[Lamellar macular holes with hyporeflective epiretinal proliferation : OCT diagnostics and clinical course]

BACKGROUND

High-resolution spectral domain optical coherence tomography (SD-OCT) is the standard examination for assessment of lamellar macular holes (LMH). According to the current SD-OCT classification of LMHs, they are characterized by (1) an irregular foveal contour, (2) a defect in the inner fovea, and (3) a separation of inner retinal layers from outer retinal layers of the fovea leading to an intraretinal splitting with loss of retinal tissue.

OBJECTIVE

The article aims to give an overview on the current knowledge of retinal imaging in LMH diagnostics and clinical course of disease.

MATERIALS AND METHODS

This review is based on current literature and analyses of data from different case series from the Department of Ophthalmology, Ludwig-Maximilian University Munich, Germany.

RESULTS

In eyes with LMH, a homogenous atypical, hyporeflective epiretinal tissue has been described in addition to conventional tractional epiretinal membranes (ERM). By SD-OCT, this named lamellar hole-associated epiretinal proliferation (LHEP) does not show common signs of traction and is characterized as a thick homogenous layer of moderately reflective material. LHEP has been demonstrated to be related to the occurrence of photoreceptor layer defects, enlargement of LMH diameter and poor visual acuity.

CONCLUSION

The correlation of SD-OCT and en-face OCT can help to identify LMH subgroups and morphology progression early on. FAF enables detection of structural changes at a subclinical stage without visual deterioration. With regard to a high variability of intraretinal changes in LMHs and epimacular fibro-cellular proliferation, the current classification of LMH should be discussed and re-evaluated.

Enhanced 10 Gb/s operations of directly modulated reflective semiconductor optical amplifiers without electronic equalization

We report enhanced 10 Gb/s operation of directly modulated bandwidth-limited reflective semiconductor optical amplifiers. By using a single suitable arrayed waveguide grating we achieve simultaneously WDM demultiplexing and optical equalization. Compared to previous approaches, the proposed system results significantly more tolerant to seeding wavelength drifts. This removes the need for wavelength lockers, additional electronic equalization or complex digital signal processing. Uniform C-band operations are obtained experimentally with < 2 dB power penalty within a wavelength drift of 10 GHz (which doubles the ITU-T standard recommendations).

Spontaneous resolution of a full thickness idiopathic macular hole: fundus autofluorescence and OCT imaging

BACKGROUND

To report on the spontaneous closure of a full thickness juxtafoveolar idiopathic macular hole (IMH) monitored with fundus autofluorescence (AF) as well as optical coherence tomography (OCT) imaging.

METHODS

Observational case report. Fundus Autofluorescence with a confocal SLO (HRA, Heidelberg Engineering, Germany) and OCT imaging were used to monitor the spontaneous evolution of a stage II IMH.

RESULTS

A 70 year-old woman with unremarkable ocular history received a diagnosis of idiopathic macular hole in the left eye. Bright autofluorescence corresponding to the IMH was documented with the confocal SLO and OCT imaging could confirm the presence of an hour glass shaped full thickness juxtafoveolar IMH. Biomicroscopy revealed no posterior vitreous detachment (PVD). Few months later clinical examination demonstrated the presence of typical symptoms and signs of PVD (miodesopsias and Weiss ring). The bright autofluorescence corresponding to the IMH disappeared and OCT imaging documented a normal fovea in morphology and thickness.

CONCLUSIONS

Spontaneous closure of full thickness juxtafoveolar IMH can occur and may be properly monitored with fundus AF as well as OCT imaging.

The natural history of juxtafoveal and subfoveal choroidal neovascularization in high myopia

BACKGROUND

To assess the natural history of juxtafoveal and subfoveal choroidal neovascularization in eyes with high myopia.

