Macular Degeneration: Sears JE

Moshfeghi DM, Kim BY, Kaiser PK, Sears JE, Smith SD. · Stanford University Department of Ophthalmology, Stanford, California, USA. · Am J Ophthalmol. · Pubmed #15629286 No free full text.

Abstract: PURPOSE: To identify the risk factors, prognostic factors, and clinical outcomes of patients with perioperative appositional suprachoroidal hemorrhage (ASCH). DESIGN: Case-control study. SETTING: Tertiary referral center. METHODS: Subjects included all patients with perioperative ASCH documented by B-scan ultrasound between May 1990 and March 2001. Two or three control patients were selected for each case, matched by surgeon, procedure, and date of surgery within 1 month. Surgery was performed as necessary. main outcome measures. The odds of ASCH associated with clinical risk factors. secondary outcome measure: visual acuity. RESULTS: Thirty-seven cases with ASCH were identified. Ninety-two procedure- and surgeon-matched control subjects (2.48:1) were selected. Twenty-six cases (71%) of ASCH were related to a glaucoma operation. Risk factors for the development of ASCH included previous vitrectomy (P = .003, odds ratio of 12) and older age (P = .007, odds ratio 1.57/decade of increasing age). Hypertension was found to be protective (P = .02, odds ratio of 0.33). Factors associated with a poor visual outcome in patients with ASCH included apposition >30 days (P = .01), history of uveitis (P = .04), history of dry age-related macular degeneration (P = .05), and history of extracapsular cataract extraction (P = .05). Median pre-ASCH visual acuity was 20/100, and final median visual acuity was 20/1600. CONCLUSIONS: Risk factors for the development of ASCH include previous vitrectomy and older age. Patients with these risk factors should be informed of their greater chance of poor visual acuity and anatomic outcomes secondary to the development of ASCH.

Galor A, Margolis R, Brasil OM, Perez VL, Kaiser PK, Sears JE, Lowder CY, Smith SD. · Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA. · Ophthalmology. · Pubmed #17908594 No free full text.

Abstract: PURPOSE: To evaluate the rates of adverse ocular events after intravitreal triamcinolone acetonide (IVTA) injection in patients with and without uveitis. DESIGN: Retrospective observational case series. PARTICIPANTS: Two hundred twenty-two eyes of 173 patients were included in the study: 45 eyes of 31 patients with macular edema (ME) due to uveitis and 177 eyes of 142 patients with ME secondary to other etiologies. METHODS: Retrospective review of patients who received IVTA at the Cole Eye Institute for ME attributable to various causes between the years 2001 and 2005. Data review of clinical records included patient demographics, etiology of ME, and adverse outcomes after injection. Rates of adverse outcomes in patients with and without uveitis were compared. MAIN OUTCOME MEASURES: Intraocular pressure (IOP) elevation and posterior subcapsular cataract (PSC) progression. RESULTS: Uveitis patients were significantly younger, more likely to be female, and more likely to have had prior posterior sub-Tenon's capsule steroid injection and/or glaucoma therapy than their nonuveitis counterparts. In a multivariate analysis adjusting for the differences in these factors, the presence of uveitis was the strongest risk factor for an adverse IOP event (odds ratio, 2.5; 95% confidence interval [CI], 1.0-6.1; P = 0.05). The odds of having a documented increase in PSC after IVTA injection were 5.6 times greater in uveitis eyes (P = 0.007; 95% CI, 1.6-19.6). CONCLUSIONS: Intraocular pressure elevation and PSC progression occurred with greater frequency in uveitis patients receiving IVTA. Patients with uveitis treated with IVTA should be counseled about these risks and monitored closely.

Margolis R, Lowder CY, Sears JE, Kaiser PK. · Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA. · Semin Ophthalmol. · Pubmed #17564933 No free full text.

