Subthreshold diode micropulse panretinal photocoagulation for proliferative diabetic retinopathy.

PURPOSE: To report the visual acuity and clinical outcomes of a pilot study of subthreshold diode micropulse (SDM) panretinal photocoagulation (PRP) for treatment of diabetic retinopathy. METHODS: A retrospective chart review of all patients undergoing PRP for diabetic retinopathy between April 2000 and February 2003 was performed. Treated conditions ranged from severe non-proliferative to severe proliferative diabetic retinopathy. An SDM PRP protocol designed to avoid detectable laser lesions was employed. Treatment failure end points included the development of vitreous haemorrhage or the performance of vitrectomy. RESULTS: Ninety-nine eyes of 63 patients undergoing SDM PRP were identified. Median follow-up was 1.0 year (range of 0.3-2.7 years). Treatment sessions per eye ranged from 1 to 6 (with a median of two sessions per eye). Overall visual acuity remained unchanged. The probability of treatment failure end points at 12 months post-treatment was 12.5% for vitreous haemorrhage and 14.6% for vitrectomy (from Kaplan-Meier survival analysis). Age, sex, diabetes type, and baseline retinopathy status were not significantly associated with the risk of either failure event. No treatment complications were observed. No eye demonstrated any laser lesion detectable clinically or by fluorescein angiography postoperatively. CONCLUSION: SDM pan retinal photocoagulation minimized retinal damage and treatment complications in the management of high-risk non proliferative and proliferative diabetic retinopathy. Visual loss was prevented with a low rate of vitreous haemorrhage and vitrectomy postoperatively. Further study of the safety, efficacy, and optimal treatment parameters of SDM pan retinal photocoagulation for diabetic retinopathy is warranted.

Subthreshold diode micropulse photocoagulation for the treatment of clinically significant diabetic macular oedema.

AIM: To report the visual and clinical outcomes of a pilot study of subthreshold diode micropulse (SDM) laser photocoagulation for clinically significant diabetic macular oedema (CSMO). METHODS: The results of infrared (810 nm) SDM laser photocoagulation for CSMO were retrospectively reviewed in 95 eyes of 69 consecutive patients with mild to moderate non-proliferative diabetic retinopathy. The same laser parameters were used for each patient. Only the number of laser applications varied between patients, depending on their macular findings. Primary outcome measures were Snellen visual acuity, fluorescein angiographic leakage, and CSMO status. RESULTS: Visual acuity was stable or improved in 85% of treated eyes, with a mean follow up of 12.2 months (range 3-29 months). CSMO decreased in 96% and resolved in 79% of treated eyes. No adverse laser events occurred. No laser lesions were detectable ophthalmoscopically or angiographically after treatment, consistent with calculations based on ANSI Z136.1 laser safety standards suggestive of only histologically detectable tissue effects at the laser exposure levels. No laser scarring was observed during the follow up period. CONCLUSION: Subthreshold diode micropulse laser photocoagulation minimises chorioretinal damage in the management of CSMO and demonstrates a beneficial effect on visual acuity and CSMO resolution. Prospective studies are needed to fully evaluate this technique.

Initial experience with pneumatically stented baerveldt implant modified for pars plana insertion for complicated glaucoma.

OBJECTIVE: To assess the efficacy of pneumatically stented drainage tube implants specially modified for pars plana insertion in the treatment of complicated glaucoma. DESIGN: Retrospective, non-comparative case series. PARTICIPANTS: 50 consecutive patients with refractory complicated glaucoma nonresponsive to medical treatment. INTERVENTION: Baerveldt glaucoma implants modified by Hofmann for pars plana insertion were placed following pars plana vitrectomy and gas-fluid exchange (pneumatically stented implant, or PSI procedure). MAIN OUTCOME MEASURE: Reduction of intraocular pressure (IOP) to 21 mmHg or less. RESULTS: 31 neovascular and 19 complicated non-neovascular glaucoma eyes in 48 patients referred to a vitreoretinal subspecialty practice, average age 69 years (range 29-91), were followed an average of 18 months (range 3-41). The average preoperative IOP was 44 mmHg (14-78) on an average 3.2 glaucoma medications (range 2-6). The average final postoperative IOP was 14 mmHg (range 5-31) on an average 0.6 glaucoma medications (range 0-3, median 0). The final intraocular pressure was 21 mmHg or less in 47 of 50 (94%) operated eyes. Serious complications related to the procedure occurred in five eyes (10%). CONCLUSIONS: Pneumatically stented Baerveldt glaucoma implants modified with the Hofmann elbow to facilitate pars plana insertion are effective in the treatment of complicated glaucoma.

Progressive confluent circumpapillary multiple evanescent white-dot syndrome.

