Macular hemorrhage after excimer laser photorefractive keratectomy

We describe three patients with high myopia, 13.0 to 20.0 diopters (D), who had typical myopic macular hemorrhages 1 to 6 months after photorefractive keratectomy (PRK). The hemorrhages eventually resolved, with resultant permanent decrease in vision and pigmentary and atrophic changes in the macula. Highly myopic eyes are predisposed to bleeding in areas of lacquer cracks and to myopic choroidal neovascularization formation. Awareness of potential retinal pathology in patients having PRK and follow-up retinal examinations are warranted.     

Idiopathic polypoidal choroidal vasculopathy of the macula

OBJECTIVE: The authors evaluated the clinical, fluorescein, and indocyanine green (ICG) angiographic characteristics of the macular variant of idiopathic polypoidal choroidal vasculopathy (IPCV). DESIGN: Observational case series. PARTICIPANTS: The records, photographs, and fluorescein and ICG angiograms of eight eyes of seven patients with IPCV lesions confined to the macula were reviewed. MAIN OUTCOME MEASURES: The visual acuity, fundus examination, fluorescein and ICG angiographic characteristics, and clinical course were compared. RESULTS: All patients demonstrated polypoidal lesions arising from macular choroidal vessels on ICG angiography. One patient had bilateral lesions. These lesions appeared hyperfluorescent in the early phases of both fluorescein and ICG angiography. Late-phase leakage was seen in cases associated with subretinal fluid or exudate. None of these patients demonstrated polypoidal lesions arising from the peripapillary choroidal circulation or peripapillary choroidal neovascularization. Three eyes with polypoidal lesions that were associated with subretinal fluid and exudates were treated with photocoagulation. Five eyes were not treated. Final visual acuity ranged from 20/20 to hand motions. Severe visual loss was associated with vitreous and subretinal hemorrhage, but this resolved without permanent severe visual loss in several cases. CONCLUSIONS: In the macular variant of IPCV, ICG and fluorescein angiography demonstrate characteristic macular polypoidal lesions without evidence of peripapillary lesions. The vascular origin of these polypoidal lesions appears to be the macular choroidal circulation. This is distinguished from classic IPCV, in which lesions appear to arise from the peripapillary choroidal circulation. Visual prognosis appears to be good, with most patients retaining visual acuity of 20/80 or better. If subretinal fluid or exudates reduce visual acuity, photocoagulation should be considered.     

Choroidal vascular lesions in serous retinal detachment viewed with indocyanine green angiography

In serous retinal detachment due to damaged retinal pigment epithelium (RPE), fluorescein angiography shows dye leakage into the subretinal space from the choroid. We performed indocyanine green (ICG) angiography in 110 eyes with serous retinal detachment comprising 71 eyes with central serous chorioretinopathy (CSC), 19 with bullous retinal detachment, 18 with Harada's disease, and 2 with toxemia of pregnancy. Choroidal tissue staining was present around the site of subretinal leakage in late-phase ICG angiograms from 63 eyes with CSC and 18 with bullous retinal detachment. ICG angiography also showed leakage from choroidal vessels in 16 eyes with Harada's disease and 2 with toxemia of pregnancy. As a common feature, ICG angiography showed choroidal vascular hyperpermeability in various types of serous retinal detachment. Choroidal circulation was delayed in Harada's disease and toxemia of pregnancy. Choroidal hypoperfusion and hyperpermeability of choroidal vessels probably contribute to the damage of RPE, and choroidal vascular hyperpermeability probably provides fluid pressure to move fluid into the subretinal space from the choroid.     

Comparison of indocyanine green and fluorescein angiography of choroidal neovascularization

We compared indocyanine green (ICG) and fluorescein angiography for evaluation of choroidal neovascularization (CNV). Cast preparations of CNV induced in monkey eyes by laser photocoagulation were correlated with ICG and fluorescein angiographies of the same CNV formations. Fluorescein angiography was more effective, in general, than ICG angiography in detecting CNV; however, CNVs with subretinal hemorrhage (2 of 35 sites) were visible only with ICG angiography. In early phase ICG angiography, CNV formations that casts showed to be dense or composed of thick vessels were seen, but less dense areas were not visible. Lesions that ICG angiography revealed as leaking were not differentiated morphologically from non-leaking areas by the CNV casts. This study confirms that only ICG angiography can identify CNV hidden by subretinal hemorrhage, although fluorescein angiography is otherwise superior. Indocyanine green angiography is indicated as a valuable complement to fluorescein angiography for evaluation of CNV.     

