Serial Optical Coherence Tomography of Subthreshold Diode Laser Micropulse Photocoagulation for Diabetic Macular Edema

BACKGROUND AND OBJECTIVE

To use serial optical coherence tomography (OCT) to evaluate low-intensity, high-density subthreshold diode laser micropulse photocoagulation treatment of clinically significant diabetic macular edema.

PATIENTS AND METHODS

Eighteen consecutive eyes of 14 patients with clinically significant diabetic macular edema and a minimum foveal thickness of 223 microm or greater were prospectively evaluated by OCT preoperatively and 1, 4, and 12 weeks following treatment.

RESULTS

Overall, estimated macular edema 3 months postoperatively (minimum foveal thickness--223 microm) was reduced a mean of 24% (P = .02). Eleven eyes treated for recurrent or persistent clinically significant diabetic macular edema following prior treatment more than 3 months before study entry were most improved, with a mean reduction in estimated macular edema 3 months postoperatively of 59%. No treatment complications were observed. No patient demonstrated laser lesions following treatment.

CONCLUSIONS

Low-intensity, high-density subthreshold diode laser micropulse photocoagulation can reduce or eliminate clinically significant diabetic macular edema measured by OCT. Further study is warranted.

Combination therapy of intravitreal triamcinolone and photodynamic therapy with verteporfin for subfoveal choroidal neovascularization

AIM

To evaluate the six months follow-up outcome of combined intravitreal triamcinolone acetonide (IVTA) and photodynamic therapy (PDT) for subfoveal choroidal neovascularization compared to PDT alone.

STUDY DESIGN

Prospective interventional pilot study.

MATERIALS AND METHODS

Patients with six months follow-up of IVTA following PDT (Group I, eight eyes) and PDT alone (Group II, eight eyes) were included. Four mg/ 0.1 ml of IVTA was injected 7-10 days following PDT. The patients were reevaluated every month for the first two months and every three months thereafter in both the groups.

RESULTS

Group I: The mean age was 65.8+/-11.8 years (range: 47-79 years). Five patients were male. The total treatment sessions in six months were 11 (mean: 1.36). At six months, one eye had >or= 10 letters gain and three eyes had > 10 letters loss. Four eyes had stable vision. Two eyes (25%) developed increased intraocular pressure (>40 mmHg) during follow-up. Group II: The mean age was 58.7+/-11.7 years (range: 46-76 years). Five patients were male. The total treatment sessions in six months were 17 (mean: 2.13). At six months, six eyes had >or= 10 letters gain and none had > 10 letters loss. Two eyes had stable vision.

CONCLUSION

The mean number of treatment sessions following combination therapy of IVTA (4 mg) and PDT appears relatively less (1.36 at six months) compared to PDT alone (mean: 2.13). (P =0.02).

Verteporfin

Photodynamic therapy (PDT) with verteporfin (Visudyne), a photosensitising protoporphyrin derivative, is used in the management of subfoveal choroidal neovascularisation (CNV) secondary to age-related macular degeneration (AMD) or pathological myopia (PM). PDT with verteporfin over 1 and 2 years reduces the decline in visual acuity in patients with classic-containing subfoveal CNV secondary to AMD. Verteporfin is generally well tolerated by most patients. Verteporfin is also effective in patients with CNV secondary to PM, although data in this indication are limited and further controlled studies are required. Although verteporfin has shown efficacy in patients with occult AMD-related subfoveal CNV lesions in early trials, data are currently limited on its first-line use in this indication; fully published data from the Verteporfin In Occult (VIO) trial are therefore awaited with interest. Verteporfin should be considered as a first-line treatment in patients with predominantly classic subfoveal CNV secondary to AMD, and in patients with smaller minimally classic subfoveal CNV lesions. It may also be considered an option for the treatment of patients with occult AMD-related subfoveal CNV in whom visual acuity decreases or predominantly classic features develop over time.

