Virtual Visits in Ophthalmology: Timely Advice for Implementation During the COVID-19 Public Health Crisis.

Virtual visits (VVs) are necessitated due to the public health crisis and social distancing mandates due to COVID-19. However, these have been rare in ophthalmology. Over 3.5 years of conducting >350 ophthalmological VVs, our group has gained numerous insights into best practices. This communication shares these experiences with the medical community to support patient care during this difficult time and beyond. We highlight that mastering the technological platform of choice, optimizing lighting, camera positioning, and "eye contact," being thoughtful and creative with the virtual eye examination, and ensuring good documenting and billing will make a successful and efficient VV. Moreover, we think these ideas will stimulate further VV creativity and expertise to be developed in ophthalmology and across medicine. This approach, holds promise for increasing its adoption after the crisis has passed.

Assessment of tear film optical quality in a young short tear break-up time dry eye: Case-control study.

BACKGROUND: The aim of the study was to evaluate the dynamic changes of tear film optical quality in a short tear break-up time (TBUT) dry eye by using a double-pass system. METHODS: Thirty-five short TBUT dry eye participants and 43 control subjects without dry eye were included in this study. One eye for each subject was analyzed. The Objective Scatter Index (OSI), modulation transfer function (MTF), and strehl ratio (SR) were recorded within a 20-second period with the participants asked to blink freely, and 10 successive seconds of nonblinking immediately after a blink was recorded to analyze the tear film OSI. The mean tear film OSI in 10 successive seconds, ΔOSI, and ΔOSI/time were evaluated. The correlation between tear film OSI and MTF, and the correlation between tear film OSI and MIT were also analysed. RESULTS: Short TBUT dry eye participants showed significant deterioration of MTF and SR compared to control subjects. The mean tear film OSI in 10 successive seconds was significantly higher in dry eye participants than in control subjects. The mean OSI of the tear film (0-5 seconds) and the mean OSI of the tear film (6-10 seconds) were significantly higher in dry eye participants than in control participants. Moreover, the ΔOSI was significantly higher in dry eye participants than in control participants. The tear film OSI was significantly correlated with the MTF and the SR. CONCLUSIONS: The tear film OSI of short TBUT dry eye participants is significantly increased in the early stage. Tear film instability in short TBUT dry eye participants has a significant effect on optical quality.

Automated qualitative and quantitative assessment of posterior capsule opacification by Automated Quantification of After-Cataract II (AQUA II) system.

BACKGROUND: The present study aims to investigate an automated qualitative and quantitative assessment system (Automated Quantification of After-Cataract [AQUA II]) of posterior capsule opacification (PCO) in high-resolution digital retroillumination images and consequently reduce observer bias and increase accuracy of PCO grading. METHODS: A data set of 100 eyes with no to severe PCO was analysed. Ten eyes were consecutively photographed twice and ten images were rotated to give a total of 120 images for PCO assessment. Validity was determined by including subjective grading and repeatability was determined by evaluating the 20 additional images. Evaluation of posterior capsular opacification (EPCO), posterior capsule opacity (POCO) and AQUA I methods were included for comparative analysis of the data. RESULTS: The system developed proved to classify six types of PCO. Validity was confirmed by a Pearson correlation coefficient of r = 0.95 (EPCO r = 0.93; POCO r = 0.72 and AQUA I r = 0.94). Repeatability was better in AQUA II (95% confidence interval [CI] for mean difference: 0.5 ± 1.2) than in subjective grading (95% CI for mean difference: 0.6 ± 1.7), in EPCO grading (95% CI for mean difference: - 0.2 ± 1.5), in POCO grading (95% CI for mean difference: 1.6 ± 2.7) and in AQUA I (95% CI for mean difference: - 1.1 ± 1.9). CONCLUSIONS: AQUA II is a system that for the first time not only objectively quantifies PCO, but also qualitatively assesses PCO in an automated manner with texture classification. AQUA II showed an excellent validity and repeatability.

Diabetic Retinopathy Assessment Variability Among Eye Care Providers in an Urban Teleophthalmology Program.

