A pilot study of normative data for macular thickness and volume measurements using cirrus high-definition optical coherence tomography.

PURPOSE: To establish preliminary normative data for macular thickness (MT) and macular volume (MV) by Cirrus high-definition optical coherence tomography (Carl Zeiss Meditec, Dublin, CA). METHODS: Retrospective case series of 192 eyes of 192 subjects (age, 20-90 years) without retinal disease or surgery with best-corrected visual acuity ≥ 20/25, intraocular pressure <21 mmHg, and cup-to-disc ratio ≤ 0.5 were enrolled. Retinal thicknesses in nine Early Treatment Diabetic Retinopathy Study subfields (including central subfield thickness [CST]), MT, and MV were measured with Cirrus high-definition optical coherence tomography. Effects of age, gender, lens status, and diabetic status on these measurements were analyzed. RESULTS: The mean ± SD CST, MT, and MV were 262.4 ± 22.8 µm, 281.3 ± 14.5 µm, and 10.1 ± 0.6 mm3, respectively. Although CST and age were not associated (P = 0.45), both mean MT and mean MV declined with age (P < 0.0001). Central subfield thickness (P = 0.002), mean MT (P = 0.021), and MV (P = 0.041) were higher in men compared with women. Neither lens status nor diabetic status affected CST, MT, or MV. CONCLUSION: A pilot study showed that preliminary normative CST, MT, and MV values were obtained by Cirrus high-definition optical coherence tomography. The authors propose that CST ranges from 216.8 µm to 308 µm in normal eyes. Older age and female gender were associated with thinner MT.

Ischemic index and neovascularization in central retinal vein occlusion.

PURPOSE: To explore the association of angiographic nonperfusion with anterior segment and posterior segment neovascularization in central retinal vein occlusion (CRVO). METHODS: An imaging database at one institution was searched for the diagnosis of central retinal vein occlusion. Ultra wide field fluorescein angiograms were graded for image quality, the presence of retinal neovascularization, and the quantity of nonperfusion; an ischemic index (ISI) was calculated. Charts were reviewed to exclude eyes with previous treatment and to determine which eyes had anterior segment or posterior segment neovascularization on the day of the angiogram. Time from onset to presentation could not accurately be ascertained. RESULTS: In a 39-month period, there were 69 eyes that met inclusion criteria. The mean ISI was 25% (SD, 26%; range, 0-100%), and 15 eyes (21%) with neovascularization had a mean ISI of 75% (range, 47-100%) compared with eyes without neovascularization that had an ISI of 6% (range, 0-43%). Ischemic index significantly correlated to neovascularization, and eyes that had evidence of neovascularization had an ISI >45% (P < 0.0001). CONCLUSION: Ultra wide field fluorescein angiography provides visualization of nonperfusion in eyes with central retinal vein occlusion. Eyes with neovascularization on the day of the angiogram were found to have significantly larger areas of retinal nonperfusion compared with eyes without neovascularization. A prospective study is indicated to know if early treatment of peripheral retinal nonperfusion in CRVO improves outcomes.

A prospective randomized trial of intravitreal bevacizumab or laser therapy in the management of diabetic macular edema (BOLT study) 12-month data: report 2.

