Biomedical subjects
Richard F Spaide
Publications and source records attributed to Richard F Spaide.
Cancer-associated nummular loss of the pigment epithelium.
PURPOSE: To report a case of bilateral diffuse uveal melanocytic proliferation (BDUMP) that had areas of retinal pigment epithelial loss. DESIGN: Observational case report. METHODS: A 67-year-old woman with a history of uterine cancer presented with 4 months of bilateral visual loss. RESULTS: Although B-scan ultrasonography revealed both small shallow serous retinal and choroidal detachments in the periphery, the choroid was normal in thickness. Fluorescein angiography revealed numerous nummular-shaped areas of transmission defects suggesting retinal pigment epithelium loss. Autofluorescence photography showed complete absence of autofluorescence in these nummular areas, and optical coherence tomography showed segmental areas with lack of any signal from affected areas of the retinal pigment epithelium, suggesting complete loss of retinal pigment epithelium cells. CONCLUSIONS: Although the fundus findings in BDUMP have been attributed to the proliferation of uveal melanocytic cells in the outer choroid in previous papers, our patient had nummular areas of loss of the retinal pigment epithelium as the apparent reason for visual decline.
Photodynamic therapy with verteporfin combined with intravitreal injection of triamcinolone acetonide for choroidal neovascularization.
PURPOSE: To examine the 12-month results of a group of patients treated with combined photodynamic therapy (PDT) with verteporfin and intravitreal triamcinolone acetonide for choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). DESIGN: Noncomparative case series. PARTICIPANTS: Twenty-six eyes of 26 patients with CNV secondary to AMD. Thirteen with CNV, without restriction to type, were not treated with prior PDT (newly treated group). Thirteen patients with prior PDT therapy who experienced visual loss while being treated with PDT alone comprised the remainder (prior PDT group). METHODS: Patients with CNV were treated with PDT, immediately followed by an intravitreal injection of 4 mg of triamcinolone acetonide. Visual acuity was measured by Early Treatment Diabetic Retinopathy Study protocol refraction. Need for retreatment was based on fluorescein angiographic evidence of leakage at 3-month follow-up intervals. MAIN OUTCOME MEASURES: Visual acuity and retreatment rate. RESULTS: In the newly treated group, the mean acuity change was an improvement of 2.5 lines (last observation carried forward [LOCF], +2.4 lines; P = 0.011, Wilcoxon signed ranks test, as compared with baseline acuity) for patients completing the 12-month follow-up. In the prior PDT group, the mean change was an improvement of +0.44 lines (LOCF, +0.31 lines; P = 0.53). Retreatment rates were 1.24 for the newly treated group and 1.2 for the prior PDT group over the first year. Ten patients (38.5%) developed an intraocular pressure (IOP) of >24 mmHg during follow-up, a threshold used to institute pressure reduction therapy. No patient developed endophthalmitis. CONCLUSION: Although the number of patients in this pilot study was limited, the improvement of acuity and the reduced treatment frequency in these patients suggest that combination therapy with PDT and intravitreal triamcinolone acetonide, particularly when used as first-line therapy, merits further investigation. Elevated IOP seems to be the most frequent early side effect of the treatment.
Coats' disease diagnosed in adulthood.
