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Purpose: To determine if intravitreal injection of triamcinolone acetonide is safe and effective in treating diabetic macular edema unresponsive to prior laser photocoagulation., Design: Prospective, noncomparative, interventional case series., Participants: Sixteen eyes with clinically significant diabetic macular edema (CSME) that failed to respond to at least two previous sessions of laser photocoagulation., Methods: Eyes were diagnosed with CSME and treated with at least two sessions of laser photocoagulation according to Early Treatment Diabetic Retinopathy Study guidelines. At least 6 months after initial laser therapy, the response was measured by clinical examination and optical coherence tomography (OCT). Eyes with a residual central macular thickness of more than 300 microm (normal, 200 microm) and visual loss from baseline were offered intravitreal injection of 4 mg triamcinolone acetonide. The visual and anatomic responses were observed as well as complications related to the injection procedure and corticosteroid medication., Main Outcome Measures: Visual acuity and quantitative change in OCT macular thickening were assessed. Potential complications were monitored, including intraocular pressure response, cataract progression, retinal detachment, vitreous hemorrhage, and endophthalmitis., Results: All patients completed 3 months of follow-up, and 8 of 16 patients (50%) completed 6 or more months of follow-up. Mean improvement in visual acuity measured 2.4, 2.4, and 1.3 Snellen lines at the 1-, 3-, and 6-month follow-up intervals, respectively. The central macular thickness as measured by OCT decreased by 55%, 57.5%, and 38%, respectively, over these same intervals from an initial pretreatment mean of 540.3 microm (+/-96.3 microm). Intraocular pressure exceeded 21 mmHg in 5, 3, and 1 eye(s), respectively, during these intervals. One eye exhibited cataract progression at 6 months. No other complications were noted over a mean follow-up of 6.2 months. Reinjection was performed in 3 of 8 eyes after 6 months because of recurrence of macular edema., Conclusions: Intravitreal triamcinolone is a promising therapeutic method for diabetic macular edema that fails to respond to conventional laser photocoagulation. Complications do not appear to be prohibitive. Further study is warranted to assess the long-term efficacy and safety, and the need for retreatment.

We developed a clinical strategy for dealing with situations in which ophthalmoscopic examination and vitreoretinal surgery are difficult in patients with an ARRAY refractive multifocal intraocular lens (IOL) implant. The ARRAY zonal-progressive IOL has a central 2.1-mm distance-vision zone for optically-unobstructed posterior pole observation. A concentric near-vision zone (+3.5-diopter add) surrounds this central zone. Optical ray-tracing is used to determine how a 2.1-mm pupil limitation restricts monocular and binocular retinal image size in head-mounted, slit-lamp, and operating microscope ophthalmoscopy. A 2.1-mm pupil decreases the retinal field of view of high magnification, narrow field lenses much more than that of wider-field, lower magnification lenses. This "worst-case" analysis suggests an ophthalmoscopic strategy, but is not strictly valid for the ARRAY lens because the near-vision zone surrounding its 2.1-mm central zone is not opaque. The near-vision zone contributes defocused information to the ophthalmoscopic image, diminishing its resolution and depth information. Wide-field, low magnification lenses are potentially less problematic than higher magnification lenses for examining and treating patients with an ARRAY IOL implant. This strategy is useful for panretinal photocoagulation or photodynamic therapy, but not for procedures requiring high magnification stereoscopic vision such as macular vitreoretinal surgery.

Objectives: To determine the rate of anatomical closure of idiopathic macular holes undergoing vitreous surgery with respect to preoperative horizontal diameter as determined by optical coherence tomography (OCT) and to correlate postoperative visual acuity, duration of symptoms, and late reopening with initial idiopathic macular hole diameter by OCT., Materials and Methods: Forty eyes of 40 patients with an idiopathic macular hole were examined with OCT before and after vitreous surgery. All eyes were treated with pars plana vitrectomy, peeling of posterior cortical vitreous, and dilute perfluoropropane or sulfur hexafluoride gas. Face-down positioning was maintained for 7 to 14 days., Results: Twenty-two (92%) of 24 eyes with a preoperative idiopathic macular hole diameter smaller than 400 microm measured by OCT attained anatomical closure following surgery. Anatomical closure was observed in 9 (56%) of 16 eyes with a macular hole diameter of 400 microm or larger measured by OCT (P =.02). The median postoperative visual acuity improvement was 4 Snellen lines in the 31 eyes achieving anatomical closure and no change in the 9 eyes not achieving anatomical closure (P< .001). Late macular hole reopening at longer than 6 months occurred in 3 (10%) of 31 eyes with an initially closed macular hole. This event was observed only in macular holes 400 microm or larger measured by OCT. The preoperative macular hole diameter (P =.02) and duration of symptoms (P =.02) were factors predictive of anatomical closure of the macular hole postoperatively., Conclusions: The postoperative closure of idiopathic macular holes following vitreous surgery was related to the preoperative macular hole diameter determined by OCT, with lesions smaller than 400 microm demonstrating higher success rates. A trend toward greater visual acuity improvement was demonstrated for idiopathic macular holes smaller than 400 microm. Late reopening was only seen in macular holes that were 400 microm or larger measured by OCT. Preoperative analysis and measurement of idiopathic macular holes with OCT may help delineate postoperative expectations for successful anatomical closure of the macular hole, visual acuity, and long-term closure.