PURPOSE: To describe a morphologic variant of the multiple evanescent white-dot syndrome that can mimic other conditions. METHODS: We examined three patients with severe cases of unilateral multiple evanescent white-dot syndrome characterized by an atypical progressive circumpapillary discoloration of the fundus. RESULTS: The confluent circumpapillary lesion progressed toward or beyond the equator of the fundus, raising initial concern of a viral retinitis. However, pinpoint dots at the leading edge evolved into the typical wreath-like spots of multiple evanescent white-dot syndrome, which then coalesced into the advancing edge of a geographic retinitis or retinal pigment epitheliitis, before spontaneous resolution. CONCLUSION: Progressive geographic circumpapillary discoloration, appearing as a giant white spot, occurs rarely in severe cases of multiple evanescent white-dot syndrome. The distinctive appearance may suggest a disorder other than multiple evanescent white-dot syndrome, which can make initial diagnosis more difficult and lead to unnecessary or inappropriate testing and treatment.

Laser pointer-induced macular injury.

PURPOSE: To report a patient with a macular injury caused by a laser pointing device. METHODS: Case report. A healthy 34-year-old man was examined 2 days after he deliberately gazed into the beam of a laser-pointing device with his left eye for an estimated 30 to 60 seconds. His uncorrected visual acuity in each eye was 20/20. He reported a transient central scotoma in the left eye and headache after laser exposure. RESULTS: Both eyes were unremarkable except for a focal retinal pigment epithelial disturbance at the nasal edge of the fovea in the left eye. Fundus fluorescein angiography demonstrated window- defect type hyperfluoresence in the same location. CONCLUSIONS: Laser-pointing devices may cause macular injury when used inappropriately. Conformance with consumer safety recommendations should minimize potential hazards.

Surfing-related ocular injuries.

PURPOSE: This report evaluates the clinical characteristics of surfing-related ocular trauma to learn the nature of such injuries and propose possible preventive measures. METHODS: The authors reviewed 11 cases of surfing-related eye injuries caused by direct trauma from the surfboard, studying their mechanism of injury, the associated ocular complications, and the anatomic and visual outcomes of surgical repair. RESULTS: Surfing-related ocular injuries occurred exclusively in young males (mean age, 24.8 years; range, 14-37 years). The mechanism of injury most frequently responsible was impact with the sharp nose of the surfboard following a fall. Serious posterior segment complications were observed in all 11 patients, with nine patients suffering ruptured globes. Despite immediate medical attention, five patients did not recover ambulatory levels of visual acuity (>5/200). CONCLUSIONS: Surfing-related ocular trauma presenting to the retinal specialist typically leaves the patient with a permanent visual disability. Important factors contributing to these high-velocity injuries include the sharply pointed nose of the surfboard and the leash keeping the surfer in close proximity to the board following a fall. A simple modification in surfboard design such as blunting the sharp nose of the surfboard, or appropriate protective guards fitted over the surfboard nose, should lessen the severity of such injuries.

Epiretinal membrane and traction retinal detachment complicating laser-induced chorioretinal venous anastomosis.

PURPOSE: To report a patient with a sight-threatening complication of laser-induced chorioretinal venous anastomosis for treatment of central retinal vein occlusion. METHOD: A 69-year-old woman with a nonischemic central retinal vein occlusion underwent focal argon laser photocoagulation treatment to create a chorioretinal venous anastomosis. RESULTS: Massive preretinal fibrosis and traction retinal detachment developed over the area of argon laser photocoagulation, which required vitreous surgery. CONCLUSION: Laser-induced chorioretinal venous anastomosis to treat central retinal vein occlusion can be associated with severe complications, underscoring the need for additional study of this new treatment modality.

Acute retinal pigment epitheliitis.

PURPOSE: To report a patient with acute retinal pigment epitheliitis examined less than 24 hours after onset of symptoms. METHOD: One day after the onset of blurred vision in her left eye, a 33-year-old woman had a best-corrected visual acuity of LE, 20/60 -2. The left eye had classic uniform golden-colored nodules in a honeycomb pattern in the foveal retinal pigment epithelium. Intravenous fundus fluorescein angiography disclosed staining of the foveal pigment epithelium. RESULTS: One month after initial examination, visual acuity was LE, 20/20, and fine subfoveal pigmentary clumping was present. CONCLUSION: The pigmentary maculopathy of acute retinal pigment epitheliitis may be nonspecific, resulting from more than one type of primary foveal inflammation.

Acute retinal pigment epitheliitis.

PURPOSE: We examined a patient with acute retinal pigment epitheliitis before the development of the characteristic pigmentary retinopathy. METHODS: Three days after onset of blurred vision in her left eye, a 25-year-old woman had a visual acuity of L.E.: 20/40 -2. There were uniform outer retinal golden-colored vacuoles in the area of subsequent foveal pigmentary alterations. RESULTS: Two months after examination, visual acuity was L.E.: 20/25 -2, and fine subfoveal pigmentary clumping was present. CONCLUSION: The pigmentary maculopathy of acute retinal pigment epitheliitis may be secondary to primary inflammation of the neurosensory retina.

Treatment of ocular fungal infections with oral fluconazole.

PURPOSE: We treated five patients who had ocular fungal infections with oral fluconazole to determine its safety and effectiveness. METHODS: We reviewed the case histories of the five patients. One patient had coccidioidomycosis and four had endogenous Candida endophthalmitis. RESULTS: The intraocular fungal infection resolved in all patients. CONCLUSION: Fluconazole appears to be a safe and effective antifungal agent that can be administered orally and may be a useful agent for treating some intraocular fungal infections.

