Search

Objective: To establish a role for vascular endothelial growth factor (VEGF) during the onset and clinical course of neovascularization of the iris (NVI) in ischemic central retinal vein occlusion., Methods: Sixteen patients with ischemic central retinal vein occlusion were followed up for 12 months by clinical examination, retinal and iris angiography, and serial anterior chamber sampling of aqueous humor. Aqueous VEGF level was determined by enzyme-linked immunoassay, and permeability changes were estimated by capillary zone electrophoretic assessment of aqueous albumin., Results: A correlation was found between aqueous VEGF concentrations and the onset, persistence, and regression of NVI; extent of retinal capillary nonperfusion; and vascular permeability. The NVI occurred when aqueous VEGF concentrations were 849 to 1569 pg/mL and regressed fully when they fell below 550 pg/mL. Aqueous concentrations of serum albumin, a marker of increased permeability, correlated with increased VEGF. Placental growth factor was found at low levels only when VEGF levels exceeded 330 pg/mL. The NVI remained VEGF-dependent during the course of the disease, regressing only if VEGF concentrations were reduced after laser ablation of hypoxic retina., Conclusions: The close temporal correlation between aqueous VEGF levels and the course of neovascularization and permeability in human ischemic central retinal vein occlusion indicates that increased aqueous VEGF level may predict the need for treatment, and that anti-VEGF therapy at an early stage of ischemic central retinal vein occlusion may be therapeutically beneficial.

Objective: To evaluate visual outcomes following macular translocation with 360 degrees peripheral retinectomy in patients with subfoveal choroidal neovascularization secondary to age-related macular degeneration., Methods: In a prospective study, 15 consecutive patients with large subfoveal choroidal neovascularization underwent macular translocation with 360 degrees peripheral retinectomy and silicone oil tamponade. Preoperative and postoperative photographs and fluorescein angiograms were obtained to evaluate lesion size and characteristics and translocation results. Standardized near and distance visual acuity and reading speed were measured preoperatively and 6 and 12 months postoperatively., Main Outcome Measures: Changes in and final levels of near and distance visual acuity and reading speed., Results: Median lesion size was 9 Macular Photocoagulation Study disc areas (range, 4-16 disc areas). In all patients, the fovea was successfully translocated off the subfoveal lesion. The median near visual acuity logMAR score (logarithm of the minimum angle of resolution) improved significantly from 0.54 units to 0.40 units (Snellen equivalent, 20/70 to 20/50; P =.02) at the 6-month follow-up and stabilized at 0.54 (12 months postoperatively; Snellen equivalent, 20/70). Seven (54%) of 13 patients and 7 (58%) of 12 patients achieved reading speeds of 70 words/min or greater at the 6-month and 12-month postoperative visits, respectively. Median preoperative distance visual acuity (20/100) was maintained at both the 6-month and 12-month examinations. No postoperative retinal detachments occurred in this series., Conclusion: Macular translocation with 360 degrees peripheral retinectomy and silicone oil tamponade stabilizes and can sometimes improve near and distance visual acuity and reading speed in patients with vision loss from subfoveal neovascular age-related macular degeneration.

Objective: To describe the comparative impact of current and preventive treatments on incidence of choroidal neovascularization (CNV) and severe vision loss in patients with bilateral soft drusen (BSD)., Design: Stochastic model., Setting: US population., Patients: Prevalence cohort of white patients 43 years or older with BSD., Interventions: Application of prophylaxis of 10% to 50% efficacy to 1 or both eyes of patients with BSD, application of laser photocoagulation to eligible CNV lesions, or both., Main Outcome Measures: Proportion of patients with BSD after 10 years with unilateral and bilateral CNV and resultant unilateral and bilateral vision loss to visual acuity of 20/200 or worse., Results: The natural history of patients with BSD generated by the model shows that 12.40% of these patients develop either unilateral or bilateral CNV within 10 years of their entry into the BSD prevalence cohort. Bilateral disease occurs in 3.86% of patients with BSD within 10 years. The proportion of patients with BSD becoming legally blind from CNV within 10 years is 2.54% if no treatment is performed. Current laser treatment for CNV decreases the proportion with legal blindness within 10 years to 2.24%. The addition of a preventive treatment of 10% efficacy applied bilaterally to the current laser treatment regimen decreases the proportion with legal blindness to 1.86%; a 25% effective preventive treatment decreases it to 1.34%. Comparatively, preventive treatment of 10% and 25% efficacy given to the fellow eye only after the first eye has developed CNV decreases the proportion of legally blind patients at 10 years only to 2.06% and 1.77%, respectively. All outcomes vary with sex and age at entry into the BSD cohort., Conclusions: Patients with BSD face a 12.40% risk of developing CNV within 10 years. The addition of even a modest (10% effective) bilateral preventive treatment to the current regimen for CNV would more than double the prevention of legal blindness in the BSD population relative to current laser treatment; a preventive treatment of 33% efficacy more than halves the rate of legal blindness caused by CNV. Preventive treatment given to the fellow eye only after the first develops CNV has substantially less impact.

