PANRETINAL PHOTOCOAGULATION VERSUS RANIBIZUMAB FOR PROLIFERATIVE DIABETIC RETINOPATHY: Comparison of Peripapillary Retinal Nerve Fiber Layer Thickness in a Randomized Clinical Trial.

PURPOSE: Compare changes in retinal nerve fiber layer (RNFL) thickness between eyes assigned to intravitreous ranibizumab or panretinal photocoagulation and assess correlations between changes in RNFL and visual field sensitivity and central subfield thickness. METHODS: Eyes with proliferative diabetic retinopathy were randomly assigned to ranibizumab or panretinal photocoagulation. Baseline and annual follow-up spectral domain optical coherence tomography RNFL imaging, optical coherence tomography macular imaging, and automated static perimetry (Humphrey visual field 60-4 algorithm) were performed. RESULTS: One hundred forty-six eyes from 120 participants were analyzed. At 2 years, for the ranibizumab (N = 74) and panretinal photocoagulation (N = 66) groups, respectively, mean change in average RNFL thickness was -10.9 ± 11.7 µm and -4.3 ± 11.6 µm (difference, -4.9 µm; 95% confidence interval [-7.2 µm to -2.6 µm]; P < 0.001); the correlation between change in RNFL thickness and 60-4 Humphrey visual field mean deviation was -0.27 (P = 0.07) and +0.33 (P = 0.035); the correlation between change in RNFL thickness and central subfield thickness was +0.63 (P < 0.001) and +0.34 (P = 0.005), respectively. CONCLUSION: At 2 years, eyes treated with ranibizumab had greater RNFL thinning than eyes treated with panretinal photocoagulation. Correlations between changes in RNFL thickness, visual field, and central subfield thickness suggest that the decrease in RNFL thickness with ranibizumab is likely due to decreased edema rather than loss of axons.

NEOVASCULAR AGE-RELATED MACULAR DEGENERATION WITH ADVANCED VISUAL LOSS TREATED WITH ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY: Clinical Outcome and Prognostic Indicators.

PURPOSE: To describe visual outcome and prognostic indicators in neovascular age-related macular degeneration with advanced visual loss at the initiation of anti-vascular endothelial growth factor therapy. METHODS: A retrospective chart review was performed on a consecutive series of 1,410 patients with neovascular age-related macular degeneration treated with anti-vascular endothelial growth factor therapy at the Medical College of Wisconsin. Subjects were included if at the initiation of therapy they had 20/200 or worse visual acuity (VA) with no other visually limiting eye disease and a minimum follow-up of 6 months. The change in VA at 6 months and 12 months was assessed compared with baseline. Visual improvement/worsening was defined as at least ± 0.3 logMAR (equivalent to 15 ETDRS [Early Treatment Diabetic Retinopathy Study] letters) change. Other factors for analysis included number of injections received, drug type, and various clinical and imaging findings. RESULTS: One hundred thirty-one cases met the study criteria, and 97 were followed for 12 months. Baseline VA was 1.38 logMAR (20/480 Snellen equivalent). Mean VA change (logMAR) consisted of an improvement of 0.23 (P < 0.0001) at 6 months and 0.17 (P = 0.003) at 12 months. At 12 months, VA improved in 45% and worsened in 20%. Among subjects with baseline VA worse than 20/400, VA improved in 57% and worsened in 20%. On univariate analysis at either the 6 months or 12 months follow-up, visual improvement was associated with retinal hemorrhage (P = 0.03) and subretinal fluid (P = 0.02), whereas visual worsening was associated with retinal pigment epithelial detachment (P = 0.04) and intraretinal fluid (P = 0.01). With multivariate analysis, visual improvement was predicted by both a larger number of injections received (P = 0.001) and a poorer baseline VA (P = 0.001). Injection medication type did not influence outcome. CONCLUSION: Statistically significant visual improvement was observed in association with anti-vascular endothelial growth factor therapy in patients with severe neovascular age-related macular degeneration, even in patients whose initial VA was worse than that studied in large anti-vascular endothelial growth factor clinical trials. Numerous clinically discernable or potentially modifiable factors may influence outcome in such patients.

