Retinopathy in juvenile-onset type I diabetes of short duration.

We evaluated the prevalence and severity of diabetic retinopathy in 173 juvenile-onset, type I diabetic subjects and 78 nondiabetic controls of similar age, race, and sex distribution by stereoscopic fundus photography and fluorescein angiography, performed by a standardized protocol and evaluated by five expert, masked observers. The overall prevalence of retinopathy was 18% in the diabetic group and 0% in the controls. Retinopathy prevalence increased with duration of diabetes in the diabetic group, with a prevalence of 1% from 0--4 yr after diagnosis, 25% after 5--9 yr, and 67% 10--16 yr after onset of the systemic disease. There was an independent association with age, with little retinopathy before age 15 and a 48% prevalence in older persons. Retinopathy was also found to be independently associated with the following: diabetic "control," evaluated semiquantitatively but on a masked basis; lens opacities; and frequency of daily insulin injections. Among the 166 diabetic subjects who had both angiography and photography, a retinopathy prevalence of 17% was detected by angiography and 11% by photography. This difference was statistically significant (P = 0.01). This study provides baseline data for use in estimating sample size in controlled trials of therapeutic measures to prevent retinopathy in juvenile diabetic populations. The study also supports the hypothesis that long-term hyperglycemia as well as changes (possibly hormonal in nature) associated with puberty are causally related to diabetic retinopathy.

Gelatin implants in scleral buckling procedures.

In 375 scleral buckling procedures, an absorbable gelatin implant (Retina Gelfilm) was used. This series included 192 trapdoor and scleral pouch procedures, and 183 operations in which a gelatin implant was used beneath a silicone rubber implant. Two thicknesses of gelatin implants were used, 0.5 mm and 0.75 mm. Absorption time varied from 2 to 24 months, depending on the thickness of the implant and whether it was used alone or beneath a silicone rubber implant. Gelatin is an excellent absorbable implant when used alone or under a silicone rubber implant in selected patients with retinal detachment to produce a temporary elevation or posterior extension of the buckle, or both.

Effect of perifoveal tissue dissection in the management of acute idiopathic full-thickness macular holes.

OBJECTIVE: To evaluate the efficacy of perifoveal tissue dissection (PTD) on patients undergoing pars plana vitrectomy for idiopathic macular holes of less than 1-year's duration. METHODS: Pars plana core vitrectomy was performed on 107 eyes of 104 consecutive patients with acute idiopathic macular holes. One cohort had routine PTD. In the other cohort, no attempt was made to strip preretinal tissue. Follow-up was longer than 6 months (follow-up range, 6 to 36 months). RESULTS: Overall, 95 (89%) of all macular holes were closed. Visual acuity improved 2 lines or more of the Snellen letter chart in 91 eyes (85%). A postoperative visual acuity of 20/50 or better was achieved in 79 eyes (74%). A transient increase in intraocular pressure (230 mm Hg) developed in 25 eyes (23.4%). In 6 eyes (5.6%) a retinal detachment developed. One eye had retinal pigment epithelial changes and 1 patient reported peripheral field loss. No statistically significant differences were noted between eyes having PTD and those without PTD for any outcome measure. CONCLUSION: In this series, no beneficial or adverse effect could be demonstrated by performing PTD in eyes undergoing pars plana core vitrectomy for acute idiopathic macular holes.

Occult choroidal neovascularization in age-related macular degeneration. A natural history study.

OBJECTIVE: To explore morphological and vision changes in untreated eyes with subfoveal choroidal neovascularization (CNV) that have poorly demarcated boundaries. DESIGN: Analysis of photographs of untreated patients with poorly demarcated occult CNV participating in a prospective clinical trial evaluating laser treatment compared with observation. SETTING: Two tertiary retinal referral centers. PATIENTS: Symptomatic individuals with poorly demarcated subfoveal occult CNV associated with age-related macular degeneration. MAIN OUTCOME MEASURES: Change in size of lesion, development of classic CNV, change in vision, and development of subretinal fibrosis. RESULTS: During follow-up (9-12 months), 32% of the occult choroidal neovascular lesions more than doubled their original size. Classic CNV developed in 52% of eyes that started without it. The median loss in visual acuity was 2.5 lines. Eyes with classic CNV or subretinal blood or both at baseline developed subretinal fibrosis more frequently and lost more visual acuity, but not to a statistically significant degree. CONCLUSIONS: The morphological changes of eyes with subfoveal occult CNV in which the boundaries are poorly demarcated in variable; the presence of subretinal blood or a component of classic CNV may influence the prognosis for further loss of vision.