BACKGROUND: Teleophthalmology is an evidence-based method for diabetic eye screening. It is unclear whether the type of eye care provider performing teleophthalmology interpretation produces significant variability. INTRODUCTION: We assessed grading variability between an optometrist, general ophthalmologist, and retinal specialist using images from an urban, diabetic retinopathy teleophthalmology program. METHODS: Three readers evaluated digital retinal images in 100 cases (178 eyes from 90 patients with type 2 diabetes). Fisher's exact test, percent agreement, and the observed proportion of positive (Ppos) or negative agreement (Pneg) were used to assess variability. RESULTS: Among cases deemed gradable by all three readers (n = 65), there was substantial agreement on absence of any retinopathy (88% ± 4.6%, Pneg = 0.91-0.95), presence of moderate nonproliferative or worse retinopathy (87% ± 3.9%, Ppos = 0.67-1.00), and presence of macular edema (99% ± 0.9%, Ppos = 0.67-1.00). There was limited agreement regarding presence of referable nondiabetic eye pathology (61% ± 11%, Ppos = 0.21-0.59) and early, nonroutine referral for a follow-up clinical eye exam (66% ± 8.1%, Ppos = 0.19-0.54). Among all cases (n = 100), there was acceptable agreement regarding which had gradable images (77% ± 5.0%, Ppos = 0.50-0.90). DISCUSSION: Inclusion of multiple types of eye care providers as teleophthalmology readers is unlikely to produce significant variability in the assessment of diabetic retinopathy among high-quality images. Greater variability was found regarding image gradability, nondiabetic eye pathology, and recommended clinical referral times. CONCLUSIONS: Our results suggest that more extensive training and uniform referral standards are needed to improve consensus on image gradability, referable nondiabetic eye pathology, and recommended clinical referral times.

The unmet need for better risk stratification of non-proliferative diabetic retinopathy.

Diabetic retinopathy is a common microvascular complication of diabetes and remains one of the leading causes of preventable blindness in working-age people. Non-proliferative diabetic retinopathy is the earliest stage of diabetic retinopathy and is typically asymptomatic. Currently, the severity of diabetic retinopathy is assessed using semi-quantitative grading systems based on the presence or absence of retinal lesions. These methods are well validated, but do not predict those at high risk of rapid progression to sight-threatening diabetic retinopathy; therefore, new approaches for identifying these people are a current unmet need. We evaluated published data reporting the lesion characteristics associated with different progression profiles in people with non-proliferative diabetic retinopathy. Based on these findings, we propose that additional assessments of features of non-proliferative diabetic retinopathy lesions may help to stratify people based on the likelihood of rapid progression. In addition to the current classification, the following measurements should be considered: the shape and size of lesions; whether lesions are angiogenic in origin; the location of lesions, including predominantly peripheral lesions; and lesion turnover and dynamics. For lesions commonly seen in hypertensive retinopathy, a detailed assessment of potential concomitant diseases is also recommended. We believe that natural history studies of these changes will help characterize these non-proliferative diabetic retinopathy progression profiles and advance our understanding of the pathogenesis of diabetic retinopathy in order to individualize management of people with diabetic retinopathy.

Role of a Standardized Prism Under Cover Test in the Assessment of Dissociated Vertical Deviation.

BACKGROUND: Dissociated vertical deviation (DVD) is commonly measured using a prism and alternate cover test (PACT), but some providers use a prism under cover test (PUCT). The aim of this study was to compare a standardized PUCT measurement with a PACT measurement, for assessing the magnitude of DVD. METHODS: Thirty-six patients with a clinical diagnosis of DVD underwent measurement of the angle of deviation with the PACT, fixing with the habitually fixing eye, and with PUCT, fixing both right and left eyes. The PUCT was standardized, using a 10-second cover for each prism magnitude, until the deviation was neutralized. The magnitude of hyperdeviation by PACT and PUCT was compared for the non-fixing eye, using paired non-parametric tests. The frequency of discrepancies more than 4 prism diopters (PD) between PACT and PUCT was calculated. RESULTS: The magnitude of hyperdeviation was greater when measured with PUCT (range 8PD hypodeviation to 20PD hyperdeviation) vs. PACT (18PD hypodeviation to 25PD hyperdeviation) with a median difference of 4.5PD (range -5PD to 21PD); P < 0.0001. Eighteen (50%) of 36 measurements elicited >4PD hyperdeviation (or >4PD less hypodeviation) by PUCT than by PACT. CONCLUSIONS: A standardized 10-second PUCT yields greater values than a prism and alternate cover test in the majority of patients with DVD, providing better quantification of the severity of DVD, which may be important for management decisions.