Abstract: Systemic vasculitides can cause retinal vascular pathology, including cotton-wool spots, retinal hemorrhages, vascular occlusion, and capillary nonperfusion. Two main causes of visual decline include macular edema and retinal neovascularization. Presumably, both of these complications are caused by increased intraocular levels of vascular growth and permeability factors. We report a patient with occlusive retinal vasculitis associated with mixed connective tissue disease who was treated with intravitreal bevacizumab for chronic macular edema. One month after treatment, visual acuity improved from 20/80 to 20/60, and foveal thickness decreased from 543 microns to 306 microns. This effect persisted for at least 3 months after treatment. No complications, including increased retinal ischemia, were observed.

Brasil OF, Smith SD, Galor A, Lowder CY, Sears JE, Kaiser PK. · The Cleveland Clinic, Cole Eye Institute, Cleveland, Ohio 44195, USA. · Br J Ophthalmol. · Pubmed #17108013 No free full text.

Abstract: AIM: To evaluate the predictive factors for visual outcome after intravitreal triamcinolone acetonide injection to treat refractory diabetic macular oedema (DME). METHODS: A retrospective chart review of patients with DME who met the following inclusion criteria was performed: clinically significant diabetic macular oedema, receipt of a 4 mg/0.1 ml intravitreal triamcinolone acetonide injection and an optical coherence tomography (OCT) of the macula performed up to 10 days before injection. All patients received a full ophthalmic examination including best-corrected Snellen visual acuity (VA). The main outcome measure was the mean change in vision 3 months after injection. RESULTS: Data from 73 eyes of 59 patients were analysed. After a mean follow-up of 324 days, the mean change in vision was -0.075 logarithm of minimum angle of resolution (logMAR) units, with 27.3% improving > or =3 lines, 6.8% declining > or =3 lines and 60.2% remaining stable within 1 line of baseline vision. Statistical analysis was performed using multivariate generalised estimating equations on the basis of data from 52 eyes of 42 patients. Factors associated with an improvement in vision 3 months after injection were worse baseline VA (-0.27 logMAR units/unit increase in baseline VA, p = 0.002) and presence of subretinal fluid (-0.17 logMAR units, p = 0.06). The presence of cystoid macular oedema negatively affected the visual outcome (0.15 logMAR units, p = 0.03). In addition, the presence of an epiretinal membrane (ERM) was associated with less visual improvement. ERM modified the effect of baseline VA as demonstrated by a significant interaction between these two variables (0.34 logMAR units/unit increase in baseline VA, p = 0.04). CONCLUSIONS: OCT factors and baseline VA can be useful in predicting the outcomes of VA 3 months after intravitreal triamcinolone acetonide injection in patients with refractory DME.

Bakri SJ, Sears JE, Lewis H. · Department of Ophthalmology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA. · Graefes Arch Clin Exp Ophthalmol. · Pubmed #16871381 No free full text.

Abstract: BACKGROUND: To report the management of patients with a macular hole and submacular hemorrhage in the same eye. METHODS: Case reports of two eyes of two patients undergoing pars plana vitrectomy (PPV), subretinal injection of tissue plasminogen activator (t-PA) and air-fluid exchange to displace a submacular hemorrhage. In one eye with a submacular hemorrhage due to age-related macular degeneration, a macular hole formed during subretinal t-PA injection. In another patient with a submacular hemorrhage due to a ruptured retinal arterial macroaneurysm (RAM), a sub-internal limiting membrane (ILM) hemorrhage was noted, and a macular hole was found after peeling the ILM, overlying the subretinal hemorrhage. RESULTS: In the first case, after 45 min was allowed for the subretinal clot to liquefy, the macular hole was noted to be closed. A partial air-fluid exchange was performed and the patient was positioned upright, to displace the submacular hemorrhage and tamponade the macular hole. Two weeks later, visual acuity had improved from 20/400 with eccentric viewing to 20/100, the macular hole was closed by optical coherence tomography, and the patient subsequently underwent two sessions of verteporfin photodynamic therapy (PDT) to treat choroidal neovascularization detected by fluorescein angiography. At last follow-up 7 months after surgery, vision was 20/200, the CNV was active angiographically, and another session of PDT was performed. In the second case, PPV was combined with phacoemulsification and intraocular lens implantation. An 80% air-fluid exchange was performed after injecting the subretinal t-PA, the air was exchanged for 14% perfluoropropane gas, and the patient was positioned upright. Visual acuity improved from 20/400 to 20/200 at last follow-up 4 months after surgery, with the RAM spontaneously sclerosed and the macular hole closed clinically and angiographically. CONCLUSIONS: Intraoperative evacuation of subretinal hemorrhage is not necessary in cases with coexisting macular hole and submacular hemorrhage. The submacular hemorrhage can be displaced using air or gas, and the bubble can be used to tamponade the macular hole.

