Stereo nonmydriatic digital-video color retinal imaging compared with Early Treatment Diabetic Retinopathy Study seven standard field 35-mm stereo color photos for determining level of diabetic retinopathy.

OBJECTIVE: To evaluate the ability to determine clinical levels of diabetic retinopathy, timing of next appropriate retinal evaluation, and necessity of referral to ophthalmology specialists using stereoscopic nonmydriatic digital-video color retinal images as compared with Early Treatment Diabetic Retinopathy Study (ETDRS) seven standard field 35-mm stereoscopic color fundus photographs. DESIGN: Prospective, clinic-based, comparative instrument validation study. PARTICIPANTS: Fifty-four patients (108 eyes) with type 1 or type 2 diabetes mellitus selected after chart review from a single center to include the full spectrum of diabetic retinopathy. METHODS: Nonsimultaneous 45 degrees -field stereoscopic digital-video color images (JVN images) were obtained from three fields with the Joslin Vision Network (JVN) system before pupil dilation. Following pupil dilation, ETDRS seven standard field 35-mm stereoscopic color 30 degrees fundus photographs (ETDRS photos) were obtained. Joslin Vision Network images and ETDRS photos were graded on a lesion-by-lesion basis by two independent, masked readers to assess ETDRS clinical level of diabetic retinopathy. An independent ophthalmology retina specialist adjudicated interreader disagreements in a masked fashion. MAIN OUTCOME MEASURES: Determination of ETDRS clinical level of diabetic retinopathy, timing of next ophthalmic evaluation of diabetic retinopathy, and need for prompt referral to ophthalmology specialist. RESULTS: There was substantial agreement (kappa = 0.65) between the clinical level of diabetic retinopathy assessed from the undilated JVN images and the dilated ETDRS photos. Agreement was excellent (kappa = 0.87) for suggested referral to ophthalmology specialists for eye examinations. Comparison of individual lesions between the JVN images and the ETDRS photos and for interreader comparisons were comparable to the prior ETDRS study. CONCLUSIONS: Undilated digital-video images using the JVN system were comparable photographs for the determination of diabetic retinopathy level. The results validate the agreement between nonmydriatic JVN images and dilated ETDRS photographs and suggest that this digital technique may be an effective telemedicine tool for remotely determining the level of diabetic retinopathy, suggesting timing of next retinal evaluation and identifying the need for prompt referral to ophthalmology specialists. Thus, the JVN system would be an appropriate tool for facilitating increased access of diabetic patients into recommended eye evaluations, but should not be construed as a paradigm that would replace the need for comprehensive eye examinations.

Ophthalmic fluorescein angiography.

Ophthalmic fluorescein angiography is an important clinical procedure used to investigate and document the status of the retinal and choroidal vascular systems. Administered intravenously and followed by rapid-sequence serial photographs, the fluorescein dye produces an angiographic display that is used to visualize and document retinal blood flow dynamics while recording the integrity of the inner blood-retinal barriers and the fine details of the retinal pigment epithelium. It is an important diagnostic and research tool, and has the added advantage of serving to illustrate the manner in which the retina and choroid respond to disease. More visual resolution is possible with this diagnostic procedure than with others, and it is a valuable adjunct to stereoscopic fundus biomicroscopy and binocular indirect ophthalmoscopy. The procedure has further utility in determining the suitability for laser photocoagulation surgery in macular and retinal vascular disease states. Ophthalmic angiography is also applicable the anterior segment, where it is employed as a research tool in the evaluation of conjunctival, episcleral, corneal, and especially iris blood vessels. Anterior segment use of fluorescein angiography has yet to become a prevalent clinical tool; rather, it currently has more extensive application through research, in developing a better understanding of the nature of anterior segment disorders.

Idiopathic macular hole: a clinical review and current concepts in the diagnosis and management.

BACKGROUND: A full-thickness macular hole is a retinal opening involving the fovea causing severe central vision loss among the elderly. METHODS: This paper examines the pathogenesis and mechanistic constructs for the development and formation of idiopathic macular hole, reviews the stages of evolution, and provides guidelines for management by the primary care clinician. An update of the current methods of diagnosis and the criteria for surgical intervention, including vitrectomy and epiretinal membrane removal are presented. A perspective on the emerging trends in the treatment of macular hole using transforming growth factor beta-2 application is also introduced. CONCLUSIONS: Clinical practice guidelines for the management of patients with macular holes can be established based on an improved understanding of the pathogenesis of macular hole formation, a knowledge of the various stages of evolution, and the primary care clinician's familiarity with improved diagnostic techniques. An enhanced understanding of the pathogenesis of macular hole will help to predict the risk for the fellow eye, will promote more effective patient education and counseling, and will result in more timely surgical intervention. RESULTS: More promising results in the surgical closure of macula holes can prevent or minimize significant central vision loss.

Enhanced non-contact examination of the vitreous and retina.

BACKGROUND: Fundus biomicroscopy is the clinical standard for comprehensive stereoscopic examination of the posterior segment of the eye. METHODS: Double aspheric hand-held condensing lenses provide excellent stereopsis and a uniformly illuminated wide-field image of the vitreous, retina and choroid. Although there is adequate visualization of vitreous structure, reflectance, and optical lens aberrations, including pupil aberrations, impose limitations on the resolving capabilities of the observation system. RESULTS: Fundus biomicroscopy using the Volk Superfield NC lens provides a superior view of the vitreous structure and a stereoscopic, wide field of view of the structures of the retina and choroid, including a detailed view of the optic disc and macula. CONCLUSIONS: This paper describes the new Volk Superfield NC lens and presents an overview of the high quality imaging capabilities and clinical application of the lens especially with respect to vitreous examination.

Retinal detachment.

Retinal detachment is a separation of the neurosensory retina from the retinal pigment epithelium. Most retinal detachments are rhegmatogenous, and identification of risk factors and predisposing lesions are important aspects of patient management. Retinal detachment is relatively rare, but can pose a significant threat to vision if there is macular involvement. Prompt diagnosis combined with patient education and appropriate intervention often can avert irrevocable visual impairment. This paper presents an overview of the categories of retinal detachment, discusses the pathogenesis of the various types of detachment, and provides recommendations for primary care of patients with predisposing factors and high-risk characteristics.

The secondary glaucomas.

Glaucoma resulting from secondary congenital, ocular, or systemic conditions represents a formidable diagnostic and management challenge for optometrists. This paper discusses the pathogenesis, diagnosis, and treatment of six common forms of the disease: exfoliation syndrome, pigmentary glaucoma, neovascular glaucoma, lens-induced glaucoma, glaucoma accompanied by ocular inflammation, and trauma-induced glaucoma. For each of these conditions, clinical experience, observational skills, and an understanding of the mechanisms by which elevated intraocular pressure may result are prerequisites for accurate diagnosis. Management requires that the intraocular pressure be reduced and that the underlying condition be diagnosed so that other appropriate treatment may be initiated. Follow-up is predicated on risk factors, relative control of the intraocular pressure, and the fragility of the optic nerve.