Tear instability importance, mechanisms, validity and reliability of assessment.

PURPOSE: To examine the factors which contribute to tear stability and the validity and reliability of methods used for assessing tear break up time which is a core part of an examination of tear stability in dry eye patients. METHODS: A review of publications which are relevant to tear stability and its assessment. RESULTS: Tear break up time may be more invasive than intended if difficulty avoiding blinking during assessment results in reflex tearing. Notwithstanding control of instilled volume and concentration of fluorescein, on-eye dilution is highly variable according to resident tear volume. Blinking to evenly distribute fluorescein may improve tear and lipid layer thickness so habitual tear function is not assessed. Emphasis on a role for Meibomian gland dysfunction as a cause of tear instability may be appropriate in many cases but ignores the roles for other sources of tear lipid and other non-lipid contributions to tear instability such as aqueous or mucus deficiency, desiccated epitheliopathy or anomalous blinking. Objective less-invasive methods eliminate problems of inter-observer variability and can reliably 'maintain vigilance' over wide areas of the tear layer. However less-invasive results to date include mean tear break up findings which are both shorter and longer than expected for normal controls. CONCLUSIONS: Fluorescein tear break up time assessments cannot be standardised and less-invasive methods are not yet standardised. Objective less-invasive and subjective fluorescein break up time tests do not appear to be measuring the same tear phenomena although both should be performed before other invasive procedures.

Comparative quantitative assessment of the human corneal sub-basal nerve plexus by in vivo confocal microscopy and histological staining.

PurposeThis study was designed to compare and contrast quantitative data of the human corneal sub-basal nerve plexus (SBP) evaluated by two different methods: in vivo confocal microscopy (IVCM), and immunohistochemical staining of ex vivo donor corneas.MethodsSeven parameters of the SBP in large-scale IVCM mosaicking images from healthy subjects were compared with the identical parameters in ex vivo donor corneas stained by ß-III-tubulin immunohistochemistry. Corneal nerve fiber length (CNFL), corneal nerve fiber density (CNFD), corneal nerve branch density (CNBD), average weighted corneal nerve fiber tortuosity (CNFTo), corneal nerve connection points (CNCP), average corneal nerve single-fiber length (CNSFL), and average weighted corneal nerve fiber thickness (CNFTh) were calculated using a dedicated, published algorithm and compared.ResultsOur experiments showed significantly higher values for CNFL (50.2 vs 21.4 mm/mm2), CNFD (1358.8 vs 277.3 nerve fibers/mm2), CNBD (847.6 vs 163.5 branches/mm2), CNFTo (0.095 vs 0.081 µm-1), and CNCP (49.4 vs 21.6 connections/mm2) in histologically staining specimens compared with IVCM images. In contrast, CNSFL values were higher in IVCM images than in histological specimens (32.1 vs 74.1 µm). No significant difference was observed in CNFTh (2.22 vs 2.20 µm) between the two groups.ConclusionsThe results of this study have shown that IVCM has an inherently lower resolution compared with ex vivo immunohistochemical staining of the corneal SBP and that this limitation leads to a systematic underestimation of several SBP parameters. Despite this shortcoming, IVCM is a vital clinical tool for in vivo characterization, quantitative clinical imaging, and evaluation of the human corneal SBP.

[Ophthalmological assessment in procedures for disability benefits for the blind : Why medical certificates alone are insufficient]. / Augenärztliche Begutachtung im Blindengeldverfahren : Warum Atteste alleine nicht ausreichen.

