Evaluating persistent and recurrent choroidal neovascularization. The role of indocyanine green angiography.

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.

Surgical management of retinoschisis.

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.

An unusual case of cryptococcal endophthalmitis.

BACKGROUND: Cryptococcal endophthalmitis is a rare disorder, almost invariably diagnosed after enucleation or at postmortem examination. There are therefore few guidelines as to its identification or treatment. METHODS: A case of culture-positive cryptococcal endophthalmitis in a patient with chronic uveitis was diagnosed by vitreous biopsy at the time of retinal detachment repair. The patient was treated with oral fluconazole for 5 months. All reported cases of cryptococcal endophthalmitis were reviewed and compared. RESULTS: After oral fluconazole therapy, the patient was culture negative on repeat tap. Despite conversion to culture-negative status, however, visual acuity declined to hand motions because of hyphema and hypotony. The organism was successfully identified as a non-neoformans species, Cryptococcus laurentii, previously unreported as an ocular pathogen. CONCLUSION: This unique case demonstrates that cryptococcal disease can be diagnosed antemortem by vitreous biopsy, and should be added to the differential diagnosis in cases of chronic smoldering uveitis. A non-neoformans organism is also identified for the first time as a cause of ocular cryptococcosis. Fluconazole, used here for the only time of which we are aware to treat cryptococcal endophthalmitis, produced successful conversion to culture negativity and resolution of the uveitis.

Retinal and other manifestations of incontinentia pigmenti (Bloch-Sulzberger syndrome).

BACKGROUND: One of the largest series of patients with incontinentia pigmenti who have undergone detailed ophthalmologic examination is reported here, including previously unrecognized findings with visually disabling consequences. METHODS: Thirteen females with incontinentia pigmenti from eight unrelated families were evaluated. The diagnosis of incontinentia pigmenti had been established previously by a referring pediatrician or dermatologist in 12 patients and by the authors in one other patient on the basis of retinal findings and history of characteristic skin manifestations. RESULTS: Abnormalities of the eye, central nervous system, skeleton, teeth, and hair develop in a majority of patients. The authors describe the evolution of retinal vascular abnormalities, and, for the first time, document foveal hypoplasia (in 4 of their 13 patients). The authors also provide the first report of a child with a normal brain shown on computed tomographic scan at 3 days old, which evolved to devastating cerebral ischemia, edema, and cortical blindness beginning at 6 days old. CONCLUSIONS: Incontinentia pigmenti should be included in the differential diagnosis of patients with peripheral retinal vascular nonperfusion, preretinal neovascularization, infantile retinal detachment, or foveal hypoplasia, particularly if there is evidence of characteristic dermatologic or other systemic manifestations. In infants with incontinentia pigmenti, retinal vascular anomalies are best detected by examination under anesthesia using fluorescein angiography.

Laser management of subfoveal choroidal neovascularization in age-related macular degeneration.

Subfoveal choroidal neovascularization in eyes with age-related macular degeneration is associated with a poor natural prognosis. The Macular Photocoagulation Study Group recently has demonstrated that subfoveal photocoagulation in select cases of subfoveal choroidal neovascularization for patients with age-related macular degeneration effectively prevents severe visual acuity loss and reduces the average loss of contrast sensitivity and reading speed associated with this condition. Eligibility criteria and treatment recommendations from the Macular Photocoagulation Study will be reviewed. Results of alternative strategies for laser photocoagulation of such lesions are also discussed; however, the Macular Photocoagulation Study results stand alone in documenting a long-term treatment benefit of photocoagulation for subfoveal choroidal neovascularization.

Posterior internal ophthalmomyiasis. Identification of a surgically removed Cuterebra larva by scanning electron microscopy.

The clinical presentation of an 11-year-old boy with unilateral posterior internal ophthalmomyiasis is described. Ophthalmoscopy of the affected eye in this individual disclosed characteristic subretinal depigmented linear tracks and a larva within the vitreous. The intravitreal larva was retrieved successfully by pars plana vitrectomy and identified as the first instar of Cuterebra sp. (rodent botfly) by scanning electron microscopy. This was done by examining the external features of the larva by scanning electron microscopy and comparing them to scanning electron micrographs that were prepared on other first instar larvae of flies known to be implicated in internal ophthalmomyiasis. The study demonstrates the usefulness of scanning electron microscopy for taxonomic identification of fly larvae. Since even a small fragment of these organisms may contain characteristic features of external morphology, scanning electron microscopy may be useful in cases where the specimen is damaged or incomplete.