Vitrectomy for chronic pseudophakic cystoid macular edema.

PURPOSE: We report the results of pars plana vitrectomy for chronic pseudophakic cystoid macular edema unresponsive to medical treatment. METHODS: Retrospective analysis of 23 consecutive eyes of 23 patients with chronic pseudophakic cystoid macular edema was performed. Eyes with vitreous incarceration into the cataract wound or vitreous-cornea contact were excluded from the study. Preoperatively, all eyes had cystoid macular edema confirmed on fluorescein angiography and were unresponsive to medical treatment. Pars plana vitrectomy was performed using standard techniques and vitreous adhesions to the iris, intraocular lens, or both were lysed if present. RESULTS: The mean interval between cataract surgery and vitrectomy was 32.3+/-30.9 months (median, 20 months; range, 3 to 110 months). The vitreous was adherent to the iris or intraocular lens in 12 eyes (52.2%) and was present in the anterior chamber with no evidence of adhesions in seven eyes (30.4%). In four eyes (17.4%) the vitreous was posterior to the iris plane with no adhesions to anterior segment structures. The median preoperative best-corrected visual acuity was 20/200, and the median final postoperative best-corrected visual acuity was 20/60 (P<.0001) after a mean follow-up of 30.2+/-31.2 months (median, 14 months; range, 2 to 109 months). Final best-corrected visual acuity improved by a mean of 3.3+/-2.6 Snellen lines, with a median percent change of 70% (mean, 57.3%; range, 0% to 99%). In all 23 eyes the cystoid macular edema resolved postoperatively by biomicroscopic examination in a mean period of 3.3 months (median, 2 months; range, 1 to 12 months). CONCLUSIONS: In pseudophakic eyes with chronic cystoid macular edema unresponsive to medical treatment, vitrectomy resulted in resolution of the cystoid macular edema with improved visual acuity in some cases. Clinical improvement may occur in eyes with no apparent vitreous disturbance.

Vitrectomy for diffuse diabetic macular edema associated with a taut premacular posterior hyaloid.

PURPOSE: To evaluate the role of vitrectomy in eyes with diffuse diabetic macular edema associated with a taut posterior hyaloid. METHODS: Records of 55 eyes of 50 patients with diabetic retinopathy and diffuse clinically significant diabetic macular edema who underwent vitrectomy with stripping of the premacular posterior hyaloid were reviewed. In all 55 eyes, diffuse diabetic macular edema was present on contact lens examination and confirmed with fluorescein angiography. On fundus examination, the premacular posterior hyaloid was attached and appeared taut. RESULTS: The mean preoperative best-corrected visual acuity was 20/160, and the mean final best-corrected visual acuity was 20/80 (P <.0001, Wilcoxon signed rank test), with 27 (49.1%) of the 55 eyes demonstrating improvement in best-corrected visual acuity of 2 or more lines. Fifty-two (94.5%) of the 55 vitrectomized eyes showed improvement in clinically significant macular edema and in 45 eyes (81.8%) the macular edema resolved completely during a mean period of 4.5 months (range, 1 to 13 months). Eyes with macular ischemia and preoperative best-corrected visual acuity of 20/200 or less tended to respond less favorably to vitrectomy than eyes lacking these characteristics. All eyes had at least 6 months of follow-up after surgery, with a mean follow-up of 23.2 months. CONCLUSION: In eyes with persistent diffuse diabetic macular edema with a taut premacular posterior hyaloid face unresponsive to laser therapy, vitrectomy with removal of the posterior hyaloid appears to be beneficial in some cases. Careful selection of eyes with favorable preoperative clinical characteristics may improve surgical outcomes.

Laser treatments with verteporfin therapy and its potential impact on retinal practices.

