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1/158. The use of vitreoretinal surgical techniques in subfoveal choroidal neovascularization.

    Subfoveal choroidal neovascularization generally carries a poor visual prognosis. This review traces the evolving vitreoretinal surgical techniques for the treatment of this entity. Extensive retinotomies to expose large submacular scars caused frequent complications and poor visual results. More recently, small retinotomy techniques with manipulation of subfoveal membranes behind neurosensory retina have been described. Removal of subfoveal neovascularization with this latter approach is summarized. Visual results are variable. If foveal retinal pigment epithelium can be preserved, excellent central visual function can be regained. In the majority of subfoveal membranes, surgical removal creates retinal pigment epithelium defects, and acuity is limited. These approaches merit further evaluation.
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2/158. Peripheral choriovitreal neovascularization in proliferative diabetic retinopathy: histopathologic and ultrastructural study.

    We describe the histopathologic and ultrastructural evidence of choriovitreal neovascularization in the peripheral fundus of a non-vitrectomized eye with proliferative diabetic retinopathy (PDR). One eye with PDR was surgically enucleated because of neovascular glaucoma and studied with light and electron microscopy. The eye had neovascular membranes at the ora serrata of the peripheral fundus. The newly formed vessels originated from the choroid, passed through Bruch's membrane and the retina, and extended into the vitreous. These vessels had either developing or mature characteristics. The endothelial cells of the developing vessels contained a bulky cytoplasm with many intracytoplasmic filaments, ribosomes and rough endoplasmic reticulum. Budding endothelial cells were frequently found in the developing vessels. The endothelial cells of the mature vessels had attenuated cytoplasm and fenestrations with diaphragms. These observations suggest that choriovitreal neovascularization in the peripheral fundus is one of the features of PDR.
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3/158. Ill-defined choroidal neovascularization within ocular histoplasmosis scars.

    Seven patients with scars typical of ocular histoplasmosis syndrome presented with new symptoms of decreased vision or metamorphopsia. In each patient the symptoms corresponded to an atrophic or "punched-out" histoplasmosis scar in the macula. Clinically, a small amount of subretinal fluid overlying the scars and slight hyperfluorescence were seen on fluorescein angiography. These findings were due to a choroidal neovascular membrane growing within the margins of the atrophic scar. The membranes were difficult to diagnose because of the absence of hemorrhage, pigmentation, or growth of vessels beyond the margins of the scar. Clinicians should be aware that these patients may have early and growing choroidal neovascularization and may need to undergo photocoagulation or to be followed closely.
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4/158. Scatter macular photocoagulation for subfoveal neovascular membranes in age-related macular degeneration. A pilot study.

    Forty eyes with age-related macular degeneration and a choroidal neovascular membrane involving the entire foveal avascular zone were enrolled in a pilot study to evaluate an unconventional photocoagulation technique that was postulated to stimulate inhibitors of neovascularization. Eighteen (45%) eyes were treated with extrafoveal scatter macular photocoagulation, and 22 (55%) eyes were treated with this type of photocoagulation and focal extrafoveal ablation of the choroidal neovascular membrane. The eyes were followed for at least 1 year and up to 4 years (average, 2.4 years). One to 7 months after treatment, approximately 45% of the membranes treated with each technique did not leak fluorescein during angiography. The absence of leakage was associated with better visual acuity, but this difference was not statistically significant. At the beginning of the study, the visual acuity was 20/200 or better in 32 eyes (80%) and 20/80 or better in 11 (28%). At the conclusion of the study, the visual acuity was 20/200 or better in 21 eyes (53%) and 20/80 or better in 7 (18%). After treatment, 24 eyes (60%) had the same or better (plus or minus two lines) visual acuities. Compared with eyes in natural history studies, those treated with scatter macular photocoagulation had less visual loss from baseline but did not recover acuity of 20/100 or better more frequently. There was no difference in results between these two methods of treatment.
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5/158. Acute onset of rubeosis iridis after diabetic vitrectomy can indicate peripheral traction retinal detachment.

