A preliminary study of photodynamic therapy using verteporfin for choroidal neovascularization in pathologic myopia, ocular histoplasmosis syndrome, angioid streaks, and idiopathic causes.

OBJECTIVE: To evaluate short-term safety and the effects on visual acuity and fluorescein angiography of single or multiple sessions of photodynamic therapy with verteporfin for choroidal neovascularization (CNV) not related to age-related macular degeneration (AMD), including pathologic myopia, the ocular histoplasmosis syndrome, angioid streaks, and idiopathic causes. DESIGN: A nonrandomized, multicenter, open-label, dose-escalation phase 1 and 2 clinical trial. SETTING: Four ophthalmic centers in Europe and North America providing retinal care. PARTICIPANTS: Thirteen patients with subfoveal CNV due to pathologic myopia, the ocular histoplasmosis syndrome, angioid streaks, or idiopathic causes. METHODS: Standardized protocol refraction, visual acuity testing, ophthalmic examinations, color photographs, and fluorescein angiograms were used to evaluate the results of photodynamic therapy treatments with verteporfin. Follow-up ranged from 12 weeks for patients who were treated once to 43 weeks for patients who were treated up to 4 times. RESULTS: Verteporfin therapy was well tolerated in patients with CNV not related to AMD. No deterioration in visual acuity was observed; most patients gained at least 1 line of vision. Reduction in the size of leakage area from classic CNV was noted in all patients as early as 1 week after verteporfin therapy, with complete absence of leakage from classic CNV in almost half of the patients. Improvement in visual acuity after verteporfin therapy was greatest (+6, +8, and +9 lines) in 3 patients with relatively poor initial visual acuity (between 20/200 and 20/800). Up to 4 treatments were found to have short-term safety even with retreatment intervals as short as 4 weeks. CONCLUSIONS: Treatment of CNV not related to AMD with verteporfin therapy achieves short-term cessation of fluorescein leakage from CNV in a small number of patients without loss of vision. Further randomized clinical trials including a larger number of patients are under way to confirm whether verteporfin therapy is beneficial for subfoveal CNV not related to AMD.

Photodynamic therapy with verteporfin for choroidal neovascularization caused by age-related macular degeneration: results of a single treatment in a phase 1 and 2 study.

OBJECTIVE: To evaluate the safety and short-term visual and fluorescein angiographic effects of a single photodynamic therapy treatment with verteporfin with the use of different dosage regimens in patients with choroidal neovascularization (CNV) from age-related macular degeneration. DESIGN: Nonrandomized, multicenter, open-label, clinical trial using 5 dosage regimens. SETTING: Four ophthalmic centers in North America and Europe providing retinal care. PARTICIPANTS: Patients with subfoveal CNV caused by age-related macular degeneration. METHODS: Standardized protocol refraction, visual acuity testing, ophthalmic examination, color photographs, and fluorescein angiograms were used to evaluate the effects of a single treatment of photodynamic therapy with verteporfin. Follow-up was planned through 3 months in 97 patients and for less than 3 months in 31 other patients. RESULTS: The mean visual acuity change (and range of change) from baseline at the follow-up examination at week 12 after a single treatment with regimens 1 through 5 was -0.2 (-3 to +2), -0.9 (-9 to +5), -1.6 (-9 to +2), +0.4 (-8 to +7), and +0.1 (-8 to +9) lines, respectively. Only the highest light dose (150 J/cm2) in regimens 2 and 3, which produced angiographic nonperfusion of neurosensory retinal vessels, caused marked vision loss. Some cessation of fluorescein leakage from CNV was achieved without loss of vision when the light dose used was less than 150 J/cm2. Systemic adverse events were rare. Cessation of fluorescein leakage from CNV was noted in all regimens by 1 week after photodynamic therapy. Fluorescein leakage from at least a portion of the CNV reappeared by 4 to 12 weeks after treatment in almost all cases. Progression of classic CNV beyond the area of CNV identified before treatment was noted in 42 (51%) of the 83 eyes with classic CNV followed up for 3 months after a single treatment. Eyes in which the area of any CNV leakage at 12 weeks was less than at baseline had a significantly better visual acuity outcome (+0.8 line) than eyes in which CNV leakage progressed (-0.8 line). CONCLUSIONS: Photodynamic therapy with verteporfin achieved short-term cessation of fluorescein leakage from CNV without loss of vision or growth of classic CNV in some patients with age-related macular degeneration. Except for nonperfusion of neurosensory retinal vessels at a light dose of 150 J/cm2, no other adverse events were of concern. Randomized clinical trials to investigate whether this new modality can preserve vision in patients with CNV secondary to age-related macular degeneration are justified.

