Atrophy in Neovascular Age-Related Macular Degeneration: Age-Related Eye Disease Study 2 Report Number 15.

PURPOSE: To identify the development and progression of macular retinal pigment epithelial atrophy in eyes with neovascular (CNV) age-related macular degeneration (AMD) and to correlate with visual acuity (VA). DESIGN: Cohort study. PARTICIPANTS: Age-Related Eye Disease Study 2 (AREDS2) participants with intermediate AMD enrolled in a randomized controlled clinical trial of oral supplements. Analyses were conducted in the subset of AREDS2 participants who were also enrolled in the fundus autofluorescence ancillary (FAF) ancillary study. METHODS: Color photographs and FAF images were evaluated in eyes that developed CNV. Presence of geographic atrophy (GA) prior to the incidence of CNV and the development of macular atrophy following incident CNV were assessed. Areas of hypoautofluorescence representing atrophy were measured for area and macular involvement. Enlargement rate of atrophy and change in visual acuity over time were analyzed. MAIN OUTCOME MEASURES: incidence and enlargement rate of atrophy and VA changes in eyes with incident CNV. RESULTS: Incident CNV developed in 334 (9.2%) of eyes evaluated in the AREDS2 FAF substudy. Of these, 40% had macular atrophy at incidence of CNV with half of these attributable to pre-existing GA. Atrophy developed in 14.7 % of eyes over 4 years of follow-up. Mean area of atrophy was largest in eyes with pre-existing GA and CNV (5.17 mm2, p<0.001), and atrophy involved the center of the macula in > 65% of eyes. Mean VA letter score at the annual visit in which CNV was documented was similar in the three groups with atrophy; eyes with CNV and pre-existing GA, incident atrophy at the first visit with CNV, and atrophy during follow up (60 letters). Enlargement rate of atrophy was also similar in eyes in the three groups (1.23 - 1.86 mm2, p = 0.47). Eyes with macular atrophy lost more visual acuity compared to eyes without atrophy, particularly after 2 years of follow-up (-10.9 vs. - 3.6 letters, p = 0.07). CONCLUSION: Atrophy is commonly seen in neovascular AMD and often can be attributed to pre-existing GA. Macular atrophy and GA appear to be a continuum of the same disease process and are both associated with poor vision.

Association of outer retinal layer morphology with visual acuity in patients with retinal vein occlusion: SCORE Study Report 13.

PURPOSE: To assess associations between visual acuity (VA) and the status of the photoreceptor inner segment-outer segment (IS-OS) junction in a subset of patients in the Standard Care vs COrticosteroid for REtinal Vein Occlusion (SCORE) Study. METHODOLOGY: High-resolution time domain optical coherence tomography (OCT) scans of study eyes from a single site participating in the SCORE Study were evaluated. Integrity of the IS-OS junction in the central subfield was evaluated using a three-step scale: absent, abnormal or normal. Associations of the IS-OS status with ETDRS VA letter score and center point thickness (CPT) were investigated. RESULTS: Baseline OCTs of 42 eyes were evaluated. The IS-OS junction was absent in 30 (71%) and abnormal in 12 (29%). At month 12, the IS-OS junction was absent in 18 (43%), abnormal in 12 (28%), and normal in 12 (28%) eyes. At baseline, IS-OS status was significantly associated with CPT, but not with VA. At month 12, IS-OS status was significantly associated with CPT and VA, that is, absent or abnormal IS-OS was associated with increased CPT and worse VA. Change in IS-OS status was not associated with change in CPT (P=0.8). Worsening of IS-OS status was associated with loss of VA and improvement in IS-OS status to normal was associated with gain in VA (P=0.03). CONCLUSION: In this data set with long-term follow-up of OCTs as part of the SCORE Study, there is a correlation between change in IS-OS status and VA. This supports further evaluation of outer retinal morphology in larger data sets.

Treatment of submacular hemorrhage with low-dose intravitreal tissue plasminogen activator injection and pneumatic displacement.

