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Dear Editor, Laser photocoagulation of the fovea is historically an accidental and sight-threatening complication rarely reported during routine treatment [1]. We present a case of inadvertent foveal laser photocoagulation during multi-spot Pascal macular grid laser. A 66-year-old woman presented with left branch retinal vein occlusion and non-resolving cystoid macular oedema (Fig. 1), and underwent macular laser treatment. Vision was 6/18, with an artificial fellow eye. The patient was comfortable during initial laser titration stages, using single-spot 10ms 100μm burns, (power 125mW;fluence 16 Joules/cm). Modified Pascal grid laser involved multispot arrays applied to the macula. During delivery of the first multi-spot array, the patient’s head moved suddenly away from the slit-lamp due to anxiety from the light flashes produced. Laser burns were inadvertently scattered across the foveal zone (Fig.1). Immediately postlaser, vision was 6/19. Routine fundus autofluorescence (AF) and OCT identified misdirected parafoveal burns, with a single burn overlying the anatomical fovea (Fig. 2). At day 3, vision was stable despite increased central retinal thickness (Fig. 1). Burns showed initial hyper-autofluorescence on serial AF, and the intraretinal hyper-reflectivity slowly resolved (Fig. 2) [2]. At 6 months, the anatomical foveal burn showed restoration of the inner and outer segment junction of the photoreceptors (Fig. 2). Vision was 6/9 and with barely-visible foveal burns (Fig. 1). Retrospective review of our laser logbook documented 3,932 Pascal laser procedures between 11 December 2006 and April 1 2011. Institutional Pascal auditing has not reported any operational or laser-related adverse events [3]. The prevalence of inadvertent foveal photocoagulation complication following Pascal is 0.025% (1/3,932) in our institution. The Pascal photocoagulator has safety mechanisms in place [4]. The inner row of Pascal spots is delivered in 132ms, theoretically below patients’ reaction time. Lowfluence 10–30ms pulse duration Pascal can minimize scarring [2, 5]. The foveal 10ms burns healed over time, with photoreceptor infilling and minimal retinal pigment epithelium damage [6]. After this case, we routinely advise patients pre-laser application about multi-spot Pascal light flashes. In borderline cases, single-spot laser strategies are recommended. Despite a potentially sight-threatening adverse event such as foveal photocoagulation, a pattern-spot laser system application of low fluence 10ms burns may not lead to long-term microstructural alterations on FD-OCT or visual complications. Funding support None

Background:\ud Retinitis Pigmentosa (RP) is a hereditary genetic disease causing bilateral retinal degeneration. RP is a leading cause of blindness resulting in incurable visual impairment and drastic reduction in the Quality of life of the patients. Second Sight Medical Products Inc. developed Argus II, a retinal prosthesis system for treating RP. Argus II is the world’s first ever-commercial implant intended to restore some vision in the blind patients. The objective of this study was to assess the cost-effectiveness of the Argus® II Retinal Prosthesis System (Argus II) in Retinitis Pigmentosa (RP) patients.\ud \ud Method:\ud A multi -state transition Markov model was developed to determine the cost-effectiveness of Argus II versus usual care in RP from the perspective of healthcare payer. A hypothetical cohort of 1000 RP patients aged 46 years followed up over a (lifetime) 25-year time horizon. Health outcomes were expressed as quality adjusted life years (QALYs) and direct healthcare costs expressed in 2012 €. Results are reported as incremental cost per ratios (ICERs) with outcomes and costs discounted at an annual rate of 3.5%.\ud \ud Results:\ud The ICER for Argus II was €14,603/QALY. Taking into account the uncertainty in model inputs the ICER was €14,482/QALY in the probabilistic analysis. In the scenarios of an assumption of no reduction on cost across model visual acuity states or a model time horizon as short as 10 years the ICER increased to €31,890/QALY and €49,769/QALY respectively.\ud \ud Conclusion:\ud This economic evaluation shows that Argus II is a cost-effective intervention compared to usual care of the RP patients. The lifetime analysis ICER for Argus II falls below the published societal willingness to pay of EuroZone countries.