Photodynamic therapy with verteporfin for choroidal neovascularization caused by age-related macular degeneration: results of retreatments in a phase 1 and 2 study.

OBJECTIVES: To evaluate safety and short-term visual acuity and fluorescein angiographic effects of photodynamic therapy (PDT) after retreatments with verteporfin for choroidal neovascularization (CNV) in age-related macular degeneration (AMD) that demonstrated fluorescein leakage after at least 1 course of PDT. DESIGN: Nonrandomized, multicenter, open-label phase 1 and 2 clinical trial using 2 different retreatment dosage regimens. SETTING: Four ophthalmic centers in Europe and North America providing retinal care. METHODS: Standardized protocol refraction, visual acuity testing, ophthalmic examinations, color photographs, and fluorescein angiograms were used to evaluate the results of multiple PDT treatments. Two regimens (regimens 2 and 4) for treatment and retreatment were chosen from 5 used in a single-treatment study. Both regimens used a verteporfin dose of 6 mg/m2 infused for 10 minutes. However, regimen 2 used a light dose of 100 J/cm2 applied 20 minutes after the start of the verteporfin infusion, whereas regimen 4 used a light dose of 50, 75, or 100 J/cm2 applied 15 minutes after infusion commenced. Posttreatment evaluations were planned in 31 participants up to 3 months after up to 2 retreatments given at 2- or 4-week intervals after initial PDT treatment. Similar posttreatment evaluations were planned after retreatments in 5 additional participants who were reenrolled some time more than 12 weeks after an initial PDT treatment. RESULTS: The average visual acuity change for the 31 participants who had retreatment within 2 to 4 weeks after the initial treatment and a follow-up examination 16 to 20 weeks after the initial treatment was 0.2 lines (range, -4 to 4 lines) in regimen 2 and -1.0 line (range, -5 to 3 lines) in regimen 4. Similar outcomes were noted in the 5 reenrolled participants. Cessation of fluorescein leakage from classic CNV for at least 1 to 4 weeks could be achieved without loss of visual acuity after at least 2 treatments in 2 (6.5%) of 31 patients. Similar to single-treatment effects, the disappearance of leakage was documented regularly at 1 week after each retreatment. Fluorescein leakage reappeared by 4 to 12 weeks after a retreatment in almost all cases. However, compared with baseline, leakage activity appeared to be reduced after multiple PDT courses. For the 31 patients who had follow-up for 3 months after the last retreatment and had received retreatment 2 to 4 weeks after the initial treatment, progression of CNV beyond the area identified before the retreatment was noted in 10 (48%) of the 21 eyes with classic CNV in regimen 2 and 9 (90%) of 10 eyes in regimen 4. The rate and severity of ocular or systemic adverse events were not increased by multiple applications. CONCLUSIONS: Multiple applications of PDT with verteporfin achieve repetitive, short-term cessation of fluorescein leakage from CNV secondary to AMD, without loss of visual acuity. This strategy can be used in randomized clinical trials investigating the efficacy of verteporfin in PDT for recurrent fluorescein dye leakage from persistent or recurrent CNV, following an initial or subsequent PDT treatment, with maintenance of visual acuity. Retreatments may achieve progressive cessation of leakage and prevent further growth of CNV and subsequent visual loss.

Deep sclerectomy with collagen implant: medium term results.