Identification of visually significant operculum without macular hole by optical coherence tomography

CASE REPORT

We report a case that illustrates the effectiveness of optical coherence tomography (OCT) in identifying visually significant vitreoretinal interface opacities in the absence of a macular hole. A patient presented with a scotoma in the right eye. Fundoscopic examination revealed a small lesion in close proximity to the foveal avascular zone. OCT of the right eye revealed a small operculum in the vitreous anterior to the fovea without evidence of a macular hole.

COMMENTS

To our knowledge, ours is the first reported case of the use of OCT to identify the presence of a visually significant operculum without an associated macular hole.

Photodynamic therapy for subretinal neovascularization in type 2A idiopathic juxtafoveolar telangiectasis

BACKGROUND

Photodynamic therapy (PDT) with verteporfin is now the standard of care worldwide for the treatment of choroidal neovascularization, but has been used only rarely in those with subretinal neovascular membranes (SRNVM) due to type 2A idiopathic juxtafoveolar retinal telangiectasis (IJT). We performed a retrospective study to examine the outcome of patients treated with PDT for SRNVM secondary to IJT.

METHODS

Retrospective interventional case series of 7 eyes of 6 IJT patients with SRNVMs treated with PDT. Ophthalmic examination and fluorescein angiography were performed before treatment, with retreatment every 3 months as needed. The main outcome was the proportion of patients avoiding vision loss (change of +/- 4 letters, or better).

RESULTS

Baseline Snellen acuity ranged from 20/40 to 20/400 (median 20/80). Mean follow-up was 21 months. Patients received 2.4 treatments on average. Five of 7 patients avoided vision loss; acuity improved in 3 eyes (> or = 1 line improvement), stayed the same in 2 eyes (+/- 4 letters) and decreased in 2 eyes (> or = 1 line decrease) over time. Median final acuity was 20/80. Five of 7 eyes had final acuities of > or = 20/200. No leakage was observed in any eyes following cessation of treatment.

Visual fields correlate better than visual acuity to severity of diabetic retinopathy

AIMS/HYPOTHESIS

We compared the outcomes of perimetric and visual acuity tests in patients with diabetic retinopathy.

METHODS

We examined 59 diabetic patients with different degrees of retinopathy using stereo fundus photography in accordance with the Early Treatment of Diabetic Retinopathy Study (ETDRS) and fluorescein angiography. Conventional white-on-white perimetry (WWP) and short wavelength automated perimetry (SWAP) were performed and analysed with reference to normal values. Visual acuity was measured with ETDRS charts.

RESULTS

Regression analysis revealed that visual acuity was significantly associated with increasing severity of retinopathy according to the ETDRS scale when visual acuity was estimated by counting logarithm of minimum angle of resolution (LogMar) scores, but not when visual acuity was measured by the conventional reading of the smallest line that could be seen. Visual acuity decreased by 0.02 LogMar per ETDRS step (p=0.03). The degree of visual field loss was significantly associated with increasing severity of retinopathy according to the ETDRS scale, perimetric sensitivity decreasing by 0.44 dB per ETDRS step (p=0.0001) using WWP, and by 0.40 dB per ETDRS step (p=0.04) with SWAP. The size of the area of the foveal avascular zone and adjacent perifoveal intercapillary areas (PIAs) also affected the central visual field as obtained both by WWP (-2.6 dB/mm2, p=0.03), and by SWAP (-7.9 dB/mm2, p=0.002), but did not affect visual acuity. The regression model fit for peripheral retinopathy according to the ETDRS scale was better using WWP than SWAP or visual acuity, while SWAP testing was superior to both WWP and visual acuity when measuring effects caused by enlarged foveal avascular zones and PIAs.

CONCLUSIONS/INTERPRETATION

Perimetry can provide more useful information than visual acuity on functional loss in diabetic retinopathy, particularly when the perifoveal capillary network is damaged.

