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We recently encountered two patients who were referred to us with the diagnosis of cystoid macular edema and visual loss of unknown etiology. In each of these cases, their initial work-up included ...

Currently available data from multicenter randomized trials on laser treatment of diabetic macular edema refer only to eyes with pretreatment visual acuities of 20/160 or better. After observing reduction of more severe macular edema and visual improvement following panretinal photocoagulation (PRP) alone in some patients, we reviewed our experience with this problem. In 18 eyes of 14 patients with proliferative diabetic retinopathy and visual acuity of 20/200 or worse, secondary to severe macular edema were identified. At 6 months after PRP without focal macular laser treatment, macular edema was reduced in 13 eyes, 8 of which improved by greater than or equal to 2 lines of vision. Among the latter 8 eyes, the visual acuity of 4 recovered to 20/80 or better; the remaining 10 eyes, which had chronic retinal pigment epithelial atrophy or extensive macular ischemia, did not improve. Based on these observations, we suggest that peripheral PRP performed in multiple sessions over several months may have a beneficial effect on severe macular edema in some eyes with adequate macular perfusion.

A 16-year-old Caucasian girl who showed no evidence of tuberculosis or other systemic disease developed acute panuveitis progressing to bilateral serous retinal detachments following purified protein derivative (PPD) skin testing on two separate occasions separated by an interval of 8 years. Both episodes responded rapidly to steroid therapy. Uveal hypersensitivity to PPD skin testing has been described in the presence of ocular or systemic tuberculosis, Eales' disease, and the Vogt-Koyanagi-Harada syndrome (VKH). Our case, however, suggests that profound uveitis may be precipitated by routine PPD skin testing alone.

INCE THE 1950s, scleral buckling has been S the standard of care for the repair of retinal detachments. In the quest for the perfect retinal detachment procedure, alternate techniques have been developed over the past decade. The Lincoff balloon was designed with the idea that not all retinal breaks require the permanent support afforded by a buckle.' Although the Lincoff balloon has been used successfully to treat retinal detachments, it requires a conjunctival incision, and is associated with some of the same adverse consequences as scleral b~ckling."~ Obviating the need for hospitalization, pneumatic retinopexy, or the outpatient injection of a gas bubble into the vitreous cavity to tamponade the retinal breaks, offers potential advantages over more conventional approaches. HISTORY OF PNEUMATIC RETINOPEXY

Medical imaging has long played a critical role in diagnosing and assessing various pathologic conditions. In the past decade alone, along with the rapid evolution of computer technologies, various new imaging modalities have been introduced. These provide three-dimensional (3D) image datasets and are proving themselves to be clinically useful. One of the main advantages afforded with a 3D image dataset is flexible image visualization capability. One can slice the target tissue in any arbitrary plane, allowing clinicians to study abnormalities from various vantage points (e.g., sagittal, coronal, and horizontal sections). Optical coherence tomography (OCT) was developed in 1991 and was commercially introduced to ophthalmology in 1996.1,2 First-generation OCT instruments provided a 2D cross-sectional view of the human retina at a microscopic resolution (10 μm) in vivo. Because of its noncontact and noninvasive imaging capabilities, OCT quickly became an indispensable clinical tool for assessing retinal abnormalities, including the leading causes of blindness: age-related macular degeneration, diabetic retinopathy, and glaucoma.2–5 New techniques based on spectral/Fourier domain detection have achieved approximately 50× increases in imaging speeds.6–8 With its fast axial imaging rate, SD-OCT has enabled us to obtain relatively high-density 3D cube data of the human retina within a reasonable scan time (e.g., 27 kHz sampling or 200 × 200 × 1024 samples in approximately 1.48 seconds; Fig. 1a). Although conventional C-mode images along the planes perpendicular to the scanning axis provide an interesting perspective, interpretation of such C-mode images is not intuitive because multiple different retinal layers are sliced in the same view given the natural spherical curvature of the eye (Fig. 1b).9,10 In addition to this natural tissue curvature, an eye moves along the z-axis on a microscopic scale even within the short scanning time, leading to a distorted 3D SOCT image dataset (Fig. 1c). Figure 1 (a) SD-OCT sample images showing (left) horizontal slice and (right) circular slice. (b) Conventional C-mode view of human retina obtained by prototype SD-OCT unit (501 × 180 × 1024 samplings in a 6 × 6 × 1.4-mm region). ... A commercial SD-OCT (Cirrus HD-OCT; Carl Zeiss Meditec, Dublin, CA; software version 3.0) was used to solve this problem because it provides the capability of sampling the OCT data set along a segmented layer (internal limiting membrane [ILM], retinal pigment epithelium [RPE], or fitted curve to the RPE) with arbitrary thickness. This segmented C-mode method contains only structures in the segmented layer(s) and provides an improved view compared with conventional C-mode, which intersects multiple tissue planes (Fig. 2). Unfortunately, the quality of the segmented C-mode image depends on the quality of the automated segmentation algorithm performance. The deterioration of segmentation algorithm performance in the presence of retinal pathology is well described (Fig. 3).11,12 Figure 2 OCT segmented C-mode image. C-mode image (left) shows a projection from the ILM (right, within light blue lines) with a thickness of 23 μm. Figure 3 Segmentation error sample. The segmented ILM border (top, light blue line) is not following the ILM properly at the cystic lesion (arrows) because of unusual retinal structure and poor signal quality. The smoothed fitted line (magenta) of the RPE also ... The purpose of this study was to develop a method to easily isolate structures of interest (SoIs) while generating C-mode images in a semiautomated fashion and to describe the clinical applications of such a technique.

