Low-intensity/high-density subthreshold microPulse diode laser for chronic central serous chorioretinopathy.

PURPOSE: To evaluate the visual outcomes and macular thickness change in patients with symptomatic chronic central serous chorioretinopathy after treatment with a subthreshold MicroPulse diode laser. METHODS: In this retrospective, interventional case series, 10 patients were treated with the subthreshold 810-nm diode MicroPulse laser. Selected patients had symptomatic disease that may or may not have involved the foveal center. The MicroPulse laser was applied to the areas of leakage seen on fluorescein angiogram, over the areas of clinical neurosensory detachment, and/or pigment epithelial detachments. Pretreatment and posttreatment vision, change in maximum macular thickness, number of treatment sessions, and number of laser spot applications were recorded. Patients were excluded if they did not attend follow-up, had other confounding macular diseases, were using steroid medications, or application of another treatment modality had been used (i.e., photodynamic therapy or anti-vascular endothelial growth factor medication). RESULTS: Ten patients met the inclusion criteria, with 1 patient treated in both eyes. Three patients were excluded for lack of follow-up, one for the use of systemic steroids, and one for treatment with anti-vascular endothelial growth factor injection. Maximum macular thickness decreased after subthreshold MicroPulse laser treatment between 20 µm and 338 µm (mean = 97 µm decrease, P = 0.0046) in 11 treated eyes. CONCLUSION: Subthreshold diode MicroPulse laser is a potential treatment option for patients with symptomatic chronic central serous chorioretinopathy.

Sequential in-office vitreous aspirates demonstrate vitreous matrix metalloproteinase 9 levels correlate with the amount of subretinal fluid in eyes with wet age-related macular degeneration.

PURPOSE: To evaluate levels of 37 native pathway proteins of the vitreous proteome from a subset of wet age-related macular degeneration (AMD) patients with and without subretinal fluid (SRF). METHODS: A total of 62 consecutive samples were aspirated from 12 patients with AMD, six who had SRF at baseline, and six who did not have SRF at any point during the study. Vitreous levels of the 37 native pathway proteins were analyzed in these patients using reverse phase protein microarray technology. At each visit, at which the 62 samples were taken, SRF and central retinal thickness were measured. These values were then compared to the relative intensity level of the 37 proteins screened. RESULTS: In the subset of AMD patients with SRF, the average matrix metalloproteinase 9 (MMP-9), interleukin (IL)-12, Abelson murine leukemia viral oncogene homolog 1 (cABL) Thr735, heme oxygenase-1, Musashi, platelet-derived growth factor receptor beta Tyr751 (PDGFRß), IL-8, and BCL-2 associated death promoter (BAD) Ser112 levels in the vitreous were found to be significantly different with a 21%-82% increase in expression compared to those without SRF (p<0.0001). Within the SRF group, there was a positive correlation between the vitreous MMP-9 levels and the SRF level. MMP-9 levels in the vitreous proteome varied with the level of SRF but not retinal edema. Compared to patients without SRF, the patients with initial SRF had persistent or progressive disease. CONCLUSIONS: This is the first prospective case series sequentially monitoring the vitreous proteome in patients with wet AMD. The results suggest that MMP-9 is a proteomic biomarker of SRF accumulation, separate from macular edema.

Aqueous cytokine and growth factor levels do not reliably reflect those levels found in the vitreous.

PURPOSE: Recent studies have illuminated the vitreous proteome as a potentially important diagnostic tool that will predict disease progression and response to treatment, in eyes with retinal disease. Studies to date have demonstrated correlations of protein levels between vitreous and aqueous humor. Because these results are un-expected and analysis was only done on a few endpoints, the present study further analyzes the relationship between aqueous and vitreous by probing a wide array of proteins in patients with posterior segment diseases. METHODS: Anterior chamber aqueous fluid was obtained using a limbal approach with a 30 gauge needle. Immediately following, the vitreous sample was obtained via a pars plana approach. A 25 gauge needle with a 1 ml syringe was directed into the mid-vitreous cavity and vitreous fluid was gently aspirated. Aqueous and vitreous samples were then analyzed using the quantitative native protein analysis method called reverse phase protein microarray technology (RPPM). RESULTS: The entire sample population (n=11) was probed against 34 proteins, revealing 8 proteins that significantly correlate, 3 proteins that trend to correlation but fell short of significance and 23 proteins that have no correlation between the vitreous and aqueous humor. CONCLUSIONS: Proteins in the aqueous cannot be assumed to correlate with their counterparts in the vitreous.

A prospective study of in-office diagnostic vitreous sampling in patients with vitreoretinal pathology.