Transpupillary thermotherapy in the management of juxtapapillary and parafoveal circumscribed choroidal hemangioma

BACKGROUND

Circumscribed choroidal hemangioma (CCH) is a rare, vascular tumor that may be associated with formation of subretinal fluid, cystic retinal de-generation, and serous retinal detachment. Studies have suggested that proximity of this tumor to the fovea or optic nerve precludes the use of trans-pupillary thermotherapy (TTT) for treatment. We report our experience using TTT in managing patients with juxtapapillary and parafoveal CCH.

METHODS

We reviewed the records of consecutive patients with CCH treated by TTT at Princess Margaret Hospital, Toronto, between November 1999 and March 2003. This resulted in 11 eyes of 11 patients with juxtapapillary or parafoveal tumors. Treatment was delivered via slit lamp using an 810 nm diode laser with 350 to 800 mW, a 3.0 mm spot, and duration range from 5 s to 90 s. Outcome measures were reduction in tumor thickness, resolution of serous fluid, tumor control, visual acuity, and complications of treatment.

RESULTS

Mean age of patients was 47.6 years. Symptoms included blurred vision, metamorphopsia, light flashes, and floaters. Macular and optic disk edema, field defect, presence of subretinal fluid, and retinal detachment were noted. At presentation, Snellen visual acuity ranged from 20/70 to hand motions. Mean tumor base diameter was 6.0 mm and tumor thickness at baseline was 3.0 mm. Mean follow-up was 18.0 months. Post-TTT, mean tumor thickness was 2.8 mm. Macular and optic disk edema resolved in the majority of patients. Partial regression of the tumor was noted in 4 cases (36%) and good tumor control in 9 cases (82%). Visual acuity improved in 6 patients (55%).

INTERPRETATION

TTT can be effective for treating juxtapapillary and para-foveal CCH. Proximity to the fovea and optic nerve may not be predictive of poor post-treatment visual acuity, although statistical analysis with a larger sample size would more clearly demonstrate a clear advantage.

Retinal Arterial Macroaneurysms: Risk Factors of Poor Visual Outcome

PURPOSE

To evaluate the long-term natural course and to identify the risk factors of a poor visual outcome in patients with retinal arterial macroaneurysms (MA).

METHODS

In this observational case series, we retrospectively evaluated the consecutive patients with MA at our institution over a 17-year period. The visual outcomes of the different types of MA (presented as predominantly hemorrhagic or exudative) were compared.

RESULTS

A total of 31 patients with 46 confirmed MA were identified. The ocular manifestations of MA included retinal hemorrhage (96.7%), retinal exudate (61.3%), macular involvement (77.4%) and vitreous hemorrhage (12.9%). Among the 10 cases of hemorrhagic-type MA, visual acuity improved by 2 or more lines in 9 (90%) and decreased in 1 patient (10%). In the 15 cases of exudative-type MA, 4 improved (26.7%), 8 remained stationary (53.3%) and 3 had decreased visual acuity (20.0%). The average vision change in the minimum angle of resolution improved by 0.59 log units in hemorrhagic MA and decreased by 0.07 log units in exudative MA (p < 0.01). With respect to change of vision, the eyes with hemorrhagic-type MA showed greater improvement than those with the exudative type, but the final visual outcome was not different in the 2 groups. Foveal exudate was a statistically significant risk factor for final vision equal to or worse than 6/30 (odds ratio = 6.93, p < 0.05).

CONCLUSIONS

Different types of MA may have different clinical presentations. In the majority of MA, there is gradual and spontaneous involution. However, poor visual outcome may occur secondary to foveal exudates and subfoveal hemorrhage.

Optical coherence tomography in group 2A idiopathic juxtafoveolar telangiectasis

BACKGROUND AND OBJECTIVE

To describe the optical coherence tomographic features in patients with group 2A idiopathic juxtafoveolar telangiectasis.