Singh RP, Sears JE. · Retina Service, Cole Eye Center, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. · Am J Ophthalmol. · Pubmed #16815269 No free full text.

Abstract: PURPOSE: To report two cases of retinal pigment epithelium (RPE) tears following intravitreal pegaptanib injections for occult choroidal neovascularization. DESIGN: Noncomparative case series. METHODS: The charts of two patients with pigment epithelial tears after receiving intravitreal pegaptanib were reviewed. Approval from the institutional review board and informed consent were obtained before chart review. Fundus photos, intravenous fluorescein angiograms, and optical coherence tomography (OCT) were obtained before and after therapy confirmed the diagnosis. RESULTS: Two patients had turbid pigment epithelial detachments (PEDs) and occult choroidal neovascular membranes (CNVMs) treated with intravitreal pegaptanib. Both patients developed RPE tears weeks following one intravitreal pegaptanib injection. CONCLUSIONS: This report describes the development of RPE tears after intravitreal pegaptanib injection. Caution should be taken in cases of turbid pigment epithelial detachments in the monocular patient when treatment with intravitreal pegaptanib is entertained. Future studies should be performed to evaluate which subtypes of lesions are most susceptible to this devastating visual complication.

Singh RP, Patel C, Sears JE. · Vitreo-retinal Service, Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA. · Br J Ophthalmol. · Pubmed #16547320 links to  free full text

Abstract: BACKGROUND/AIMS: Recent studies on the treatment of acute subretinal macular haemorrhage have shown that the volume of the clot and the time to evacuation have strong prognostic factors for visual outcome. A novel technique for surgical evacuation of these lesions involves direct injection of tissue plasminogen activator (t-PA) into the haematoma using pars plana vitrectomy. The aim of this study was to evaluate the clinical outcomes of this recently described procedure. METHODS: 17 consecutive patients with subretinal macular haemorrhages caused by age related macular degeneration were enrolled. Patient demographics, acuities, and fluorescein angiograms were obtained for all evaluations. All patients underwent complete three port pars plana vitrectomy to enable direct cannulation of the subretinal space and injection of 48 mug of t-PA, partial fluid-air exchange, 1 hour face up supine positioning postoperatively, followed by upright positioning overnight. RESULTS: 88% of patients within the study had stabilisation or improvement of visual acuity. Nine patients had total clearing of the macular haemorrhage and eight patients had subtotal clearing. Two patients had recurrence of the haemorrhage after the procedure and one patient underwent repair for retinal detachment. Occult lesions demonstrated similar outcomes to classic or predominately classic lesions. Nine patients required no therapy after the study to treat subfoveal neovascularisation. CONCLUSIONS: This study represents one of the largest case series to date showing that direct injection of subretinal t-PA with air-fluid exchange only and no intraoperative clot lysis period can have favourable results.