AIMS: To study prospectively the success rate and complications of deep sclerectomy with collagen implant (DSCI), a new non-penetrating filtration procedure. METHODS: Non-randomised prospective trial involving consecutive patients. 100 eyes of 100 patients with medically uncontrolled primary and secondary open angle glaucoma. A superficial scleral flap was raised and a deep sclerectomy was performed in the scleral bed. Schlemm's canal was opened and dissection of the cornea was performed up to Descemet's membrane, at which point aqueous percolated through the remaining trabeculo-Descemet's membrane. A collagen implant was sutured radially in the scleral bed. Visual acuity, intraocular pressure (IOP) measurements, and slit lamp examinations were performed before surgery and after surgery at 1 and 7 days, and 1, 3, 6, 9, 12, 18, 24, 30, and 36 months. RESULTS: The mean follow up period was 17.8 (SD 8.7) months. The mean preoperative IOP was 27.8 (8.6) mm Hg; the mean postoperative IOP was 5.7 (4.0) at day 1, 11.2 (4.6) at month 1, 14.0 (3.5) at month 12, and 13.0 (3.8) at month 36. Complete success rate, defined as an IOP lower than 21 mm Hg without medication, was 44.6% at 36 months. Qualified success rate, defined as an IOP lower than 21 mm Hg with medication, was 97.7% at 36 months. Early postoperative complications included hyphaema in seven patients, would leak in 10 patients, and subtle choroidal detachment in 11 patients. Goniopuncture was performed in 41 of the patients, and 5-fluorouracil injections were made in 23 patients; cataract progression occurred in seven patients. When comparing the different types of open angle glaucoma, no difference was found in terms of reduction in IOP, number of patients requiring antiglaucoma medications, or success rate. CONCLUSIONS: Deep sclerectomy with collagen implant appears to provide reasonable control of IOP at medium term follow up, with few immediate postoperative complications.

Change in capsulorhexis size after implantation of three types of intraocular lenses.

PURPOSE: To compare the change in size of continuous curvilinear capsulorhexis (CCC) used for implantation of three types of intraocular lenses (IOLs) and to determine the role of postoperative inflammation, initial CCC dimension, haptic design, and optic material. SETTING: Hôpital Ophtalmique Universitaire Jules Gonin, Lausanne, Switzerland. METHOD: Twenty-nine three-piece, silicone/poly(methyl methacrylate) (PMMA) IOLs (lovision 127), 26 one-piece PMMA IOLs (Pharmacia 812A), and 27 plate-haptic silicone IOLs (Staar AA4203) were implanted in the capsular bag after phacoemulsification. Photographs of the CCCs taken 1 day and 6 months after surgery were scanned and digitized on a computer. Using different software, the surface of the CCC was measured and the 6 month change evaluated. Flare, measured the day before surgery and postoperatively at days 1, 7, 30, and 180, was integrated to obtain a global estimate of inflammation during the 180 day follow-up. RESULTS: The CCCs used with three-piece, silicone/PMMA IOLs showed little changes in surface, with a mean enlargement of +0.57 mm2 +/- 1.15 (SD) (+3.5%). The CCCs used with the one-piece PMMA IOLs had a slight tendency to constrict, with a mean surface decrease of -0.59 +/- 2.16 mm2 (-4.3%). The CCCs used with plate-haptic silicone IOLs showed a marked and statistically significant constriction, with a mean decrease of -2.55 +/- 3.51 mm2 (-14.4%). The change in CCC size was not associated with the integrated flare, and no correlation was found between the initial CCC size and the magnitude of change. There was no statistically significant difference in CCC change between the PMMA optic IOL (Pharmacia) and silicone optic IOL (lovision and Staar) groups. The CCC in the plate-haptic IOL (Staar) group showed a significant (P < .0002) constriction when compared with that in the loop-haptic IOL (Pharmacia and lovision) group. CONCLUSION: The IOLs' haptic design seemed to play a major role in the evolution of the CCC. The CCC constriction seen with the Staar IOLs was related to their plate haptics.

Change in capsulorhexis size with four foldable loop-haptic lenses over 6 months.

PURPOSE: To compare the change in continuous curvilinear capsulorhexis (CCC) size after implantation of four types of three-piece foldable intraocular lenses (IOLs) and determine whether initial CCC size and IOL characteristics play a role in the change. METHODS: This study comprised 133 eyes that had phacoemulsification and in-the-bag implantation of one of four types of foldable IOLs: Alcon AcrySof MA30BA (n = 36); lovision 127 (n = 29); Mentor ORC MemoryLens (n = 39); Allergan PhacoFlex II (n = 29). Photographs of the CCCs were taken with a digital retinograph 1 day and 6 months after surgery. Using image-analysis software, the CCC surface was measured and changes between 1 week and 6 months were evaluated. Characteristics of the IOLs including overall diameter, optic thickness, and haptic centrifugal force were measured with micrometric tools. RESULTS: The median change in CCC surface size at 6 months was +5.5% in the lovision group, indicating a slight enlargement. This finding was significantly different from that in the other three IOL groups (P < .0001), which had a tendency toward CCC contraction. Median change in CCC size was -2.3% in the MemoryLens group, -2.8% in the AcrySof group, and -6% in the PhacoFlex group. The MemoryLens was the most predictive IOL, with the smallest standard deviation; it was the only group in which no patient developed CCC contraction of more than 10%. Although the lovision and PhacoFlex IOLs have common physical characteristics except for optic thickness (lovision 30% thicker), the CCCs in the lovision group were significantly more stable (P < .0001). Results indicate that the high centrifugal haptic force associated with acrylate/methacrylate polymer optics of the AcrySof and MemoryLens IOLs may prevent CCC contraction of greater than 10% in 97.4% of cases. CONCLUSION: Although there were statistically significant differences, patients in all four three-piece foldable IOL groups had good CCC stability. However, the more stable and predictable CCCs were in the IOL groups that had the strongest centrifugal haptic force and an acrylate/methacrylate polymer optic (AcrySof and MemoryLens).