    Acute onset or exacerbation of rubeosis iridis associated with peripheral retinal detachment after vitrectomy represents a rare but serious complication of advanced diabetic retinopathy that indicates a poor prognosis. The clinical features, surgical procedures, and anatomical and functional results for a series of 13 eyes presenting with this complication are reported. In addition to rubeosis iridis and peripheral retinal detachment, anterior hyaloidal fibrovascular proliferation (APH) was also present in 10 eyes. All eyes had undergone one or more previous vitrectomies for diabetic complications such as nonclearing vitreous hemorrhage and traction retinal detachment. Treatment modalities for iris neovascularization and peripheral retinal detachment included reattachment procedures with an encircling band, peripheral membrane peeling, and, if necessary, peripheral retinectomy. Peripheral coagulation therapy was performed in all eyes. Eight eyes received an intraocular silicone-oil tamponade. Early results (4 weeks post-surgery) showed regression or stabilization of rubeosis iridis in all eyes. Later results (mean, 9 months post-surgery) revealed nine eyes with stabilized anterior ocular neovascularization and reattachment of the retina. Four eyes were anatomic failures due to recurrent rubeosis iridis/AHP or traction retinal detachment, and three of them also developed ocular hypotony. None of the eyes has thus far been lost as a result of neovascular glaucoma or painful phthisis. Ambulatory vision was retained in ten eyes, but function was limited to a low level as a result of the underlying ischemic disease. Immediate reattachment surgery in combination with anterior/peripheral coagulation therapy was shown to be an effective measure for controlling iris neovascular activity in eyes afflicted with acute anterior ocular neovascularization.
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6/158. Clinicopathologic correlation of occult choroidal neovascularization in age-related macular degeneration.

    We report the clinicopathologic features of an eye with occult choroidal neovascularization associated with age-related macular degeneration. Ophthalmoscopic findings at presentation included subretinal fluid and lipid. We noted angiographic staining of irregularly elevated areas of retinal pigment epithelium. In the late phase of the angiogram, fluorescein leakage at the level of the outer retina was observed that did not correspond to well-demarcated areas of hyperfluorescence in earlier phases. The patient was randomized to treatment in a pilot trial comparing the effects of grid laser treatment with the effects of no treatment for occult choroidal neovascularization. Three weeks after treatment, some of the subretinal fluid had cleared and vision improved. The patient died 6 weeks after laser treatment. Histopathologic study disclosed a subretinal pigment epithelial fibrovascular membrane. Neovascularization originated from the choroid.
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7/158. Transmission electron microscopic study of a subretinal choroidal neovascular membrane due to age-related macular degeneration.

    From a patient with age-related macular degeneration we studied ultrastructurally a disciform scar that was removed from an eye with a vitreous hemorrhage. In cross section, the scar was divided by a retinal pigment epithelial (RPE) cell layer. The choroidal side consisted of fibrovascular tissue with active neovascular buds and inflammatory cells, including macrophages attached to the RPE basement membrane. Apart from the RPE, no components of Bruch's membrane could be identified. The retinal side contained organizing hemorrhage and a collagenous matrix with fibroblastlike cells probably of RPE and choroidal origin. The anatomy and the clinical findings at surgery suggest that such scars lie on (rather than within) the inner collagenous layer of Bruch's membrane and contain two components divided by the original RPE layer. The choroidal side is fibrovascular, including active neovascularization, and the retinal side is fibrous and formed by metaplastic RPE cells and choroidal fibrovascular ingrowth.
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8/158. Surgical management of subfoveal choroidal neovascularization.