PATIENTS AND METHODS

Forty eyes of 20 consecutive patients with idiopathic juxtafoveolar telangiectasis seen between August 2002 and January 2004 were included in the study. All of the patients underwent color fundus photography, fluorescein angiography, and optical coherence tomography. The main outcome measure was optical coherence tomography findings.

RESULTS

The most consistent finding between stages 2 through 5 of group 2A idiopathic juxtafoveolar telangiectasis seen in 35 (87.5%) eyes on optical coherence tomography was the presence of hyporeflective intraretinal spaces in the absence of retinal thickening. Other findings included the presence of hyperreflectivity in the middle or inner retinal layers, suggesting retinal pigment epithelium proliferation and migration corresponding to the stellate foci of pigmentation in stage 4 and features of choroidal or subretinal neovascular membrane in stage 5.

CONCLUSION

The optical coherence tomography findings in group 2A idiopathic juxtafoveolar telangiectasis were characteristic and may be helpful in making the diagnosis and defining, as far as possible, the anatomical staging.

[Lamellar macular hole and continuous vitreofoveal adherence]

PURPOSE

To demonstrate a sub-type of idiopathic inner lamellar macular hole (ILH) that may merit surgical consideration.

METHODS

The study was conducted on patients examined with optical coherence tomography (OCT) between August 2001 and December 2003 and included 22 patients each with ILH in one eye. Eyes with persistent vitreofoveal adherence at the ILH site were included in the study. Eyes that had previously undergone posterior vitrectomy and removal of the posterior hyaloid were excluded.

RESULTS

Out of the 22 cases, persistent vitreous adherence to the edge of the ILH was detected in 3 eyes (3 patients; 13.6%). The ILH occurred spontaneously in 2 eyes and was detected after extraction of an intraocular foreign body in one eye. The vitreous adherence at the ILH, related to the incompletely detached posterior hyaloid in each, was asymmetric: in 2 eyes it was detached only nasal to the ILHs; in the third eye the posterior hyaloid was detached for 360 degrees around the adherence site, but appeared much thicker at a specific site than elsewhere.

CONCLUSIONS

The findings indicate that persistent vitreofoveal adherence might be present in eyes with ILH. Further studies should signify whether such ILHs have a potential of progression, cases in which surgical intervention should be considered.

The management of primary rhegmatogenous retinal detachment not involving the fovea

AIM

To establish the likelihood of, and risk factors associated with, progression of 'macula-on' retinal detachment.

METHODS

A multi-centre prospective observational study of patients with acute retinal detachment, not involving the fovea, was conducted over a 6-month period. Data collected included duration of symptoms, visual acuity, presence of posterior vitreous detachment, retinal drawings and subretinal fluid (SRF) distance from the fovea at a minimum of two time points.

RESULTS

A total of 82 data sets from 15 institutions were analysed. Of 82 cases 11 (13%) demonstrated progression of fluid. Mean progression in those cases which progressed was 2.3 disc diameters (dd) and the average rate of progression was 1.80 dd/day. Binary regression analysis failed to reveal any statistically significant risk factors for progression. Multiple regression analyses were made to identify risk factors. With distance of SRF from fovea at operation as a function, distance of SRF at presentation was the only statistically significant risk factor. In all, 26% of patients underwent surgery out-of-hours. A total of 83% patients achieved a 6-week best-corrected vision of 6/9 or better.

CONCLUSION

Most retinal detachments in this study did not progress within the first few days. The distance of SRF from the fovea at presentation was the only statistically significant risk factor for progression to foveal detachment.

Pars plana vitrectomy for diabetic macular oedema: OCT and functional correlations

PURPOSE

A prospective study to evaluate the macular structural and functional effects of pars plana vitrectomy (PPV) for persistent diffuse clinically significant macular oedema (CSMO).

METHOD

A total of 12 patients with persistent diffuse CSMO were recruited and underwent assessment including best-corrected visual acuity, fundus fluorescein angiography, optical coherence tomography (OCT) and fine matrix mapping (FMM) at baseline and over a period of a year poststandard three-port PPV.