Purpose: To evaluate the efficacy of transpupillary thermotherapy (TTT) for the treatment of occult choroidal neovascularization., Methods: A retrospective, noncomparative case series of 57 eyes of 52 patients who presented with occult subfoveal CNV and were treated with TTT., Results: 83% of eyes were either stable (+/- one line) or showed improvement in visual acuity. 83% of eyes showed stabilization of their exudative process after one TTT treatment as evidenced by resorption of subretinal and/or intraretinal exudate or hemorrhage. Nine percent of eyes developed classic CNV during the mean follow-up time of ten months., Conclusions: TTT appears to stabilize the exudative process in eyes with occult CNV. A prospective, sham-controlled, randomized study (TTT4CNV Clinical Trial) is currently underway to directly compare TTT to the natural history of occult CNV.

Transpupillary thermotherapy (TTT) is a subthreshold, low irradiance, long exposure duration, large spot size, infrared diode laser protocol. Retinal temperature increases in TTT for choroidal neovascularization (CNV) are substantially lower than those in conventional short-pulse photocoagulation, but they are maintained for 60 seconds to achieve therapeutic results. Treatment power is adjusted for retinal lesion size, chorioretinal pigmentation, macular elevation and media clarity. TTT uses 810-nm diode laser infrared radiation, which has no significant retinal phototoxicity. A parfocal laser delivery system is required to assure uniformity of irradiance across large diameter treatment spots. Relative contraindications for TTT include dense subretinal hemorrhage, prior focal photocoagulation and serous RPE detachment. Adverse events are rare, and include decreased vision and retinal arteriole occlusion. Randomized, prospective multi-center trials are underway to compare the results of TTT for occult CNV in age-related macular degeneration to the natural history of the disorder. Imaging, electrophysiologic or thermometric techniques may ultimately provide intra-operative or post-operative monitoring to assure the adequacy of TTT for CNV, despite the absence of ophthalmoscopically visible lesions.

Ophthalmoscopic contact lenses for transpupillary thermotherapy (TTT) must provide effective visualization of retinal treatment sites and transmission of infrared diode laser radiation. Selection and proper use of retinal laser lenses requires knowledge of their lateral magnification, laser beam magnification factor, field of view and resolution. Optical performance is analyzed for Goldmann-type lenses and a series of inverted image lenses of differing magnification. Goldmann lenses have the highest resolution, but inverted image lenses of comparable magnification have 2.5 times or more their field of view. Inverted image lenses of similar magnification can differ in resolution. They require 2-4% more incident laser power to produce the same retinal irradiance as a Goldmann lens, but this difference is small in comparison to other clinical variables. Tilting an ophthalmoscopic contact lens up to 15 degrees causes little distortion in the circularity of the retinal spot formed by a laser beam or difference in retinal irradiance across the spot. Inverted image lenses produce higher anterior segment irradiances than Goldmann-type lenses, but anterior segment injuries are less likely in TTT than conventional visible light, short-pulse retinal photocoagulation because of the comparatively low irradiances used in TTT and the decreased absorption of diode laser infrared radiation in ocular media and melanin.

Objective: To provide a biophysical foundation for using transpupillary thermotherapy (TTT) to manage choroidal neovascularization in age-related macular degeneration (ARMD)., Methods: Retinal temperature rise in laser therapy is proportional to retinal irradiance (laser power/area) for a particular spot size, exposure duration, and wavelength. TTT is a low irradiance, large spot size, prolonged exposure (long-pulse), infrared laser photocoagulation protocol. Results from an experimentally confirmed, finite element model of retinal light absorption and heat conduction are used to analyze laser parameter selection and its consequences. Results from apoptosis, heat shock protein and hyperthermia research are used to examine how chorioretinal damage from clinical procedures might be reduced., Results: Chorioretinal thermal equilibration occurs during long-pulse TTT photocoagulation. Retinal temperature increases are similar in the RPE where laser radiation absorption is significant and in the adjacent neural retina where there is negligible radiation absorption. For parameters used to treat occult choroidal neovascularization in lightly-pigmented fundi (800-mW, 810-nm, 3-mm retinal spot diameter, 60-sec exposure duration), the maximum chorioretinal temperature elevation is calculated to be roughly 10 degrees C, significantly lower than the 20 degrees C temperature elevations measured in threshold, conventional short-pulse retinal photocoagulation., Conclusions: To achieve a preselected temperature rise, TTT laser power must be increased or decreased in proportion to the diameter rather than the area of the laser spot. Clinical power settings should be adjusted for fundus pigmentation and media clarity because both of these factors affect absorbed retinal irradiance and thus retinal temperature rise. Noninvasive thermal dosimetry currently is unavailable for clinical retinal photocoagulation, but potential thermometric techniques include MRI, liposomal-encapsulated dyes, multispectral imaging or reflectometry, and subretinal or episcleral thermometry. TTT may be useful not only as independent therapy, but also as an adjunct to PDT, antiangiogenic drugs and ionizing radiation therapy in the management of neovascular ARMD. Low temperature, long-pulse photocoagulation is a potential strategy for decreasing neural retinal damage in subsequent TTT or short-pulse photocoagulation and perhaps even for treating glaucoma or retinal degenerations.