Objective: To study the histologic and ultrastructural features of surgically excised choroidal neovascularization (CNV) from patients who had undergone submacular surgery., Materials and Methods: Voluntarily submitted surgically excised CNV specimens from a subset of specimens obtained by the Submacular Surgery Trials Research Group between January 1, 1994, and December 31, 1996, were available for this study. The specimens were routinely processed for transmission electron microscopic examination. The largest horizontal and vertical dimensions, cellular and extracellular constituents, and relationship of the CNV to the neurosensory retina and retinal pigment epithelium (RPE) were recorded., Results: Seventy-eight surgical specimens were obtained from 160 patients treated surgically in Submacular Surgery Trials centers. Sixty-one (78%) were from patients with age-related macular degeneration (ARMD) and 17 (22%) were from patients with ocular histoplasmosis syndrome or idiopathic causes (hereafter referred to as the non-ARMD group). The histologic diagnosis was fibrovascular tissue, fibrocellular tissue, or hemorrhage in all cases. Vascular endothelium and RPE were the most common constituents of the CNV. Basal laminar deposit was only present in CNV from patients with ARMD. Age-related macular degeneration specimens were larger (mean +/- SD, 2042 [+/- 1175] x 320 [+/- 185] microm vs 1498 [+/- 792] x 227 [+/- 166] microm) and were more likely to have a sub-RPE (beneath the RPE) component than non-ARMD specimens., Conclusions: All evaluated surgically excised CNV specimens in this study from patients enrolled in the Submacular Surgery Trials consisted of fibrovascular tissue, fibrocellular tissue, or hemorrhage. Surgically excised CNV associated with ARMD in this series was larger and often was located beneath the RPE compared with non-ARMD CNV, although fewer than half of all the specimens could be oriented by topographic relationship to the RPE.

Objective: To determine the visual results, recurrence rates, and postoperative complications of surgical removal of subfoveal choroidal neovascularization (CNV) in patients with the presumed ocular histoplasmosis syndrome., Design: A consecutive surgical series of 63 eyes of 62 patients with subfoveal CNV and the presumed ocular histoplasmosis syndrome with longer than 6 months of follow-up., Setting: Tertiary care university medical center., Methods: Patients underwent surgical removal of subfoveal CNV using vitreoretinal surgical techniques. The anatomical and functional results of surgery were analyzed., Results: The median age of the patients was 42 years (range, 16-68 years), and the median follow-up time was 24 months (range, 6-48 months). Visual acuity improved by 2 or more Snellen lines in 22 (35%) of the 63 eyes, was unchanged in 28 (44%) of the eyes, and worsened in 13 (21%) of the eyes. Eleven (17%) of the 63 eyes improved to a visual acuity of 20/50 or better. Eyes with an initial visual acuity of 20/200 or worse had a better prognosis for improved vision (ie, 26 [41%] of the eyes) than those with an initial visual acuity of 20/100 or better (ie, 5 [8%] of the eyes). Recurrence of the subfoveal CNV occurred in 24 (38%) of the 63 eyes and was more common in those eyes that received preoperative laser photocoagulation (ie, 15 [47%] of the eyes). The median time to recurrence was 5 months after surgery. Post-operative complications included macular striae in 4 (6%) of the 63 eyes, rhegmatogenous retinal detachment in 2 (3%) of the eyes, retinal tear in 1 (1.6%) of the eyes, and progression of cataract in 19 (30%) of the eyes., Conclusions: Surgical excision of subfoveal CNV may be an effective therapeutic modality in patients with the presumed ocular histoplasmosis syndrome that offers the possibility of improving central vision in many patients. Factors possibly associated with a favorable visual prognosis include younger patient age and the absence of previous laser photocoagulation.

Objectives: To verify and quantify previously reported risk factors for development of choroidal neovascularization (CNV) in the fellow eye of patients with 1 eye affected with CNV secondary to age-related macular degeneration, to examine the value of characteristics of the pericentral macula in the quantification of risk for developing CNV, and to explore whether the presence of occult CNV in the first eye affects the development of CNV in the fellow eye., Design, Patients, and Setting: Follow-up study of fellow eyes of 670 patients enrolled in multicenter, randomized clinical trials of laser photocoagulation of juxtafoveal or subfoveal CNV., Main Outcome Measure: Development of CNV., Results: Three characteristics of the central macula of the fellow eye and 1 systemic factor were associated independently with an increased risk of developing CNV: the presence of 5 or more drusen (relative risk, 2.1; 95% confidence interval, 1.3-3.5), focal hyperpigmentation (relative risk, 2.0; 95% confidence interval, 1.4-2.9), 1 or more large drusen (relative risk, 1.5; 95% confidence interval 1.0-2.2), and definite systemic hypertension (relative risk, 1.7; 95% confidence interval, 1.2-2.4). Estimated 5-year incidence rates ranged from 7% for the subgroup with no risk factors to 87% for the subgroup with all 4 risk factors. Characteristics of the pericentral macula were not strongly associated with the development of CNV. The presence of occult CNV in the first eye affected had no influence on the development of CNV or on the type of CNV in the fellow eye., Conclusions: The prognosis of the fellow eye is affected strongly by characteristics of its central macula and by systemic hypertension. These factors should be considered when counseling patients with unilateral neovascular age-related macular degeneration and when targeting patients for preventive interventions.

Objectives: To determine the effects of macular scatter ("grid") laser photocoagulation compared with observation on the visual function of eyes with subfoveal choroidal neovascularization (CNV) that has poorly demarcated boundaries and to provide preliminary data for the evaluation of the feasibility and design of a larger, definitive trial., Design: Randomized pilot clinical trial., Setting: Two tertiary care retinal referral practices., Patients: Symptomatic individuals with subfoveal CNV secondary to age-related macular degeneration in whom fluorescein angiography showed occult CNV with poorly demarcated boundaries; classic CNV was allowed but did not need to be present for entry into the study., Main Outcome Measure: Change in visual acuity from baseline to specified time periods., Results: Fifty-two eyes were assigned to observation. Fifty-one eyes were assigned randomly to treatment consisting of macular scatter ("grid") laser photocoagulation to the area of CNV. The treatment protocol for 8 of these eyes also included confluent laser photocoagulation to areas of classic CNV. The average visual acuity decrease from baseline was greater in the treated than in the observed group. The difference between these groups was greatest within the first year after study enrollment. At 24 months, slightly more than 40% of the eyes in each group had lost 6 or more lines of visual acuity. Similar results were noted for the subgroup of eyes initially with angiographic features of occult CNV but no classic CNV., Conclusions: These short-term study results suggest that macular scatter ("grid") laser treatment is not beneficial and is possibly harmful compared with observation for symptomatic subfoveal CNV with poorly demarcated boundaries in age-related macular degeneration. With or without treatment, a significant proportion of these patients are at risk of severe visual loss within 2 years of seeking treatment, even when the eye initially has occult CNV and no classic CNV.

