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The purpose of this study was to evaluate the efficacy and visual outcome of massive submacular hemorrhage (SMH) displacement with a planned two-step pars plana vitrectomy (PPV) using tissue plasminogen activator (tPA) and perfluorocarbon liquid (PFCL) tamponade. A retrospective case series of patients with age related macular degeneration and SMH was used. All patients underwent a 23G PPV, subretinal tPA injection and a medium term PFCL tamponade. A second stage PPV for PFCL removal was performed 7-17 days later. The main outcome was the change in macular and sub-RPE thickness after 6 months. Secondary outcomes were visual acuity and complications. Seven patients (seven eyes) with mean age of 79.85 years were enrolled. The average SMH size was 17.5 disc area (range 4.5-33) with mean symptoms of a duration of 9.5 days (range: 2-21). SMH was successfully displaced in six eyes. Mean macular and sub-RPE thickness decreased from 1505μ to 711.3μ and 900 μ to 457μ, respectively. Visual acuity (VA) remained stable in five eyes. Complications included corneal edema and transient intraocular pressure elevation in three patients. SMH displacement using subretinal tPA injection and medium term PFCL tamponade is an effective alternative treatment option. In our experience, it can be safely performed, avoiding complications commonly attributed to other techniques.

BACKGROUND AND OBJECTIVE: To assess eyes with flat, irregular retinal pigment epithelial detachments (RPEDs) associated with central serous chorioretinopathy (CSCR) for choroidal neovascularization (CNV) using optical coherence tomography angiography (OCTA). MATERIALS AND METHODS: Retrospective review of OCTA images of chronic CSCR eyes with irregular RPED (group 1) and regular RPED (controls, group 2) for presence of CNV, subretinal fluid, and intraretinal fluid. Fluorescein angiography was also evaluated for CNV. RESULTS: CNV was detected using OCTA in 13 of 31 eyes (41.9%) in group 1 and in one of 18 eyes (5.6%) in group 2 ( P = .007). Irregular RPED was a risk factor for CNV (odds ratio [OR] = 12.28; 95% CI, 1.45–104.3). There was no significant difference between detection by OCTA and FA ( P = 1.0). Sensitivity and specificity of detection by OCTA were 85.7% and 95.7%, respectively. CONCLUSIONS: Irregular RPEDs in chronic CSCR eyes may harbor neovascularization more often than previously thought, which has implications on therapy. [ Ophthalmic Surg Imaging Laser Retina . 2016;47:128–133.]

BACKGROUND AND OBJECTIVE To evaluate the role of photodynamic therapy (PDT) in the management of vascularized pigment epithelial detachment in age-related macular degeneration (AMD) when the pigment epithelial detachment is the predominant component of the neovascular complex. PATIENTS AND METHODS Seventeen eyes of 17 patients underwent indocyanine green angiography-guided PDT and had at least 6 months of follow-up. Data retrieved included visual acuity and angiographic features prior to the treatment, number of PDT sessions, visual acuity, angiographic outcomes at the end of the follow-up, length of follow-up, and status of the fellow eye. RESULTS Eleven women and 6 men were included in the series, with an average age of 77 years and a mean follow-up time of 11 months. Six (35%) of the patients lost less than 3 lines of visual acuity, 6 (35%) lost between 3 and 6 lines, and 5 (30%) lost 6 or more lines. Angiographic outcomes were categorized as failures in 14 (82%) of the treated eyes and successful in 3 (17%) eyes. CONCLUSIONS In 82% of the eyes, PDT failed to flatten the pigment epithelial detachment or prevent growth of the choroidal neovascular membrane. Visual acuity outcomes correlated poorly with angiographic outcomes. PDT does not seem to improve the prognosis of eyes with large pigment epithelial detachments in AMD. [Ophthalmic Surg Lasers Imaging 2006;37:358-363.] AUTHORS From the Department of Ophthalmology (TW-J, HD, AA, JM), The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer; the Department of Ophthalmology (MG, AL), Tel-Aviv Sourasky Medical Center, Tel-Aviv; and the Department of Ophthalmology (RZ), Zriffin Medical Center, Beer Yacov, Israel. Accepted for publication October 30, 2005. Address reprint requests to Joseph Moisseiev, MD, Director, Department of Ophthalmology, The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer 52621, Israel.

