Surgical Management of Advanced Coats Disease in 32 Eyes: A 20-Year Study.

Purpose: This work studies outcomes of external subretinal fluid (SRF) drainage in management of eyes with advanced Coats disease. Methods: Patients with advanced-stage Coats disease (≥stage 3B), who were younger than 12 years and underwent external SRF drainage from 1996 to 2016, were included in this retrospective study. Surgical intervention involved external drainage of SRF and cryotherapy. SRF drainage was performed by lamellar scleral dissection or by external needle drainage. Favorable anatomical outcome was defined as retinal reattachment with normal intraocular pressure (IOP). IOP greater than 24 mm Hg was considered raised. Univariate and multivariate analyses were performed to measure the association between preoperative or intraoperative factors and retinal status at final follow-up. Outcome measures evaluated included visual acuity, IOP, retinal status, globe status, and complications of surgery. Kaplan-Meier analysis was performed for globe salvage without pain. Results: Thirty-two eyes of 32 patients were included in the study. Mean age at surgery was 3.8 ± 3 years. The mean duration of follow-up was 7 years (range, 6 months-15.7 years). Improvement in visual acuity was seen in 5 eyes. Retina was attached at final visit in 6 eyes. IOP in the range of 8 to 24 mm Hg was noted in 16 eyes. Favorable anatomical outcome was achieved in 3 (9%) eyes. Globe salvage was achieved in 84% of eyes. Complications included intraoperative vitreous hemorrhage (n = 1) and postoperative inflammation (n = 1). Kaplan-Meier ocular survival rate without pain at 10 years was 76%. Conclusions: SRF drainage and cryotherapy in eyes with advanced Coats disease favorably alter the natural history of the disease and prevent end-stage complications. Visual outcomes remain poor.

Coats' disease of adult-onset in 48 eyes.

BACKGROUND: Coats' disease diagnosed in adulthood is an idiopathic, retinal exudative vascular disease without an inciting factor and has retinal features different from the childhood disease. AIM: To describe clinical features, treatment, and outcomes of eyes with Coats' disease first diagnosed in patients 35 years or older. MATERIALS AND METHODS: Retrospective chart review of patients first diagnosed with Coats' disease at the age of 35 years or more at a tertiary eye care center between January 1995 and 2012. Eyes with retinal exudation or Coats'-like response from secondary causes were excluded. RESULTS: Forty-five of 646 patients (7%) diagnosed with Coats' disease had adult-onset disease. Mean age at presentation was 47 years. Systemic hypertension was the most common (22%) systemic association and decreased vision the predominant presenting feature (83%). Localized (<6 clock h) presentation (74%) was unique to adults as against diffuse involvement (69%) in children (P < 0.001). Eyes were treated with laser photocoagulation 29 (60%), cryotherapy (4%), or both (2%) with surgical intervention in three (6%) eyes. Following treatment eight (35%) eyes improved, 11 (48%) eyes were stable while four (12%) eyes worsened due to complications. CONCLUSION: Adult-onset Coats' disease has less extensive involvement, more benign natural course, and a more favorable treatment outcome as against the childhood-onset disease. The bilateral presentation emphasizes the need for regular follow-up to detect possible future involvement of the fellow eye.

Principal components' analysis of multifocal electroretinogram in retinitis pigmentosa.

AIMS: To determine waveforms of multifocal electroretinogram (mfERG) in patients with retinitis pigmentosa (RP) contributing significantly to the overall retinal response by using principal components' analysis. SETTINGS AND DESIGN: Prospective, non-randomized, single-visit, observational, case-control study from a single tertiary ophthalmic center. MATERIALS AND METHODS: Patients with various forms of RP underwent mfERG testing for a period of one year. The first-order kernel responses of RP cases were compared with concurrently recruited healthy controls. STATISTICAL ANALYSIS USED: Parametric data was analyzed using the unpaired t test for differences between the implicit time and amplitudes of cases and controls. Principal components' analysis was done for each implicit time and amplitude in cases with RP using the Varimax rotation method. RESULTS: From March 2006 to March 2007, 24 cases with typical RP (56%, 47 eyes) were included in the final analysis. Their mean age was 33.7 years (19-69 ± 15.5 years). Comparison of latencies and amplitudes among RP cases with log MAR acuity ≤ 0.18 and those > 0.18, revealed significant difference in the implicit time (P1) in Ring 2 only (P=0.028). Two components (predominently from Ring 1 and 2) each contributing 66.8% and 88.8% of the total variance in the data for latencies and amplitudes respectively, were seen. CONCLUSIONS: The first two rings of the mfERG contributed to the variance of waveforms in RP, irrespective of the visual acuity and poor visual field results.

Laser photocoagulation (810 nm diode) for threshold retinopathy of prematurity: a prospective randomized pilot study of treatment to ridge and avascular retina versus avascular retina alone.