METHODS

We retrospectively reviewed the charts of 31 patients (31 eyes) with myopia > or = 6 diopters, well-defined juxtafoveal (1-200 microm from the foveal center) or subfoveal choroidal neovascularization (CNV) on fluorescein angiography at baseline, no prior laser treatment, age < or = 55 years and presenting visual acuity (VA) > or = 20/200. Initial and final VA were compared with the Wilcoxon signed rank test. Multifactor analysis of variance was used to assess the association between baseline characteristics of the lesion and final VA.

RESULTS

Twenty-two patients were females and 9 males with a median age of 44 years (range 14-55). Median diopters spherical equivalent was -11.5 (range -6, -25). Follow-up ranged from 1 to 20 years (median, 3 years). Nine eyes had juxtafoveal CNV and 22 subfoveal involvement. Median final VA (20/100) was significantly worse than median initial VA (20/50)(p = 0.02). A decrease in VA > or = 2 lines occurred in 18 eyes, whereas 8 eyes remained stable and 5 improved (4 juxtafoveal membranes and 1 subfoveal membrane). Of the 9 juxtafoveal CNV, 7 had a final VA > or = 20/40 after a median follow-up of 4 years. By contrast, only 2 of the 22 subfoveal CNV had a final VA > or = 20/40 (median, 20/100) with a median follow-up of 2.5 years. The only factor associated with better final VA was the initial location of CNV (p = 0.0000).

CONCLUSION

This study confirms the poor functional outcome of subfoveal CNV in degenerative myopia with more than 70% of patients having a final VA of 20/100 or less. Juxtafoveal CNV shows a better functional prognosis. These differences should be considered when planning treatment strategies.

Surgical removal of subfoveal choroidal neovascular membranes in high myopia

BACKGROUND

A study was carried out to elucidate the anatomical and functional outcome after surgical excision of subfoveal choroidal neovascular membranes in high myopia.

METHODS

Sixty-five patients with high myopia (> or =6 diopters), well-defined subfoveal neovascular membranes on fluorescein angiography and preoperative visual acuity < or =20/100 were selected for surgery. A standardized surgical technique was used in all cases, by a single surgeon. The main outcomes assessed were Snellen visual acuity, surgical retinal pigment epithelium defect and postoperative perfusion of the choriocapillaris. Multifactor analysis of variance and chi-square/Fisher's exact test statistics were used to assess the association between patients' pre- and postoperative characteristics and outcome measures.

RESULTS

Follow-up ranged from 6 to 48 months (mean 16 months). Mean postoperative visual acuity (0.18) was significantly better than mean preoperative visual acuity (0.09). Visual acuity improved by at least two lines in 29 eyes (45%) and was unchanged in 24 (37%). Overall, 43 eyes (66%) had visual acuity of 20/200 or better and 15 (23%), 20/60 or better. Predictive factors with a significant effect on final visual acuity were mean visual acuity, preoperative status of retinal pigment epithelium and postoperative perfusion of the choriocapillaris. Postoperative perfusion was detected in 31 (48%) of the total 65 eyes and in 12 (67%) of the 18 eyes with normal retinal pigment epithelium at baseline. The mean postoperative retinal pigment epithelium defect was 4.6 times larger than the original neovascular membrane. In selected patients, SLO macular scotometry showed areas of retained retinal sensitivity within the atrophic scar.

CONCLUSION

The natural history of subfoveal neovascularization in high myopia is rarely visually restorative. By contrast, surgical excision of the membranes is feasible and may restore visual acuity in selected patients. This therapeutic approach merits a formal multicenter clinical trial.

Experimental short-term tolerance to perfluorodecalin in the rabbit eye: a histopathological study

PURPOSE

Perfluorocarbon liquids are largely used in vitreoretinal surgery, but their permanence into the eye is considered harmful and early withdrawal is routinely performed by most of the surgeons. We undertook this investigation to evaluate the effects of Perfluorodecalin (PFD) tamponade following vitrectomy in the rabbit eye.

METHODS

Twenty-four rabbits underwent vitrectomy of the right eye according with a standard procedure. Eighteen rabbits received PFD and 6 control rabbits received Balanced Salt Solution (BSS) as vitreous substitute. The eyes were examined with light microscopy and transmission electron microscopy after two, four and six days after tamponade and thirty days after the withdrawal of PFD.

