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UNLABELLED: PURPORSE: To determine the associated balance of forces of the vitreofoveal interface in focal vitreomacular traction evolving to full-thickness macular hole (FTMH) and to link/explain the observed changes in the context of mathematical and physics models. PATIENTS AND METHODS: This is a multicenter, prospective, and observational case series conducted at the Vitreoretinal Department of three different referral centers. Fellow eyes of patients with unilateral idiopathic FTMH were included. Eighty-nine patients were included in the analysis. The fellow normal eye of the study patients was imaged with spectral-domain optical coherence tomography. The main outcome measure was the optical-coherence-tomography-defined characteristics of the vitreofoveal interface and their analysis with mathematical and physics models at the end of follow-up period. RESULTS: Of the included 89 patients (66 women and 23 men; mean age±SD, 68.5 years±9.8), 10 (11.2%) developed FTMH at the fellow eye at the end of the follow-up period. We observed two types of vitreofoveal attachment. A V-shaped (cord-like) configuration and a U-shaped configuration. The eyes with the V-shaped attachment demonstrated initial structural changes in the outer foveal layers and the eyes with the U-shaped attachment showed inner morphological changes. CONCLUSION: We hypothesize that the type (V- or U-shaped) of the vitreofoveal attachment may affect the type and location of the initial structural change leading to the formation of FTMH from the stage of the focal vitreomacular traction.

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PURPOSE: To describe the evolution of a full-thickness macular hole in myopic foveoschisis. METHODS: A 62-year-old woman with myopic foveoschisis developed a full-thickness maculare hole after 36 months. The evolution of the macular hole was observed by optical coherence tomography (Stratus OCT3). RESULTS: During the first stages of macular hole formation, a small triangular foveolar retinal detachment, with corresponding elevation of inner segment/outer segment junction line, was observed. The retinal detachment later enlarged. A concrete intraretinal columnar structure, extending between the inner fovea's layer and the roof of foveal detachment, was observed. CONCLUSION: The so-called columnar structure, detected in our case, possibly transmitted the vitreomacular traction contributing to the opening of the RD roof, the outer lamellar macular hole formation, and finally in the creation of a full-thickness macular hole.

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PURPOSE: To study the natural course of lamellar macular hole (LMH) as examined by optical coherence tomography (OCT) in a noncomparative observational case series. METHODS: Forty-one eyes of 41 patients with LMH were included in this analysis. Baseline and final OCT findings related to LMH diameter, foveal thickness and visual acuity (VA) were collected and compared. Mean follow-up was 37.1 months. Main outcome measures were best-corrected visual acuity (BCVA), diameter of the LMH opening, foveal thickness, epiretinal membrane (ERM), posterior vitreous detachment (PVD) and vitreoretinal traction. RESULTS: The diameter of the LMH increased by an average of 13.7%. A statistically significant association was found between the LMH diameter increase and the presence of ERM. The mean foveal thickness depicted a statistically significant decrease between the initial and the final examination. The decrease of the foveal thickness showed to correlate with visual acuity deterioration. BCVA was stable in 30 (78%) and deteriorated in 11 (22%) cases. In eight of the 11 cases, the visual acuity deterioration ranged from 2 to 15 letters. CONCLUSION: We identified an increase of LMH diameter related to the presence of ERM and a decrease of the foveal thickness within a period of observation which ranged from 24 to 54 months (mean 37.1 months).

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PURPOSE: To study the evolution of idiopathic epiretinal membrane (IERM) as examined by optical coherence tomography (OCT) in the 1-mm-diameter circle centered on the fovea. METHODS: In a case series study 71 subjects (71 eyes) with idiopathic epiretinal membrane and macular thickness greater than 220-/+10 micro m were evaluated by OCT. The fellow healthy eye of 52 patients was used as the control group. The mean follow-up was 36 months. Measurements of macular thickness at baseline and at the final examination were performed. Best-corrected visual acuity was expressed as the number of letters read on the Early Treatment Diabetic Retinopathy Study chart. RESULTS: Within the inner macular central circle of 1 mm diameter the thickness of the fovea increased by an average of 12.29% (p<0.001) during follow-up in the study group while in the control group the foveal thickness decreased by -0.44% (p=0.43). The mean increase of the fovea thickness was accompanied by a modest decrease of best-corrected visual acuity from a mean 43.26 letters at baseline to a mean 39.20 letters at the last examination (p<0.001). CONCLUSIONS: In the study group the macular thickness increased during a mean follow-up period of 36 months. The average increase between the baseline and the final examination at the inner central circle of 1 mm diameter was 12.29%. Decrease of the macular thickness was not observed in any of the studied cases. The mean decrease of visual acuity was 9.4%. OCT also depicted with accuracy the changing morphology of the affected macula during the study period.