Recent innovations in vitrectors have led to studies of evaluated aspiration rates of basic saline solution, porcine vitreous, and human vitreous, but each of these substances has potential drawbacks. The authors determined the timed removal rates of egg white with the Accurus 20-, 23-, and 25-gauge vitreous cutters (Alcon Laboratories, Inc., Fort Worth, TX) and the Millennium AVE 20-and 25-gauge system (Bausch & Lomb, St. Louis, MO and MID Labs, Inc., San Diego, CA) using various machine parameters. The Accurus 20-and 23-gauge cutters and the Millennium AVE 20-and 25-gauge cutters removed egg white easily. At higher cut rates, where slow and delicate removal of vitreous is typically desired, the probes, as expected, removed egg white more slowly.

Non-exudative, age-related macular degeneration, which accounts for 85 percent of AMD cases, includes a spectrum of macular pathology. In its most mild form, the macula possesses few Drusen or retinal pigmentary epithelial (RPE) change with no visual disability. At the other end of this spectrum, the macula is affected by large areas of RPE atrophy, with devastating loss of central vision.

When a binocular indirect ophthalmoscope was coupled to an argon laser console via a fiberoptic cable, a unique laser delivery system for retinal photocoagulation was established

Ranibizumab (Lucentis), a recombinant monoclonal antibody, blocks all active forms of vascular endothelial growth factor A and was the first treatment for age-related macular degeneration shown to improve visual acuity in a substantial percentage of patients rather than slowing visual loss. Bevacizumab (Avastin) has a similar action, is related to the ranibizumab compound with respect to its structure, but has not been approved by the FDA for intravitreal use and therefore must be utilized only in an off-label setting. While ranibizumab was approved by the FDA at a dose of 0.5 mg per intravitreal injection, the manufacturer recently issued a letter to physicians warning of the increased risk of stroke at the FDA-approved dose as compared to a lower studied dose of 0.3 mg. An interim analysis of the ongoing SAILOR study revealed a 1.2% risk of stroke in the 0.5 mg arm versus 0.3% in the 0.3 mg arm (p = 0.02). It is unclear whether the trend toward a higher risk of stroke in patients receiving 0.5 mg dose of ranibizumab would persist in the final analysis, but details such as causality, topography, and severity of stroke in the SAILOR study should also be delineated. The risks of intraocular use of bevacizumab remain largely unknown at this time.

Idiopathic choroidal neovascularization is a rather uncommon condition in children and young adults. While some cases resolve spontaneously, in this case visual acuity deteriorated from 20/25 to 20/80 in the affected eye of a 20-year-old college student. After weighing numerous treatment options, she was treated with an intravitreal injection of Ranibizumab (Lucentis) which induced an involution of the membrane over one month's time. Vision recovered to 20/20-1. A follow-up injection with Pegaptanib sodium (Macugen) was administered to promote further involution of the membrane. Vision remained stable over the next four months with no recurrence of the membrane.

In a previous preliminary report, the perception of a decrease in ambient light intensity appeared to be correlated with depression. We prospectively studied this potential link in a controlled study.The question, "I've noticed that the lights in my surroundings seem dimmer than usual", was added to the Center for Epidemiologic Studies Depression Scale (CES-D) questionnaire and administered prospectively to 213 subjects 50-80 years of age participating in the Age-Related Eye Disease Study (AREDS). All had visual acuity of 20/32 or better in at least one eye. Main outcome measures were the relationship between the dimness question answer and severity of depression, and the likelihood that patients reporting dimness were depressed.Subjects endorsing their surroundings as being dimmer than usual at least some of the time had a mean CES-D score of 10.6 (SD=7.0) compared to a mean of 5.5 (SD=5.4) for subjects who never noted dimness (t=-4.22, p=.0001). Depressed individuals (CES-Dor = 16) were significantly more likely to report dimness than non-depressed (CES-D16) subjects (chi(2)=15.6, p0.0001). The total CES-D score and the degree of reported dimness (0-3) were significantly associated (r=0.31, p.0001). Using a stepwise regression analysis, subjects who reported any dimness were more likely to be depressed.A relatively small number of subjects, 38 (18%), reported dimness requiring us to dichotomize their dimness level in some analyses.Perceived dimness of one's ambient surroundings and clinical depression are linked. Health care professionals should inquire about this symptom in potentially depressed patients.