Implantable contact lens for moderate to high myopia: short-term follow-up of 2 models.

PURPOSE: To confirm the safety, efficacy, and predictability of the surgical correction of moderate to high myopia by the ICM V3 and ICM V4 implantable contact lenses (ICLs), with emphasis on vaulting, intraocular pressure (IOP), and pigment dispersion. SETTING: University Eye Hospital, Lausanne, Switzerland. METHODS: Thirty-two eyes had implantation of an ICL. In 22 eyes with a mean spherical equivalent (SE) of -11.5 diopters (D), the target was emmetropia; in 10 eyes with a mean SE of -22.3 D, the goal was a reduction in the myopia. Nineteen eyes received the ICM V3 ICL and 13, the ICM V4 ICL. The mean follow-up was 7.4 months. RESULTS: The mean postoperative SE in the 32 eyes was -2.16 D. Best spectacle-corrected visual acuity was maintained or improved in all eyes. In the 22 eyes targeted to achieve emmetropia, 10 (45%) were within +/-1.00 D; 15 (68%) had an uncorrected visual acuity of 20/40 or better and 4 (18%), of 20/20 or better. Vaulting of the ICL over the crystalline lens was more pronounced with the V4 than with the V3, and the difference was statistically significant. Subtle, localized anterior subcapsular opacification was encountered in 4 eyes. In 3 of them, the ICL (model V3) vaulting was minimal and 1 ICL (model V4) did not show any vaulting. Eighteen eyes had an IOP higher than the preoperative level, and the difference was statistically significant. No correlation was seen between final IOP and vaulting. Pigment dispersion on the ICL did not appear to be related to vaulting or ICL thickness. CONCLUSION: Implantation of an ICL was effective in correcting moderate to high myopia of up to -17.50 D. Although the procedure appears to be safe, the predictability of the refractive outcome must be improved. The new generation of ICLs for myopia (ICM V4) offers a better vault over the crystalline lens than the older models (ICM V3), which should decrease the risk of cataract. No explanation was found for the IOP increase in several eyes 3 months or more after surgery.

Comparison of deep sclerectomy with collagen implant and trabeculectomy in open-angle glaucoma.

PURPOSE: To assess the efficacy and postoperative complications of deep sclerectomy with collagen implant (DSCI), a nonpenetrating filtration procedure. SETTING: Glaucoma Unit, Department of Ophthalmology, University of Lausanne, Switzerland. METHODS: Forty-four eyes of 44 patients with medically uncontrolled open-angle glaucoma had DSCI and a matched control group of 44 patients, trabeculectomy. A superficial scleral flap was raised and a deep sclerectomy performed in the scleral bed. Schlemm's canal was opened, and the cornea was dissected to Descemet's membrane. At that stage, aqueous filtered through the remaining trabeculo-Descemet's membrane. A collagen implant was sutured radially in the scleral bed; the scleral flap and conjunctiva were then closed. Examinations were performed before surgery and postoperatively at 1 and 7 days and 1, 2, 3, 6, 9, 12, 15, 18, and 24 months. RESULTS: The mean follow-up was 14.4 months +/- 6.3 (SD) (range 3 to 24 months). The mean preoperative intraoperative pressure (IOP) was 26.7 +/- 7.3 mm Hg. The mean postoperative IOP was 6.1 +/- 4.5 mm Hg at 1 day and 11.0 +/- 4.4 mm Hg at 1 week; it remained stable for the next 24 months. The success rate, defined as an IOP lower than 21.0 mm Hg without medication, was 69% in the DSCI group and 57% in the trabeculectomy group at 24 months postoperatively (P = .047). The number of postoperative complications was significantly lower in the DSCI group than in the trabeculectomy group. CONCLUSIONS: The success rate of DSCI may be comparable to that of trabeculectomy, with fewer complications.