PURPOSE: To investigate the manifestations and clinical course of Coats' disease diagnosed in adulthood and to describe the characteristics of patients who develop it. DESIGN: Retrospective observational case series. PARTICIPANTS: Thirteen eyes of 13 patients with Coats' disease diagnosed after age 35 years. METHODS: All patients examined in the authors' referral practices for Coats' disease diagnosed after the age of 35 years were identified. Patients with a history of radiation exposure, intraocular inflammation, retinal vascular occlusion, or Coats' response were excluded. A review of their historical, clinical, and fluorescein angiographic features and demographics was performed. RESULTS: There were 13 patients with a mean age at diagnosis of 50 years (range, 36-79) and a mean follow-up of 5.8 years (range, 0-17). These patients manifested many findings typical of Coats' disease, including the unilateral nature of the disease (13/13 patients), male predominance (12/13), vascular telangiectasis, lipid exudation, macular edema, and areas of capillary nonperfusion with adjacent webs of filigreelike capillaries. Disease was limited to < or =6 clock hours in 10 of 13 patients (76.9%), did not generally involve the retinal vasculature anterior to the equator, and showed limited potential to expand during the follow-up period. A localized hemorrhage was noted in 10 of 13 patients (76.9%), almost always near larger aneurysmal dilatations. Limited exudative detachment of the retina was seen in 4 eyes, 3 of which responded to localized laser photocoagulation. One patient had subretinal fluid seen on ocular coherence tomography that did not require treatment. On average, patients lost 2.1 lines of visual acuity during the follow-up period; 6 patients had a decline in vision, 2 patients had improved vision, and 3 patients had stable vision. No patient had end-stage findings of Coats' disease, such as iris neovascularization or total exudative detachment. CONCLUSIONS: Coats' disease can first be diagnosed in adulthood with retinal vascular abnormalities similar to those seen in younger patients. There are a number of important differences in disease manifestation in adults, including limited area of involvement, slower apparent progression of disease, and hemorrhage near larger vascular dilatations.
Fundus autofluorescence and central serous chorioretinopathy.
PURPOSE: To investigate the autofluorescence characteristics in patients with central serous chorioretinopathy. DESIGN: Observational case series. PARTICIPANTS: Thirty consecutive patients examined in a private referral practice. METHODS: Patients were imaged with autofluorescence photography, fundus photography, fluorescein angiography, and optical coherence tomography (OCT). The mean and standard deviation (SD) of the grayscale values from a 100-pixel-diameter circle centered on the fovea were obtained and normalized with the level of autofluorescence of the posterior pole. RESULTS: There were 30 patients, 23 male (76.7%) and 7 female (23.3%), with a median visual acuity (VA) of 20/25 and a range of 20/15 to 20/400. Stepwise linear regression that included individual fixed effects found that normalized central macular autofluorescence (P < 0.001), pigment mottling in the fovea (P = 0.045), subfoveal fluid detected by OCT (P = 0.033), and the SD of the central macular autofluorescence (P = 0.025) produced a highly significant model (R2 = 0.92, P < < 0.001) predicting VA. Increasing levels of autofluorescence were correlated with accumulation of material on the outer surface of the retina as seen by OCT. Decreased central macular autofluorescence, particularly in those eyes with central geographic retinal pigment epithelial atrophy, was associated with poor VA. CONCLUSIONS: This study established that autofluorescence changes occurring in central serous chorioretinopathy with explicit patterns can be measured in a noninvasive manner, and this information can be used to estimate the damage induced by central serous chorioretinopathy with a high degree of statistical significance. We hypothesize that the material on the outer surface of the elevated retina may represent accumulation of photoreceptor outer segments secondary to the lack of direct apposition and phagocytosis by the retinal pigment epithelium.
Photodynamic therapy for focal retinal pigment epithelial leaks secondary to central serous chorioretinopathy.
PURPOSE: To report the use of photodynamic therapy with verteporfin as a treatment for patients with focal retinal pigment epithelial leaks secondary to central serous chorioretinopathy (CSC). DESIGN: Noncomparative, nonrandomized, retrospective interventional case series. PARTICIPANTS: Nine eyes of 9 symptomatic patients with acute focal retinal pigment epithelial leaks secondary to CSC, confirmed with fluorescein angiography, evaluated at 1 of 3 referral retina practices. METHODS: Patients were treated with photodynamic therapy using verteporfin. Best-corrected visual acuity (VA) was recorded at presentation and follow-up visits. MAIN OUTCOME MEASURES: Resolution of neurosensory detachment, status of fluorescein leakage, and VA. RESULTS: Neurosensory detachment and fluorescein leakage resolved in all patients within 1 month. Visual acuity improved from 1 to 6 lines in 7 eyes and remained unchanged in 2. At 6 months, there was a statistically significant improvement in mean VA (P = 0.012, Wilcoxon signed ranks test), and mean VA improved from 20/80 to 20/40. No patient lost vision or suffered any treatment-related complications. CONCLUSION: The treatment of acute CSC with photodynamic therapy may result in prompt resolution of neurosensory detachment and fluorescein leakage, which can be associated with rapidly improved vision. Although this case series is limited in follow-up and number of patients, the encouraging results and lack of visually significant complications suggest that further investigation is warranted.