CLINICAL EVALUATION OF THE RAPID ACCESS VITREAL INJECTION GUIDE: A Handheld Instrument for Assisting Intravitreal Injections.

PURPOSE: The Rapid Access Vitreal Injection (RAVI) guide combines the function of an eyelid speculum and measuring caliper into a single instrument for assisting intravitreal injections. This study clinically evaluated the RAVI guide with respect to patient acceptance, complication rates, and operative goals. METHODS: A prospective study was performed on 54 patients undergoing intravitreal injections using the RAVI guide (n = 32) or the speculum/caliper (n = 22). Device-related pain was assessed using the Wong-Baker scoring system, scaled from 0 (no pain) to 10 (agonizing pain). RESULTS: Mean device-related pain score did not differ significantly between the 2 groups, with scores of 0.6 and 0.7 for the RAVI guide and speculum groups, respectively. The rate of significant pain (score of ≥2) was twice as high in the speculum group (7 of 22, 32%) compared with the RAVI guide group (5 of 32, 16%), but this difference was not statistically significant (P = 0.19, Fisher's exact test). Operative goals of avoiding needle touch to lashes/lids and guiding needle insertion to the intended site were achieved in all patients. CONCLUSION: The RAVI guide appeared equivalent to the eyelid speculum in achieving operative goals, with similarly low pain scores. It has the potential for facilitating efficient, accurate, and safe intravitreal injections.

ASSESSING PHOTORECEPTOR STRUCTURE ASSOCIATED WITH ELLIPSOID ZONE DISRUPTIONS VISUALIZED WITH OPTICAL COHERENCE TOMOGRAPHY.

PURPOSE: To compare images of photoreceptor layer disruptions obtained with optical coherence tomography (OCT) and adaptive optics scanning light ophthalmoscopy (AOSLO) in a variety of pathologic states. METHODS: Five subjects with photoreceptor ellipsoid zone disruption as per OCT and clinical diagnoses of closed-globe blunt ocular trauma (n = 2), macular telangiectasia type 2 (n = 1), blue-cone monochromacy (n = 1), or cone-rod dystrophy (n = 1) were included. Images were acquired within and around photoreceptor lesions using spectral domain OCT, confocal AOSLO, and split-detector AOSLO. RESULTS: There were substantial differences in the extent and appearance of the photoreceptor mosaic as revealed by confocal AOSLO, split-detector AOSLO, and spectral domain OCT en face view of the ellipsoid zone. CONCLUSION: Clinically available spectral domain OCT, viewed en face or as B-scan, may lead to misinterpretation of photoreceptor anatomy in a variety of diseases and injuries. This was demonstrated using split-detector AOSLO to reveal substantial populations of photoreceptors in areas of no, low, or ambiguous ellipsoid zone reflectivity with en face OCT and confocal AOSLO. Although it is unclear if these photoreceptors are functional, their presence offers hope for therapeutic strategies aimed at preserving or restoring photoreceptor function.

Whole exome sequencing in dominant cataract identifies a new causative factor, CRYBA2, and a variety of novel alleles in known genes.

Pediatric cataracts are observed in 1-15 per 10,000 births with 10-25 % of cases attributed to genetic causes; autosomal dominant inheritance is the most commonly observed pattern. Since the specific cataract phenotype is not sufficient to predict which gene is mutated, whole exome sequencing (WES) was utilized to concurrently screen all known cataract genes and to examine novel candidate factors for a disease-causing mutation in probands from 23 pedigrees affected with familial dominant cataract. Review of WES data for 36 known cataract genes identified causative mutations in nine pedigrees (39 %) in CRYAA, CRYBB1, CRYBB3, CRYGC (2), CRYGD, GJA8 (2), and MIP and an additional likely causative mutation in EYA1; the CRYBB3 mutation represents the first dominant allele in this gene and demonstrates incomplete penetrance. Examination of crystallin genes not yet linked to human disease identified a novel cataract gene, CRYBA2, a member of the ßγ-crystallin superfamily. The p.(Val50Met) mutation in CRYBA2 cosegregated with disease phenotype in a four-generation pedigree with autosomal dominant congenital cataracts with incomplete penetrance. Expression studies detected cryba2 transcripts during early lens development in zebrafish, supporting its role in congenital disease. Our data highlight the extreme genetic heterogeneity of dominant cataract as the eleven causative/likely causative mutations affected nine different genes, and the majority of mutant alleles were novel. Furthermore, these data suggest that less than half of dominant cataract can be explained by mutations in currently known genes.