BACKGROUND: In the 1990s, the only available treatment for neovascular age-related macular degeneration (ARMD) was laser photocoagulation, but a minority of patients could be treated. Photodynamic therapy with verteporfin potentially allows many more patients to be treated. The authors' aim was to assess the impact of this increase on retinal practices. METHODS: The number of patients who received laser photocoagulation in 1998 was determined. Based on that number and a retrospective review of 1000 consecutive records of new patients with ARMD referred to the Associated Retinal Consultants practices during 1998, estimates were made of how many patients would have been eligible for verteporfin therapy. RESULTS: Of the 1000 patients, 171 had predominantly classic subfoveal choroidal neovascularization secondary to ARMD and would have been eligible for verteporfin therapy, compared with 99 treated with laser photocoagulation according to Macular Photocoagulation Study guidelines. If this patient population is representative of the general population, approximately 84,000 patients would be eligible for verteporfin therapy in the United States per year, compared with 42,000 for laser photocoagulation. This would lead to 286,000 verteporfin treatments per year if retreatments are required. CONCLUSIONS: This increase in treatments for neovascular ARMD will have a considerable impact on retinal practices. Although the resources that will need to be expended are high, the potential benefit of verteporfin therapy in reducing vision loss will outweigh the costs.

Preoperative fluorescein angiographic features of surgically removed idiopathic epiretinal membranes.

PURPOSE: To determine whether preoperative fluorescein angiograms can be used to predict visual prognosis in eyes undergoing surgical removal of idiopathic epiretinal membranes. METHODS: A retrospective study of preoperative fluorescein angiographic findings in cases of idiopathic epimacular membrane removal during vitreous surgery was conducted. Of 422 consecutive cases, 229 met the criteria for minimum follow-up period of 6 months. Angiograms from these 229 cases were analyzed in a standardized, masked fashion for macular edema, retinal vascular distortion, and contraction of the foveal avascular zone. RESULTS: Visual improvement was greatest in 7 eyes (3%) with the most severe degree of macular edema (P = 0.0215). No difference in visual outcome was noted between eyes with less severe macular edema or no macular edema. Change in visual acuity was not associated with the extent of retinal vascular distortion (P = 0.477) or contraction of the foveal avascular zone (P = 0.248). CONCLUSION: The presence of macular edema on preoperative fluorescein angiography is not predictive of a poor visual outcome in eyes undergoing surgery for idiopathic epiretinal membranes. In general, preoperative fluorescein angiography is not useful in predicting visual prognosis in these cases.

Surgical management of vitreomacular traction syndromes.

A series of 106 consecutive symptomatic eyes considered to be at high risk for idiopathic macular holes developing underwent pars plana vitrectomy with membrane peeling. One of three types of vitreomacular traction was noted intraoperatively in all the eyes. The elimination of the vitreomacular traction resulted in improved vision in 89% of the eyes, no change in 7%, and decreased vision in 4%. A total of 62% of the patients were women (median age, 67 years). Follow-up ranged from 6 months to 118 months (average, 35 months). Complications included accelerated nuclear sclerosis in 16% and a 2% incidence of retinal detachment, macular pucker, and macular holes.

Removal of epimacular membranes.

Vitreous surgery was used to remove epiretinal macular membranes in 328 cases, 184 (56%) of which had membranes that were considered idiopathic and 144 (44%) which were due to other causes. The 12- to 92-month follow-up showed that visual acuity improved two lines or more in 243 (74%) of the eyes, 79 (24%) were unchanged and 6 (2%) became worse. Recurrence of membranes was seen in 24 (7.3%) eyes and 27 (8%) eyes developed complications. In the idiopathic cases visual results were significantly better and complications fewer. Rapidly progressive nuclear sclerosis was noted in 23 (12.5%) eyes. The degree of cystoid edema had no relationship to the final visual result. Pseudoholes which were present in 14 (8%) of the idiopathic cases either became smaller or disappeared following successful surgery with an average increase in acuity of five lines.

Plasmin enzyme-assisted vitrectomy in traumatic pediatric macular holes.

OBJECTIVE: This study aimed to evaluate the benefit of plasmin enzyme-assisted macular hole surgery on a consecutive series of pediatric patients with traumatic macular holes. DESIGN: Prospective noncomparative case series operated on at William Beaumont Hospital between July 13, 1996, and November 16, 1996, and observed for at least 6 months. PARTICIPANTS: During this interval, the authors operated on four eyes from four consecutive patients who were 14 years of age or younger with traumatic macular holes. INTERVENTION: The patients underwent plasmin enzyme-assisted pars plana vitrectomy with membrane peeling, fluid-gas exchange, and postoperative positioning. The enzyme used was 0.4 international unit (IU) of autologous plasmin enzyme. MAIN OUTCOME MEASURES: Snellen lines of improvement in visual acuity and rate of final visual acuity of 20/40 or greater, and incidence of complications and reoperations were measured. RESULTS: All four macular holes were closed successfully. Follow-up was from 6 to 12 months. There were no reoperations. Visual acuity improved from four to eight lines in all eyes. Three eyes (75%) achieved a postoperative visual acuity of 20/40 or better. Three eyes (75%) had transient, posterior, subcapsular cataracts develop: two of the eyes after surgery and one as a result of the initial injury. CONCLUSION: The treatment of pediatric traumatic macular holes with plasmin enzyme-assisted vitrectomy, membrane peeling, and gas-fluid exchange resulted in closure of the macular holes with significant visual improvement.

