Routine funduscopy in immune thrombocytopenic purpura-is it really necessary?

Immune thrombocytopenic purpura (ITP) is a common cause of symptomatic thrombocytopenia in children, most of whom present with cutaneous and mucosal bleeding. Complications, such as intracranial hemorrhage and occult hemorrhage from various sites, are rare, and retinal hemorrhage is exceptionally rare. Our institutional clinical practice guidelines for managing ITP in the pediatric emergency department (PED) include routine funduscopy. The aim of this retrospective case series is to provide evidence-based recommendations for a tertiary care PED work-up of ITP, with special emphasis on the guidelines for funduscopy. The medical records of all pediatric patients diagnosed with ITP over a 4-year period (2013-2016) who had a platelet count < 50,000/mm3 were retrieved and reviewed. Seventy-five patients with thrombocytopenia (platelet count < 50,000/mm3) were diagnosed as having ITP in the PED. Sixty-one (79%) of these patients underwent funduscopy and retinal hemorrhage was ruled out in all of them, indicating that retinal hemorrhage as a complication of ITP is very rare.Conclusion: Our data suggest that funduscopy should not be performed routinely on pediatric ITP patients, but rather be reserved for those who present with concurrent anemia or visual complaints. What is Known: • Many internal institutional protocols in Israel call for retinal hemorrhage bleeding surveillance in work up of ITP. Our study found no case of ITP with retinal bleeding. What is New: • Many internal institutional protocols in Israel call for retinal hemorrhage bleeding surveillance in work up of ITP. Our study found no case of ITP with retinal bleeding.

Optic nerve head and fibre layer imaging for diagnosing glaucoma.

BACKGROUND: The diagnosis of glaucoma is traditionally based on the finding of optic nerve head (ONH) damage assessed subjectively by ophthalmoscopy or photography or by corresponding damage to the visual field assessed by automated perimetry, or both. Diagnostic assessments are usually required when ophthalmologists or primary eye care professionals find elevated intraocular pressure (IOP) or a suspect appearance of the ONH. Imaging tests such as confocal scanning laser ophthalmoscopy (HRT), optical coherence tomography (OCT) and scanning laser polarimetry (SLP, as used by the GDx instrument), provide an objective measure of the structural changes of retinal nerve fibre layer (RNFL) thickness and ONH parameters occurring in glaucoma. OBJECTIVES: To determine the diagnostic accuracy of HRT, OCT and GDx for diagnosing manifest glaucoma by detecting ONH and RNFL damage. SEARCH METHODS: We searched several databases for this review. The most recent searches were on 19 February 2015. SELECTION CRITERIA: We included prospective and retrospective cohort studies and case-control studies that evaluated the accuracy of OCT, HRT or the GDx for diagnosing glaucoma. We excluded population-based screening studies, since we planned to consider studies on self-referred people or participants in whom a risk factor for glaucoma had already been identified in primary care, such as elevated IOP or a family history of glaucoma. We only considered recent commercial versions of the tests: spectral domain OCT, HRT III and GDx VCC or ECC. DATA COLLECTION AND ANALYSIS: We adopted standard Cochrane methods. We fitted a hierarchical summary ROC (HSROC) model using the METADAS macro in SAS software. After studies were selected, we decided to use 2 x 2 data at 0.95 specificity or closer in meta-analyses, since this was the most commonly-reported level. MAIN RESULTS: We included 106 studies in this review, which analysed 16,260 eyes (8353 cases, 7907 controls) in total. Forty studies (5574 participants) assessed GDx, 18 studies (3550 participants) HRT, and 63 (9390 participants) OCT, with 12 of these studies comparing two or three tests. Regarding study quality, a case-control design in 103 studies raised concerns as it can overestimate accuracy and reduce the applicability of the results to daily practice. Twenty-four studies were sponsored by the manufacturer, and in 15 the potential conflict of interest was unclear.Comparisons made within each test were more reliable than those between tests, as they were mostly based on direct comparisons within each study.The Nerve Fibre Indicator yielded the highest accuracy (estimate, 95% confidence interval (CI)) among GDx parameters (sensitivity: 0.67, 0.55 to 0.77; specificity: 0.94, 0.92 to 0.95). For HRT measures, the Vertical Cup/Disc (C/D) ratio (sensitivity: 0.72, 0.60 to 0.68; specificity: 0.94, 0.92 to 0.95) was no different from other parameters. With OCT, the accuracy of average RNFL retinal thickness was similar to the inferior sector (0.72, 0.65 to 0.77; specificity: 0.93, 0.92 to 0.95) and, in different studies, to the vertical C/D ratio.Comparing the parameters with the highest diagnostic odds ratio (DOR) for each device in a single HSROC model, the performance of GDx, HRT and OCT was remarkably similar. At a sensitivity of 0.70 and a high specificity close to 0.95 as in most of these studies, in 1000 people referred by primary eye care, of whom 200 have manifest glaucoma, such as in those who have already undergone some functional or anatomic testing by optometrists, the best measures of GDx, HRT and OCT would miss about 60 cases out of the 200 patients with glaucoma, and would incorrectly refer 50 out of 800 patients without glaucoma. If prevalence were 5%, e.g. such as in people referred only because of family history of glaucoma, the corresponding figures would be 15 patients missed out of 50 with manifest glaucoma, avoiding referral of about 890 out of 950 non-glaucomatous people.Heterogeneity investigations found that sensitivity estimate was higher for studies with more severe glaucoma, expressed as worse average mean deviation (MD): 0.79 (0.74 to 0.83) for MD < -6 db versus 0.64 (0.60 to 0.69) for MD ≥ -6 db, at a similar summary specificity (0.93, 95% CI 0.92 to 0.94 and, respectively, 0.94; 95% CI 0.93 to 0.95; P < 0.0001 for the difference in relative DOR). AUTHORS' CONCLUSIONS: The accuracy of imaging tests for detecting manifest glaucoma was variable across studies, but overall similar for different devices. Accuracy may have been overestimated due to the case-control design, which is a serious limitation of the current evidence base.We recommend that further diagnostic accuracy studies are carried out on patients selected consecutively at a defined step of the clinical pathway, providing a description of risk factors leading to referral and bearing in mind the consequences of false positives and false negatives in the setting in which the diagnostic question is made. Future research should report accuracy for each threshold of these continuous measures, or publish raw data.