PURPOSE: To evaluate the safety and efficacy of in-office vitreous sampling (50-100 microL). METHODS: A prospective, consecutive case series of 578 diagnostic vitreous sample attempts performed between February 23, 2007 and September 31, 2008. A standardized technique of vitreous sampling followed by intravitreal injection of therapeutic medication was performed. All subjects were followed for adverse events after sampling/injection. RESULTS: Out of a total of 578 vitreous sampling attempts, a total of 550 positive diagnostic vitreous samples were collected from 157 eyes of 144 patients. There were a total of 28 "dry" samples in 19 subjects (13 females and 6 males). The rate of dry sample was 4.8% (28 of 578). Complications included transient vitreous hemorrhage (n = 3), transient intraocular inflammation (n = 3), localized, chronic retinal detachment (n = 1). None of the complications resulted in permanent visual sequelae. These complications were no different than those expected from intravitreal injection alone. CONCLUSION: This prospective study has shown that in-office vitreous sampling of 50 microL to 100 microL is a safe and reproducible procedure. Larger randomized studies will be helpful to further assess the safety and long-term effects of in-office diagnostic vitreous sampling.

Low incidence of choroidal neovascularization following subthreshold diode micropulse laser (SDM) in high-risk AMD.

PURPOSE: To determine the incidence of new choroidal neovascularization (CNV) in eyes with dry age-related macular degeneration (AMD) following subthreshold diode micropulse laser (SDM). METHOD: In an observational retrospective cohort study, the records of all patients active in the electronic medical records database were reviewed to identify eyes with dry AMD treated with SDM. Identified eyes were classified by simplified AREDS categories, and analyzed for the primary endpoint of new CNV after treatment. RESULTS: The EMR revealed SDM was offered to 373/392 (95%) patients with dry AMD and elected by 363/373 (97%) between 2008-2017. Follow up was available for 354/363 patients (547 eyes, 98%) (range 6-108 mos., avg. 22). CNV risk factors included age (median 84 years, 67% > 80); reticular pseudodrusen (214 eyes, 39%); AREDS category (78% category 3 and 4); and fellow eye CNV (128 eyes, 23%). New CNV developed in 9/547 eyes (1.6%, annualized rate 0.87%). Visual acuity was unchanged. There were no adverse treatment effects. SUMMARY: In a review of a large group of eyes with exceptionally high-risk AMD, SDM was followed by a very low incidence of new CNV. If confirmed by further study, SDM would offer a new and highly effective treatment to reduce the risk of vision loss from AMD.

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.

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.

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.

Activated VEGF receptor shed into the vitreous in eyes with wet AMD: a new class of biomarkers in the vitreous with potential for predicting the treatment timing and monitoring response.

OBJECTIVE: To examine whether phosphorylated vascular endothelial growth factor (VEGF) receptors shed into the vitreous reflect the ongoing retinal and choroidal signal pathway activity in wet age-related macular degeneration (AMD). METHODS: Vitreous samples obtained immediately prior to anti-VEGF injection from 11 patients with choroidal neovascularization were analyzed using reverse-phase microarrays. Two patients had samples collected at the time of injection and 1 month later. Samples from 5 patients were collected prior to vitrectomy for macular hole, epiretinal membrane, or retinal detachment. RESULTS: Phosphorylated forms of VEGF receptor (VEGFR Y996 and Y1175), platelet-derived growth factor receptor beta (PDGFRbeta Y716 and Y751), and c-KIT (Y703) were present in the vitreous. A significant difference in PDGFRbeta Y751 (P < .002), VEGFR Y996 (P < .04), and VEGFR Y1175 (P < .006), but not c-KIT Y703 (P < .05) or PDGFRbeta Y716 (P < .96), was noted for the responders to treatment (n = 5) compared with nonresponders (n = 6) and controls (n = 5). CONCLUSIONS: Vitreous levels of activated receptors constitute a new class of biomarkers. Activated forms of VEGF and PDGF receptors, previously not known to exist in the vitreous, correlate with response to anti-VEGF therapy. These findings could provide the basis for the development of individualized treatment and discovery of new therapeutic targets.

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.

Adult-onset foveomacular dystrophy associated with full-thickness macular hole: report of 5 cases / Distrofia viteliforme foveomacular de início na vida adulta associada a buraco macular: relato de 5 casos

Objetivo: Relatar uma série de 5 casos de distrofia viteliforme foveomacular de início na vida adulta, uma das distrofias padrão da mácula, em associação com o desenvolvimento de buraco macular. Local: Manhattan Eye, Ear & Throat Hospital, New York, NY, USA. Métodos: Relato de uma série de casos. Resultados: Cinco casos de distrofia viteliforme foveomacular de início na vida adulta, uma das distrofias padrão da mácula, desenvolveram buraco macular. Todos os 5 casos, ou 7 olhos, evoluíram com perda de visão, e em um olho foi realizada cirurgia para buraco macular e obtido sucesso anatômico (fechamento do buraco). Conclusão: Distrofia viteliforme foveomacular de início na vida adulta pode associar?se ao desenvolvimento de buraco macular e esta associação pode resultar em perda de visão.