Background and Objective: To demonstrate the utility of optical coherence tomography (OCT) for documenting an early response to laser photocoagulation in clinically significant macular edema (CSME) secondary to diabetes., Patients and Methods: Five eyes of four patients were selected for review based on the diagnosis of CSME. All eyes had a clinical diagnosis of CSME based on slit lamp biomicroscopy. All eyes underwent focal/grid laser photocoagulation to areas of retinal thickening detected by OCT and clinical exam. Pre and post-treatment optical coherence tomograms were obtained for all patients., Results: All eyes selected for review had an early positive response to focal laser photocoagulation. OCT was useful for demonstrating areas of retinal thickening prior to laser treatment. Serial macular maps demonstrated the resolution of retinal thickening after laser photocoagulation in all eyes., Conclusion: OCT is a useful tool for evaluating and documenting CSME both before and after focal/grid laser photocoagulation. OCT is capable of detecting an early positive response to photocoagulation for macular edema.

Objective: This study aimed to develop a protocol to screen and monitor patients with diabetic macular thickening using optical coherence tomography (OCT), a technique for high-resolution cross-sectional imaging of the retina., Design: A cross-sectional pilot study was conducted., Participants: A total of 182 eyes of 107 patients with diabetic retinopathy, 55 eyes from 31 patients with diabetes but no ophthalmoscopic evidence of retinopathy, and 73 eyes from 41 healthy volunteers were studied., Intervention: Six optical coherence tomograms were obtained in a radial spoke pattern centered on the fovea. Retinal thickness was computed automatically from each tomogram at a total of 600 locations throughout the macula. Macular thickness was displayed geographically as a false-color topographic map and was reported numerically as averages in each of nine regions., Main Outcome Measures: Correlation of OCT with slit-lamp biomicroscopy, fluorescein angiography, and visual acuity was measured., Results: Optical coherence tomography was able to quantify the development and resolution of both foveal and extrafoveal macular thickening. The mean +/- standard deviation foveal thickness was 174 +/- 18 microns in normal eyes, 179 +/- 17 microns in diabetic eyes without retinopathy, and 256 +/- 114 microns in eyes with nonproliferative diabetic retinopathy. Foveal thickness was highly correlated among left and right eyes of normal eyes (mean +/- standard deviation difference of 6 +/- 9 microns). Foveal thickness measured by OCT correlated with visual acuity (r2 = 0.79). A single diabetic eye with no slit-lamp evidence of retinopathy showed abnormal foveal thickening on OCT., Conclusions: Optical coherence tomography was a useful technique for quantifying macular thickness in patients with diabetic macular edema. The topographic mapping protocol provided geographic information on macular thickness that was intuitive and objective.

Purpose: Sustained-release ganciclovir implants are effective in delaying progression of newly diagnosed cytomegalovirus (CMV) retinitis. An uncontrolled case series was assembled to evaluate the efficacy of the intravitreal ganciclovir implant for patients with sight-threatening CMV retinitis who had previously failed to respond to intravenous ganciclovir and/or foscarnet., Methods: Between August 1993 and March 1995, 72 eyes of 55 patients received intravitreal ganciclovir implants. Patients were examined monthly after implant surgery., Results: A total of 56 eyes (77.8%) were available for evaluation after implant surgery. At the 1-month postoperative visit, 48 eyes (85.7%) of 38 patients had no progression. Implants failed to control progression at the 1-month visit in eight eyes (14.3%) of six patients receiving primary implants. A total of 32 eyes (57.1%) of 29 patients did not experience three-line loss of visual acuity through the follow-up period. The median time to three-line loss was 190 days from implantation. Four eyes (7.1%) developed visual acuity of 20/200 or worse by the 1-month follow up. The median time from implantation to development of visual acuity of 20/200 or less was 224 days. The median survival time was 376 days from study entry. The most common postoperative complication was retinal detachment, which was observed in 12 eyes receiving implants. Additional self-limiting complications included significant vitreous hemorrhage (three eyes) and hypotony maculopathy (two eyes)., Conclusion: Ganciclovir implants were effective in delaying visual loss in a significant proportion of patients who failed ganciclovir or foscarnet therapy. A number of these patients, however, experienced visual loss. Although the implants can be effective as therapy for relapsed CMV retinitis, the efficacy does not appear to match that noted in initial CMV retinitis therapy.

The purpose of this study was to determine the nature of the relationship between density of indocyanine green (ICG) and the activity of occult choroidal neovascular membranes (CNVM) in patients with age-related macular degeneration (AMD) using ICG angiography. Ten eyes of ten patients with AMD and associated CNVM formation were retrospectively classified into either active or silent group on the basis of clinical outcome. Density of ICG for ICG leakage of CNVM was retrospectively determined from baseline ICG angiograms using an image analysis system. The means of relative density of the two groups were significantly different at five minutes after injection of ICG (p = 0.02). Densitometric analysis with ICG angiography may enable the discrimination of active from silent CNVM in patients with AMD, and thereby, prove useful in guiding clinical decision concerning treatment of these patients.