Optical coherence tomography in unilateral resolved central serous chorioretinopathy.
PURPOSE: To evaluate the correlation between optical coherence tomographic evaluations of foveal thickness and anatomical changes within the fovea and visual acuity in patients who have unilateral resolved central serous chorioretinopathy. METHODS: A retrospective review of cases of unilateral resolved central serous chorioretinopathy imaged with high-resolution optical coherence tomography was performed. The foveal thickness of the involved eye was normalized by dividing its thickness by that of the uninvolved fellow eye. The best-corrected visual acuity of the involved eye was normalized as well. The normalized foveal thickness was compared with the normalized visual acuity. The anatomical findings of the fovea were compared with the visual acuity. RESULTS: Twenty patients were evaluated (11 men and 9 women; age range, 31-66 years [mean, 46.8 years]). The mean foveal thickness was 135.8 mum in the involved eyes and 184.4 mum in the uninvolved eyes (P < 0.001). There was a correlation between the normalized foveal thickness and the normalized visual acuity (Spearman rho, 0.67; P = 0.001). The external limiting membrane was visible in 7 (35%) of the involved eyes compared with 19 uninvolved eyes (95%) (P < 0.001). In the involved eyes, those with a visible external limiting membrane had better visual acuity than did those that did not (P = 0.001). It was possible to visualize the boundary between the photoreceptor cell bodies and the outer segments in 8 (40%) of the involved eyes and in the 17 uninvolved eyes (85%) (P < 0.001). In the involved eyes, those with a visible boundary between the photoreceptor bodies and the outer segments had a better visual acuity than did those that did not (P = 0.019). CONCLUSIONS: Patients with unilateral resolved central serous chorioretinopathy had a decrease in the central foveal thickness in the involved eyes, and there was a statistically significant correlation between the foveal thickness and the visual acuity, even in eyes with relatively good visual acuity. The inability to observe a discrete signal corresponding to the external limiting membrane layer was more common in involved eyes and was significantly associated with decreased visual acuity. This same relationship was seen with the ability to visualize the boundary between the photoreceptor bodies and the outer segments; this boundary was less commonly observed in involved eyes and was associated with decreased visual acuity. Resolved central serous chorioretinopathy causes a number of morphologic changes in the fovea that are associated with visual acuity.
Submacular placoid pigment epithelial alteration after resolution of macular edema in central retinal vein occlusion.
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Combined photodynamic therapy and intravitreal triamcinolone for nonsubfoveal choroidal neovascularization.
PURPOSE: To examine the 12-month results for a group of patients with nonsubfoveal choroidal neovascularization who were treated with combined photodynamic therapy (PDT) with verteporfin and intravitreal triamcinolone acetonide. METHODS: Patients with nonsubfoveal choroidal neovascularization, which was defined as either juxtafoveal or extrafoveal neovascularization, were treated with PDT immediately followed by an intravitreal injection of 4 mg of triamcinolone acetonide. Need for retreatment was based on fluorescein angiographic evidence of leakage at 3-month follow-up intervals. The main outcome measures were visual acuity and the proportion of patients developing subfoveal extension. RESULTS: Of the 15 patients, 9 were women and 6 were men (mean age +/- SD, 80 +/- 7.5 years). The mean baseline visual acuity was almost 20/60 (mean logMAR = 0.46), and 14 of the 15 eyes had juxtafoveal choroidal neovascularization. At 3, 6, and 9 months, the patients had significant improvement in the mean visual acuity (P = 0.002, 0.001, and 0.007, respectively), but at the end of the 12-month follow-up period, the mean visual acuity was slightly worse than 20/40 (mean logMAR = 0.34), which was not statistically significant at an alpha level adjusted for multiple comparisons of .013 (P = .057) as compared with the baseline visual acuity. One patient had subfoveal extension of choroidal neovascularization. The mean number of treatments was 1.9. Three patients (20%) developed an intraocular pressure of >24 mmHg during follow-up, a threshold used to institute pressure reduction therapy. No patient developed endophthalmitis. CONCLUSION: The number of patients in this pilot study was limited; however, the visual acuity response and the low incidence of subfoveal extension suggest that PDT combined with intravitreal triamcinolone for the treatment of nonsubfoveal choroidal neovascularization merits further investigation as a first-line treatment.