Verteporfin therapy for subfoveal choroidal neovascularization in age-related macular degeneration: from clinical trials to clinical practice.

People with choroidal neovascularization (CNV) due to age-related macular degeneration (AMD) are at high risk of central vision loss. Until verteporfin therapy became available, there was no safe and effective treatment for a large majority of these people. The phase III clinical trials of verteporfin therapy showed that treatment could safely reduce the risk of vision loss in the majority of patients presenting with either predominantly classic CNV or with occult with no classic CNV, and in selected patients with minimally classic CNV. The decision to treat patients with subfoveal CNV due to AMD using verteporfin therapy, requires an understanding of the outcomes of these clinical trials and of published guidelines. This review presents the key findings of the trials and outlines the factors that should be considered in clinical practice when deciding whether verteporfin therapy is indicated.

Nd:Yag goniopuncture after deep sclerectomy with collagen implant.

BACKGROUND AND OBJECTIVE: To study the need, the safety and the success rate of Nd:Yag goniopuncture in eyes that underwent deep sclerectomy with collagen implant. PATIENTS AND METHODS: The first 100 patients that underwent deep sclerectomy with collagen implant were prospectively followed. Deep sclerectomy with collagen implant is a non-penetrating filtering surgery which allows filtration of aqueous from the anterior chamber to the subconjunctival space through a remaining trabeculo-Descemet's membrane without opening the anterior chamber. Goniopunctures with Nd:Yag laser were performed at the site of surgery when the filtration through the trabeculo-Descemet's membrane was considered to be insufficient with elevated intraocular pressure. The laser treatment was performed using a Lasag 15 gonioscopy contact lens (CGA1). Goniopunctures were performed using the free-running Q-switched mode with an energy ranging from 2 to 4 mJ. RESULTS: Of 100 patients who underwent deep sclerectomy with collagen implant, goniopunctures with Nd:Yag laser were performed in 41 patients (41%). The mean time between deep sclerectomy with collagen implant and goniopuncture was 9.9 months +/-1.2 months (+/-SE). The mean IOP before laser treatment was 22.2 mm +/-7.0 mm Hg and decreased to 12.5 mm +/-5.8 mm Hg immediately after laser treatment and remained stable for the next 2 years of follow-up. The immediate success rate of goniopuncture was 83%. Choroidal detachment occurred in two patients (5%). CONCLUSION: Nd:Yag goniopuncture is an efficient and safe treatment for low filtration through the trabeculo-Descemet's membrane after deep sclerectomy with collagen implant.

On the selectivity of photodynamic therapy of choroidal neovascularization associated with age-related macular degeneration.

PURPOSE: This paper discusses the lack of complete selectivity in the photodynamic closure of choroidal neovasculature (CNV) associated with age-related macular degeneration. The arguments presented are supported by examples of clinical observations and may be useful for the design of the next generation of photosensitizers. RESULTS AND CONCLUSION: Based on worldwide patient follow-up, it can be concluded that a substantial number of the more than 200000 treatments that have been dispensed so far could have resulted in stabilization of the disease for at least a number of years. Clinical observations also indicate that, in addition to the effective closure of the CNV observed 1 week after PDT, a significant closure (or at least reduced leakage) of normal choriocapillaries is observed in the treated area. Some of the concepts associated with the selectivity of Visudyne photodynamic therapy of choroidal neovascularization in age-related macular degeneration are also discussed. DISCUSSION: Novel approaches to improving selectivity could include attaching a photosensitizer to a targeting moiety such as a monoclonal antibody or a peptide. The undesirable closure of normal choriocapillaries in the treated area is one area of possible improvement to be sought for the next generation of drugs.

[Visudyne photodynamic therapy and feeder vessel occlusion: rationale of a synergistic association and clinical options]. / Photothérapie dynamique à la Visudyne et occlusion du vaisseau afférent: rationnel d'une association synergique et options cliniques illustrées.

