Does radial optic neurotomy alter retinal blood flow in eyes with a central retinal vein occlusion?
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Decompression, Surgical↗
Biomedical subjects
Sharon Fekrat
Publications and source records attributed to Sharon Fekrat.
Disappearance of myelinated retinal nerve fibers after pars plana vitrectomy.
PURPOSE: To describe a case of extramacular myelinated retinal nerve fibers disappearing after pars plana vitrectomy for an epiretinal membrane and macular edema. DESIGN: Interventional case report. METHODS: A 61-year-old African-American man with extramacular myelinated retinal nerve fibers underwent pars plana vitrectomy for an epiretinal membrane. A posterior vitreous detachment was present preoperatively. Humidified air was used. A gas bubble was placed for an intraoperative macular hole. RESULTS: Nine months after surgery, the myelinated retinal nerve fibers had disappeared. CONCLUSIONS: Loss of myelinated retinal nerve fibers may occur after vitreoretinal surgery. Possible mechanisms include postoperative nerve fiber layer atrophy or ischemia.
Epiretinal Membrane↗
Progression of choroidal neovascularization following injection of pegaptanib sodium (macugen) in two eyes with neovascular age-related macular degeneration.
PURPOSE: To describe two cases of neovascular age-related macular degeneration (AMD) that progressed despite a single intravitreal injection of pegaptanib sodium (Macugen) six weeks earlier. DESIGN: Interventional case report. METHODS: A 62-year-old man and a 76-year-old woman with occult and minimally classic lesions, respectively, each received a single injection of intravitreal pegaptanib. RESULTS: Within six weeks of an intravitreal pegaptanib injection, the choroidal neovascularization (CNV) progressed. In one eye, the chronic occult lesion developed subfoveal classic CNV. In the other eye, the classic component of the minimally classic lesion tripled in size. CONCLUSIONS: A single dose of intravitreal pegaptanib was not effective in these two patients at six weeks. This report reminds the ophthalmologist to consider obtaining a fluorescein angiogram during follow-up after an intravitreal pegaptanib injection to monitor CNV lesion characteristics, particularly if the visual acuity decreases.
Aged↗
Central retinal vein occlusion in patients treated with long-term warfarin sodium (Coumadin) for anticoagulation.
PURPOSE: To describe the clinical features of persons who developed central retinal vein occlusion (CVO) while being treated with Coumadin for chronic anticoagulation. METHODS: In a retrospective, comparative, noninterventional case series of patients diagnosed with CVO while being treated with Coumadin as a systemic anticoagulant, visual and anatomical outcomes were compared with those for a cohort of patients diagnosed with CVO who were not treated with any systemic anticoagulation. RESULTS: Fourteen eyes of 14 patients treated with Coumadin were identified. At presentation, the median international normalization ratio (INR) was 2.20 (range, 1.3-5.0). Eight patients (57%) had a therapeutic INR at the time of CVO. Their visual acuity and perfusion status were similar to those of patients with subtherapeutic INR. At the last follow-up (median, 16 months), visual acuity and perfusion status of the group of 14 eyes were similar to baseline findings (P = 0.62). Clinical features and outcomes were similar to those for a cohort of patients with CVO who were not being treated with systemic anticoagulation. CONCLUSION: CVO can occur in patients being treated with Coumadin for systemic anticoagulation. Final visual acuity and perfusion status were similar to those in a cohort of patients with CVO who were not treated with Coumadin. Although visual acuity is unaffected, ensuring that the INR for these patients remains in the therapeutic range may be important to help prevent secondary systemic thrombotic and embolic disease.
Aged↗
Retrospective review of eyes with neovascular age-related macular degeneration treated with photodynamic therapy with verteporfin and intravitreal triamcinolone.
