- Email: [email protected]
Submacular deposition of triamcinolone acetonide after triamcinolone-assisted vitrectomy
FIGURE 2. The continuous outflow perfluorocarbon liquid injection needle with a soft tip.
trolled leakage of intravitreal fluid and interruption of complete fluid–air exchange. Our continuous outflow needle eliminates the problem by allowing simultaneous creation of the smallest possible retinotomy and maintenance of lower intravitreal pressure by controlled outflow of intravitreal fluid. The continuous outflow rigid needle can also be used in limited macular translocation. Following the retinal separation, the next step is rotation of the mobile retina around the optic nerve head. At this stage, because the free retina tends to roll onto the disk, injection of perfluorocarbon liquid over the retina is needed to unroll, unfold, and then properly rotate it. The smaller diameter shaft of this device makes it especially useful, because a 21-gauge shaft permits fluid to flow during perfluorocarbon liquid injection (Figure 2). The soft silicon tip permits the surgeon to hold the retina gently in place while allowing injection of more perfluorocarbon liquid until complete retinal reattachment is achieved. We have used these two continuous outflow instruments in 54 macular translocation surgery cases without complications. Continuous outflow instruments are useful tools to facilitate critical steps in the delicate process of macular translocation surgery.
3. Zivojnovic R, Vijfvinkel G. A brush back-flush needle. Arch Ophthalmol 1988;106:695. 4. Lewis JM, Park I, Ohji M, Saito Y, Tano Y. Diamond-dusted silicone cannula for epiretinal membrane separation during vitreous surgery. Am J Ophthalmol 1997;124:552–554. 5. Toth CA, Machemer R. Macular translocation. In: Berger JW, Fine SL, Maguire MG, editors. Age-related macular degeneration. St. Louis, MO: Mosby, 1999:353–362.
Submacular Deposition of Triamcinolone Acetonide After Triamcinolone-assisted Vitrectomy Hiroshi Enaida, MD, Taiji Sakamoto, MD, Akifumi Ueno, MD, Takao Nakamura, MD, Yoshihiro Noda, MD, Keiko Maruoka, MD, and Tatsuro Ishibashi, MD PURPOSE: We describe a case demonstrating a submacular deposition of triamcinolone acetonide (TA) after a TAassisted vitrectomy for retinal detachment. DESIGN: Interventional case report. METHODS: A 48-year-old Japanese man with rhegmatogenous retinal detachment in his left eye underwent a
REFERENCES
1. C ¸ ekic¸ O, Ohji M, Hayashi A, Fujikado T, TanoY. Foveal translocation surgery in age-related macular degeneration [Letter]. Lancet. 1999;354:340. 2. Ohji M, Fujikado T, Kusaka S, et al. Comparison of three techniques of foveal translocation in patients with subfoveal choroidal neovascularization resulting from age-related macular degeneration. Am J Ophthalmol 2001;132:888 –896.
VOL. 135, NO. 2
Accepted for publication Sept 5, 2002. From the Department of Ophthalmology, Kyushu University Graduate School of Medicine, Fukuoka, Japan. Inquiries to Taiji Sakamoto, MD, Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan; fax: (⫹81) 92-642-5663; e-mail: [email protected]
BRIEF REPORTS
243
FIGURE 1. Fundus photographs after a vitrectomy. (Top left) The day after a vitrectomy, submacular TA (arrowhead) was observed through SF6 gas. (Top right) Seven days after the surgery. The deposition of TA thereafter gradually decreased in size. (Bottom left) Ten days after the surgery. The thin arrow shows an intentional drainage hole. (Bottom right) A view 2 weeks after the surgery, by which time the TA had been completely absorbed. No apparent change was observed.