Scleral buckle removal in the vitrectomy era: a 20-year clinical experience.

PURPOSE: To describe the effect of scleral buckle (SB) removal on preoperative symptoms and signs prompting removal and to assess the risk of recurrent retinal detachment (RD) after SB removal. METHODS: A retrospective study of 36 patients who underwent SB removal between August 1988 and December 2007 was performed. Indications for SB removal, presence or absence of pain or diplopia, and recurrence of RD were recorded. Composite RD rates were estimated from previously published studies and stratified into those occurring during the previtrectomy era versus later (1980 to present). RESULTS: Mean follow-up time was 75.5 months after SB removal. Thirty-two of 33 patients (97%) who had preoperative pain had symptom relief. Twelve of 12 patients who had clinical infection had resolution. Of the four patients with diplopia, two experienced complete resolution and two reported substantial improvement but required prisms to obtain single vision. Four of 34 patients (12%) whose retinas were attached at the time of SB removal developed recurrent RD but were successfully repaired without significant visual loss from the RD. CONCLUSION: Scleral buckle removal is effective in eliminating SB-related pain and infection. Symptomatic diplopia can sometimes improve after SB removal. The rates of RD after SB removal observed in this study (12%) and in others performed in the era of vitrectomy were notably lower than those of previous reports.

Implementation of a Novel Near Visual Acuity Chart in an Emergency Department Setting.

PURPOSE: The quality of visual acuity (VA) measurement in emergency department (ED) settings can be affected by patient immobility and lack of standardized testing conditions. We implemented a previously validated, novel VA chart, the Runge Sloan letter near card, in a hospital ED and evaluated its impact on frequency and consistency of VA testing. METHODS: Two hundred seventeen hospital ED ophthalmology consult records from December 1, 2016, to November 15, 2017, were evaluated in an IRB-approved protocol. Frequency of VA measurement and agreement between nonophthalmic ED technicians and ophthalmology physicians-in-training were assessed. RESULTS: Implementation of the Runge card saw missed technician VA evaluations decrease from 36% (43/120) to 21% (20/97) of ophthalmic consults (p = .01), without significant change in agreement of VA measurements. After implementation, the proportion of VA measurements differing between technicians and residents by ≤2 lines was 51%; with pinhole testing, it improved to 64% (p < .05). In patients with good VA of >20/80, pinhole increased agreement from 58% to 73% (p < .05). CONCLUSIONS: Implementation of the Runge card was associated with improved frequency of VA measurement and, when combined with pinhole testing, increased agreement rates. Our findings suggest utility of training in the use of the Runge card in ED settings.

Transconjunctival 20-gauge pars plana vitrectomy using a single entry cannulated sutureless system.