PURPOSE: To report the findings at 1 year of a study comparing repeated intravitreal bevacizumab (ivB) and modified Early Treatment of Diabetic Retinopathy Study (ETDRS) macular laser therapy (MLT) in patients with persistent clinically significant diabetic macular edema (CSME). DESIGN: Prospective, randomized, masked, single-center, 2-year, 2-arm clinical trial. PARTICIPANTS: A total of 80 eyes of 80 patients with center-involving CSME and at least 1 prior MLT. METHODS: Subjects were randomized to either ivB (6 weekly; minimum of 3 injections and maximum of 9 injections in the first 12 months) or MLT (4 monthly; minimum of 1 treatment and maximum of 4 treatments in the first 12 months). MAIN OUTCOME MEASURES: The primary end point was the difference in ETDRS best-corrected visual acuity (BCVA) at 12 months between the bevacizumab and laser arms. RESULTS: The baseline mean ETDRS BCVA was 55.7+/-9.7 (range 34-69) in the bevacizumab group and 54.6+/-8.6 (range 36-68) in the laser arm. The mean ETDRS BCVA at 12 months was 61.3+/-10.4 (range 34-79) in the bevacizumab group and 50.0+/-16.6 (range 8-76) in the laser arm (P = 0.0006). Furthermore, the bevacizumab group gained a median of 8 ETDRS letters, whereas the laser group lost a median of 0.5 ETDRS letters (P = 0.0002). The odds of gaining > or =10 ETDRS letters over 12 months were 5.1 times greater in the bevacizumab group than in the laser group (adjusted odds ratio, 5.1; 95% confidence interval, 1.3-19.7; P = 0.019). At 12 months, central macular thickness decreased from 507+/-145 microm (range 281-900 microm) at baseline to 378+/-134 microm (range 167-699 microm) (P<0.001) in the ivB group, whereas it decreased to a lesser extent in the laser group, from 481+/-121 microm (range 279-844 microm) to 413+/-135 microm (range 170-708 microm) (P = 0.02). The median number of injections was 9 (interquartile range [IQR] 8-9) in the ivB group, and the median number of laser treatments was 3 (IQR 2-4) in the MLT group. CONCLUSIONS: The study provides evidence to support the use of bevacizumab in patients with center-involving CSME without advanced macular ischemia.

Bilateral central serous chorioretinopathy resolving rapidly with treatment for obstructive sleep apnea.

BACKGROUND: Central serous chorioretinopathy (CSR) is a common disorder that affects many individuals, often for unknown reasons; we present a case of bilateral CSR that rapidly resolved with treatment of obstructive sleep apnea (OSA). METHODS: Observational case report. RESULTS: Bilateral decreased vision to 20/30 OD and 20/40 OS due to typical CSR lesions. Systemic evaluation led to a diagnosis of OSA, which was treated and resulted in rapid resolution of the CSR and improvement of visual acuity in both eyes. DISCUSSION: We present the first case of rapidly resolving bilateral CSR due to the treatment of OSA.

Short-duration focal pattern grid macular photocoagulation for diabetic macular edema: four-month outcomes.

PURPOSE: To evaluate the visual acuity (VA) and optical coherence tomography thickness results of short-duration pattern scanning laser macular photocoagulation in the treatment of clinically significant macular edema because of diabetes. METHODS: Consecutive retrospective analysis of VA and optical coherence tomographic data from eyes treated in a modified Early Treatment Diabetic Retinopathy Study style using a short-duration pattern scanning laser. RESULTS: A total of 100 eyes from 70 patients met study criteria. All subjects were treated with the same PASCAL (pattern scanning laser) photocoagulation unit. Parameters varied according to media and pigmentation status, but typical settings were 100-µm spot size, 10-millisecond pulse duration, 225-mW power, and 29 J/cm fluence to give a pale but visible lesion. At 4 months posttreatment, there was an average improvement in VA of 0.060 logMAR (an improvement from 20/45 to 20/40, or approximately 3 Early Treatment Diabetic Retinopathy Study letters; P = 0.0007) and a reduction of central optical coherence tomographic thickness of 40 µm and 37 µm (spectral domain and time domain optical coherence tomography groups, respectively), both of which were statistically significant (P = 0.0049 and 0.012, respectively). CONCLUSION: Short-duration PASCAL macular photocoagulation has a biological treatment effect at 4 months for the treatment of clinically significant macular edema. While caution must be used when converting between different VA measurement methods and when using literature-based controls, the observed VA improvement seems equivalent to 3 Early Treatment Diabetic Retinopathy Study letters. These findings are similar to the recently published results from the diabetic retinopathy clinical research network cohort. PASCAL laser photocoagulation for clinically significant macular edema appears safe and effective in the short term and may have significant long-term advantages.

Macular perfusion determined by fundus fluorescein angiography at the 4-month time point in a prospective randomized trial of intravitreal bevacizumab or laser therapy in the management of diabetic macular edema (Bolt Study): Report 1.