Objective: To determine whether indocyanine green-guided laser photocoagulation of focal spots at the edge of plaques of neovascularization is beneficial for patients with untreatable occult choroidal neovascularization by fluorescein imaging., Patients: A pilot series of 23 eyes were identified that had untreatable occult choroidal neovascularization secondary to age-related macular degeneration with focal spots at the edge of a plaque of neovascularization on the indocyanine green study. After informed consent was obtained, indocyanine green-guided laser photocoagulation was applied solely to the focal spot at the edge of the plaque., Results: Anatomical success with resolution of the exudative findings was noted in 15 (79%) of 19 eyes at 6 months, 13 (68%) of 19 eyes at 12 months, and six (37.5%) of 16 eyes at 24 months. The median follow-up period was 18 months (range, 3 to 44 months). Visual acuity was stabilized or improved in nine (69%) of 13 successfully treated eyes at 1 year. Of the successfully treated cases at 1 year, nine (69%) of 13 had a final visual acuity of 20/100 or better., Conclusions: Our preliminary study of indocyanine green-guided laser photocoagulation of focal spots at the edge of plaques of neovascularization suggests that this technique may improve the visual prognosis of these patients with presently untreatable disease. A prospective, randomized, controlled clinical trial is warranted to evaluate this treatment approach.

Objectives: To document the incidence of choroidal neovascularization (CNV) in unaffected fellow eyes among individuals with ocular histoplasmosis and extrafoveal or juxtafoveal CNV in 1 eye; to determine whether the location and type of "histo spots" in the macula predict the site of future CNV development in second eyes; to describe changes over time in neovascular lesions present in fellow eyes at baseline; and to describe changes in visual acuity of fellow eyes with and without CNV at baseline., Design, Patients, and Setting: Five-year prospective follow-up study of fellow eyes of 516 patients enrolled in 2 randomized clinical trials of laser photocoagulation of extrafoveal and juxtafoveal CNV. Best-corrected visual acuity and reading vision were measured, and both maculas were photographed at baseline and at 6-month intervals., Main Outcome Measures: Cumulative incidence of CNV in fellow eyes free of neovascular maculopathy at the time of study enrollment, 5-year change in visual acuity of fellow eyes from baseline, and incidence of legal blindness (visual acuity < or = 20/200 in the better eye)., Results: Photographically documented CNV developed in 35 (9%) of 394 eyes initially free of neovascular maculopathy; nevertheless, good visual acuity was maintained in most newly affected eyes until the end of the 5-year follow-up period. Histo spots of any type in the macula at baseline tripled the risk for later development of CNV in comparison to eyes without histo spots in the macula. Although the type of histo spots present in the central macula at baseline did not predict future CNV development, in 32 of 35 second eyes in which CNV developed and in 7 of 9 fellow eyes in which a second area of CNV developed during follow-up, CNV was preceded by an "atypical" histo spot in the same location. Among 122 patients who had bilateral neovascular maculopathy initially, 100 were examined 5 years later; 8 (8%) were legally blind, compared with 3 (1%) of 339 patients examined who had unilateral CNV initially. At the 5-year examination, 355 (81%) of 439 patients examined had a visual acuity of 20/20 or better in at least 1 eye, including 74 (55%) of 134 patients who had bilateral neovascular maculopathy., Conclusions: Although the incidence of CNV in fellow eyes that initially were unaffected remained low throughout 5 years of follow-up, it persisted at a nearly constant rate. The risk of legal blindness was low, even for patients who had bilateral involvement. Perhaps most important, 81% of all patients followed up for 5 years retained a visual acuity of 20/20 in at least 1 eye, and 20% retained this visual acuity in both eyes. Retrospective review of photographs suggests that the ophthalmologist should pay special attention to areas of the central macula in which new "atypical" histo spots are observed, with the goal of treating CNV that may develop in the same area at a time when the benefits of laser treatment may be greatest.

Objective: To determine whether the presence of occult choroidal neovascularization (CNV) influenced the anatomic and visual acuity outcomes in a randomized clinical trial of krypton red laser photocoagulation to treat juxtafoveal neovascular lesions in age-related macular degeneration., Design, Setting, and Patients: The fluorescein angiograms obtained at the baseline examination at tertiary retinal referral centers between April 1, 1981, and December 31, 1987, as part of the Macular Photocoagulation Study (MPS) Age-Related Macular Degeneration Study-Krypton Laser were evaluated retrospectively at the MPS Fundus Photograph Reading Center by two senior readers independently (with open adjudication of any differences) from 1992 to 1994. Criteria for classifying classic and occult CNV by the MPS Group were established in 1989, 2 years after the last patient had been assigned randomly to treatment or observation in the krypton laser study., Main Outcome Measures: Treatment coverage of classic and occult CNV, persistent CNV, recurrent CNV, and visual acuity from scheduled follow-up examinations for up to 5 years were analyzed for the absence or presence of occult CNV at baseline., Results: The number of eyes with classic CNV but not occult CNV, classic and occult CNV, and occult CNV but no classic CNV were almost identical for the eyes assigned randomly to treatment or observation. Classic CNV almost always was covered completely with intense laser treatment; nevertheless, recurrent CNV developed in more than half of these eyes within 1 year after initial laser treatment. In contrast, in more than half of the eyes with occult CNV, more than 50% of the occult CNV was not covered with heavy laser treatment. Laser treatment was clearly beneficial for eyes with classic CNV but no occult CNV and almost equivalent to no treatment for eyes with classic and occult CNV. The few eyes with occult CNV but no classic CNV precluded conclusions about the value of treatment in this subgroup., Conclusions: These results strengthen previous reports that laser treatment is beneficial for eyes with juxtafoveal choroidal neovascular lesions when classic CNV is present, even though CNV often recurs. Treatment of classic CNV alone in eyes with classic and occult CNV was not beneficial in this study. Distinguishing classic CNV from occult CNV can aid in the selection of patients who will benefit most from laser treatment.

