Hypotensive effect of endothelin-1 in a rat model of pre-eclampsia

OBJECTIVE: To characterize a group of phakic patients with idiopathic intermediate uveitis as defined by vitritis, cystoid macular edema, and retinal periphlebitis. DESIGN: Cross-sectional study. PARTICIPANTS: Nineteen phakic patients (35 eyes) with vitreous inflammation, cystoid macular edema, and/or retinal periphlebitis of unknown cause. INTERVENTION: None. MAIN OUTCOME MEASURES: Best-corrected final visual acuities, standardized clinical examinations, photographic and fluorescein angiographic evaluations, and class I and II HLA analysis on all 19 patients. RESULTS: Fifteen of the 19 patients were women. The mean age was 38 years, the mean follow-up was 104 months, and the mean duration of symptoms was 154 months. All 35 affected eyes had significant vitritis; 21 eyes (60%) had cystoid macular edema, 21 eyes (60%) had retinal periphlebitis. The median initial visual acuity was 20/30. The median final visual acuity was 20/20 with 32 (91%) of 35 eyes having 20/40 or better visual acuity at the final visit. No patient developed "snow-banks" or evidence of systemic disease, including multiple sclerosis or sarcoidosis, during the follow-up period. There were no statistically significant HLA associations in these patients compared with controls from another study from Iowa, but the Iowa phakic patients with cystoid macular edema did differ from the Iowa patients with pars-planitis at loci HLA-B8, HLA-B51, and HLA-DR2. CONCLUSIONS: We describe a disease entity of idiopathic intermediate uveitis that affects primarily young to middle-aged women and usually causes bilateral vitritis, cystoid macular edema, and retinal periphlebitis. Most patients retained good vision over a prolonged follow-up period. Multiple sequential examinations and HLA associations suggest that these conditions are distinct from other syndromes of intermediate uveitis, particularly parsplanitis.     

Submacular hemorrhage removal

PURPOSE: To determine whether pars plana vitrectomy combined with tissue plasminogen activator for evacuation of submacular hemorrhage results in improved visual acuity. METHODS: Retrospective review of 18 patients who received a subretinal injection of tissue plasminogen activator during a pars plana vitrectomy to evacuate dense submacular hemorrhages. RESULTS: Diagnoses included age-related macular degeneration (16 patients), ruptured macroaneurysm (1 patient), and penetrating ocular trauma (1 patient). Preoperative visual acuity ranged from 20/200 to counting fingers (median visual acuity, counting fingers). Follow-up ranged from 10 to 104 weeks (median, 33 weeks). Best postoperative visual acuity ranged from 20/30 to counting fingers (median, 20/300). Best postoperative visual acuity improved two or more lines in 11 (61%) of 18 eyes, remained unchanged in 4 (22%) of 18 eyes, and decreased two or more lines in 3 (17%) of 18 eyes (P = 0.10, Wilcoxon sign-rank test). Final visual acuity ranged from 20/40 to light perception (median, counting fingers). Final visual acuity improved two or more lines in 5 (28%) of 18 eyes, remained unchanged in 6 (33%) of 18 eyes, and decreased two or more lines in 7 (39%) of 18 eyes (P = 0.53, Wilcoxon sign-rank test). CONCLUSIONS: Pars plana vitrectomy to evacuate massive subretinal hemorrhage can improve visual acuity, but final visual acuity is limited by the underlying disease.     

Renal extraction of gentamicin in anesthetized dogs

Follow-up examinations, ranging from four to more than 20 years, were performed on 100 patients with chronic cyclitis whose ages at onset were from 4 to 58 years. Cataracts were found in 42% of eyes and macular disease secondary to macular edema in 28% of eyes. Band keratopathy, glaucoma, retinal detachment, retinoschisis, vitreous hemorrhage, retinal hemorrhage, and vessels leaving the disk margin were also noted. The complications resulting in decreased vision in chronic cyclitis were macular edema in active cases and macular degenerative changes in the late inactive stages. Of all eyes with final visual acuity of 6/12 (20/40) or less, 74% had permanent, late macular changes secondary to earlier cystoid macular edema. Vitreous opacities or cells, or both, caused decreased visual acuity in the early active stages of chronic cyclitis but were not major factors in the ultimate visual prognosis in the late inactive stages. At the final examination, vitreous opacities caused a visual loss in only 9% of the eyes that had visual acuity of 6/12 (20/40) or less. It was difficult to determine whether corticosteroids caused cataract formation and glaucoma.     

