Macrophage polarization in the maculae of age-related macular degeneration: a pilot study.

Macrophages can be polarized to exhibit either pro-inflammatory M1 or pro-angiogenic M2 phenotypes, but have high phenotypic plasticity. This pilot study investigated macrophage polarization in the macular retina and choroid of age-related macular degeneration (AMD) and non-AMD subjects, as well as in AMD choroidal neovascular membranes (CNVM). All specimens were evaluated for routine histopathology. Quantitative real-time polymerase chain reaction for representative M1 (CXCL11) and M2 (CCL22) transcripts were performed on macular choroidal trephines (MCT) of 19 AMD and nine non-AMD eye bank eyes, on the microdissected macular retinal cells from the archived slides of five geographic atrophic AMD, five exudative/neovascular AMD, and eight normal autopsied eyes, and on microdissected inflammatory cells from two surgically removed CNVM that did not respond to anti-vascular endothelial growth factor (VEGF) therapy. High M2-chemokine transcript and a low ratio of M1 to M2 chemokine transcript were found in aging non-AMD MCT. Advanced AMD maculae had a higher M1 to M2 chemokine transcript ratio compared to normal autopsied eyes. Macrophages in the two CNVM of patients unresponsive to anti-VEGF therapy were polarized toward either M1 or M2 phenotypes. The number of M2 macrophages was increased compared to M1 macrophages in normal aging eyes. A pathological shift of macrophage polarization may play a potential role in AMD pathogenesis.

Microperimetry in multiple evanescent white dot syndrome.

BACKGROUND: This study investigates a new instrument, called the Microperimeter-1 (MP-1), which maps areas of retinal sensitivity, in a series of patients with multiple evanescent white dot syndrome (MEWDS). METHODS: A retrospective observational case series from a private retina practice, in which 3 patients with a diagnosis of MEWDS underwent testing with the MP-1. RESULTS: All 3 patients in this series showed an enlarged blind spot on MP-1 testing. INTERPRETATION: Microperimetry is a useful tool in visual field testing for patients with MEWDS. The MP-1 allows retinal sensitivity mapping to be displayed on a fundus photograph, which permits correlation of scotomata with retinal pathology.

Subfoveal fluid resolves slowly after pars plana vitrectomy for tractional retinal detachment secondary to proliferative diabetic retinopathy.

PURPOSE: To report delayed visual recovery resulting from slow resolution of subfoveal subretinal fluid measured with optical coherence tomography (OCT) after pars plana vitrectomy (PPV) for repair of tractional retinal detachment (TRD) involving the fovea secondary to proliferative diabetic retinopathy (PDR). METHOD: In this retrospective case series, charts of three patients with persistent subfoveal fluid after PPV for TRD secondary to PDR were reviewed. All patients were followed up for a minimum of 1 year after surgery, using OCT and serial ophthalmic examination. RESULTS: Subfoveal fluid resolved completely after a minimum of 6 months after PPV as measured by OCT. All three patients had improvement in visual acuity after subfoveal fluid was completely resolved. CONCLUSION: Persistent subfoveal fluid may take several months to resolve in patients undergoing PPV to repair TRD secondary to PDR and account for delayed visual recovery. OCT is an important tool in the follow-up of patients undergoing vitrectomy for TRD.

Branch retinal vein occlusion associated with vitreoretinal traction.

CASE REPORT: Branch retinal vein occlusion (BRVO) is believed to arise at arteriovenous crossing sites. Surgical dissection of the arteriovenous sheath has been proposed as a treatment option, yet induction of a posterior vitreous detachment may be as important in obtaining a successful surgical outcome, suggesting that vitreoretinal traction may play a role in the development of BRVO. A retrospective review of 3 patients presenting with clinical features of BRVO and evidence of vitreoretinal traction at the occlusion site was conducted. COMMENTS: All patients presented with mild vitreous hemorrhage. Intraretinal hemorrhages were distributed in an unusual linear pattern along the involved venous segment, suggesting the presence of vitreoretinal traction. Fluorescein angiography demonstrated blocked fluorescence secondary to hemorrhage with delay of venous flow at the avulsion site. Partial avulsion of the involved venous segment was evident on clinical examination, B-scan ultrasound, or optical coherence tomography. Vitreoretinal traction may contribute to the pathogenesis of BRVO in some patients.

Focal laser ablation of retinal angiomatous proliferation.

PURPOSE: To evaluate the feasibility of focal laser ablation of retinal angiomatous proliferation (RAP) identified with clinical examination and high-speed indocyanine green (ICG) imaging in patients with age-related macular degeneration. METHODS: In this retrospective, interventional case series, 16 consecutive eyes of 15 patients with macular degeneration and leakage from a stage I or II RAP lesion were identified. RAP lesions were identified using clinical examination and high-speed ICG imaging. High-speed ICG imaging was used to identify the intraretinal component of the lesion. RAP lesions were treated with a 100- to 200-mum green or yellow wavelength laser spot that was applied to completely ablate the intraretinal component of the lesion. In eyes with stage II lesions, the subretinal component of the lesion was not treated. Early Treatment of Diabetic Retinopathy Study visual acuity, optical coherence tomography retinal thickness, angiographic leakage, and progression of the angiomatous process shown by ICG imaging were evaluated preoperatively and postoperatively. RESULTS: Sixteen eyes underwent successful ablation of the RAP lesions with an average of 1.9 treatment sessions. At a mean follow-up of 15.5 months, 94% of eyes had stable or improved visual acuity. Only 6% of eyes had a loss of >or=3 lines of visual acuity. The average visual acuity at the last follow-up was 20/45 in the stage I lesion group and 20/160 in the stage II lesion group. Of the patients, 87.5% had a reduction in retinal edema and subretinal fluid, with 69% of patients having complete resolution of retinal edema and subretinal fluid; 14% of patients had progression to retinal choroidal anastomoses. No treatment complications were encountered. CONCLUSION: Focal laser photocoagulation of RAP lesions appears to be feasible. This treatment appears to be a safe method of managing the leakage from RAP. Treatment of solely the intraretinal component of the lesion may be adequate to control leakage. Treatment may allow the angiomatous process to be arrested, resulting in stabilization of visual acuity. Visual acuity results appear to be better for patients with early stage lesions.