Purpose. To explore the spatial distribution of central visual field loss in untreated proliferative diabetic retinopathy (PDR)and to quantify the effect of medium-pulse Optos-guided 20-millisecond Pascal laser treatment on the central field.Methods. Visual field data (Swedish Interactive Threshold Algorithm 24-2) from 99 eyes (66 patients) with treatment-naivePDR were used to train a self-organizing map (SOM) that classified the defects into nine patterns. Twenty-eight eyes of 23patients treated with 20-millisecond Pascal retinal laser photocoagulation underwent Optos widefield fundus fluoresceinangiography(WF-FFA)atbaselineand3monthsaftertreatment.PostlaserchangesinSOMpatternsandglobalindiceswereanalyzed.Visualfielddefectchanges(TotalDeviation[TD])witheccentricityandextentofinitiallosswereanalyzed.Gradingof WF-FFA after laser was undertaken by two masked retina specialists.Results. At baseline, 44.4% of PDR eyes showed early visual field loss patterns (1 to 3), with 23.2% classified into theadvanced patterns (7 to 9). Mild SOM patterns had more superior hemifield field defects, whereas advanced patterns in-volved both superior and inferior hemifield field loss. After laser, a significant shift to early SOM patterns were observed(p=0.02),aswellasimprovementofMeanDeviationandPatternStandardDeviation(p=0.003andp=0.06,respectively).Improvement of TD was commonly observed in test locations of 0 to 10, 10 to 20, and 20 to 30 degrees. Greater im-provement was observed with deeper baseline TD (p G 0.001). Masked WF-FFA image grading showed 78.6% PDRregression.Conclusions. The SOM method is a promising technique to classify and monitor over time PDR-associated visual fielddefects. Medium-pulse Optos-guided 20-millisecond Pascal laser treatment improved the spatial patterns and global pa-rameters of central field defects.(Optom Vis Sci 2014;91:111Y120)Key Words: laser photocoagulation, self-organizing mapping, proliferative diabetic retinopathy, visual field, perimetry

AIMS—To determine the prevalence of polypoidal choroidopathy in consecutive patients presenting with large haemorrhagic and exudative neurosensory retinal and retinal pigment epithelial detachments (PEDs) of over 2 mm in diameter in the absence of drusen. METHODS—40 patients were identified over a 5 month period of which 29 had haemorrhagic detachments, and 11 had purely exudative detachments. All had indocyanine green (ICG) angiography, and the presence was sought of large blood vessels in the choroid associated with localised dilated terminals that filled slowly and leaked ICG. RESULTS—In 34 cases (85%) there was an appearance consistent with previous descriptions of idiopathic polypoidal choroidal vasculopathy. Of the six without polypoidal lesions the disorder was attributed to choroidal neovascularisation in four, chorioretinitis in one, and a fibrovascular PED in one. Of those with polypoidal lesions 20 (65%) were female, the mean age was 65.4 years (range 44-88), and 25 (74%) were white, seven (20%) black, and two (6%) east Asian. Eight had a history of hypertension. Visual acuity varied from 6/6 to counting fingers in the involved eye (mean 6/24). Bilateral polypoidal choroidal lesions were demonstrated in 16 patients (47%). The predominant location for these lesions was the macular region in 23 patients (68%). Polypoidal vasculopathy was found in 16 patients (47%) who had a previous diagnosis of age related macular disease (AMD). No patients had evidence of intraocular inflammation. CONCLUSIONS—In a largely white patient population a high proportion of patients with haemorrhagic and exudative PEDs has evidence of polypoidal lesions on ICG angiography.

Aim To describe the in vivo spatial and morphological vitreoretinal relationships associated with diabetic retinal neovascularisation using Fourier-domain optical coherence tomography (FD-OCT). Methods Qualitative assessment of macula, retina and optic disc head FD-OCT (Topcon 3D OCT-1000) imaging of patients with treatment-naive and laser-treated proliferative diabetic retinopathy (PDR). The morphology and plane of retinal neovascularisation at the disc (NVD) and elsewhere in the retina (NVE) were examined, and the posterior vitreous relationships were evaluated. The FD-OCT characteristics of clinical versus subclinical PDR disease were correlated with conventional and wide-field Optos fundus fluorescein angiography. Results 50 eyes of 50 patients were evaluated in this retrospective study. Retinal neovascularisation appears as a hyper-reflective complex, with NVE arising from inner retina with disruption through the internal limiting membrane to attach to the posterior hyaloid surface. FD-OCT detected subclinical hyper-reflective NVD complexes that were subvisible on colour fundus imaging. We describe retinoschisis, vitreoretinal adhesions and pegs, zones of separation, and intraretinal tractional elements in untreated PDR patients using high resolution FD-OCT. Conclusions FD-OCT can non-invasively characterise retinal and optic nerve head neovascular complexes at different stages of the proliferative disease process. In clinical practice, FD-OCT can monitor the in vivo serial changes of retinal neovascularisation over time.

