ISCHEMIC CENTRAL RETINAL VEIN OCCLUSION IN THE ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR ERA.

PURPOSE: Anti-vascular endothelial growth factor therapy has improved the prognosis for patients with central retinal vein occlusion (CRVO). However, most studies published to date exclude ischemic CRVO. The purpose of this study was to describe the outcome in eyes with ischemic CRVO treated with anti-vascular endothelial growth factor therapy. METHODS: Thirty-seven patients with ischemic CRVO from 3 centers were followed for at least 6 months. Data on patient demographic, vision status, and anti-vascular endothelial growth factor treatments were collected. RESULTS: Average number of injections during the study period was 5. Younger age was associated with improved vision (P = 0.006). Patients with improved visual outcomes tended to have macular edema as the primary indication for treatment, whereas patients with worse outcomes tended to have neovascularization as the primary indication for treatment. CONCLUSION: This study highlights significant variability in the use of anti-vascular endothelial growth factor therapy for ischemic CRVO and underscores that eyes with neovascularization tend to have worse visual outcomes.

Persistent placoid maculopathy: a new clinical entity.

PURPOSE: To describe a previously unreported clinical entity superficially resembling macular serpiginous choroiditis but with a distinct presentation and clinical course. DESIGN: Retrospective observational case series. PARTICIPANTS: Six patients, 50 to 68 years old, exhibiting this entity who were seen at 5 different centers from 1984 to 2006. METHODS: Review of medical records. MAIN OUTCOME MEASURES: Best-corrected visual acuity (VA) and clinical and angiographic findings. RESULTS: The lesions in our patients are similar to those of acute macular serpiginous choroiditis. Our patients had well-delineated whitish plaquelike lesions involving the macula and sparing the peripapillary areas of both eyes. In contrast to serpiginous choroiditis, VA remained good despite early involvement of the fovea until complications related to choroidal neovascularization or pigmentary mottling developed. Angiographic characteristics and the clinical course were also atypical. Fluorescein angiography revealed well-defined early hypofluorescent areas that partially filled in in the late phase. Indocyanine green angiography showed the hypofluorescence to be persistent. Unlike serpiginous choroiditis, the white macular lesions faded over a period of months to years, whereas the characteristic angiographic findings often persisted longer. Choroidal neovascularization developed in 11 of 12 eyes, with subsequent conversion to disciform macular scars in 9 of 12 eyes. Unlike serpiginous choroiditis, none of the eyes showed chorioretinal scar formation unless related to choroidal neovascularization. CONCLUSION: Persistent placoid maculopathy has features resembling macular serpiginous choroiditis but differs in its clinical course and effect on VA. It appears to be a new entity. The majority of eyes develop choroidal neovascularization that results in loss of central vision.

Photodynamic therapy of choroidal hemangioma in sturge-weber syndrome, with a review of treatments for diffuse and circumscribed choroidal hemangiomas.

We report three new cases of patients with Sturge-Weber Syndrome and symptomatic retinal detachments from diffuse choroidal hemangiomas successfully treated with photodynamic therapy (PDT) and review medical literature on the available treatment options for choroidal hemangiomas. All patients were treated with a single session of PDT with verteporfin infused at a concentration of 6 mg/m(2) and treated for 83 seconds with 689-nm Zeiss laser that was delivered with total energy level of 50 J/cm(2) with an intensity of 600 mW/cm(2). The exudative retinal detachment (RD) and macular edema completely resolved in all cases by 1-4 months after PDT treatment. Visual acuity improved in all three cases with diminished tumor size in the areas of treatment. One case was followed for 5 months, another for 2 years, and the third case for 6 years, with no recurrence of exudative RD. PDT is an effective treatment option for visual deterioration from exudative retinal detachment in patients with diffuse choroidal hemangiomas.

Torpedo maculopathy.

AIM: To describe the fluorescein angiographic, fundus autofluorescence and optical coherence tomography (OCT) findings in patients with a unique unilateral lesion of the temporal macula previously named torpedo maculopathy. METHOD: This study was a retrospective, observational case series. The medical records of 13 patients, age 1-68 years, seen between 1982 and 2009 were reviewed. Patients were evaluated for lesion features and course on follow-up, visual acuity, fluorescein angiography, visual-field defects, fundus autofluorescence and OCT findings. RESULTS: In all 13 patients, the lesion was flat, torpedo-shaped and solitary, and involved the temporal macula. The hypopigmented lesion had well-defined margins and a characteristic leading edge which pointed towards the centre of the macula. Fluorescein angiography revealed transmission hyperfluorescence of the lesion. OCT indicated a thin abnormal retinal pigment epithelium signal, and Humphrey Visual Field testing revealed a corresponding blind spot. Fundus autofluorescence performed on one patient was dark in the affected area. CONCLUSION: Torpedo maculopathy is an apparently congenital hypopigmented torpedo-shaped lesion of the temporal macula. Although it may result in a corresponding visual-field defect, these non-foveal lesions do not affect central visual acuity.

Increased prevalence of autoimmunity in patients with white spot syndromes and their family members.