[Content-based automatic retinal image recognition and retrieval system].

This paper is aimed to fulfill a prototype system used to classify and retrieve retinal image automatically. With the content-based image retrieval (CBIR) technology, a method to represent the retinal characteristics mixing the fundus image color (gray) histogram with bright, dark region features and other local comprehensive information was proposed. The method uses kernel principal component analysis (KPCA) to further extract nonlinear features and dimensionality reduced. It also puts forward a measurement method using support vector machine (SVM) on KPCA weighted distance in similarity measure aspect. Testing 300 samples with this prototype system randomly, we obtained the total image number of wrong retrieved 32, and the retrieval rate 89.33%. It showed that the identification rate of the system for retinal image was high.

The Pupillographic SleepinessTest in adults: effect of age, gender, and time of day on pupillometric variables.

OBJECTIVES: The Pupillographic Sleepiness Test (PST) measures the level of alertness based on spontaneous oscillations in pupillary size. Reference data are available for male and female adults within the age range 20-60 years. The aim of the present multicenter study was to extend the age range for reference data from 20 to 79 years. METHODS: A total of 239 healthy subjects, selected from three different centers (Berlin, Regensburg, and Vienna), were administered the PST. Data were analyzed with respect to possible effects of age, gender, and time of day on the pupillary unrest index (PUI) and the pupil diameter (PD). RESULTS: Reliable data were available in 85.8% of the entire study sample and in 82.4% of elderly subjects (60+ years). Age-related changes were identified for the PUI and PD. There was no effect of gender on pupillometric variables as revealed by univariate analysis. The PD was found to be smaller in the afternoon compared with the morning. However, if subjects aged 60+ years were excluded from the analyses, the age-related changes disappeared and a time-of-day effect regarding the PUI became apparent. CONCLUSIONS: PUI and PD were found to decrease with increasing age. In addition, the present data show that nonreliable PST data occur more frequently in the elderly probably because of dry eyes, inadequate testing conditions, and technical resolution limitations. Thus, the PST results obtained here from elderly subjects are limited and have to be interpreted with caution. Additional research on elderly specific assessment tools is needed.