Intraocular rake for removal of epiretinal membranes.

PURPOSE: To examine the feasibility of the use of a flexible intraocular rake to remove epiretinal membranes (ERM). DESIGN: Interventional case series. METHODS: A multi-tine flexible intraocular rake was designed. Ten consecutive patients with idiopathic epiretinal membranes underwent vitrectomy and removal of the ERM with the intraocular rake. Outcome measures included intraoperative complications, Early Treatment Diabetic Retinopathy Study visual acuity, rate of recurrent ERM, and rate of persistent cystoid macular edema. RESULTS: The rake was used successfully to remove the ERM in all cases. Two patients had intraoperative retinal tears. At a mean postoperative follow-up examination of 24 weeks, the visual acuity was improved significantly (20/90 before the operation vs 20/50 after the operation; P<.05). One patient had a recurrent epiretinal membrane. CONCLUSION: The flexible intraocular rake appears to be capable of the removal of idiopathic ERM. The increased tolerance for retinal contact that results from the flexible tines may make the rake of value to many vitreoretinal surgeons.

Micropulse laser treatment of retinal-choroidal anastomoses in age-related macular degeneration.

BACKGROUND: Retinal-choroidal anastomoses (RCA) are a common finding in advanced cases of age-related macular degeneration. These high-flow lesions are associated with extensive subretinal exudation. This study examines the role of high-energy, short-duration (micropulse) laser pulses in effectively closing these shunts and reducing subretinal fluid. METHODS: Nineteen consecutive eyes with advanced age-related macular degeneration undergoing treatment of RCAs to reduce subretinal exudation in a referral-only retina practice were reviewed retrospectively. RCA were identified using high-speed indocyanine green angiography. RCA were closed using a high-energy, short-duration laser pulse technique. Outcome measures included visual acuity, resolution of subretinal fluid and persistence of RCA. RESULTS: Nineteen eyes with RCA associated with macular degeneration were successfully treated. Mean baseline visual acuity was 20/140 (HM to 20/50). One hundred percent of eyes had subretinal exudation and 73% had subretinal fibrosis at the time initial treatment. At mean follow-up of 11.7 (2-23) months, patients had undergone an average of 3.52 (1-12) sessions of laser treatment. Average final visual acuity was 20/146 (CF to 20/40). Fifty-three percent of eyes had complete resolution of subretinal fluid. One hundred percent had subretinal fibrosis. Forty-three percent had complete closure of RCA. No significant complications were encountered. CONCLUSION: High-energy, short-duration laser appears to be a reproducible technique to obtain closure of RCA associated with advanced macular degeneration. It appears to be effective in reducing subretinal exudation associated with these lesions. The technique is associated with stabilization of visual acuity without significant risk of complication.

Pathogenic implications of subretinal gas migration through pits and atypical colobomas of the optic nerve.

OBJECTIVE: To describe subretinal migration of gas and silicone oil in a series of patients with congenital cavitary optic disc anomalies and to further clarify the pathogenesis of the associated maculopathy. METHODS: Medical records of 4 female patients, aged 8 to 34 years, who developed subretinal gas migration after vitreous surgery for macular detachment associated with cavitary optic disc anomalies were reviewed. A theoretical model was used to calculate the pressure differential required to induce subretinal gas migration through an optic pit. RESULTS: The 4 patients had bilateral atypical optic nerve colobomas or a unilateral large optic pit. A definite defect in the tissue overlying the disc excavation could be seen in one eye, and intraoperative drainage of subretinal fluid through the disc anomaly was possible in all cases. Subretinal migration of gas or silicone oil was seen intraoperatively in one case and first appeared between 1 and 17 days postoperatively in the remaining cases. Theoretical calculations suggest that the pressure differential required for migration of gas through a small defect in the roof of a cavitary disc lesion is within the range of expected fluctuations in cerebrospinal fluid pressure. CONCLUSIONS: These observations provide clinical confirmation of a defect in tissue overlying cavitary optic disc anomalies and imply interconnections between the vitreous cavity, subarachnoid space, and subretinal space. We theorize that intermittent pressure gradients resulting from normal variations in intracranial pressure play a critical role in the pathogenesis of retinopathy associated with cavitary disc anomalies.

Coats' syndrome as a cause of secondary open-angle glaucoma.

A case of Coats' syndrome presenting with acute secondary open-angle glaucoma is described. A 41-year-old woman presented with eye pain and an intraocular pressure of 50 mm Hg in the right eye. Numerous hyperrefringent yellow-white crystals were seen in the anterior chamber and in a recessed anterior chamber angle. Fundus examination revealed an inferior yellow exudative retinal detachment with retinal vascular abnormalities resembling Coats' disease. Following lensectomy, vitrectomy, retinal reattachment, and endolaser photocoagulation, the intraocular pressure stabilized within normal limits. Coats' syndrome may cause increased intraocular pressure by a secondary open-angle mechanism, even in phakic eyes. Removal of the lipid crystals and treatment of the anomalous vessels may be sufficient to control the intraocular pressure.