Management of submacular hemorrhage with intravitreous tissue plasminogen activator injection and pneumatic displacement.

OBJECTIVE: To investigate the efficacy and safety of treating thick submacular hemorrhages with intravitreous tissue plasminogen activator (tPA) and pneumatic displacement. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: From 5 participating centers, 15 eligible patients had acute (<3 weeks) thick subretinal hemorrhage involving the center of the macula in eyes with pre-existing good visual acuity. Hemorrhages were secondary to age-related macular degeneration in 13 eyes and macroaneurysm and trauma in 1 eye each. METHODS: The authors reviewed the medical records of 15 consecutive patients who received intravitreous injection of commercial tPA solution (25-100 microg in 0.1-0.2 ml) and expansile gas (0.3-0.4 ml of perfluoropropane or sulfur hexafluoride) for thrombolysis and displacement of submacular hemorrhage. After surgery, patients maintained prone positioning for 1 to 5 days (typically, 24 hours). MAIN OUTCOME MEASURES: Degree of blood displacement from under the fovea, best postoperative visual acuity, final postoperative visual acuity, and surgical complications. RESULTS: In 15 (100%) of 15 eyes, the procedure resulted in complete displacement of thick submacular hemorrhage out of the foveal area. Best postprocedure visual acuity improved by 2 lines or greater in 14 (93%) of 15 eyes. After a mean follow-up of 10.5 months (range, 4-19 months), final visual acuity improved by 2 lines or greater in 10 (67%) of 15 eyes and measured 20/80 or better in 6 (40%) of 15 eyes. Complications included breakthrough vitreous hemorrhage in three eyes and endophthalmitis in one eye. Four eyes developed recurrent hemorrhage 1 to 3 months after treatment, three of which were retreated with the same procedure. CONCLUSIONS: Intravitreous injection of tPA and gas followed by brief prone positioning is effective in displacing thick submacular blood and facilitating visual improvement in most patients. The rate of serious complications appears low. Final visual outcomes are limited by progression of the underlying macular disease in many patients.

Macular hole surgery without face-down positioning. A pilot study.

PURPOSE: To investigate whether postoperative face-down positioning is necessary for successful macular hole repair. BACKGROUND: Although never proven, face-down positioning is strongly considered an important maneuver to achieve macular hole closure. Face-down posturing is inconvenient, and for patients with physical or mental limitations, weeks of face-down positioning may be an impossible task. A gas bubble that completely fills the vitreous cavity will tamponade a macular hole despite head position and may close a macular hole as effectively as a partial gas fill with face-down positioning. If face-down positioning were not necessary, more patients would be eligible to benefit from this surgery. METHODS: Thirty-three consecutive eyes in 31 patients aged 65-79 years with Stage II, III, or IV full-thickness macular holes underwent macular hole surgery with a complete 15% C3F8 vitreous fill. Hole duration varied from 1 month to 10 years; in 21% of eyes, (seven of 33) holes had been present for more than 1 year. All phakic eyes (n = 25) had cataract extraction with intraocular lens insertion when macular hole surgery was done. No patients were positioned face down. RESULTS: The follow-up period was 6-40 months; 73% of the patients have been observed for more than 1 year. Preoperative hole duration did not affect hole closure rate. The success rate after one surgery was 79% (26 of 33 eyes), and with additional vitrectomy surgery, the total success rate was 85% (28 of 33 eyes). Forty-eight percent of eyes attained visual acuity of 20/50. Eighty percent of eyes with preoperative acuity of > 20/100 attained > 20/50 acuity. Significant complications included iris incarceration into the cataract wound during a postoperative fluid-gas exchange (one eye), posterior synechiae (four eyes), intraocular lens capture (two eyes), elevated intraocular pressure (three eyes), and retinal detachment (three eyes). Most of these problems can be avoided or reduced. CONCLUSION: This pilot study suggests that successful macular hole closure is possible without face-down positioning. This technique may be an alternative for patients with macular holes in pseudophakic eyes who are unable to assume face-down posturing. Combining cataract surgery with this technique for macular hole repair is reasonable for phakic patients who cannot maintain prone positioning. Major disadvantages of combined surgery include the morbidity of the second procedure and removal of a visually insignificant cataract. This approach should be considered for those patients unable to tolerate face-down positioning.

Interferon alpha-2a for subfoveal neovascularization in age-related macular degeneration.