Purpose: Indocyanine green (ICG) angiography may improve visualization of choroidal neovascularization (CNV) associated with serous retinal pigment epithelial detachment (RPED) in age-related macular degeneration (AMD). The features of ICG hyperfluorescence associated with serous RPED and therapeutic effect of ICG-directed laser photocoagulation in eyes with serous RPED is evaluated., Design: Retrospective review of all simultaneous fluorescein/ICG angiograms (n = 918) performed over an 18-month period to identify 44 eyes in 39 patients with serous RPED secondary to AMD on fluorescein angiography., Participants: Thirty-nine patients with AMD, aged 53 to 89 years, participated., Intervention: Eyes were nonrandomly treated with ICG-directed laser photocoagulation or observation., Main Outcome Measures: Characteristics of ICG hyperfluorescence associated with a serous RPED are reviewed. Final visual acuity and anatomic appearance of the serous RPED are given., Results: Twenty-three (52%) of the 44 eyes had an isolated serous RPED without obvious CNV, and 21 (48%) of the 44 eyes had a serous RPED associated with occult CNV on fluorescein angiography. Indocyanine green angiography demonstrated underlying CNV in 19 eyes (83%) with an isolated serous RPED and in all 21 eyes (100%) with serous RPED and occult CNV. The pattern of ICG hyperfluorescence revealed focal CNV in 15 eyes and plaque CNV in 4 eyes with an isolated serous RPED. In eyes with serous RPED and occult CNV, focal CNV and plaque CNV were noted with ICG in 8 and 13 eyes, respectively. No follow-up was available for two eyes. Twenty eyes were treated with ICG-directed laser photocoagulation. In these eyes, the visual acuity remained stable in 6 eyes (30%) and decreased in 14 eyes (70%). Twenty-two eyes were observed, and the visual acuity remained stable in 8 (36%), improved in 2 (9%), and decreased in 12 eyes (55%)., Conclusions: Although ICG angiography may enhance visualization of CNV associated with serous RPED in AMD, ICG-directed laser treatment did not appear to improve visual acuity when compared with observed eyes in this series.

Objective: To evaluate optical coherence tomography (OCT), a novel noncontact and noninvasive imaging technique, for the diagnosis and quantitative characterization of epiretinal membranes., Methods: Optical coherence tomography is similar to an ultrasound B-scan, except that light rather than sound is used, which enables higher resolution. Over a 2-year period, OCT was used to examine 186 eyes of 160 patients who had a diagnosis of an epiretinal membrane. Optical coherence tomograms were correlated with visual acuity, slit-lamp biomicroscopy, fluorescein angiography, and funds photography., Results: Based on OCT, the epiretinal membrane was clearly separated from the retina with focal points of attachment in 49 eyes and globally adherent (no observed separation) in 125 eyes. Globally adherent membranes were associated with the following features: macular pseudohole (32 eyes), a difference in optical reflectivity between the membrane and retina (65 eyes), and/or a visible membrane tuft or edge (92 eyes). The membrane was undetectable on OCT in 12 eyes. The membrane thickness (mean +/- standard deviation) was 61 +/- 28 microns in the 169 eyes in which the thickness could be measured with OCT. Mean central macular thickness measured with OCT correlated with visual acuity (R2 = 0.73)., Conclusion: Optical coherence tomography was able to provide a structural assessment of the macula that was useful in the preoperative and postoperative evaluation of epiretinal membrane surgery. Quantitative measurements and the assessment of membrane adherence with OCT may be useful in characterizing the surgical prognosis of eyes with an epiretinal membrane.

Objective: The authors used optical coherence tomography (OCT), a new technique for cross-sectional imaging of the retina, to morphologically study eyes with nonexudative and exudative age-related macular degeneration (AMD). In patients with untreated exudative AMD, OCT was compared with fluorescein angiography in the identification and classification of choroidal neovascularization (CNV)., Methods: Optical coherence tomography imaging is analogous to ultrasound, except that the use of light rather than sound enables higher longitudinal resolution with a noncontact and noninvasive measurement. Optical coherence tomography was performed on 391 patients with the clinical diagnosis of AMD and was compared with conventional clinical examination to establish the cross-sectional morphology of different lesions and to develop a classification scheme for CNV. Optical coherence tomograms and fluorescein angiograms then were reviewed and correlated independently in 90 eyes of 86 patients who had exudative AMD without previous laser treatment., Results: Pigmentary changes, soft drusen, and detachments of the neurosensory retina and retinal pigment epithelium all had distinct presentations on OCT. Subretinal and intraretinal fluid caused changes in retinal thickness or elevation that could be quantified directly from the images. Choroidal neovascularization was evident in the tomograms as a thickening and fragmentation of a reflective layer, which corresponded to the retinal pigment epithelium and choriocapillaris. Changes in the reflection from this layer were observed during the progression of neovascularization, and after laser photocoagulation treatment. Classic CNV consistently presented with well-defined boundaries on OCT, whereas occult CNV had a variable cross-sectional appearance., Conclusions: Optical coherence tomography was useful in quantitatively evaluating subretinal and intraretinal fluid, assessing possible subfoveal involvement of neovascularization, and in monitoring CNV before and after laser photocoagulation. Optical coherence tomography was unable to detect CNV beneath serous pigment epithelial detachments. Optical coherence tomography may have potential in accurately defining the boundaries in a subset of angiographically occult CNV.

