Loculated fluid. A previously undescribed fluorescein angiographic finding in choroidal neovascularization associated with macular degeneration. Macular Photocoagulation Study Reading Center.

The Foveal Photocoagulation Study, a component of the Macular Photocoagulation Study, is designed to evaluate whether laser treatment can reduce the risk of severe visual loss in eyes with well-defined choroidal neovascular membranes associated with macular degeneration that extend through the foveal center. On one third of the 554 baseline angiograms of study patients enrolled in and whose eyes were graded in the study as of January 31, 1990, the Reading Center staff has noted an unusual pattern of hyperfluorescence in the late-transit frames that has not been described previously. This pattern, which we call "loculated fluid," consists of a well-demarcated area of hyperfluorescence that appears to represent pooling of fluorescein in a compartmentalized space anterior to the choroidal neovascular leakage. Although the loculated fluid may conform to a pattern of typical cystoid macular edema, it can also pool within an area deep to the sensory retina in a shape that does not bear any resemblance to cystoid macular edema. This pattern is important to recognize because it (1) should not be confused with the angiographic pattern or extent of choroidal neovascularization and (2) should be differentiated from a serous detachment or tear of the retinal pigment epithelium.

Laser burn intensity and the risk for choroidal neovascularization in the CNVPT Fellow Eye Study.

OBJECTIVE: To explore the relationship between laser burn intensity and the subsequent risk for development of choroidal neovascularization (CNV) in eyes assigned to the treatment group of the Fellow Eye Study (FES) of the Choroidal Neovascularization Prevention Trial (CNVPT), using computerized methods for laser burn quantitation, and to examine the association between laser burn intensity and (1) drusen reduction and (2) visual acuity. METHODS: Color fundus images before and immediately after laser treatment in the CNVPT FES were available for 53 of 59 eyes. Prelaser and postlaser treatment images were analyzed using custom-developed computer software, allowing for laser burn identification and quantitation. As measures of laser burn intensity, we derived integrated burn rating (IBR) (the integral of the normalized intensity difference divided by the burn pixels), and the maximum burn intensity (MAX). We identified CNV using fluorescein angiography. A Cox proportional hazards model was fit to the time to development of CNV. Baseline and 6-month color photographs were used to determine reduction in drusen. Visual acuity was measured using a standardized protocol. RESULTS: The IBR and MAX spanned 4.5 logarithm units. After adjusting for smoking history and predominant drusen size, the risk ratio for CNV per logarithm unit of increasing laser burn intensity for each measure was 2.0 (P =.05) for MAX and 1.7 (P =.07) for IBR. When patients were divided into high- and low-intensity treatment groups of equal size, the high-intensity group had more drusen reduction (57% vs 32%; P =.14). There was no effect of laser intensity on change in visual acuity at 6 months. CONCLUSION: Higher-intensity prophylactic laser applications appear to be associated with a greater risk for development of CNV and with more extensive drusen reduction.

Comparison of diabetic retinopathy detection by clinical examinations and photograph gradings. Barbados (West Indies) Eye Study Group.

OBJECTIVE: To compare the use of clinical examination and fundus photograph gradings in detecting diabetic retinopathy in a population that includes persons with and without diabetes. DESIGN: Population-based epidemiologic study. SETTING: Sir Winston Scott Polyclinic, Bridgetown, Barbados, West Indies. PARTICIPANTS: Subset of a random sample of the country's population aged 40 to 86 years. RESULTS: Among 1168 black persons with fundus photograph evaluations, ophthalmologic examinations, diabetes history, and glycated hemoglobin data, 21% reported a history of diabetes; 9.5% had definite diabetes (glycated hemoglobin > 11.5%); and 13.3% had a diabetes history and glycated hemoglobin value less than or equal to 11.5%. The frequency of diabetic retinopathy in this group was 7.7% (90/1168) by clinical examination, 8.7% (102/1168) by photograph gradings, and 6.7% (78/1168) by both methods. CONCLUSIONS: These results suggest that in certain populations that include diabetics and nondiabetics, a clinical examination by an ophthalmologist will detect most cases of diabetic retinopathy identified by disc and macula photographs read by skilled graders. However, it will lead to an underestimate of prevalence. Staff availability and cost, issues not examined in this study, should determine which approach is selected.

Psychopathological differences among three groups of school children affected by the war in Croatia.

