most patients. The rate of serious complications appears low. Final visual outcomes are limited by progression of the underlying macular disease in many patients.
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Fibrinolíticos/uso terapéutico , Fluorocarburos/uso terapéutico , Mácula Lútea , Hemorragia Retiniana/tratamiento farmacológico , Hexafluoruro de Azufre/uso terapéutico , Terapia Trombolítica , Activador de Tejido Plasminógeno/uso terapéutico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Aneurisma/complicaciones , Lesiones Oculares/complicaciones , Femenino , Humanos , Inyecciones , Degeneración Macular/complicaciones , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Posición Prona , Hemorragia Retiniana/etiología , Vasos Retinianos/patología , Estudios Retrospectivos , Resultado del Tratamiento , Agudeza Visual , Cuerpo VítreoRESUMEN
OBJECTIVE: To determine the long-term visual acuity after diode laser photocoagulation for threshold retinopathy of prematurity. DESIGN: Retrospective, noncomparative case series. INTERVENTION: Photocoagulation of the peripheral avascular retina with a diode laser indirect ophthalmoscope. MAIN OUTCOME MEASURES: The principal outcome evaluated was best-corrected visual acuity (BCVA). The most recent refractions for these eyes were also collected for analysis. PARTICIPANTS: Thirty-five infants with threshold retinopathy of prematurity treated with laser photocoagulation from 1991 to 1996. RESULTS: After bilateral laser treatment, 14 (56%) of 25 patients who were capable of accurate visual acuity testing had 20/50 or better BCVA in at least 1 eye with 11 (44%) of 25 patients having at least 20/50 BCVA in both eyes. After unilateral treatment, four (40%) of ten had 20/50 or better BCVA in the treated eye while five (50%) of ten laser-treated eyes had a BCVA at least equal to the untreated fellow eye. Compared to eyes with 4 or more diopters (D) of myopia, those with less than 4 D of myopia were 6.4 times more likely to achieve 20/50 or better BCVA (95% confidence interval, 1.7-22.7). The average age at follow-up was 3.7 years. CONCLUSIONS: After laser photocoagulation for threshold retinopathy of prematurity, 29 (48%) of 60 eyes had 20/50 or better visual acuity. Eyes with 4 or more D of myopia were significantly less likely to achieve 20/50 or better visual acuity than eyes with less than 4 D of myopia.
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Coagulación con Láser , Retinopatía de la Prematuridad/fisiopatología , Retinopatía de la Prematuridad/cirugía , Agudeza Visual/fisiología , Preescolar , Femenino , Estudios de Seguimiento , Edad Gestacional , Humanos , Recién Nacido , Masculino , Refracción Ocular , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVE: To evaluate the clinical utility of routinely using indocyanine green angiography (ICGA) with fluorescein angiography (FA) in detecting persistent or recurrent choroidal neovascularization (CNV). DESIGN: Prospective, consecutive case series. PARTICIPANTS: Twenty-four eyes of 21 patients with exudative age-related macular degeneration (AMD) that had conventional laser treatment for CNV were examined. INTERVENTION: Fluorescein angiography and ICGA were performed together on all eligible eyes at the first post-treatment visit and all subsequent follow-up visits in which persistent or recurrent CNV was suspected clinically. MAIN OUTCOME MEASURES: Choroidal neovascularization detection and delineation by each angiographic technique were measured. RESULTS: Of the 54 FA-ICGA study pairs performed over a 20-month investigation period, FA showed well-defined, ill-defined, and no CNV in 10 (19%), 19 (35%), and 25 (46%) eyes, respectively. Indocyanine green angiography had a high concordance rate at 70% and 88% when persistent or recurrent CNV was well-defined and absent, respectively, on FA and rarely added additional, clinically useful information in these settings, particularly in the former presentation. Of the 29 eyes that showed some evidence of CNV by FA, the neovascular complex was ill-defined in 19 (66%) eyes. When CNV was ill-defined by FA, the corresponding ICGA showed well-defined CNV in 9 (47%) of 19 eyes, in 5 of which the CNV was nonsubfoveal in location. CONCLUSIONS: Persistent or recurrent CNV in AMD was frequently ill-defined by FA. Indocyanine green angiography was a valuable adjunct to FA by better delineating CNV in this specific setting. However, ICGA was not useful when the post-treatment FA showed well-defined CNV. Furthermore, ICGA was not helpful when the first post-treatment FA was negative and there were no ophthalmoscopic signs of exudation.