Purpose This study evaluated the Argus II Retinal Prosthesis System (Second Sight Medical Products, Inc., Sylmar, CA) in blind subjects with severe outer retinal degeneration. Design Single-arm, prospective, multicenter clinical trial. Participants Thirty subjects were enrolled in the United States and Europe between June 6, 2007, and August 11, 2009. All subjects were followed up for a minimum of 6 months and up to 2.7 years. Methods The electronic stimulator and antenna of the implant were sutured onto the sclera using an encircling silicone band. Next, a pars plana vitrectomy was performed, and the electrode array and cable were introduced into the eye via a pars plana sclerotomy. The microelectrode array then was tacked to the epiretinal surface. Main Outcome Measures The primary safety end points for the trial were the number, severity, and relation of adverse events. Principal performance end points were assessments of visual function as well as performance on orientation and mobility tasks. Results Subjects performed statistically better with the system on versus off in the following tasks: object localization (96% of subjects), motion discrimination (57%), and discrimination of oriented gratings (23%). The best recorded visual acuity to date is 20/1260. Subjects' mean performance on orientation and mobility tasks was significantly better when the system was on versus off. Seventy percent of the patients did not have any serious adverse events (SAEs). The most common SAE reported was either conjunctival erosion or dehiscence over the extraocular implant and was treated successfully in all subjects except in one, who required explantation of the device without further complications. Conclusions The long-term safety results of Second Sight's retinal prosthesis system are acceptable, and most subjects with profound visual loss perform better on visual tasks with system than without it. Financial Disclosure(s) Proprietary or commercial disclosure may be found after the references.

AIMS: To quantify the 20-ms Pattern Scan Laser (Pascal) panretinal laser photocoagulation (PRP) ablation dosage required for regression of proliferative diabetic retinopathy (PDR), and to explore factors related to long-term regression. METHODS: We retrospectively studied a cohort of patients who participated in a randomised clinical trial, the Manchester Pascal Study. In all, 36 eyes of 22 patients were investigated over a follow-up period of 18 months. Primary outcome measures included visual acuity (VA) and complete PDR regression. Secondary outcomes included laser burn dosimetry, calculation of retinal PRP ablation areas, and effect of patient-related factors on disease regression. A PDR subgroup analysis was undertaken to assess all factors related to PDR regression according to disease severity. RESULTS: There were no significant changes in logMAR VA for any group over time. In total, 10 eyes (28%) regressed after a single PRP. Following top-up PRP treatment, regression rates varied according to severity: 75% for mild PDR (n=6), 67% for moderate PDR (n=14), and 43% in severe PDR (n=3). To achieve complete disease regression, mild PDR required a mean of 2187 PRP burns and 264 mm(2) ablation area, moderate PDR required 3998 PRP burns and area 456 mm(2), and severe PDR needed 6924 PRP laser burns (836 mm(2); P

Sir, Entecavir (Baraclude, Bristol-Myers Squibb, Princeton, NJ, USA) is a nucleoside analogue used to treat chronic hepatitis B virus infection.1 We report a case of presumed ocular toxicity and significant visual loss in a patient with chronic hepatitis B infection treated with entecavir.

PURPOSE To investigate the effects of panretinal photocoagulation (PRP) on macular thickness and macular nerve fiber layer thickness in eyes with proliferative diabetic retinopathy. METHODS Single-center, randomized clinical trial (n = 40 eyes). Proliferative diabetic retinopathy was treated with 1,500 burns given as Pascal 20-millisecond single-session PRP (SS-PRP) or as multiple-session PRP (100 milliseconds, MS-PRP) over a 4-week period. The main outcome measures included optical coherence tomography measurements of total retinal thickness and nerve fiber layer at the macula, visual acuity, and proliferative diabetic retinopathy regression and were recorded at baseline, 4 weeks, and 12 weeks. Optic disk photographs were graded by masked a glaucoma specialist. RESULTS At 12 weeks, in the SS-PRP group, there was no significant change in total nerve fiber layer thickness from baseline (4 weeks; +7.2 μm, P = 0.78; 12 weeks, -1.8 μm, P = 0.95). There was a significant increase in total retinal thickness for the MS-PRP group at 4 weeks from baseline (96 ± 17 μm; P < 0.001) and at 12 weeks (56 ± 21 μm; P = 0.0167). After 4 weeks in the MS-PRP group, total nerve fiber layer thickness increased significantly by 31 ± 54 μm (P = 0.029) from baseline, with a significant reduction at 12 weeks from baseline (35 ± 63 μm; P = 0.034). There was no change among groups for optic nerve appearance postlaser. At 12 weeks, the mean visual acuity was 81 ± 6 letters (SS-PRP group), compared with 77 ± 15 letters in the MS-PRP group (95% confidence interval, 5.2 to 9 letters; P = 0.286). For the SS-PRP group, a positive effect on proliferative diabetic retinopathy regression was observed in 74% of eyes compared with 53% of the eyes in the MS-PRP group (P = 0.31). CONCLUSION Compared with 20-millisecond SS-PRP, eyes treated with conventional 100-millisecond single-spot delivered over multiple sessions showed increased total macular thickness at 4 weeks, with a thinning of macular nerve fiber layer at 12 weeks.

