Quality of Life Outcomes Among Patients Being Screened for Cytomegalovirus Retinitis in Thailand.

PURPOSE: Cytomegalovirus (CMV) retinitis can have debilitating impacts on quality of life (QOL), but few contemporary studies have characterized these ramifications. This study assessed the impact of CMV retinitis on vision-related QOL for those living with HIV/AIDS in Thailand. METHODS: QOL was assessed as part of a prospective interventional cohort study of patients referred to a tertiary hospital in Thailand for CMV retinitis screening. A validated vision-related QOL questionnaire was administered at the baseline screening visit and at the 6-month study visit. Multivariable linear regression models were performed to determine the effect of CMV retinitis diagnosis on QOL score. RESULTS: A total of 152 participants completed the QOL questionnaire at their initial clinic visit. At baseline, a diagnosis of CMV retinitis diagnosis was significantly associated with decreased QOL score: unilateral retinitis was associated with a 0.11 (95% CI: -0.26-0.03) decrement in QOL, and bilateral retinitis was associated with a 0.33 (95% CI: -0.51-0.16) decrement (joint P-value = 0.0009). For the 78 participants with a 6-month visit, changes in QOL from baseline were small and not significant. A diagnosis of CMV retinitis was still associated with decreased QOL score at 6 months (joint P-value = 0.03). CONCLUSIONS: This study found that vision-related QOL was lower in those with CMV retinitis, especially with bilateral involvement, and did not improve after treatment among those with follow-up. These findings reinforce the debilitating clinical manifestations of this disease, and support efforts for earlier screening to detect CMV retinitis before impacts on QOL have occurred.

Comparison of Three Handheld Fundus Cameras for Assessment of the Vertical Cup-To-Disk Ratio.

Purpose To compare the quality of optic nerve photographs from three different handheld fundus cameras and to assess the reproducibility and agreement of vertical cup-to-disk ratio (VCDR) measurements from each camera. Methods Adult patients from a comprehensive ophthalmology clinic and an intravitreous injection clinic in northern Thailand were recruited for this cross-sectional study. Each participant had optic nerve photography performed with each of 3 handheld cameras: the Volk iNview, Volk Pictor Plus, and Peek Retina. Images were graded for VCDR in a masked fashion by two photo-graders and images with > 0.2 discrepancy in VCDR were assessed by a third photo-grader. Results A total of 355 eyes underwent imaging with three different handheld fundus cameras. Optic nerve images were judged ungradable in 130 (37%) eyes imaged with Peek Retina, compared to 36 (10%) and 55 (15%) eyes imaged with the iNview and Pictor Plus, respectively. For 193 eyes with gradable images from all 3 cameras, inter-rater reliability for VCDR measurements was poor or moderate for each of the cameras, with intraclass correlation coefficients ranging from 0.41 to 0.52. A VCDR ≥ 0.6 was found in 6 eyes on iNview images, 9 eyes on Pictor Plus images, and 3 eyes on Peek images, with poor agreement between cameras (e.g., no eyes graded as VCDR ≥ 0.6 on images from both the iNview and Pictor Plus). Conclusions Inter-rater reliability of VCDR grades from 3 handheld cameras was poor. Cameras did not agree on which eyes had large VCDRs.

Clinic-Based Eye Disease Screening Using Non-Expert Fundus Photo Graders at the Point of Screening: Diagnostic Validity and Yield.