PURPOSE: Pars plana vitrectomy with a 20-gauge transconjunctival cannulated sutureless (TCS) system has the potential of combining the advantages of smaller-gauge vitrectomy systems with the economical advantage of not needing to purchase any additional handheld instruments. However, the sclerotomy size is much larger, and self-sealing sclerotomies may be more difficult to construct. Therefore, we evaluated the need for sclerotomy suturing after performing 20-gauge TCS vitrectomy. METHODS: A retrospective chart review was performed on the first consecutive 55 eyes of 54 patients who underwent 20-gauge TCS vitrectomy. The main outcome measure was the number of sclerotomies requiring suturing and complications. RESULTS: Of the 164 sclerotomies made, 101 sclerotomies (62%) were not sutured, whereas the remaining 63 sclerotomies (38%) were closed with a single transconjunctival- scleral suture. The reasons for suturing included leakage and gaping at the sclerotomy, conjunctiva not covering the sclerotomy site, and prevention of gas leak. Complications noted include premature dislodging of cannulas, retinal tear, hypotony, hemorrhagic choroidals, subconjunctival gas, and less than full gas fill. CONCLUSION: Twenty-gauge transconjunctival sutureless vitrectomy is associated with risks similar to other cannulated systems while retaining most of the functionality and handheld instrumentation of the 20-gauge approach. A possibly higher sclerotomy suturing rate relative to smaller-gauge approaches is a disadvantage of this technique.

Microbiological spectrum of organisms isolated from explanted scleral buckles.

Scleral buckle removal is an uncommon procedure performed for various reasons. Microbiological information on explanted scleral buckles remains limited. The authors identified 37 cases of scleral buckle removal during an 18-year period. Bacterial cultures isolated an organism in 4 of 9 patients (44%) with clinical infection. Organisms identified included methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, Mycobacterium abscessus, and coagulase-negative Staphylococcus species. Bacterial cultures isolated an organism in 3 of 11 patients (27%) without clinical infection. Organisms identified included Nocardia species, Alcaligenes xylosoxidans, and Mycobacterium chelonae. Scleral buckles appearing clinically infected may be associated with more virulent organisms and a greater chance of identifying an organism. Bacterial cultures may be of value for scleral buckles upon removal.

Physician assessment of changing lesion size of predominantly classic choroidal neovascular membranes in age-related macular degeneration.

BACKGROUND AND OBJECTIVE: To quantify the interpretation of fluorescein angiograms of evolving predominantly classic choroidal neovascularization in age-related macular degeneration. PATIENTS AND METHODS: Thirty-six fluorescein angiograms of predominantly classic choroidal neovascularization were used to define 22 fluorescein angiogram pairs. Imaging software was used to measure surface area and greatest linear dimension (GLD). Six retina physicians estimated the change in surface area and GLD for each pair before and after demarcation of the lesions' borders and GLD. RESULTS: For enlarging lesions, the smallest changes consistently detected by physicians were a 5% to 15% increase in surface area and a 5% to 15% increase in GLD; for shrinking lesions, they were a 5% to 15% decrease in surface area and a 5% to 15% decrease in GLD. Linear regression demonstrated moderate correlation between physician and software estimates of surface area and GLD change (r(2) = 0.50 and 0.67, respectively; P < .001), which was higher with lesion demarcation (r(2) = 0.91 and 0.93, respectively; P < .001). CONCLUSION: Computer-assisted demarcation of lesion surface area and GLD reduced variability in physicians' estimates of choroidal neovascularization size change and improved correlation with software measurements.

Sustained Anti-Vascular Endothelial Growth Factor Activity of Aflibercept (Eylea) After Storage in Polycarbonate Syringes Used for Intravitreal Injection: A Pathway to Safety and Efficiency.

Purpose: Aflibercept (Eylea™, Regeneron) is supplied in single-use glass vials along with 1 cc polycarbonate syringes. We sought to determine if storage of aflibercept for sustained periods within these syringes would result in loss of antivascular endothelial growth factor (anti-VEGF) activity. Methods: Aflibercept samples were drawn from commercially available glass vials into manufacturer-supplied 1-mL syringes and stored at 4°C. Anti-VEGF activity was assessed using enzyme-linked immunosorbent assays at the following storage durations: 0, 4, 9, 14, and 28 days. Frozen samples stored at -20°C for 28 and 56 days were also assayed. Also, a subset of aflibercept samples was stored and then diluted to 1:10 and progressively smaller concentrations and the assays repeated. Aggregation of aflibercept was tested using a dynamic light scattering assay. Results: There were no statistical differences in anti-VEGF activity among aflibercept samples of 1:1 or 1:10 dilution stored at either 4°C or -20°C at any of the storage intervals (P > 0.05). We also observed persistence of robust anti-VEGF activity for up to 14 days when diluted poststorage to 1:16,000, a concentration that would be expected after >7 vitreous half-lives within the eye (estimated at >50 days). No evidence of drug aggregation in specimens stored for 14 days was observed. Conclusions: Our findings support feasibility of prefilling and storage of aflibercept within manufacturer-supplied polycarbonate syringes for as long as 14 days before use under pharmacy-based sterile conditions, facilitating greater safety and efficiency in many clinics delivering anti-VEGF therapy.