We present the clinicopathologic features of the eye of a patient with age-related macular degeneration who underwent submacular membranectomy and had retention of good visual acuity for almost 4 years despite recurrent choroidal neovascularization treated with krypton laser photocoagulation and mild expansion of the laser lesion with time. Histopathologic study of the surgically removed membrane from the right eye disclosed a thin fibrovascular membrane lined by retinal pigment epithelium on one surface. Microscopic examination of the right eye obtained post mortem disclosed a 2.75-mm (horizontal) x 2.1-mm (vertical) retinal pigment epithelium defect with overlying photoreceptor cell atrophy centered on the temporal parafoveal area, and a 0.6 x 0.1-mm subretinal pigment epithelium fibrovascular membrane with an area of retinal pigment epithelial hyperplasia and vascularization from the retina 0.4 mm temporal to the fovea. Basal laminar deposit was present in the region of the fovea and nasal parafoveal area.

Objective: To identify specific features of pigment epithelium detachments with limited hyperfluorescent lesions (hot spots)., Design: One hundred eighty-two consecutive patients (186 eyes) who had vascularized pigment epithelium detachments and recent onset of symptoms were examined with indocyanine green and fluorescein videoangiography using the scanning laser ophthalmoscope. The choroidal neovascularization complex and macular retinal vessels were studied. The natural history and the effect of laser treatment were evaluated., Results: Fifty-four eyes had hot spots on indocyanine green angiography. In 50 of these 54 eyes, the video analysis showed an anastomosis of one or more retinal vessels, with the choroidal neovascularization within the hot spot. One or two retinal veins or arteries or both filled with both dyes and were seen to enter into the hot spot. Results of indocyanine green-guided photocoagulation of the hot spot in 28 eyes were disappointing., Conclusion: Continuous recording of the early phases of fluorescein and indocyanine green angiography allowed identification of chorioretinal anastomoses in vascularized pigment epithelium detachments with hot spots at an early exudative stage of age-related macular degeneration in 50 (26.8%) of 186 eyes. The poor outcome of laser photocoagulation could be related not only to the development of an overlying pigment epithelium detachment, but also to the retinal and choroidal vascularization of the lesion.

Background: Peripheral cryotherapy appears to be efficacious in the treatment of neovascularization of the vitreous base in patients with pars planitis, although it may be associated with the development of rhegmatogenous retinal detachments., Objective: To evaluate the safety and efficacy of peripheral scatter photocoagulation for treatment of neovascularization of the vitreous base when used alone or combined with pars plana vitrectomy., Methods: Six patients (10 eyes) presented with vitritis, cystoid macular edema, and neovascularization of the vitreous base, unresponsive to corticosteroid therapy. Three patients (five eyes) received scatter diode or argon photocoagulation treatment alone. The other three patients (five eyes) underwent pars plana vitrectomy coupled with argon or diode photocoagulation, placed in three rows, posterior to the area of inferior neovascularization of the vitreous base., Results: Pretreatment visual acuity ranged from 20/20 to 20/200. All patients were followed up for a minimum of 6 months. After placement of photocoagulation (with or without concurrent pars plana vitrectomy), the neovascularization regressed, inflammation was stabilized, and cystoid macular edema improved in all eyes. There were no retinal detachments or other complications of treatment. Posttreatment visual acuity ranged from 20/20 to 20/100. When final visual acuity was 20/40 or less, cataract formation was generally responsible., Conclusions: Peripheral scatter photocoagulation is efficacious and appears at least equal to peripheral cryotherapy in causing regression of neovascularization of the vitreous base in patients with pars planitis.

Objective: To determine the long-term visual outcome, rate of persistent choroidal neovascularization, and rate of recurrent choroidal neovascularization in eyes undergoing laser photocoagulation for choroidal neovascularization secondary to ocular histoplasmosis syndrome., Design and Patients: One hundred one eyes with 5 to 16 years of follow-up that presented with choroidal neovascularization secondary to ocular histoplasmosis were retrospectively evaluated. Patients were grouped according to location of choroidal neovascularization and assignment to observation or laser photocoagulation., Main Outcome Measures: Visual acuity outcome and loss for all groups were compared. The rates of persistent and recurrent choroidal neovascularization for the treated eyes were also evaluated., Results: Visual acuity of 20/40 or better was obtained in 71% of eyes with treated extrafoveal choroidal neovascularization and 68% with treated juxtafoveal choroidal neovascularization. Recurrent choroidal neovascularization was observed in 23% of treated eyes during a mean follow-up of 9.6 years., Conclusion: Results support the long-term benefit of photocoagulation and need for careful follow-up.