Indocyanine-green videoangiography of drusen as a possible predictive indicator of exudative maculopathy

OBJECTIVE: Recent studies have shown that indocyanine-green videoangiography (ICG-V) is useful to image occult choroidal neovascularization. The authors studied the ICG-V findings in fellow drusen eyes of patients with unilateral exudative age-related macular degeneration (AMD). The authors also studied the occurrence of exudative changes to determine whether ICG-V is useful in predicting future exudative changes in these eyes with only drusen. DESIGN: Cohort study. PARTICIPANTS: The authors studied 432 consecutive patients diagnosed with unilateral exudative AMD in whom the fellow eye had only drusen by clinical fundus examination and fluorescein angiography. All of these eyes had ICG-V performed. Follow-up data were obtained in all eyes with abnormal indocyanine-green (ICG) angiograms and randomly sampled ICG angiograms of normal eyes. MAIN OUTCOME MEASURES: The initial ICG findings were classified as showing normal or abnormal hyperfluorescence. Abnormal hyperfluorescence eyes were subdivided into focal spots (focal areas of hyperfluorescence < 1 disc area in size) and plaques (areas of hyperfluorescence > 1 disc area). The development of exudative changes in eyes with normal and abnormal hyperfluorescence was compared. RESULTS: Of the 432 fellow eyes, 386 (89%) eyes with drusen had a normal ICG-V study, whereas 46 (10 focal spots and 36 plaques) (11%) eyes had an abnormal ICG-V. Exudative changes occurred in 6 (10%) of 58 normal ICG eyes and 9 (24%) of 38 eyes with abnormal ICG findings during a mean follow-up period of 21.7 months. The difference between drusen eyes with normal ICG angiograms and those with plaques on ICG-V regarding future exudative changes (10% vs. 27%, respectively) was statistically significant (P = 0.038). CONCLUSIONS: Abnormal ICG findings were found in 11% of eyes with clinically and fluorescein angiographically nonsuspicious drusen. The subgroup of patients with plaques on ICG-V had a higher chance of having exudative changes develop. Indocyanine-green videoangiography may be a predictive indicator of future exudative changes in eyes with drusen. A much larger prospective study seems justified.     

Pre-injection fluorescence in indocyanine green angiography

PURPOSE: To verify whether infrared pre-injection fluorescence can be observed in patients undergoing indocyanine green (ICG) angiography. METHODS: Infrared fundus photographs were taken before dye injection for 450 consecutive patients undergoing ICG angiography for different chorioretinal disorders. The authors used a high-resolution videoangiography system with the standard ICG filters inserted (overlap, < 0.5%) and the highest flash intensity. RESULTS: Pre-injection fluorescence was detected in 184 patients (40.8%). It was a strong fluorescence in 75 patients (40.7%) and a faint fluorescence in 109 (59.2%). When fluorescence was strong, it simulated vascular filling on the ICG angiogram. Pre-injection fluorescence resulted from the following lesions: (1) old grayish subretinal hemorrhages (35 patients); (2) lipofuscin-like deposits (65 patients); (3) pigmented choroidal neovascular membranes (72 patients); and (4) serous retinal detachments lasting from several months or years (12 patients). Highly reflecting white lesions were not fluorescent. CONCLUSION: Pre-injection fluorescence of chorioretinal lesions is frequently detectable in patients with diseases requiring ICG examination. A pre-injection photograph may help to avoid misinterpretation of the angiograms. The authors' findings may be interpreted as pseudofluorescence or autofluorescence. Pigments contained in pathologic structures of the ocular fundus may be the source of autofluorescence emissions in the near-infrared range.     