RESULTS

The tamponade lasting four or more days caused irreversible retinal damage involving the photoreceptors and retinal pigment epithelium. Peculiar impressions were formed in the inner retina at the site of the gravitational effect of PFD droplets.

CONCLUSIONS

Based on the results of this study we suggest that the tamponade with PFD lasting more than two days is detrimental to the retina, at least in the case of the rabbit. Damage seems to be related only to the high specific gravity of PFD.

Surgical removal of idiopathic, myopic and age-related subfoveal neovascularization

BACKGROUND

We investigated the functional outcomes of macular surgery for idiopathic, myopic and age-related subfoveal neovascular membranes and looked for preoperative features associated with better final visual acuity (VA).

METHODS

We retrospectively studied 61 patients who had undergone macular surgery in our department between October 1992 and September 1994. Follow-up ranged from 5 to 27 months. Of 61 eyes with subfoveal neovascularizations, 6 were idiopathic, 21 had high myopia (-13 D median) and 34 displayed age-related macular degeneration (AMD). Median preoperative VA was 5/200 in AMD, 20/300 in myopia and 20/200 in idiopathic cases.

RESULTS

Four of the six eyes with idiopathic subfoveal neovascularization had VA 20/60 or better after a median follow-up of 18 months. Of the 21 eyes with high myopia, 10 (48%) improved and 13 (62%) were 20/200 or greater after a median follow-up of 12 months. Among the 34 eyes with AMD, VA improved in 7 (21%), but only 6 (18%) were 20/200 or better after a median follow-up of 7 months. Overall, complications included five retinal detachments, ten cataracts and an increase in size of the retinal pigment epithelium defect over the neovascular membrane of 2.3 +/- 0.8 times (mean +/- SD) in idiopathic eyes. 5.9 +/- 3.6 times in myopia and 19.5 +/- 12.2 times in AMD. Recurrence rates for idiopathic, myopic and age-related neovascular membranes were 33%, 19% and 18% respectively. Etiology (P = 0.035), initial VA in myopic eyes (P = 0.026) and initial size of the neovascular membranes in AMD (P = 0.025) were preoperative factors with a significant effect on final visual outcome.

CONCLUSIONS

Surgical excision of subfoveal neovascular membranes yields different functional results depending on the underlying disease. Severe alteration of the retinal pigment epithelium-Bruch's membrane complex may be responsible for the poor visual outcomes in AMD.

Management of giant retinal tears using perfluorodecalin as a postoperative short-term vitreoretinal tamponade: a long-term follow-up study

To avoid postoperative "compartmentalization" of the vitreous cavity, which may accelerate the recurrence of proliferative vitreoretinopathy (PVR), and to provide a tamponading effect lasting long enough to allow the formation of a firm chorioretinal adhesion by retinopexy, we managed 11 eyes with giant retinal tears and grade-B PVR with lensectomy, vitrectomy, 5-day internal tamponade with perfluorodecalin (PFD), and postoperative supine positioning until the PFD was removed. Baseline characteristics included myopia (10 eyes; range, 5.00 to 15.00 diopters) and perforating trauma (one eye). All patients underwent PFD/fluid exchange 5 days after surgery. Anatomic attachment of the retina was achieved with two operations (the second one being the removal of the PFD) in 9 (82%) of the 11 eyes (median follow up, 18 months). In eight eyes (73%), there was no evidence of reproliferation; in one (successfully reattached after PFD/fluid exchange), a macular pucker developed. The intraocular PFD used as an internal tamponade appeared to be well tolerated for up to 5 days, as judged by static threshold perimetry in the two patients tested, and by the functional outcomes (64% of the reattached eyes had a final visual acuity of 20/40 or better).