Objective: To study the differential abilities of diode infrared, krypton red, and argon blue-green laser energies to penetrate experimental subretinal hemorrhage and coagulate the underlying choroid., Methods: Autologous, heparinized whole blood was injected beneath the neurosensory retina of pigmented rabbit eyes. After 30 to 60 minutes, confluent patches of moderate or severe diode, krypton, or argon laser burns were applied to adjacent healthy retina and continued into the region of the subretinal hematoma without varying the power setting or focal plane. Histopathologic evaluation of early lesions was performed in a masked fashion, and subretinal hemorrhage thickness was determined with computer-assisted image capture and analysis., Results: Retina overlying treated subretinal hemorrhage showed no ophthalmoscopically visible signs of photocoagulation with diode energy, a faint gray reaction with krypton energy, and an intense white reaction with argon energy. Histopathologic analysis revealed photocoagulative inner choroidal damage beneath a mean (+/- SD) maximum blood thickness of 0.56 +/- 0.14 mm with severe diode burns, 0.42 +/- 0.09 mm with severe krypton burns, and 0.22 +/- 0.04 mm with severe argon burns., Conclusions: These data demonstrate that laser penetration of subretinal blood increases with longer wavelengths in vivo. Diode infrared laser energy is capable of penetrating subretinal blood to coagulate the choroid in the absence of ophthalmoscopically visible changes in the overlying retina.

Objective: To determine the percent of cases with all primary forms of exudative age-related macular degeneration that are eligible for treatment by the Macular Photocoagulation Study (MPS) guidelines in a retina clinic serving both as a primary care center and as a referral center., Design: Fluorescein angiograms of patients with age-related macular degeneration examined at the Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, during a 5-year period (1985 to 1990) were randomly selected and reviewed. Angiograms showing all forms of exudative age-related macular degeneration were eligible. The first 100 eligible angiograms identified constituted the study series and were classified into four groups: active choroidal neovascularization (CNV), pigment epithelium detachment, hemorrhage, and disciform scars. The active CNVs were further divided into three subgroups: classic (well defined), occult (poorly defined), and combined. Eligibility for laser treatment was determined exclusively with use of the published MPS recommendations for treatment of extrafoveal, juxtafoveal, and subfoveal membranes., Results: There were 10 cases in the pigment epithelium detachment group, 11 cases in the hemorrhagic group, and 16 cases with disciform scars. All of these 37 cases were ineligible for treatment by MPS guidelines. Sixty-three eyes had active membranes; 37 were classic CNVs (eight extrafoveal, seven juxtafoveal, and 22 subfoveal). All extrafoveal and juxtafoveal CNVs were found to be eligible for laser treatment. Eleven membranes of the subfoveal group were larger than 2 disc areas, a size for which the MPS did not demonstrate benefit from laser treatment. There were 19 membranes in the strictly occult CNV subgroup, all of them untreatable by MPS criteria. Seven cases had both occult and classic CNV, and all were larger than 3.5 disc areas and therefore ineligible for treatment. Overall, 26 cases were eligible for treatment by strict MPS criteria; these constitute 26% of the whole series and 41% of the active CNV cases in the series., Conclusions: Our results indicate that the MPS guidelines for laser treatment are applicable only to a minority of the cases with exudative age-related macular degeneration presenting to our clinic. Further studies should be conducted to identify additional treatment modalities for this common eye disease.

Purpose: To examine the direct relationship between the extent of treatment with krypton red laser photocoagulation and visual acuity loss in eyes with choroidal neovascularization secondary to ocular histoplasmosis or age-related macular degeneration., Patients and Methods: Photographic and visual acuity records from 129 eyes treated in the Ocular Histoplasmosis Study--Krypton Laser and 224 eyes treated in the Age-Related Macular Degeneration Study--Krypton Laser were reviewed. The proportion of eyes with severe visual acuity loss (6 or more lines of loss) was examined for subgroups of eyes based on the distance of the neovascular lesion from the center of the foveal avascular zone and on the extent of laser treatment to the lesion. Differences in the proportions with severe visual acuity loss were evaluated by longitudinal data analysis methods., Results: Among eyes in the Ocular Histoplasmosis Study--Krypton Laser with lesions less than 200 microns from the center of the foveal avascular zone, only 5% of eyes with laser treatment that covered the foveal side and had a narrow (< or = 100 microns) border of treatment to adjacent uninvolved retina experienced severe visual acuity loss compared with approximately 25% of eyes with either some of the foveal side of the lesion left untreated or a wide border of treatment on the foveal side. Treatment extent had little influence on severe visual acuity loss in eyes in the Ocular Histoplasmosis Study--Krypton Laser with neovascular lesions 200 to 500 microns from the center of the foveal avascular zone or in eyes in the Age-Related Macular Degeneration Study--Krypton Laser with lesions in either distance category., Conclusions: Accurate, complete treatment of choroidal neovascularization close to the foveal center is required to provide the patient with the best chance of avoiding further severe visual acuity loss, especially in patients with ocular histoplasmosis. Even among experienced retinal specialists, the required accuracy of treatment is difficult to achieve.

Objective: To determine whether laser photocoagulation of peripapillary choroidal neovascularization (CNV) or large neovascular lesions that are located nasal to the fovea is beneficial with respect to preservation of remaining vision--consistent with the overall study findings., Patients and Interventions: A total of 113 eyes (112 patients) having either peripapillary CNV or CNV that was located nasal to the fovea and larger than 750 microns in longest diameter associated with either ocular histoplasmosis or idiopathic causes were identified from the eyes that were randomly assigned to either laser photocoagulation or observation only in clinical trials conducted by the Macular Photocoagulation Study Group., Main Outcome Measures: Visual acuity and change in visual acuity from baseline examination were compared for laser-treated and untreated eyes., Results: At the 3-year examination, 11% (6/54) of the treated eyes vs 41% (21/51) of the untreated eyes had lost six or more lines of visual acuity (P < .001). Among eyes with peripapillary lesions, 14% (3/22) of the treated eyes vs 26% (6/23) of the untreated eyes had lost six or more lines of visual acuity at the 3-year examination (P = .29). Among eyes with nasal lesions, 9% (3/32) of the treated eyes vs 54% (15/28) of the untreated eyes had lost six or more lines of visual acuity at the 3-year examination (P < .001)., Conclusion: Results from the subset of patients who had extrafoveal or juxtafoveal peripapillary CNV or CNV that was located nasal to the fovea were consistent with the beneficial results of treatment observed in the entire group of eyes that were studied by the Macular Photocoagulation Study Group.