The results of vitreous surgery for chronic macular holes

PURPOSE: To evaluate the visual and anatomic results of macular hole surgery in eyes that have had symptoms of a macular hole for 2 years or longer. METHODS: Fifty-one eyes with chronic macular holes (> or = 2 years' duration) were treated in a retrospective analysis of the results of vitrectomy, 16% perfluoropropane gas tamponade, and one of three adjunctive agents (bovine transforming growth factor beta-2, recombinant transforming growth factor beta-2, or autologous platelet extract). Of 51 eyes, 45 (88.2%) were examined 3 months after surgery. Visual acuity of these 45 eyes was measured preoperatively and 3 months postoperatively using the Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity chart. Twenty-eight eyes (62.2%) had no prior vitrectomy and 17 eyes (37.8%) had a prior vitrectomy for the macular hole that failed. RESULTS: The macular holes had a mean duration of 3.7 years and were successfully closed in 32 of 51 total eyes (62.7%) and 32 of 45 eyes (71.1%) that were examined 3 months after surgery. The mean preoperative visual acuity was 20/100 -2 and the mean visual acuity at 3 months was 20/80 for a mean gain of 6.6 ETDRS letters (+ 1.3 lines). Of 45 eyes, 17 (37.8%) were 20/63 or better 3 months after surgery; 21 (46.7%) gained 2 or more ETDRS lines. There was no statistically significant difference in macular hole closure (P = 0.311) or visual acuity change (P = 0.095) in eyes with or without prior vitreous surgery. Eyes with macular holes between 2-2.99 years experienced a somewhat better anatomic and functional result overall than eyes with macular hole from 3-14 years, duration, but the visual acuity change was not statistically significant (P = 0.187). There was substantial variability in visual improvement among eyes with successful closure of the chronic macular hole. CONCLUSIONS: Macular holes of > or = 2 years' duration may be more difficult to close successfully than are more recent macular holes, and the visual improvement appears to be less favorable. Many eyes with chronic macular holes in our study gained substantial visual acuity, so vitreous surgery can be considered in selected eyes with chronic macular holes based on visual needs.     

Plasmin enzyme-assisted vitrectomy in traumatic pediatric macular holes

OBJECTIVE: This study aimed to evaluate the benefit of plasmin enzyme-assisted macular hole surgery on a consecutive series of pediatric patients with traumatic macular holes. DESIGN: Prospective noncomparative case series operated on at William Beaumont Hospital between July 13, 1996, and November 16, 1996, and observed for at least 6 months. PARTICIPANTS: During this interval, the authors operated on four eyes from four consecutive patients who were 14 years of age or younger with traumatic macular holes. INTERVENTION: The patients underwent plasmin enzyme-assisted pars plana vitrectomy with membrane peeling, fluid-gas exchange, and postoperative positioning. The enzyme used was 0.4 international unit (IU) of autologous plasmin enzyme. MAIN OUTCOME MEASURES: Snellen lines of improvement in visual acuity and rate of final visual acuity of 20/40 or greater, and incidence of complications and reoperations were measured. RESULTS: All four macular holes were closed successfully. Follow-up was from 6 to 12 months. There were no reoperations. Visual acuity improved from four to eight lines in all eyes. Three eyes (75%) achieved a postoperative visual acuity of 20/40 or better. Three eyes (75%) had transient, posterior, subcapsular cataracts develop: two of the eyes after surgery and one as a result of the initial injury. CONCLUSION: The treatment of pediatric traumatic macular holes with plasmin enzyme-assisted vitrectomy, membrane peeling, and gas-fluid exchange resulted in closure of the macular holes with significant visual improvement.     