PURPOSE.To correlate in vivo spatial and spectral morphologic changes of short- to long-pulse 532 nm Nd:YAG retinal laser lesions using Fourier-domain optical coherence tomography (FD OCT), autofluorescence (AF), fluorescein angiography (FA), and multispectral imaging. METHODS.Ten eyes with treatment-naive preproliferative or proliferative diabetic retinopathy were studied. A titration grid of laser burns at 20, 100, and 200 milliseconds was applied to the nasal retina and laser fluence titrated to produce four grades of laser lesion visibility: subvisible (SV), barely visible (BV, light-gray), threshold (TH, gray-white), and suprathreshold (ST, white). The AF, FA, FD-OCT, and multispectral imaging were performed 1 week before laser, and 1 hour, 4 weeks, and 3 and 6 months post-laser. Multispectral imaging measured relative tissue oxygen concentration. RESULTS.Laser burn visibility and lesion size increased in a linear relationship according to fixed fluence levels. At fixed pulse durations, there was a semilogarithmic increase in lesion size over 6 months. At 20 milliseconds, all grades of laser lesion were reduced significantly in size after 6 months: SV, 51%; BV, 54%; TH, 49%; and ST, 50% (P!0.001), with retinal pigment epithelial proliferation and photoreceptor infilling. At 20 milliseconds, there was healing of photoreceptor inner segment/ outer segment junction layers compared with 100- and 200millisecond lesions. Significant increases in mean tissue oxygenation (range, four to six units) within the laser titration area and in oxygen concentration across the laser lesions (P! 0.01) were detected at 6 months. C ONCLUSIONS.For patients undergoing therapeutic laser, there may be improved tissue oxygenation, higher predictability of burn morphology, and more spatial localization of healing responses of burns at 20 milliseconds compared with longer pulse durations over time. (Invest Ophthalmol Vis Sci.2011; 52:994‐1002) DOI:10.1167/iovs.10-6309

In this prospective study, the authors report fourier-domain optical coherence tomography (FD-OCT) imaging of gas–inner retinal tamponade following surgery for full-thickness macular hole and evaluate postoperative posturing based on FD-OCT findings. Patients underwent FD-OCT 1 day after pars plana vitrectomy, internal limiting membrane peel, and gas injection. Three-dimensional FD-OCT and high-resolution line scans demonstrated gas–inner retinal tamponade across the macula with the apex of tamponade located at the fovea. Inner and outer retina landmarks could be accurately identified along the curvature of the eye using FD-OCT in x-, y-, and z-planes. No patients required face-down positioning postoperatively based on FD-OCT findings. Satisfactory gas–inner retinal tamponade with 75% fill of any gas agent in the upright position was observed. Full-thickness macular hole closure was successful in 90% at 1 day, 2 weeks, and 12 weeks postoperatively. These FD-OCT findings may support decisions to not require face-down positioning postoperatively.