RESULTS

The median baseline ETDRS letters score for all 12 patients was 52 (range 41-63) while at 12 months it had increased to 65 (range of 27-68), an improvement of two complete ETDRS lines (P=0.037). Similarly, there was an improvement in the perifoveal cone thresholds (P=0.02). The foveal thickening for all 12 patients ranged from a median of 183 to 751 microm (normal range 126-180 microm) and the macular volume ranged from a median of 2.13 to 6.42 mm(3) (normal <1.66 mm(3)). After surgery, both the median foveal thickness (from 334 to 280 microm) and median macular volume (from 3.24 to 2.61 mm(3)) demonstrated decreases over 12 months (P=0.01). On baseline OCT, the patients fell into two anatomically distinct groups: Group 1 (n=4) had a dome-shaped thickened macula with a partial posterior hyaloid separation and a significantly higher foveal thickness and macular volume than Group 2 (n=8) which had a diffuse low-elevation profile of the thickened macula (P=0.007).

CONCLUSIONS

In this prospective study of PPV for persistent fovea-involving CSMO there was structural and functional improvement.

Foveal detachment after successful retinal reattachment for macula on rhegmatogeneous retinal detachment: an ocular coherence tomography evaluation

PURPOSE

Foveal detachment after apparently successful retinal reattachment surgery for macula-on retinal detachments (RDs) has been previously documented. This pilot study aimed to utilize ocular coherence tomography (OCT) imaging to investigate foveal architecture after routine retinal detachment surgery and correlate this to visual acuity.

METHODS

Prospective recruitment of patients attending one unit with macula-on RDs. Patients underwent full clinical examination including OCT preoperatively and RD surgery undertaken by scleral buckling, external drainage and air injection. Postoperatively patients had clinical examinations and OCT at 1 week, 1, 3, 6, and 12 months.

RESULTS

A total of 12 consecutive patients were recruited into the study. All had macula-on RDs and normal OCTs at onset. There were no operative or postoperative complications. Retinal reattachment was achieved in all cases within 24 h postoperatively. At 1 month six of 12 patients (50%) showed foveal detachment on OCT, which was invisible on clinical examination. At 3 months, the foveal detachment persisted in four (33%) of these patients. In these cases the foveal detachment persisted at 6 months follow-up, however, a reduction in subfoveal fluid was noted. All cases had foveal reattachment by 12 months postoperatively. Visual acuity was closely correlated to the presence of foveal attachment.

DISCUSSION

A high proportion of patients with successful retinal reattachment surgery had foveal detachments postoperatively. This phenomenon was associated with reduced visual acuity. The aetiology of this occurrence is unknown and warrants further investigation as there is the potential of a long-term effect on vision.

"Light" versus "classic" laser treatment for clinically significant diabetic macular oedema

AIM

To compare the effectiveness of "light" versus "classic" laser photocoagulation in diabetic patients with clinically significant macular oedema (CSMO).

METHODS

A prospective randomised pilot clinical trial in which 29 eyes of 24 diabetic patients with mild to moderate non-proliferative diabetic retinopathy (NPDR) and CSMO were randomised to either "classic" or "light" Nd:YAG 532 nm (frequency doubled) green laser. "Light" laser treatment differed from conventional ("classic") photocoagulation in that the energy employed was the lowest capable to produce barely visible burns at the level of the retinal pigment epithelium. Primary outcome measure was the change in foveal retinal thickness as measured by optical coherence tomography (OCT); secondary outcomes were the reduction/elimination of macular oedema on contact lens biomicroscopy and fluorescein angiography, change in visual acuity, contrast sensitivity, and mean deviation in the central 10 degrees visual field. Examiners were masked to patients' treatment.