Surgical repair of full-thickness idiopathic macular holes associated with significant macular drusen.

OBJECTIVE: To evaluate the visual and anatomic results of surgically repaired macular holes in eyes with intermediate or large-sized macular drusen. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Thirty-four eyes of 32 patients undergoing macular hole surgery with preoperative intermediate or large-sized macular drusen as defined by the Age-Related Eye Disease Study (AREDS). INTERVENTION: Pars plana vitrectomy for standard macular hole repair performed by multiple surgeons. MAIN OUTCOME MEASURES: Visual acuity, anatomic hole closure. RESULTS: Initial hole closure failed in 8 eyes (24%) overall, 5 of 28 eyes (18%) with AREDS category 2 drusen and 3 of 6 eyes (50%) with category 3 drusen (P = 0.1263). Final macular hole closure was seen in 93% of category 2 and 67% of category 3 eyes (P = 0.1347). Mean final visual acuity was 20/60 overall, 20/60 for category 2, and 20/50 for category 3 eyes. CONCLUSIONS: A trend of reduced initial macular hole closure was seen in eyes with significant macular drusen. Reoperation improved closure rates. If closure was accomplished, visual outcomes were excellent.

Successful closure of traumatic macular holes.

PURPOSE: To establish the efficacy of vitreoretinal surgery without the use of transforming growth factor-beta or autologous platelet concentrate in the repair of traumatic macular holes. METHODS: This retrospective review consisted of 16 eyes from 16 consecutive patients treated by five vitreoretinal surgeons at a single institution between 1993 and 1997. Intervention included pars plana vitrectomy with creation of posterior vitreous detachment, placement of 14% to 16% C3F8 gas, and postoperative face-down positioning. Ten eyes received intraoperative autologous plasmin to facilitate formation of posterior vitreous detachment. Main outcome measures were anatomic closure rate and visual outcome. RESULTS: Anatomic closure of the macular holes was achieved in 15 (94%) of 16 eyes, with an average follow-up of 7 months. Six (38%) eyes achieved visual acuity of 20/40 or better. Visual acuity improved by 2 or more lines in 11 (69%) of 16 eyes. The average preoperative logMAR-converted visual acuity of 20/175 improved to 20/60 postoperatively. CONCLUSION: Traumatic macular holes can be closed successfully with substantial visual recovery without the use of transforming growth factor-beta or platelet concentrate.

Comparison of recombinant transforming growth factor-beta-2 and placebo as an adjunctive agent for macular hole surgery.

OBJECTIVE: This study aimed to compare the visual and anatomic results of macular hole surgery in eyes treated with recombinant transforming growth factor-beta-2 (TGF-beta2) or placebo. DESIGN: The design was a prospective, multicenter, randomized, double-masked, placebo-controlled clinical study. PARTICIPANTS: One hundred thirty eyes with idiopathic macular holes of 1 year or less and a refracted Early Treatment Diabetic Retinopathy Study visual acuity of 20/80 or worse were treated with 1.1 microg recombinant TGF-beta2 or placebo to the macular hole after fluid-gas exchange. INTERVENTION: The effect of recombinant TGF-beta2 as an adjunctive agent for macular hole surgery was evaluated. MAIN OUTCOME MEASURES: Closure of the macular hole and change in visual acuity at 3 months were measured. RESULTS: The 3-month visits were completed for 120 eyes. The macular hole was closed at 3 months in 35 (61.4%) of 57 eyes treated with placebo and 49 (77.8%) of 63 eyes treated with recombinant TGF-beta2 (P = 0.08). The mean visual acuity gain was +6.4 letters in eyes receiving placebo and +8.9 letters in eyes treated with recombinant TGF-beta2 (P = 0.27). Visual acuity improved 2 or more lines in 23 (40.4%) of 57 eyes treated with placebo and 30 (47.6%) of 63 eyes treated with recombinant TGF-beta2 (P = 0.42). Intraocular pressure elevation greater than 30 mmHg was more common 2 weeks after surgery in eyes treated with recombinant TGF-beta2 (P < 0.001). CONCLUSIONS: Recombinant TGF-beta2 resulted in a similar proportion of successful closure of macular holes as placebo. There was no statistically significant visual acuity benefit with the use of recombinant TGF-beta2 for the treatment of macular holes.