To evaluate pain responses following Pascal 20 ms multi-spot and 100 ms single-spot panretinal photocoagulation (PRP).Single-centre randomised clinical trial. 40 eyes of 24 patients with treatment-naive proliferative diabetic retinopathy randomised to 20 and 100 ms PRP under topical 0.4% oxybuprocaine. A masked grader used a pain questionnaire within 1 h (numerical pain score (NPS)) and 1 month after treatment (numerical headache score (NHS)). Primary outcome measure was NPS immediately post-PRP. Secondary outcome measures were mean NHS scores and levels of photophobia reported within 4 weeks of primary PRP.Mean laser fluence was significantly lower using 20 ms PRP (4.8 J/cm²) compared to 100 ms PRP (11.8 J/cm²); p0.001). Mean NPS scores for treatment were 2.4 (2.3) (mild) for 20 ms PRP group compared to 4.9 (3.3) (moderate) in 100 ms PRP group-a significant difference (95% CI 4.3 to 0.68; p = 0.006). Mean NHS score within 1 month was 1.5 (2.7) in 20 ms PRP group compared to 3.2 (3.5) in the 100 ms PRP group (p0.05). The median duration of photophobia after 20 ms PRP was 3 h, and significantly less compared to 100 ms PRP after which 72 h of photophobia was reported (p0.001).Multi-spot 20 ms PRP was associated with significantly lower levels of anxiety, headache, pain and photophobia compared to 100 ms single-spot PRP treatment. Possible reasons include lower fluence, shorter-pulse duration, and spatial summation of laser nociception with multi-spot Pascal technique.

To investigate the effects of pattern scanning laser (Pascal; OptiMedica, Santa Clara, California) multispot panretinal photocoagulation given in a single-session (SS-PRP) vs single-spot multiple-session PRP (MS-PRP) on proliferative diabetic retinopathy (PDR).Single-center, randomized clinical trial of 40 eyes. Proliferative diabetic retinopathy was treated with a 400-mum spot size in 1500 burns given either as Pascal in 20-millisecond SS-PRP or in 3 sessions (100-millisecond MS-PRP) during a 4-week period. Visual acuity, central subfield retinal thickness (CRT), and 24-2 Swedish interactive thresholding algorithm visual fields were recorded at baseline and 4 and 12 weeks.Central subfield retinal thickness, mean deviation, and PDR grade at 12 weeks.There was a significant increase in mean CRT with MS-PRP (22 mum at 4 weeks, 95% CI, -32.25 to -10.75; 20 mum at 12 weeks, 95% CI, -28.75 to -10.82; P.001) and no significant increase in the SS-PRP group. The mean deviation increased significantly in the SS-PRP group after 4 weeks (0.73 dB, P = .048), with no significant changes in either group at other points. A positive effect on PDR was observed in 74% of eyes in the SS-PRP group vs 53% in the MS-PRP group (P = .31). Mean treatment time for SS-PRP was 5.04 minutes (SD, 1.5 minutes) compared with 59.3 (SD, 12.7 minutes) in the MS-PRP group (P.001).There were no adverse outcomes (CRT, visual acuity, or visual field) from using multispot SS-PRP vs single-spot MS-PRP at 12 weeks postlaser, and treatment times were significantly shorter for multispot SS-PRP. Pascal SS-PRP was as effective as MS-PRP in the treatment of PDR.Twenty-millisecond Pascal SS-PRP may be safely and rapidly performed in 1500 burns with a similar efficacy to conventional MS-PRP. TRIAL IDENTIFIER: Research and Development Office PIN R00037, Central Manchester University Hospitals Foundation Trust.

To establish safe laser parameter standards for 10-30 ms Pascal(®) laser in clinical practice and to evaluate clinical and visual outcomes using this 532-nm multi-spot photocoagulation system.Retrospective observational case series of 313 patients treated between 2006 and 2008. Evaluation of eight groups: A - panretinal photocoagulation (PRP) for proliferative diabetic retinopathy (PDR); B - focal laser treatment for clinically significant diabetic macular oedema; C - grid laser for diffuse diabetic macular oedema; D - sector PRP for ischaemic branch retinal vein occlusions (I-BRVO); E - full PRP for ischaemic central retinal vein occlusions (I-CRVO); F - macular laser treatment for macular oedema secondary to non-ischaemic BRVO; G - full PRP for rubeosis iridis and/or neovascular glaucoma (NVG) secondary to I-BRVO, I - CRVO or PDR; H - laser retinopexy for retinal breaks/degenerations.Mean LogMAR visual acuity for all procedures improved postlaser (p = 0.065), and laser prevented visual loss in 85% eyes. Topical anaesthesia was only required. At mean follow-up of 5 months, 72% procedures had a successful clinical outcome. Significantly higher powers were required for PRP using Pascal(®) compared to conventional laser (p = 0.001) in PDR, I-BRVO, I-CRVO and NVG. Sixty-seven per cent of patients (15/20) were successfully treated with single-session 20-ms PRP using a mean 1952 burns. There were no laser-associated adverse effects or ocular complications associated with multi-spot PRP or macular Pascal(®) arrays.The clinical efficacy using 10- to 30-ms pulse duration Pascal(®) laser is comparable to conventional standard protocols used for the treatment of vascular retinal disorders. Higher power, 10- to 30-ms pulse duration laser may be safely and effectively used in clinical practice.