PURPOSE: The intent of this study was to determine the diagnostic accuracy of several diagnostic tests for age-related macular degeneration (AMD), diabetic retinopathy (DR), glaucoma, and cataract, as well as the proportions of patients with eye disease from each of 3 enrolling clinics. DESIGN: Diagnostic accuracy study. METHODS: Patients ≥50 years old in a diabetes, thyroid, and general medicine clinic were screened using visual acuity, tonometry, and fundus photography. Photographs were graded at the point-of-screening by non-ophthalmic personnel. Participants with positive screening test results in either eye and a 10% random sample with negative results in both eyes were referred for an in-person, reference-standard ophthalmology examination. RESULTS: Of 889 participants enrolled, 229 participants failed at least 1 test in either eye, of which 189 presented for an ophthalmic examination. An additional 76 participants with completely normal screening test results were referred for examination, of which 50 attended. Fundus photography screening had the highest yield for DR (sensitivity: 67%; 95% confidence interval [CI]: 39%-87%), visual acuity screening for cataract (sensitivity: 89%; 95% CI: 86%-92%), and intraocular pressure screening for glaucoma or suspected glaucoma (sensitivity: 25%; 95% CI: 14%-40%). The burden of disease was relatively high in all 3 clinics, with at least 1 of the diseases of interest (ie, AMD, DR, glaucoma or suspected glaucoma, or cataract) detected in 25% of participants (95% CI: 17-35%) from the diabeteses clinic, 34% (95% CI: 22%-49%) from the thyroid clinic, and 21% (95% CI: 13%-32%) from the general clinic. CONCLUSIONS: Non-expert eye disease screening in health clinics may be a useful model for detection of eye disease in resource-limited settings.

Accuracy of computer-assisted vertical cup-to-disk ratio grading for glaucoma screening.

PURPOSE: Glaucoma screening can be performed by assessing the vertical-cup-to-disk ratio (VCDR) of the optic nerve head from fundus photography, but VCDR grading is inherently subjective. This study investigated whether computer software could improve the accuracy and repeatability of VCDR assessment. METHODS: In this cross-sectional diagnostic accuracy study, 5 ophthalmologists independently assessed the VCDR from a set of 200 optic disk images, with the median grade used as the reference standard for subsequent analyses. Eight non-ophthalmologists graded each image by two different methods: by visual inspection and with assistance from a custom-made publicly available software program. Agreement with the reference standard grade was assessed for each method by calculating the intraclass correlation coefficient (ICC), and the sensitivity and specificity determined relative to a median ophthalmologist grade of ≥0.7. RESULTS: VCDR grades ranged from 0.1 to 0.9 for visual assessment and from 0.1 to 1.0 for software-assisted grading, with a median grade of 0.4 for each. Agreement between each of the 8 graders and the reference standard was higher for visual inspection (median ICC 0.65, interquartile range 0.57 to 0.82) than for software-assisted grading (median ICC 0.59, IQR 0.44 to 0.71); P = 0.02, Wilcoxon signed-rank test). Visual inspection and software assistance had similar sensitivity and specificity for detecting glaucomatous cupping. CONCLUSION: The computer software used in this study did not improve the reproducibility or validity of VCDR grading from fundus photographs compared with simple visual inspection. More clinical experience was correlated with higher agreement with the ophthalmologist VCDR reference standard.

Clinical presentation and treatment outcomes of primary ocular adnexal MALT lymphoma in Thailand.

BACKGROUND: Primary ocular adnexal extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (POML) is the most common subtype of lymphoma involving the eyes in Thailand. We sought to assess the characteristics and treatment outcomes of patients with POML in Thailand. METHODS: We retrospectively reviewed patient data and included patients diagnosed with POML between January 2004 and December 2016 at Chiang Mai University Hospital and King Chulalongkorn Memorial Hospital, Thailand. We collected and analyzed patients' clinical characteristics and treatment outcomes. RESULTS: Among 146 patients with lymphoma involving the eyes, 121 (82%) were diagnosed with POML. Sixty-four (52.9%) were women with median age 58 (range, 22-86) years. The most common presenting symptom was orbital mass (71.1%). Common sites of origin were the orbit (46.3%) and lacrimal gland (34.7%). At presentation, 22.3% of patients had bilateral eye involvement. About half of patients had stage I disease (N=59, 56.2%) and 20% had stage IV. Most patients (73.3%) had a low-risk International Prognostic Index. Radiotherapy was the main treatment for patients with limited-stage disease (66.7% in stage I and 56.5% in stage II). The overall response rate was 100% with complete response rates 80%, 77.3%, and 64.7% for stages I, II, and IV, respectively. Five-year progression-free survival (PFS) and overall survival were 66.1% and 94.0%, respectively. For patients with limited-stage disease, radiotherapy significantly improved PFS compared with treatment not involving radiotherapy (5-year PFS 89.9% vs. 37.3%, P=0.01). CONCLUSION: We revealed that POML has good response to treatment, especially radiotherapy, with excellent long-term outcome.