OBJECTIVE: To determine whether there is an increased prevalence of systemic autoimmune diseases in both patients with white spot syndromes (WSS) and their family members. METHODS: Patients with WSS at participating institutions were asked to complete a questionnaire reporting their own medical histories as well as any autoimmune diseases among their first- and second-degree relatives. RESULTS: As of January 1, 2008, 114 questionnaires had been collected, providing medical histories of 114 patients with WSS and 1098 family members. The number of patients with WSS with self-reported systemic autoimmune diseases was 26 (23%). Of 1098 relatives, 106 (10%) had at least 1 autoimmune disease. Systemic autoimmunity was more prevalent in female relatives (13%) as compared with male relatives (6%). In addition, the prevalence of autoimmunity was significantly higher among first-degree relatives (13%) than second-degree relatives (8%). Patients who themselves had systemic autoimmune diseases showed a greater prevalence of systemic autoimmunity among their families as compared with the families of patients without systemic autoimmune diseases. CONCLUSIONS: Our data indicate that there is an increased prevalence of systemic autoimmunity in both patients with WSS and their first- and second-degree relatives. This suggests that WSS occur in families with inherited immune dysregulation that predisposes to autoimmunity.

Persistent placoid maculopathy: a new clinical entity.

PURPOSE: To describe a previously unreported clinical entity superficially resembling macular serpiginous choroiditis but with a distinct presentation and clinical course. METHODS: A retrospective review of the medical records of five patients, aged 50 to 68 years, exhibiting this entity seen at five different centers from 1999 to 2006. RESULTS: The lesions in the patients in this study are in some respects similar to those of acute macular serpiginous choroiditis. The patients had well-delineated whitish plaque-like lesions involving the macula and sparing the peripapillary areas of both eyes. In contrast to serpiginous choroiditis, visual acuity remained good despite early involvement of the fovea until complications related to choroidal neovascularization (CNV) or pigmentary mottling developed. The angiographic characteristics and the clinical course were also atypical. Fluorescein angiography revealed well-defined early hypofluorescent areas, which partially filled-in in the late phase. Indocyanine green angiography showed the hypofluorescence to be persistent. Unlike serpiginous choroiditis, the white macular lesions faded over a period of months to years, but the characteristic angiographic findings often persisted longer. CNV developed in nine of 10 eyes with subsequent conversion to disciform macular scars in seven of 10 eyes. Unlike serpiginous choroiditis, none of the eyes showed chorioretinal scar formation unless related to CNV. CONCLUSION: Persistent placoid maculopathy has features resembling macular serpiginous choroiditis but differs in its clinical course and effect on visual acuity. It appears to be a new entity. The majority of eyes develop CNV, which results in loss of central vision.

The safety of carotid endarterectomy in patients with preoperative renal dysfunction.

Recent published data suggest that performing carotid endarterectomy (CEA) in patients with renal dysfunction is associated with a prohibitively high perioperative stroke and death rate. On the basis of our experience, we hypothesized that CEA is a safe procedure in patients with renal insufficiency. A retrospective review of one surgeon's CEA experience from 1988 to 1998 was performed. A total of 398 procedures performed on 370 patients were reviewed for patient demographics and adverse events in the 30-day perioperative period. Risk factors, indications for procedure, and degree of stenosis, as well as intraoperative use of shunts, patch angioplasty, drains, completion angiography, and EEG monitoring were compared. Patients were categorized by preoperative creatinine (Cr) levels as normal (Cr 1.5). All data were subjected to statistical analysis. Our results showed that CEA can be performed safely in patients with renal dysfunction with no increase in perioperative stroke or death rate. Performing CEA in patients with renal insufficiency does require preoperative cardiac evaluation and close cardiac monitoring, as there appears to be an increased rate of myocardial infarction in our series.

Recent trends in upper eyelid blepharoplasties in medicare patients in the United States from 1995 to 1999.

PURPOSE: To present data regarding the rate of upper eyelid blepharoplasty in the Medicare population at both the national and the regional levels from 1995 to 1999 and to analyze these data for any correlation with reimbursement, surgical criteria differences, or the number of ophthalmologists per capita. METHODS: This was a retrospective cohort study. The subjects consisted of a 5% random sample of the Medicare population who had blepharoplasty from 1995 to 1999. Number, rate, and reimbursements of blepharoplasty of the 10 Health Care Financing Administration (HCFA) regions were compared for the 5-year period. Number of ophthalmologists per capita and differences in the regional criteria for Medicare-approved upper eyelid blepharoplasty were compared among the 10 HCFA regions. RESULTS: Across the nation, there was a 13% annual increase in the rate of blepharoplasty from 1995 to 1999 in the Medicare-population after adjusting for age, race, sex, and HCFA regions. During the same period, the average reimbursement per surgery decreased by $26.50 annually. There was a statistically significant inverse correlation between reimbursement and rate of blepharoplasty at the national level (r= - 0.74, P< 0.001). On the regional level, this relation was less profound (r= -0.29, P= 0.039). There was no correlation between the rate of blepharoplasty and the number of ophthalmologists per capita or the differences in surgical criteria. CONCLUSIONS: The inverse relation between rate of Medicare-approved blepharoplasty and reimbursement between 1995 and 1999 was evident at both the national and regional levels. No relation between regional differences in the rates of blepharoplasty and regional differences in surgical criteria or the number of ophthalmologists per capita were identified. Though our study suggests no causal link between annual rate of blepharoplasty and Medicare reimbursement, such inverse correlation is interesting and may have been affected by other factors such as changing clinical indications for this procedure.