BACKGROUND AND OBJECTIVES: Financial aid for the blind which is awarded based only on medical certificates and results of examinations has in the past resulted in too many false diagnoses; therefore, Bavaria seeks to pay financial aid to the blind only on the basis of a specific ophthalmological assessment according to the standards of the German pension medical ordinance (VersMedV, Versorgungsmedizinische Verordnung). Because these ophthalmological assessments initially contribute to a higher financial burden on the state, longer processing times and inconvenience to the patient, investigations should be undertaken to determine if ophthalmological findings, reports and medical certificates can be a suitable basis for an expert assessment and in how many cases blindness which had been certified by the original examination could be confirmed by a specific ophthalmological assessment. METHODS: A total of 925 applications for financial assistance to the blind within the catchment area of the Bavarian Center for Family and Social Services (ZBFS, Zentrum Bayern Familie und Soziales) regional center in Upper Bavaria between 2003 and 2008, all of which had been subjected to an assessment by the same practitioner acting as external expert, were statistically analyzed. RESULTS: Of the 357 applicants who had been classified as blind according to the medical certificate and findings, 283 (79 %) were confirmed as being blind after the assessment and in 73 (21 %) blindness could not be confirmed. Of the 262 applicants who were classified as not being blind during the first examination, the diagnosis was confirmed in 192 (73 %) while 70 cases (27 %) were classified as blind. Of the 304 applicants for whom an assessment was not possible by the medical certification, 165 were ultimately classified as blind and 139 as not blind. Out of 32 applicants who were explicitly classified as being blind in the medical certificate, 13 were confirmed as being blind while the remaining 18 were classified in the subsequent assessment as not blind. CONCLUSION: Apart from unambiguous cases, the awarding of financial aid to the blind should only be based on an ophthalmological assessment which follows the VersMedV guidelines. Only this approach can result in an equal treatment of all applicants before the law and the awarding of financial aid to the blind to assist those truly in need. In addition, fiscal budget results revealed that the falsely awarded financial aid to the blind reached well beyond millions of Euros.

Management of choroidal naevomelanocytic lesions: feasibility and safety of a virtual clinic model.

BACKGROUND: Choroidal naevomelanocytic lesions are often identified as an incidental finding by community optometrists and referred for expert evaluation in hospital eye units or specialist ocular oncology centres. Optimal management strategy is undecided and most centres err on the side of caution. Our aim was to test a virtual model of service delivery relying on interpretation of imaging test results by non-medically trained graders. METHODS: Patients with naevomelanocytic lesions referred to Manchester Royal Eye Hospital and Moorfields Eye Hospital were retrospectively included in this study. All patients underwent imaging tests including optical coherence tomography and ultrasound and management was subsequently decided clinically. Images were anonymised and transferred to the Moorfields Eye Hospital Reading Centre and were reviewed by a trained, masked grader who reached a management decision on the basis of a specific grading protocol. Agreement between decisions made on the basis of clinical examination and imaging ('gold standard') by an expert ophthalmologist in the clinic was compared with the decisions made by a masked ophthalmologist and a masked non-medical grader based on imaging tests alone. RESULTS: There were 102 consecutive patients included in this study. Agreement between gold-standard clinical management and decisions made by masked, non-medical grader and masked ophthalmologist on the basis of imaging test results alone was 96.1% (κ=0.97) and 100%, respectively. CONCLUSIONS: In this pilot study, a streamlined, dedicated, virtual service for rapid assessment (within 2 weeks of referral) of choroidal naevomelanocytic lesions was shown to be feasible and safe. Such a model of service delivery may prove cost-efficient while optimising patient experience. Further prospective studies are required for formal validation of the proposed service model.

Impact of the revised american academy of ophthalmology guidelines regarding hydroxychloroquine screening on actual practice.

PURPOSE: To determine the impact of the revised academy guidelines on screening for hydroxychloroquine retinopathy. DESIGN: Retrospective, observational cohort study. METHODS: setting: Private practice of 29 doctors. study population: Total of 183 patients for follow-up and 36 patients for baseline screening. observation procedure: Review of charts, 10-2 visual fields (VFs), multifocal electroretinograms (mfERG), and spectral-domain optical coherence tomography (SD-OCT) images before and after the revised guidelines. main outcome measure: Rates of use of ancillary tests and clinical intervention, costs of screening, follow-up schedules, and comparative sensitivity of tests. RESULTS: New hydroxychloroquine toxicity was found in 2 of 183 returning patients (1.1%). Dosing above 6.5 mg/kg/d was found in 28 of 219 patients (12.8%), an underestimate because patient height, weight, and daily dose were not determined in 77 (35.1%), 84 (38.4%), and 59 (26.9%), respectively. In 10 of the 28 (35.7%), the dose was reduced, in 2 (7.1%) hydroxychloroquine was stopped, but in 16 (57.1%) no action was taken. The cost of screening rose 40%/patient after the revised guidelines. Fundus autofluorescence imaging was not used. No toxicity was detected by adding mfERG or SD-OCT. In no case was a 5-year period free of follow-up recommended after baseline screening in a low-risk patient. CONCLUSIONS: Detection of toxic daily dosing is a cost-effective way to reduce hydroxychloroquine toxicity, but height, weight, and daily dose were commonly not checked. The revised guidelines, emphasizing mfERG, SD-OCT, or FAF, raised screening cost without improving case detection. The recommended 5-year screening-free interval for low-risk patients after baseline examination was ignored.