This study aimed to determine the prevalence of hyperhomocystinemia among patients with nonarteritic anterior ischemic optic neuropathy (NAION), central retinal artery occlusion (CRAO), or central retinal vein occlusion (CRVO).Retrospective, case-control study.The study cohort consisted of 74 consecutive patients with NAION, CRAO, or CRVO who were examined at the Retina or Neuro-ophthalmological Unit of the Tel-Aviv Sourasky Medical Center from 1998 through 1999. The control group consisted of 81 consecutive patients of similar gender and age with no history of these pathologic conditions.Plasma homocystine levels of all study participants were obtained.Eighteen of 40 patients (45%) with NAION and eight of 13 patients (61.5%) with CRAO had hyperhomocystinemia compared with three of 21 (14.3%) in the CRVO group (P0.001) and eight (9.8%) in the control group (P0.0001). Hypertension and ischemic heart disease were significantly more prevalent in the NAION patients with elevated plasma homocystine.Our findings suggest that hyperhomocystinemia is a risk factor for NAION and CRAO.

PURPOSE To assess circulatory properties of eyes with progressive stages of diabetic retinopathy. METHODS The intraocular pressure, pulse amplitude (PA) and pulsatile ocular blood flow (POBF) were measured with a pneumatonometer (OBF Labs UK Ltd). The eyes were grouped: (a) normal control, n = 26, (b) diabetes with no observable diabetic retinopathy (NDR), n = 18, (c) mild to moderate non-proliferative diabetic retinopathy (NPDR), n = 20, and (d) very severe pre-proliferative and proliferative diabetic retinopathy (PPDR/PDR), n = 12. RESULTS The PA and POBF values were lower than normal values in the earliest stage (NDR). The POBF increased but was still below normal levels at the NPDR stage, and then increased to an above normal level in the PPDR/PDR stage of diabetic retinopathy. The PA was at normal levels in these later two stages. CONCLUSION An initial decrease in pulsatile ocular blood flow is present with the onset of diabetes where no diabetic retinopathy has yet occurred. Subsequently, the pulsatile ocular blood flow increases with the severity of the retinopathy.

The subcranial approach has emerged as a safe and effective procedure for resection of tumors of the anterior skull base. This approach allows excellent exposure of the nasal cavities, the paranasal sinuses, and the orbit 1 I also enables a wide approach to the anterior cranial fossa, while applying minimal retraction of the frontal lobes. Complications of this procedure are acceptable and comparable to the classical transfacial transcranial approac 2

Purpose: To examine the effect of an intravitreal dexamethasone drug delivery system (DEX-DDS) in the treatment of persistent cystoid macular edema (CME) of different etiologies. Methods: Thirty-seven eyes with persistent CME were treated with DEX-DDS and analyzed for changes in best-corrected visual acuity (BCVA) and optical coherence tomography. Eyes were categorized into three groups: diabetic macular edema (DME, n = 14), vein occlusion (n = 15) and uveitis (n = 7). Results: The mean follow-up was 22 ± 6.9 weeks. BCVA improved from 0.62 ± 0.38 to 0.35 ± 0.29 logMAR (p < 0.0001). Central macular thickness decreased by 184 ± 246 µm from baseline (p < 0.0001). In eyes where CME resolved and recurred, the average CME-free period was 11 weeks. The uveitis group showed faster CME resolution (2 weeks) and a longer CME-free period (20 weeks). Similar efficacy was shown for repeat DEX-DDS injections. The safety profile was good. Conclusion: DEX-DDS is beneficial in the treatment of persistent CME. In cases of uveitis, CME resolution is rapid, resulting in the longest effect duration, when compared with other CME etiologies.

Acute, as opposed to chronic, anterior uveitis is rarely associated with macular or optic nerve edema. Nevertheless, mild changes may not be visible on examination.To implement non-invasive ocular coherence tomography (OCT) for obtaining quantitative and qualitative data in the assessment of changes in macular morphology and peripapillary retinal nerve fiber layers in eyes with acute anterior uveitis.This retrospective case-control study was conducted in patients with unilateral acute anterior uveitis lasting for up to one month. Patients with evidence of other ocular disease or who had undergone intraocular surgery were excluded. We reviewed the charts of 14 consecutive patients who were diagnosed with acute unilateral anterior uveitis between 2007 and 2008 at the Tel Aviv Medical Center. Data on demographic details, ophthalmic examination, macular thickness and peripapillary retinal nerve fiber layer (RNFL) thickness (as demonstrated by OCT) were retrieved. Retinal and RNFL thickness was compared between the healthy fellow eye (control) and the uveitic eye in the central and four perifoveal quadrant regions, and RNFL thickness was compared in the mean and four quadrant values by Student's t-test.We evaluated 28 eyes of7 males and 7 females (mean age 37.7 years, range 20-65). The diagnoses were: idiopathic in five patients, ankylosing spondylitis in five, Crohn's disease in one patient and reactive arthritis in one. Nine patients were HLA-B27 positive. The retina and the peripapillary NFL in each area were thicker in the uveitic eyes compared to the controls. The difference was statistically significant. There was no correlation between the differences in OCT values and patients' demographic characteristics.OCT demonstrated that eyes with acute anterior uveitis had thicker maculae and thicker peripapillary RNFL than controls. This finding suggests that even milder anterior uveitis may be associated with some degree of posterior segment manifestations.