AIM: To review the outcomes of eyes with neovascular age-related macular degeneration (AMD) treated with photodynamic therapy (PDT) with verteporfin and intravitreal triamcinolone acetonide injection. MATERIALS AND METHODS: We retrospectively reviewed the outcomes of consecutive eyes with neovascular AMD that received an intravitreal triamcinolone injection within 1 week of their first PDT and had at least 6 months of follow-up. Eyes were retreated with PDT at 3-month intervals if angiographic leakage was present. RESULTS: Twenty-six eyes from 24 patients were identified. The mean visual acuity at baseline was 20/118 (median 20/112). The mean visual acuity decreased to 20/138 at 9 months (P = 0.24, n = 15) and to 20/174 at 12 months (P = 0.23, n = 8). The change in visual acuity from baseline was not statistically significant at any time point. The mean central foveal thickness by OCT measured 342 microm at baseline and decreased to 296 microm at 12 months (P = 0.31). Sixty-two per cent of eyes required no additional PDT at 12 months. Nineteen per cent of 26 eyes had a rise in intraocular pressure that was controlled with topical medication alone. CONCLUSION: Photodynamic therapy with verteporfin combined with intravitreal triamcinolone injection in the treatment of neovascular AMD may be superior to PDT alone by decreasing visual loss and reducing the number or retreatments.
Age Factors↗
Functional changes after photodynamic therapy with verteporfin.
OBJECTIVE: To investigate image preferences after photodynamic therapy (PDT). DESIGN: Prospective, cross-sectional study. METHODS: Seventeen patients with neovascular age-related macular degeneration were tested by color vision, contrast sensitivity, and near visual acuity (VA) with positive images and negative images before, 1 week after, and 3 months after PDT. RESULTS: Before PDT, 13 patients (76%) preferred positive images; the difference was not significant (P < .04). One week after PDT, 16 patients (94%) preferred negative images. The average near VA improved to 27 letters on positive images and to 32 letters on negative images (P < .00001). Three months after PDT, near VA declined to 19 letters on positive images and to 26 letters on negative images (P < .000001). Color vision and contrast sensitivity remained constant during all examinations. CONCLUSION: Although PDT may not alter the neurosensory retina, it may affect intraretinal function by changing image preference.
Choroidal Neovascularization↗
Group 2A idiopathic juxtafoveolar retinal telangiectasia in monozygotic twins.
PURPOSE: To report the clinical and fluorescein angiographic characteristics of monozygotic twins affected by group 2A idiopathic juxtafoveolar retinal telangiectasia. DESIGN: Observational case report. METHODS: Both eyes of identical twins were examined in a clinical practice setting. RESULTS: Two 68-year-old Caucasian, monozygotic, female twins were examined. In one twin, visual acuity was 20/50 in the right eye (OD) and 20/40 in the left (OS). Ophthalmoscopy demonstrated right-angle venules without edema in both eyes (OU). Fluorescein angiography demonstrated areas of leakage temporal to the fovea OU with some nasal leakage OS. In her identical twin sister, with type II diabetes, visual acuity was 20/60 OD and 20/25 OS. Right-angle venules OU, refractile deposits OS, and no macular edema OU were present. Fluorescein angiography demonstrated areas of parafoveal leakage temporal and nasal OD and temporal OS. CONCLUSION: This is the second set of female monozygotic twins with group 2A idiopathic juxtafoveolar retinal telangiectasia reported in the literature. This finding suggests a genetic component in the pathogenesis of this retinal vascular disease.
Aged↗
Posterior dislocation of a crystalline lens associated with airbag deployment.
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Accidents, Traffic↗
Radial optic neurotomy in the porcine eye without retinal vein occlusion.
OBJECTIVE: To demonstrate the histopathologic changes in the porcine eye without retinal vein occlusion after radial optic neurotomy (RON). METHODS: A RON was performed in 14 normal eyes of 12 Yorkshire Cross pigs. One radial stab incision at the edge of the nasal optic nerve head was made using a 20-gauge microvitreoretinal blade (Visitec) while the intraocular pressure was elevated. Surgery was concluded when hemostasis was achieved. Weekly ophthalmoscopic examinations were performed. Group 1 eyes (4 eyes of 2 pigs) were enucleated at the end of surgery. Group 2 eyes (4 eyes of 4 pigs) were enucleated 1 week postoperatively, and group 3 eyes (4 eyes of 4 pigs) were enucleated 3 weeks postoperatively. In group 4 (2 eyes of 2 pigs), animals underwent vitrectomy and RON, and eyes were enucleated 3 weeks postoperatively. RESULTS: Ophthalmoscopic examination demonstrated engorged blood vessels at the RON site up to 3 weeks after surgery with minimal or no hemorrhage. Histological examination of the optic nerve demonstrated foci of hemorrhage, interstitial edema, reactive gliosis, and rare inflammatory cells. At 3 weeks, there was complete axonal nerve fiber loss distal to the neurotomy site. CONCLUSIONS: After RON, marked gliosis and complete axonal nerve fiber loss occur at the neurotomy site. Although bleeding was rare intraoperatively in this porcine model, hemorrhage and interstitial edema were present within the optic nerve at the neurotomy site histologically. Clinical Relevance Radial optic neurotomy remains a controversial method of treatment for central retinal vein occlusion. To our knowledge, this is the first study in the literature describing the histopathologic findings after RON.
