Search

• Of 217 patients in whom anterior ischemic optic neuropathy (AION) was diagnosed during the period from 1975 to 1985, verifiable medical information was obtained for 212 (98%). Over a median follow-up period of three years, no group of patients had an increased mortality rate over that of age-, sex-, and race-matched controls; however, patients with "idiopathic" AION and patients with systemic hypertension who developed nonarteritic AION had a statistically significant increased risk of experiencing cerebrovascular events and myocardial infarctions compared with appropriately matched control groups. In view of the findings of our study, we suggest that patients with idiopathic AION and hypertensive patients who develop nonarteritic AION undergo a complete physical examination, cardiac evaluation, tests of carotid artery patency, and careful medical follow-up to attempt to prevent subsequent cerebrovascular or cardiovascular events.

• We determined the visual prognosis of 94 eyes in 92 patients having (1) agerelated macular degeneration, (2) a discrete choroidal neovascular membrane directly under the center of the foveal avascular zone (subfoveal), and (3) an initial visual acuity of 20/100 or better. Of the patients who were reexamined 24 months following their initial presentation, 77% had lost at least four lines of vision and 64% had lost at least six lines. Estimation of visual loss using a conservative assessment procedure showed four-line visual loss in 65% of the patients and six-line loss in 50%. In general, the better the visual acuity at the initial examination, the more likely the patient was to have a smaller choroidal neovascular membrane. These results suggest that it may be reasonable to consider a randomized clinical trial of laser photocoagulation for this group of patients with a relatively poor visual prognosis.

• A 55-year-old man with the acquired immunodeficiency syndrome had cytomegalovirus (CMV) retinitis develop in his left eye. The patient declined treatment with ganciclovir but elected to be treated with zidovudine. Two months later his CMV retinitis regressed, and it remained inactive for a total of 9 months. The most likely explanation was zidovudine-mediated improvement in the patient's immune function with subsequent suppression of the CMV retinitis in the left eye. The patient ultimately and preterminally had CMV retinitis develop in his right eye. He subsequently died and his eyes were examined at autopsy. Active CMV retinitis lesions were noted in the right eye while inactive scars were noted in the left eye. Immunoperoxidase staining and in situ hybridization studies demonstrated the presence of CMV in the right eye but not in the left eye. While ganciclovir remains the treatment of choice for CMV retinitis, zidovudine treatment may have a beneficial effect on CMV retinitis in some patients.

• We prospectively examined the eyes of 120 patients with leukemia. Only 38% of patients had normal results of examination. Leukemic infiltrates were present in 3% of patients, other findings related to leukemia were seen in 39% of patients, and 20% of patients had unrelated abnormalities. Visual loss was seen in at least 5% of the patients in this study.

PURPOSE: To evaluate the use of digital indocyanine green videoangiography in patients with clinical and fluorescein angiographic evidence of "occult" choroidal neovascularization in age-related macular degeneration and to investigate indocyanine green videoangiography-guided laser photocoagulation as a therapeutic approach. METHODS: Three hundred forty-seven consecutive patients with exudative age-related macular degeneration and symptoms and clinical manifestations of occult choroidal neovascularization were studied with indocyanine green videoangiography. Patients were selected for laser treatment, using conventional guidelines, when indocyanine green videoangiography demonstrated a well-delineated area of hyperfluorescence, presumed to be a focal area of choroidal neovascularization. RESULTS: Seventy-nine (23%) of 347 eyes were found to have a localized and definable lesion that was potentially amenable to laser photocoagulation therapy; 44 (56%) of these 79 treated eyes had complete resolution of their exudative manifestations. Visual acuity improvement was noted in 10 (13%) of 79 eyes, and stabilization of vision achieved in 42 eyes (53%). CONCLUSION: Laser photocoagulation treatment guided by indocyanine green videoangiography was shown to produce promising anatomical and visual improvement in a small number of patients with occult choroidal neovascularization secondary to age-related macular degeneration. This pilot study warrants further research to investigate the efficacy and safety of this form of treatment.