BACKGROUND: The current study is a prospective randomized clinical trial to determine the effect of interferon alpha-2a on eyes with subfoveal subretinal neovascularization secondary to age-related macular degeneration (AMD). METHODS: Twenty eyes of 19 patients with subfoveal neovascularization secondary to AMD were prospectively evaluated. Ten eyes were randomized to subcutaneous interferon alpha-2a (3 million units/m2) every other day for 8 weeks, whereas 10 eyes were randomized to observation alone as controls. Fluorescein angiography, best-corrected visual acuity tests, and macular visual field assessments were performed, and all eyes were followed for a minimum of 6 months. RESULTS: At the 2-month follow-up visit, the interferon group manifested somewhat slower neovascular growth than controls, but the results were not statistically significant. At the 6-month follow-up visit, there was no difference in visual acuity, average macular sensitivities, or extent of neovascularization. The rate of neovascular progression was significantly related to the extent of previous macular photocoagulation in both groups. CONCLUSION: Though the rate of neovascular progression was slowed during the second month of interferon treatment, the effect did not persist once interferon was discontinued. No long-term benefit appeared to be present. Unfortunately, lengthening the time of administration, increasing the dosage, or increasing the frequency of administration would likely give rise to unacceptable side effects.

Retinal pigment epitheliopathy after macular hole surgery.

BACKGROUND: Full-thickness idiopathic macular holes were previously considered untreatable, but surgical intervention has been proposed to collapse the hole and improve vision. This study evaluates the fluorescein angiographic changes that occur after macular hole surgery. METHODS: Sixteen patients with stage III idiopathic macular holes underwent pars plana vitrectomy, removal of the posterior hyaloid, peeling of fine epiretinal sheets along the edges of the holes, and fluid-gas exchange. Preoperative fluorescein angiograms were performed, and best-corrected preoperative visual acuity was 20/200 or less in all eyes. RESULTS: Postoperatively, the macular hole disappeared in 12 eyes (75%). In all 12 eyes, retinal pigment epithelial swelling was present, with a unique fluorescein angiographic appearance. This pattern slowly resolved over months, with gradual visual improvement but residual retinal pigment epithelial mottling. Systemic and periocular steroids had no significant impact on the process. CONCLUSION: The combination of prolonged intraocular gas contact and light exposure exceeding threshold for an already compromised macula appears to be responsible for this pigmentary pattern. Depending on the severity of the pigment epithelial alteration, this unique pattern may portend a guarded visual prognosis in affected patients undergoing successful macular hole repair.

Scatter macular photocoagulation for subfoveal neovascular membranes in age-related macular degeneration. A pilot study.

Forty eyes with age-related macular degeneration and a choroidal neovascular membrane involving the entire foveal avascular zone were enrolled in a pilot study to evaluate an unconventional photocoagulation technique that was postulated to stimulate inhibitors of neovascularization. Eighteen (45%) eyes were treated with extrafoveal scatter macular photocoagulation, and 22 (55%) eyes were treated with this type of photocoagulation and focal extrafoveal ablation of the choroidal neovascular membrane. The eyes were followed for at least 1 year and up to 4 years (average, 2.4 years). One to 7 months after treatment, approximately 45% of the membranes treated with each technique did not leak fluorescein during angiography. The absence of leakage was associated with better visual acuity, but this difference was not statistically significant. At the beginning of the study, the visual acuity was 20/200 or better in 32 eyes (80%) and 20/80 or better in 11 (28%). At the conclusion of the study, the visual acuity was 20/200 or better in 21 eyes (53%) and 20/80 or better in 7 (18%). After treatment, 24 eyes (60%) had the same or better (plus or minus two lines) visual acuities. Compared with eyes in natural history studies, those treated with scatter macular photocoagulation had less visual loss from baseline but did not recover acuity of 20/100 or better more frequently. There was no difference in results between these two methods of treatment.

Transparency overlay. A rapid method to assess retinal pathologic changes.

Many ocular disorders are managed with the aid of serial photography to detect, document, and measure change. The authors developed a method of field mapping that is a clinically useful, rapid, and inexpensive way to assess changes in retinal anatomy using recently released Polaroid 691 transparency film. This transparency film allows the pretreatment fluorescein angiogram and the posttreatment black-and-white or color transparency images to be enlarged and compared without the use of additional photographic enlargers or projectors.

Surgical management of premacular fibroplasia.