OBJECTIVE: To investigate the safety and efficacy of low-dose intravitreal tissue plasminogen activator (tPA) and an expansile gas bubble in displacing submacular hemorrhage in patients with age-related macular degeneration (ARMD). PATIENTS AND METHODS: We reviewed retrospectively the medical records of 14 consecutive patients with ARMD from 1 academic center who received low-dose intravitreal tPA (18-50 microg) and expansile gas (0.3-0.4 mL of perfluoropropane) for thrombolysis and displacement of submacular hemorrhage. After the procedure, patients maintained face-down positioning for 1 to 3 days. MAIN OUTCOME MEASURES: Displacement of blood from the fovea, early and final visual acuity, and toxicity of tPA. RESULTS: Submacular blood was completely displaced from the fovea in 10 (71%) of the 14 patients and partially displaced in 3 (21%). In 1 patient, no displacement occurred. Early (<2 months) postoperative visual acuity improved by 2 or more lines in 8 patients (57%). With a mean follow-up of 7.7 months, 2 (15%) of 13 patients maintained 2 or more lines of improvement and 69% (9 patients) maintained preoperative visual acuity. No clinical evidence of retinal toxicity was seen at this low-dose of tPA. CONCLUSIONS: Doses of intravitreal tPA ranging from 18 to 50 microg and an expansile gas bubble are safe and effective in displacing submacular hemorrhage in patients with ARMD. Final visual acuity was limited by the underlying presence of end-stage ARMD.

Management of submacular hemorrhage with intravitreous tissue plasminogen activator injection and pneumatic displacement.

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.

Purtscher-like retinopathy after uncomplicated administration of retrobulbar anesthesia.

PURPOSE: To report a case of Purtscher-like retinopathy after administration of retrobulbar anesthesia for an otherwise uncomplicated cataract extraction. METHOD: Case report. RESULTS: After cataract surgery with retrobulbar anesthesia, the patient followed a typical course of Purtscher-like retinopathy with an initial severe loss of vision followed by a gradual and nearly complete improvement in visual function. CONCLUSIONS: Purtscher-like retinopathy is uncommon after administration of retrobulbar anesthesia but had the same clinical course as other causes of this disorder.

Cataract after vitrectomy in young patients.

OBJECTIVE: The purpose of the study was to evaluate the occurrence of cataract in young patients after pars plana vitrectomy. DESIGN: The authors reviewed the medical records for previtrectomy and postvitrectomy lens changes in patients younger than 30 years of age at the Kellogg Eye Center, University of Michigan. PARTICIPANTS: Forty-nine patients (50 eyes) younger than 30 years of age (mean age, 23.5 years; range, 5 months-30 years) underwent phakic vitrectomy over a 12-year period. MAIN OUTCOME MEASURES: Cataracts were categorized as posterior subcapsular, nuclear sclerotic, or cortical. Cataracts also were graded as mild (1+), moderate (2+), or severe (3+). RESULTS: In this series of young patients, vitrectomy was performed for a wide range of ocular conditions, including trauma and complicated retinal detachment. Postvitrectomy cataract developed in 29 patients (60%). Eighteen patients (36%) had visually significant cataract on long-term follow-up (mean follow-up, 29.7 months; range, 6 months-13 years). The most common cataract was posterior subcapsular (57%), followed by nuclear sclerosis (23%), a combination of both (17%), and cortical cataract (3%). Patients with gas-filled eyes had a significantly higher rate of cataract formation than patients with fluid-filled eyes (P < 0.05). CONCLUSIONS: Postvitrectomy cataracts were more common in the authors' series compared with those of previous reports on young patients. Cataracts were most often posterior subcapsular and were significantly associated with the use of intraocular gas. The occurrence of postvitrectomy cataract appears to be higher in patients undergoing vitrectomy for complex ocular conditions, regardless of age.

Idiopathic juxtafoveolar retinal telangiectasis. Update of classification and follow-up study.