Recombinant GM2-activator protein stimulates in vivo degradation of GA2 in GM2 gangliosidosis AB variant fibroblasts but exhibits no detectable binding of GA2 in an in vitro assay

OBJECTIVE: To examine choroidopathy in patients with Beh?et disease. DESIGN: Prospective clinical study. PARTICIPANTS: Thirty-three patients (63 eyes) with Beh?et disease. INTERVENTION: Patients underwent simultaneous indocyanine green (ICG) and fluorescein angiography with a double detector of scanning laser ophthalmoscopy. MAIN OUTCOME MEASURES: Angiographic findings recorded on videotapes were evaluated. The relation of angiographic findings with systemic activity and aqueous inflammation was also analyzed. RESULTS: Fluorescein angiography showed leakage in varying degrees from retinal vessels in 30 patients (53 eyes, 84%). The ICG angiographic findings were choroidal vascular wall staining in 16 eyes (25%), hyperfluorescent spots in 42 eyes (66%) and hypofluorescent plaques in 22 eyes (35%), both of which were not evident with fluorescein, leakage from choroidal vessels in 3 eyes (5%), and irregular filling of choriocapillaris in 11 eyes (17%). These findings did not have a statistically significant correlation with the presence or absence of aqueous inflammation or oral aphthous ulcerations. CONCLUSIONS: The patients with Beh?et disease showed choroidal abnormalities, which could be revealed only by ICG angiography, but not with funduscopy or fluorescein angiography. Simultaneous ICG and fluorescein angiography would be useful for examining choroidal lesions in Beh?et disease.     

Indocyanine green angiography of multifocal choroiditis

PURPOSE: The purpose of the study is to determine indocyanine green (ICG) angiographic characteristics of patients with multifocal choroiditis (MC) and to identify features that may assist in the differentiation of MC from other ocular inflammatory diseases. METHODS: After complete ophthalmologic examination, fluorescein angiography and ICG angiography were performed in a series of 14 patients with MC. The ICG findings were then correlated with the clinical and fluorescein angiographic appearance of these patients to determine specific characteristics and distinguishing features of the entity. These findings then were compared with those of angiographic patterns observed in patients with ocular histoplasmosis syndrome to determine whether differentiating features could be identified. RESULTS: Fourteen (50%) of the 28 eyes were found to have large hypofluorescent spots in the posterior pole on ICG angiography, which, in most cases, did not correspond to clinically or fluorescein angiographically detectable lesions. Seventeen (61%) had smaller hypofluorescent lesions (approximately 50 pm in size) in the posterior pole on the ICG study. In seven eyes exhibiting enlarged blind spots on visual field testing, ICG angiography showed confluent hypofluorescence surrounding the optic nerve. The ICG angiogram was found useful in evaluating the natural course in two patients with MC as well as a response to oral prednisone therapy in four others. The ICG angiographic findings differed from those seen in patients with ocular histoplasmosis. CONCLUSIONS: Indocyanine green angiography can provide information that is not detectable by clinical or fluorescein angiographic examination in patients with MC. This information may prove useful in differentiating this condition from the ocular histoplasmosis syndrome, provide a better understanding of the natural course and progression of the disease, and provide a potential adjunct in the clinical evaluation of patients undergoing therapeutic regimens for active inflammatory lesions.     

Human photoreceptor transplantation in retinitis pigmentosa. A safety study

OBJECTIVE: To establish the technical feasibility and safety of photoreceptor transplantation in retinitis pigmentosa. METHODS: A sheet of human photoreceptor cells was harvested from 2 human cadaveric eyes with a vibratome and transplanted into the subretinal spaces of 2 patients with advanced retinitis pigmentosa and visual acuity of no light perception by means of submacular surgery techniques. Preoperative and postoperative electrophysiologic testing, fundus photography, fluorescein angiography, and scanning laser ophthalmoscopy were performed. RESULTS: Twelve months after photoreceptor transplantation, the visual acuity of each patient remained no light perception. The temporal edge of the retinotomy in 1 patient was folded but was not associated with a retinal detachment. The patients were not immunosuppressed, and there was no evidence of rejection of the allogeneic transplant. Cystoid macular edema, uveitis, and macular pucker were not observed. CONCLUSION: A sheet of adult human photoreceptor cells can be harvested from human cadaveric eyes and safely transplanted to the subretinal spaces of patients with retinitis pigmentosa without systemic immunosuppression.     