Visual acuity outcomes in cytomegalovirus retinitis: early versus late diagnosis.

AIMS: To determine if early dilated fundus examination for cytomegalovirus (CMV) retinitis leads to better visual outcomes in areas with limited HIV care, where patients may have long-standing retinitis before they are diagnosed with HIV. METHODS: Twenty-four eyes of 17 patients with CMV retinitis who were seen at an urban HIV clinic in Chiang Mai, Thailand, were included in this retrospective cohort study. Participants were divided into two groups based on the amount of time from the first documented CD4 count below 100 cells/mm3 to the first eye examination for CMV retinitis. Average visual acuity in each group was calculated at the time CMV retinitis was first detected, and then at 3, 6 and 12 months after diagnosis. RESULTS: The group of patients who received an eye examination within approximately 4 months of the initial low CD4 count measurement had better baseline visual acuity (median 20/30,IQR 20/20 to 20/60) compared with patients who presented later (median 20/80, 20/60 to hand motion); p=0.03). Visual acuity did not change significantly during the 12-month study period in either the early group (p=0.69) or late group (p=0.17). CONCLUSION: In this study, patients who were examined sooner after a low CD4 count had better vision than patients who were examined later. Routine early screening of patients with CD4 counts under below 100 cells/mm3 may detect earlier disease and prevent vision loss.

Retinal detachment associated with AIDS-related cytomegalovirus retinitis: risk factors in a resource-limited setting.

PURPOSE: To determine risk factors predictive of retinal detachment in patients with cytomegalovirus (CMV) retinitis in a setting with limited access to ophthalmic care. DESIGN: Case-control study. METHODS: Sixty-four patients with CMV retinitis and retinal detachment were identified from the Ocular Infectious Diseases and Retina Clinics at Chiang Mai University. Three control patients with CMV retinitis but no retinal detachment were selected for each case, matched by calendar date. The medical records of each patient were reviewed, with patient-level and eye-level features recorded for the clinic visit used to match cases and controls, and also for the initial clinic visit at which CMV retinitis was diagnosed. Risk factors for retinal detachment were assessed separately for each of these time points using multivariate conditional logistic regression models that included 1 eye from each patient. RESULTS: Patients with a retinal detachment were more likely than controls to have low visual acuity (odds ratio [OR], 1.24 per line of worse vision on the logMAR scale; 95% confidence interval [CI], 1.16-1.33) and bilateral disease (OR, 2.12; 95% CI, 0.92-4.90). Features present at the time of the initial diagnosis of CMV retinitis that predicted subsequent retinal detachment included bilateral disease (OR, 2.68; 95% CI, 1.18-6.08) and lesion size (OR, 2.64 per 10% increase in lesion size; 95% CI, 1.41-4.94). CONCLUSION: Bilateral CMV retinitis and larger lesion sizes, each of which is a marker of advanced disease, were associated with subsequent retinal detachment. Earlier detection and treatment may reduce the likelihood that patients with CMV retinitis develop a retinal detachment.

Telemedicine diagnosis of cytomegalovirus retinitis by nonophthalmologists.

