Comet-tailed drusen of the retinal pigment epithelium in angioid streaks.

PURPOSE: To describe a fundus finding in angioid streaks, namely comet-tailed drusen of the retinal pigment epithelium. METHODS: A review was carried out of fundus photographs in 110 cases of angioid streaks. RESULTS: Five patients had comet-tailed drusen and the halo tail was radial and parallel to adjacent angioid streaks. CONCLUSIONS: Comet-tailed drusen may represent zones of minor stress of the retinal pigment epithelium--Bruch's membrane complex compared with zones of major stress as in angioid streaks.

Color Doppler imaging of arterial blood flow in central retinal vein occlusion.

PURPOSE: The hemodynamics of the retrobulbar arterial circulation of patients with central retinal vein occlusion were evaluated in order to better understand the pathophysiology of this disease. METHODS: Color Doppler imaging was used to measure the peak systolic velocity and vascular resistance (pulsatility index) in the retrobulbar arteries of involved eyes and clinically healthy fellow eyes of patients with central retinal vein occlusion and in the control eyes of age- and sex-matched healthy volunteers. RESULTS: Average peak systolic velocity was significantly lower and average vascular resistance was significantly higher in the central retinal artery of involved eyes of patients with central retinal vein occlusion compared with clinically healthy fellow eyes and compared with control eyes. There also was a trend toward higher vascular resistance in the central retinal artery of clinically healthy fellow eyes of patients with central retinal vein occlusion compared with control eyes. In the ophthalmic arteries and short posterior ciliary arteries, vascular resistance was significantly higher in both the involved eyes and clinically healthy fellow eyes of patients with central retinal vein occlusion compared with control eyes. CONCLUSION: Color Doppler imaging parameters of the central retinal artery circulation were abnormal in eyes with central retinal vein occlusion, suggesting impaired arterial blood flow associated with this disease. The high vascular resistance in the central retinal arteries, ophthalmic arteries, and short posterior ciliary arteries of both involved and clinically healthy fellow eyes of patients with central retinal vein occlusion suggests that diffuse small vessel disease may predate and contribute to the development of central retinal vein occlusion.

Indocyanine green angiography and occult choroidal neovascularization.

PURPOSE: To evaluate the use of digital indocyanine green (ICG) angiography as an adjunct to fluorescein angiography in the diagnosis and treatment of ill-defined choroidal neovascularization (CNV) associated with age-related macular degeneration (AMD). METHODS: The authors retrospectively reviewed all ICG angiograms performed at Wills Eye Hospital from March to July 1992. Included in this study were all cases with exudative manifestations of AMD in which fluorescein angiography showed ill-defined CNV. The initial ICG findings and the clinical outcome of both treated and untreated cases were evaluated through 6 months of follow-up. RESULTS: Of the 101 eligible cases, ICG angiography at presentation demonstrated well-defined hyperfluorescence in 40 cases (group 1), ill-defined hyperfluorescence in 43 cases (group 2), mixed pattern of well- and ill-defined hyperfluorescence in 14 cases (group 3), and no abnormalities in 4 cases (group 4). Approximately one half of the cases with well-defined ICG hyperfluorescence (21% of the total) had only extrafoveal changes. Laser photocoagulation treatment based solely on ICG angiogram findings was performed in 19 group 1 cases (extrafoveal hyperfluorescent foci only) and in 8 group 3 cases, with treatment in both groups being directed only to areas of well-defined hyperfluorescence. Successful treatment was achieved in 12 (63%) of 19 cases and in 2 (25%) of 8 cases, respectively. There was a strong correlation between post-treatment persistence or recurrence of ICG hyperfluorescence and treatment failure. CONCLUSIONS: Indocyanine green angiography is a valuable diagnostic adjunct to fluorescein angiography in evaluating occult CNV in AMD. In this series, well-defined, extrafoveal ICG hyperfluorescence was identified in 21% of the cases, and preliminary, short-term results suggest that ICG-guided laser treatment is promising in this subgroup.

Evolution of angioid streaks.

Angioid streaks of the fundus are not apparent at birth. In order to study their evolution, we examined in a retrospective manner the fundus pictures of 111 subjects with angioid streaks. The earliest form of angioid streaks became apparent at age 8 with findings of narrow short radial discontinuous hypopigmented streaks. Thereafter angioid streaks enlarged in length and width. The end-stage was disciform macular degeneration, helicoid peripapillary atrophy, or diffuse choroidal sclerosis with obscuration of the angioid streaks. We conclude that angioid streaks represent a dynamic manifestation of an underlying retinochoroidal degenerative process.

Pseudophakic retinal detachments. Anatomic and visual results.