An innovative visual acuity chart for urgent and primary care settings: validation of the Runge near vision card.

OBJECTIVE: We evaluated the Runge card, a near-vision eye chart designed for ease of use, by testing agreement in visual acuity results between it and the Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity chart. As a clinical reference point, we compared the Runge card and an electronic Snellen chart with respect to agreement with ETDRS results. METHODS: Participants consisted of adult eye clinic patient volunteers who underwent a protocol refraction, followed by testing with a Runge card, ETDRS chart, and Snellen chart. Mean logMAR visual acuities were calculated for each method. Agreement levels among the tests were assessed for the group overall and for subjects with good (ETDRS logMAR < 0.6; better than 20/80 Snellen equivalent) and poor (logMAR ≥ 0.6) acuity. RESULTS: One hundred and thirty-eight participants completed testing. The mean ( ± standard deviation) logMAR visual acuities (Snellen equivalent) with Runge, ETDRS, and Snellen, respectively, were 0.66 ± 0.50 (20/91, n = 138), 0.59 ± 0.51 (20/78, n = 138), and 0.67 ± 0.62 (20/94, n = 137). Runge testing agreed similarly with ETDRS and Snellen testing, with CCC 0.92 between Runge and ETDRS, and 0.87 between Runge and Snellen (p = 0.14). Runge agreed better with ETDRS than Snellen agreed with ETDRS in participants with poor acuity (CCC = 0.79 vs. 0.63, respectively, p = 0.001) but not in those with good acuity (CCC = 0.70 vs. 0.87, respectively, p = 0.005). CONCLUSION: Visual acuity measurements with the Runge near card agreed with measurements from the ETDRS to approximately the same degree as did the Snellen chart, suggesting potential utility of the Runge near card, particularly given its user-friendly characteristics and ease of use.

Risk factors for scleral buckle removal: a matched, case-control study.

PURPOSE: To identify preoperative, perioperative, and postoperative risk factors for scleral buckle (SB) removal. DESIGN: Retrospective, consecutive, matched, case-control study. METHODS: Cases included all patients undergoing SB removal between August 1988 and December 2007 at a single academic center. Cases were matched against four randomly selected control patients who underwent SB implantation during the same year as the case. Odds ratios (OR) were calculated for each factor investigated. RESULTS: Forty cases of SB removal and 148 matched control cases were identified. Three cases of SB removal were omitted from analysis because of incomplete records. Factors associated with SB removal for any reason, using univariate analysis, included concurrent globe-penetrating injury at time of SB placement (OR, 24; 95% confidence interval [CI], 2.9 to 200), concurrent pars plana vitrectomy (PPV) (OR, 17.3; 95% CI, 4.9 to 61), diabetes mellitus (DM) (OR, 7.3; 95% CI, 1.8 to 30), prior chronic topical ocular therapy (OR, 4.3; 95% CI, 1.7 to 11), and subsequent ocular procedures (OR, 3.4; 95% CI, 1.5 to 7.5). Factors independently associated with SB removal using multivariate analysis included concurrent globe-penetrating injury (OR, 27.3; 95% CI, 1.7 to 426), concurrent PPV (OR, 11.3; 95% CI, 2.9 to 45), DM (OR, 8.9; 95% CI, 1.3 to 58), and subsequent ocular procedures (OR, 3.9; 95% CI, 1.4 to 11). Factors that did not alter SB removal risk included patient age; gender; and type, size, or location of buckling elements used. CONCLUSIONS: Awareness of these risk factors may be valuable for the surgical planning of retinal detachment repair in patients at higher risk for subsequent SB removal and for risk stratification subsequent to SB implantation.