Long-term results after drainage of premacular subhyaloid hemorrhage into the vitreous with a pulsed Nd:YAG laser

OBJECTIVE: To investigate the effects of drainage of premacular subhyaloid hemorrhage into the vitreous with an Nd:YAG laser in a large series of patients with long-term follow-up. METHODS: A retrospective review was conducted on 21 eyes with a circumscribed premacular subhyaloid hemorrhage of various causes. These eyes were treated with a pulsed Nd:YAG laser to drain the entrapped blood into the vitreous. The period of review ranged from 12 to 32 months (mean, 22 months). RESULTS: In 16 eyes, visual acuity improved within 1 month. Four eyes had persistent, dense, nonclearing vitreous opacity for at least 3 months and finally required vitrectomy. One clotted hemorrhage did not drain into the vitreous. Final visual outcome was determined by the underlying diagnosis, such as Valsalva retinopathy (7 eyes), diabetic retinopathy (7 eyes), branch retinal vein occlusion (4 eyes), and retinal macroaneurysm, Terson syndrome, or blood dyscrasia (1 eye each). Eyes with Valsalva retinopathy fared the best. Complications included a macular hole in 1 eye and a retinal detachment from a retinal break in a myopic patient. CONCLUSIONS: Drainage of premacular subhyaloid hemorrhage into the vitreous with an Nd:YAG laser is a viable treatment alternative for eyes with recent bleeding. However, a macular hole and a retinal detachment were observed as complications. Thus, to establish Nd:YAG laser treatment as a routine procedure, the risks and benefits have to be weighed in a randomized trial and compared with those of deferral of treatment or primary vitrectomy.     

Role of indocyanine green fluorescence videoangiography in evaluation of subretinal disease

BACKGROUND: Indocyanine green (ICG) is a sterile, water-soluble, tricarbocyanine dye that can be used in fundus angiography as an adjunct to sodium fluorescein. It has a peak spectral absorption of 805 nm in blood plasma or blood, as compared with fluorescein, which has a peak spectral absorption of 465 nm. Because the absorption and emission of ICG lies around 835 nm, transmission of energy by the retinal pigment epithelium (RPE) and serosanguinated material is more efficient in this region than in the region of visible light energy. ICG has the property of being approximately 98% bound to blood protein, disallowing extravasation of excessive dye in the highly fenestrated choroidal vasculature. METHODS: The characteristics of ICG are discussed, including administration and dosage, adverse reactions and use of infrared filters for fundus photography. In addition, two cases are presented to illustrate the clinical application of ICG for diagnosis and treatment of choroidal neovascular membranes. RESULTS: ICG videoangiography can be used to reveal subfoveal choroidal neovascular membranes not previously identified with fluorescein; angiograms can also be used to dramatically highlight retinal and choroidal changes. CONCLUSIONS: The use of ICG for fundus videoangiography provides a more accurate and complete evaluation in certain cases of subretinal and choroidal disease.     

Digital indocyanine green angiography in chorioretinal diseases

BACKGROUND: Fluorescein angiography (FA) is important in the diagnosis of chorioretinal diseases; however, it has some limitations. We conducted this study to evaluate whether digital indocyanine green (ICG) angiography can offer enhanced image in chorioretinal diseases. METHODS: Digital indocyanine green angiography with scanning laser ophthalmoscope (SLO) was performed in 314 patients with various chorioretinal diseases. This coupled digital imaging system can offer instant images, process and store data by computer, and give convenient hardcopy generation. RESULTS: The digital ICG angiography provided enhanced image resolution of the choroid compared with FA. The disease categories included choroidal neovascularization (CNV), choroidal tumor, inflammatory choroidal disease, ischemic choroidal disorder, idiopathic central serous chorioretinopathy and retinal macroaneurysm. CONCLUSIONS: ICG angiography is a useful adjunctive diagnostic technique to fluorescein angiography for various chorioretinal diseases. It is especially useful in the diagnosis of occult and recurrent CNV, as well as choroidal tumor and choroiditis. With greater clinical experience, ICG angiography is promising in giving additional clinical information for many other chorioretinal diseases.     