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PURPOSE: To report in a single case the effectiveness of bevacizumab in the treatment of feeder vessels (FVs) of subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). METHODS: One patient received intravitreal bevacizumab (Avastin) (1.25 mg) which was repeated 4 weeks after the first intravitreal injection. Fluorescein angiography and optical coherence tomography (OCT) were performed. Visual acuity (VA) was also checked. RESULTS: Occlusion of the FVs was observed 4 weeks after starting treatment. During the follow-up period and in the final examination 13 months after the first injection, the FVs remained occluded. Complete resolution of macular edema and improvement of the VA were noticed after the second bevacizumab intravitreal injection. CONCLUSIONS: This report documents the successful occlusion of FVs of subfoveal neovascularization after two intravitreal bevacizumab injections in a patient who was followed up for 1 year after the occlusion. Further long-term investigation is warranted given the promising 12-month results.

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PURPOSE: To evaluate by optical coherence tomography (OCT) the vitreous involvement in full thickness macular hole associated with optic disk pit maculopathy. METHODS: Two patients with optic disk pit maculopathy and full thickness macular hole underwent OCT for evaluation of vitreous involvement in the pathogenesis of the disease. Fluorescein angiography and fundus photographs were also performed. RESULTS: OCT documented the presence of vitreous traction at the edge of the full thickness macular hole in the first case and on the elevated macula in the second case. Partial posterior vitreous detachment was also noticed. CONCLUSIONS: Previously unreported OCT findings such as vitreous traction at the edge of the macular hole and on the elevated macula were found. OCT provided evidence for vitreous participation in full thickness macular hole associated with optic disk pit maculopathy. OCT was also able to show that the full thickness macular hole and optic disk pit maculopathy were probably caused by similar vitreous tractional forces.

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PURPOSE: To report a case of pigment epithelium detachment (PED) which appeared after photodynamic therapy (PDT) and was followed up for 50 months. METHODS: Case report. RESULTS: A 71-year-old woman with occult choroidal neovascular membrane due to age-related macular degeneration (ARMD) developed PED 48 hours after PDT. The patient was studied with fluorescein angiography (FA) and optical coherence tomography (OCT). Fluorescein angiographic evidence of PED remained essentially unchanged during the follow-up period of 50 months. Although OCT initially gave clear evidence of PED, in the last 12 months of follow-up the PED appears to have resolved. CONCLUSIONS: Photodynamic treatment could be involved in the occurrence of PED in occult choroidal neovascular membrane due to ARMD. In this particular case OCT could be considered since it offers useful information in the pretreatment and the post-treatment follow-up period.

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PURPOSE: To evaluate macular function, before and after photodynamic therapy (PDT) using multifocal electroretinogram (MF-ERG), in eyes suffering from classic subfoveal choroidal neovascularization (CNV) resulting from age-related macular degeneration (ARMD). METHODS: Twenty eyes of 20 patients (10 male, 10 female) with classic subfoveal CNV resulting from ARMD were studied. All received PDT with verteporfin. Fluorescein angiography and mF-ERG were performed in each patient 1 day before and 1 week, 3 months and 6 months after photodynamic therapy. RESULTS: Before treatment, visual acuity (VA) and electrical retinal response densities (RRD) in the foveal and parafoveal areas were low in all patients. The mean VA (ETDRS chart) before PDT was 24.35 (SD, 15). The mean RRD before PDT in area 1 was 4.39 nV/deg(2) (SD, 2.59) and in area 2 it was 2.11 (SD, 1.86). Six months after treatment, the mean VA was stable in 70% of the patients. However, the mean RRD after PDT was 2.24 nV/deg(2) in area 1 (SD, 2.59) and 1.07 nV/deg(2) in area 2 (SD, 1.59). CONCLUSION: Multifocal ERG objectively evaluates the macular function in eyes with CNV attributable to ARMD. In this study, the stability of VA coincided with a clear impairment of electrical activity of the foveal and parafoveal areas. This finding suggests that MF-ERG should be adopted to assess the efficacy of PDT objectively in the treatment of ARMD.