The consequences of extreme violence such as war torture affect children in different ways and may immediately manifest at the physical and/or psychologic level, or may remain hidden and unrecognized for years. The victims are usually very reluctant to speak about their traumatic experiences, and try to deny the existence of psychological disturbances. They often seek help for somatic problems. Taking these physical complaints seriously helps to progressively reach the psychological effects of violence. Therefore, identification of such children should be directed to more complete evaluation of their symptomatology and functioning. This can be done by: a) individual evaluation to get enough information on the historical events, functioning and symptoms of these children; and b) standardized instruments which may allow the children to disclose more about their psychological experiences during the war. In this study rating scales and assessment instruments for children aged < 15, such as CPRS with General Scoring Sheet (Fish, 1985), were used to assess the broad spectrum of psychopathology in this age group. These questionnaires were used in a large group of school children (N = 1888), 989 girls and 899 boys aged 7-16 years. The sample was divided into 3 groups: 843 non-displaced, 377 displaced and 669 refugee children. Results of statistical analysis (arithmetical mean and standard deviation of discriminative variables transformed in Z-values with F-ratio) showed the three groups of children (non-displaced, displaced and refugees) to significantly differ in 13 out of 15 psychopathologic clusters. Discriminative cannonic analysis of the 3 groups of children (non displaced, displaced and refugees) also showed significant differences. The first discriminative function (80.24% of total variance) indicated depression, violence and antisocial behavior to be rare in non-displaced children, more pronounced in displaced, and most pronounced in refugee children. The second discriminative function (19.76% of total variance) showed hyperactivity, anxiety and psychosomatic disturbances to be rare in non-displaced children; more frequent in refugee, and most expressed in displaced children. According to the results, the authors concluded that war is very painful for a large group of children, among whom the displaced and refugee children are most affected by psychopathologic disturbances.

Computer-assisted, interactive fundus image processing for macular drusen quantitation.

PURPOSE: To design and validate a software package to quantitate the area subtended by drusen in color fundus photographs for the conduct of efficient, accurate clinical trials in age-related macular degeneration. DESIGN: Algorithm and software development. Comparisons with manual methodologies. PARTICIPANTS: Evaluation and testing on color fundus photographs from patient records and from eyes enrolled in the Choroidal Neovascularization Prevention Trial. METHODS: Fundus photographs of eyes with drusen were digitized. The green channel was selected for maximum contrast and preprocessed with filtering and shade correction to minimize noise, improve contrast, and correct for illumination and background inhomogeneities. Local thresholding and region-growing algorithms identified drusen. Multiple levels of supervision were incorporated to maximize robustness, accuracy, and validity. Validation studies compared computer-assisted with manual grading by an experienced grader. Intraclass correlation coefficients were calculated as a measure of the concordance between manual and computer-assisted fundus gradings. MAIN OUTCOME MEASURES: Drusen area and concordance with manual grading. RESULTS: Automated supervised image analysis offers extreme robustness and accuracy. Most images were segmented with little or no supervision, with processing times on the order of 5 seconds. More complicated images required supervision and a total analysis time varying from 20 seconds to 5 minutes, with most of this time devoted to inspection and comparison. Interactive image processing affords arbitrarily close concordance with manual drusen identification, with calculated intraclass correlation coefficients of 0.92 and 0.93 for comparison of manual with automated, supervised grading by two observers. CONCLUSIONS: Automated supervised fundus image analysis is an efficient, robust, valid technique for drusen quantitation from color fundus photographs. This approach should prove useful in the conduct of efficient accurate clinical trials for age-related macular degeneration.

Laser-induced drusen reduction improves visual function at 1 year. Choroidal Neovascularization Prevention Trial Research Group.

OBJECTIVE: To describe the relationship of laser-induced drusen reduction to change in visual function at 1 year among patients enrolled in the Choroidal Neovascularization Prevention Trial (CNVPT). DESIGN: Comparison of groups with and without drusen reduction; follow-up of a randomized controlled trial. PARTICIPANTS: Evaluations of drusen and visual acuity at baseline and at 1 year were performed for 351 eyes of the 432 eyes enrolled in the CNVPT Bilateral Drusen Study and Fellow Eye Study (81%). One hundred eighty-four eyes were assigned to observation, and 167 eyes were assigned to laser treatment. Eyes with conditions that precluded an analysis of drusen reduction, such as those that developed choroidal neovascularization (CNV) within the first year, are excluded from this analysis. METHODS: Change in macular drusen between initial visit and after 1 year was assessed by side-by-side grading by evaluators masked to information on visual function. Visual acuity, contrast threshold, and critical print size were measured by certified visual function examiners. MAIN OUTCOME MEASURES: Change in visual acuity is the primary outcome. Change in contrast threshold and change in critical print size are secondary outcome measures. RESULTS: Laser-treated eyes with 50% or more drusen reduction at 1 year had more 1- and 2-line increases in visual acuity and less losses in visual acuity compared with laser-treated eyes with less drusen reduction or with observed eyes (P = 0.001). Similar improvements were noted for contrast threshold but not critical print size at 1 year. CONCLUSIONS: Laser-induced drusen reduction is associated with improved visual acuity and contrast sensitivity in eyes at 1 year. Longer term effects of laser-induced drusen reduction on visual function require additional observation. The overall potential value of laser treatment in eyes with high-risk drusen requires consideration of not only short-term effects on vision but also the effects of CNV and atrophy on vision.