The results of pars plana vitrectomy and membrane peeling for premacular fibroplasia (PMF) were reviewed retrospectively for 88 eyes of 86 patients. Premacular fibroplasia was idiopathic in 61 eyes (69%) and postdetachment in 27 eyes (31%). All patients had a minimum follow-up of 12 months. Visual symptoms of blurring and metamorphopsia were reduced in 75 (85%) study eyes at the end of the follow-up period. Poor visual outcome was significantly related to preoperative cystoid macular edema and prolonged duration of visual blurring. Posterior retinal breaks occurred in three eyes (5%) with idiopathic PMF and five eyes (19%) with postdetachment PMF. Cataract progression was demonstrated in 35 eyes (48%) at 12 months of follow-up and 49 eyes (68%) at 24 months of follow-up, reflecting an incidence of cataract formation that has not been previously reported (to our knowledge) after limited vitrectomy and membrane peeling for PMF.

Modified vitreoretinal forceps for membrane peeling.

We have designed a modified vitreoretinal forceps specifically for peeling delicate epiretinal membranes in cases of premacular fibroplasia. Improved features of the forceps include a positive-action closure, barrel design, and lightly serrated surfaces. Rotational movements are made easier by this modified forceps design. Over the past three years, 96 cases of premacular fibroplasia have been successfully managed with the modified forceps. Delicate membranes have been removed without tearing or shredding.

New retinal detachment after pneumatic retinopexy.

Thirteen cases of rhegmatogenous retinal detachment repaired by pneumatic retinopexy were reviewed retrospectively. All patients were followed for a minimum of 6 months after surgery. At the end of follow-up, retinal detachment repair by pneumatic retinopexy succeeded in nine cases (70%) and failed in four (30%). Within 2 days of pneumatic retinopexy, vitreous condensation and traction with new retinal tears and associated detachments in previously uninvolved quadrants developed in two patients. The occurrence of new retinal detachments in the early postoperative period after pneumatic retinopexy has not been previously observed.

Intraocular pressure assessment in gas-filled eyes following vitrectomy.

The accuracy and precision of tonometric methods in measuring intraocular pressure (IOP) was assessed in 24 eye-bank eyes subjected to pars plana lensectomy/vitrectomy and air-fluid exchange. Intraocular pressure was measured in masked fashion with a Perkins' applanation tonometer, pneumatic applanation tonometer; a mercury manometer served as a reference standard. Pneumatic tonometry underestimated actual IOP by as much as 25%, and Schiotz' indentation tonometry underestimated actual IOP by as much as 79%. Perkins' applanation tonometry was significantly more accurate in estimating actual IOP in gas-filled eyes than pneumatic tonometry or Schiotz' indentation tonometry.

Natural history of retinal pigment epithelial detachments in age-related macular degeneration.

The natural history of 100 eyes of 93 patients with retinal pigment epithelial detachment (PED) and bilateral age-related macular degeneration (AMD) was retrospectively studied for a minimum of 12 months in the offices of Retina Consultants, Ltd. Detachment was defined as serous in 46 eyes, turbid in 12 eyes, hemorrhagic without evident neovascular membrane (NVM) in 20 eyes, and hemorrhagic with angiographically proven NVM in 17 eyes. Final visual results demonstrated visual acuity of 20/200 or worse in 33% of serous PED, 83% of turbid PED, and 89% of hemorrhagic PED. Despite strict inclusion criteria, 26% of serous PED developed NVM by one year and 49% of serous PED developed NVM by three years. Variables associated with NVM development in serous PED include older patient age, larger detachment size, presence of subretinal fluid at initial examination, and disciform scar in the fellow eye at presentation.

Neovascular glaucoma after intracapsular and extracapsular cataract extraction in diabetic patients.

A retrospective study of the rate of development of neovascular glaucoma after cataract extraction in 242 eyes of 186 diabetic patients identified neovascular glaucoma in 13 of 146 eyes (8.9%) after intracapsular extraction, in two of 17 eyes (11.8%) after extracapsular extraction with primary capsulotomy, and in zero of 53 eyes after extracapsular extraction without capsulotomy. The incidence of neovascular glaucoma was significantly lower in patients who underwent extracapsular extraction with preservation of an intact posterior capsule than in those undergoing intracapsular cataract extraction (P less than .01) or extracapsular cataract extraction with primary capsulotomy (P less than .05).