Comparison of fluorescein angiography and optical coherence tomography for patients with choroidal neovascularization after photodynamic therapy.
PURPOSE: To investigate retinal morphology by means of fluorescein angiography (FA) and optical coherence tomography (OCT) in patients who had undergone photodynamic therapy (PDT) with verteporfin at their 3-month-interval examination. METHODS: Sixty patients with predominantly classic choroidal neovascularization (CNV) secondary to age-related macular degeneration were evaluated with FA and OCT 3 months after their last PDT. FA images were evaluated in a masked fashion for staining of and leakage from the lesion and also for cystoid loculation of fluorescein in the macula. OCT was used to evaluate foveal thickness and the presence of subretinal fluid or cystoid spaces within the retina, also in a masked fashion. RESULTS: The median age of the 60 patients was 78 years, and the median visual acuity of the eyes examined was 20/100. The median number of previous PDT sessions was 2. Fluorescein staining was seen in 57 eyes (95%), and fluorescein leakage was seen in 50 eyes (83%). Cystoid loculation of fluorescein was seen in 21 eyes (35%). By OCT, cystoid spaces in the macula were seen in 42 patients (70%), and subretinal fluid was seen in 15 patients (25%). Leakage seen shown by FA was correlated with the OCT finding of cystoid spaces but not with the OCT finding of subretinal fluid. Some patients had leakage during FA that did not have any observable induced OCT abnormality attributable to fluid accumulation. CONCLUSIONS: After PDT leakage from CNV seen during FA is associated with intraretinal fluid, often seen in loculated cystoid spaces, but not with subretinal fluid.
Optical coherence tomography in a case of apparent double macular holes.
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Fundus autofluorescence and vitelliform macular dystrophy.
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Ophthalmic fundus imaging: today and beyond.
PURPOSE: To review and update techniques of posterior segment ophthalmic fundus imaging. DESIGN: Literature review and collective experience of the authors. METHODS: This perspective includes sections on digital imaging, fundus autofluorescence, ultrasonography, angiography, and optical coherence tomography (OCT) -ophthalmoscopy written by leading clinicians and researchers in these areas. RESULTS: Digital angiography has become the new standard in the ophthalmic community based upon improved technology which has enhanced resolution, processing time, and ease of image duplication, manipulation, and transmission. A relatively new imaging technique, fundus autofluorescence, highlights lipofuscin deposits and improves our understanding of the metabolic status of the retinal pigment epithelium. Diagnostic ultrasonography continues to be a major adjunct to ocular evaluation where advances now allow for exceptional versatility and portability. High speed angiographic techniques provide detailed visualization of choroidal perfusion which improves our understanding of both normal and pathologic vascular phenomenon. Advances in high-resolution OCT currently under development promise an even more detailed fundus representation. The integration of the scanning laser ophthalmoscope and OCT has produced a dynamic new instrument, the OCT ophthalmoscope, which simultaneously images the fundus in numerous ways with point to point correlation. CONCLUSIONS: Ophthalmic imaging technology has revolutionized fundus examination. Currently available systems have contributed significantly to our understanding of the pathophysiology and treatment of various retinal diseases. Future advances promise near histologic resolution of retinal structures as well as real-time image manipulation and instantaneous transmission world-wide.