RESULTS

14 eyes were assigned to "classic" and 15 were assigned to "light" laser treatment. At 12 months, seven (50%) of 14 eyes treated with "classic" and six (43%) of 14 eyes treated with "light" laser had a decrease of foveal retinal thickness on OCT (p = 0.79). A comparison of reduction/elimination of oedema, visual improvement, visual loss, change in contrast sensitivity, and mean deviation in the central 10 degrees showed no statistical difference between the groups at 12 months (p>0.05 for all groups).

CONCLUSIONS

This study suggests that "light" photocoagulation for CSMO may be as effective as "classic" laser treatment, thus supporting the rationale for a larger equivalence trial.

Classification of abnormal fundus autofluorescence patterns in the junctional zone of geographic atrophy in patients with age related macular degeneration

AIM

To describe and classify patterns of abnormal fundus autofluorescence (FAF) in the junctional zone of geographic atrophy (GA) in patients with age related macular degeneration.

METHODS

Digital FAF images were recorded in 164 eyes of 107 patients using a confocal scanning laser ophthalmoscope (cSLO; excitation 488 nm, detection above 500 nm) as part of a prospective multicentre natural history study (FAM Study). FAF images were obtained in accordance with a standardised protocol for digital image acquisition and generation of mean images after automated alignment.

RESULTS

Image quality was sufficient for classification of FAF patterns in 149 eyes (90.9%) with lens opacities being the most common reason for insufficient image quality. Abnormal FAF outside GA in 149 eyes was classified into four patterns: focal (12.1%), banded (12.8%), patchy (2.0%), and diffuse (57.0%), whereby 12.1% had normal background FAF in the junctional zone. In 4% there was no predominant pattern. The diffuse pattern was subdivided into four groups including reticular (4.7%), branching (27.5%), fine granular (18.1%), and fine granular with peripheral punctate spots (6.7%).

CONCLUSIONS

Different phenotypic patterns of abnormal FAF in the junctional zone of GA can be identified with cSLO FAF imaging. These distinct patterns may reflect heterogeneity at a cellular and molecular level in contrast with a non-specific ageing process. A refined phenotypic classification may be helpful to identify prognostic determinants for the spread of atrophy and visual loss, for identification of genetic risk factors as well as for the design of future interventional trials.

Indocyanine green dye enhanced laser photocoagulation for juxtafoveal choroidal neovascularisation

PURPOSE

To evaluate the initial results of pilot study of indocyanine green dye enhanced laser photocoagulation for juxtafoveal choroidal neovascularisation (CNV).

MATERIALS AND METHODS

The study was conducted on eleven eyes of 11 patients of CNV during the period 2001 and 2002. Two to three minutes after the injection of 5 ml of 25 mgm of indocyanine green (ICG) dye, 810 nm diode laser was used to treat the choroidal neovascular lesions.

RESULTS

The age of the patients ranged from 45 to 80 years. All patients completed 12 months of follow-up. Eight eyes (72.7%) had neovascular age related macular degeneration, 2 eyes (18.2%) had myopic CNV and one eye (9.09%) had CNV secondary to angioid streak. The presenting visual acuity was <or=6/60 in seven, 6/36 in one and >or=6/12 in three patients. The final visual acuity at the end of at least 12 months follow-up was 6/12 or better in one eye (9%); 6/18-6/36 in 3 eyes (27.27%) and <or=6/60 in 7 eyes (63.64%). In four patients the vision improved whereas it worsened or remained same in 7 eyes.

CONCLUSION

ICG dye enhanced diode laser photocoagulation appears to be a potential option for juxtafoveal CNV.

Macular hole development in fellow eyes of patients with unilateral macular hole

PURPOSE

To determine the incidence of developing an idiopathic full-thickness macular hole in fellow eyes that have vitreofoveal attachments and perifoveal vitreous detachment in patients with unilateral idiopathic macular hole.

DESIGN

Retrospective cross-sectional observational study.