Reproducibility of straylight measurement by C-Quant for assessment of retinal straylight using the compensation comparison method.

BACKGROUND: Straylight gives the appearance of a veil of light thrown over a person's retinal image when there is a strong light source present. We examined the reproducibility of the measurements by C-Quant, and assessed its correlation to characteristics of the eye and subjects' age. PARTICIPANTS AND METHODS: Five repeated straylight measurements were taken using the dominant eye of 45 healthy subjects (age 21-59) with a BCVA of 20/20: 14 emmetropic, 16 myopic, eight hyperopic and seven with astigmatism. We assessed the extent of reproducibility of straylight measures using the intraclass correlation coefficient. RESULTS: The mean straylight value of all measurements was 1.01 (SD 0.23, median 0.97, interquartile range 0.85-1.1). Per 10 years of age, straylight increased in average by 0.10 (95%CI 0.04 to 0.16, p < 0.01]. We found no independent association of refraction (range -5.25 dpt to +2 dpt) on straylight values (0.001; 95%CI -0.022 to 0.024, p = 0.92). Compared to emmetropic subjects, myopia reduced straylight (-.011; -0.024 to 0.02, p = 0.11), whereas higher straylight values (0.09; -0.01 to 0.20, p = 0.09) were observed in subjects with blue irises as compared to dark-colored irises when correcting for age. The intraclass correlation coefficient (ICC) of repeated measurements was 0.83 (95%CI 0.76 to 0.90). CONCLUSIONS: Our study showed that straylight measurements with the C-Quant had a high reproducibility, i.e. a lack of large intra-observer variability, making it appropriate to be applied in long-term follow-up studies assessing the long-term effect of surgical procedures on the quality of vision.

Classification and Guidelines for Widefield Imaging: Recommendations from the International Widefield Imaging Study Group.

PURPOSE: To summarize the results of a consensus meeting aimed at defining terminology for widefield imaging across all retinal imaging methods and to provide recommendations for the nomenclature used to describe related images. DESIGN: An international panel with expertise in retinal imaging was assembled to define consensus terminology for widefield imaging and associated terminology. PARTICIPANTS: A panel of retina specialists with expertise in retinal imaging. METHODS: Before the consensus meeting, a set of 7 images acquired with a range of imaging methods and representing both healthy and diseased eyes was circulated to the expert panel for independent assignment of nomenclature for each example. The outputs were assembled and used as the starting point for discussions occurring at a subsequent roundtable meeting. The anatomic location, field of view, and perspective provided by each image example was reviewed. A process of open discussion and negotiation was undertaken until unanimous terminology for widefield imaging was achieved. MAIN OUTCOME MEASURES: Definitions of widefield imaging applicable to multiple imaging methods. RESULTS: Across a range of different imaging methods, the expert panel identified a lack of uniform terminology being used in recent literature to describe widefield images. The panel recommended the term widefield be limited to images depicting retinal anatomic features beyond the posterior pole, but posterior to the vortex vein ampulla, in all 4 quadrants. The term ultra widefield was recommended to describe images showing retinal anatomic features anterior to the vortex vein ampullae in all 4 quadrants. The definitions were recommended over other device-specific terminology. CONCLUSIONS: A consistent nomenclature for widefield imaging based on normal anatomic landmarks that is applicable to multiple retinal imaging methods has been proposed by the International Widefield Imaging Study Group. The panel recommends this standardized nomenclature for use in future publications.

Comparison of 1-field, 2-fields, and 3-fields fundus photography for detection and grading of diabetic retinopathy.