BACKGROUND AND OBJECTIVE: To evaluate choroidal thickness at five macular locations and assess the correlations between choroidal thickness at these locations with age, refractive error, and axial length. PATIENTS AND METHODS: Eighty-four eyes from 42 healthy adult volunteers were included. Enhanced depth imaging by spectral-domain optical coherence tomography was performed, and choroidal thickness was measured at five macular locations: subfoveal and 3 mm nasal, temporal, superior, and inferior. Correlations of choroidal thickness at each location with age, refractive error, and axial length were analyzed. RESULTS: Mean choroidal thicknesses at the subfoveal, superior, inferior, temporal, and nasal locations were 293, 308, 264, 263, and 174 μm, respectively. A correlation was found between choroidal thickness, age, refractive error, and axial length at all locations. CONCLUSION: Mean subfoveal choroidal thickness in healthy adults is approximately 300 μm. A correlation was found between choroidal thickness and all parameters studied.

Capsular bag distension syndrome after endophacoemulsification and in-the-bag intraocular lens (IOL) implantation has been reported. We describe 2 cases in which sulcus implantation of a posterior chamber IOL caused marked capsular bag distension. Both cases resolved with conservative treatment or a neodymium:YAG posterior capsulotomy.

PURPOSE To compare the preferential hyperacuity perimeter (PHP) with an Amsler grid in detection of age-related macular degeneration (AMD). METHODS Patients underwent refraction, visual acuity examination, PHP, Amsler grid examination, and macular photography. RESULTS One hundred fifty patients participated in the trial. Of 19 eyes with neovascular AMD, 19 (100%) were positive on the PHP, and 10 (53%), on the Amsler grid. Of 27 eyes with geographic atrophy, 26 (96%) were positive on the PHP, and 12 (44%), on the Amsler grid. Of 20 eyes with intermediate AMD, 14 (70%) were positive on the PHP, and 4 (20%), on the Amsler grid. Of 51 eyes with early AMD, 21 (41%) were positive on the PHP, and 4 (8%), on the Amsler grid. Of 33 eyes with no AMD, 6 (18%) were positive on the PHP, and none, on the Amsler grid. Thus, 80 (68%) of 117 patients with AMD had a positive PHP, while 30 (26%) had positive results of Amsler grid examination (P < 0.001, McNemar test). CONCLUSION The PHP had greater sensitivity, although with a relatively high rate of false-positive results for healthy individuals, than the Amsler grid in detecting AMD-related lesions.

To investigate a method that uses hyperacuity, the Macular Computerized Psychophysical Test (MCPT), to evaluate the central macular visual field in patients with age-related macular degeneration (AMD).Prospective case-control study of a diagnostic test.One hundred eight eyes of 108 Patients with AMD and 51 eyes of 51 age-matched patients with no retinal disease. Patients with AMD included 32 (30%) patients with choroidal neovascularization (CNV), 23 (21%) with geographic atrophy (GA), 35 (32%) with AMD with high-risk characteristics (HRC), and 18 (17%) with early AMD with non-HRC.Each subject underwent the MCPT, in which a virtual line composed of dots (white dots on a black background, maximal contrast) is flashed across different macular loci to a perifoveal radius of 7 degrees. Patients' responses were recorded and automatically analyzed using a specific algorithm developed before the onset of the study. All patients also underwent a supervised Amsler grid examination on the encounter before or after the MCPT in random order.Distortion, scotoma, or blurring perceived by the patient after a swift change of fixation was considered positive on the MCPT. Any perception of distortion, scotoma, or blurring was considered positive on the Amsler grid.Of the 32 patients with CNV, 30 (94%) were found positive on the MCPT and 11 (34%) were found positive on the Amsler grid. Of the 23 GA patients, 21 (91%) were found positive on the MCPT and 7 (30%) were found positive on the Amsler grid. Of the 35 HRC patients, 28 (80%) were found positive on the MCPT and 3 (9%) were found positive on the Amsler grid, and of the 18 early AMD with non-HRC patients, 8 (44%) were found positive on the MCPT and 3 (17%) were found positive on the Amsler grid. Of the 51 controls, 3 (6%) were positive on the MCPT and 1 (2%) was positive on the Amsler grid.The MCPT was superior to the Amsler grid in detecting AMD-related lesions in this cohort. Studies are underway to determine whether the MCPT is feasible for home monitoring to provide early detection of progression to CNV.