IMPORTANCE: Cytomegalovirus (CMV) retinitis continues to be a leading cause of blindness in many developing countries. Telemedicine holds the potential to increase the number of people screened for CMV retinitis, but it is unclear whether nonophthalmologists could be responsible for interpreting fundus photographs captured in a telemedicine program. OBJECTIVE: To determine the accuracy of nonophthalmologist photographic graders in diagnosing CMV retinitis from digital fundus photographs. DESIGN, SETTING, AND PARTICIPANTS: Fifteen nonexpert graders each evaluated 182 mosaic retinal images taken from the eyes of patients with AIDS who were evaluated at the Ocular Infectious Diseases Clinic at Chiang Mai University in Chiang Mai, Thailand. MAIN OUTCOMES AND MEASURES: Graders diagnosed each image as CMV retinitis present, CMV retinitis absent, or unknown. The results from each grader were compared with those of an indirect ophthalmoscopic examination from an experienced on-site ophthalmologist as well as with the consensus grade given by a panel of CMV retinitis experts. RESULTS: Relative to the on-site ophthalmologist, the sensitivity of remote CMV retinitis diagnosis by nonexpert graders ranged from 64.0% to 95.5% (mean, 84.1%; 95% CI, 78.6%-89.6%)), and the specificity ranged from 65.6% to 92.5% (mean, 82.3%; 95% CI, 76.6%-88.0%)). Agreement between nonexpert and expert graders was high: the mean sensitivity and specificity values of nonexpert diagnosis using expert consensus as the reference standard were 93.2% (95% CI, 90.6%-95.8%) and 88.4% (95% CI, 85.4%-91.1%), respectively. Mean intrarater reliability also was high (mean Cohen κ, 0.83; 95% CI, 0.78-0.87). CONCLUSIONS AND RELEVANCE: The sensitivity and specificity of remote diagnosis of CMV retinitis by nonexpert graders was variable, although several nonexperts achieved a level of accuracy comparable to that of CMV retinitis experts. More intensive training and periodic evaluations would be required if nonexperts are to be used in clinical practice.

Histopathological diagnosis of eyelid tumors in Chiang Mai University Hospital.

OBJECTIVE: To report the histopathological diagnosis ofeyelid tumors and to study the prevalence of eyelid tumors in Chiang Mai University Hospital Chiang Mai, Thailand. MATERIAL AND METHOD: A retrospective review of medical and pathological records ofpatients diagnosed as eyelid tumor that underwent histopathological biopsy between January 2007 and December 2013 in Chiang Mai University Hospital was done. RESULTS: Three hundred sixteen cases of eyelid tumors were reviewed. The mean age at diagnosis was 54.2 +/- 19.6 years (range 1 month-99 years), women were 59.5% (n = 188) and men 40.5% (n = 128). The tumor sites were left lower eyelid (27.5%), right upper eyelid (24.4%), right lower eyelid (21.2%), and left upper eyelid (18.7%). There were 204 (64.6%) benign tumors and 112 (35.4%) malignant tumors. Nevi were the most common in benign group (16.4%) and basal cell carcinoma was the most common eyelid malignancy (18.0%). CONCLUSION: The most common histopathological diagnosis for benign eyelid tumor was nevus, while the most common malignant eyelid tumor was basal cell carcinoma at Chiang Mai University Hospital.

Access to ophthalmologic care in Thailand: a regional analysis.

PURPOSE: The World Health Organization (WHO) recommends that Southeast Asian countries have ≥ 1 ophthalmologist per 100,000 persons, equally distributed in urban and rural areas. However, regional patterns of eye care have been poorly characterized. This study investigates the distribution of ophthalmologists in Thailand and provides regional estimates of access to ophthalmologists. METHODS: We geocoded the work address of ophthalmologists listed in the 2008 directory of the Royal College of Ophthalmologists of Thailand. We determined the number of ophthalmologists per 100,000 persons at the national, provincial, and district levels using data from the 2000 Thai Population Census, and assessed demographic factors associated with meeting the WHO recommendation of ≥ 1 ophthalmologist per 100,000 persons. RESULTS: In 2008, Thailand had 1.52 ophthalmologists per 100,000 persons; however, only 20 of 76 provinces (26%) and 134 of 926 districts (14%) met the WHO recommendation of ≥ 1 ophthalmologist per 100,000 persons. District factors associated with not meeting the WHO recommendation included a high proportion of children, a high proportion of elderly, and a high proportion of rural residents. CONCLUSION: Thailand meets the WHO's goal for access to ophthalmologic care, but the distribution of ophthalmologists is uneven, with less access to ophthalmologic care in rural areas.

Clinical features of newly diagnosed cytomegalovirus retinitis in northern Thailand.