T
TA-assisted vitrectomy, endolaser photocoagulation, and sulfur hexafluoride (SF6) gas tamponade. RESULTS: At the end of the surgery and the day after undergoing vitrectomy, the deposition of TA was observed between the retinal pigment epithelium and neurosensory retina in the submacular area. These TA granules disappeared after 2 weeks. Two months after the operation, the retina was observed to be successfully attached and no abnormality was observed in the macula. The patient’s visual acuity improved to 20/16, and no ophthalmoscopic or functional damage was observed. CONCLUSION: No apparent adverse effect was found in this case demonstrating a submacular deposition of TA. (Am J Ophthalmol 2003;135:243–246. © 2003 by Elsevier Science Inc. All rights reserved.) 244
AMERICAN JOURNAL
RIAMCINOLONE-ACETONIDE (TA) (KENAKOLT-A, BRISTOL
Pharmaceuticals KK, Tokyo, Japan) is a water-insoluble corticosteroid, and the intraocular injection of TA is used during a pars plana vitrectomy (PPV) for the treatment of proliferative ocular diseases.1– 4 The intraoperative use of TA has two advantages for patients; one is to assist the surgical maneuvers by visualizing the hyaloid; the other is to reduce the degree of postoperative inflammation.1,2 Nonetheless, the direct effect of TA on the retina remains uncertain. A 48-year-old Japanese man presented at Kyushu University Hospital complaining of visual loss in his left eye. A slit-lamp and ophthalmoscopic examination revealed a mild cataract and a bullous retinal detachment with macula off in his left eye. Best-corrected visual acuity was 20/1000. A standard phacoemulsification and PPV thus was performed. A
OF
OPHTHALMOLOGY
FEBRUARY 2003
FIGURE 2. Fluorescein angiography and the central 10-2 Humphrey perimetric results. (Top left) Fluorescein angiography shows no abnormality in the region of TA accumulation at 10 days after the surgery. (Top right) Two months after the surgery. The fluorescein angiography findings were the same at 2 months after surgery as they were at 10 days after surgery. (Bottom left) The average sensitivity of the fovea was 29.8 dB, and the mean deviation was ⴚ3.54 dB on the central 10-2 Humphrey perimetric results at 10 days after surgery. (Bottom right) The average sensitivity of the fovea improved to 31.8 dB, and mean deviation was ⴚ1.85 dB at 2 months after surgery.
TA suspension was injected into the vitreous intraoperatively as previously described (1.0 ml TA suspension).2 Retinotomy for drainage was performed about 3 mm superior to the optic disk. Retinal endolaser photocoagulation was performed, followed by sulfur hexafluoride (SF6) gas tamponade. At the end of surgery, a small amount of TA was observed in the submacular area. However, it could not be completely removed because doing so might have damaged the macula. The next day there was a white material, namely TA, that could be observed under the macula (Figure 1). The volume of the submacular TA gradually decreased and finally disappeared within 2 weeks. The central perimetry (Humphrey Field Analyzer II, Zeiss-Humphrey Systems, Dublin, CaliforVOL. 135, NO. 2
nia, USA) showed the average sensitivity of the fovea and the mean deviation to be 29.8 and ⫺3.54 dB, respectively, on day 10 (Figure 2). The visual acuity improved to 20/40. No morphologic change was observed by either ophthalmoscopic examinations or optical coherence tomography (OCT; ZeissHumphrey, Dublin, California, USA) (data not shown).4 At 2 months after surgery, the visual acuity had further improved to 20/20 and the average sensitivity of fovea was 31.8 dB, whereas the mean deviation was ⫺1.85 dB. Fluorescein angiography showed no remarkable finding (Figure 2). At 5 months after surgery, the best-corrected visual acuity improved to 20/16. Throughout this period, the intraocular pressure in the left eye was within the normal range.
BRIEF REPORTS
245
Compared to the intraocular TA injection in a nonvitrectomized eye, special care should be paid to a vitrectomized eye. Triamcinolone-acetonide, which tends to be trapped mostly by vitreous gel of nonvitrectomized eyes, can easily accumulate in the macula of vitrectomized eyes owing to gravity. In our experience of more than 200 cases, however, the occurrence of supramacular TA deposition is quite rare, because supraretinal TA can normally be easily removed by a silicone-tipped needle intraoperatively. However, it is difficult to remove TA that has become subretinally deposited. Several reports have noted that intraocular TA may be tolerated by ocular tissues, but there is still a concern about the potentially harmful effects of the vehicle contained in commercial TA on the retinal structure and function.5 At the same time, because TA induces apoptosis in certain cells owing to the effect of glucocorticoid receptor, its safety still has to be fully established before general clinical application can be recommended. In this case, the damage attributable to subretinal TA deposition was not significant either morphologically or functionally. Certainly, the present findings do not mean that TA is nontoxic to any retinal cells. However, this case provided us with important information regarding the safety of intraocular TA therapy for retinal diseases.