Animals↗
Controversy in the management of retinal venous occlusive disease.
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Connective Tissue↗
Diagnostic and therapeutic challenges.
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Humans↗
Vision-related quality of life in people with central retinal vein occlusion using the 25-item National Eye Institute Visual Function Questionnaire.
OBJECTIVE: To study visual function and vision-related quality of life in persons with central retinal vein occlusion using the 25-item National Eye Institute Visual Function Questionnaire (VFQ-25). METHODS: Interviewer-administered study of persons with central retinal vein occlusion. Scores on the VFQ-25 were analyzed and converted to a 100-point scale in which 100 represents the best possible score and 0 represents the worst. Subscale results were compared with previously published data, and a subgroup analysis was performed. RESULTS: Fifty-one patients participated. The mean adjusted subscale responses were significantly lower than those from a reference group of patients without ocular disease but not significantly different from patients with diabetic retinopathy. Responses to the VFQ-25 correlated most strongly with visual acuity in the better-seeing eye, number of systemic medical conditions, and patients' opinions about their general health. Responses did not correlate with visual acuity in the involved eye. CONCLUSIONS: Central retinal vein occlusion is an ocular disease that is associated with a decreased vision-related quality of life as measured by the VFQ-25. A decrease in VFQ-25 scores is related to the degree of visual loss in the better-seeing eye and the overall systemic health of the patient.
Aged↗
Intravitreal triamcinolone acetonide in eyes with cystoid macular edema associated with central retinal vein occlusion.
PURPOSE: To evaluate treatment of cystoid macular edema associated with central retinal vein occlusion with intravitreal triamcinolone acetonide. METHODS: This study included 10 eyes of nine patients with perfused central retinal vein occlusion with visual acuity of 20/50 or worse. Following baseline evaluation, including best-corrected visual acuity, intraocular pressure (IOP), fluorescein angiography, and volumetric optical coherence tomography (VOCT), triamcinolone acetonide (4 mg in 0.1 ml) was injected into the vitreous cavity. RESULTS: Mean duration from the time of diagnosis to the intravitreal injection was 15.4 months. All 10 eyes demonstrated biomicroscopic improvement in cystoid macular edema with corresponding improvement in VOCT measurements from a mean of 4.2 mm(3) preinjection to a mean of 2.6 mm(3) at last follow-up (P <.001). Mean best-corrected visual acuity improved from 58 letters (range, 37-72) at baseline to 78 letters (range, 50-100 letters) at last follow-up (average, 4.8 months). The visual acuity improvement was statistically significant (P =.01). Six eyes (60%) were > or =20/50. There were no significant complications. Three eyes (30%) without previous history of glaucoma required initiation of topical aqueous suppressant therapy for IOP elevation at last follow-up. One eye with a previous history of open-angle glaucoma required a trabeculectomy. CONCLUSIONS: Intravitreal injection of triamcinolone acetonide appears to be effective in reducing cystoid macular edema associated with central retinal vein occlusion. This reduction often corresponded to an improvement in visual acuity. Further evaluation is warranted to assess its safety and efficacy in these eyes.
Adult↗
Meta-analysis of plasma homocysteine, serum folate, serum vitamin B(12), and thermolabile MTHFR genotype as risk factors for retinal vascular occlusive disease.
