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Objective: To determine predictors of choroidal neovascularization (CNV) and visual outcome after traumatic choroidal rupture., Methods: A retrospective review of patients with traumatic choroidal rupture diagnosed in the Retina Service, Massachusetts Eye and Ear Infirmary, Boston, between January 1993 and August 2001 was performed. Parametric and nonparametric statistical methods were used to evaluate visual prognosis, CNV, and retinal detachment after traumatic choroidal rupture., Results: One hundred eleven cases were identified and reviewed. Visual acuity (VA) changes were recorded in all of the cases. Thirty-eight (34%) of the 111 patients recovered driving vision (VA > or =20/40). Rupture location was recorded in 107 cases. Recovery of driving vision was seen in 20 (59%) of 34 eyes with peripheral choroidal ruptures, 17 (22%) of 73 eyes with macular choroidal ruptures, 38 (38%) of 99 eyes without CNV, 1 (8%) of 12 eyes with CNV, 38 (40%) of 96 eyes without retinal detachment, and 1 (7%) of 15 eyes with retinal detachment. Older age and location of rupture within the arcades were positively associated with CNV formation (P = .04 and .03, respectively). Foveal location of rupture, multiple ruptures, and poor baseline VA were associated with failure to recover driving vision in univariate regression analyses. In multivariate analysis, rupture location and baseline VA were independently associated with visual outcome. Of 12 patients diagnosed with CNV, 5 were not treated, 4 were treated with argon laser photocoagulation, 1 was treated with surgery, 1 was treated with argon laser photocoagulation followed by surgery, and 1 was treated with verteporfin photodynamic therapy., Conclusions: Most patients with traumatic choroidal rupture do not achieve final VA of 20/40 or better. Poor visual outcome was most highly associated with a macular rupture and baseline VA of less than 20/40. The formation of CNV was most strongly associated with older age and macular choroidal rupture.

Objectives: To describe the type and severity of ocular injuries caused by paintballs, to summarize the outcomes, to determine if the injury occurred in a commercial or noncommercial setting, to compare the number of injuries in each setting as a function of time, and to ascertain whether eye-protective devices were worn and why they were removed., Design: Retrospective analysis of 35 patients who sustained ocular injuries caused by paintballs and underwent evaluation and treatment at an eye hospital from January 1, 1985, to September 30, 1998. Thirty-five eyes of 35 patients underwent a complete ocular examination, diagnostic testing, and surgical intervention when indicated., Results: All patients were male (average age, 22 years). Twenty-six patients (74%) had an initial visual acuity of 20/200 or worse, and visual acuity in 16 (46%) remained 20/200 or worse on follow-up (range, 2 weeks to 22 months). Traumatic hyphema was seen in 21 patients (60%). Twenty-two patients (63%) had access to goggles, 7 (33%) of whom removed them due to fogging before the injury. Injuries sustained after 1995 were 5.8 times (relative risk, 5.8; 95% confidence interval, 1.5-22.4) more likely to occur during a noncommercial war game than those occurring in 1995 or before., Conclusions: As the popularity of war games increases, so does the potential for serious ocular injury caused by paint pellet guns. Most injuries seen after 1995 occurred in noncommercial war game settings, where the use of eye-protective devices is not required. Industry standards for eye protection have been developed recently and should be implemented.

We used a pulsed holmium-YAG laser that emitted in the midinfrared (2.12 microns) to cut experimental vitreous membranes in rabbits via an intraocular fiberoptic delivery system. Thirty-five membranes were treated at distances of 0.5 to 3.8 mm from the retina. All of the membranes that were treated were transected or partially cut. In cases that were treated with the optical fiber encased in a retinal-shielding pick, membranes could be readily transected without retinal injury. Laser vitreous membrane cutting may offer the advantage of near-tractionless membrane segmentation. The combination of a moderately strong target tissue absorption and the ready availability of commercial optical fibers for transmission of 2.12-microns laser energy suggests that the holmium-YAG laser merits further investigation for this application.