PURPOSE: The purpose of this study was to assess macular perfusion with fundus fluorescein angiography at the 4-month time point in a prospective randomized, single-center 2-year trial comparing intravitreal bevacizumab and laser therapy in patients with diabetic macular edema. METHODS: All enrolled patients had standard Early Treatment of Diabetic Retinopathy Study 7-field fundus photographs and fundus fluorescein angiography at baseline and subsequently at 4-month intervals. Patients were excluded from the study if either the greatest linear dimension of the foveal avascular zone (FAZ) was >1,000 microm in diameter or there was severe perifoveal capillary loss (Early Treatment of Diabetic Retinopathy Study criteria) on fundus fluorescein angiography. The fundus fluorescein angiograms of the bevacizumab (n=42) and laser (n=38) groups were graded for greatest linear dimension of the FAZ, area of the FAZ, and perifoveal capillary loss by the Moorfields Reading Centre in a masked fashion. RESULTS: At baseline, the mean greatest linear dimension of the FAZ in the laser group was 685 +/- 262 microm and in the bevacizumab group was 737 +/- 262 microm. There was no significant difference at the 4-month time point (P 0.40) with the mean greatest linear dimension of the FAZ in the laser group recorded as 678 +/- 221 microm and in the bevacizumab group was 678 +/- 231 microm. At baseline, the median area of the FAZ in the laser group was 0.36 mm(2) (interquartile range, 0.21-0.46) and in the bevacizumab group was 0.33 mm(2) (interquartile range, 0.27-0.49). There was no significant difference at the 4-month time point (P=0.30) with the median area of the FAZ in the laser group recorded as 0.35 mm(2) (interquartile range, 0.20-0.52) and in the bevacizumab group was 0.34 mm(2) (interquartile range, 0.23-0.47). Similarly, there was no difference between the two treatment groups (P=0.64) when a comparison was made of the number of grades of change in perifoveal capillary loss observed in each patient. To date, no patients have been withdrawn from the study because of worsening macular ischemia. CONCLUSION: At 4 months, there was no evidence of worsening macular ischemia in either group.

Update on treatments for diabetic macular edema.

PURPOSE OF REVIEW: Due to modest outcomes with macular laser, other treatment modalities for diabetic macular edema have been evaluated. Intravitreal triamcinolone acetonide, pars plana vitrectomy, oral protein kinase C inhibitors and, from more recently, anti-vascular endothelial growth factor therapy are reviewed. RECENT FINDINGS: Intravitreal triamcinolone acetonide may be more effective than laser. Intravitreal triamcinolone acetonide followed by laser may be more effective than intravitreal triamcinolone acetonide alone. Ruboxistaurin, a selective protein kinase C betainhibitor, reduced retinal vascular leakage in patients with diabetic macular edema and reduced the rate of sustained moderate visual loss in those with moderately severe to very severe non proliferative diabetic retinopathy. Several anti-vascular endothelial growth factor agents are under evaluation. Intravitreal pegaptanib sodium (0.3 mg) improved vision and reduced central retinal thickness compared to sham. Data on the other anti-vascular endothelial growth factor agents is limited, but there are promising results, with ranibizumab (0.5 mg) and bevacizumab reducing foveal thickness and improving visual acuity in some patients with diabetic macular edema. SUMMARY: There remains no proven intervention that consistently prevents or reverses visual loss from diabetic macular edema in all patients. A variety of promising new medical and surgical therapies are under investigation, but further research is required to determine their role alone or in combination.

Intraocular contact lens tamponade to facilitate penetrating keratoplasty in perforated corneas.

Penetrating keratoplasty in the presence of a perforated cornea is a relatively common and difficult surgical problem. In the worst scenario, there may be extrusion of ocular contents during trephination. Two cases of perforated corneas are presented in which a new technique was used to close the perforation and normalize intraocular pressure. This involves inserting a soft contact lens through a paracentesis into the anterior chamber. An ophthalmic viscosurgical device is then injected behind the contact lens, opening it, and allowing it to tamponade the perforation. This stabilizes the anterior chamber and allows a stable operating environment. This has not been described previously.

Conjunctival squamous cell carcinoma with perineural invasion resulting in death.