Aim: To report the evolution of pattern scanning laser (Pascal) photocoagulation burns in the treatment of diabetic retinopathy, using Fourier-domain optical coherence tomography (FD-OCT) and fundus autofluorescence (AF), and to evaluate these characteristics with clinically visible alterations in outer retina (OR) and retinal pigment epithelium (RPE). Methods: Standard red-free and colour fundus photography (FP), FD-OCT, and fundus camera-based AF were performed in 17 eyes of 11 patients following macular and panretinal photocoagulation (PRP). Results: One hour following Pascal application, visibility of threshold burns on FP was incomplete. AF enabled visualisation of complete treatment arrays at 1 h, with hypoautofluorescence at sites of each laser burn. AF signals accurately correlated with localised increased optical reflectivity within the outer retina on FD-OCT. AF signals became hyperautofluorescent at 1 week, and corresponded on FD-OCT to defects at the junction of the inner and outer segments of the photoreceptors (JI/OSP) and upper surface of RPE. A 10 ms macular laser pulse produced a localised defect at the level of JI/OSP and RPE. Macular and 20 ms PRP burns did not enlarge at 1 year’s and 18 months’ follow-up respectively. Conclusions: We report the in vivo spatial localisation and clinical correlation of medium-pulse Pascal photocoagulation burns within outer retina and RPE, using high-resolution FD-OCT and AF. Ophthalmoscopically invisible and threshold Pascal burns may be accurately localised and mapped by AF and FD-OCT, with monitoring over time.

Involvement of the orbit and posterior segment of the eye in early-onset sarcoidosis may necessitate prompt and aggressive immunosuppressive treatment to prevent a poor visual outcome.

TOPIC/PURPOSE: To assess the clinical usefulness and relevance of indocyanine green angiography (ICG) in the investigation of chorioretinal disorders and assess specifically in what conditions it may add useful information to that obtained using standard fluorescein angiography.Many publications on ICG have appeared in recent years touting its use in ophthalmology. These publications have led to increasing use of this technique and to its application in numerous retinal diseases in which the fluorescein angiographic findings have been thoroughly described.During this systematic literature review, we identified and reviewed a total of 376 articles, from among which we selected 92 that we considered most relevant to our purpose of evaluating published evidence as to the efficacy of ICG. We excluded many articles with weak study designs and those that simply duplicated previously published information. Our literature search used PubMed and was confined to articles in English or that included an English abstract.Our systematic review suggests that ICG has relatively few specific indications for use as justified by previously published peer-reviewed studies. In keeping with the requirements for this Journal's evidence-based articles, we have divided our clinical recommendations for the use of ICG into three categories: (A) strongly recommended and supported by strong evidence; (B) recommended with moderately strong supporting evidence; (C) not recommended at present because supported only by anecdotal or group consensus evidence. We highly recommended ICG for (1) identification of polypoidal choroidal vasculopathy, (2) occult choroidal neovascularization, (3) neovascularization associated with pigment epithelial detachments, and (4) recurrent choroidal neovascular membranes. These are all conditions in which ICG contributes to the identification of lesions that may be treatable. We recommend ICG with some enthusiasm for identifying feeder vessels in age-related macular degeneration, choroidal neovascular membranes, chronic central serous retinopathy, multiple evanescent white dot syndrome, vasculitis, acute multifocal placoid pigment epitheliopathy, Vogt-Koyanagi-Harada syndrome, macular lesions associated with angioid streaks, and birdshot retinopathy. In all these conditions, ICG may help establish a diagnosis and provide some useful guidance for therapy. At present, we do not recommend ICG for scleritis and posterior scleritis, drusen differentiation, Behçet's disease, or sarcoidosis, because it has not been demonstrated to add useful clinical information.ICG, although now a well established technique, has clear advantage over fluorescein angiography in relatively few chorioretinal disorders. It has, however, contributed to the understanding of pathologic processes in many ocular diseases. As yet, no published randomized controlled clinical trials show any benefit to the use of ICG in the management of any specific ocular disease.