Objective/design: To evaluate prospectively the ability of three retina specialists to detect recurrent choroidal neovascularization (CNV) after clinical examination alone and then with fluorescein angiography at 3 and 6 weeks and at 3, 6, 9, and 12 months after laser photocoagulation., Setting: Single tertiary retinal referral center., Patients: All patients who had laser treatment for CNV within 14 months of their study visit. One hundred thirty-seven eyes of 134 patients were evaluated during 401 visits., Main Outcome Measures: Sensitivity, specificity, positive predictive value, and negative predictive value of clinical examination with biomicroscopy to detect recurrent CNV when defined as leakage on the periphery of the laser-treated area on the fluorescein angiogram., Results: Ninety-seven definite or probable recurrences in 56 eyes were identified on the fluorescein angiogram. Clinical examination had a sensitivity of 59%, specificity of 94%, positive predictive value of 76%, and negative predictive value of 88%. These figures varied somewhat by underlying cause, age, time since treatment, and lesion location. Using either a reported or measured loss of vision with the results of biomicroscopy as an indication of recurrence increased the sensitivity to 77% but reduced the specificity to 81%., Conclusions: Clinical examination probably cannot replace fluorescein angiography in detecting all recurrent CNV after laser treatment. However, for follow-up visits in which recurrent CNV was not suspected on biomicroscopy, definite or questionable recurrent CNV was identified on the fluorescein angiogram only 12% of the time, while the absence of recurrent CNV using this method was confirmed 88% of the time.

Objective: To evaluate the risks and benefits of argon-green compared with krypton red laser photocoagulation in the treatment of subfoveal choroidal neovascularization (CNV)., Design: Prospective randomized clinical trial assessing efficacy of laser treatment vs no treatment in the course of subfoveal CNV. Patients randomly assigned to laser treatment were randomly allocated to either argon green or krypton red laser photocoagulation. Scheduled follow-up for periods up to 5 years was performed., Setting: Tertiary retinal referral centers., Patients: Individuals with age-related macular degeneration and new subfoveal CNV or recurrent subfoveal CNV enrolled in the Foveal Photocoagulation Studies of the Macular Photocoagulation Study., Main Outcome Measures: Visual acuity, contrast sensitivity, reading spread, persistent and/or recurrent CNV, and treatment complications., Results: There was no significant difference in average loss of visual acuity or contrast sensitivity from baseline levels in eyes treated with either wavelength. From baseline, eyes treated with argon green laser in the Subfoveal Recurrent CNV Study lost an average of 12 words per minute less than eyes treated with krypton red laser. Comparable rates of persistent and recurrent CNV were observed in the two laser treatment groups. Focal retinal vascular narrowing was more common in eyes treated with argon green laser., Conclusions: Small differences in outcomes favored argon-green treatment of subfoveal CNV, but the only statistically significant difference observed between green- and red-laser treatments was a smaller loss of reading speed among argon green-treated eyes in the Recurrent CNV Study. The multiple analyses performed in these two Macular Photocoagulation Study trials failed to identify any consistent clinically and statistically significant differences between green- or red-laser treatment in the management of eyes with subfoveal CNV.

Objective: To determine whether the krypton red laser is superior to the argon green laser or vice versa for treatment of choroidal neovascularization located between 200 and 2500 microns from the center of the foveal avascular zone in patients with ocular histoplasmosis syndrome., Design: Multicenter, randomized, controlled clinical trial., Setting: Ophthalmologic clinics throughout Canada., Participants: Patients who provided informed consent, were aged 18 years or older, and had extrafoveal membranes associated with ocular histoplasmosis syndrome., Results: One hundred forty-one patients were randomized, 134 (95%) of whom were determined eligible. Of the eligible patients, 128 (96%) had sufficient follow-up for the primary outcome comparison of visual acuity at 1 year. In the argon green laser group, there was a mean increase of 3 letters at 1 year, while in the krypton red laser group there was a mean decrease of 2.5 letters in visual acuity., Conclusion: The krypton red laser is no better than the argon green laser for the treatment of well-defined extrafoveal choroidal neovascularization secondary to ocular histoplasmosis syndrome.

Objective: To characterize choroidal neovascularization (CNV) in black patients examined at a retinal disease referral center., Design: Retrospective review of the medical records of all patients diagnosed as having CNV to identify black patients with CNV., Setting: Single tertiary retinal referral center that included four ophthalmologists., Patients: All patients diagnosed as having CNV between April 1990 and October 1992., Main Outcome Measures: Prevalence, demographic information, fundus photographic and fluorescein angiographic characteristics, natural history, and response to laser photocoagulation of CNV in black patients., Results: Black patients comprise 15% of all patients seen at this center. Of 1725 patients identified as having CNV who were seen at the center during a 2.5-year period, only 25 were black (1.4%). In these patients, CNV was associated with a variety of retinal diseases, the most frequent being age-related macular degeneration. The average age of the study group was 54 years, women outnumbered men 2:1, and 13 of the patients developed bilateral lesions. Twelve of the 38 lesions were extrafoveal on presentation, and five of these were peripapillary. In the laser-treated eyes, recurrence of CNV was frequent and associated with visual loss., Conclusions: Choroidal neovascularization seems to be rare in blacks among a retinal disease referral center population. The overall presentation, natural history, and response to laser treatment seems to be similar to that of white patients. No feature of CNV in black patients was identified that would suggest that results of randomized clinical trials of laser photocoagulation for CNV are not valid for these patients.