To evaluate the efficacy of intravitreal triamcinolone in refractory pseudophakic cystoid macular edema. DESIGN: A prospective, interventional case series. METHODS: Three eyes of three patients with longstanding pseudophakic cystoid macular edema following uncomplicated cataract surgery, refractory to any medication, were treated with 8 mg of intravitreal triamcinolone. All three eyes were evaluated before injection and throughout follow-up with the Early Treatment Diabetic Retinopathy Study’s visual acuity chart, fluorescein angiography, and macular mapping using optical coherence tomography. RESULTS: A month after intravitreal triamcinolone injection, a dramatic decrease in macular thickness was noted by optical coherence tomography in all three eyes (from a mean of 502–233 m). Mean improvement in visual acuity was 3.7 Snellen lines. Two to 4 months after triamcinolone injection, however, the edema recurred in all cases, to the same degree as before the injection, combined with a decrease in vision. Two eyes underwent a second injection of triamcinolone, and macular thickness decreased, but the edema again recurred 3 months after injection. CONCLUSION: Intravitreal injection of triamcinolone induces striking regression, within 1 month, of chronic refractory macular edema. This regression appears to be transient, however, even after a second injection. (Am J Ophthalmol 2003;135:246 –249. © 2003 by Elsevier Science Inc. All rights reserved.) PURPOSE:
REFERENCES
1. Peyman GA, Cheema R, Conway MD, Fang T. Triamcinolone acetonide as an aid to visualization of the vitreous and the posterior hyaloid during pars plana vitrectomy. Retina 2000;20:554 –555. 2. Sakamoto T, Miyazaki M, Hisatomi T, et al. Triamcinoloneassisted pars plana vitrectomy improves the surgical procedures and decreases the post-operative blood-ocular barrier breakdown. Graefes Arch Clin Exp Ophthalmol 2002;240: 423–429. 3. Jonas JB, Hayler JK, Sofker A, Panda-Jonas S. Intravitreal injection of crystalline cortisone as adjunctive treatment of proliferative diabetic retinopathy. Am J Ophthalmol 2001; 131:468 –471. 4. Antcliff RJ, Spalton DJ, Stanford MR, Graham EM, Ffytche TJ, Marshall J. Intravitreal triamcinolone for uveitic cystoid macular edema: an optical coherence tomography study. Ophthalmology 2001;108:765–772. 5. Hida T, Chandler D, Arena JE, Machemer R. Experimental and clinical observations of the intraocular toxicity of commercial corticosteroid preparations. Am J Ophthalmol 1986; 101:190 –195.
C
YSTOID MACULAR EDEMA IS AN INFREQUENT COMPLI-
Intravitreal Triamcinolone for Refractory Pseudophakic Macular Edema
cation of cataract extraction. In most cases, it tends to resolve, spontaneously or with drug treatment. In a few cases, however, it persists with decreased visual acuity despite aggressive treatment. Intravitreal triamcinolone acetonide was recently reported to be effective in macular edema of various etiologies.1–2 In this investigation, we prospectively studied the efficacy of intravitreal triamcinolone in three eyes of three patients with persistent refractory cystoid macular edema after cataract extraction. Three patients (two women, and one man), aged 62 to 76 years, presented with pseudophakic refractory cystoid macular edema in three eyes lasting for 7 to 15 months following uncomplicated cataract surgery (Table 1). Before intravitreal triamcinolone injection, all three patients had been followed up in our department for at least 6 months; they were treated with topical corticosteroid and nonsteroid antiinflammatory medication and oral acetazolamide but without success regarding either visual acuity or retinal thickness. Before injection and throughout follow-up, each patient underwent a comprehensive ocular examination including assessment of best-corrected visual acuity using the Early Treatment Dia-
Nathanael Benhamou, MD, Pascale Massin, MD, PhD, Belkacem Haouchine, MD, Francois Audren, MD, Ramin Tadayoni, MD, and Alain Gaudric, MD
Accepted for publication Aug 28, 2002. From the Department of Ophthalmology, Hoˆ pital Lariboisie`re, Assistance Publique-Hoˆ pitaux de Paris, Universite´ Paris 7, Paris, France. Inquiries to Nathanael Benhamou, MD, Department of Ophthalmology, Hoˆ pital Lariboisie`re, 2 rue Ambroise Pare´ , 75475 Paris Cedex 10, France; fax: (⫹ 33) 1-49956483; e-mail: [email protected]
246
AMERICAN JOURNAL
OF
OPHTHALMOLOGY
FEBRUARY 2003
trolled leakage of intravitreal fluid and interruption of complete fluid–air exchange. Our continuous outflow needle eliminates the problem by allowing simultaneous creation of the smallest possible retinotomy and maintenance of lower intravitreal pressure by controlled outflow of intravitreal fluid. The continuous outflow rigid needle can also be used in limited macular translocation. Following the retinal separation, the next step is rotation of the mobile retina around the optic nerve head. At this stage, because the free retina tends to roll onto the disk, injection of perfluorocarbon liquid over the retina is needed to unroll, unfold, and then properly rotate it. The smaller diameter shaft of this device makes it especially useful, because a 21-gauge shaft permits fluid to flow during perfluorocarbon liquid injection (Figure 2). The soft silicon tip permits the surgeon to hold the retina gently in place while allowing injection of more perfluorocarbon liquid until complete retinal reattachment is achieved. We have used these two continuous outflow instruments in 54 macular translocation surgery cases without complications. Continuous outflow instruments are useful tools to facilitate critical steps in the delicate process of macular translocation surgery.