Assessment of binocular alignment using the three-dimensional Strabismus Photo Analyzer.

AIM: To evaluate the efficacy of the three-dimensional (3D) Strabismus Photo Analyzer for estimating binocular alignment using photographs. METHODS: Thirty-two subjects with exotropia, 30 subjects with esotropia and 38 orthotropic subjects were included. Two independent ophthalmologists examined the angle of deviation using the Krimsky test and prism and alternate cover test (PCT). Full-face photographs were obtained using an 8.2-megapixel digital single-lens reflex camera, and the images were analysed using the 3D Strabismus Photo Analyzer. The images were adjusted for age-dependent ophthalmic biometry and angle κ. The main outcome measures were inter-observer variability, test-retest reliability and correlation between the angles of deviation measured by different methods. RESULTS: The 95% limit of agreement of inter-observer variability was ± 3.5° (6.1 prism dioptres (PD)), ± 3.1° (5.4 PD) and ± 1.5° (2.6 PD) for the Krimsky test, PCT and the 3D Strabismus Photo Analyzer, respectively. The test-retest reliability was ± 2.8° (4.9 PD) for the 3D Strabismus Photo Analyzer versus the Krimsky test. The results of the Krimsky test and 3D Strabismus Photo Analyzer showed a strong positive correlation. CONCLUSIONS: The 3D Strabismus Photo Analyzer is a simple and reliable tool for measuring ocular deviation. It has excellent agreement with the Krimsky test and substantially improved reproducibility.

Cataract prevalence varies substantially with assessment systems: comparison of clinical and photographic grading in a population-based study.

PURPOSE: Cataract is the major cause of blindness worldwide yet there is no consensus on its assessment and definition. This study compares age-related cataract prevalence derived from two commonly used methods: clinical assessment using the Lens Opacity Classification System (LOCS III) and photographic grading using the Wisconsin Cataract Grading System (Wisconsin System). METHODS: The Singapore Malay Eye Study is a population-based study of 3,280 Singapore Malays aged 40-80 years. Presence of nuclear, cortical and posterior sub-capsular cataract was assessed clinically during slit-lamp examination using LOCS III, and via slit-lamp and retro-illumination photographic grading using the Wisconsin System. Analyses were conducted to determine agreement in cataract prevalence estimates between the two grading Systems and approaches. RESULTS: Poor agreement was found between severity levels of the two grading scales for all three cataract types. Using currently accepted cut-offs to define nuclear (≥ 4 on both LOCS III and Wisconsin System), cortical (≥ 2 in LOCS III, ≥ 25% in Wisconsin) and PSC (≥ 2 in LOCS III, ≥ 5 % in Wisconsin) cataract, the LOCS III overestimated the prevalence of significant cataract as compared to the Wisconsin System, with nuclear cataract prevalence, 27.5% (LOCS III) versus 17.0% (Wisconsin System), cortical cataract prevalence, 27.9% versus 7.0% and posterior sub-capsular cataract prevalence, 7.8% versus 5.1%. CONCLUSION: The prevalence of cataract in a population varies substantially by measurement methods, with systematically different estimates found using the two most frequent cataract grading systems. This study re-emphasizes the need for global standards to assess and define cataract for epidemiologic and clinical studies.

Retinal ganglion cell layer volumetric assessment by spectral-domain optical coherence tomography in multiple sclerosis: application of a high-precision manual estimation technique.

