Assessing the Impact of En Face Retinal Nerve Fiber Layer Imaging on Clinical Decision Making for Glaucoma Suspects.

SIGNIFICANCE: Assessing and managing glaucoma are a complicated process in which experience plays a key role in decision making. Although advanced glaucoma is more easily diagnosed, patients with early glaucoma or who present with suspicious findings are more complicated. A need to aid clinicians in the decision-making process exists. PURPOSE: The purpose of this study was to assess the impact of en face ocular coherence tomography images to clinical decision making when added to standard presentations of circumpapillary retinal nerve fiber layer thickness and automated perimetry. METHODS: Thirty participants from two centers presenting either as a glaucoma suspect or for an initial glaucoma evaluation were enrolled. Six masked investigators were given standard presentations of circumpapillary retinal nerve fiber layer thickness and perimetry. They were asked if glaucomatous damage was present as well as a recommended plan of management on 5-point Likert scales. They were then given en face images of the retinal nerve fiber layer in three different presentations coupled with the standard presentation, and the questions were repeated. An intraclass correlation coefficient (ICC) was generated. RESULTS: The masked investigators had moderate agreement from the standard presentation for assessment (ICC = 0.67 [95% confidence interval {CI}, 0.54 to 0.80] and ICC = 0.69 [95% CI, 0.52 to 0.80], respectively), as well as with the addition of the en face images (ICC = 0.69; 95% CI, 0.56 to 0.81). The en face images tended to change decisions in both assessment and plan toward likely to have glaucoma and likely to start treatment. CONCLUSIONS: The addition of en face images to a standard presentation has an impact on clinical decision making. Although en face images seem to influence the decision toward likely to have glaucoma and likely to treat, it is unclear if this leads to a more accurate decision. Further investigations seem warranted to assess sensitivity and specificity of this approach.

Symmetry of peripheral retinal nonperfusion in diabetic retinopathy by ischemic index.

PURPOSE: Diabetic retinopathy is the leading cause of blindness among working-age adults in most developed countries. It affects eyes bilaterally and is generally believed to be symmetrical, yet there are few studies evaluating the symmetry of diabetic retinopathy. The purpose of the present study was to evaluate the symmetry of the amount of peripheral retinal ischemia in patients with diabetic retinopathy. METHODS: Ultra-widefield fluorescein angiography images were obtained on both eyes of 54 subjects, mean age 56.4 years, from an urban eye clinic. A single, high quality image from the arteriovenous phase of the angiogram of each eye was selected for analysis. The total area of gradable fundus and area of nonperfusion seen in the arteriovenous phase of the ultra-widefield fluorescein angiogram were determined. An ischemic index (ISI) was calculated by dividing the non-perfused retinal area by the total retinal area and multiplying by 100. RESULTS: The mean ISI OD was 11.27, mean ISI OS was 11.64. The mean absolute value (±SD) of ISI difference between OD and OS was 4.46±6.09. A difference in ISI of 10% or less was found in 92.6% of subjects. A statistically significant correlation was found in the ISI between right and left eyes (rs=0.80, p<0.0001) and there was no statistically significant difference in ISI between the right and left eyes (p=0.85). CONCLUSION: Asymmetrical retinopathy in diabetic patients is uncommon and additional pathological processes should be considered in the presence of asymmetric DR.

Ruptured retinal arterial macroaneurysm: diagnosis and management.

Retinal arterial macroaneurysm is an acquired, focal dilation of a retinal artery, typically occurring within the first three bifurcations of the central retinal artery. The clinical presentation of a retinal arterial macroaneurysm is highly variable, making initial diagnosis difficult and differentials many. Identification of retinal arterial macroaneurysms is crucial to appropriately co-manage with the primary care physician for hypertension control. Prognosis is generally good and observation is often an adequate treatment. However, in cases of macular threat or involvement, some treatment options are available and referral to a retinal specialist is indicated.