BACKGROUND AND OBJECTIVE The authors used a drusen detection algorithm to quantitate drusen on digitized images and determined its precision and accuracy. PATIENTS AND METHODS Fundus images from 349 participants in the Age-Related Eye Disease Study trial were digitized and analyzed with the Drusen Analyzer (IRIDEX Corporation, Mountain View, CA). The size, number, and area of the drusen in two macular regions were computed by two readers using an interactive approach. Measurements were compared to data generated by reading center methods. RESULTS For the Analyzer, inter-observer agreement was 0.79 (SE = 0.02) and 0.86 (SE = 0.01) (kappa statistic). Intra-observer precision was 0.835 and 0.880 (Spearman coefficients). Categorical agreement (weighted kappa) between the Analyzer and reading center results for the two regions was (0.76, 0.58) and (0.68, 0.68) for readers A and B. The time required to quantitate an image using the Analyzer was 105 ± 52 and 218 ± 102 seconds for the two regions, respectively. CONCLUSIONS Quantitative detection of drusen can be performed reproducibly and efficiently. Comparisons to more labor intensive reading center techniques suggest that the results are similar but that the algorithm is more sensitive and precise. [Ophthalmic Surg Lasers Imaging 2007;38:126-134.] AUTHORS From the UPMC Eye Center (TRF, LH, MP), Department of Ophthalmology; and the Department of Psychiatry (RB), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Accepted for publication January 12, 2007. Supported in part by the National Eye Institute, National Institutes of Health, Bethesda, Maryland (R03 EY13807-01), Research to Prevent Blindness, Inc., New York, New York, and unrestricted funds from William H. Rea. Address correspondence to Thomas R. Friberg, MS, MD, UPMC Eye Center, 203 Lothrop Street, Suite 824, Pittsburgh, PA 15213.

Purpose: To illustrate the utility of ultrawide-angle fundus imaging in documenting the clinical course of a retinal detachment. Design: Observational case report. Method: A 20-year-old man with high myopia and a blind fellow eye noted symptoms of retinal detachment and was imaged with an ultrawide-angle fundus imaging device (Optos P200). Imaging was performed after scleral buckling and before and after additional vitreoretinal surgery. Results: Ultrawide-angle images were useful in delineating the extent of retinal detachment even in the presence of intraocular gas. Conclusion: The ability to rapidly image the ocular fundus well anterior to the equator facilitates clinical management and may prove particularly useful in electronic record keeping.

Purpose A biomechanical model was constructed to simulate the potential therapeutic effect that the surgical procedure radial optic neurotomy (RON) would have on an eye with a central retinal vein occlusion. Design Experimental study. Controls Model eyes undergoing RON were compared to control eyes under the same baseline conditions. Intervention Radial optic neurotomy. We modeled the optic nerve, lamina cribrosa, and the sclera separately and then reassembled the components. Material properties of the sclera and lamina cribrosa were extracted from the literature and both stiff and more elastic values were used for the optic nerve. Intraocular and arterial pressures were varied across a wide range in the analysis. Main Outcome Measure Change in central retinal vein lumen size. Results Over a clinically relevant range of boundary conditions, the increase in the lumen area of the central retinal vein lumen after RON remained trivial, ranging from 1% to a maximum of 5%. Conclusions The biomechanical effect of RON is negligible, and is unlikely to be a procedure that could mechanically ameliorate the clinical sequelae of a central vein occlusion.