Objective To report on the occurrence of methylenetetrahydrofolate reductase (MTHFR) deficiency in patients with retinal vein occlusion (RVO). Design Prospective case series Participants Fifty-nine consecutive patients with newly diagnosed RVO seen at the Retina Unit in the Tel Aviv Medical Center during 1997. Methods/testing Interviews and multiple blood analyses were done. Data were compared to the reported incidence of MTHFR deficiency in the Israeli population at large. Results Twenty-six patients (44.1%) were heterozygotes and 11 (18.6%) were homozygotes for 677C-T mutation in MTHFR. The MTHFR 677C-T homozygosity was documented as being present in 10.4% of healthy individuals in the Israeli population. The difference in homozygosity was found to be statistically significant ( P = 0.038). Conclusions Retinal vein occlusion may be associated with a mutation in MTHFR.

The CT scans of three patients whose eyes were lacerated by trauma failed to demonstrate the lens. A slit-lamp examination of those eyes clearly indicated that the lenses were present behind the iris but that they were swollen and opaque (intumescent cataract). Apparently, a shift of water into the injured lens had reduced the expected hyperdense CT image of the lens to a level that it was no longer discernible.

Awareness and the use of nutritional supplementation for age-related macular degeneration patients

• Background: Our purpose was to investigate the efficacy of instillation of eye drops in the medial canthus with the lids closed at the time of application. • Methods: The pupils of 50 healthy volunteers were dilated with tropicamide 0.125%. The effect of the drug on pupillary dilatation when instilled in one eye with the lids closed was compared to its effect when instilled in the conventional mode in the other eye. • Results: Maximal mydriasis achieved was 2.75 ± 0.76 mm in the eye with closed lids and 2.8 ± 0.77 mm in the eye in which eye drops were instilled in the conventional mode. • Conclusion: Eye drop instillation in the medial canthus with the lids closed at the time of application seems to be an effective means of ophthalmic drug delivery.

Trachoma is still one of the world's major blinding diseases. Characteristically, trachoma causes deep scarring of the conjunctiva and tarsus that can result in tear deficiency, trichiasis, and entropion. Another common finding is a diffused corneal opacity that is the end stage of peripheral and central corneal infiltrates. The conventional treatment of the corneal opacities is keratoplasty, which has a guarded prognosis because of severe dryness and trichiasis. We report on our experience in treating patients with corneal trachoma with phototherapeutic keratectomy (PTK) with the excimer laser. [J Refract Corneal Surg. 1994;10:S290-S292.]

Transient phacodonesis after circling buckle procedure for rhegmatogenous retinal detachment

A series of 34 patients with Fuchs' endothelial corneal dystrophy was studied to investigate a possible association with hypermetropia and angleclosure glaucoma. The refraction, axial length, anterior chamber depth, and prevalence of angle-closure glaucoma of the patients were compared with those of a control group of 56 patients. Twelve of 34 patients with Fuchs' dystrophy (35.3%) had had attacks of angle-closure glaucoma requiring iridectomy in the past. Fuchs' dystrophy patients had a shorter axial length (mean, 22.5 mm; range, 19.8-25.6) and a shallower anterior chamber (mean, 2.4 mm; range, 1.8-3.45), as well as a higher frequency of hypermetropia than the control group patients (axial length: mean, 23.7 mm; range, 21.4-28.1; anterior chamber depth: mean 2.87 mm; range, 2.2-4.0). Fuchs' corneal endothelial dystrophy patients have a high incidence of angle-closure glaucoma because of their high incidence of axial hypermetropia and shallow anterior chamber.