Incidence of retinal detachment and visual outcome in eyes presenting with posterior vitreous separation and dense fundus-obscuring vitreous hemorrhage.

PURPOSE: To determine visual outcomes and the incidence of retinal detachment in eyes presenting with posterior vitreous separation and dense fundus-obscuring vitreous hemorrhage. DESIGN: Retrospective consecutive noncomparative interventional case series. PARTICIPANTS: Thirty-six eyes (15 right eyes and 21 left eyes) of 34 patients (18 female and 16 male) ranging in age from 42 to 94 years. Mean follow-up was 14 months. METHODS: A comparison of the best-corrected initial visual acuities versus final visual acuities after spontaneous resolution of vitreous hemorrhage or surgical intervention. The number of eyes that were found to have retinal tears or that had a rhegmatogenous retinal detachment develop was documented. Logarithm of the minimum angle of resolution-converted visual acuities was used for comparison. Categorical data were analyzed by Fisher's exact test, and population means were compared by Student's t test. MAIN OUTCOME MEASURES: Final mean visual acuities, number of eyes with at least one retinal tear, location of retinal tears, number of eyes that had retinal detachment develop, and the number of eyes repaired with scleral buckling surgery and/or pars plana vitrectomy. RESULTS: Twenty-four of 36 eyes (67%) were found to have at least one retinal break (range, 0-4 breaks), with 88% of breaks located in the superior retina. Eleven eyes (31%) had more than one retinal break. Fourteen of 36 eyes (39%) had a rhegmatogenous retinal detachment develop that was repaired with pars plana vitrectomy and scleral buckling. An additional 14 eyes (39%) underwent vitrectomy for nonclearing vitreous hemorrhage. The incidence of retinal detachment in eyes with a history of retinal detachment in the contralateral eye was 75% (P = 0.04). Seven of 14 eyes (50%) with retinal detachment had coexisting proliferative vitreoretinopathy. Most retinal breaks and detachments occurred in emmetropic or myopic eyes. For all 36 eyes the mean preoperative visual acuity was 20/1233, and the mean final visual acuity was 20/62 (P < 0.0001). Eyes that had a macula-off retinal detachment develop had worse final visual outcomes (20/264; P = 0.01), as did eyes that had proliferative vitreoretinopathy develop (20/129; P = 0.04). CONCLUSIONS: Acute, spontaneous, nontraumatic posterior vitreous separation with dense fundus-obscuring vitreous hemorrhage is associated with a high incidence of retinal tears and detachment. Close follow-up with clinical examination and ultrasonography is necessary, because many of these eyes may eventually require surgical intervention. Aggressive management with early vitrectomy should be considered when there is a history of retinal detachment in the contralateral eye.

Clinical course and surgical treatment of macular epiretinal membranes in young subjects.

OBJECTIVE: To examine the surgical and nonsurgical visual outcomes of young subjects with idiopathic macular epiretinal membranes (ERMs). DESIGN: Retrospective observational and noncomparative interventional case series. PARTICIPANTS: Nineteen consecutive subjects (20 eyes) aged 40 years or less with an idiopathic macular ERM. METHODS: Group 1: 10 consecutive eyes were initially seen with visual acuity of 20/50 or better; 7 eyes were observed, and 3 eyes with progressive visual loss to <20/50 underwent vitrectomy and membrane peeling. Group 2: 10 consecutive eyes with presenting visual acuity of 20/60 or worse underwent vitrectomy and membrane peeling. MAIN OUTCOME MEASURES: Visual acuity, cataract formation, ERM recurrence, operative complications. RESULTS: Group 1: With no surgery, visual acuity remained stable or improved in 5 of 10 eyes (50%), with a mean follow-up of 3.7 years. Three of 10 eyes (30%) had visual loss < or =20/60 develop and underwent vitrectomy. Postoperative visual acuity improved an average of 6 lines with a mean follow-up of 17.6 months. Group 2: After vitrectomy, visual acuity improved 2 or more lines in 7 of 10 eyes (70%), with a mean improvement of 4.4 lines and mean follow-up of 29.2 months. Groups 1 and 2: Three of 13 eyes (23%) that underwent vitrectomy had recurrent ERM formation. CONCLUSIONS: Young subjects with idiopathic macular ERMs and a presenting visual acuity of 20/50 or better had a favorable visual outcome with observation. Subjects with an initial vision of 20/60 or worse, or those who had a visual decrease to < or =20/60 had significantly improved visual acuity after vitrectomy. ERM recurrence is relatively high after surgery.