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PURPOSE: To evaluate by multifocal electroretinogram (MF-ERG) macular function before and after photodynamic therapy (PDT) in myopic eyes with choroidal neovascularization (CNV). PATIENTS AND METHODS: Ten eyes with classic subfoveal CNV due to pathologic myopia were studied with MF-ERG before and after PDT in order to evaluate the results of PDT with verteporfin. The post-treatment follow-up was 6 months. Visual acuity testing, ophthalmic examinations, fluorescein and indocyanine green angiograms, and MF-ERG recordings were used to evaluate the results of PDT with verteporfin. The post-treatment period was 6 months. RESULTS: Before treatment, the electrical response densities in the foveal and perifoveal areas were apparently decreased in all patients. Six months after treatment, the mean retinal response densities in the same areas were found to be higher than before treatment. CONCLUSIONS: MF-ERG evaluates objectively the macular function in myopic eyes with CNV. After successful PDT, the electrical activity of the foveal and parafoveal areas is higher than before treatment. This finding postulates the efficacy of PDT in the treatment of CNV.

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PURPOSE: To report the frequency and the evolution of the extensive retinal hemorrhages that can appear within 48 h after the application of photodynamic therapy. METHODS: Two hundred and fifteen individual eyes of 194 consecutive patients with subfoveal choroidal neovascularization (CNV) due to age-related macular degeneration who underwent photodynamic treatment were included in the study. The visual acuity was measured before and after treatment. Color and red-free photographs were taken. Fluorescein angiography and optical coherence tomography (OCT) were also performed in order to describe the macular hemorrhages. RESULTS: Four out of 215 eyes developed macular hemorrhage within 48 h after the photodynamic therapy. Before treatment one of the four patients had classic CNV, one predominantly classic and two patients occult CNV without any classic component. In all four cases, the hemorrhage after photodynamic therapy (PDT) was extensive, it extended beyond the arcades and it was not absorbed during the follow-up period, which ranged from 11 to 21 months. The greatest linear dimension of the hemorrhage was extremely high (>12,000 microm). CONCLUSION: Extensive macular hemorrhage was observed in 1.86% of the studied cases. The hemorrhage was not related to the type of the CNV lesion before treatment. The size and the appearance of hemorrhage within 48 h after treatment support the view that the hemorrhage is a direct consequence of the photodynamic therapy and not related to the natural course of the disease.

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PURPOSE: The main purpose of this study is to evaluate the visual function of eyes operated on for rhegmatogenous retinal detachment. METHODS: Fifteen patients were studied suffering from peripheral retinal detachment treated with the Lincoff-Custodis method. Visual field was tested with the Humphrey Field Analyzer and the analyzer program 30-2, which scanned a 0-30 degrees field. The multifocal ERG was recorded with the VERIS III (Visual Evoked Imaging System, Tomey, Nagoya, Japan). RESULTS: There was great loss of retinal response densities in the area of retinal detachment (1.3 +/- 0.7 nV/deg2). However, a decrease in retinal response densities was also recorded in the reattached retina (6.90 +/- 0.7 nV/deg2). CONCLUSIONS: MFERG is an objective tool for monitoring the functional abnormalities affecting the vision of eyes operated for retinal detachment.

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To evaluate the visual function of 15 eyes suffering from macular hole the multifocal ERG was used pre and postoperatively. In all the cases a successful vitrectomy has been done with macular hole closure in all the eyes. The Multifocal ERG shows an improvement of retinal response density in regions 1 and 2, even in the 2 eyes with unchanged visual acuity postoperatively. Although a relationship exist between the postoperative retinal response density and the visual acuity, the retinal response density varies between eyes with the same visual acuity.