PURPOSE: To characterize the clinical manifestations of cytomegalovirus (CMV) retinitis in northern Thailand. DESIGN: Prospective, observational, cross-sectional study. METHODS: We recorded characteristics of 52 consecutive patients newly diagnosed with CMV retinitis at a tertiary university-based medical center in northern Thailand. Indirect ophthalmoscopy by experienced ophthalmologists was supplemented with fundus photography to determine the proportion of eyes with various clinical features of CMV retinitis. RESULTS: Of the 52 patients with CMV retinitis, 55.8% were female. All were HIV-positive. The vast majority (90.4%) had started antiretroviral therapy. CMV retinitis was bilateral in 46.2% of patients. Bilateral visual acuity worse than 20/60 was observed in 23.1% of patients. Of 76 eyes with CMV retinitis, 61.8% had zone I disease and 21.6% had lesions involving the fovea. Lesions larger than 25% of the retinal area were observed in 57.5% of affected eyes. CMV retinitis lesions commonly had marked or severe border opacity (47.4% of eyes). Vitreous haze often was present (46.1% of eyes). Visual impairment was more common in eyes with larger retinitis lesions. Retinitis lesion size, used as a proxy for duration of disease, was associated with fulminant appearance (odds ratio, 1.24; 95% confidence interval, 1.01 to 1.51) and marked or severe border opacity (odds ratio, 1.36; 95% confidence interval, 1.11 to 1.67). Based on lesion size, retinitis preceded antiretroviral treatment in each patient. CONCLUSIONS: Patients seeking treatment at a tertiary medical center in northern Thailand had advanced CMV retinitis, possibly because of delayed diagnosis. Earlier screening and treatment of CMV retinitis may limit progression of disease and may prevent visual impairment in this population.

Comparison of autophotomontage software programs in eyes with CMV retinitis.

PURPOSE: Automated mosaic software programs are used to stitch together overlapping retinal fundus photographs. The performance of these programs in eyes with retinal diseases has not been independently evaluated. This study compares the quality of the mosaic products of three autophotomontage software programs, using digital fundus photographs of eyes with cytomegalovirus (CMV) retinitis. METHODS: Photographs of 99 eyes with CMV retinitis of 94 patients with HIV were taken at Maharaj Nakorn Chiang Mai Hospital in Chiang Mai, Thailand. Automated mosaic images were created for each of the 99 eyes by three different commercially available programs: IMAGEnet (Topcon, Oakland, NJ), i2k Retina (DualAlign LLC, Clifton Park, NY), and AutoMontage (OIS, Sacramento, CA). Three masked graders ranked each set of mosaics for each eye. The graders also assessed the overall image quality and documented mosaic artifacts in each image. RESULTS: i2k Retina was ranked as the best program (70%-88%) more often than AutoMontage (10%-33%, P < 0.001) or IMAGEnet (0%-4%, P < 0.001) for creating automontages from digital fundus photographs of eyes with CMV retinitis. Acceptable quality mosaic images were reported most commonly for i2k Retina (93%-94%) and AutoMontage (91%-95%), followed by IMAGEnet (27%-56%, P < 0.001). IMAGEnet had a significantly higher percentage of mosaic errors than did either i2k Retina or AutoMontage (P < 0.001). CONCLUSIONS: In eyes with CMV retinitis, both the i2k Retina and AutoMontage software packages appear to create higher quality mosaics than does IMAGEnet. Automated retinal mosaic imaging may be valuable in diagnosing CMV retinitis and observing disease progression.

Accuracy and reliability of telemedicine for diagnosis of cytomegalovirus retinitis.