    BACKGROUND: Subfoveal choroidal neovascularization (CNV) usually is associated with a poor visual prognosis. Laser photocoagulation of certain subfoveal membranes secondary to age-related macular degeneration (ARMD) appears preferable to observation based on recent Macular Photocoagulation Study (MPS) findings but is associated with decreased vision. The authors explored the use of vitreoretinal surgical techniques as an alternative method of eradicating subfoveal CNV. methods: After vitrectomy, a small retinotomy technique was used to extract or disconnect from the choroidal circulation subfoveal CNV in 58 eyes. There were 33 eyes with ARMD, 20 eyes with presumed ocular histoplasmosis, and 5 eyes with miscellaneous etiologies. Five eyes also received subfoveal RPE patches. RESULTS: With limited follow-up, significant improvement in vision (defined as 2 Snellen lines) was achieved in 7 of 22 eyes with ARMD CNV removal (1 eye 20/20), 0 of 4 eyes with ARMD CNV removal and RPE patches, and 1 of 7 eyes with ARMD CNV disconnection. Significant improvement was achieved in 6 of 16 eyes with presumed ocular histoplasmosis removal and 0 of 4 eyes with presumed ocular histoplasmosis CNV disconnection. In 5 eyes with miscellaneous CNV, 2 improved (20/20 and 20/40). CNV recurred in 29%. CONCLUSIONS: Some patients with subfoveal CNV appear to benefit from surgical removal. Only rarely do eyes with ARMD improve. Longer-term follow-up and refined case selection are required before this approach can be widely recommended.
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9/158. Idiopathic choriovitreal membrane--a case report.

    A case of a macular idiopathic choriovitreal membrane is described which developed in a diabetic man. On initial examination the patient was found to have a pigment epithelial detachment with a choroidal neovascular membrane (CNVM) in the right eye. Two months after the first visit the CNVM was seen to have penetrated the retina and presented as a choriovitreal membrane. Panretinal photocoagulation was applied after which the choriovitreal membrane demonstrated fibrotic involution. This case is unusual in that the choriovitreal membrane developed in the absence of a choroidal or retinal pigment epithelial disease process that may be associated with a CNVM as well as in the absence of previous macular laser treatment.
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10/158. The natural history of juxtafoveal and subfoveal choroidal neovascularization in high myopia.

    BACKGROUND: To assess the natural history of juxtafoveal and subfoveal choroidal neovascularization in eyes with high myopia. methods: We retrospectively reviewed the charts of 31 patients (31 eyes) with myopia > or = 6 diopters, well-defined juxtafoveal (1-200 microm from the foveal center) or subfoveal choroidal neovascularization (CNV) on fluorescein angiography at baseline, no prior laser treatment, age < or = 55 years and presenting visual acuity (VA) > or = 20/200. Initial and final VA were compared with the Wilcoxon signed rank test. Multifactor analysis of variance was used to assess the association between baseline characteristics of the lesion and final VA. RESULTS: Twenty-two patients were females and 9 males with a median age of 44 years (range 14-55). Median diopters spherical equivalent was -11.5 (range -6, -25). Follow-up ranged from 1 to 20 years (median, 3 years). Nine eyes had juxtafoveal CNV and 22 subfoveal involvement. Median final VA (20/100) was significantly worse than median initial VA (20/50)(p = 0.02). A decrease in VA > or = 2 lines occurred in 18 eyes, whereas 8 eyes remained stable and 5 improved (4 juxtafoveal membranes and 1 subfoveal membrane). Of the 9 juxtafoveal CNV, 7 had a final VA > or = 20/40 after a median follow-up of 4 years. By contrast, only 2 of the 22 subfoveal CNV had a final VA > or = 20/40 (median, 20/100) with a median follow-up of 2.5 years. The only factor associated with better final VA was the initial location of CNV (p = 0.0000). CONCLUSION: This study confirms the poor functional outcome of subfoveal CNV in degenerative myopia with more than 70% of patients having a final VA of 20/100 or less. Juxtafoveal CNV shows a better functional prognosis. These differences should be considered when planning treatment strategies.
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