Objective To determine the effects of subthreshold 810-nm-diode laser treatment on the rate of development of choroidal neovascularization (primary end point) and the effect on visual acuity (VA) in participants with multiple large drusen in one eye and a preexisting neovascular age-related macular degeneration (AMD) lesion in the other. Design Multicenter, prospective, randomized controlled trial. Participants Two hundred forty-four patients ≥50 years of age and with a neovascular or advanced AMD lesion in one eye and, in the fellow "study" eye, (1) at least 5 drusen ≥ 63 μm in diameter, (2) Early Treatment Diabetic Retinopathy Study best-corrected VA (BCVA) of 20/63 or better, and (3) no evidence of neovascularization at baseline. Methods Patients were randomized to treatment or observation of their study eye at each of 22 centers. At each visit, the protocol specified that BCVA, a complete retinal examination, and fluorescein angiography be documented. Treated eyes had a grid of 48 extrafoveal, subthreshold diode (810 nm) laser spots, 125 μm in diameter, placed in an annulus outside of the foveola. Patients were seen at baseline and at 3, 6, 12, 18, 24, 30, and 36 months after randomization. No retreatments were allowed. Main Outcome Measures Development of choroidal neovascularization (as confirmed by fluorescein angiography) and change in BCVA. Results Throughout follow-up, the rate of choroidal neovascularization events in treated eyes consistently exceeded that in observed eyes. At 1 year, the difference was 15.8% versus 1.4% ( P = 0.05). Most of the intergroup differences in choroidal neovascularization events occurred during the first 2 years of follow-up. Treated eyes showed a higher rate of VA loss (≥3 lines) at 3- and 6-month follow-ups relative to observed eyes (8.3% vs. 1% and 11.4% vs. 4%, respectively; P s = 0.02, 0.07). After 6 months, no significant differences were observed in VA loss between groups. Conclusion Prophylactic subthreshold 810-nm-diode laser treatment to an eye with multiple large drusen in a patient whose fellow eye has already suffered a neovascular event places the treated eye at higher risk of developing choroidal neovascularization. We advise against using prophylactic subthreshold diode laser treatment in these eyes.

A 28-year-old patient developed proliferative diabetic retinopathy with florid rubeosis iridis and ultimately required the placement of a Baerveldt tube to control his secondary glaucoma. Eighteen months later, he underwent a pars plana vitrectomy, scleral buckle, lensectomy, and membrane peeling to reattach a severe diabetic retinal detachment. Ultimately, some of the 5000 cs silicone oil migrated through the tube to the episcleral region under the plate of the Baerveldt device. The oil intermittently blocked the shunt, causing elevated intraocular pressure. Despite ultimate surgical removal of the oil from around the tube and plate, a substantial amount remained encapsulated in the subconjunctival space. Prevention of this complication includes placement of a short tube well anterior to the iris in the inferior portion of the anterior chamber.

To review the results of transpupillary thermotherapy (TTT) on choroidal neovascular membranes associated with age-related macular degeneration (AMD).35 eyes of 35 patients with AMD and choroidal neovascularization and exudation were treated with TTT and had fundus photographs and fluorescein angiography (FA) before and at least six months after TTT. 28 eyes had predominantly occult lesions as seen on FA, while 7 demonstrated primarily classic lesions. All were treated with 650mw power or less using the 810 nm diode laser (3000 micron spot, duration of 60 seconds). Visual acuity, lesion size, and amount of subretinal fluid were determined by results of examination and review of photographs and fluorescein angiograms.A 50% reduction in subretinal fluid was achieved in 67% of treated eyes overall, with stabilization of vision (less than three lines of visual acuity lost) in 86%. Complications from treatment were infrequent (9%) and involved hemorrhage noted in the region of treatment upon follow-up.TTT promotes resolution of subretinal fluid and appears to stabilize visual acuity in patients with exudative AMD.

(2001). Transpupillary thermotherapy – introduction. Seminars in Ophthalmology: Vol. 16, No. 2, pp. 53-54.

Purpose Ocular trauma is one of the main causes of visual reduction or loss, particularly in the younger population. METHODS In this prospective study the authors included 67 consecutive patients with ocular trauma secondary to motor vehicle accidents who were hospitalized in the Athens University Eye Clinic from September 1993 to December 1996. The mean follow-up time was 31 months, the mean age was 31.7 years, and the ratio between men and women was 2.7:1. Results Thirty-two of the accidents (47.76%) took place in populated areas. Among the 67 injured persons, 58 (86.56%) were car passengers, 8 (11.95%) were on motorcycles, and 1 (1.49%) was a pedestrian. Only 3 (5.2%) of the 58 persons injured inside automobiles used safety belts and none of the motorcyclists used crash helmets during the accidents. Fifty-three (79.1%) ocular traumas were penetrating in nature, with glass fragments being the main cause in 36 of them (67.9%). Among the 53 injured persons experiencing penetrating ocular trauma, 49 had a follow-up time of more than 6 months. Twenty of them (40.8%) underwent one surgical procedure, 22 (44.9%) were submitted to two surgical procedures, and the remaining 7 persons (14.3%) needed three or more operations. Eighteen (36.7%) of the 49 patients with penetrating ocular trauma and with 6 months follow-up had a final visual acuity of less than 1/20, 21 (42.9%) had a visual acuity of more than 5/10, and 3 (6.1%) underwent enucleation. Among the 67 patients, 61 had a follow-up time of more than 6 months, regardless of their history of penetrating ocular trauma. Eighteen of them (29.5%) had a final visual acuity of less than 1/20, 8 (13.1%) had a visual acuity between 2/10 and 4/10, and 22 (52.5%) had a visual acuity of more than 5/10. CONCLUSIONS Because motor vehicle accidents can cause severe ocular trauma, it would be helpful for drivers to be more careful and aware of motor vehicle regulations. There seems to be a great need of enforcement of seatbelt laws in Greece.