3. Zivojnovic R, Vijfvinkel G. A brush back-flush needle. Arch Ophthalmol 1988;106:695. 4. Lewis JM, Park I, Ohji M, Saito Y, Tano Y. Diamond-dusted silicone cannula for epiretinal membrane separation during vitreous surgery. Am J Ophthalmol 1997;124:552–554. 5. Toth CA, Machemer R. Macular translocation. In: Berger JW, Fine SL, Maguire MG, editors. Age-related macular degeneration. St. Louis, MO: Mosby, 1999:353–362.
Submacular Deposition of Triamcinolone Acetonide After Triamcinolone-assisted Vitrectomy Hiroshi Enaida, MD, Taiji Sakamoto, MD, Akifumi Ueno, MD, Takao Nakamura, MD, Yoshihiro Noda, MD, Keiko Maruoka, MD, and Tatsuro Ishibashi, MD PURPOSE: We describe a case demonstrating a submacular deposition of triamcinolone acetonide (TA) after a TAassisted vitrectomy for retinal detachment. DESIGN: Interventional case report. METHODS: A 48-year-old Japanese man with rhegmatogenous retinal detachment in his left eye underwent a
REFERENCES
1. C ¸ ekic¸ O, Ohji M, Hayashi A, Fujikado T, TanoY. Foveal translocation surgery in age-related macular degeneration [Letter]. Lancet. 1999;354:340. 2. Ohji M, Fujikado T, Kusaka S, et al. Comparison of three techniques of foveal translocation in patients with subfoveal choroidal neovascularization resulting from age-related macular degeneration. Am J Ophthalmol 2001;132:888 –896.
VOL. 135, NO. 2
Accepted for publication Sept 5, 2002. From the Department of Ophthalmology, Kyushu University Graduate School of Medicine, Fukuoka, Japan. Inquiries to Taiji Sakamoto, MD, Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan; fax: (⫹81) 92-642-5663; e-mail: [email protected]
BRIEF REPORTS
243
FIGURE 1. Fundus photographs after a vitrectomy. (Top left) The day after a vitrectomy, submacular TA (arrowhead) was observed through SF6 gas. (Top right) Seven days after the surgery. The deposition of TA thereafter gradually decreased in size. (Bottom left) Ten days after the surgery. The thin arrow shows an intentional drainage hole. (Bottom right) A view 2 weeks after the surgery, by which time the TA had been completely absorbed. No apparent change was observed.