Cahill MT, Kaiser PK, Sears JE, Fekrat S. · Duke University Eye Center, Erwin Road, PO Box 3802, Durham, NC 27710, USA. · Br J Ophthalmol. · Pubmed #14609825 links to  free full text

Abstract: BACKGROUND: Arteriovenous (AV) sheathotomy, a potential treatment for branch retinal vein occlusion (BVO), surgically separates retinal vessels at an AV crossing. Relief of the aetiological obstruction, with resolution of cystoid macular oedema (CMO), may result in improved visual acuity. METHODS: A retrospective review of consecutive cases of AV sheathotomy for BVO was undertaken. Eyes were categorised as having resolution (group 1), reduction (group 2), or persistence (group 3) of CMO. Intergroup comparisons were made with regard to preoperative, intraoperative, and postoperative parameters. Preoperative and postoperative visual acuities were compared within each group. RESULTS: Of the 27 eyes identified, eight (29.6%) had resolution, 14 (51.8%) had reduction, and five (18.6%) had persistence of CMO. Median preoperative visual acuity was similar in all groups (1.0, 1.0, 1.3, respectively; p = 0.29). Overall median follow up was 12.0 months (Q1 = 12.0, Q2 = 22.5). Eyes in group 1 had significantly better median postoperative visual acuity than eyes in groups 2 and 3 (0.6, 1.0, 2.0 respectively; p = 0.01). A significantly higher proportion of eyes in group 1 had visual acuity improvement compared with eyes in the other groups (87.5% v 35.7% and 20.0%; p = 0.03). Median postoperative visual acuity was significantly better than median preoperative visual acuity in group 1 eyes only (p = 0.02). A higher percentage of group 1 eyes had evidence of postoperative retinal perfusion (83.0% v 21.43% and 40.0%; p = 0.16). Postoperative retinal detachment occurred in three eyes (11.1%). CONCLUSION: Complete resolution of CMO after AV sheathotomy occurred in one third of patients, and postoperative vision improved significantly in this group. However, in the majority of cases, despite an improvement in CMO, there was no improvement in vision after AV sheathotomy.

Moshfeghi DM, Kaiser PK, Grossniklaus HE, Sternberg P, Sears JE, Johnson MW, Ratliff N, Branco A, Blumenkranz MS, Lewis H. · Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. · Am J Ophthalmol. · Pubmed #12614752 No free full text.

Abstract: PURPOSE: To report the clinicopathologic findings after submacular removal of choroidal neovascular membranes (CNV) treated with verteporfin ocular photodynamic therapy. DESIGN: Interventional case series. METHODS: Retrospective review of eight eyes of eight patients who underwent submacular surgery for CNV after having previously received verteporfin ocular photodynamic therapy for presumed ocular histoplasmosis (one patient), age-related macular degeneration ([AMD] three patients) pathologic myopia (two patients), punctate inner choroiditis (one patient), and idiopathic CNV (one patient). All cases had undergone ocular photodynamic therapy with verteporfin using standard protocols. Six of eight patients suffered a submacular hemorrhage after ocular photodynamic therapy, and two of eight patients refused further ocular photodynamic therapy. All patients subsequently had submacular surgery with removal of the CNV. One membrane was routinely processed, sectioned, and stained with hematoxylin and eosin. Five membranes were stained with toluidine blue for light microscopic examination. Semithin (1.0 microm) sections were cut and stained with uranyl acetate-lead citrate for transmission electron microscopy. RESULTS: Choroidal neovascular membranes were removed at 3 days (presumed ocular histoplasmosis), 29 days (punctate inner choroiditis), 63 days (AMD, pathologic myopia), 66 days (AMD), 107 days (pathologic myopia), 116 days (AMD), and 152 days (idiopathic) after verteporfin ocular photodynamic therapy. Histopathologic and ultrastructural examination showed areas of vascular occlusion at 3 days that were not seen at later time points. All specimens had patent CNV. There were signs of vascular damage with extravasated erythrocytes and fibrin, pigment clumping in cells, and inflammatory cells in all but the 3-day specimen.CONCLUSIONS: This case series presents data only from patients who refused repeat treatment with ocular photodynamic therapy or who developed submacular hemorrhage after initial photodynamic therapy. Histopathologic evaluation of CNV 3 days after verteporfin ocular photodynamic therapy showed partial vascular occlusion that was not present in later specimens. These later specimens demonstrated evidence of vascular damage. Verteporfin ocular photodynamic therapy does not appear to lead to permanent and complete occlusion of the CNV. Thus, treatments that lead to permanent closure of CNV without damage to the retinal pigment epithelium and sensory retina are still needed.