Perfluorocarbon liquids as postoperative short-term vitreous substitutes in complicated retinal detachment

To avoid postoperative "compartmentalization" of the vitreous cavity, which can potentially accelerate the recurrence of proliferative vitreoretinopathy (PVR), 32 eyes of 32 selected patients with complicated retinal detachment were managed with lensectomy, vitrectomy, 5-day internal tamponade with perfluorocarbon liquids (PFCL) and postoperative supine positioning until PFCL removal. Intraoperatively, 19 eyes had grade C3 or greater PVR; 10 eyes exhibited ocular trauma and 6 displayed giant tears. All but 5 patients (PFCL/fluid exchange) underwent PFCL/silicone oil exchange 5 days after surgery. Anatomic attachment of the retina was achieved with one operation in 25 (78%) of the 32 eyes with a median follow-up of 8 months (mean 8.4 months). Of the 20 eyes that underwent silicone oil removal, none redetached. Nineteen eyes (61%) showed no or only mild reproliferation; a macular pucker developed in 50% of the 20 eyes successfully reattached after PFCL/silicone oil exchange and in none of the 5 eyes successfully reattached after PFCL/fluid exchange. Intraocular tolerance of PFCL for up to 5 days of internal tamponade appeared to be good as judged by static threshold perimetry in the two patients tested and by our functional outcomes, with 88% of the reattached eyes showing a final visual acuity of 5/200 or better.

The effect of simultaneous internal tamponade on fluid compartmentalization and its relationship to cell proliferation

To determine whether the residual free spaces within the vitreous chamber that result after vitreoretinal surgery and internal tamponade may be avoided, and to verify whether such compartmentalization is of real importance in the recurrence of postoperative proliferative vitreoretinopathy (PVR), the use of simultaneous double filling with polydimethylsiloxane (PDMS) and fluorosilicone (FSiO) in the repair of complicated retinal detachment is evaluated in 12 selected cases. Initial retinal reattachment was achieved in all cases. PVR recurred in 10 patients (83%), 6 of whom showed partial retinal detachment. Inferior and superior postoperative residual free spaces were abolished by this procedure, but a new residual fluid space was created, lying horizontally between the bubbles and expanding in a triangular shape nasal to the optic disc and temporal to the macula. Overall, 9 of 10 eyes with PVR after surgery had proliferation involving these areas. These findings support the concept that compartmentalization is of major importance in determining postoperative cell proliferation.

Drusen and 'choroidal filling defects': a cross-sectional survey

The present study was designed as a cross-sectional survey to assess the association between soft drusen and 'choroidal filling defects'. Sixty-eight eyes presenting hard drusen and 58 eyes with soft drusen of 126 subjects with an age range of 45-83 years were examined in the present study. Choroidal filling defects were present in 13 out of 68 (19.1%) patients with hard drusen and 29 out of 58 (50%) with soft drusen (chi 2 square = 13.4; p < 0.0001 and an odds ratio = 4.2 with 95% CI 1.9-9.3). Age, ocular and systemic hypertension, and diabetes did not influence the results. The association between soft drusen and choroidal filling defects, found in our study, suggests that these abnormalities are possibly due to changes in the staining or permeability properties of Bruch's membrane rather than to a defect in the choroidal blood supply. Soft drusen and choroidal filling defects may both be caused by an accumulation of hydrophobic material within the Bruch's membrane, which is discrete in the case of drusen and diffuse in the case of choroidal filling defects. Choroidal filling defects and soft drusen may represent useful clinical sign of hydrophobicity of Bruch's membrane.

Combined silicone and fluorosilicone oil tamponade (double filling) in the management of complicated retinal detachment

We evaluated the use of simultaneous double filling with polydimethylsiloxane (PDMS) and fluorosilicone (FSiO) in the repair of complicated retinal detachment in 12 selected cases. Initial retinal reattachment was achieved in all cases. Proliferative vitreoretinopathy (PVR) recurred in 10 patients (83%), 6 of which showed partial retinal detachment. Inferior and superior postoperative residual free spaces were abolished by this procedure, but a new residual fluid space was created, lying horizontally between the bubbles and expanding in a triangular shape nasally to the optic disk and temporally to the macula. Overall, 9 of 10 eyes with postoperative PVR had proliferation involving these areas. These findings support the concept that 'compartmentalization' is of major importance in determining postoperative cell proliferation.