PURPOSE: To determine the feasibility of remote diagnostic screening for cytomegalovirus (CMV) retinitis among HIV patients in northern Thailand. DESIGN: Prospective, observational cross-sectional study. METHODS: One hundred eighty-two eyes from 94 consecutive patients with HIV seen in 2008 and 2009 at a tertiary university-based medical center were photographed using a digital retinal camera. Individual and composite images were uploaded to a secure web site. Three expert graders accessed the electronic images and graded each image for signs of CMV retinitis. Results of remote expert grading were compared with on-site patient examination by local expert ophthalmologists. RESULTS: On-site ophthalmologists diagnosed CMV retinitis in 89 (48.9%) of 182 eyes. Trained ophthalmic photographers obtained digital retinal images for all 182 eyes. As compared with the on-site examinations, the sensitivity for detecting CMV retinitis by remote readers using composite retinal images ranged from 89% to 91%. The specificity for detecting CMV retinitis by remote readers ranged from 85% to 88%. Intrarater reliability was high, with each grader achieving a κ value of 0.93. Interrater reliability among the 3 graders also was high, with a κ value of 0.86. CONCLUSIONS: Remote diagnostic screening for CMV retinitis among HIV-positive patients may prove to be a valuable tool in countries where the burden of HIV exceeds the capacity of the local eye care providers to screen for ocular opportunistic infections.

An outbreak of acute postoperative endophthalmitis after cataract surgery.

BACKGROUND: Endophthalmitis is one of the most serious complications of ophthalmic surgery, which includes postoperative cataract extraction. Outbreak of acute postoperative endophthalmitis after cataract surgery has been reported in Thailand and other countries. OBJECTIVE: To describe an outbreak of acute postoperative endophthalmitis after cataract surgery that was referred to Chiang Mai University Hospital during March 2006. MATERIAL AND METHOD: Observational case series were made from the records of inpatients and outpatients, who had been referred for treatment of acute postoperative endophthalmitis after cataract surgery at a district hospital in northern Thailand. The surgery was conducted on two consecutive days by volunteer ophthalmologists of a non-profit foundation from Bangkok. RESULTS: In this outbreak, the authors recorded 31 endophthalmitis cases, with 33 eyes (bilateral 2 cases). Of the 33 endophthalmitis eyes, 32 occurred following extracapsular cataract extraction with intraocular lens and one after the secondary intraocular lens implant. Microbiological investigations in the hospital were done with aqueous tapping, vitreous tapping, and vitreous from pars plana vitrectomy. Gram-positive cocci were detected from vitreous tapping in four eyes. Thirty-two cases were managed with intravitreous antibiotics, one with subconjunctival antibiotic only, and all eyes were treated with fortified topical antibiotics. Fifteen eyes underwent pars plana vitrectomy Assessment of visual acuity (VA) before and after treatment showed improvement in 75.8% (25/33), decrease of VA in 9.1% (3/33), while visual acuity remained stable in 15.2% (5/33). CONCLUSION: In high-volume cataract surgery, an outbreak of endophthalmitis is always possible. Prompt and appropriate treatment can improve the visual outcome.

Blindness and low vision in a tertiary ophthalmologic center in Thailand: the importance of cytomegalovirus retinitis.

PURPOSE: To determine the causes of blindness and low vision in patients consulting a tertiary ophthalmologic center in northern Thailand. METHODS: The study population included 2,951 new consecutive patients from the Department of Ophthalmology at University Hospital in Chiang-Mai, Thailand. Main outcome measures were blindness and low vision, which were defined according to World Health Organization criteria. RESULTS: Of 2,951 patients, 369 (12.5%) had blindness and/or low vision (bilateral blindness in 73, unilateral blindness in 129, bilateral low vision in 77, and unilateral low vision in 90). Of the etiological causes of visual loss, age-related ocular disease was the most frequent (128 patients [35%]) followed by infections (66 patients [18%]) and trauma (43 patients [12%]). Although infections and trauma were the predominant causes of blindness, age-related disorders were frequently found in patients with low vision. Of anatomical sites, the lens (134 patients [36%]) was the main location of visual loss, closely followed by disorders of the retina and/or uvea (126 patients [34%]). Blindness and low vision were considered avoidable in 70% of cases. Of 73 patients with bilateral blindness, 14 had active cytomegalovirus retinitis, accounting for 19% of all patients with bilateral blindness. CONCLUSION: The most common causes of blindness and low vision in a tertiary center in northern Thailand were age-related ocular disorders and infections, which were predominantly cases of cytomegalovirus retinitis in human immunodeficiency virus-infected patients.