Conjunctival squamous cell carcinoma is generally a low-grade malignancy. A 42-year-old man presented with histologic evidence of extra-tumoral perineural invasion associated with an incompletely excised limbal conjunctival squamous cell carcinoma. Despite further surgery, close observation, plaque radiotherapy, and eyelid-sparing orbital exenteration followed by external beam radiotherapy, the patient developed intracranial perineural invasion with involvement of the trigeminal and facial nerves, ultimately resulting in death. Repeated magnetic resonance imaging with contrast failed to detect perineural invasion until late in the course of disease. Awareness of the possibility of perineural invasion in patients with conjunctival squamous cell carcinoma and of its aggressive nature may be life-saving. Nevertheless, even with initial aggressive tumor control, some patients will show an aggressive tumor growth with recurrences.

A 2-year prospective randomized controlled trial of intravitreal bevacizumab or laser therapy (BOLT) in the management of diabetic macular edema: 24-month data: report 3.

OBJECTIVE: To report the 2-year outcomes of the BOLT study, a prospective randomized controlled trial evaluating intravitreous bevacizumab and modified Early Treatment Diabetic Retinopathy Study (ETDRS) macular laser therapy (MLT) in patients with persistent clinically significant macular edema (CSME). METHODS: In a 2-year, single-center, randomized controlled trial, 80 patients with center-involving CSME and visual acuity of 20/40 to 20/320 were randomized to receive either bevacizumab or MLT. PRIMARY OUTCOME: difference in ETDRS best-corrected visual acuity (BCVA) between arms. SECONDARY OUTCOMES: mean change in BCVA, proportion gaining at least 15 and at least 10 ETDRS letters, losing fewer than 15 and at least 30 letters, change in central macular thickness, ETDRS retinopathy severity, and safety outcomes. RESULTS: At 2 years, mean (SD) ETDRS BCVA was 64.4 (13.3) (ETDRS equivalent Snellen fraction: 20/50) in the bevacizumab arm and 54.8 (12.6) (20/80) in the MLT arm (P=.005). The bevacizumab arm gained a median of 9 ETDRS letters vs 2.5 letters for MLT (P=.005), with a mean gain of 8.6 letters for bevacizumab vs amean loss of 0.5 letters for MLT. Forty-nine percent of patients gained 10 or more letters (P=.001) and 32% gained at least 15 letters (P=.004) for bevacizumab vs 7% and 4% for MLT. Percentage who lost fewer than 15 letters in the MLT arm was 86% vs 100% for bevacizumab (P=.03). Mean reduction in central macular thickness was 146 µm in the bevacizumab arm vs 118 µm in the MLT arm. The median number of treatments over 24 months was 13 for bevacizumab and 4 for MLT. CONCLUSIONS: This study provides evidence supporting longer-term use of intravitreous bevacizumab for persistent center-involving CSME. APPLICATION TO CLINICAL PRACTICE: Improvements in BCVA and central macular thickness seen with bevacizumab at 1 year were maintained over the second year with a mean of 4 injections. TRIAL REGISTRATION: eudract.ema.europa.eu Identifier: 2007-000847-89

Cocaine and choroidal infarction, revisiting the triangular sign of amalric.

PURPOSE: To describe a case of choroidal infarction as illustrated by the "triangular sign of Amalric" after cocaine inhalation. METHODS: Observational case report. RESULTS: A 52-year-old male presented with an acute loss of vision in his left eye immediately after cocaine inhalation. Color photography and fluorescein angiography revealed triangular areas of choroidal ischemia following the distribution of the posterior ciliary arteries. CONCLUSION: Cocaine-induced vasospasm, specifically of the distal short posterior ciliary arteries, may explain the triangular wedge-shaped choroidal infarcts in our patient. A thorough drug history may circumvent unnecessary and costly investigations in such cases.

Nasal Retinoschisis Associated with Glaucoma.

The authors describe a case of nasal and macular retinoschisis in a patient with open angle glaucoma. A 75 year-old female with optic nerve head damage secondary to chronic open angle glaucoma developed macular schisis and a separate area of retinoschisis nasal to her optic disk. There were no other identifiable causes for her retinoschisis. Glaucoma related structural defects offer a plausible explanation for multiple cavities of retinoschisis in favor of multiple occult congenital pits of the optic nerve head.

Ultra-wide-field and autofluorescence imaging of choroidal dystrophies.