A comparison of visual results and complications in eyes with posterior chamber intraocular lens dislocation treated with pars plana vitrectomy and lens repositioning or lens exchange.

PURPOSE: To compare the visual results and the postoperative complications in eyes with posterior chamber intraocular lens (PCIOL) dislocation that underwent pars plana vitrectomy with lens repositioning with eyes that underwent pars plana vitrectomy with lens exchange. DESIGN: Nonrandomized consecutive comparative case series. PARTICIPANTS: Fifty-nine eyes (27 right eyes and 32 left eyes) of 56 subjects (28 women and 28 men) ranging in age from 59 to 90 years. Mean follow-up was 34 months. METHODS: A comparison of the best-corrected preoperative visual acuities, final visual acuities, and postoperative complications in subjects with dislocated PCIOLs that underwent pars plana vitrectomy. Logarithm of the minimum angle of resolution (LogMAR)-converted visual acuities were used for comparison. Categorical data were analyzed by Fisher's exact test, and population means were compared by a pooled Student's t test. MAIN OUTCOME MEASURES: Final mean visual acuities, change in mean visual acuities, and postoperative complications. RESULTS: For all 59 eyes the mean preoperative visual acuity was 20/152, and the mean final visual acuity was 20/48. Final visual results were similar between the eyes that underwent lens repositioning (20/55) and the eyes that underwent lens exchange (20/43; P = 0.19). Final visual results were also similar between the eyes that underwent lens exchange with sutured PCIOL placement (20/51) and the eyes that underwent lens exchange with anterior chamber intraocular lens (ACIOL) placement (20/38; P = 0.26). Final mean visual acuity in eyes that received an ACIOL (20/38) was better than in eyes that underwent repositioning of the dislocated lens into the ciliary sulcus (20/65; P = 0.01). The mean increase in visual acuities was greater for eyes with ACIOL placement compared with eyes with sutured PCIOL placement (P = 0.01). For all eyes, final visual results were unaffected by a concurrent diagnosis of age-related macular degeneration (20/52; P: = 0.71), glaucoma (20/48; P = 0.95), or postoperative cystoid macular edema (20/55; P = 0.45). Final visual acuities were significantly worse in eyes with a detectable preoperative afferent pupillary defect (20/200; P<0.0001). Postoperative retinal detachments developed in 4 of 29 eyes (14%) that underwent lens repositioning and in 2 of 30 eyes (7%) that had lens exchange (P = 0.42). Postoperative lens subluxations occurred in 6 of 29 eyes (21%) that underwent lens repositioning and in 1 of 30 eyes (3%) that underwent lens exchange (P = 0.05). CONCLUSIONS: The final visual results in eyes with dislocated PCIOLs that underwent pars plana vitrectomy with lens repositioning were similar to the visual results obtained in eyes that underwent pars plana vitrectomy with lens exchange. For eyes that underwent lens exchange, final visual results in eyes that received an ACIOL were similar to the visual results obtained in eyes that received a PCIOL; however, eyes with an ACIOL showed a greater increase in mean visual acuity. Eyes with a preoperative afferent pupillary defect had worse final visual results.

Retinopathy in juvenile-onset diabetes of short duration.

To study objectively the epidemiology of retinopathy in juvenile-onset diabetes, we performed fundus photography and fluorescein angiography, using the Diabetic Retinopathy Study protocol, on 122 juvenile diabetics and 65 demographically similar non-diabetic subjects as the control group. Photographs and angiograms were masked as to subjects' identities and evaluated independently by five retinal subspecialists. There was no retinopathy in control subjects. In diabetics, prevalence of retinopathy increased with the duration of disease, being 0% after zero to four years, 27% for five to nine years, and 71% for more than ten years. Retinopathy also increased in prevalence with age with a sharp rise after age 15. There is indication that age and duration act independently. Details of our method for establishing the diagnosis of diabetic retinopathy are presented, together with the degree of observer variability in identifying early lesions.