BACKGROUND: Idiopathic juxtafoveolar retinal telangiectasis may cause visual loss. The treatment of this disease is controversial. METHODS: The authors reviewed the records of 140 patients with idiopathic juxtafoveolar telangiectasis. A classification scheme based on biomicroscopic and fluorescein angiographic findings is presented. In addition, the effect of photocoagulation on the natural history of the disorder is evaluated. FINDINGS: Patients are categorized into three groups. Group 1 comprises 39 male patients with nonfamilial, easily visible telangiectasis and intraretinal exudation. The telangiectasis is unilateral in 94% of patients. The telangiectasia in this group is probably of developmental origin (Coats syndrome). Group 2 comprises 94 patients with occult juxtafoveolar telangiectasis, minimal exudation, superficial retinal crystalline deposits, and right-angle venules. Late in the course of the disease, foveolar atrophy, intraretinal pigment plaques, and subretinal neovascularization develop. The telangiectasis is acquired during middle age and is bilateral in 98% of patients. Group 3 comprises seven patients with bilateral easily visible telangiectasis, minimal exudation, and capillary occlusion. All of these patients had systemic disease, which was probably related to their eye disease. CONCLUSION: Slow visual loss beginning in adulthood characterizes most of these patients. The telangiectasis appears to be caused primarily by retinal capillary leakage in group 1, capillary diffusion abnormalities in group 2, and capillary occlusion in group 3. Photocoagulation is probably beneficial for patients in group 1 and not for patients in group 2, at least before their development of subretinal neovascularization.

Echographic evaluation of retinal tears in patients with spontaneous vitreous hemorrhage.

We studied the ability of standardized echography to correctly diagnose a retinal tear in patients with opaque ocular media due to vitreous hemorrhage. Records were studied of 42 patients with spontaneous vitreous hemorrhage and no ophthalmoscopic view of fundus details. Of these 42 patients, 11 had an echographic diagnosis of probable retinal tear and no retinal detachment. In 10 (91%) of 11 cases, the presence and location of the tears that were diagnosed echographically were confirmed on clinical follow-up. In one patient, an area of peripheral neovascularization was mistaken for a tear. Echography failed to identify one retinal tear that was later detected on clinical examination. Therefore, we have found standardized echography to be a reliable tool in identifying retinal breaks.

Retained nuclei after cataract surgery.

The authors reviewed the medical records of 36 patients in whom the nucleus or nuclear fragments were retained in the eye after cataract surgery. In 4 patients, there was no further surgery, and visual acuity deteriorated to counting fingers or worse (mean follow-up time, 14 months). Thirty-two patients underwent vitrectomy to remove the retained, unencapsulated nuclear material. Sixty percent (6 of 10) of patients in whom vitrectomy was performed after 3 weeks had chronic glaucoma on long-term follow-up, whereas this complication developed in only 18% (4 of 22) of patients in whom vitrectomy was performed in less than 3 weeks. Sixty-three percent (21 of 32) of vitrectomy patients had final visual acuity of 20/200 or better after removal of the retained nuclear fragments. The causes of the poorest visual outcome (less than 20/200) included 1 or more of the following: corneal decompensation, chronic inflammation, chronic glaucoma with optic atrophy, and retinal detachment.

Purtscher's-like retinopathy after childbirth.

Severe bilateral visual loss attributable to multiple retinal arteriolar occlusions occurred in four young women within 24 hours after childbirth. In two patients, labor was complicated by preeclampsia requiring cesarean section. One patient was suffering from pancreatitis. None had connective tissue disease or antecedent trauma. Ophthalmoscopy and fluorescein angiography revealed evidence of multiple superficial peripapillary and macular patches of ischemic retinal whitening simulating Purtscher's retinopathy. By 8 weeks, the white patches were resolving in all eyes and visual acuity had significantly improved in three of the four patients. The pathogenesis of this disorder is unknown but may involve arteriolar obstruction by complement-induced leukoemboli formed during parturition.

Goblet cell population among patients with inactive trachoma.

Trachoma is a chlamydial disease that affects millions of people each year, particularly in developing countries. In the chronic phase, inflammation causes scarring of the conjunctiva followed by dry eye which can result in blindness. Trachoma may cause dryness of the eye by decreasing mucus production and aqueous secretions. Conjunctival impression cytology was carried out to determine the goblet cell population among patients with trachoma. We performed impression cytology on 32 patients with inactive trachoma and 31 age and sex matched controls. Impression cytology showed that the nasal conjunctiva contains the greatest number of goblet cells. Trachoma patients with severe scarring had significantly less goblet cell counts than those with mild scarring (p less than 0.05). In the group of ten patients with severe trachoma and keratinization, there was marked reduction or absence of goblet cells. Trachoma appears to initiate a viscious cycle of conjunctival scarring, mucus deficiency, and chronic conjunctival inflammation.