AIM: To evaluate the sensitivity and specificity of 1-, 2-, and 3-fields, nonmydriatic (NM), 45° color photography compared with mydriatic ophthalmoscopy for detection of diabetic retinopathy (DR). METHODS: Masked, comparative case series was performed utilizing a group of 128 diabetic patients (256 eyes) with various stages of DR who underwent both 3-fields NM color photography and ophthalmologic examination. In a blinded manner, the same optometrist who read the original 3-fields images for a patient read the 1- and 2-fields photographs on separate dates later. RESULTS: The sensitivity and specificity of digital retinal photography compared with dilated ophthalmoscopy were, respectively: 88% and 76% for 1-field; 94% and 69% for 2-fields; and 100% and 79% for 3-fields. The proportion of agreement between fundus photography reading and exam DR diagnosis were 58% for 1-field, 58% for 2-fields, and 77% for 3-fields. Kappa and Cramer's V statistics for 1-, 2-, and 3-fields were 0.55 and 0.60, 0.52 and 0.57, and 0.72 and 0.74, respectively. Three-fields measurement of DR was most similar to the dilated ophthalmological exam overall and across all DR severity levels. CONCLUSIONS: Compared to 1- and 2-fields fundus photography, 3-fields is superior for detecting vision-threatening DR. One- and 2-fields have reasonable sensitivity for DR screening.

Retinopathy of prematurity management using single-image vs multiple-image telemedicine examinations.

PURPOSE: To compare performance of single-image vs multiple-image telemedicine examinations for retinopathy of prematurity (ROP) diagnosis. DESIGN: Prospective comparative study. METHODS: A total of 248 eyes from 67 consecutive infants underwent wide-angle retinal imaging by a trained neonatal nurse at 31 to 33 weeks and/or 35 to 37 weeks postmenstrual age (PMA) at a single academic institution. Data were uploaded to a web-based telemedicine system and interpreted by three masked retinal specialists. Diagnoses were provided based on single images, and subsequently on multiple images, from both eyes of each infant. Findings were compared to a reference standard of indirect ophthalmoscopy by a pediatric ophthalmologist. Primary outcome measures were recommended follow-up interval, presence of plus disease, presence of type-2 or worse ROP, and presence of visible peripheral ROP. RESULTS: Among the three graders, mean sensitivity/specificity for detection of infants requiring follow-up in less than one week were 0.85/0.93 by single-image examination and 0.91/0.88 by multiple-image examination at 35 to 37 weeks PMA. Mean sensitivity/specificity for detection of infants with type-2 or worse ROP were 0.82/0.95 by single-image examination and 1.00/0.91 by multiple-image examination at 35 to 37 weeks PMA. Mean sensitivity/specificity for detection of plus disease were 1.00/0.86 by single-image examination and 1.00/0.87 by multiple-image examination at 35 to 37 weeks PMA. There were no statistically-significant intragrader differences between accuracy of single-image and multiple-image telemedicine examinations for detection of plus disease. CONCLUSIONS: Single-image and multiple-image telemedicine examinations perform comparably for determination of recommended follow-up interval and detection of plus disease. This may have implications for development of screening protocols, particularly in areas with limited access to ophthalmic care.

[Revised guideline 'Diabetic retinopathy: screening, diagnosis and treatment']. / Richtlijn 'diabetische retinopathie: screening, diagnostiek en behandeling' (herziening).

The revised evidence-based guideline 'Diabetic retinopathy: screening, diagnosis and treatment' contains important recommendations concerning screening, diagnosis and treatment of diabetic retinopathy. Regular screening and the treatment of risk factors, such as hyperglycemia, hypertension, adipositas and dyslipidemia, can prevent retinopathy and slow down its development. Fundus photography is recommended as a screening method. If necessary, diagnosis by biomicroscopy and a treatment consisting of photocoagulation and/or vitrectomy should be performed by the ophthalmologist. The reassessment of responsibilities is a vital component of the implementation of the guideline bearing in mind that the screening in particular, can be performed by personnel other than ophthalmologists.

Oman Eye Study 2005: validity of screening tests used in the glaucoma survey.

We carried out a validity assessment study for glaucoma screening procedures used during the survey conducted in Oman in 2005 on 6644 eyes in 3324 people > or = 30 years. Ocular pressure and fundus changes were the screening parameters used: glaucoma was found in 433 eyes. Sensitivity for ocular pressure was 49.7% and specificity 95.6%. For optic disc changes, sensitivity was 48.4% and specificity 97.9%. Combining both through parallel testing, sensitivity improved to 67.3% and specificity to 96.5%. An eye may, thus, be declared as not having glaucoma, but cannot be labelled as having glaucoma, using these parameters.

Video Diversion Improves Success Rate of Fundoscopic Examination in Children: A Prospective Randomized Controlled Trial.