Background and Objective: To determine the use of indocyanine green (ICG) angiography in detecting choroidal neovascularization obscured by hemorrhage. STUDY/DESIGN: Indocyanine green angiography was performed on 20 consecutive patients who were suspected to have choroidal neovascular membranes (CNVs) that were obscured by subretinal or intraretinal hemorrhage on fluorescein angiography. The etiology of choroidal neovascularization was age-related macular degeneration., Results: In all patients, ICG angiography was able to detect some choroidal neovascularization. The entire extent of the CNV was identified in 12 (60%) of these patients after ICG angiography was performed. In the remaining eight eyes (40%), the CNV still was obscured partially by a thick layer of hemorrhage. Difficulty in detection was due to thick subretinal hemorrhage, lipid exudate, and pigment., Conclusion: The authors conclude that ICG angiography is superior to fluorescein angiography in showing the presence and extent of CNVs associated with age-related macular degeneration that are almost entirely obscured by hemorrhage.

Background and Objective: Recurrence of choroidal neovascular membranes (CNV) occurs frequently following laser photocoagulation. Recurrent CNV can be difficult to treat because they may not be well defined by fluorescein angiography., Patients and Methods: The fluorescein and indocyanine green (ICG) angiograms of 58 eyes of 57 patients who presented with clinically suspected recurrence were evaluated retrospectively., Results: In 14 eyes (24%), a well-defined recurrent CNV could be identified by evaluating the fluorescein angiogram. In 6 (14%) of the remaining 44 eyes, a well-defined recurrent CNV was identifiable by ICG angiography., Conclusion: A role for ICG angiography in the care of patients with suspected recurrent CNV is discussed.

Emergencies that affect the visual system can be devastating, with loss of vision being the most feared complication. In addition, visual signs and symptoms may indicate the coexistence of systemic conditions that can result in stroke, myocardial infarction and death. In patients who present with sudden loss of central or peripheral vision or pain in or around the eye, a careful examination of the eye and adnexa is warranted. Traumatic injuries also necessitate a careful examination to locate treatable problems. Prompt evaluation and treatment of vitreoretinal emergencies are important in the preservation of vision. These conditions can result in loss of vision or other severe consequences, especially if they are not promptly evaluated and treated by an ophthalmologist specializing in vitreoretinal disorders.

Objective: To evaluate optical coherence tomography, a new technique for high-resolution cross-sectional imaging of the retina, for quantitative assessment of retinal thickness in patients with macular edema., Design: Survey examination with optical coherence tomography of patients with macular edema., Setting: Referral eye center., Patients: Forty-nine patients with the clinical diagnosis of diabetes or diabetic retinopathy and 25 patients with macular edema secondary to retinal vein occlusion, uveitis, epiretinal membrane formation, or cataract extraction., Main Outcome Measures: Correlation of optical coherence tomograms with slit-lamp biomicroscopy, fluorescein angiography, and visual acuity., Results: Optical coherence tomograms of cystoid macular edema closely corresponded to known histopathologic characteristics. Quantitative measurement of retinal thickness is possible because of the well-defined boundaries in optical reflectivity at the inner and outer margins of the neurosensory retina. Serial optical coherence tomographic examinations allowed tracking of both the longitudinal progression of macular thickening and the resolution of macular edema after laser photocoagulation. In patients with diabetic retinopathy, measurements of central macular thickness with optical coherence tomography correlated with visual acuity, and optical coherence tomography was more sensitive than slit-lamp biomicroscopy to small changes in retinal thickness., Conclusions: Optical coherence tomography appears useful for objectively monitoring retinal thickness with high resolution in patients with macular edema. It may eventually prove to be a sensitive diagnostic test for the early detection of macular thickening in patients with diabetic retinopathy.

Purpose: To assess the potential of a new imaging technique, optical coherence tomography, for the diagnosis and monitoring of central serous chorioretinopathy. Optical coherence tomography is a novel noninvasive, noncontact imaging modality that produces high longitudinal resolution, cross-sectional tomographs of ocular tissue., Methods: Optical coherence tomography is analogous to ultrasound, except that it uses light rather than sound to obtain higher image resolution in the retina. Cross-sectional tomographs of optical reflectivity within the retina are produced with longitudinal resolution of 10 microns. Optical coherence tomography was used to examine 16 patients at a referral eye center whose initial examination disclosed the clinical diagnosis of central serous chorioretinopathy. The optical coherence tomography results were correlated with slit-lamp biomicroscopy, fundus photography, and fluorescein angiography., Results: The cross-sectional view produced by optical coherence tomography was effective in objectively quantifying the amount of serous retinal detachment in the disease. Optical coherence tomography disclosed detachments that were undetected by slit-lamp biomicroscopy. Longitudinal measurements with optical coherence tomography were successfully able to track the resolution of subretinal fluid accumulation., Conclusion: Optical coherence tomography is potentially useful as a new, noninvasive diagnostic technique for quantitative examination of patients with central serous chorioretinopathy and objectively monitoring the clinical course of the serous retinal detachment in this disease.