Assessing photoreceptor structure in patients with traumatic head injury.

OBJECTIVE: Previous work using adaptive optics scanning light ophthalmoscopy (AOSLO) imaging has shown photoreceptor disruption to be a common finding in head and ocular trauma patients. Here an expanded trauma population was examined using a novel imaging technique, split-detector AOSLO, to assess remnant cone structure in areas with significant disruption on confocal AOSLO imaging and to follow photoreceptor changes longitudinally. METHODS AND ANALYSIS: Eight eyes from seven subjects with head and/or ocular trauma underwent imaging with spectral domain optical coherence tomography, confocal AOSLO and split-detector AOSLO to assess foveal and parafoveal photoreceptor structure. RESULTS: Confocal AOSLO imaging revealed hyporeflective foveal regions in two of eight eyes. Split-detector imaging within the hyporeflective confocal areas showed both remnant and absent inner-segment structure. Both of these eyes were imaged longitudinally and showed variation of the photoreceptor mosaic over time. Four other eyes demonstrated subclinical regions of abnormal waveguiding photoreceptors on multimodal AOSLO imagery but were otherwise normal. Two eyes demonstrated normal foveal cone packing without disruption. CONCLUSION: Multimodal imaging can detect subtle photoreceptor abnormalities not necessarily detected by conventional clinical imaging. The addition of split-detector AOSLO revealed the variable condition of inner segments within confocal photoreceptor disruption, confirming the usefulness of dual-modality AOSLO imaging in assessing photoreceptor structure and integrity. Longitudinal imaging demonstrated the dynamic nature of the photoreceptor mosaic after trauma. Multimodal imaging with dual-modality AOSLO improves understanding of visual symptoms and photoreceptor structure changes in patients with head and ocular trauma.

Comparison of the modified Early Treatment Diabetic Retinopathy Study and mild macular grid laser photocoagulation strategies for diabetic macular edema.

OBJECTIVE: To compare 2 laser photocoagulation techniques for treatment of diabetic macular edema: the modified Early Treatment Diabetic Retinopathy Study (ETDRS) direct/grid photocoagulation technique and a potentially milder (but potentially more extensive) mild macular grid (MMG) laser technique in which microaneurysms are not treated directly and small mild burns are placed throughout the macula, whether or not edema is present. METHODS: Two hundred sixty-three subjects (mean age, 59 years) with previously untreated diabetic macular edema were randomly assigned to receive laser photocoagulation by either the modified ETDRS (162 eyes) or MMG (161 eyes) technique. Visual acuity, fundus photographs, and optical coherence tomography measurements were obtained at baseline and at 3.5, 8, and 12 months. Treatment was repeated if diabetic macular edema persisted. MAIN OUTCOME MEASURE: Change in optical coherence tomography measurements at 12-month follow-up. RESULTS: Among eyes with a baseline central subfield thickness of 250 microm or greater, central subfield thickening decreased by an average of 88 microm in the modified ETDRS group and by 49 microm in the MMG group at 12-month follow-up (adjusted mean difference, 33 microm; 95% confidence interval, 5-61 microm; P = .02). Weighted inner zone thickening by optical coherence tomography decreased by 42 microm in the modified ETDRS group and by 28 microm in the MMG group (adjusted mean difference, 14 microm; 95% confidence interval, 1-27 microm; P = .04); maximum retinal thickening (maximum thickening of the central and 4 inner subfields) decreased by 66 and 39 microm, respectively (adjusted mean difference, 27 microm; 95% confidence interval, 6-47 microm; P = .01), and retinal volume decreased by 0.8 and 0.4 mm3, respectively (adjusted mean difference, 0.3 mm3; 95% confidence interval, 0.02-0.53 mm3; P = .03). At 12 months, the mean change in visual acuity was 0 letters in the modified ETDRS group and 2 letters worse in the MMG group (adjusted mean difference, 2 letters; 95% confidence interval, -0.5 to 5 letters; P = .10). CONCLUSIONS: At 12 months after treatment, the MMG technique was less effective at reducing optical coherence tomography-measured retinal thickening than the more extensively evaluated current modified ETDRS laser photocoagulation approach. However, the visual acuity outcome with both approaches is not substantially different. Given these findings, a larger long-term trial of the MMG technique is not justified. APPLICATION TO CLINICAL PRACTICE: Modified ETDRS focal photocoagulation should continue to be a standard approach for treating diabetic macular edema. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00071773.

