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About 80% of uncomplicated rhegmatogenous retinal detachments can be cured with one operation; an addi-
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tional 15% will need repeated operations; and the remainder never reattach The prognosis is worse if the macula is detached or if the detachment is of long duration Without treatment, retinal detachment often becomes total within 6 months Spontaneous detachments are ultimately bilateral in up to 25% of cases
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Erie JC et al Risk of retinal detachment after cataract extraction, 1980 2004: a population-based study Ophthalmology 2006 Nov;113(11):2026 32 [PMID: 16935341]
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The precursor to age-related macular degeneration is agerelated maculopathy, characterized by retinal drusen Hard drusen appear ophthalmoscopically as discrete yellow deposits Soft drusen are larger, paler, and less distinct Large, confluent soft drusen are particularly associated with exudative age-related macular degeneration Atrophic degeneration is characterized by gradually progressive bilateral visual loss of moderate severity due to atrophy and degeneration of the outer retina and retinal pigment epithelium In exudative degeneration, choroidal new vessels grow between the retinal pigment epithelium and Bruch s membrane, leading to accumulation of serous fluid, hemorrhage, and fibrosis The onset of visual loss is more rapid and more severe in exudative degeneration than in atrophic degeneration The two eyes are frequently affected sequentially over a period of a few years Exudative disease accounts for about 90% of all cases of legal blindness due to age-related macular degeneration
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VITREOUS HEMORRHAGE
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Patients with vitreous hemorrhage complain of sudden visual loss, abrupt onset of floaters that may progressively increase in severity or, occasionally, bleeding within the eye Visual acuity ranges from 20/20 to light perception only The eye is not inflamed, and the clue to diagnosis is the inability to see fundal details clearly despite the presence of a clear lens Causes of vitreous hemorrhage include diabetic retinopathy, retinal tears (with or without detachment), retinal vein occlusions, exudative age-related macular degeneration, blood dyscrasias, trauma, and subarachnoid hemorrhage In all cases, examination by an ophthalmologist is essential Retinal tears and detachments necessitate urgent treatment (see above)
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Goff MJ et al Causes and treatment of vitreous hemorrhage Compr Ophthalmol Update 2006 May-Jun;7(3):97 111 [PMID: 16882398]
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Treatment
Treatment of exudative age-related macular degeneration is changing rapidly with improvement in visual outcome, at least in the short-term Conventional laser retinal photocoagulation continues to be suitable for well-defined ( classic ) choroidal neovascular membranes away from or adjacent to the fovea (extrafoveal or juxtafoveal), but these are a relatively small proportion Photodynamic laser therapy (PDT), involving intravenous injection of verteporfin activated by subsequent retinal laser irradiation to produce selective vascular damage, has been particularly indicated for well-defined lesions lying under the fovea (subfoveal) Recently, the emphasis has changed from refining laser techniques that obliterate the choroidal neovascular membrane to developing antiangiogenic agents, particularly inhibitors of vascular endothelial growth factors (VEGF), which reverse the neovascularization and thus could be beneficial in both well and poorly defined ( occult ) lesions, whether they are subfoveal or not Anecortave (not available in the United States), a synthetic steroid with angiostatic activity administered by juxtascleral depot injection, and intravitreal triamcinolone has been shown to be beneficial Better results have been obtained with intravitreal pegaptanib, for which there is the most published data and clinical experience, ranibizumab, and bevacizumab A major drawback is that treatment with intravitreal antiangiogenic agents has to be repeated every 4 6 weeks, with the attendant risks including intraocular infection and inflammation, retinal detachment, and traumatic cataract (Photodynamic therapy generally needs to be repeated every 12 weeks) Intravenous infusion of bevacizumab has been studied but the potential risks of systemic anti-VEGF therapy are a contraindication to its use As the long-term benefits and risks of antiangiogenic agents become known, as well as their relative costs, the indications for their use as well as for photodynamic therapy and conventional retinal laser photocoagulation, possibly including combinations of antiangiogenic and laser therapy, will become clearer
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