A non-contact scanning laser-based retinal imaging system produces a 200 degrees wide-field panoramic image of the fundus through the novel use of a large elliptical mirror. The authors investigated whether accurate diagnoses could be made from these images alone.Images were obtained from both eyes of arbitrarily selected patients and were retrospectively reviewed by retinal specialists. Each physician made a diagnosis, suggested the follow-up interval, and determined whether any intervention was needed based solely on image review. Diabetic retinopathy was categorized as background retinopathy only, preproliferative retinopathy, maculopathy, and proliferative retinopathy. The results of the image review were then compared with the results of clinical examination, and the sensitivity and specificity of the review were calculated.The correct overall diagnosis was made by the two specialists in 87% and 77% of cases, respectively; the specificity and sensitivity each averaged 76%. Follow-up interval recommendations from image review matched those made on clinical examination in 86% of cases. Diabetic retinopathy was correctly identified as a general diagnosis with a sensitivity of 94% and the follow-up recommendations corresponded to the clinical recommendations in 82%. Sixty-two percent of the images were judged to be of good quality or better, with only 6.4% deemed unreadable. Iris color did not influence image quality.The non-contact scanning laser-based retinal imaging system provides images of sufficient resolution and clarity to make accurate general diagnoses in a high percentage of cases. Its use as a screening device for specific diseases is feasible and merits further study.

To survey active vitreoretinal surgeons to determine how often they intentionally debride the corneal epithelium during vitrectomy surgery for diabetic patients and to ascertain whether the selection of the surgical lens type influences the debridement rate.Observational retrospective case series.Fifty-five vitreoretinal surgeons were asked to retrospectively report how many pars plana vitrectomies they performed in 1 year on diabetic eyes and in what percent of the cases was debridement of the cornea necessary. In a second query, they were asked to note which specific type of surgical lens system (hand-held irrigating, Landers sew-on, or Oculus BIOM noncontact) was used for their surgical intervention.The total number of diabetic vitrectomies performed in 1 year by the respondents was 8,002. The frequency of epithelial debridement was 17.4%, with a range of 0% to 90%. The use of irrigating contact lenses was associated with a significantly higher rate of debridement compared with the use of sew-on or BIOM noncontact lenses (23.5% vs 12.1%, P.001). Regarding the 41 surgeons who indicated a specific type of lens used, we found that the debridement rate for infusion lenses was 23.8% compared with 13.0% for sew-on lenses and 15.6% for noncontact BIOM lenses. The difference between these groups was statistically significant (P.025).Irrigating contact lenses appear to increase the need for epithelial debridement compared with other alternatives. Sew-on lenses with a viscoelastic cushion may provide the best corneal protection.

Perfluorocarbon liquids (PFCL) are used extensively in complex vitreoretinal surgery, sometimes before the placement of silicone oil (SiO). We suspected that PFCL and SiO interact physically when in opposition, potentially making their removal more difficult. The nature of some of these interactions was explored using a mass spectrometric approach in in-vitro and in-vivo samples.We incubated silicone oil (1,000 or 5,000 centistokes viscosity) and PFCL [perfluoro-n-octane (PFO) or perfluorotributylamine] together in vitro for 6 months and performed electron impact ionization mass spectrometry (EIMS) on the PFCL to characterize interactions between the liquid phases. Packaged samples of PFCL served as controls. We also examined in vivo samples of PFO which had been retained in human eyes for several months prior to surgical removal.Perfluorocarbon liquids packaged for surgical use all contain SiO in trace amounts, possibly as a manifestation of the processes used in their manufacture. Furthermore, all PFCLs incubated with SiO showed much more prominent contamination with SiO molecular fragments. PFCL was found in the SiO phase of eyes in which both liquids were present for extended periods of time. The EIMS analysis of in vivo samples suggested that proteins coat PFCL droplets, forming micelle-like structures.Medical-grade PFCLs contain small amounts of SiO, and PFCLs dissolve small amounts of oil into solution over time. Interactions between retained vitreous substitutes may have clinical relevance.