Objective: To determine the incidence and visual impact of and risk factors for persistent and recurrent neovascularization after laser photocoagulation of subfoveal choroidal neovascularization (CNV) in patients with age-related macular degeneration., Design, Patients, and Methods: The records of 189 eyes in the Subfoveal New CNV Study and 100 eyes in the Subfoveal Recurrent CNV Study assigned to laser photocoagulation were examined. Persistent CNV (detected within 6 weeks of treatment) and recurrent CNV (detected after 6 weeks) were defined angiographically by fluorescein leakage from the periphery of the treatment scar. Incidence was estimated using survival analysis methods., Results: In both studies, persistent CNV was observed in approximately 13% of the eyes, and recurrent CNV was estimated to have developed by 3 years in an additional 35% of the eyes. In the New CNV Study, by 3 years, 36% of the eyes with persistent CNV had lost 6 or more lines of visual acuity as had 19% of the eyes with recurrent CNV and 27% of the eyes without persistence or recurrence. The presence of neovascular maculopathy in the fellow eye was associated with an increased risk for persistence or recurrence in the study eye. In the New CNV Study, partial coverage of the lesion with heavy laser treatment and/or runoff was associated with increased risk for persistence; less extensive natural scarring of the lesion at study entry was associated with increased risk for recurrence., Conclusions: Close to half of the eyes treated for subfoveal CNV have persistent or recurrent CNV within 3 years. There is a strong association between neovascular maculopathy in the fellow eye and the inability of laser photocoagulation to permanently obliterate signs of CNV from the study eye. Within these two studies, there was little additional damage to visual function resulting from persistent or recurrent neovascularization. There appears to be no reason to deviate from the protocol goal of covering the entire neovascular complex when treating eyes with subfoveal CNV.

Objective: To provide detailed information specific to the initial visual acuity and initial lesion size on the outcome of patients with subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration., Design and Patients: The 189 eyes assigned to laser photocoagulation and the 184 eyes assigned to observation in the Subfoveal New CNV Study were divided into nine subgroups based on initial visual acuity and initial lesion size., Main Outcome Measures: The pattern of visual acuity loss for both treated and untreated eyes through 4 years of follow-up was compared among the subgroups. Reading speed and contrast thresholds also were examined., Results: Four patterns (A, B, C, D) of visual acuity loss in treated eyes relative to untreated eyes were identified. Eyes in group A (small lesion and moderate or poor initial visual acuity or medium lesion and poor visual acuity) had the best visual outcome with treatment; treated eyes were better throughout follow-up. Eyes in group B (small lesion and good initial visual acuity or medium lesion and moderate or good visual acuity) had substantial treatment benefit by 12 months, but were worse immediately after treatment. Eyes in group C (large lesion and poor initial visual acuity) had a small treatment benefit throughout follow-up. Eyes in group D (large lesion and moderate or good visual acuity) had the worst visual outcome with treatment; treated eyes were substantially worse for the first 18 months and were not appreciably better through 4 years of follow-up., Conclusions: Recommendations for treatment of subfoveal CNV should take account of the initial visual acuity and lesion size. Eyes in group D are poor candidates for laser treatment.

Objective: To summarize findings from three randomized clinical trials of krypton laser treatment of juxtafoveal neovascular lesions regarding changes in visual acuity during 5 years of follow-up, rates of persistent and recurrent choroidal neovascularization, and status of macular lesions 5 years after enrollment. DESIGN, PATIENTS, AND PRIMARY OUTCOME MEASURES: Follow-up of patients enrolled in three randomized trials of choroidal neovascularization secondary to age-related macular degeneration (AMD), ocular histoplasmosis, or idiopathic causes ended in March 1991. All patients were eligible to complete at least 3 years of follow-up examinations. Data on visual acuity, reading vision, and anatomic outcomes during 5 years of follow-up were available for 276 (92%) of 300 patients with AMD, 236 (92%) of 256 patients with ocular histoplasmosis, and 38 (97%) of 39 patients with idiopathic choroidal neovascularization enrolled 5 or more years earlier who were still living., Results: Among eyes with AMD, the estimated relative risk (RR) of a loss of 6 or more lines of visual acuity from baseline to any examination from 6 months through 5 years after enrollment for untreated eyes in comparison with treated eyes was 1.20 (P = .04). Normotensive patients with AMD realized the greatest benefit from laser treatment (RR, 1.82) and hypertensive patients experienced little or no benefit (RR, 0.93). Untreated eyes with ocular histoplasmosis were at much greater risk of a 6-line decrease in visual acuity from the 1-year through the 5-year examination than were treated eyes (unadjusted RR, 2.60; RR, 4.26 after adjustment for visual acuity and hypertension at baseline; P < .001 for both). The treatment effect for eyes with idiopathic choroidal neovascularization was between the effects for eyes with AMD and eyes with ocular histoplasmosis., Conclusions: The early beneficial effects of laser treatment on visual acuity persisted for at least 5 years in eyes with all three underlying conditions. Laser treatment of similar eyes with choroidal neovascularization in a juxtafoveal location is recommended for patients with these conditions, with the caveat that hypertensive patients with AMD may fare no better with laser treatment than without treatment.