Pars plana implant and vitrectomy for treatment of neovascular glaucoma.

PURPOSE: To evaluate the effectiveness of pars plana implants in the treatment of neovascular glaucoma. PATIENTS AND METHODS: Twenty-two consecutive pars plana implant procedures performed for neovascular glaucoma were retrospectively reviewed. RESULTS: Preoperative intraocular pressures ranged from 22 to 80 mmHg (mean 46 mmHg) on a mean of three glaucoma medications. With a mean follow-up interval of 16 months, final postoperative intraocular pressures ranged 9-21 mmHg (mean 16) on a mean 0.7 medications. One patient required a second implant to achieve final intraocular pressure control. Visual acuity was stabilized or improved in 19 of 22 cases (86%). Complications included retinal detachment in two cases (9%). Macular pucker, vitreous hemorrhage, hyphema, choroidal hemorrhage, diplopia, and loss of light perception occurred in one case (5%) each. None developed phthisis bulbi. CONCLUSION: Pars plana drainage tube implants are effective in the treatment of neovascular glaucoma.

Prevalence and significance of acquired immunodeficiency syndrome-related retinal microvasculopathy.

We performed ophthalmologic examinations on 127 subjects with or at risk for human immunodeficiency virus (HIV) infection over a one-year period to determine the prevalence and significance of retinal cotton-wool spots and hemorrhages (AIDS-related retinal microvasculopathy). Of 26 asymptomatic homosexual men, of whom 13 were HIV seronegative and 13 were HIV seropositive, none manifested this retinopathy. Three of 34 patients (9%) with AIDS-related complex and 29 of 67 patients (43%) with AIDS manifested retinopathy on the initial examination. This difference in the prevalence of retinopathy between groups was statistically significant (P less than .05). Patients with AIDS demonstrated 7.2 times greater odds of manifesting retinopathy than patients with AIDS-related complex (P less than .05). Within the group of patients with AIDS, the T helper (CD4) to suppressor (CD8) cell ratio was significantly associated with retinopathy at the initial ocular examination. The CD4:CD8 ratio of the total group of AIDS and AIDS-related complex patients with retinopathy was significantly lower than that of patients without retinopathy (P less than .05). There was no significant association between retinopathy and any specific past or concurrent opportunistic infection or neoplasm. The presence of retinopathy was not associated with symptoms in any patient. The lesions of AIDS-related retinal microvasculopathy may be an important finding in the evaluation of patients suspected to have HIV-related disease.

In vitro contractility of avascular corneal wounds in rabbit eyes.

Contraction of corneal wounds has been the topic of recent speculation, particularly in reference to regression of corneal flattening following radial keratotomy. In an animal model of corneal wound fibroplasia, we offer the first demonstration of in vitro contractility by avascular corneal wound tissue. Three millimeter diameter full-thickness corneal trephine wounds were made in 17 New Zealand white rabbit eyes. The animals were killed and specimens were extracted 3-4 wk postinjury. Contractile responses of corneal wounds were measured on a microdynagauge force transducer. When exposed to serotonin, epinephrine or norepinephrine corneal wounds showed contractions reaching maximum force of 20-100 mg with a peak response obtained within 5-10 min and persisting several hours. Normal corneas did not respond to any agent. All normal iris muscle specimens contracted to acetylcholine exhibiting peak responses of 30-60 mg of force within 5 sec decaying over the following 10-20 min. This is different from corneal wounds which fail to respond to acetylcholine (P less than 0.005). These data suggest that avascular corneal wounds possess contractile properties.

In vivo biomicroscopy and photography of meibomian glands in a rabbit model of meibomian gland dysfunction.

The usefulness of transillumination and biomicroscopy of the lid margin in assessing meibomian gland dysfunction was studied in a rabbit model. Transillumination of rabbit lids treated with topical epinephrine for 2 to 3 months revealed plugging of the meibomian gland orifice. Plugging appeared to be correlated histopathologically with increased thickness and hyperkeratinization of the ductal epithelium at the orifice. Continued treatment resulted in microcystic changes within the duct, which were not easily discernible by routine examination without the aid of a transilluminator. Cystic changes were correlated with dilation of the duct by retained desquamated cornified cells. Biomicroscopy proved valuable in identifying and documenting early lesions associated with epinephrine-induced meibomian gland dysfunction.

The effect of radial keratotomy on ocular integrity in an animal model.

The safety of deep corneal incisions in radial keratotomy was evaluated in a porcine model of blunt trauma. One eye of each enucleated pair (right and left) of porcine eyes was subjected to a variation of radial keratotomy; the fellow eyes served as unoperated-on controls. All eyes were subjected to a standard injury. Control eyes ruptured at the equatorial sclera. Eyes with radial incisions cut through approximately 70% of corneal thickness also ruptured at the equator. When incisions of this depth (70%) were extended across the limbus (rather than to the corneal-scleral junction), all ruptures occurred at the limbal incisions. Eyes cut 95% to 100% of corneal thickness tended to rupture at the incisions. The safety of deep radial keratotomy incisions with respect to ocular integrity is discussed.