Retinal reattachment rates and visual results were analyzed in 227 consecutive primary pseudophakic rhegmatogenous retinal detachments. The overall anatomic reattachment rate was 90%, with no significant difference between the anterior chamber (AC) and posterior chamber intraocular lens groups. Visual results were significantly worse in the AC lens group (P less than 0.05). Negative prognostic indicators for reattachment included age greater than 65 years, poorer preoperative vision, larger extent of the retinal detachment, inability to identify a retinal break, longer duration of symptoms before presentation, and grades C or D proliferative vitreoretinopathy (P less than 0.05). In addition to the above factors, eyes with AC reaction, AC lenses, and macular detachment had a poorer visual prognosis.

Central retinal vein occlusion associated with drusen of the optic disc.

A 43-year-old man had gradual visual changes OD. Funduscopic examination revealed central retinal vein occlusion OD. Complete ocular examination revealed bilateral drusen of the optic disc, confirmed by b-scan ultrasonography. Complete systemic evaluation showed no other etiology for the central retinal vein occlusion. Over a ten-year follow-up, in the absence of systemic disease or other local ocular anomalies, we concluded that central retinal vein occlusion can arise from external compression secondary to drusen of the optic disc.

Visual prognosis correlated with the presence of internal-limiting membrane in histopathologic specimens obtained from epiretinal membrane surgery.

Forty-one patients with a unilateral, macular epiretinal membrane (ERM) underwent pars plana vitrectomy and membrane peeling to improve the visual acuity. The authors retrospectively reviewed the histopathology of the vitrectomy specimen in each instance to determine whether the presence of internal-limiting membrane (ILM) had an adverse effect on visual acuity. Eleven specimens contained long segment of ILM, as determined by light microscopy. With a minimum of 6 months of follow-up, none of these 11 eyes achieved a visual acuity of better than 20/60. Of 30 eyes that did not have ILM present, 41% achieved a visual acuity of 20/60 or better. Overall, 29% of the eyes in the entire series achieved 20/60 or better visual acuity. The difference between the group with ILM versus that without ILM was statistically significant (P = 0.01). The presence of long segments of ILM within the histopathologic specimen after vitreous surgery for removal of a macular ERM appears to indicate a less favorable visual outcome.

Computerised visual field deficits in tears of the retinal pigment epithelium.

Retinal Pigment epithelial tears have been well documented as a complication of pigment epithelial detachment in patients with age related macular degeneration. Spontaneous and iatrogenic separation of detached retinal pigment epithelium, with subsequent retraction and exposure of the underlying choriocapillaris and Bruch's membrane, usually results in poor visual function in the affected areas. However, exact characterisation of the resultant scotomas has not been previously described. We present two patients with spontaneous pigment epithelial tears who underwent Octopus computerised visual field analysis. The density and characteristics of their associated field loss is compared with their clinical and fluorescein angiographic appearance.

Clinicopathologic study of organic dye. Laser in the human fundus.

One day before enucleation for choroidal melanoma, four patients consented to experimental laser photocoagulation for the purpose of comparing the histopathologic appearance of acute chorioretinal lesions produced by various dye laser wavelengths with krypton red and argon green laser controls. Three patients had simulated "light" and "heavy" treatment of an extrafoveal choroidal neovascular membrane (CNVM) with wavelengths 577 nm (yellow), 595 nm (orange), and 600 nm (orange). One patient had simulated panretinal photocoagulation (PRP) with four different dye laser wavelengths. Extrafoveal "light" treatment with the three dye wavelengths and both controls spared the inner retina and produced similar effects in the outer retina, pigment epithelium, and choriocapillaris. Choroidal penetration was deepest with the longer wavelengths (590-647 nm) in both "light" and "heavy" treatment groups. "Heavy" treatment gave varying degrees of full-thickness retinal uptake for all dye and both control wavelengths. Both ends of the orange spectrum (590-600 nm) produced the most severe inner retinal uptake. Panretinal photocoagulation produced similar full-thickness retinal uptake for all four dye wavelengths tested. These results indicate that caution should be used when treating "heavily" with 590 and 600 nm in the extrafoveal area.

Macular degeneration in angioid streaks.

This study examines different clinical parameters and the occurrence of macular degeneration in a series of 110 patients with angioid streaks of the fundus. Among the parameters considered were: age of the patient at the time of ocular diagnosis, associated systemic disease, optic nerve drusen, peau d'orange appearance in the fundus, number of radiating angioid streaks as well as their length, width, and distance from the fovea. Statistically significant correlations were found between the occurrence of macular degeneration (of the exudative hemorrhagic type) and the following: angioid streak length, distance from the fovea, and the diffuse type or 'cracked egg-shell' fundus appearance.

Subretinal neovascular membranes associated with choroidal nonperfusion and retinal ischemia.