PURPOSE: To assess the role of plasma total homocysteine (tHcy) levels, serum folate and vitamin B(12)levels, and homozygosity for the thermolabile methylenetetrahydrofolate reductase genotype (TT) as risk factors for retinal vascular occlusive disease. DESIGN: Meta-analysis of literature. METHODS: A MEDLINE search was performed to identify all published case-control studies of plasma tHcy levels, serum folate and vitamin B(12) levels, and TT genotype in persons with retinal vascular occlusive disease. Main outcome measures included calculation of plasma tHcy, serum folate, and serum vitamin B(12) standard differences and odds ratios (OR) of TT genotype between cases and controls. RESULTS: In total, 614 patients with all types of retinal vein occlusion had higher plasma tHcy levels than 762 control subjects (standard difference, 0.867; 95% confidence interval [CI] = 0.735, 0.999; P <.001). Plasma tHcy levels were also higher in 154 patients with retinal artery occlusion compared with 358 control subjects (standard difference 1.174; 95% CI = 0.947, 1.402; P <.001). Serum folates, but not vitamin B(12) levels, were lower in 287 patients with retinal vascular occlusion than in the same number of control subjects (standard difference, 0.508; 95% CI = 0.340, 0.675; P <.001; and -0.060; 95% CI = -0.024, 0.104; P =.474, respectively). Similar proportions of 690 patients with retinal vein occlusion and 2754 control subjects demonstrated the TT genotype (OR = 1.332; 95% CI = 0.995, 1.783; P =.054) as did 152 patients with retinal artery occlusions and 435 control subjects (OR = 1.716; 95% CI = 0.977, 3.014; P =.060). CONCLUSIONS: Retinal vascular occlusion is associated with elevated plasma tHcy levels and low serum folate levels, but not serum vitamin B(12) levels and TT genotype. Until a prospective multicenter trial is undertaken, plasma tHcy levels and serum folate levels should be determined in patients with retinal vascular occlusions, and dietary supplementation with low doses of folate and vitamin B(12) should be considered for affected persons.
Folic Acid↗
Radial optic neurotomy as treatment for central retinal vein occlusion.
PURPOSE: To review our initial experience with radial optic neurotomy as treatment for retinal vein occlusion. DESIGN: Interventional case series. METHODS PATIENT POPULATION: five patients (four with central retinal vein occlusion and one with hemiretinal vein occlusion). INTERVENTION: Pars plana vitrectomy with radial optic neurotomy was performed in each case. MAIN OUTCOME MEASURES: Best-corrected visual acuity, presence of macular edema, perfusion status, and time to venous phase of the angiogram were reviewed retrospectively. RESULTS: Mean preoperative visual acuity was 4/200. Preoperatively, the vein occlusion was perfused in one (20%), nonperfused in one (20%), and indeterminate in three (60%). Mean follow-up time was 4.5 months. Mean postoperative visual acuity was 20/400 at last follow-up. Four patients (80%) had improvement in visual acuity and one (20%) worsened. Two patients (40%) improved to 20/80 postoperatively. In four cases (80%), disk congestion improved and intraretinal hemorrhage reabsorbed more quickly than would be expected without treatment. Time to the venous phase of fluorescein angiography improved slightly in three cases (60%) postoperatively. Perfusion status as determined by fluorescein angiography was not significantly altered postoperatively. One patient (20%) had resolution of macular edema postoperatively as shown by volumetric optical coherence tomography. One patient developed choroidovitreal neovascularization and one developed iris neovascularization postoperatively, both of which responded to panretinal photocoagulation. CONCLUSIONS: Radial optic neurotomy may improve visual acuity in eyes with central retinal vein occlusion, although choroidovitreal neovascularization from the neurotomy site can occur. Further study is needed to determine its role in the management of central vein occlusion.
Aged↗
A phase III, multicenter, randomized, placebo-controlled clinical trial of topical aminocaproic acid (Caprogel) in the management of traumatic hyphema.