BACKGROUND: Neuronal loss in the retina has been demonstrated pathologically in eyes of patients with multiple sclerosis (MS). In vivo, MS eyes have reduced total macular volumes by optical coherence tomography (OCT). Using a high-resolution spectral-domain OCT, this pilot study used a manual method to measure ganglion cell layer (GCL) volumes and to determine the relation of these volumes to visual function in MS eyes. METHODS: Sixteen eyes of 8 patients with MS and 8 eyes of 5 disease-free control participants were studied using fast macular OCT scans performed with Spectralis OCT (Heidelberg Engineering). Visual function tests of low-contrast letter acuity and high-contrast visual acuity were administered. RESULTS: MS patient eyes had significantly lower GCL volumes than the control eyes (P < 0.001 vs controls, generalized estimating equation regression models accounting for age and within-patient intereye correlations). Within the MS group, eyes with a history of optic neuritis (ON, n = 4) had significantly lower GCL volumes than MS eyes with no ON history (P < 0.001). In contrast to measures of high-contrast visual acuity (P = 0.14), decreased GCL volumes were associated with worse performance on low-contrast letter acuity testing (P = 0.003). CONCLUSIONS: This pilot study has characterized thinning of the GCL in MS patient eyes, particularly in those with a history of acute ON, which corresponded to a reduced performance on low-contrast letter acuity testing. Studies utilizing computerized segmentation algorithms will continue to facilitate the detection of GCL loss on a larger scale and provide important information in vivo on the role and timing of neuronal vs axonal loss in MS eyes.

Evidence-based approach to glaucoma management.

Evidence-based medicine is an evolving new paradigm. With the advent of numerous new diagnostic techniques and therapeutic interventions, one needs to critically evaluate and validate them by appropriate methods before adopting them into day-to-day patient care. The concepts involved in the evaluation of diagnostic tests and therapy are discussed. For delivering the highest level of clinical care, evidence alone is not sufficient. Integrating individual clinical experience and patients' perspectives with the best available external evidence is essential.

Glaucoma classification model based on GDx VCC measured parameters by decision tree.

This study is to propose and evaluate the diagnostic accuracy of decision tree classifiers using the full set of standard GDx VCC measurements for classifying glaucoma in a Taiwan Chinese population. The classifiers were trained and tested using standard GDx VCC parameters from examinations of 74 subjects with glaucoma and 72 normal subjects. Six promising decision rules were generated from decision tree methods and the overall accuracy from tenfold cross validation was 0.801. Classification tree based on GDx VCC data promises to be a diagnostic tool in glaucoma disease. However, its exact clinical application in glaucoma practice should be retested. Further longitudinal study should address this issue.

The influence of the new general ophthalmic services (GOS) contract in optometrist referrals for glaucoma in Scotland.

PURPOSE: To assess the quality of referrals from community optometrists in the northeast of Scotland to the hospital glaucoma service before and after the implementation of the new General Ophthalmic Services (GOS) contract in Scotland. METHODS: Retrospective study encompassing two 6-month periods, one before the implementation of the new GOS (Scotland) contract in April 2006 (from June to November 2005), and the other after (from June to November 2006). The community optometrist referral forms and hospital glaucoma service notes were reviewed. Comparisons were performed using the t-test and chi (2)-test. RESULTS: In all, 183 referrals were made during the first 6-month period from June to November 2005, and 120 referrals were made during the second 6-month period from June to November 2006. After the introduction of the new GOS contract, there was a statistically significant increase in true-positive referrals (from 18.0 to 31.7%; P=0.006), decrease in false-positive referrals (from 36.6 to 31.7%; P=0.006), and increase in the number of referrals with information on applanation tonometry (from 11.8 to 50.0%; P=0.000), dilated fundal examination (from 2.2 to 24.2%; P=0.000), and repeat visual fields (from 14.8 to 28.3%; P=0.004) when compared to the first 6-month period. However, only 41.7% of referrals fulfilled the new GOS contract requirements, with information on applanation tonometry the most commonly missing. CONCLUSIONS: After the implementation of the new GOS (Scotland) contract in April 2006, there has been an improvement in the quality of the glaucoma referrals from the community optometrists in the northeast of Scotland, with a corresponding reduction in false-positive referrals. Despite the relatively positive effect so far, there is still scope for further improvement.

Incorporation of a virtual assessment into a care pathway for initial glaucoma management: feasibility study.