Autologous platelet concentrate as an adjunct in macular hole healing: a pilot study

PURPOSE: A pilot study was undertaken to assess the efficacy of autologous platelets in macular hole healing. PATIENTS AND METHODS: Eight eyes of eight patients with stage 3 or 4 macular holes, two of which had failed to heal after previous vitrectomy and gas tamponade, were included. The procedure consisted of pars plana vitrectomy with removal of posterior cortical vitreous, stripping of associated epimacular membranes, 15% perfluoroethane-air tamponade, and instillation of autologous platelet concentrate onto the posterior pole. Strict postoperative facedown positioning was observed for 12 days. Postoperative evaluation included visual acuity measurement, biomicroscopic macular appearance and scanning laser ophthalmoscope examination. The follow-up period ranged from 3 to 13 months (mean, 7 months). RESULTS: Of eight eyes, flattening of the surrounding retina and closure of the hole were achieved in seven (87.5%). Visual acuity improved two lines or more in four eyes (50%) Four eyes (50%) reached a postoperative visual acuity of 20/50 or more. Increased nuclear sclerosis was observed in six eyes (75%), and retinal detachment occurred in two eyes (25%). CONCLUSIONS: Autologous platelet concentrate administered peroperatively in full-thickness macular holes seems to be a safe and effective adjunct to vitrectomy with removal of posterior hyaloid and gas tamponade. A larger multicenter randomized prospective study is underway to verify these encouraging results before advocating the use of autologous platelets in macular hole surgery.     

Prothrombin gene G20210-->A transition is a risk factor for cerebral venous thrombosis

OBJECTIVE: The objective of the study was to determine the long-term outcome of patients with uveitis who underwent extracapsular cataract extraction (ECCE) and posterior chamber intraocular lens (PCIOL) implantation. DESIGN: Retrospective review. PARTICIPANTS: Twenty-eight patients (36 eyes). INTERVENTION: Extracapsular cataract extraction and PCIOL implantation. MAIN OUTCOME MEASURES: Level of best-corrected Snellen visual acuity, change in visual acuity, length of follow-up, long-term findings, and complications. RESULTS: In long-term follow-up (mean, 81.4 months), 94% of eyes had visual acuity improvement compared with preoperative levels. Average change in visual acuity for all eyes was an improvement of 6.4 Snellen lines; 75% of eyes were 20/40 or better. The prevalences of cystoid macular edema (CME), epiretinal membrane (ERM), and posterior capsule opacification (PCO) were 56%, 56%, and 58%, respectively. CONCLUSIONS: Patients with uveitis who are treated with ECCE with PCIOL implantation can have successful visual results in long-term follow-up despite the prevalence of PCO or macular abnormalities such as CME and ERM.     

Vitrectomy for retained lens fragments after phacoemulsification

PURPOSE: Posterior lens fragments after phacoemulsification can be a serious complication of cataract surgery. This study is designed to evaluate the clinical features of eyes after pars plana vitrectomy has been performed to remove posteriorly dislocated lens fragments after phacoemulsification. METHODS: The authors performed a retrospective chart review of 126 consecutive eyes of 126 patients with dislocated lens fragments after phacoemulsification, managed with pars plana vitrectomy at Associated Retinal Consultants of Michigan. These eyes were operated on from January 1986 through January 1996. RESULTS: The relation of the intervals between cataract surgery and vitrectomy to various postoperative clinical parameters was studied. Clinical features at presentation included elevated intraocular pressure (IOP over 25 mmHg) in 52.4% of the eyes, uveitis in 69.6%, and corneal edema in 50.8%. Initial visual acuity was 20/400 or worse in 73.8% of the eyes. The mean preoperative visual acuity was 20/278 (median, 20/400), whereas the mean final visual acuity was 20/40 (median, 20/50) after a mean follow-up of 18.9 months. Retinal detachments were found in 20 eyes: 7 before vitrectomy and 13 during or after it. After surgery, 44% of eyes achieved a final visual acuity of 20/40 or better and 90% were 20/400 or better. The distribution of best-corrected final visual acuities among the eyes showed statistically significant differences based on the type of intraocular lens (IOL) used, with posterior chamber IOL greater than anterior chamber IOL, and anterior chamber IOL greater than aphakia. Reasons for a poor visual outcome included persistent corneal edema (four eyes), retinal detachment (two eyes), central retinal vein occlusion (two eyes), age-related macular degeneration (two eyes) glaucoma (one year), and endophthalmitis (one eye). CONCLUSIONS: There were no statistically significant differences between early (< 7 days) and delayed (8 days or more) vitrectomy when increased IOP, corneal edema, choroidal effusions, cystoid macular edema, and visual acuity were analyzed. The use of vitrectomy to remove posteriorly dislocated lens fragments has been shown to be an effective treatment method that significantly reduces the inflammatory response and hastens visual recovery.     