PURPOSE: Visudyne photodynamic therapy (PDT) has provided considerable improvement in patient care of subfoveal choroidal neovascularization (CNV). Patients tend to loose vision for a few months after the initial treatment, but the 4-year proven stability in vision most often provides an acceptable quality of life, sometimes with additional low vision rehabilitation. The initial visual acuity loss, borderline cost-effectiveness, and subgroups of patients not responding to PDT warrant improving the symptomatic treatment of subfoveal CNV. Today, the most tempting solution would be to combine PDT with an occlusion of the feeder vessel (FV). METHODS: Two patients are described in whom the feeder vessel was occluded using modifications of the classic PDT treatment method. The FV was identified in both patients using fluorescein and indocyanine green angiographies at a recorded video rate using a modified scanning laser ophthalmoscope (Rodenstock SLO). The feeder vessel of the first patient was occluded by minimal photocoagulation immediately after a Visudyne PDT treatment in order to take advantage of the reduced blood flow within the feeder vessel. The second patient presenting a subfoveal FV was treated using a modified PDT treatment called feeder-vessel PDT. The photosensitizing agent was activated by a first classic spot covering the lesion, followed immediately by a small spot focused on the feeder vessel. RESULTS: Both subfoveal CNVs were successfully and selectively occluded and some visual acuity was gained following the treatment. CONCLUSION: Occlusion of the feeder vessel is an appealing clinical option that is complementary to Visudyne PDT. Both treatment methods presented here could provide additional options to close subfoveal CNV with an optimal efficacy-risk ratio.

Early detection, diagnosis and management of choroidal neovascularization in age-related macular degeneration: the role of ophthalmologists.

Choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD) is a serious condition which, if unrecognized and untreated, can result in the rapid deterioration of vision. Early detection and prompt referral to a retina specialist may potentially reduce the high risk of severe vision loss. The majority of AMD patients with CNV who present to an ophthalmologist will have been referred by either a primary care physician or an optometrist. Following referral, ophthalmologists will confirm diagnosis and identify the location and composition of the CNV. This information will provide the basis for a decision on what treatment, if any, is indicated. Until last year, laser photocoagulation was the only clinically-proven treatment option for neovascular AMD in large-scale randomized clinical trials, although many patients were not eligible for this treatment. Verteporfin (Visudyne(TM)) therapy is a new treatment option that uses photodynamic therapy in patients with predominantly classic subfoveal CNV secondary to AMD. Retrospective analyses show that the introduction of verteporfin therapy is likely to increase the number of patients with neovascular AMD who can be treated. Early detection, prompt referral and treatment, together with appropriate use of low vision aids, will help to optimize patient outcomes and quality of life.

Lymphedema of the face.

Lymphedema of the extremities is well documented in the literature. We present a case of lymphedema involving the face of a 27-year-old man and discuss the clinical presentation, microscopic findings, and surgical treatment. To our knowledge, this is the first such case report in the literature.

[Exudative parafoveal astrocytic hamartoma associated with Bourneville tuberous sclerosis: spontaneous evolution]. / Hamartome astrocytaire parafovéolaire exsudatif associé à une sclérose tubéreuse de Bourneville: évolution spontannée.

The authors present an unusual case of exsudative parafoveolar astrocytic hamartome associated with tuberous sclerosis. The spontaneous regression of the serous retinal detachment and of the hard exsudates is described.

[The role of a new method for occlusion of fistula tracts]. / Intérêt d'un nouveau moyen d'occlusion de trajets fistuleux.

Digestive fistulae have a quite variable clinical presentation, depending on their origin and topography. Even when very small, they can cause considerable mechanical or metabolic derangement. Surgical correction often implies an operation with important consequences. The injection of an occlusive emulsion can, in a certain number of cases, close off the fistulous tract with minimal inconvenience. We have injected several invalidating fistulae between the digestive or respiratory tract and the skin with Ethibloc. Total occlusion of the fistulae was accomplished after one or more injections. The emulsion is resorbed after around 10 days, leaving a scar. The inclusion of radio-opaque material allows intraoperative control of injection. This technique widens the therapeutic modalities applicable to a difficult medical condition. When confronted with advanced inflammatory or neoplastic disease, for example, Ethnibloc injection can be considered if the tissue quality is sufficient. Gross infection or tissue necrosis are, in our experience, relative contraindications; the occlusive emulsion cannot adhere and is rapidly evacuated by the fistula.

Morphometric characteristics of traumatic choroidal ruptures associated with neovascularization.