METHODS

The fellow eyes of 201 patients with full-thickness macular holes were examined by optical coherence tomography (OCT). A subset of 58 fellow eyes with vitreofoveal attachments and perifoveal vitreous detachment was observed during follow-up, and the changes in the vitreofoveal attachment within 24 months from the initial OCT examination were investigated.

RESULTS

In the 58 eyes, the vitreofoveal relationship changed in 27 eyes. Among the 27 eyes, three eyes developed a full-thickness macular hole, and the other 24 eyes developed a posterior vitreous detachment only over the fovea or a complete posterior vitreous detachment without macular hole formation. The vitreofoveal relationship did not change in 31 eyes during the 24-month period.

CONCLUSION

From an analysis of the changes in the vitreoretinal relationship identified by OCT, three (11%) of 27 fellow eyes in patients with unilateral idiopathic macular hole developed a full-thickness macular hole.

The dragged-fovea diplopia syndrome: clinical characteristics, diagnosis, and treatment

PURPOSE

To identify the clinical characteristics of the dragged-fovea diplopia syndrome, to introduce a simple diagnostic test that aids in the evaluation of such patients, and to provide a simple treatment option to improve the diplopia in some of these patients.

DESIGN

Retrospective, observational case series.

PARTICIPANTS

Ninety-five affected eyes in 83 consecutive patients seen between January 1, 1993, and August 9, 2004, who were diagnosed with the dragged-fovea diplopia syndrome at one institution.

METHODS

We reviewed the records of 222 patients who have been seen in the Krieger Children's Eye Center at The Wilmer Institute since 1993 with a diagnosis of maculopathy, internal limiting membrane, or dragged fovea. We collected ocular findings and history for those patients who reported binocular diplopia that was not amenable to prism therapy and not secondary to acquired strabismus.

MAIN OUTCOME MEASURES

We recorded the presence of metamorphopsia on Amsler grid testing or other clinical evidence of macular wrinkling, response to prism trial, response to the small-field central fusion test (lights on-off test), and response to partial occlusion with Scotch Satin tape (3M Co., St. Paul, MN).

RESULTS

Ninety-five affected eyes in 83 patients met the criteria for inclusion in the study. All patients who were tested with the lights on-off test (n = 69) responded positively, demonstrating rapid central fusion with room lights off, and recurrence of central diplopia with peripheral fusion with room lights on. Forty-six patients (of 64 tested) were receptive to monocular occlusion with Scotch Satin tape.

CONCLUSIONS

The dragged-fovea diplopia syndrome consists of central diplopia in the presence of peripheral fusion, secondary to dragging of the fovea in one or both eyes by retinal disease. The central diplopia cannot be eliminated by prism therapy or eye muscle surgery. The lights on-off test has proved pathognomonic for this syndrome, and many patients have benefited from partial monocular occlusion with Scotch Satin tape.

Subfoveal nodule in Coats' disease

An atypical presentation of Coats' disease is reported with a prominent subfoveal nodule with peripheral retinal exudates. A 6-year old boy presented with 6/120 vision in the left eye associated with an elevated 1 mm subfoveal, circular lesion with peripheral exudates. The fluorescein angiogram showed peripheral retinal telangiectasias with leakage consistent with Coats' disease. The prominent subfoveal nodule is an uncommon initial presentation of Coats' disease and physicians should be aware of this atypical finding.

Tractional cystoid macular edema: a subtle variant of the vitreomacular traction syndrome

PURPOSE

To describe clinical characteristics and treatment outcomes in a series of patients with tractional cystoid macular edema, a subtle variant of the vitreomacular traction syndrome.

DESIGN

Retrospective, uncontrolled, observational, and interventional case series.

METHODS

PATIENT POPULATION

Ten consecutive patients (11 eyes) with multicystoid foveolar thickening caused by localized perifoveal vitreous detachment.