To test the feasibility of a new surgical technique and to assess visual function over the translocated retinal pigment epithelium (RPE) cells in patients operated on for subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (ARMD).Retrospective, noncomparative, interventional case series.Nine patients with previously untreated exudative ARMD underwent surgical excision of the subfoveal CNV with RPE translocation and were observed for 12 to 32 months.The surgery consisted of a standard three-port pars plana vitrectomy, excision of the CNV, and RPE translocation. Pre- and postoperative ocular examination included best-corrected visual acuity measurement, fundus color stereo photography, and fundus fluorescein angiography. Optical coherence tomography and confocal laser scanning ophthalmoscopy (cLSO) were performed after surgery. A crossfixation target and a single-point flashing light were projected on different areas of the posterior pole using a cLSO. Photopic 10 to 2 perimetry, photopic fine matrix mapping, and cLSO microperimetry were also performed after surgery in six patients.Optical coherence tomography cross-sectional scans and cLSO RPE autofluorescence were recorded to detect the presence of viable translocated RPE. Visual acuity, fixation, photopic 10 to 2 perimetry, photopic fine matrix mapping, and cLSO microperimetry were used to test central visual function.Retinal pigment epithelium was translocated successfully at the time of CNV removal from the edge of the RPE defect to a subfoveal location in seven of nine patients. One patient experienced proliferative vitreoretinopathy, but significant hemorrhage was not a feature. Optical coherence tomography showed the translocated RPE as an area of increased optical reflectivity with optical shadowing external to it. Confocal laser scanning ophthalmoscopy showed autofluorescence of the translocated RPE. The crossfixation target was seen when projected on the translocated RPE. During eccentric fixation, the patients could see a flashing point-target projected on the translocated RPE. Photopic 10 to 2 perimetry, photopic fine-matrix mapping, and cLSO microperimetry showed the presence of central visual function.The authors propose that translocation of RPE at the time of CNV removal, from the edge of the RPE defect to a subfoveal location, may have a role in the surgical management of ARMD.

Purpose To image the cortical vitreous, determine the prevalence of the bursa premacularis and space of Martegiani, and measure the dimensions of the bursa using the new 1050-nm swept-source deep range imaging optical coherence tomography (DRI OCT-1 Atlantis). Design Retrospective cross-sectional study. Methods One hundred and nineteen consecutive patients (5-100 years) underwent an OCT scan using 1050-nm swept-source deep range imaging optical coherence tomography. Prevalence of the bursa premacularis and space of Martegiani and the stage of posterior vitreous detachment (PVD) were determined. The horizontal (width) and anteroposterior (depth) dimensions of the bursa were recorded along with the patient's age. Results A bursa was detected in 57.1% (136/238) of eyes. The bursa and space of Martegiani coexisted in 97.8% of eyes. Prevalence of detected bursa was 84.5% in eyes with either no PVD or perifoveal PVD only; the prevalence fell with further increases in the extent of PVD. Prevalence of detected bursa was 75.4% in patient group aged 0-60 years and 38% in the group aged 60-100 years. Mean width was 7001 μm (range: 3354-10 316 μm, SD: 1412 μm). Mean depth was 416 μm (range: 31-1189 μm, SD: 187 μm). Width and depth of the bursa did not correlate with age (R 2 width = 0.0316; R 2 depth = 0.0108). Bilateral bursa tended to be symmetrical in width but less so in depth (R 2 width = 0.63, P 2 depth = 0.33, P Conclusion Swept-source OCT has allowed us to demonstrate the almost invariable coexistence of the bursa premacularis and space of Martegiani. Swept-source OCT can image both in patients from as early as the first to as late as the tenth decade of life.

X linked retinoschisis (XLRS) is a frequent cause of macular dystrophy in males with an estimated prevalence of between 1 in 15 000 and 1 in 30 000. The diagnosis is based on the presence of central and peripheral schisis within the inner retina and supported by electroretinography, which shows a characteristic electronegative response to a bright flash in the dark-adapted state.1 Fundus related perimetry or microperimetry is a useful tool for assessing macular function and mapping central visual fields, scotomas and fixation behaviour.2 The MP-1 microperimeter (Nidek technologies, Padua, Italy) utilises an LCD microperimeter and allows a direct correlation of macular function with pathology. We present an observational study of nine patients (17 eyes) aged between 7.5 years and 20 years (median age 10 years) with XLRS who underwent …

Retinal pigment epithelial tear following intravitreal injection of bevacizumab (avastin ® ): optical coherence tomography and fluorescein angiographic findings

The safe and effective use of lasers in medicine and surgery requires that the operator understands the various interactions that occur when laser light is incident upon biological tissue. Incident laser radiation can be absorbed at the surface or the light energy can be absorbed throughout the bulk of the tissue with a distribution depending upon the degree of tissue transparency. When transmitted into deeper layers, the laser radiation will be redirected (Figure 3.1) by reflection and scattering. The relative contribution of each of these optical phenomena varies with the laser wavelength and the type of tissue.