PURPOSE: To investigate the feasibility of a glaucoma triage assessment based on the consideration of clinical data in a virtual clinic environment. METHODS: One hundred consecutive new patients were assessed by masked observers for a possible diagnosis of glaucoma or ocular hypertension by evaluation of clinical data compiled by a technician in the absence of the patient. The virtual clinic diagnoses were compared with those made by actual examination of the patient in the outpatient clinic. RESULTS: A total of 22% of subjects were excluded from interobserver comparison because of atypical scanning laser ophthalmoscopy. Of the 78% of subjects completing virtual and actual clinical assessments diagnostic agreement was good, weighted Kappa was of 0.72 (95% confidence interval 0.85 to 0.59), sensitivity 94.4% and specificity 86.7%. No case of glaucoma was misdiagnosed as normal by virtual assessment. CONCLUSION: Clinical findings and data relating to glaucoma may be evaluated in a virtual clinic with satisfactory diagnostic accuracy.

Population-based assessments of ophthalmologic and audiologic follow-up in children with very low birth weight enrolled in Medicaid: a quality-of-care study.

OBJECTIVE: The purpose of our work was to determine whether children with very low birth weight (< 1500 g) who are at high risk for vision and hearing problems and enrolled in Medicaid receive recommended follow-up vision and hearing services and to examine predictors of services. PATIENTS AND METHODS: We conducted a retrospective analysis of 2182 children born in South Carolina from 1996 to 1998 with birth weights of 401 to 1499 g, gestations of > or = 24 weeks, and survival of > or = 90 days of life. Receipt of services for Medicaid-enrolled children was assessed by using a linked data set that included files from vital records, death certificates, Medicaid, Chronic Rehabilitative Services, and the Early Intervention Program. We assessed the receipt of hearing rehabilitation by 6 months of age for children with nonconductive hearing loss and routine ophthalmologic examination between ages of 1 and 2 years for all children with very low birth weight. Multivariate logistic regression was restricted to ophthalmologic examinations because of sample size. RESULTS: Among children with very low birth weight with nonconductive hearing loss, 20% received hearing rehabilitation by 6 months of age. Twenty-three percent of children with very low birth weight received an ophthalmologic examination between the ages of 1 and 2 years. Limiting our analysis to children < 1000 g or extending the measurement period to 7 months (hearing) and age 3 years (vision) did not substantially increase the percentage of children receiving the services. The receipt of an ophthalmologic examination was associated positively with Medicaid enrollment by the time of hospital discharge and birth in a level-3 hospital and negatively associated with higher birth weight, an Apgar score of > or = 7, and black maternal race. Among children born at < 1000 g, all of whom were eligible for the Early Intervention Program, the receipt of an ophthalmologic examination was positively associated with program enrollment. CONCLUSIONS: There is a shortfall in the provision of critical services for children with very low birth weight. These findings reinforce the Institute of Medicine's concerns regarding inadequate outcome data and health care services for preterm infants and support the importance of enrollment in the Early Intervention Program for children with very low birth weight.

Preperimetric glaucoma assessment with scanning laser polarimetry (GDx VCC): analysis of retinal nerve fiber layer by sectors.

PURPOSE: To evaluate the capability of the GDx VCC nerve fiber analyzer to detect preperimetric glaucoma across 12 retinal nerve fiber layer (RNFL) peripapillary sectors. METHODS: Data were obtained in a cross-sectional, hospital clinic-based study; 699 eyes from 699 glaucoma suspects were enrolled in this protocol. All subjects underwent ophthalmologic examination, static automated perimetry [Humphrey 24-2 Swedish interactive threshold algorithm (SITA) Standard], optic nerve stereoscopic photographs, red-free digital RNFL photographs and GDx VCC examination. Group S included 283 normal eyes and 39 preperimetric glaucoma eyes with RNFL superior or diffuse defects in the fiber layer photographs. Group I included 324 normal subjects and 24 with preperimetric glaucoma eyes with RNFL inferior or diffuse defects in fiber layer photographs. RESULTS: Mean values of the area under the curve (AUC) for receiver operating characteristic analysis for inferior average (Inf Avg), temporal-superior-nasal-inferior temporal average (TSNIT Avg), superior average (Sup Avg), and the nerve fiber indicator were significantly less in the eyes with RNFL defects than the control group compared with the AUC for thickness at hour 12 and at hour 6 calculated from the RNFL sector density. The AUC for receiver operating characteristic analysis of the new parameters improved by 12% with respect to the best GDx VCC standard values. CONCLUSIONS: Our results confirm that the 12 sector divisions of the GDx VCC have better diagnostic reliability in preperimetric glaucoma, and are able to improve the discrimination capability between normal and early damaged RNFLs.