T
TA-assisted vitrectomy, endolaser photocoagulation, and sulfur hexafluoride (SF6) gas tamponade. RESULTS: At the end of the surgery and the day after undergoing vitrectomy, the deposition of TA was observed between the retinal pigment epithelium and neurosensory retina in the submacular area. These TA granules disappeared after 2 weeks. Two months after the operation, the retina was observed to be successfully attached and no abnormality was observed in the macula. The patient’s visual acuity improved to 20/16, and no ophthalmoscopic or functional damage was observed. CONCLUSION: No apparent adverse effect was found in this case demonstrating a submacular deposition of TA. (Am J Ophthalmol 2003;135:243–246. © 2003 by Elsevier Science Inc. All rights reserved.) 244
AMERICAN JOURNAL
RIAMCINOLONE-ACETONIDE (TA) (KENAKOLT-A, BRISTOL
Pharmaceuticals KK, Tokyo, Japan) is a water-insoluble corticosteroid, and the intraocular injection of TA is used during a pars plana vitrectomy (PPV) for the treatment of proliferative ocular diseases.1– 4 The intraoperative use of TA has two advantages for patients; one is to assist the surgical maneuvers by visualizing the hyaloid; the other is to reduce the degree of postoperative inflammation.1,2 Nonetheless, the direct effect of TA on the retina remains uncertain. A 48-year-old Japanese man presented at Kyushu University Hospital complaining of visual loss in his left eye. A slit-lamp and ophthalmoscopic examination revealed a mild cataract and a bullous retinal detachment with macula off in his left eye. Best-corrected visual acuity was 20/1000. A standard phacoemulsification and PPV thus was performed. A
OF
OPHTHALMOLOGY
FEBRUARY 2003
FIGURE 2. Fluorescein angiography and the central 10-2 Humphrey perimetric results. (Top left) Fluorescein angiography shows no abnormality in the region of TA accumulation at 10 days after the surgery. (Top right) Two months after the surgery. The fluorescein angiography findings were the same at 2 months after surgery as they were at 10 days after surgery. (Bottom left) The average sensitivity of the fovea was 29.8 dB, and the mean deviation was ⴚ3.54 dB on the central 10-2 Humphrey perimetric results at 10 days after surgery. (Bottom right) The average sensitivity of the fovea improved to 31.8 dB, and mean deviation was ⴚ1.85 dB at 2 months after surgery.
TA suspension was injected into the vitreous intraoperatively as previously described (1.0 ml TA suspension).2 Retinotomy for drainage was performed about 3 mm superior to the optic disk. Retinal endolaser photocoagulation was performed, followed by sulfur hexafluoride (SF6) gas tamponade. At the end of surgery, a small amount of TA was observed in the submacular area. However, it could not be completely removed because doing so might have damaged the macula. The next day there was a white material, namely TA, that could be observed under the macula (Figure 1). The volume of the submacular TA gradually decreased and finally disappeared within 2 weeks. The central perimetry (Humphrey Field Analyzer II, Zeiss-Humphrey Systems, Dublin, CaliforVOL. 135, NO. 2
nia, USA) showed the average sensitivity of the fovea and the mean deviation to be 29.8 and ⫺3.54 dB, respectively, on day 10 (Figure 2). The visual acuity improved to 20/40. No morphologic change was observed by either ophthalmoscopic examinations or optical coherence tomography (OCT; ZeissHumphrey, Dublin, California, USA) (data not shown).4 At 2 months after surgery, the visual acuity had further improved to 20/20 and the average sensitivity of fovea was 31.8 dB, whereas the mean deviation was ⫺1.85 dB. Fluorescein angiography showed no remarkable finding (Figure 2). At 5 months after surgery, the best-corrected visual acuity improved to 20/16. Throughout this period, the intraocular pressure in the left eye was within the normal range.
BRIEF REPORTS
245
Compared to the intraocular TA injection in a nonvitrectomized eye, special care should be paid to a vitrectomized eye. Triamcinolone-acetonide, which tends to be trapped mostly by vitreous gel of nonvitrectomized eyes, can easily accumulate in the macula of vitrectomized eyes owing to gravity. In our experience of more than 200 cases, however, the occurrence of supramacular TA deposition is quite rare, because supraretinal TA can normally be easily removed by a silicone-tipped needle intraoperatively. However, it is difficult to remove TA that has become subretinally deposited. Several reports have noted that intraocular TA may be tolerated by ocular tissues, but there is still a concern about the potentially harmful effects of the vehicle contained in commercial TA on the retinal structure and function.5 At the same time, because TA induces apoptosis in certain cells owing to the effect of glucocorticoid receptor, its safety still has to be fully established before general clinical application can be recommended. In this case, the damage attributable to subretinal TA deposition was not significant either morphologically or functionally. Certainly, the present findings do not mean that TA is nontoxic to any retinal cells. However, this case provided us with important information regarding the safety of intraocular TA therapy for retinal diseases.