To evaluate the efficacy of different surgical strategies on the postoperative outcomes of retinal detachments (RDs) associated with macular holes (MHs) in high myopia.Prospective, noncomparative case series.The study included 120 phakic, highly myopic eyes (mean degree of myopia, -22.2+/-4.80 diopters) with RDs and MHs that underwent surgical repair. The patients were divided into 2 groups. Group 1 consisted of 60 eyes with a posterior vitreous detachment (PVD). Mean preoperative visual acuity (VA) was 20/200+/-20/500. Group 2 consisted of 60 eyes with posterior vitreous schisis (PVS). The mean preoperative VA was 20/152+/-20/333. The minimum follow-up was 6 months.The surgical approach was chosen on the basis of the clinical characteristics. Twenty-five eyes of group 1 underwent pneumoretinopexy (group 1A), whereas 35 eyes of group 1 were repaired with vitrectomy (group 1B). Forty-nine eyes of group 2 underwent pars plana vitrectomy (group 2A), whereas 11 eyes of group 2 underwent scleral buckling of the macula (group 2B).Anatomic attachment of the retina and VA.Retinal reattachment at 6 months was achieved in 23 of 25 (92%) eyes of group 1A, 31 of 35 (88.5%) eyes of group 1B, 45 of 49 (91.8%) eyes of group 2A, and 8 of 11 (72.7%) eyes of group 2B. A significant (P0.01) improvement of postoperative VA with respect to the preoperative values was observed in all groups. The greatest percentage improvement in postoperative VA was observed in groups 1A and 1B eyes.Different surgical approaches can be used to repair myopic RD associated with an MH. The choice between different surgical techniques may depend on vitreoretinal relationships, the extent of chorioretinal atrophic areas, and presence of posterior staphyloma. In our study, eyes with a PVD had significantly better visual outcomes than detachments in eyes with PVS.

Importance The Age-Related Eye Disease Study (AREDS) formulation for the treatment of age-related macular degeneration (AMD) contains vitamin C, vitamin E, beta carotene, and zinc with copper. The Age-Related Eye Disease Study 2 (AREDS2) assessed the value of substituting lutein/zeaxanthin in the AREDS formulation because of the demonstrated risk for lung cancer from beta carotene in smokers and former smokers and because lutein and zeaxanthin are important components in the retina. Objective To further examine the effect of lutein/zeaxanthin supplementation on progression to late AMD. Design, Setting, Participants The Age-Related Eye Disease Study 2 is a multicenter, double-masked randomized trial of 4203 participants, aged 50 to 85 years, at risk for developing late AMD; 66% of patients had bilateral large drusen and 34% had large drusen and late AMD in 1 eye. Interventions In addition to taking the original or a variation of the AREDS supplement, participants were randomly assigned in a factorial design to 1 of the following 4 groups: placebo; lutein/zeaxanthin, 10 mg/2 mg; omega-3 long-chain polyunsaturated fatty 3 acids, 1.0 g; or the combination. Main Outcomes and Measures Documented development of late AMD by central, masked grading of annual retinal photographs or by treatment history. Results In exploratory analysis of lutein/zeaxanthin vs no lutein/zeaxanthin, the hazard ratio of the development of late AMD was 0.90 (95% CI, 0.82-0.99; P = .04). Exploratory analyses of direct comparison of lutein/zeaxanthin vs beta carotene showed hazard ratios of 0.82 (95% CI, 0.69-0.96; P = .02) for development of late AMD, 0.78 (95% CI, 0.64-0.94; P = .01) for development of neovascular AMD, and 0.94 (95% CI, 0.70-1.26; P = .67) for development of central geographic atrophy. In analyses restricted to eyes with bilateral large drusen at baseline, the direct comparison of lutein/zeaxanthin vs beta carotene showed hazard ratios of 0.76 (95% CI, 0.61-0.96; P = .02) for progression to late AMD, 0.65 (95% CI, 0.49-0.85; P = .002) for neovascular AMD, and 0.98 (95% CI, 0.69-1.39; P = .91) for central geographic atrophy. Conclusion and Relevance The totality of evidence on beneficial and adverse effects from AREDS2 and other studies suggests that lutein/zeaxanthin could be more appropriate than beta carotene in the AREDS-type supplements. Trial Registration clinicaltrials.gov Identifier:NCT00345176