This is the first well-documented case of co-existent underlying choroidal nonperfusion in an eye with a subretinal neovascular membrane that was subsequently treated with krypton red laser photocoagulation by the senior author (LEM). The possible role of chronic macular ischemia secondary to choroidal circulatory impairment is discussed in relationship to other well-established risk factors. Perhaps treatment to improve macular oxygenation would be a reasonable alternative to eradication of the neovascularization by direct laser photocoagulation.

Temporal branch retinal vein obstruction: a review.

Two hundred forty-six eyes with temporal branch retinal vein obstruction (TBRVO) were studied prospectively. Of the 85 eyes not receiving laser treatment, 35 (41%) presented with greater than or equal to 20/50 vision and 89% remained in this group; whereas, 29 eyes (34%) presented with less than or equal to 20/200 vision and only 17% improved. Of the 161 eyes receiving laser, 40 (25%) had greater than or equal to 20/50 vision pre-treatment and 75% remained in this group; whereas, 64 eyes (40%) had less than or equal to 20/200 vision pre-treatment and 50% improved. The average final VA (20/70 vs 20/100), risk of developing neovascularization in ischemic TBRVO (3% vs 34%) and risk of vitreous hemorrhage in proliferative TBRVO (10% vs 57%) were all significantly better in treated eyes (p less than or equal to 0.01).

Krypton red laser photocoagulation of peripapillary subretinal neovascular membranes.

The visual outcome of 20 eyes of 20 patients with peripapillary subretinal neovascular membranes (SRNVM) treated with krypton red laser photocoagulation (KRLP) was studied. Complete obliteration of the SRNVM was achieved in all eyes in the study. In 18 of 20 patients, the visual acuity improved or remained the same during an average follow-up of 9.9 months. There were no treatment-related complications. The efficacy of KRLP in the management of patients with peripapillary SRNVM is discussed.

Diabetic retinopathy under age 20. A review of 71 cases.

A review of the fluorescein angiograms on 4547 diabetic patients with clinically suspected retinopathy was performed. Although only 26 (1%) of the 2013 males and 45 (2%) of the 2534 females were less than 20 years old (71 patients total), proliferative diabetic retinopathy (PDR) was diagnosed in 14 females (31%) and 4 males (15%). The youngest patient, a 13-year-old boy with diabetes for eight years, presented with severe proliferative diabetic retinopathy in both eyes as documented angiographically. He showed no evidence of other systemic complications of diabetes. A review of the literature revealed one other case of proliferative diabetic retinopathy in a patient this young; a 13-year-old girl who was nephrotic and hypertensive upon presentation. This study emphasizes the importance of having prepubescent and teenage diabetics examined for the presence of retinopathy.

Krypton red laser photocoagulation of subretinal neovascular membranes located within the foveal avascular zone.

Fifty-one eyes with senile macular degeneration and a well-defined subretinal neovascular membrane located within 250 microns from the center of the foveal avascular zone were treated with krypton red laser photocoagulation. Follow-up ranged from 8 to 18 months (mean, 10 months). The eyes were divided into two groups based upon the location of the neovascular membrane. Group I (juxtafoveal membrane 1 to 250 microns from the center of the foveal avascular zone) contained 26 eyes. Following treatment the visual acuity in 16 of the 26 eyes (62%) improved by two or more lines on the Snellen chart or stabilized. Group II (subfoveal membrane present under the center of the foveal avascular zone) contained 25 eyes. Following treatment only 7 of 25 eyes (28%) improved by two or more Snellen lines or maintained their pretreatment visual acuity. Of 16 eyes that had a pretreatment visual acuity of 20/100 or better, only 2 eyes (12%) remained in this group following treatment.

Complications of krypton red laser photocoagulation to subretinal neovascular membranes.

The use of krypton red laser photocoagulation (KRLPC) to treat subretinal neovascular membranes (SRNVM) is increasing. The complications of this treatment in a large series of patients have not been reported. Over a 15-month period, 195 patients had KRLPC to SRNVM of the following etiologies: senile macular degeneration (151), presumed ocular histoplasmosis (33), miscellaneous (11). Fourteen patients had the following complications attributable to KRLPC: choroidal hemorrhage (9), retinal pigment epithelial tears (3), choroidal ischemia (1) and choroidal folds (1). The visually significant complication rate was 3.6%. Proper patient selection and treatment technique may decrease the risk of complications.

Central serous chorioretinopathy: a seasonal variation?

A review of 345 consecutive cases of patients under the age of 40 years with central serous chorioretinopathy seen between 1969 and 1979 was performed in order to define temporal patterns of occurrence. The monthly distribution of cases significantly differed (p less than 0.01) from an expected random distribution. Although a statistical trend analysis failed to confirm a definite seasonal variation (p less than 0.01), an increased number of cases were seen in March and April.