PURPOSE: To define the morphometric characteristics of indirect choroidal ruptures associated with choroidal neovascularization (CNV). METHODS: A total of 79 eyes that had sustained traumatic indirect choroidal ruptures was studied retrospectively. Color pictures of the fundus and fluorescein angiograms were available in all cases, and patients were followed for at least 1 year. Eyes that were free of CNV constituted Group I; eyes that developed CNV constituted Group II. Baseline characteristics of both groups, including age, sex, and visual acuity, were recorded. Distance of indirect choroidal ruptures from the center of the fovea and morphometric characteristics of the ruptures were calculated using image analysis software (Image 1.60; National Institutes of Health, Bethesda, MD). RESULTS: A total of 63 eyes (79.7%) free of CNV was included in Group I and 16 eyes (20.3%) that developed CNV were included in Group II. Morphometric analysis showed a greater distance between the indirect choroidal rupture and the center of the fovea in Group I than in Group II (median, 1480 microm versus 612 microm; P = 0.009). In addition, the length of the rupture was shorter in Group I than in Group II (median, 3054 microm versus 4504 microm; P = 0.03). CONCLUSIONS: Two significant factors associated with the presence of CNV in case of traumatic choroidal rupture were identified and quantified: the proximity of the rupture to the center of the fovea and the length of the rupture. Both should be considered as risk factors for the development of CNV and monitoring should take them into account.

A computer-based method to quantify the classic pattern of choroidal neovascularization in order to monitor photodynamic therapy.

BACKGROUND: Photodynamic therapy (PDT) is a new treatment modality which relies on a nonthermal light exposure of choroidal neovascularization (CNV) which has accumulated a photosensitizer, to produce a photochemical thrombosis. The aim of the present study was to develop a more quantitative outcome parameter that can be used to optimize a number of treatment parameters which in PDT are larger than many other modalities. METHODS: Nine patients underwent up to four standardized fluorescein angiography (FA) examinations on a Zeiss 30 degrees retinograph using Kodak Trimax film. The 35-mm pictures were digitized. The CNV size was evaluated using the NIH Image 1.60 software, comparing the CNV surface to the disk area. The fluorescence intensity was measured comparing the grayscale fluorescence levels of the CNV classic pattern with the mean grayscale level of control areas. A combination of the CNV size parameter with the fluorescence contrast parameter was called "integrated contrast" (IC). The IC amplitude was then used to describe and compare the fluorescence before and after PDT. RESULTS: FAs on three normal patients defined the normal range of the IC. IC measurements on two patients with a classic CNV who underwent FA examinations respectively 1 and 3 months apart demonstrated the robustness and the reproducibility of the method. IC measurements on three patients who underwent PDT with three different treatment parameters demonstrated the feasibility of using this IC measurement as a PDT outcome criteria. CONCLUSION: We have developed a method to transform a qualitative clinical evaluation of CNV leakage into a more quantitative grading.

Deep sclerectomy: results with and without collagen implant.

PURPOSE: To study the need, the safety and the success rate of collagen implant in eyes that underwent deep sclerectomy, a new non penetrating filtration procedure, we compared the results of deep sclerectomy with (DSCI) and without (DS) collagen implant. METHODS: Of 168 patients (168 eyes) with various types of medically uncontrolled open angle glaucoma, 86 (86 eyes) underwent DSCI, and 82 (82 eyes) underwent DS. Visual acuity, slit lamp examination, intraocular pressure (IOP) measurements were performed before surgery and prospectively at days 1 and 7 and months, 1, 2, 3, 6, 9, 12, 15, 18, and 24 after surgery. Deep sclerectomy was performed according to Kozlov's original technique. The collagen implant drainage device was radially secured in the center of the deep sclerectomy dissection. RESULTS: The mean follow-up period was 9.7 +/- 6.5 months for DSCI, and 9.0 +/- 4.8 months for DS. The mean preoperative IOP was 26.9 +/- 8.8 mmHg for DSCI and 25.8 +/- 8.5 mmHg for DS. The mean postoperative IOP and visual acuity were similar between the two groups. Complete and qualified success rates were better when the collagen implant was used (Log-Rank test: p = 0.0002 and 0.033 for complete and qualified success respectively). The need for postoperative glaucoma medications was significantly lower when the collagen implant was used (0.2 +/- 0.5 versus 0.5 +/- 0.7 medication per patient in the DSCI and DS respectively, Student's t test: p = 0.0038). There was significantly less bleb fibrosis when the collagen implant was used (2% and 11% in DSCI and DS respectively, p = 0.029). CONCLUSION: The collagen implant device is safe, increases the success rate of deep sclerectomy, and lowers the need for postoperative glaucoma medications.