Objective: In a non-randomized, uncontrolled pilot study, the authors investigated whether depressed patients were more likely to perceive the lighting in their environment as being dimmer than usual. Method: 120 patients (46 males, 74 females) who presented for possible admission for depression at a psychiatric facility were administered a Diagnostic and Statistical Manual of disorders (DSM-IV) based questionnaire and underwent psychiatric evaluation. A question asking whether ‘the lights in my surroundings seem dimmer than usual’ was included in the 15-point question survey. Statistical analyses were performed to determine whether an affirmative response to this dimness question was correlated with the depth of depression (mild, moderate, severe) and also whether significant correlation was present between the percentage of patients answering yes to the dimness question versus the number of yes responses to the core symptoms of depression. Results: Two thirds of the patients categorized as severely depressed responded that their ambient environment appeared dimmer than usual compared to 21% of moderately and 14% of mildly depressed patients. This difference was statistically significant (P

Oral supplementation with the Age-Related Eye Disease Study (AREDS) formulation (antioxidant vitamins C and E, beta carotene, and zinc) has been shown to reduce the risk of progression to advanced age-related macular degeneration (AMD). Observational data suggest that increased dietary intake of lutein + zeaxanthin (carotenoids), omega-3 long-chain polyunsaturated fatty acids (docosahexaenoic acid [DHA] + eicosapentaenoic acid [EPA]), or both might further reduce this risk.To determine whether adding lutein + zeaxanthin, DHA + EPA, or both to the AREDS formulation decreases the risk of developing advanced AMD and to evaluate the effect of eliminating beta carotene, lowering zinc doses, or both in the AREDS formulation.The Age-Related Eye Disease Study 2 (AREDS2), a multicenter, randomized, double-masked, placebo-controlled phase 3 study with a 2 × 2 factorial design, conducted in 2006-2012 and enrolling 4203 participants aged 50 to 85 years at risk for progression to advanced AMD with bilateral large drusen or large drusen in 1 eye and advanced AMD in the fellow eye.Participants were randomized to receive lutein (10 mg) + zeaxanthin (2 mg), DHA (350 mg) + EPA (650 mg), lutein + zeaxanthin and DHA + EPA, or placebo. All participants were also asked to take the original AREDS formulation or accept a secondary randomization to 4 variations of the AREDS formulation, including elimination of beta carotene, lowering of zinc dose, or both.Development of advanced AMD. The unit of analyses used was by eye.Median follow-up was 5 years, with 1940 study eyes (1608 participants) progressing to advanced AMD. Kaplan-Meier probabilities of progression to advanced AMD by 5 years were 31% (493 eyes [406 participants]) for placebo, 29% (468 eyes [399 participants]) for lutein + zeaxanthin, 31% (507 eyes [416 participants]) for DHA + EPA, and 30% (472 eyes [387 participants]) for lutein + zeaxanthin and DHA + EPA. Comparison with placebo in the primary analyses demonstrated no statistically significant reduction in progression to advanced AMD (hazard ratio [HR], 0.90 [98.7% CI, 0.76-1.07]; P = .12 for lutein + zeaxanthin; 0.97 [98.7% CI, 0.82-1.16]; P = .70 for DHA + EPA; 0.89 [98.7% CI, 0.75-1.06]; P = .10 for lutein + zeaxanthin and DHA + EPA). There was no apparent effect of beta carotene elimination or lower-dose zinc on progression to advanced AMD. More lung cancers were noted in the beta carotene vs no beta carotene group (23 [2.0%] vs 11 [0.9%], nominal P = .04), mostly in former smokers.Addition of lutein + zeaxanthin, DHA + EPA, or both to the AREDS formulation in primary analyses did not further reduce risk of progression to advanced AMD. However, because of potential increased incidence of lung cancer in former smokers, lutein + zeaxanthin could be an appropriate carotenoid substitute in the AREDS formulation.clinicaltrials.gov Identifier: NCT00345176.

To define one possible etiology for the rise in intraocular pressure (IOP) after neodymium: YAG (Nd:YAG) laser capsulotomy and provide information for the continued investigation of this process.Laser Center, Eye and Ear Institute, Pittsburgh, Pennsylvania.Samples of 1% sodium hyaluronate or balanced salt solution (BSS) (control) were placed in a closed system and exposed to varying amounts of Nd:YAG energy delivered by a Coherent YAG laser. This system was hydrostatically coupled to a pressure monitor, and changes in pressure were recorded as a function of time.Average pressure increase was 0.140 mm Hg/mJ of YAG energy in the sodium hyaluronate samples and 0.017 mm Hg/mJ in BSS (P.01). The relationship between total energy delivered and maximum pressure recorded for both substances was nearly linear. Further analysis of treated sodium hyaluronate samples showed that Nd:YAG energy can produce structural alterations.Neodymium:YAG laser energy has a pronounced effect on sodium hyaluronate that exceeds the thermal effect seen with BSS when the pressure is monitored in a closed system. These structural changes might contribute to the IOP rise seen clinically.