To evaluate the efficacy of intravitreal triamcinolone in refractory pseudophakic cystoid macular edema. DESIGN: A prospective, interventional case series. METHODS: Three eyes of three patients with longstanding pseudophakic cystoid macular edema following uncomplicated cataract surgery, refractory to any medication, were treated with 8 mg of intravitreal triamcinolone. All three eyes were evaluated before injection and throughout follow-up with the Early Treatment Diabetic Retinopathy Study’s visual acuity chart, fluorescein angiography, and macular mapping using optical coherence tomography. RESULTS: A month after intravitreal triamcinolone injection, a dramatic decrease in macular thickness was noted by optical coherence tomography in all three eyes (from a mean of 502–233 m). Mean improvement in visual acuity was 3.7 Snellen lines. Two to 4 months after triamcinolone injection, however, the edema recurred in all cases, to the same degree as before the injection, combined with a decrease in vision. Two eyes underwent a second injection of triamcinolone, and macular thickness decreased, but the edema again recurred 3 months after injection. CONCLUSION: Intravitreal injection of triamcinolone induces striking regression, within 1 month, of chronic refractory macular edema. This regression appears to be transient, however, even after a second injection. (Am J Ophthalmol 2003;135:246 –249. © 2003 by Elsevier Science Inc. All rights reserved.) PURPOSE:
REFERENCES
1. Peyman GA, Cheema R, Conway MD, Fang T. Triamcinolone acetonide as an aid to visualization of the vitreous and the posterior hyaloid during pars plana vitrectomy. Retina 2000;20:554 –555. 2. Sakamoto T, Miyazaki M, Hisatomi T, et al. Triamcinoloneassisted pars plana vitrectomy improves the surgical procedures and decreases the post-operative blood-ocular barrier breakdown. Graefes Arch Clin Exp Ophthalmol 2002;240: 423–429. 3. Jonas JB, Hayler JK, Sofker A, Panda-Jonas S. Intravitreal injection of crystalline cortisone as adjunctive treatment of proliferative diabetic retinopathy. Am J Ophthalmol 2001; 131:468 –471. 4. Antcliff RJ, Spalton DJ, Stanford MR, Graham EM, Ffytche TJ, Marshall J. Intravitreal triamcinolone for uveitic cystoid macular edema: an optical coherence tomography study. Ophthalmology 2001;108:765–772. 5. Hida T, Chandler D, Arena JE, Machemer R. Experimental and clinical observations of the intraocular toxicity of commercial corticosteroid preparations. Am J Ophthalmol 1986; 101:190 –195.
C
YSTOID MACULAR EDEMA IS AN INFREQUENT COMPLI-
Intravitreal Triamcinolone for Refractory Pseudophakic Macular Edema
cation of cataract extraction. In most cases, it tends to resolve, spontaneously or with drug treatment. In a few cases, however, it persists with decreased visual acuity despite aggressive treatment. Intravitreal triamcinolone acetonide was recently reported to be effective in macular edema of various etiologies.1–2 In this investigation, we prospectively studied the efficacy of intravitreal triamcinolone in three eyes of three patients with persistent refractory cystoid macular edema after cataract extraction. Three patients (two women, and one man), aged 62 to 76 years, presented with pseudophakic refractory cystoid macular edema in three eyes lasting for 7 to 15 months following uncomplicated cataract surgery (Table 1). Before intravitreal triamcinolone injection, all three patients had been followed up in our department for at least 6 months; they were treated with topical corticosteroid and nonsteroid antiinflammatory medication and oral acetazolamide but without success regarding either visual acuity or retinal thickness. Before injection and throughout follow-up, each patient underwent a comprehensive ocular examination including assessment of best-corrected visual acuity using the Early Treatment Dia-
Nathanael Benhamou, MD, Pascale Massin, MD, PhD, Belkacem Haouchine, MD, Francois Audren, MD, Ramin Tadayoni, MD, and Alain Gaudric, MD
Accepted for publication Aug 28, 2002. From the Department of Ophthalmology, Hoˆ pital Lariboisie`re, Assistance Publique-Hoˆ pitaux de Paris, Universite´ Paris 7, Paris, France. Inquiries to Nathanael Benhamou, MD, Department of Ophthalmology, Hoˆ pital Lariboisie`re, 2 rue Ambroise Pare´ , 75475 Paris Cedex 10, France; fax: (⫹ 33) 1-49956483; e-mail: [email protected]
246
AMERICAN JOURNAL
OF
OPHTHALMOLOGY
FEBRUARY 2003