Long-term prognosis of cystoid macular edema after microsurgery of rhegmatogenous retinal detachment

We reviewed 25 eyes of 24 patients who had undergone successful repair of rhegmatogenous retinal detachment and who showed cystoid macular edema disclosed by routine fluorescein angiography performed 10-12 weeks postoperatively. The follow-up ranged from 18 months to 10 years (average: 60 months). Angiographic CME spontaneously disappeared in 19 eyes (76%). Complete disappearance of CME occurred less than 2 years postoperatively in all eyes. No late recurrence was observed. The final visual acuity was 20/40 or better in 15 eyes (78.9%). The final near reading visual acuity was normal in 16 eyes (84.2%). Angiographic CME was still present in 6 eyes (24%) 2 years postoperatively. It remained unchanged during the follow-up period (average 64 months) in all eyes. Cystoid macular degeneration developed in only 1 of the 6 eyes with chronic angiographic CME. Five of the 6 eyes with chronic CME retained useful near reading visual acuity during the follow-up period. The long-term prognosis of angiographic CME after microsurgical repair of rhegmatogenous retinal detachment appears to be good in most cases.     

Outpatient postoperative fluid-gas exchange after early failed vitrectomy surgery for macular hole

BACKGROUND: Vitrectomy surgery with fluid-gas exchange and prone positioning has been shown to close macular holes and improve vision. In those eyes that have failed surgery, repeat vitrectomy has been advocated. As an alternative, the authors performed an outpatient postoperative fluid-gas exchange on eyes when the macular hole failed to close after vitrectomy surgery. METHODS: The authors reviewed all cases of failed vitrectomy surgery for macular holes that underwent a postoperative fluid-gas exchange. Eyes were considered to have failed initial surgery if a rim of subretinal fluid surrounded an open full-thickness macular hole. RESULTS: Twenty-three consecutive eyes underwent outpatient fluid-gas exchange 1 week to 8 weeks after vitrectomy surgery. In 17 eyes (74%), fluid-gas exchange resulted in flattening and closure of the macular hole. In all 17 eyes, visual acuity improved 2 or more lines, with 8 (35%) of the 23 eyes achieving 20/50 or better visual acuity. CONCLUSIONS: Postoperative fluid-gas exchange may achieve successful closure of macular holes and improve vision in eyes that have failed surgery for full-thickness macular holes and should be considered as a cost-effective alternative to repeat vitrectomy.     

Natural outcome of idiopathic macular hole

To ascertain the natural outcome of idiopathic macular holes, we studied 186 eyes with the disorder: stages 1 (48 eyes), 2 (30 eyes), 3 (71 eyes), and 4 (37 eyes), which were followed for over twelve months. In 11 (23%) eyes with stage 1 lesions full-thickness macular hole developed during the follow-up period, and in 12 (25%) eyes visual acuity decreased two or more Snellen lines. Twenty-five (83%) and 21 (70%) eyes with stage 2 lesions, 39 (55%) and 22 (31%) eyes with stage 3 lesions, and 7 (19%) and 5 (14%) eyes with stage 4 lesions had enlarged macular holes and decreased visual acuity during the follow-up, respectively. The present results suggest that different stages of macular holes have different natural outcomes and the treatment should be based on their stages.     

Efficacy of proton therapy in circumscribed choroidal hemangiomas associated with serious retinal detachment

OBJECTIVE: The purpose of the study is to evaluate the efficacy and safety of proton therapy in complicated circumscribed choroidal hemangiomas. DESIGN: The study design was a retrospective review. PARTICIPANTS: Studied were 13 patients (13 eyes) who had circumscribed choroidal hemangioma associated with serous retinal detachment. Of these, four eyes previously underwent laser unsuccessfully. INTERVENTION: Proton therapy including a total dose of 30 Cobalt-Gray-Equivalent was administered to each eye. MAIN OUTCOME MEASURES: Patients were controlled for initial and final best-corrected visual acuity, slit-lamp examination, intraocular pressure, fundus examination, fluorescein angiography, and tumor thickness on B-scan ultrasonography. RESULTS: The mean follow-up period was 26 months (range, 9-48 months). Retinal reattachment was obtained in all cases after a mean period of 52 days. The tumor height decreased in all cases. Visual acuity improved to two lines or more in eight eyes (62%) and reached 20/200 or more in nine eyes (69%). No radiation complication was detected during follow-up. CONCLUSIONS: Proton radiation seems to be effective and safe in the management of choroidal hemangioma associated with serous retinal detachment. It may be useful when photocoagulation can not be performed.     