BACKGROUND: Fundoscopy is an important component of the neurological examination as it can detect pathologies such as high intracranial pressure. However, the examination can be challenging in young children. This study evaluated whether playing a video during eye examination improves the success, duration, and ease of pediatric fundoscopy. MATERIALS AND METHODS: This was a prospective, multipractitioner, multiclinic, randomized controlled trial. Patients aged one to four years were recruited in the emergency department, neurology clinic, spinal cord clinic, and general pediatric clinic. Eye examination was randomized to video or non-video-assisted fundoscopy. Successful examinations were defined as visualizing the fundus within 60 seconds. Time to visualize optic disc was recorded and difficulty of examination was assessed using a 10-point Likert scale. RESULTS: We recruited 101 subjects with a mean age of 2.8 years. Overall, there was a 20% absolute improvement in the success rate of visualizing the optic disc in the video versus non-video group (P < 0.001, 95%CI: 7.8% to 31%). Time to visualize optic disc was also improved (Δ5.3 seconds, P < 0.01, 95%CI: 1.4 to 9.1 seconds). Practitioners and caregivers noticed a 33% (P < 0.01, 95%CI: 21% to 44%) and 42% (P < 0.01, 95%CI: 30% to 56%) relative improvement in the ease of examination with video, respectively. CONCLUSIONS: The use of videos improved the ease, duration, and, most importantly, the success of fundoscopy in younger children. This simple, inexpensive adjunct has great potential to improve the ease and efficacy of this aspect of the neurological examination and allow fundoscopic examination to be effectively performed earlier in the age-appropriate vision screening protocols.

Use of a fundus photograph matching program in imparting proficiency in ophthalmoscopy.

OBJECTIVE: To determine whether practice using an online fundus photograph program results in a long-term increase in proficiency with direct ophthalmoscopy skills in medical students. DESIGN: This study was a prospective medical education trial. Students were enrolled to participate in a voluntary Objective Structured Clinical Examination (OSCE) using 5 patients with ocular findings. Students who matched a minimum of 6 discs 16 months before the study were assigned to the intervention group and were compared with students who did not participate in the exercise. PARTICIPANTS: Forty-six second-year medical students at Queen's University: 15 in the intervention group and 31 in the control group. METHODS: Students were evaluated using the Queen's University Ophthalmoscopy OSCE Checklist (QUOOC). Students were asked to calculate the cup-to-disc ratio, comment on disc margins, and whether there was any macular pathology. Students participated in a summative OSCE as part of the curriculum in which all students attempted to match fundus photographs. RESULTS: Students in the intervention group performed significantly better on the QUOOC, with a mean score of 78.3% (± 4.2), compared with the control, who had a mean score of 69.4% (± 4.2) (p = 0.005). The intervention group was significantly more accurate at matching optic nerve photographs, with 100% (15/15) of the students correctly identifying the correct optic nerve on first attempt compared with 53.3% (16/30) in the control group (p = 0.0014). CONCLUSIONS: The use of an online peer fundus photograph program leads to a long-term increase in examination technique, proficiency in ophthalmoscopy, and accuracy at matching optic nerve photographs.

Reliability of Cyclotorsion measurements using Scanning Laser Ophthalmoscopy imaging in healthy subjects: the CySLO study.

BACKGROUND/AIMS: To evaluate inter-rater and intra-rater reliability of objective cyclotorsion measurements obtained in healthy subjects using the Heidelberg Spectralis spectral domain-optical coherence tomography (SD-OCT) device. METHODS: In this prospective methodological study, 32 healthy subjects (14 men, 18 women; aged 21-64 years) were enrolled, 31 right eyes were examined and their foveo-papillary angles (FPAs) were measured. The retinal nerve fibre layer (RNFL) programme by Heidelberg Spectralis (Heidelberg Engineering, Heidelberg, Germany) was used to measure cyclotorsion based on the in-built algorithm for the measurement of the FPA on the scanning laser ophthalmoscopy (SLO) image. Repeated scans of the fixating and non-fixating right eye without and with eye tracker each were obtained by three different examiners. RESULTS: The mean FPA measured overall by all three examiners was 6.6°±2.8°. The inter-rater reliability of the measured FPAs using the linear mixed effects model is estimated as rhointer=0.8803. The intra-rater reliability is estimated as rhointra=0.9589. CONCLUSIONS: Repeatability of objective cyclotorsion measurements within and between observers using the Heidelberg Spectralis OCT is very high. SD-OCT/SLO imaging is a reliable imaging technique to measure and study cyclotorsion. CLINICAL TRIAL NUMBER: NCT02631369, Results.