Purpose: Digital indocyanine green videoangiography (ICG-V) was used to study recurrent choroidal neovascularization (CNV) in patients with the clinical and fluorescein angiographic findings indicative of ill-defined, or recurrent occult, CNV (RO-CNV). The use of ICG-V-guided laser caphotocoagulation as an alternative form of treatment was also investigated when a well-delineated area of CNV was imaged with this technique., Methods: A consecutive series of 66 patients were studied who presented with exudative age-related macular degeneration and symptoms and clinical manifestations of recurrent CNV in which fluorescein angiography did not reveal classic, or well-defined, neovascularization. Patients were selected for laser treatment based on conventional guidelines if ICG-V imaged a well-delineated area of recurrent CNV., Results: Indocyanine green videoangiography showed late staining that was consistent with recurrent CNV in 64 (97%) of these 66 patients with RO-CNV. Twenty-nine (44%) of the 66 were eligible for laser treatment, and 18 (62%) of these 29 patients experienced successful anatomic and visual results, which were defined as resolution of the exudative manifestations and improvement or stabilization (+/- 1 line on a Snellen chart) of vision., Conclusions: This pilot study suggests that ICG-V is of value in imaging patients with RO-CNV after laser photocoagulation for CNV secondary to age-related macular degeneration. Laser treatment of RO-CNV with ICG-V guidance may be successful both anatomically and functionally in a promising number of these otherwise untreatable cases. Further studies are necessary to validate these preliminary findings.

Purpose: To evaluate the use of digital indocyanine green videoangiography in patients with clinical and fluorescein angiographic evidence of "occult" choroidal neovascularization in age-related macular degeneration and to investigate indocyanine green videoangiography-guided laser photocoagulation as a therapeutic approach., Methods: Three hundred forty-seven consecutive patients with exudative age-related macular degeneration and symptoms and clinical manifestations of occult choroidal neovascularization were studied with indocyanine green videoangiography. Patients were selected for laser treatment, using conventional guidelines, when indocyanine green videoangiography demonstrated a well-delineated area of hyperfluorescence, presumed to be a focal area of choroidal neovascularization., Results: Seventy-nine (23%) of 347 eyes were found to have a localized and definable lesion that was potentially amenable to laser photocoagulation therapy; 44 (56%) of these 79 treated eyes had complete resolution of their exudative manifestations. Visual acuity improvement was noted in 10 (13%) of 79 eyes, and stabilization of vision achieved in 42 eyes (53%)., Conclusion: Laser photocoagulation treatment guided by indocyanine green videoangiography was shown to produce promising anatomical and visual improvement in a small number of patients with occult choroidal neovascularization secondary to age-related macular degeneration. This pilot study warrants further research to investigate the efficacy and safety of this form of treatment.

Objective: To report 3- and 4-year visual outcomes in eyes followed up in two randomized clinical trials of laser photocoagulation for subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration., Design and Main Outcome Measures: Eyes of consenting patients were assigned randomly to laser treatment or no treatment. Visual acuity, reading speed, and contrast threshold were measured before random assignment, 3 and 6 months later, and at 6-month intervals thereafter. Visual acuities of treated and untreated eyes were compared 4 years after enrollment, in the Subfoveal New CNV Study (eyes without prior laser treatment), and 3 years after enrollment, in the Subfoveal Recurrent CNV Study (eyes with subfoveal recurrent CNV at the periphery of an earlier laser treatment scar)., Results: Four years after enrollment in the Subfoveal New CNV Study, 39 (47%) of 83 untreated eyes and 17 (22%) of 77 laser-treated eyes had lost 6 or more lines of visual acuity from baseline levels (P = .002). At the 3-year examination in the Subfoveal Recurrent CNV Study, 21 (36%) of 58 untreated eyes and six (12%) of 49 treated eyes had lost 6 or more lines of visual acuity from baseline levels (P = .009). Comparisons based on contrast threshold and reading speed for enlarged text also favored laser treatment in both trials., Conclusions: Stronger evidence favoring laser photocoagulation of subfoveal CNV has been provided by continued follow-up of patients enrolled in these two clinical trials. The benefits of laser treatment have persisted through at least 4 years of follow-up in the Subfoveal New CNV Study and 3 years of follow-up in the Subfoveal Recurrent CNV Study.

Objective: We undertook a retrospective study of all choroidal nevi with overlying neovascularization seen at Bascom Palmer Eye Institute, Miami, Fla, to determine long-term effects on vision and whether the presence of neovascularization represented increased malignant potential of the lesion., Design: A computer search of patients with a coded diagnosis of both a choroidal nevus and choroidal neovascularization was performed. Cases in which the neovascularization was directly overlying the nevus were used for the study., Results: The records of 23 patients followed up for a mean of 6.5 years were reviewed for visual acuity, effect of treatment, and change in the size of the choroidal lesion. Fifteen of the 23 patients had a final visual acuity in the affected eye of 20/200 or better. Five of six patients treated with laser had visual improvement of 2 or more lines. Only one of these lesions showed any growth, and this was after 17 years of no growth., Conclusions: Choroidal neovascularization associated with choroidal nevi can have profound effects on vision. Laser treatment, when indicated, is effective and may be safely performed. The clinical course of these lesions, to date, does not indicate any clinically significant malignant transformation.

This multicenter randomized controlled clinical trial performed in Canada was designed to determine whether krypton red laser or argon green laser is superior for treatment of choroidal neovascularization located between 200 and 2500 microns from the center of the foveal avascular zone in patients with age-related macular degeneration. Two hundred ten patients were randomly assigned to treatment with either argon green or krypton red laser, of whom 191 (91%) were determined eligible. Of the eligible patients, 185 (97%) had sufficient follow-up for a comparison of primary-outcome visual acuity at 1 year. We conclude, with 95% confidence, that the krypton red laser is no better than the argon green laser for the treatment of well-defined extrafoveal choroidal neovascularization.

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.