Objective: To characterize the ocular fundus findings of patients who suffered sudden visual loss associated with sexual activity. Design: Case series. Setting: Outpatient ophthalmic practice. Patients: Six patients presented with a precipitous decrease in vision in one eye with no apparent predisposing factors. After obtaining a careful history, each patient revealed that he or she had been engaging in rigorous sexual activity immediately before experiencing the visual loss. Intervention: Five of the six patients were followed up without intervention. One patient required prophylactic laser photocoagulation of a retinal tear to decrease the risk of retinal detachment. Results: Six patients aged 24 to 53 years suffered sudden loss of vision secondary to intraretinal, preretinal, or vitreous hemorrhaging. Visual acuity in the affected eyes ranged from a mild decrease (20/40) to profound visual loss (counting fingers at 6 in). Five of the six patients were followed up for at least 1 month and showed spontaneous improvement in vision as the blood cleared. Those who returned for long-term follow-up enjoyed complete visual recovery without any sequelae. Conclusions: Sudden debilitating visual loss may occur during sexual activity from the rupture of retinal blood vessels in the macular region or from the development of vitreous bleeding from an induced retinal tear. The longterm prognosis after such hemorrhaging appears to be excellent, with good visual recovery occurring as the blood resorbs spontaneously.

Subretinal neovascular membranes (SRNVM) in the pediatric population are rare. The clinical presentation, etiology, course, and management of SRNVM in 25 children (27 eyes) were studied retrospectively. Inflammatory or infectious conditions predominated (10 of 25). Eleven of 19 untreated SRNVM (58%) spontaneously involuted, with 9 of these 11 achieving a final visual acuity of 20/50 or better. A hyperpigmented ring on fluorescein angiography was associated with 9 of the 1 1 involuted SRNVM. The presence of this pigmented ring may help to identify those cases with a better visual prognosis.

Purpose: To evaluate the surgical success of vitrectomy without initial lensectomy in the primary treatment of retinal detachment associated with giant tears without proliferative vitreoretinopathy. Methods: Thirty-four consecutive phakic eyes with idiopathic giant retinal tears underwent vitrectomy, injection of perfluorocarbon liquid, endolaser, and gas tamponade. Encircling scleral buckling was performed in 14 of 34 patients. Preoperative visual acuity ranged from 20/25 to hand motions. Giant tear size ranged from 90° to 330°. Follow-up ranged from 10 to 64 months. Results: Anatomic retinal re-attachment was achieved intraoperatively in all eyes. The re-operation rate was 14% for eyes that underwent scleral buckling with the initial vitrectomy and 45% in eyes without primary scleral buckling. In 59% of eyes with cataract formation, 32% underwent cataract surgery with or without intraocular lens implantation. Best-corrected final visual acuity ranged from 20/15 to 20/400. Conclusion: Most phakic eyes with giant retinal tear not associated with proliferative vitreoretinopathy can be re-attached successfully with initial preservation of the lens.

Patients with rhegmatogenous retinal detachments involving the fovea have visual loss that may not be recoverable despite anatomically successful surgery. Few guidelines exist to predict ultimate visual outcome with any certainty. We found that despite macular detachment, a device commonly used to predict visual acuity in cataractous eyes, the Potential Acuity Meter (Mentor O & O, Inc., Norwell, Massachusetts), provided acuity measurements even when Snellen visual acuity levels were poor or unmeasurable. In a study of 50 consecutive patients with clear media, we investigated a possible correlation between postoperative Snellen visual acuity with the preoperative Potential Acuity Meter results. We found that actual visual improvement correlated well with potential visual improvement as determined by Potential Acuity Meter measurements (R = .92). Preoperative assessment of patients with this device was a better predictor of final visual outcome than preoperative Snellen visual acuity, the extent of retinal detachment, or the duration of the retinal detachment by history.

Two patients developed unilateral serous retinal detachments of the macula resembling idiopathic center serous chorioretinopathy within 9 months of cardiac transplantation, while one renal transplant recipient developed bilateral serous detachments within 6 months of surgery. In two cases (three eyes), dense, yellow, fibrlin-like exudates were present in the subretinal fluid. At the time of presentation, each of the three patients had a modest elevation of blood urea nitrogen. Laser photocoagulation was performed in three eyes with limited success, although ultimately the detachments resolved leaving only mild visual impairment (6/9 vision). The differential diagnosis of visual loss in the transplant population includes serous detachment of the sensory retina as well as more serious chorioretinal infections related to immunosuppression.