Purpose: To assess the potential of a new diagnostic technique called optical coherence tomography (OCT) for diagnosing and monitoring macular holes. This technique is a novel noninvasive, noncontact imaging modality that produces high longitudinal resolution (10-micron) cross-sectional tomographs of ocular tissue., Methods: Optical coherence tomography is analogous to ultrasound except that optical rather than acoustic reflectivity is measured. Cross-sectional tomographs of the retina profiling optical reflectivity in a thin, optical slice of tissue are obtained with a longitudinal resolution of 10 microns. Optical coherence tomography was used to examine 49 patients with the clinical diagnosis of idiopathic full-thickness macular hole, impending macular hole, epimacular membrane with macular pseudohole, or partial-thickness hole. The resulting OCTs were correlated with contact lens and slit-lamp biomicroscopy, fundus photography, and fluorescein angiography., Results: The cross-sectional view produced by OCT was effective in distinguishing full-thickness macular holes from partial-thickness holes, macular pseudoholes, and cysts. Optical coherence tomography was successful in staging macular holes and provided a quantitative measure of hole diameter and the amount of surrounding macular edema. Optical coherence tomography also was used to evaluate the vitreoretinal interface in patients' fellow eyes and was able to detect small separations of the posterior hyaloid from the retina., Conclusion: Optical coherence tomography appears potentially useful as a new, noninvasive, diagnostic technique for visualizing and quantitatively characterizing macular holes and assessing fellow eyes of patients with a macular hole. The tomographic information provided by OCT eventually may lead to a better understanding of the pathogenesis of macular hole formation.

Purpose: To evaluate the digital indocyanine green (ICG) videoangiography characteristics of well-defined choroidal neovascularization (CNV)., Methods: The authors retrospectively reviewed all ICG angiograms performed at the New England Eye Center over a 2-year period. Included in this study were all patients with the clinical and fluorescein angiographic diagnosis of well-defined CNV according to the Macular Photocoagulation Study Group criteria., Results: Of the 25 eligible patients, 18 (72%) had a well-demarcated area of ICG hyperfluorescence that was observed either both early and late (6 patients = 24%) or only late (12 patients = 48%) on the ICG angiogram. Five patients (20%) showed only poorly demarcated late hyperfluorescence on ICG angiography. Two patients (8%) had type II occult CNV associated with classic CNV as per the Macular Photocoagulation Study Group criteria. Both patients showed a late, well-demarcated area of ICG hyperfluorescence greater than the area imaged with fluorescein angiography., Conclusions: Choroidal neovascularization which is well-defined on fluorescein angiography has variable ICG appearances. When there is late leakage associated with a well-defined CNV on fluorescein angiography (type II occult CNV), ICG angiography may more completely delineate the extent of the lesion.

Background/purpose: To assess the potential of a new diagnostic technique called optical coherence tomography for imaging macular disease. Optical coherence tomography is a novel noninvasive, noncontact imaging modality which produces high depth resolution (10 microns) cross-sectional tomographs of ocular tissue. It is analogous to ultrasound, except that optical rather than acoustic reflectivity is measured., Methods: Optical coherence tomography images of the macula were obtained in 51 eyes of 44 patients with selected macular diseases. Imaging is performed in a manner compatible with slit-lamp indirect biomicroscopy so that high-resolution optical tomography may be accomplished simultaneously with normal ophthalmic examination. The time-of-flight delay of light backscattered from different layers in the retina is determined using low-coherence interferometry. Cross-sectional tomographs of the retina profiling optical reflectivity versus distance into the tissue are obtained in 2.5 seconds and with a longitudinal resolution of 10 microns., Results: Correlation of fundus examination and fluorescein angiography with optical coherence tomography tomographs was demonstrated in 12 eyes with the following pathologies: full- and partial-thickness macular hole, epiretinal membrane, macular edema, intraretinal exudate, idiopathic central serous chorioretinopathy, and detachments of the pigment epithelium and neurosensory retina., Conclusion: Optical coherence tomography is potentially a powerful tool for detecting and monitoring a variety of macular diseases, including macular edema, macular holes, and detachments of the neurosensory retina and pigment epithelium.

Proliferative diabetic retinopathy is one of the leading causes of permanent vision loss. Vitrectomy for the complications of proliferative changes has resulted in preservation of vision. Recent studies have focused on the cellular and structural changes in patients with proliferative changes. Data obtained from the early Treatment of Diabetic Retinopathy Study show that the rate of vitrectomy is reduced in eyes that have early-scatter photocoagulation in comparison with those that have deferral of treatment. The efficacy and complications of silicone oil tamponade have been more carefully evaluated with respect to complex detachments associated with proliferative diabetic retinopathy.

Indocyanine green (ICG) is a dye with an absorption peak (795 to 810 nm) similar to the emission peak of the diode laser (805 nm). Therefore, ICG dye-enhanced diode laser photocoagulation may permit the selective ablation of ICG-retaining choroidal neovascular membranes (CNVM) with relative sparing of the neighboring neurosensory retina. Ten patients with poorly defined subfoveal CNVM were treated with ICG dye-enhanced diode laser photocoagulation and followed for an average of 15 months. One of the 10 patients experienced an immediate significant drop in visual acuity after photocoagulation. Obliteration of the CNVM at the site of laser photocoagulation was confirmed by fluorescein angiography and ICG angiography. Subfoveal chorioretinal scar formation was noted postoperatively in all 10 patients. At last follow up, 9 of these 10 patients had no more than a two-line increase or decrease in visual acuity. These preliminary results suggest that poorly defined subfoveal CNVM can be successfully treated by ICG dye-enhanced diode laser photocoagulation with minimal adverse affect on visual acuity in most cases.