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PURPOSE: To report optical coherence tomography in optic disk pit maculopathy treated with macular scleral buckling procedure. METHODS: Twenty six eyes (26 patients) with optic disk pit maculopathy were treated with macular buckling procedure and evaluated with optical coherence tomography. In group 1, five eyes were evaluated with optical coherence tomography before and after macular buckling procedure. In group 2, 21 eyes were evaluated with optical coherence tomography after macular buckling procedure. With optical coherence tomography, cross-sectional, horizontal retinal images were obtained through the fovea and optic disk pit. RESULTS: In group 1, four of five eyes showed absorption of intraretinal fluid 7 to 9 months after macular buckling procedure. After absorption of fluid, retinal thickness in the foveal center ranged from 128 to 178 microm. In one eye the channel from optic disk to fovea reopened and fluid reappeared. In group 2, 20 of 21 eyes showed absorption of intraretinal schisis and subretinal fluid after macular buckling procedure. After absorption of fluid, retinal thickness in the foveal center ranged from 119 to 216 microm. CONCLUSIONS: In optic disk pit maculopathy, optical coherence tomography enabled morphologic assessment of the retina before and after macular buckling procedure. In the successfully treated cases the permanent closure of the connection between the optic disk pit and the intraretinal schisis was demonstrated. Eventual disappearance of schisis and subretinal fluid was depicted. It was also proved that the thickness of the macula returned to normal and visual acuity improved.

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PURPOSE: To compare pain control using topical anesthesia with that using sub-Tenon's anesthesia for clear corneal phacoemulsification cataract surgery and foldable intraocular lens (IOL) implantation. SETTING: Departments of Ophthalmology, General Hospital Asklepeion Voulas and General Hospital of Athens, University of Athens, Athens, Greece. METHODS: One hundred consecutive patients scheduled for bilateral cataract surgery 1 to 2 months apart were prospectively randomized to receive topical anesthesia (100 eyes) or sub-Tenon's anesthesia (100 eyes). The randomization was stratified so that one half of first-eye surgeries and one half of second-eye surgeries were assigned to each anesthesia group, with each patient receiving each type of anesthesia once. All patients had clear corneal phacoemulsification with foldable IOL implantation. Patients were asked to rate their pain level on a 10-point scale for 4 periods: during the administration of the anesthetic agent, during surgery, immediately after surgery, and 24 hours postoperatively. The surgeon recorded his subjective assessment of ease of surgery and surgical complications using a standardized template. RESULTS: Eighty-one percent of patients who received topical anesthesia and 8% of patients who received sub-Tenon's anesthesia reported no pain during delivery of the anesthetic agent. The mean pain score was 0.19 +/- 0.39 (SD) in the topical group and 1.35 +/- 0.63 in the sub-Tenon's group. The difference between groups was statistically significant (P <.001). Seventy-two percent of patients in the topical anesthesia group and 86% in the sub-Tenon's anesthesia group reported no pain or slight discomfort during surgery (mean score 1.13 +/- 1.57 and 0.57 +/- 1.28, respectively) (P <.001). Ninety percent of topical anesthesia patients and 100% of sub-Tenon's anesthesia patients reported no pain or slight discomfort 30 minutes postoperatively (mean score 0.80 +/- 0.93 and 0.12 +/- 036, respectively) (P <.001). All patients in the topical anesthesia group and 77% in the sub-Tenon's group reported no pain 24 hours postoperatively (mean pain 0.00 +/- 0.00 and 0.23 +/- 0.40, respectively) (P <.001). Complications including prolonged akinesia of the globe, chemosis, and conjunctival hemorrhage occurred significantly more frequently in the sub-Tenon's than in the topical group (P <.001). CONCLUSIONS: Patients having cataract surgery under topical anesthesia had more intraoperative and postoperative discomfort than patients receiving sub-Tenon's anesthesia. However, patients having topical anesthesia reported less pain during its administration and had fewer complications. Both anesthesia methods provided high levels of pain control without additional sedation.

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We used the Ahmed valve for the treatment of 142 eyes with high-risk glaucoma. The glaucoma was neovascular in 74 cases, aphakic or pseudophakic in 19 eyes and occurred after previous faliure of filtering surgery in 49 eyes. Preoperative mean IOP was 31.6+/-10.4 mmHg under topical and/or systemic treatment. The success rate (IOP<22 mmHg with only topical treatment) was 56.3% with a mean follow-up of 32.4 months. Complications were fewer and milder compared with those reported for other types of drainage implants and for other types of antiglaucoma procedures.