Purpose To investigate the morphologic features and clinical efficacy of barely visible Pascal (Optimedica Corporation) photocoagulation burns in diabetic macular edema (DME) using Fourier-domain optical coherence tomography (FD OCT) and fundus autofluorescence (AF). Design Interventional case series. Methods Retrospective evaluation of 10 eyes with newly diagnosed DME that underwent barely visible Pascal photocoagulation using an array of 10-μm, 10-millisecond photocoagulation burns. FD OCT and camera-based AF was performed at baseline and at 1 hour, 2 weeks, 4 weeks, and 12 weeks after laser. Changes in retinal thickening after laser treatment were measured using retinal thickness maps within the treated sector and the central foveal subfield. Results At 1 hour after treatment, burns were visualized partially with clinical biomicroscopy. AF demonstrated spots lacking autofluorescence that confirmed effective laser uptake within the Pascal arrays. Sequential changes in hyperreflectivity on FD OCT correlated with morphologic alterations seen on AF. Burns became increasingly hyperautofluorescent between 2 and 4 weeks. There were significant reductions in the retinal thickness within treated sectors on FD OCT at 2 weeks (26 ± 32 μm; P = .012) and 3 months after laser (20 ± 21 μm; P = .02) compared with baseline. Clinical biomicroscopic reduction of DME was the most common finding in 80%. Conclusions Barely visible 10-millisecond Pascal laser seems to produce an effect at the level of the inner and outer photoreceptor segments and apical retinal pigment epithelium, with minimal axial and lateral spread of burns. FD OCT confirmed spatial localization of AF signal changes that correlated with laser burn–tissue interactions over 3 months. The technique of lower-fluence barely visible 10-millisecond laser may reduce retinal edema within affected sectors and effectively treat DME with minimization of scar formation.

To compare in vivo burn morphologic features and healing responses of Pascal 20- and 100-millisecond panretinal photocoagulation (PRP) burns in proliferative diabetic retinopathy.Prospective randomized controlled trial with 24 eyes assigned to either 20- or 100-millisecond Pascal PRP. Fundus autofluorescence and Fourier domain optical coherence tomography (FD-OCT) were performed 1 hour and 2 and 4 weeks after treatment. Main outcome measures included burn morphologic features on FD-OCT and greatest linear diameter (GLD) of laser burns as evaluated in 6 standard Early Treatment of Diabetic Retinopathy Study photographic fields using autofluorescence.The contemporaneous increase in autofluorescence is observed with increasing pulse duration. Differences in mean GLD between 100- and 20-millisecond burns were 63 mum at 1 hour and 198 mum at 4 weeks (P.001 for both). At 4 weeks, all burns corresponded to defects at the junction of inner and outer segments of photoreceptors (JI/OSP) and apical retinal pigment epithelium. After 4 weeks, the GLD of 20-millisecond burns reduced significantly by 35% (P.001), with no change in 100-millisecond burns.All burns initially appear as equivalent square-edged, columnar foci of hyperreflectivity in the outer retina. Pascal 20-millisecond burns progressively reduce in size, and this suggests a novel healing response localized to the JI/OSP and apical retinal pigment epithelium. The higher-fluence 100-millisecond burns develop larger defects due to thermal blooming and collateral damage.

The commonest cause of solar retinopathy is direct viewing of a solar eclipse.1 Other associations include sun gazing during religious rituals, drug or alcohol intoxication, and mental illness.2,,3 However, it may not be considered in the absence of a history of sun gazing. We report an unusual case of solar retinopathy in a patient with bipolar affective disorder and demonstrate the value of optical coherence tomography in aiding the diagnosis in cases of unexplained visual loss in patients with mental illness. A 45 year old woman presented complaining of a gradual deterioration in vision over 3 years. Past medical history included hypothyroidism and bipolar affective disorder treated with antidepressant and antipsychotic medication. Presenting visual acuities were 6/12 in the right eye and 6/9 …