Sears JE, Aaberg TA, Daiger SP, Moshfeghi DM. · Cole Eye Institute, 9500 Euclid Avenue Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. · Am J Ophthalmol. · Pubmed #11704030 No free full text.

Abstract: PURPOSE: To report the phenotype and genotype of a splice site mutation at intron 2 of the peripherin/RDS gene in four half-siblings with pattern dystrophy of the retina. DESIGN: Experimental study. METHODS: In four siblings with a common mother and three separate fathers, complete ophthalmic examination, pedigree, electrophysiologic testing, and fluorescein angiography studies were obtained. Genomic DNA from serum lymphocytes was isolated and used as a template for primers specific for the cone homeobox gene (CRX), rhodopsin (RHO), and peripherin/RDS genes to conduct single stranded conformational analysis and cycle sequencing. RESULTS: The pedigree of four affected siblings suggested probable autosomal dominance transmission of pattern dystrophy. In the four siblings, best corrected visual acuity ranged from 20/20 to 20/80 by Snellen chart. Clinical findings included discrete, localized degenerative changes of the macular retinal pigment epithelium in all patients, with subclassification foveal. One patient exhibited pigment clumping within the atrophic areas. Another patient exhibited yellow flecks diffusely in the macula. Fluorescein angiographic findings included central hypofluorescence with a surrounding rim of hyperfluorescence that corresponded to the observed fundus lesions and window defects. There was a range of electroretinography (ERG) and electrooculography (EOG) findings. One patient demonstrated both cone and rod dysfunction on ERG testing and another demonstrated decreased rod function. EOG testing was normal in two patients and mildly diminished in one patient. DNA sequencing identified a point mutation in intron 2 of the peripherin/RDS gene, consisting of an A to T change at 1068+3, present in all four affected patients. CONCLUSIONS : Four siblings with pattern dystrophy of the retina presented a splice site mutation in the peripherin/RDS gene.

Kaiser PK, Riemann CD, Sears JE, Lewis H. · Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA. · Am J Ophthalmol. · Pubmed #11162978 No free full text.

Abstract: PURPOSE: To review the clinical, photographic, fluorescein angiographic, and optical coherence tomographic findings in patients with the diabetic macular traction and edema (DMTE) associated with posterior hyaloidal traction (PHT). METHODS: We performed a prospective review of nine eyes of nine patients with diabetic macular edema (DME) and PHT on clinical examination. The patients had a comprehensive ophthalmic history and examination, color photographs, fluorescein angiography, and optical coherence tomography (OCT). RESULTS: All patients had diabetic retinopathy and DME. Of the nine eyes, eight patients had previous focal or grid photocoagulation. All nine eyes had a thickened, taut, glistening posterior hyaloid on clinical biomicroscopic examination with no posterior vitreous separation. Fluorescein angiography was performed on seven eyes, and all had early hyperfluorescence with deep, diffuse, late leakage in the macular area consistent with DMTE associated with PHT. Optical coherence tomography scans of the macular region revealed retinal thickening in all eyes with a mean retinal thickness of 556.9 +/- 114.7 microns. In addition, eight of the nine eyes had a shallow macular traction detachment associated with PHT. CONCLUSION: Eyes with DME associated with PHT may have a shallow, subclinical, macular detachment. Optical coherence tomography may be useful in evaluating patients with DME to see if a macular detachment is present.