PURPOSE: Digital indocyanine green videoangiography (ICG-V) was used to study recurrent choroidal neovascularization (CNV) in patients with the clinical and fluorescein angiographic findings indicative of ill-defined, or recurrent occult, CNV (RO-CNV). The use of ICG-V-guided laser caphotocoagulation as an alternative form of treatment was also investigated when a well-delineated area of CNV was imaged with this technique. METHODS: A consecutive series of 66 patients were studied who presented with exudative age-related macular degeneration and symptoms and clinical manifestations of recurrent CNV in which fluorescein angiography did not reveal classic, or well-defined, neovascularization. Patients were selected for laser treatment based on conventional guidelines if ICG-V imaged a well-delineated area of recurrent CNV. RESULTS: Indocyanine green videoangiography showed late staining that was consistent with recurrent CNV in 64 (97%) of these 66 patients with RO-CNV. Twenty-nine (44%) of the 66 were eligible for laser treatment, and 18 (62%) of these 29 patients experienced successful anatomic and visual results, which were defined as resolution of the exudative manifestations and improvement or stabilization (±1 line on a Snellen chart) of vision. CONCLUSIONS: This pilot study suggests that ICG-V is of value in imaging patients with RO-CNV after laser photocoagulation for CNV secondary to age-related macular degeneration. Laser treatment of RO-CNV with ICG-V guidance may be successful both anatomically and functionally in a promising number of these otherwise untreatable cases. Further studies are necessary to validate these preliminary findings.

In some cases of occult choroidal neovascularization (CNV) visualized with fluorescein angiography, indocyanine green videoangiography (ICGV) performed on an outpatient basis may identify distinct areas of ICG dye (Cardiogreen, Becton Dickinson, Cockeysville, Md) hyperfluorescence.1 A recent histopathologic report has confirmed the presence of CNV in an area of ICG hyperfluorescence (W. R. Green, MD, oral communication, December 1993); however, the precise clinical significance of these areas remains to be determined. Indocyanine green dye excitation and emission spectra occur in the nearinfrared range, thereby allowing improved penetration of fluorescence through intraocular pigments, fluid, or thin layers of hemorrhage.We describe herein a system that can be used to perform real-time intraoperative ICGV during subretinal surgery. This system may be used to identify CNV after removal of thick subretinal hemorrhage, to identify areas of CNV for potential excision or endolaser treatment, and to confirm the adequacy of surgical excision of CNV

IN REPLY. —Drs Ellenberger and Lavin have emphasized a major dilemma that also concerned us when we reported the results of our study. Our data indicate that while the general population has a risk of cerebral infarction that is less than 1% per year, a population of patients with nonarteritic AION seems to have a risk that is at least three times (3%) higher per year. Given these statistics, one must consider whether anything can be done to lower the risk of cerebral infarction in this (or any) group of patients. We certainly agree with Ellenberger and Lavin that not all vascular lesions that cause cerebrovascular attacks are treatable by endarterectomy, and we are, of course, aware of the controversy regarding the treatment itself. It is for this reason that we did not recommend either cerebral angiography or endorse endarterectomy in our article, even though in selected patients these procedures

Our article,1 published in the September 1992 issue of the Archives, was presented in part at the annual meeting of the American Academy of Ophthalmology (October 29 through November 2,1989, New Orleans, La) and was submitted to Ophthalmology, which did not accept it for publication. During a 1991 telephone conversation, two of the authors (D.R.G. and S.L.F.) agreed to submit a revised manuscript to the Archives. There were no changes in the data.Whereas in 1989, all four authors were living in Baltimore, Md, by 1991, the authors were living in four different cities. Because there had been no substantial changes in the manuscript to which all four authors had agreed 2 years earlier, the senior author submitted the revised manuscript to the Archives without prior review by two of the coauthors to expedite the submission and review process.After publication, one author (S.de B.) contended that, had he