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Neovascularización Coroidal/diagnóstico , Angiografía con Fluoresceína , Colorantes Fluorescentes , Verde de Indocianina , Anciano , Anciano de 80 o más Años , Neovascularización Coroidal/etiología , Neovascularización Coroidal/cirugía , Femenino , Estudios de Seguimiento , Humanos , Coagulación con Láser , Degeneración Macular/complicaciones , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Recurrencia , Agudeza VisualRESUMEN
OBJECTIVE: The goal of this study was to determine whether there was a significant difference between the visual outcomes of eyes with threshold retinopathy of prematurity (ROP) treated with trans-scleral cryotherapy compared to those treated with laser photocoagulation. DESIGN: Extended follow-up study of a prospective, randomized clinical trial. PARTICIPANTS: Fifty-two patients with bilateral threshold ROP participated. Follow-up data were available for 25 of these patients. INTERVENTION: Patients were randomized to receive cryotherapy in one eye and laser photocoagulation in the other eye. MAIN OUTCOME MEASURES: The best-corrected visual acuity of each eye was measured. Best-corrected visual acuities of 20/50 or better were classified as "good" clinical outcomes, whereas those 20/60 or worse were considered "poor" outcomes. A secondary outcome of this study was the spherical equivalent (SE) of each eye's most recent refraction. RESULT: At an average follow-up point of 5.8 years (range, 4.3-7.6 years), the odds that an eye treated with laser had a good clinical outcome were 6.91 times greater than for eyes treated with cryotherapy (95% confidence interval, 1.70-28.0; n = 21). Additionally, the laser-treated eyes were less myopic with a mean SE of-3.05 diopters compared to a mean SE of -5.08 diopters for the cryotherapy-treated eyes (P = 0.0072, n = 23). CONCLUSION: The authors' study suggests that laser photocoagulation for threshold ROP was more likely to result in a good clinical outcome with better final visual acuity and less myopia compared to cryotherapy treatment.
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Criocirugía , Coagulación con Láser , Retinopatía de la Prematuridad/cirugía , Niño , Preescolar , Femenino , Estudios de Seguimiento , Edad Gestacional , Humanos , Recién Nacido , Recién Nacido de muy Bajo Peso , Masculino , Estudios Prospectivos , Retinopatía de la Prematuridad/fisiopatología , Resultado del Tratamiento , Agudeza Visual/fisiologíaRESUMEN
Most cases of X-linked juvenile retinoschisis and degenerative retinoschisis never require any type of surgical intervention. However, on rare occasions, associated problems such as retinal detachment come about and threaten the visual prognosis. Both conditions have in common the adherence of cortical vitreous to the inner layer of peripheral schisis cavities, which can make the secondary complications technically difficult to manage. Although good surgical results can often be obtained, it is not unusual to require relatively advanced vitreoretinal techniques to achieve long-term surgical success.
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Ligamiento Genético , Enfermedades de la Retina/cirugía , Vitrectomía/métodos , Cromosoma X , Humanos , Retina/patología , Enfermedades de la Retina/diagnóstico , Enfermedades de la Retina/genética , Resultado del TratamientoAsunto(s)
Enfermedades de la Coroides/patología , Hematopoyesis , Accidentes de Tránsito , Adulto , Enfermedades de la Coroides/etiología , Enucleación del Ojo , Lesiones Oculares Penetrantes/complicaciones , Humanos , Masculino , Retina/lesiones , Desprendimiento de Retina/etiología , Esclerótica/lesiones , Hemorragia Vítrea/etiologíaAsunto(s)
Enfermedades de la Coroides/diagnóstico , Hemorragia de la Coroides/diagnóstico , Coroides/irrigación sanguínea , Colorantes , Angiografía con Fluoresceína/métodos , Verde de Indocianina , Neovascularización Patológica/diagnóstico , Anciano , Coroides/cirugía , Enfermedades de la Coroides/complicaciones , Enfermedades de la Coroides/cirugía , Hemorragia de la Coroides/etiología , Hemorragia de la Coroides/cirugía , Exudados y Transudados , Femenino , Estudios de Seguimiento , Fondo de Ojo , Humanos , Coagulación con Láser , Neovascularización Patológica/etiología , Neovascularización Patológica/cirugíaRESUMEN
The authors present a technique of transscleral fixation of a posterior chamber intraocular lens modified to permit a small-incision approach by using a foldable silicone lens. This modification improved intraoperative globe stability and reduced operative time. This procedure also has the potential for expediting postoperative recovery and visual rehabilitation.
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Extracción de Catarata/métodos , Lentes Intraoculares , Técnicas de Sutura , Cuerpo Ciliar/cirugía , Humanos , Agudeza Visual , VitrectomíaRESUMEN
OBJECTIVE: To better define the spectrum of patient characteristics and fundus findings in patients with a presumably unique clinical entity referred to as diabetic papillopathy. DESIGN: Retrospective series. SETTING: A university-based referral practice. METHODS: We retrospectively reviewed the medical records of all diabetic patients with benign, transient disc swelling who were evaluated at our institution from 1986 to 1992. Data pertaining to patient demographics, visual acuity and symptoms, disc and retinal findings, ancillary test results, and clinical course were collected. RESULTS: Twenty-seven eyes of 19 patients met the study definition of diabetic papillopathy. Patients were generally older (mean age, 50 years) and of a broader age range (19 to 79 years) compared with those in prior reports. Two thirds of patients had type II diabetes. Disc swelling was consistently hyperemic and, on average, resolved within 3.7 months. Macular edema was a frequent associated finding (70% of eyes) as was significant capillary nonperfusion (52% of tested eyes). Only four eyes (15%) had final visual acuities of less than 20/50 and each had prominent macular edema. Cup-disc ratio analysis of uninvolved eyes revealed a significantly small physiologic cup. CONCLUSIONS: The clinical profile of diabetic papillopathy can be expanded to include people who are older or have type II diabetes and that affected eyes commonly have macular edema or retinal vascular changes that can adversely affect the visual outcome. Last, a small physiologic cup may represent an anatomic predisposition to the condition.