Photodynamic therapy and intravitreal triamcinolone for a subretinal neovascularization in bilateral idiopathic juxtafoveal telangiectasis.
PURPOSE: To report combined treatment of photodynamic therapy (PDT) with verteporfin and intravitreal triamcinolone acetonide injection for subfoveal neovascularization secondary to bilateral idiopathic juxtafoveal telangiectasis. DESIGN: Interventional case report. METHOD: A patient with a subfoveal neovascularization secondary to bilateral idiopathic juxtafoveal telangiectasis was treated with PDT plus an intravitreal injection of 4 mg of triamcinolone acetonide. RESULTS: Leakage in the late-phase of fluorescein angiography resolved with attenuation of telangiectatic vessels and improvement in visual acuity from 20/200 to 20/50. At 9 months post-treatment, recurrent leakage was treated with repeat PDT and intravitreal triamcinolone. One year after initial presentation, visual acuity was 20/60 with no leakage on fluorescein. CONCLUSION: Combined treatment with PDT and intravitreal triamcinolone acetonide resulted in regression of a subfoveal neovascular membrane and improvement in visual acuity during the course of follow-up.
Collateral damage in acute zonal occult outer retinopathy.
PURPOSE: To evaluate the disease involvement in a patient with acute zonal occult outer retinopathy (AZOOR). DESIGN: Observational case report. METHODS: A patient with acute zonal occult outer retinopathy was imaged with fundus photography, fluorescein and indocyanine green angiography, and autofluorescence photography. RESULTS: There was subtle depigmentation in the central portion of the lesion with a drusen-like deposit at the outer border. Fluorescein angiography showed a transmission defect centrally and a blocking defect at the border where the drusenoid material accumulated. Autofluorescent photography demonstrated that the drusenoid material was intensely autofluorescent, consistent with the presence of lipofuscin, and the central portion of the lesion showed atrophy of the retinal pigment epithelium. Indocyanine green angiography showed atrophy of the choriocapillaris underlying areas of atrophy of the retinal pigment epithelium. CONCLUSIONS: In this case acute zonal occult outer retinopathy caused an area of retinal pigment epithelium cell death with lipofuscin-laden cells at the border of the expanding lesion and associated atrophy of the underlying choriocapillaris.
Intravitreal triamcinolone acetonide and intraocular pressure.
PURPOSE: To analyze the incidence of intraocular pressure (IOP) elevation following intravitreal triamcinolone injection. DESIGN: Retrospective observational case series. METHODS: Charts of patients undergoing intravitreal triamcinolone injection in one clinical practice were reviewed. A pressure elevation was defined as a pressure of 24 mm Hg or higher during follow-up. RESULTS: There were 89 patients with a mean age of 76.4 years. The mean baseline IOP was 14.9 mm Hg with a mean change of 8.0 mm Hg. Thirty-six patients (40.4%) experienced a pressure elevation to 24 mm Hg or higher at a mean of 100.6 days (SD = 83.1 day) after treatment. Of nonglaucomatous patients with baseline IOP of 15 mm Hg or above, 60.0% experienced a pressure elevation, compared with only 22.7% of those with baseline pressures below 15 mm Hg (relative risk = 2.1, P < .01). In glaucoma patients, 6 of 12 (50%) experienced a pressure elevation, and this elevation was not correlated with baseline pressure. Thirty-two patients (36.0%) received repeat injections, and there was no difference in the incidence of procedure elevation in patients receiving multiple injections versus those receiving a single injection. Pressure elevation was controlled with topical medications in all patients. CONCLUSIONS: IOP elevation after intravitreal triamcinolone injection is common and may take an extended period of time to manifest. The proportion of patients who developed a pressure elevation to at least 24 mm Hg was much higher for those with baseline IOP 15 mm Hg or greater.
Optical coherence tomography of X-linked retinoschisis.
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Deposition of yellow submacular material in central serous chorioretinopathy resembling adult-onset foveomacular vitelliform dystrophy.
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