Results of excimer laser photorefractive keratectomy for the correction of myopia

PURPOSE: This report summarizes the authors' 3-year experience with excimer laser photorefractive keratectomy on 240 eyes of 161 patients. METHODS: With constant laser emission parameters, nitrogen flow across the cornea was used on 79 eyes, whereas 161 eyes had no nitrogen flow. Of the 240 eyes, 74 were operated on without suction ring fixation. Postoperative pain management included patching and oral analgesics in 77 eyes and the use of topical diclofenac or ketorolac and a therapeutic soft contact lens in 163 eyes. Follow-up ranged from 1 month (206 eyes) to 36 months (10 eyes). RESULTS: At 3 months, 88% (144 eyes) had uncorrected visual acuity of 20/40 or better; 86% (151 eyes) had corrected visual acuity to within +/- 1 diopter of intended correction, and 10% (17 eyes) lost two or more lines of best-corrected visual acuity. At 12 months, 89% (122 eyes) achieved uncorrected visual acuity of 20/40 or better, 79% (115 eyes) had corrected visual acuity to within +/- 1 diopter of intended correction, and 4% (6 eyes) lost two or more lines of best-corrected visual acuity. At 24 months, 92% (44 of 48 eyes) had uncorrected visual acuity of 20/40 or better, 86% (44 of 51 eyes) had corrected visual acuity to within +/- 1 diopter of intended correction, and 5% (2 eyes) lost two or more lines of best-corrected visual acuity. At 36 months, 90% (9 eyes) achieved an uncorrected visual acuity of 20/40 or better, 90% (9 eyes) had corrected visual acuity to within +/- 1 diopter of intended correction, and no eyes lost two or more lines of best-corrected visual acuity. CONCLUSIONS: The results obtained with one procedure are within accepted standards of accuracy for refractive surgery, and there is the potential for refinement of the final optical correction. Complication rates are low and are not vision threatening. They included increased intraocular pressure, epithelial "map dot" changes, and recurrent corneal erosion syndrome, "central islands," and others. Photorefractive keratectomy appears to be a safe procedure over the short and medium term.     

Bilateral idiopathic macular pucker: a case report

BACKGROUND: Idiopathic epiretinal membrane or macular pucker is a common disorder which typically affects older individuals. Contraction of epiretinal tissue causes changes to occur in the underlying retina stimulating the appearance of a macular hole. This paper presents a case of bilateral macular pucker with accompanying pseudohole. The diagnosis, pathophysiology and management are discussed. METHODS: A 68-year-old male was examined for decreased vision in both eyes. Relevant ophthalmoscopic findings included macular changes compatible with surface wrinkling maculopathy. RESULTS: The patient was diagnosed with bilateral epiretinal membranes with accompanying pseudoholes. The diagnosis was confirmed by fluorescein angiography. Since the patient's vision loss was minimal, the need for surgery was precluded. The patient was to be monitored routinely. CONCLUSIONS: Macular pucker, the most common of acquired macular disorders, has become an important clinical entity. Recognizing distinguishing features, especially in cases associated with pseudohole, will allow more precise diagnostic and prognostic patient counseling. Regular follow-up examinations of patients with mild visual loss become important, because they permit optimal time for surgical intervention.     

Macular hole surgery without using adjunctive additives

BACKGROUND AND OBJECTIVE: To evaluate the efficacy of performing surgical techniques for macular holes without using adjunctive additives. PATIENTS AND METHODS: A prospective study was completed of consecutive eyes treated for macular holes of 1 year or less duration that had not had previous vitreous surgery. The best-corrected visual acuity and hole flattening were determined. RESULTS: Postoperative flattening of the hole was achieved in 39 (91%) of 43 eyes, with at least a 50% reduction of the minimum resolvable visual angle (3-line visual increase) in 65% of the eyes and a final vision of 20/40 or better in 40% of the eyes during the follow-up interval (mean 10.6 months). CONCLUSIONS: The success rate of current macular hole surgical techniques suggests that adjunctive additives may not be necessary for most cases. Thus, new treatment modalities need to be evaluated with carefully controlled studies.     