We report the case of a man with oxycephaly, bilateral ectopia lentis, and total retinal detachment in one eye. Although the association of retinal detachment with ectopia lentis is well known, this is the first report to our knowledge of a craniosynostosis, specifically oxycephaly, being associated with ectopia lentis and retinal detachment.

For the laser-induced shockwave lithotripsy (LISL) the laser-pulses of a Q-switched Nd:YAG laser produce an optical breakdown in the irrigation liquid surrounding the urinary stone. Subsequently high-pressure shockwaves are emitted causing stone fragmentation. Since the LISL is an endoscopic technique, problems arise from the transmission of the laser pulses through optical fibers. The intensity threshold for an optical breakdown in commonly used saline solution amounts to 21 GW/cm2, in optical silica fibers, to about 3 GW/cm2. Therefore bare fibers cannot be used without being destroyed by a breakdown. So we have developed an irrigation liquid by adding small quantities of metal ions to saline solution to lower the threshold intensity. The most suitable ion was Fe3+ in a concentration of 0.02 mmol/l, which shows a lowering to 5 GW/cm2. In combination with a spherically shaped fiber exit the intensities that have to be transmitted are below the threshold of the fiber material. Using this irrigation liquid the overall reliability of the method could be significantly increased and several stone fragmentations can be performed with a single optical fiber.

Background: Night blindness is an early symptom of retinitis pigmentosa. The rod photoreceptors are responsible for night vision and use rhodopsin as the photosensitive pigment., Methods and Results: We found three mutations in the human rhodopsin gene; each occurred exclusively in the affected members of some families with autosomal dominant retinitis pigmentosa. Two mutations were C-to-T transitions involving separate nucleotides of codon 347; the third was a C-to-G transversion in codon 58. Each mutation corresponded to a change in one amino acid residue in the rhodopsin molecule. None of these mutations were found in 106 unrelated normal subjects who served as controls. When the incidence of these three mutations was added to that of a previously reported mutation involving codon 23, 27 of 150 unrelated patients with autosomal dominant retinitis pigmentosa (18 percent) were found to carry one of these four defects in the rhodopsin gene. All 27 patients had abnormal rod function on monitoring of their electroretinograms. It appears that patients with the mutation involving codon 23 probably descend from a single ancestor., Conclusions: In some patients with autosomal dominant retinitis pigmentosa, the disease is caused by one of a variety of mutations of the rhodopsin gene.

Laser-induced shock wave lithotripsy (LISL) with a Q-switched neodymium-YAG laser depends on the generation of a laser-induced breakdown in the fluid surrounding the stone. An oscillating plasma bubble is created, directing shock waves towards the stone. These cavitational effects fragment the calculus into small particles. A new bifunctional laser is introduced: this allows both nanosecond pulses for shock wave generation and disintegration of urinary calculi and millisecond pulses for biliary stones and tissue coagulation. It can be supplied with 320-, 400-, and 600-micron fibers. We have treated 189 ureteric stones in 185 patients with laser lithotripsy utilizing flexible ureteroscopes (n = 26) or rigid ureteroscopes (n = 159). It proved possible to fragment 179 stones into small pieces. In eight patients LISL was not successful. A rigid cystoscope that can be dismantled into an upper and lower hemisheath for the introduction of flexible endoscopes into the ureter without prior dilatation of the ureteral orifice was used in 15 patients.

The gene for autosomal dominant retinitis pigmentosa in a large pedigree of Irish origin has recently been found to be linked to an anonymous polymorphic sequence, D3S47 (C17), from the long arm of chromosome 3. As the gene coding for rhodopsin is also assigned to the long arm of chromosome 3 and is expressed in rod photoreceptors that are affected early in this blinding disease, we searched for a mutation of the rhodopsin gene in patients with autosomal dominant retinitis pigmentosa. We found a C----A transversion in codon 23 (corresponding to a proline----histidine substitution) in 17 of 148 unrelated patients and not in any of 102 unaffected individuals. This result, coupled with the fact that the proline normally present at position 23 is highly conserved among the opsins and related G-protein receptors, indicates that this mutation could be the cause of one form of autosomal dominant retinitis pigmentosa.

With a high intensity Q-switched Nd-YAG laser shock waves can be generated in a liquid close to the calculus. Up to 80 mJ single pulse energy with 8 nsec pulse duration can be transmitted through flexible quartz fibers. Energy conversion and enhancement can be accomplished at the fiber tip with optical focussing of the light at the quartz tip, with irrigation solutions and with high pulse energies. Iron-III-dextran solutions (1 mg Fe3+/1) and magnesium chloride (50 mmol/l) increased the pressure in the laser induced breakdown up to ten times (8,000-10,000 bar). Smaller stone particles and higher efficacy in stone fragmentation could be achieved.

Laser energy of a Nd-YAG laser (1064 nm. wave length, 8 nsec pulse duration) was directed against various tissue cultures and the urothelium of the ureter, bladder and kidney parenchyma in pigs. Single pulse energy was 50 to 120 mJ with a repetition rate of 20 Hz. Urothelium and kidney parenchyma were irradiated in seven pigs. Tissue samples were examined histologically and electron microscopically directly, two, four, eight and 12 days after irradiation. No macroscopic lesion could be found. Maximum energy caused a small 'rupture cone' of 40 micron. depth. No thermic effects or necrosis resulted, so that no harm is to be expected with unintentional irradiation during laser stone disintegration.