An eye model for practicing vitreoretinal membrane peeling.

A cost-effective, reusable practice eye model for epiretinal membrane peeling that uses easily obtained, commercially available materials was developed. A commercially available globe that is anatomically and optically similar to the human eye was modified by creating 2 ports that simulate superior sclerotomies. The model has a removable plastic anterior segment, which allows access to the posterior segment for practice membrane placement. Membranes were created on the macula by applying a coat of liquid skin bandage. Membrane peeling was performed under an ophthalmic operating microscope using a disposable flat vitrectomy lens. The basic skills required for membrane peeling can be demonstrated and acquired by practicing with this eye model. The practice eye model is expected to enhance the acquisition of skills required for epiretinal membrane peeling.

Recurrent bullous retinal detachments from photodynamic therapy for idiopathic polypoidal choroidal vasculopathy.

PURPOSE: To report the recurrent bullous retinal detachments as complications of photodynamic therapy (PDT) for idiopathic polypoidal choroidal vasculopathy (IPCV). DESIGN: Interventional case report. METHODS: A pseudophakic 84-year-old-woman had IPCV and decreased vision. Angiography demonstrated macular leakage. PDT with verteporfin was applied. Two days later, visual acuity decreased from 20/50 to 20/400. Examination revealed extensive inferior subretinal fluid, which mimicked a pseudophakic rhegmatogenous retinal detachment. A scleral buckle was placed; no retinal breaks were identified. RESULTS: Vision and fluid resolved over three weeks. Four months later, examination revealed decreased vision and persistent leakage. Two days after repeat PDT, bullous exudative macular detachment recurred. Detachment resolved over two weeks; visual acuity returned to 20/50. CONCLUSION: IPCV that is treated with PDT may be complicated by iatrogenic bullous exudative retinal detachments that resemble rhegmatogenous detachments. Modified treatment parameters may reduce the risk of recurrence. The natural history likely includes spontaneous resolution and visual recovery.

Transpupillary thermotherapy with indocyanine green dye enhancement for the treatment of occult subfoveal choroidal neovascularization in age-related macular degeneration.

BACKGROUND AND OBJECTIVES: Transpupillary thermotherapy (TTT) with indocyanine green (ICG) dye enhancement (TTT+) and TTT alone were compared for safety and effectiveness as a treatment of occult subfoveal choroidal neovascularization in age-related macular degeneration. PATIENTS AND METHODS: Twenty-one patients were randomized to receive TTT (12 eyes) or TTT+ (9 eyes) and observed for at least 6 months. ETDRS visual acuity and fluorescein and ICG angiography were obtained every 3 months. RESULTS: The median initial visual acuity was 20/80 in the TTT group and 20/100 in the TTT+ group. At 6 months, loss of less than 3 lines of visual acuity was present in 7 of 12 eyes (58%) in the TTT group and 5 of 9 eyes (56%) in the TTT+ group. At the final examination, there was no active choroidal neovascularization exudation in 6 of 12 eyes (50%) in the TTT group and 5 of 9 eyes (56%) in the TTT+ group. The median final visual acuity was 20/125 in the TTT group and 20/160 in the TTT+ group. Ocular or systemic complications were not encountered in either group. CONCLUSION: TTT with ICG dye enhancement was as safe and effective as TTT alone in this study. However, modifications of treatment protocol would be needed to see whether there is any advantage to using ICG dye enhancement.