The authors retrospectively identified 2 cases of gyrate atrophy, 3 cases of choroideremia, and 1 case of the carrier state of choroideremia who underwent ultra-wide-field fundus photography and fluorescein angiography. The findings were studied and compared to standard fundus photography and fluorescein angiography. Gyrate atrophy demonstrated a diffuse confluent extent of chorioretinal atrophy extending from the anterior to the posterior pole to the periphery. Choroideremia demonstrated a patchy irregular pattern of chorioretinal atrophy extending from the posterior pole to the periphery. Peripheral reticular degeneration without chorioretinal atrophy was appreciated in the carrier state. Ultra-wide-field imaging of these choroidal dystrophies demonstrated distinctive patterns that may aid in their identification and diagnosis.

Patterns of periphlebitis in intermediate uveitis using ultra wide field fluorescein angiography.

Intermediate uveitis is a collection of diseases which can be caused by sarcoidosis in approximately fifty percent of patients. We performed a retrospective chart review of 6 patients with acquisition and interpretation of ultra wide field fluorescein angiograms. Two eyes had central, large vessel staining; six eyes had peripheral, small vessel staining; and two eyes had both patterns of staining. We conclude that ultra wide field fluorescein angiography is important to detect inflammation early and follow treatment in patients with intermediate uveitis. Future studies with ultra wide field fluorescein angiography may help to diagnose different types of intermediate uveitis and offer insights into the pathogenesis of disease.

The use of ultra wide field fluorescein angiography in evaluation and management of uveitis.

PURPOSE: Uveitis can occur in all segments of the eye and has multiple etiologies, (many of which remain poorly understood). Appropriate diagnosis and subsequent management can depend on elucidation of the clinical signs. Many diagnostic features are often best identified with Fluorescein angiography. However these signs are often peripheral and visualization can be difficult with traditional angiography. Optos ultra wide field scanning laser ophthalmoscope (Optos Panoramic 200MA; Optos PLC, Dunfermline, Scotland, United Kingdom) performs ultra wide angle fluorescein angiography and its benefit in uveitis was reviewed. DESIGN: The Jules Stein Eye Institute retina division imaging database was reviewed and five common cases were selected. METHODS: The relative benefits of wide field angiography were evaluated in each of these cases. RESULTS: Ultra wide field angiography was found to have advantages compared to traditional angiography. It allowed clear identification of peripheral signs and accurate documentation of disease progression. CONCLUSION: In this division ultra wide field angiography has become the investigation of choice (over traditional angiography) in cases of intermediate and posterior uveitis.

Multifocal objective perimetry compared with Humphrey full-threshold perimetry in patients with optic neuritis.

BACKGROUND: The aim of the study is to compare multifocal visual evoked potential (mfVEP) objective perimetry with Humphrey full-threshold visual field (HVF) perimetry, in the assessment of patients with optic neuritis (ON). METHODS: We assessed 16 patients with clinically diagnosed ON. A comparison was made between the HVF and mfVEP, based on the global severity indices of both tests and number and topography of significant abnormalities detected. The latency data and inter-eye asymmetry findings on the mfVEP were also evaluated. RESULTS: From a total of 128 quadrants analysed in the 16 patients (100 affected, 28 unaffected eyes), HVF perimetry identified a scotoma in 39/128 (30.5%) quadrants, all of which were in affected eyes; the mfVEP detected a scotoma in 68/128 (53.1%) quadrants using amplitude and/or asymmetry data (XV2=7.2485, P=0.0071). Latency plots on the mfVEP identified a significant latency deviation cluster in 20/25 (80%) affected eyes. Abnormalities were also detected in 4/7 (57%) unaffected eyes. The global severity indices in the affected eyes showed a high correlation between the two tests (r=0.73). CONCLUSIONS: The mfVEP detected more abnormalities in patients with ON than HVF perimetry. The use of latency recordings as well as combined amplitude and asymmetry plots is advantageous and has the potential to detect abnormalities not otherwise detected on HVF perimetry.

Cavernous haemangioma in the orbital apex: stereotactic-guided transcranial cryoextraction.

A 55-year-old Caucasian woman presented with an orbital cavernous haemangioma superior to the optic nerve in the orbital apex. Preoperative imaging demonstrated a mass involving the superomedial and superolateral quadrants of the posterior orbit. A stereotactic fronto-orbital approach was performed by the neurosurgical team, and cryoextraction of the lesion was accomplished by the ocular plastic surgical team.