The energy of a Nd-YAG laser (1,064 nm wave length, 8 ns pulse duration) was used to irradiate the urothelium of the ureter or bladder and kidney parenchyma in pigs. Single pulse energy was 50-120 mJ with a 20-Hz repetition rate. The horizontal laser beam was reflected 90 degrees down by a 100% mirror and with a specially designed apparatus focussed on the surface of the tissue. Laser light from a quartz glass fiber was also focussed directly onto the tissue. Urothelium and kidney parenchyma were irradiated in 7 pigs. Tissue samples were examined histologically and raster electron microscopically 2, 4, 8 and 12 days after irradiation. No macroscopic lesion could be found. Maximum energy caused a small cone of 40 micron depth. No thermic effects or necrosis resulted, so that no harm is to be expected with unintentional irradiation.

Animal studies using a high intensity nanosecond pulsed neodymium:YAG laser did not reveal any serious tissue damage. Following these investigations patient treatment was begun in June 1987. Laser energy of a neodymium:YAG laser with an 8 nsec. pulse duration and a repetition rate of up to 50 Hz. was coupled into a flexible 600 resp. 400 micron. quartz fiber. Laser-induced breakdown was created with 35 to 50 mJ. at the fiber tip, resulting in a shock wave that disintegrated the calculus into tiny fragments. A total of 56 patients with 58 calculi (54 ureteral and 4 kidney stones) was treated from June 1987 to March 1988. Of the calculi 48 could be fragmented completely, while 6 others were reduced to a size small enough to be removed with forceps. Four stones composed of calcium oxalate monohydrate could not be disintegrated. The combination of laser stone disintegration with flexible ureterorenoscopy implies the possibility of an atraumatic, 1-step procedure for fragmentation of ureteral and kidney calculi.

Experimental laser ablation of atheromatous plaques was performed with a bare quartz glass fiber, a metal probe, and a sapphire probe. The tissue response after irradiation with increasing energies was evaluated by means of light and scanning electron microscopy. Laser emission through the bare fiber caused a narrow, deep crater with an irregular surface surrounded by a zone of thermal necrosis. After tissue ablation with the metal probe, a disproportion between the small tissue defect and the large zone of thermal necrosis was observed. The largest tissue defect was vaporized by the sapphire contact probe. A small zone of thermal necrosis surrounded the laser crater.

Repeated dialysis in hospital or at home, and renal transplantation, carried out mainly with cadaver kidney, should permit in France, in the near future, treatment of all patients with chronic terminal renal failure. This report shows the results obtained between the 1st of November 1972 and the 1st of January 1975 in 136 patients treated without any selection at the Nephrology Department and Renal Transplantation Unit of the Pitié-Salpĕtrière Hospital in Paris, in connection with 20 public and private dialysis centers. 66 patients, i.e. 45% of all, were "high risk" patients, mainly because of their age or cardiovascular condition. The overall percentage of survival rate at 2 years in dialysed patients was 81%. It was 67% in the high risk group and 94% in the others. About half of the deaths occured because of cardiovascular reasons. 82 patients were considered for transplantation. Owing to the lack of donors, the number of transplanted patients was only 21. 19 transplantations were carried out with cadaver kidneys. On the 31st of December 1974, 15 patients, i.e. 71% lived with a functioning transplant. In the reported series, complete rehabilitation was obtained in 30% of cases. The results obtained justify, in our opinion, the policy of non-selection of patients.

Data on the elastic properties of corneal tissue are needed to define the parameters involved in a model for radial keratotomy. Using bovine corneal tissue, we measured stress-strain relationships of tissue at different locations in the cornea. From this data we calculated Young's modulus of elasticity of five specimens at peripheral and central corneal locations. Increasing levels of stress produced increased resistance to stretch, a property typical of soft biologic materials such as cornea. Linear regression analysis of the data showed that the elastic modulus of the peripheral tissue was greater than that of central tissue at all values of applied stress. These linear relationships were statistically different, using an analysis of covariance, indicating that peripheral corneal tissue is stiffer than central corneal tissue. This information supports the suggestion that a peripheral circular ligament of corneal tissue exists and helps to maintain the curvature of the cornea. It is the disruption of this ligament that is believed to cause some of the change in corneal curvature when radial keratotomy is done.

We evaluated full-field electroretinograms from members of a family with X-linked cone degeneration. The 15-year-old propositus had near normal visual acuity and a protan deficiency. His maternal grandfather and great uncle had a visual acuity of 20/200, a deficiency in color vision, and signs of macular degeneration; all had normal rod electroretinographic responses and diminished cone electroretinographic responses. The mother and maternal aunt of the propositus had normal visual acuity and diminished cone electroretinograms with predominant loss of red cone function. Their cone responses were greater than those of affected males. Genomic DNA isolated from these patients was analyzed with a red cone pigment gene cDNA probe that disclosed a 6.5-kilobase deletion in the red cone pigment gene. These findings substantiate that a defect in a gene encoding for a cone photoreceptor protein can lead to a cone photoreceptor degeneration.