Reopening of macular holes after initially successful repair

OBJECTIVE: To evaluate the frequency and prognosis of reopening of a macular hole after initially successful repair in a defined patient cohort. DESIGN: Retrospective consecutive noncomparative case series. PARTICIPANTS: Seventeen cases of reopened macular holes among 390 cases of idiopathic macular holes that previously had undergone macular hole surgery were studied. MAIN OUTCOME MEASURES: Assessment of demographics, visual acuity, preoperatively, postoperatively, after reopening of macular hole and after reoperation, if applicable, and precipitating factors. RESULTS: There were 17 (4.8%) of 353 cases in which the macular hole reopened after initial successful surgical closure. The mean visual acuity before reopening was 20/48 and was 20/133 after reopening. Twelve eyes underwent reoperation with improvement to a mean visual acuity of 20/54. The five eyes that were not reoperated on maintained a mean visual acuity of 20/200. Ten of the eyes had undergone cataract surgery between macular hole surgeries, but in only one did the reopening appear to occur in association with this procedure. CONCLUSIONS: Reopening of a previously successfully operated macular hole is uncommon and seems to be a spontaneous event. Reoperation generally yields results similar to those present before the reopening. Reopening of a macular hole associated with cataract surgery is rare.     

Outcomes of vitrectomy for retained lens fragments

PURPOSE: Retained lens fragments after cataract surgery is an infrequent, but potentially serious surgical complication. The aim of this study is to evaluate outcomes after vitrectomy has been performed for removal of retained lens material. METHODS: A retrospective review was conducted to evaluate all cases of pars plana vitrectomy for removal of retained lens fragments performed at Wills Eye Hospital from April 1991 through August 1994. RESULTS: A total of 121 eyes of 121 patients underwent pars plana vitrectomy with removal of retained lens material over the 3 1/2-year period. Visual acuity on presentation was 20/200 or worse in 95 eyes (79 percent). Visual acuity after vitrectomy was 20/40 or better in 82 eyes (68 percent). The postoperative visual acuity was 20/50 to 20/400 in 21 eyes (17 percent), and counting fingers or worse in 18 eyes (15 percent). Nineteen eyes (16 percent) had retinal detachment (RD), 8 were noted at the time of vitrectomy and 11 occurred after vitrectomy. Of the 19 eyes with RD, visual acuity was 20/200 or worse in 12 (63 percent) and counting fingers or worse in 6 (32 percent) at the time of last follow-up. The use of posterior segment phacofragmentation was associated with higher rate of RD, but the difference did not reach statistical significance. Major causes of poor final visual outcome included RD (6 eyes), cystoid macular edema (4 eyes), and glaucoma (2 eyes). CONCLUSION: The timing of vitrectomy did not have a statistically significant impact on visual outcome. Neither the type of intraocular lens nor the timing of lens implantation significantly altered the final visual acuity. Most eyes with retained lens fragments do well after vitrectomy, with the majority recovering good vision. However, the risk of RD is increased, and visual outcome may be adversely affected if RD occurs.     

Full panretinal photocoagulation and early vitrectomy improve prognosis of florid diabetic retinopathy

BACKGROUND: Florid diabetic retinopathy (FDR) is a rare form of proliferative diabetic retinopathy (PDR) that is characterized by a bilateral rapidly progressive, very severe ischemic retinopathy. Florid diabetic retinopathy was reported to carry a high risk of blindness. This study was conducted to determine whether visual prognosis of FDR can be improved by appropriate photocoagulation and surgical management. METHODS: The authors retrospectively studied 20 patients (40 eyes) who were treated from October 1978 to February 1994. Systemic risk factors, visual acuity, complete ocular examination, and fundus findings, as well as fluorescein angiography, were analyzed with respect to photocoagulation and surgical management. Mean follow-up was 3.6 years. RESULTS: All patients had poorly controlled type I diabetes (mean duration, 13.5 years), which often was associated with systemic complications. Mean initial visual acuity was equal to or better than 20/40 in 32 eyes (80%). During the course of the study, high-risk PDR was observed in 38 eyes (95%) and vitreous hemorrhage occurred in 26 eyes (65%). Extensive full subconfluent panretinal photocoagulation was performed completely in 37 eyes (92.5%). Vitrectomy was necessary in 15 eyes (37.5%). Macular edema was present in 30 eyes (75%). Major complications included retinal detachment that required surgery (2 eyes, 5%) and neovascular glaucoma (2 eyes, 5%). However, final visual acuity was equal to or better than 20/40 in 23 eyes (57.5%) and less than 5/200 in only 4 eyes (10%). CONCLUSION: These results suggest that aggressive treatment of FDR with extensive panretinal photocoagulation and early vitrectomy, when necessary, may result in a much better prognosis than has been reported previously.     