Clear lensectomy and implantation of a low-power posterior chamber intraocular lens for correction of high myopia: a four-year follow-up

PURPOSE: To evaluate the 4-year postoperative outcomes of patients who are highly myopic who underwent clear lensectomy via phacoemulsification and low power posterior chamber intraocular lens implantation. METHODS: The authors performed surgery in 52 eyes of 30 patients in which prophylactic retinal treatment, clear lensectomy, and posterior chamber intraocular lens implantation were used to treat high myopia of 12 diopters (D) or greater. A total of 49 eyes of 28 patients were evaluated at the 4-year postoperative timeframe. Visual acuity, complications, and refractive stability were assessed. RESULTS: The incidence of retinal detachment through 4 years was 1.9%. No new macular complications were observed. Two patients had posterior vitreous detachment without clinical impact between 1 and 4 years after surgery. The incidence of neodymium:YAG (Nd:YAG) capsulotomy was 36.7%. The mean postoperative spherical equivalent was -0.92 D. Four patients had a myopic shift of 0.50 D to 1.00 D from the 1- to 4-year timeframe. Corrected visual acuity of 20/40 or better was achieved in 82% of eyes that had undergone Nd:YAG capsulotomy versus 56% of untreated eyes. Uncorrected visual acuity of 20/100 or better was achieved in 82% of eyes treated with the Nd:YAG laser versus 62% of untreated eyes. CONCLUSION: Visual acuity and refractive outcomes with clear lensectomy are favorable. Retinal detachment remains the major concern of this procedure. Continuous follow-up of these patients is necessary.     

Characterisation of the infarct-limiting effect of delayed preconditioning: timecourse and dose-dependency studies in rabbit myocardium

BACKGROUND: Although the choroidal neovascularization (CNV) is a common pathologic feature of a number of different eye diseases, its pathological mechanisms have not been fully elucidated. We investigated the expression of vascular endothelial growth factor (VEGF) in CNV using an experimental primate model. METHOD: CNV was induced by intense laser photocoagulation in four monkey eyes. Single eyes were enucleated at 1, 3, 7 or 14 days after photocoagulation and examined immunohistochemically for VEGF, macrophage antigen, von Willebrand factor and glial fibrillary acidic protein (GFAP). Expression of VEGF mRNA was examined by in situ hybridization. RESULTS: One day after photocoagulation, the normal structure of the outer portion of the retina and the inner portion of the choroid was destroyed. Three days after photocoagulation, choroidal vascular endothelial cells migrated into the subretinal space through the defect in Bruch's membrane. Increased expression of VEGF was detected in the accumulating macrophages, migrating retinal pigment epithelial (RPE) cells and Müller cells. Maximal expression of VEGF was observed between 3 and 7 days after wounding, and many newly formed vessels extended into the subretinal space 7-14 days after photocoagulation. CONCLUSION: VEGF derived from RPE cells, macrophages and Müller cells may play a role in the formation of CNV.     

Ocular perforation during retrobulbar and peribulbar injections

BACKGROUND AND OBJECTIVE: To determine the ocular perforations during retrobulbar and peribulbar injections. PATIENTS AND METHODS: Twenty-five ocular perforations between 1976 and 1993 occurred after 13 retrobulbar and 12 peribulbar injections. Eighteen patients (72%) were women. Eighteen eyes were myopic (72%). Risk factors included high myopia in 11 cases (44%), use of Atkinson gaze in 21 cases (84%) and a sharp injection needle. RESULTS: Deep position of the posterior pole was common. Perforation signs comprised vitreous hemorrhage in 25 eyes (100%), subretinal hemorrhage in 19 eyes (76%), retinal breaks along the inferior vascular arcade in 19 eyes (76%), and retinal detachment in 14 eyes (56%). Proliferative vitreoretinopathy developed in 11 eyes (44%). CONCLUSION: Retinal detachment strongly correlated to poor visual outcome.     