OBJECTIVE: To determine the safety and efficacy of topical aminocaproic acid (Caprogel) in the management of traumatic hyphema. DESIGN: Multicenter, randomized, double-masked, placebo-controlled clinical trial. PARTICIPANTS: A total of 51 patients participated in this trial (power = 36%, 2-tailed test). INTERVENTION: Patients presenting with traumatic hyphema were randomly assigned to 5-day treatment with topical aminocaproic acid or a placebo gel. Patients were monitored daily with ocular examination and vital sign testing for the 5 days of treatment and at 24 and 48 hours after treatment. General physical examination and laboratory testing were performed at baseline and day 5. MAIN OUTCOME MEASURES: The main efficacy variable was the rate of rebleeding. Secondary efficacy variables included time to hyphema clearance, intraocular pressure, time to secondary hemorrhage, and visual acuity. Safety variables included adverse events, vital signs, and laboratory measurements. RESULTS: Rebleeding occurred in 30% of the placebo group (8 of 27; 95% confidence interval [CI] = 14-50%), versus 8% of the treatment group (2 of 24; 95% CI = 1-27%), for an estimated continuity-corrected difference in percentage of patients with bleeding of 17% (95% CI = -3-38%). Secondary efficacy variables were similar in the groups, except that there was a trend towards more visual improvement in the topical aminocaproic acid group (54%) than in the placebo group (30%) at the last measurement (P = 0.08). Adverse events were similar. CONCLUSIONS: This study provides evidence that topical aminocaproic acid is safe and demonstrates trends towards reducing the rebleeding rate in the management of traumatic hyphema. However, because the study was terminated before complete enrollment, more definitive recommendations will require a larger trial.
Administration, Topical↗
Intraoperative ketorolac and eye pain after viteoretinal surgery: a prospective, randomized, placebo-controlled study.
PURPOSE: To compare the efficacy of one intraoperative dose of intravenous ketorolac tromethamine to saline placebo in controlling postoperative eye pain, nausea, and sedation following vitreoretinal surgery. STUDY DESIGN: Prospective, randomized, placebo-controlled clinical trial. METHODS: One hundred fourteen vitreoretinal surgical patients were randomized over a 7-month period to a single intraoperative intravenous dose of ketorolac tromethamine or placebo. All patients underwent surgery with intravenous sedation and retrobulbar anesthetic injection and had access to a standard postoperative analgesic regimen. After 2 and 5 hours, eye pain, nausea, and sedation levels were recorded using a standard visual analog scale. Analgesic requirements were tabulated. RESULTS: Patients given ketorolac were significantly less likely to have postoperative eye pain than were placebo-treated patients (P = 0.0043). Fewer ketorolac patients required postoperative analgesia than placebo patients did (P < 0.0001). Four ketorolac patients (7%) required a narcotic compared to 11 placebo patients (20%) (P < 0.0001). Fewer ketorolac patients experienced nausea and sedation than placebo patients did, but this difference was not statistically significant. CONCLUSION: Ketorolac tromethamine is an effective nonnarcotic choice for postoperative pain control following vitreoretinal surgery. Pain control is particularly important in this group of patients, whose compliance with postoperative procedures and positioning may significantly affect surgical outcome.
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Intraoperative choroidal hemorrhage in the Osler-Rendu-Weber syndrome.
PURPOSE: To describe a patient with Osler-Rendu-Weber syndrome who developed a nonsimultaneous intraoperative choroidal hemorrhage in each eye. METHOD: Interventional case report. A 65-year-old Caucasian woman with Osler-Rendu-Weber syndrome developed a choroidal hemorrhage in the left eye during vitrectomy for a complicated retinal detachment with a poor visual outcome. Fifteen years later, she developed a macula on retinal detachment in the right eye, which also had a dense cataract. Immediately after uncomplicated phacoemulsification and intraocular lens implantation, under monitored anesthesia care and retrobulbar block, and without valsalva stress, ophthalmoscopy demonstrated a choroidal hemorrhage. A planned scleral buckle was replaced by pneumatic retinopexy. RESULTS: Seven months postoperatively, the retina remained attached with resolution of the choroidal hemorrhage. Visual acuity was 20/30. CONCLUSION: Choroidal hemorrhage may occur more commonly in individuals with Osler-Rendu-Weber syndrome. Recognition of this possible association and institution of appropriate intraoperative precautions may facilitate a good visual outcome.
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