EXPERIMENTAL PROCEDURES

Slit-lamp biomicroscopy and fluorescein angiography; confirmation of vitreomacular relationship with B-scan ultrasonography, optical coherence tomography (OCT), or both. Vitrectomy with peeling of posterior hyaloid in 8 eyes with pretreatment visual acuity <or=20/60.

MAIN OUTCOME MEASURES

Visual acuity and resolution of cystoid macular edema at final follow-up.

RESULTS

The median age of symptom onset was 71 years (range 48-81 years). Shallow perifoveal vitreous detachment was detectable on biomicroscopy in 8 of 11 eyes (73%) and with ultrasound and OCT in all eyes. Fluorescein angiography revealed no leakage from perifoveal capillaries in 8 eyes (73%). After a mean postoperative follow-up of 26.0 months (range 3-84 months), the final visual acuity had improved by 2 or more Snellen lines and measured 20/40 or better in 8 (100%) of 8 operated eyes. Cystoid foveal thickening resolved in all operated eyes.

CONCLUSION

Subtle, localized perifoveal vitreous detachment may cause anterior traction on the foveola, resulting in multicystoid foveal thickening without macular hole formation or capillary leakage. OCT and ultrasound imaging are useful in detecting the detached posterior hyaloid when clinically invisible. Foveal thickening resolves and visual acuity typically improves after the relief of vitreofoveolar traction.

Bilateral sequential photodynamic therapy for sub-retinal neovascularization with type 2A parafoveal telangiectasis

PURPOSE

To report the results of repeated bilateral sequential photodynamic therapy (PDT) with verteporfin for sub-retinal neovascularization associated with parafoveal telengiectasia.

DESIGN

Interventional case series.

METHODS

Three patients (minimum of 6-month follow-up) were analyzed after bilateral sequential PDT for parafoveal telengiectasia-associated sub-retinal neovascularization.

RESULTS

Mean age was 53.3 +/- 2.1 years. Mean and median follow-up duration were 12.3 and 10 months, respectively. Mean initial Early Treatment of Diabetic Retinopathy Study chart letter acuity was 30.6 in right eyes and 19 in left eyes, and at month 6, it was 30.6 in right eyes and 22.3 in left eyes. All patients received bilateral treatment three times; one eye received a fourth treatment. The greatest linear diameter was between 2310 and 5400 microm.

CONCLUSION

PDT is a viable treatment for sub-retinal neovascularization associated with parafoveal telengiectasia. Bilateral sequential treatment is a convenient way to treat bilateral disease.

Correlation of retinal sensitivity measured with fundus-related microperimetry to visual acuity and retinal thickness in eyes with diabetic macular edema

AIM

To determine whether significant correlations exist between retinal sensitivity measured by fundus-related microperimetry and the visual acuity and the foveal thickness measured by optical coherence tomography (OCT) in eyes with diabetic macular edema (DME).

METHODS

A retrospective chart review of 32 eyes with DME and 17 normal healthy eyes that had undergone fundus-related microperimetry and OCT. The macular sensitivity was measured using the recently introduced fundus-related microperimeter, Micro Perimeter 1. The mean retinal sensitivities within the central 2 degrees and 10 degrees were correlated with the best-corrected visual acuity and OCT-measured foveal retinal thickness.

RESULTS

The mean sensitivities in the central 2 degrees and 10 degrees were significantly lower in patients with DME than in normal subjects (P<0.0001). The mean retinal sensitivities in the central 2 degrees and 10 degrees were inversely correlated with visual acuity (r(2)=0.623, P<0.0001; r(2)=0.581, P<0.0001) and foveal thickness (r(2)=0.581, P<0.0001; r(2)=0.551, P<0.0001).

CONCLUSIONS

The mean retinal sensitivities measured with fundus-related microperimetry were significantly lower in eyes with DME than in normal eyes. Because a significant correlation of the microperimeter-determined retinal sensitivity to visual acuity and foveal thickness was observed, the retinal sensitivities obtained by fundus-related microperimetry may be another measure that can be used to assess the effects of DME.