Observation and Modeling of Stress Corrosion Cracking in High Pressure Gas Pipe Steel

Stress corrosion cracking (SCC) is commonly observed to form a colony of closely spaced multiple cracks. Four stages of SCC colony evolution are discussed. The first is the colony initiation stage (CIS), which is associated with formation of corrosion pits randomly distributed over a certain domain of the surface exposed to an aggressive environment. Electrochemical processes play a leading role in CIS. The individual crack growth (ICG) driven by a combination of mechanical stresses and electrochemical processes constitutes the second stage. At the end of the second stage, the individual cracks reach certain proximity of one another resulting in much crack interaction. This becomes a transition to the third, strong crack interaction and clusters formation, stage. Cluster growth and individual crack or a cluster instability leading to the ultimate failure constitute the final, fourth stage of the SCC evolution process. In this article, we present observations and a general approach to modeling the first two stages of SCC, i.e., CIS and ICG, that together constitute the major part of the total lifetime of an engineering structure serving under SCC conditions. A computer simulation of individual SC crack growth is developed and compared with a large set of SCC observation data.     

Dark rim around choroidal neovascularization in indocyanine green angiography

Experimentally produced choroidal neovascularization (ChNV) surrounded by a dark rim in indocyanine green (ICG) angiography was studied histopathologically. Dark rims were seen in 28% of ChNVs which were detected with ICG angiography 2 weeks after photocoagulation. During the developing stage of ChNV, the dark rim around it was seen in the early phase of ICG angiography, but in the late phase, the dark rim became unclear because of extravascular dye leakage. During the regressive stage, the dark rim was seen in all phases of angiography. It was especially clear in the late phase. Histopathologically, at the site of the dark rim the retinal pigment epithelial cells proliferated to surround the ChNV in the subretinal space during both stages. These results show that proliferated retinal pigment epithelium surrounding ChNV blocks the fluorescence of the choroid, and causes the dark rim. The dark rim is helpful for diagnosis of ChNV.     

Refractive changes after pediatric intraocular lens implantation

PURPOSE: To report refractive changes after cataract surgery and intraocular lens implantation in infants and children. METHODS: In an ongoing prospective study, the refractive errors of all patients younger than 18 years undergoing intraocular lens implantation were determined at 6 weeks, 3 months, 6 months, and 1 year, and at least yearly thereafter. All patients with greater than 6 months of follow-up were included in the study. RESULTS: Eighty-three eyes of 81 patients were identified. Cataracts were traumatic in 32 eyes (38%) and developmental in 42 eyes (50%). At implantation, the mean (+/-SD) age was 6.3 +/- 4.6 years (range, 9 months to 17 years). The mean follow-up was 26.6 months (range, 6 months to 6.6 years). Patients 0 to 2 years old at the time of implantation demonstrated a mean myopic shift of -3.00 diopters during a mean follow-up period of 2.5 years. Patients 2 to 6 years old at the time of implantation demonstrated a mean myopic shift of -1.50 diopters in a similar follow-up period. Children aged 6 to 8 years experienced a mean myopic shift of -1.80 diopters during a mean follow-up period of 3.0 years, while children older than 8 years at the time of intraocular lens implantation experienced a mean myopic shift of -0.38 diopters during a mean follow-up period of 1.8 years. On average, the operated-on eye showed a greater mean myopic shift than the fellow eye. No statistically significant differences in refractive change were found in comparing amblyopic to nonamblyopic eyes, traumatic to nontraumatic cataracts, or primary to secondary intraocular lenses. CONCLUSIONS: Our data demonstrate a trend toward increasing postoperative myopia in pediatric patients undergoing intraocular lens implantation. This myopic shift is greatest in the younger age groups and persists until at least 8 years of age. There is much variability in the postoperative refractive changes, and predicting exactly when and where the refraction will stabilize for an individual patient is difficult.     

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.     

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.