Telemedical retinopathy of prematurity diagnosis: accuracy, reliability, and image quality.

OBJECTIVE: To prospectively measure accuracy, reliability, and image quality of telemedical retinopathy of prematurity (ROP) diagnosis. METHODS: Two-hundred forty-eight eyes from 67 consecutive infants underwent wide-angle retinal imaging by a trained neonatal nurse at 31 to 33 weeks' and/or 35 to 37 weeks' postmenstrual age (PMA) using a standard protocol. Data were uploaded to a Web-based telemedicine system and interpreted by 3 expert retinal specialist graders who provided a diagnosis (no ROP, mild ROP, type 2 prethreshold ROP, treatment-requiring ROP) and an evaluation of image quality for each eye. Findings were compared with a reference standard of indirect ophthalmoscopy by an experienced pediatric ophthalmologist. RESULTS: At 35 to 37 weeks' PMA, sensitivity and specificity for diagnosis of mild or worse ROP were 0.908 and 1.000 for grader A, 0.971 and 1.000 for grader B, and 0.908 and 0.977 for grader C. Sensitivity and specificity for diagnosis of type 2 prethreshold or worse ROP were 1.000 and 0.943 for grader A, 1.000 and 0.930 for grader B, and 1.000 and 0.851 for grader C. At 35 to 37 weeks' PMA, weighted kappa for intergrader reliability was 0.791 to 0.889, and kappa for intragrader reliability for detection of type 2 prethreshold or worse ROP was 0.769 to 1.000. Image technical quality was rated as "adequate" or "possibly adequate" for diagnosis in 93.3% to 100% of eyes. CONCLUSION: A telemedicine system using nurse-captured retinal images has the potential to improve existing shortcomings of ROP management, particularly at later PMAs.

Detection of arteriolar narrowing in fundoscopic examination: evidence of a low performance of direct ophthalmoscopy in comparison with a microdensitometric method.

BACKGROUND: Retinal abnormalities, particularly arteriolar narrowing, are powerful predictors of cardiovascular events. The precision of internists and ophthalmologists in the assessment of retinal vessels widths has been disputed but not evaluated against a technology of edge detection. METHODS: Fifty-two patients with hypertension had optic fundi examination done by an internist and an ophthalmologist, and had retinographies taken and digitized to determine vessel diameters by a new technology of edge detection (microdensitometric method). Physicians asserted the presence of arteriolar narrowing (

Characterization of Artifacts Associated With Multicolor Confocal Scanning Laser Ophthalmoscopy.

BACKGROUND AND OBJECTIVE: To characterize the appearance of three types of artifacts observed on multicolor confocal scanning laser ophthalmoscopy (cSLO). PATIENTS AND METHODS: Retrospective review of 159 eyes of 96 consecutive patients from the Duke Eye Center who underwent multicolor cSLO with spectral-domain optical coherence tomography (SD-OCT). Infrared (IR), green, blue, and multicolor reflectance images were evaluated for artifacts with corresponding SD-OCT scans available for reference. RESULTS: Multicolor cSLO artifacts were detected in 23.3% (37 of 159) of eyes and comprised three main patterns: spot, wisp, and net. Only three instances of these artifacts were detected on IR reflectance versus 34, 37, and 35 instances on green, blue, and multicolor reflectance, respectively. Artifacts were observed in 0% of eyes with clear lenses, 27.7% of eyes with cataracts, and in 20.8% of eyes with posterior chamber intraocular lenses. CONCLUSION: Awareness of spot, wisp, and net artifacts when interpreting multicolor cSLO images may facilitate the identification of true retinal pathology. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:810-815.].

White Dots as a Novel Marker of Diabetic Retinopathy Severity in Ultrawide Field Imaging.