Baseline characteristics, natural history, and risk factors to progression in eyes with stage 2 macular holes. Results from a prospective randomized clinical trial. Vitrectomy for Macular Hole Study Group

PURPOSE: The purpose of this study is (1) to determine baseline characteristics and natural history of immature full-thickness macular holes, (2) to describe progression and resolution, and (3) to present new aspects of pathogenesis of idiopathic macular hole. METHODS: The authors analyzed 41 eyes with stage 2 macular holes (37 patients) in a multicentered prospective randomized trial; 19 eyes were randomized to observation (versus surgery) and had more than 12 months of follow-up, allowing determination of the natural course. Baseline and subsequent examinations included best-refracted visual acuity (Early Treatment of Diabetic Retinopathy Study, potential acuity meter, Pelli-Robson contrast sensitivity, and Bailey-Lovie reading vision), of clinical examinations, photography, and fluorescein angiography. RESULT: Mean Snellen visual acuity was 20/66 at baseline. Centric holes usually had a small break (201 microns average mean diameter) with a dark yellow ring and without significant retinal elevation. Eccentric holes had a high maximum/minimum diameter ratio (mean, 1.88 +/- 0.7) and an incomplete cuff of subretinal fluid or yellow ring. Posterior vitreous detachment prevalence was 32% (8/25) in the centric hole group and 0% (0/ 16) in the eccentric hole group (P < 0.05). For the 19 eyes with 12 months of followup, progression rate to stage 3 (or 4) was 74% (n = 14). The diameter of the stage 2 holes increased significantly between baseline and 12 months (P < 0.001). Progression rate to stage 3 was 100% (8/8) in the eyes with pericentral hyperfluorescence (PCH) and 55% (6/11) in eyes without PCH (P < 0.05). Enlargement occurred in 100% of eccentric holes and 60% of centric holes (P = 0.09). Different progression patterns in eccentric and centric holes suggest different mechanisms of pathogenesis. CONCLUSION: Eccentric and centric stage 2 macular holes may have a different pathogenesis. Most stage 2 macular holes, especially with PCH (P < 0.05) or eccentric holes, progressed to stage 3 or 4. In addition to purely tangential traction, some component of obliquely oriented anteroposterior vitreous traction component may be important for pathogenesis of senile macular holes, particularly eccentric stage 2 macular holes.     

Laser photocoagulation of neovascular lesions in senile macular degeneration

Eighty-four eyes with aging macular degeneration were included in this five-year retrospective study (1989-1994). Sixty-four eyes were treated with laser, whereas in 20 eyes photocoagulation was not performed because these patients refused laser treatment. The latter served as a control group. Out of 64 laser-treated eyes, 48 (75%) eyes had extramacular choroidal, and 15 (25%) juxtafoveal neovascular membrane. A comparable percentage and alterations were recorded in the control group of eyes. At the beginning of the study, the mean visual acuity distribution was 0.5 in both the treated and untreated group of eyes, which was not statistically significant (p > 0.16). Recurrent neovascularization developed in 33 (52%) out of 64 eyes at the end of the first and in the second year after photocoagulation, being the main cause of severe vision impairment. At the beginning of the second year, the risk of severe vision loss by six or more Snellen's lines was recorded in 14 (41%) out of 33 eyes with the vision of 0.15, and after five years in 22 (73%) out of 33 eyes with the vision of 0.08. A the end of the study, unchanged or slightly deteriorated visual acuity (0.5-0.4) was found in 27 (42.1%) out of 64 laser-treated eyes, and in only 2 (10%) out of 20 untreated eyes. At the end of the five-year study, total risk of severe vision loss by six or more Snellen's lines was present in 30 (52.8%) out of 64 laser-treated eyes, and in 15 (74%) out of 20 untreated eyes. Study results showed laser treatment of neovascular aging macular degeneration to be absolutely useful in decreasing visual acuity reduction as compared to the untreated control group.