One hundred twenty-five retinochoroidal photocoagulation burns, produced by a transpupillary diode laser (810 nm) in six eyes of three cynomolgus monkeys, were evaluated by clinicopathologic correlation for up to 9 weeks after laser treatment. Diode burns of clinical grade 2 strength were comparable to those described for argon laser. However, diode burns of clinical grade 3 strength produced choroidal changes more intense than those described for argon laser. Where present underneath photocoagulation sites, ciliary nerves in choroid or sclera consistently showed scarring. Prospective randomized controlled clinical trials to document possible clinical equivalence or superiority of diode treatment have not yet been performed. Potential clinical advantages of the diode laser include its weight, size, durability, price, absence of visible flash, and its ability to produce burns that profoundly affect the choroid.

Two patients developed subretinal neovascularization after chorioretinal injury from a metallic intraocular foreign body. In the first patient, a metallic foreign body struck the retina temporal to the macula and settled inferiorly. Eight months later, subretinal neovascularization developed at the initial impact site. In the second patient, a piece of silver wire became embedded in the retina and choroid near the macula, and subretinal neovascularization occurred six months later at the nasal end of the wire. In both patients, the subretinal neovascularization was confirmed with fluorescein angiography and successfully obliterated with argon laser photocoagulation.

A neodymium-YAG laser, operating in its free-running mode with pulse durations of 10 to 20 ms, was used to treat 63 cases of choroidal and retinal diseases. These cases included diabetic background retinopathies, thrombosis of the central retinal vein or branch retinal vein, neovascular membranes under the pigment epithelium, and retinal breaks or degenerations of the peripheral retina. Because the number of diabetic retinopathies (24) and their average follow-up time (25.5 months) are insufficient for the evaluation of irradiation effects, no definite statement as to the merits of this energy modality in such cases can be made. The irradiation of infarcted retina was followed by extensive atrophy of the involved area. No secondary glaucoma was observed during a follow-up period of 16.4 months. The irradiation in four cases of neovascular subretinal membranes was followed by disappearance of the membranes. However, relapse later occurred in all four cases. The irradiation of eight retinal breaks resulted in solid scar tissue. Two choroidal melanomas were destroyed and did not recur during a follow-up period of 22 months.

Previous observations on rats suggested that subretinal neovascularization does not require a prior break in Bruch's membrane (BM). We verified this observation by using scanning electron microscopy to examine large expanses of BM that became exposed following ophthalmoscopically white krypton laser burns. Bruch's membrane appeared intact in the acute phase after injury. Subsequently, slitlike defects in BM were associated with penetrating choroidal capillaries. These observations were consistent with transmission electron microscopic findings of cellular protrusions arising from the choriocapillary endothelial cells and from regenerating retinal pigment epithelial (RPE) cells invading BM. These cell-formed defects in BM differed from thermal defects in appearance, size, and onset of occurrence. Endothelial cells penetrated all layers of BM, including the RPE basement membrane. We conclude that endothelial cells can erode their own basement membrane and the RPE basement membrane, and krypton laser burns with or without immediate rupture of BM induce cellular activity that may result in defects in BM.

The histopathologic effects of focal xenon arc and argon laser photocoagulation on three patches of preretinal new vessels were studied in a patient with proliferative diabetic retinopathy. Both treatment modalities achieved total obliteration of the vessels. However, the adjacent retina and choroid were severely damaged, and preretinal membranes were seen over all three patches. Local tissue destruction is minimized when preretinal neovascularization is treated indirectly by scatter photocoagulation. Currently, scatter photocoagulation is our treatment of choice.

The accompanying ultrastructural study showed that ophthalmoscopically white krypton laser photocoagulation in rats is followed by cellular invasion causing breakdown of Bruch's membrane (BM). We have expanded these observations, using scanning electron microscopy, transmission electron microscopy, and high-voltage transmission electron microscopy to describe the healing process. The repair of BM involves regenerating retinal pigment epithelial cells and choriocapillaris (CC) that form new basement membranes and fibroblasts that secrete collagen and elastin. The reformation of the CC is also associated with subretinal neovascularization. The involvement of macrophages was evident throughout the process of BM repair and formation of new vessels. We propose that the macrophages act as a common factor linking the diverse diseases associated with choroidal subretinal neovascularization, deduced from our evaluation of the healing process and the reformation of choriocapillaris.