The purpose of this study was to compare the structural outcome of laser treatment to avascular retina and ridge versus laser treatment to avascular retina alone in cases with threshold retinopathy of prematurity (ROP). A prospective, randomized, interventional, comparative study of consecutive cases referred to a single tertiary center was considered here. 50 infants with bilateral symmetrical threshold ROP were recruited into this study over a period of 3 years. Threshold ROP was defined as per CRYO-ROP study. Perinatal history details for all patients including significant maternal history were recorded. One eye of each patient was randomized (Microsoft Excel 2000) to one of the two treatment groups--laser treatment to avascular retina (Group A) or laser treatment to avascular retina and ridge (Group B). Laser treatment was performed with a 810 nm diode laser (Iris Medical Instruments, Inc. Mountain View, CA, USA). Treatment was continued until regression of ROP. Structural outcome was assessed at a minimum follow-up of 6 months and was considered favorable or unfavorable as per the CRYO-ROP study criteria. An unfavorable outcome consisted of either (1) a retinal fold involving the macula; (2) any retinal detachment involving zone 1; or (3) a retrolental mass that obscured visualization of the posterior pole. Secondary outcome measures included the difference in time to regression of ROP and complications of treatment between the two treatment groups. 100 eyes of 50 infants received laser photocoagulation for threshold ROP after randomization (50 eyes in each group). Of these 50 infants, 20 (40%) were female and 30 (60%) were male. A significant proportion of the children (46%) were conceived as twins. The average birth weight was 1360 ± 326 g (range 750-2200 g). The mean gestational age at birth was 30.72 ± 1.6 weeks (range 26-36 weeks). Zone I disease was present in 14 (14%) eyes and zone II in the remaining 86 eyes (86%). Threshold stage retinopathy (CRYO-ROP criteria) extending 360° (12 clock hours) was present in 21 infants (42%), 5 contiguous clock hours of stage 3+ in 14 infants (28%) and intermediate range in the remaining 15 infants (30%). At 6 months follow-up, 3 eyes (6%) in group A and 1 eye (2%) in group B had an adverse structural outcome; however, the time to regression of retinopathy 2.98 ± 1.5 weeks in group A and 3.12 ± 1.1 in group B (P = 0.889) and the rate of complications such as retinal hemorrhage, 3 eyes in group A and 4 eyes in group B, was comparable. Zone I eyes showed equal incidence of favorable anatomical outcome (85.7%) in each group. Laser treatment to ridge was found to be safe and effective in the treatment of threshold ROP in this short-term pilot study; however, it needs to be ascertained whether this treatment has long-term advantages over conventional laser treatment to avascular retina, as well as the long-term benefits of treatment to ridge.

Coats' disease: an Indian perspective.

AIM: To describe the clinical features, treatment and outcome patterns in 307 eyes with Coats' disease. MATERIALS AND METHODS: Retrospective chart review of patients diagnosed with Coats' disease between January 1996 and January 2006 from a single referral center in southern India. RESULTS: Two hundred and eighty patients (307 eyes) with mean age of 15.67 years (range: Four months-80 years) were included. Decreased vision (77%), unilateral affection (90%) and male preponderance (83.4%) were chief presenting features. Anterior segment involvement was seen in 67 (21.8%) eyes. Retinal telangiectasia were seen in 302 (99%) eyes, exudation in 274 (89%) eyes and retinal detachment in 158 (51.5%) eyes. Four-quadrant disease was seen in 207 (67.2%) eyes. Visual acuity was <20/200 in 249 (80.9%) eyes. One hundred and nine of 176 treated eyes (61.93%) had favorable anatomical outcome; 207 of 280 eyes (74%) had an optimal structural outcome. Seventeen (5.3%) eyes were enucleated. Complications following treatment included phthisis bulbi (7%), neovascular glaucoma (5%), epiretinal membrane (4.4%) and rubeosis iridis (4.4%). CONCLUSION: Indian patients with Coats' disease have a high male predominance, the majority of whom present with severe visual impairment and extensive four-quadrant exudation. Unusual presentations such as pain, vitreous hemorrhage and a high incidence of anterior segment involvement are distinctive to Indian eyes.

Intravitreal anti-vascular endothelial growth factor agents as an adjunct in the management of Coats' disease in children.

We describe the role of intravitreal anti-vascular endothelial growth factor (VEGF) agents in Coats' disease in children. In a prospective, interventional, non-randomized case series, three patients (three eyes) aged 16, seven and two years were diagnosed to have Coats' disease. In Case 1 (16 yr/ male) with macular edema, previous laser photocoagulation being unsuccessful, intravitreal pegaptanib sodium (Macugen) was tried. Case 2 (seven yr/ male) and Case 3 (two yr/ female) were diagnosed to have Stage 4 Coats' and underwent external needle drainage, laser photocoagulation, SF6 gas injection and intravitreal injection of bevacizumab (Avastin). Reduction of exudation and attached posterior pole (Cases 2 and 3) was seen at a follow-up of six months and two months respectively. Intravitreal anti-VEGF agents may be successfully used as adjunct treatment in select cases of Coats' disease in childhood.

Photodynamic therapy following intravitreal bevacizumab in multifocal choroiditis.

PURPOSE: To report the use of intravitreal bevacizumab (avastin) followed by photodynamic therapy (PDT) in a case of choroidal neovascular membrane (CNVM) due to multifocal choroiditis. DESIGN: Interventional case report. METHODS: In the setting of institutional practice, a 40-year male patient with previously diagnosed multifocal choroiditis presented with reduced vision in his left eye. A CNVM was revealed through hazy vitreous in the left eye. Due to a prior episode of increased intraocular pressure with use of periocular steroid (triamcinolone), and marked vitreous haze precluding precise assessment of the neovascular membrane, intravitreal injection of bevacizumab was tried followed by PDT. RESULTS: There was clearing of the vitreous haze and reduction of leakage one week after intravitreal injection. PDT one month after injection resulted in stable vision at three-month follow-up without angiographic leakage. CONCLUSION: Intravitreal bevacizumab may be tried in cases of CNVM due to multifocal choroiditis. Timing of the injection may vary with the clinical scenario.