Technical procedures and software for magnification-corrected morphometry of optic disk photography

In order to obtain a new diagnostic tool for the early diagnosis of glaucoma, we developed a method based on computerized analysis of the optic disk, cup and neuroretinal rim areas. A fundus camera, a personal computer and a graphic tablet are employed. Suitable software was developed for calculating the areas (disk, cup and rim) providing an index, the rim/disk ratio. The method revealed high repeatability and reproducibility. The simplicity and speed of the procedure make this test suitable for routine clinical use in the early diagnosis of glaucoma.

Fluorescein angiographic findings and results of laser treatment in circumscribed choroidal hemangioma

We studied retrospectively 12 eyes with a solitary choroidal hemangioma in 12 patients over a period of 13 years. A peculiar, even hyperfluorescence of the tumor within the retinal venous phases occurred in all 12 cases. In all but four patients, laser therapy was performed to reduce subretinal fluid and partially destroy the tumor. Two of the three eyes without extensive retinal detachment or cystoid macular edema at the initial visit regained a final vision of 20/30 or better. The remaining 5 patients with the two major complications had a final vision of 20/80 or worse due to degenerative retinal changes. We believe that laser treatment is definitely advisable in the early stages of a circumscribed choroidal hemangioma.

Twin vessels in familial retinal cavernous hemangioma

We investigated the presence of twin vessels in two patients and in four of their relatives at risk from one family with autosomal-dominant hereditary cavernous hemangioma of the retina associated with central nervous system involvement. Twin vessels were detected in four of the six patients examined. The proband had bilateral retinal vascular hamartomas with central nervous system involvement but no twin vessels. The proband's mother had vascular hamartomas of the retina and brain with twin vessels. In the other three family members, twin vessels were associated either with retinal cavernous hemangiomas (one patient) or with normal fundi (two patients). Because twin vessels may be an ocular manifestation of von Hippel-Lindau disease, their presence in one of our two patients and in the otherwise healthy three family members suggests that twin vessels may be associated with different retinal vascular hamartomas, including capillary and cavernous hemangiomas.

Diffuse necrotizing retinochoroiditis in a child with AIDS and toxoplasmic encephalitis

We examined a child with a human immunodeficiency virus (HIV) infection who at 15 months of age developed acute encephalitis, followed 1 week later by a diffuse, uniocular retinochoroiditis. The clinical picture in the right eye was characterized by the occurrence of some intraretinal hemorrhages; punctate, yellow-white, outer retinal lesions temporal to the macula; and a quadrantal, white area of necrotic retina located superotemporally. - The vitreous was remarkably clear, and the left eye was normal. Fluorescein angiography revealed small spots of late hyperfluorescence, vasculitis in the posterior pole, and a persistently hypofluorescent quadrantal superotemporal area. Toxoplasma IgM antibodies that were absent 1 week after birth became detectable in the serum and the cerebrospinal fluid. Serological testing for cytomegalovirus was negative. Neurological signs improved on a specific therapy (pyrimethamine and sulfamethopirazine), but the patient died 2 months later of disseminated cytomegalovirus infection.

Unilateral retinitis pigmentosa associated with exfoliation syndrome

A case of a 71-year-old woman showing pigmentary degeneration of the retina associated with posterior subcapsular cataract in one eye, with a normal fellow eye, is presented. Clinical examinations of the patient were performed in order to rule out the various causes which are known to produce funduscopic features that mimic retinitis pigmentosa. Since these investigations were all negative, the fundus changes were interpreted as a unilateral retinitis pigmentosa. One year later, the patient was re-examined and an exfoliation syndrome was discovered in the affected eye, while the fellow eye was unchanged. An association of unilateral retinitis pigmentosa and exfoliation syndrome in the same eye can be regarded as exceptional. The possibility of a correlation of the pathogenetic mechanisms involved in the development of both conditions is discussed.