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PURPOSE: To investigate the hemostatic effects of SF6 gas in preventing postoperative vitreous hemorrhage in diabetic vitrectomy. METHODS: A prospective, randomized study of 33 diabetic eyes with vitreous hemorrhage, treated by vitrectomy. In 17 of our cases SF6 20% was injected into the eye at the end of the operation, while in 16 cases BSS remained in the vitreous cavity. RESULTS: The incidence of vitreous hemorrhage recurrence was 17.6% for the SF6 group and 12.5% for the BSS group (statistically not significant). Progression of lens opacities was observed in 23.5% of the SF6 group, and in 18.8% of the BSS group (statistically not significant, with a higher incidence in the SF6 group). CONCLUSIONS: SF6 gas did not show hemostatic effects in the cases studied. Furthermore, it may have contributed to cataract progression. Therefore we suggest that the use of SF6 is not recommended as a treatment modality in preventing new vitreous hemorrhage after diabetic vitrectomy.

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We report the clinical and angiographic features as well as the natural course of an optic disk and juxtapapillary combined pigment epithelial and retinal hamartoma in a 23-year-old white girl. The patient presented 3 episodes of recurrent vitreous hemorrhages in the first 4 years of follow-up, which were spontaneously and totally absorbed. During the last 6 years, she was absolutely free of any ocular symptom. The tumor did not show any growth during the 10 years of follow-up. The digital indocyanine green angiography, which was normal in the early frames, revealed a mild, patchy hyperfluorescence corresponding to the tumor location in the late phase.

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PURPOSE: To evaluate macular function before and after successful surgical peeling of idiopathic epimacular membranes by means of multifocal electroretinogram (ERG) and measuring the first order Kernel. METHODS: Multifocal ERG of 10 patients (10 eyes) with idiopathic epimacular membrane were recorded before and after successful macular peeling. The retinal response densities of areas 1 and 2 were compared pre- and postoperatively and the functional state of the retina beneath the epimacular membrane was evaluated. The postoperative period was 3-6 months. RESULTS: Preoperatively, the electrical retinal response densities in the foveal and the perifoveal area were apparently decreased. After a mean postoperative period of 3 months the electrical response densities of the above areas improved. This improvement continued 6 months after the operation. CONCLUSION: In idiopathic epimacular membranes, the decrease in retinal electrophysiologic response was not limited to the fovea but also involved the perifoveal area. The electrical retinal response density of these areas gradually improved after peeling of the epimacular membrane.

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BACKGROUND: In the present prospective randomized study the effectiveness and safety of trabecular aspiration combined with clear cornea phacoemulsification (phaco) was compared to clear cornea phaco alone in patients with pseudoexfoliation (PEX) glaucoma and visually disabling cataract. METHODS: Twenty-seven patients suffering from visually significant cataract (visual acuity < 5 Snellen lines) and PEX glaucoma were randomly assigned to either phaco combined with trabecular aspiration (14 eyes of 14 patients) or phaco alone (13 eyes of 13 patients). Inclusion criteria for glaucoma were IOP < or = 22 mmHg under treatment with up to two antiglaucomatous agents, excluding pilocarpine 4%, and no previous surgery or laser trabeculoplasty treatment. Clear cornea phaco with foldable acrylic intraocular lens (IOL) implantation was carried out in all patients uneventfully. Trabecular aspiration was performed using a special probe in the inferior 180 deg of the angle after IOL implantation. RESULTS: Follow-up duration ranged from 12 to 18 months. In the combined procedure group there was a statistically significant decrease in postoperative IOP during the whole follow-up period (P < 0.01), while in 9 of the 14 patients the IOP was controlled without medications at the last examination. In the phaco alone group a statistically significant decrease in postoperative IOP was recorded at 9 and 12 months after surgery (P < 0.05), while in 4 of the 13 patients the IOP was controlled without medications at the last examination. Comparing the two groups, a statistically significantly lower number of medications was being used in the combined procedure group at the last recorded examination (P < 0.05). CONCLUSIONS: It seems that the combined clear cornea phaco and trabecular aspiration procedure in cases of PEX glaucoma associated with cataract is a safe and effective method. This technique controls IOP more effectively and with fewer postoperative medications than clear cornea phaco alone.

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