PURPOSE: To characterize white dots in diabetic retinopathy (DR) and their association with disease severity using ultra-wide-field scanning laser ophthalmoscopy. METHODS: We randomly selected 125 eyes of 77 patients (25 eyes from individual categories of the international classification of DR severity) for which ultrawide field photographs were obtained. We characterized white dots, which were delineated by higher signal levels on green but not red laser images, and evaluated the relationship between the number of white dots and the international severity scale of DR. RESULTS: Most white dots were located in nonperfused areas, and the number of total white dots was significantly correlated to that of dots in nonperfused areas. White dots corresponded to microaneurysms around the boundary between nonperfused areas and perfused areas or unknown lesions in nonperfused areas. Eyes with DR had significantly more white dots than those with no apparent retinopathy. The numbers of white dots in moderate nonproliferative diabetic retinopathy (NPDR) or more severe grades were significantly higher than in mild NPDR. The area under the receiver operating characteristics curve (AROC) analyses demonstrated that the number of white dots had the significance in the diagnosis of DR (0.908-0.986) and moderate NPDR or more severe grades (0.888-0.974). CONCLUSIONS: These data suggest the clinical relevance of white dots seen on ultrawide field images in the diagnosis of the severity of DR.

Clinical Competency of 1-Year Trained Vision Technicians in Andhra Pradesh, India.

PURPOSE: To assess clinical competency of 1-year trained vision technicians (VTs) in detecting and referring causes of visual impairment in India. METHODS: Eye examination results and management plans for 328 patients examined by 24 VTs in 24 vision centers of LV Prasad Eye Institute in Andhra Pradesh were compared with those of a standard optometrist who examined the same patients. Eye examinations included retinoscopy and subjective refraction, slit lamp examination, applanation tonometry and undilated direct ophthalmoscopy. Data were analyzed for level of concordance in retinoscopy, spectacle prescription, disease detection and referral. RESULTS: VTs demonstrated moderate to good levels of agreement in refraction, disease detection and referral. Sensitivity and specificity for ocular pathology identification were 77.4% (95% confidence interval, CI, 69.4-84.2%) and 86.6% (95% CI 81.1-91.1%), respectively. The highest sensitivity was demonstrated in detecting significant cataract (91.5%) and refractive error (83.0%). VT spectacle prescriptions were accurate 76% of the time for mean spherical equivalent and 65% of the time for astigmatism. VT sensitivity in detecting posterior segment abnormalities was low (18.5%) resulting in failure to detect retinal conditions such as diabetic retinopathy and maculopathy. Despite lack of recognition of the specific pathology, referral decisions were correct in 78.4% of cases. CONCLUSION: VTs in India competently detect and manage or refer the two most common causes of visual impairment; uncorrected refractive error and cataract. Over two-thirds of patients received accurate and appropriate services from VTs, suggesting that they are a useful and competent cadre for rural and remote eye care.

Photographic Reading Center of the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT): Methods and Baseline Results.

PURPOSE: To describe the methods used by the Photographic Reading Center (PRC) of the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT) and to report baseline assessments of papilledema severity in participants. METHODS: Stereoscopic digital images centered on the optic disc and the macula were collected using certified personnel and photographic equipment. Certification of the camera system included standardization and calibration using a model eye. Lay readers assessed disc photos of all eyes using the Frisén grade and performed quantitative measurements of papilledema. Frisén grades by PRC were compared with site investigator clinical grades. Spearman rank correlations were used to quantify associations among disc features and selected clinical variables. RESULTS: Frisén grades according to the PRC and site investigator's grades, matched exactly in 48% of the study eyes and 42% of the fellow eyes and within one grade in 94% of the study eyes and 92% of the fellow eyes. Frisén grade was strongly correlated (r > 0.65, P < 0.0001) with quantitative measures of disc area. Cerebrospinal fluid pressure was weakly associated with Frisén grade and disc area determinations (r ≤ 0.31). Neither Frisén grade nor any fundus feature was associated with perimetric mean deviation. CONCLUSIONS: In a prospective clinical trial, lay readers agreed reasonably well with physicians in assessing Frisén grade. Standardization of camera systems enhanced consistency of photographic quality across study sites. Images were affected more by sensors with poor dynamic range than by poor resolution. Frisén grade is highly correlated with quantitative assessment of disc area. (ClinicalTrials.gov number, NCT01003639.).