Altered Blood Flow in the Ophthalmic and Internal Carotid Arteries in Patients with Age-Related Macular Degeneration Measured Using Noncontrast MR Angiography at 7T.

BACKGROUND AND PURPOSE: Age-related macular degeneration is associated with reduced perfusion of the eye; however, the role of altered blood flow in the upstream ophthalmic or internal carotid arteries is unclear. We used ultra-high-field MR imaging to investigate whether the diameter of and blood flow in the ophthalmic artery and/or the ICA are altered in age-related macular degeneration and whether any blood flow changes are associated with disease progression. MATERIALS AND METHODS: Twenty-four patients with age-related macular degeneration and 13 similarly-aged healthy controls participated. TOF and high-resolution dynamic 2D phase-contrast MRA (0.26 × 0.26 × 2mm3, 100-ms effective sampling rate) was acquired at 7T. Vessel diameters were calculated from cross-sectional areas in phase-contrast acquisitions. Blood flow time-series were measured across the cardiac cycle. RESULTS: The ophthalmic artery vessel diameter was found to be significantly smaller in patients with age-related macular degeneration than in controls. Volumetric flow through the ophthalmic artery was significantly lower in patients with late age-related macular degeneration, with a significant trend of decreasing volumetric ophthalmic artery flow rates with increasing disease severity. The resistance index was significantly greater in patients with age-related macular degeneration than in controls in the ophthalmic artery. Flow velocity through the ophthalmic artery and ICA was significantly higher in patients with age-related macular degeneration. Ophthalmic artery blood flow as a percentage of ipsilateral ICA blood flow was nearly double in controls than in patients with age-related macular degeneration. CONCLUSIONS: These findings support the hypothesis that vascular changes upstream to the eye are associated with the severity of age-related macular degeneration. Additional investigation into the potential causality of this relationship and whether treatments that improve ocular circulation slow disease progression is warranted.

Steady-state PERG adaptation: a conspicuous component of response variability with clinical significance.

PURPOSE: To investigate within-test variability of the steady-state PERG (SS-PERG). METHODS: SS-PERGs were recorded in response to black-white horizontal gratings (1.6 cycles/deg, 98% contrast, 15.63 reversals/s, LED display, 25 deg square field, 800 cd/sqm mean luminance) using skin electrodes. PERG and noise (± reference) signals were averaged over 1024 epochs (~ 2.2 min) and Fourier analyzed to retrieve SS-PERG amplitude and phase. SS-PERGs were split into 16 partial averages (samples) of 64 epochs each, and corresponding amplitudes and phases combined in polar coordinates to assess their dispersion (within-test variability). To assess time-dependent variability, samples were clustered in four successive time segments of ~ 33 s each. Amplitude adaptation was defined as amplitude difference between initial and final clusters, and PERG phase adaptation as the corresponding phase difference. To determine the dynamic range of SS-PERG adaptation, recording was performed in normal controls of different age (n = 32) and patients with different severity of optic nerve dysfunction (early manifest glaucoma, EMG, n = 7; non-arteritic ischemic optic neuropathy, NAION, n = 5). RESULTS: Amplitude adaptation was largest in younger controls (amplitude adaptation ÷ noise, SNR = 9.5, 95% CI 13.1, 5.9) and progressively decreased with increasing age (older subjects, SNR = 5.5, 95% CI 9.2, 1.8) and presence of disease (EMG: SNR = 2.4, 95% CI 3.5, 1.4; NAION: SNR = 1.9, 95% CI 6.5,-2.2). In 11 young subjects, amplitude adaptation was repeatable (test-retest in two sessions a week apart; intraclass correlation coefficient = 0.59). Phase adaptation was not significantly different from zero in all groups. CONCLUSIONS: SS-PERG adaptation accounts for a sizeable portion of the within-test variability. As it has robust SNR, sufficient test-retest variability, and is altered in disease, it may have physiological and clinical significance. This study suggests that SS-PERG protocols should include adaptation in addition to SS-PERG amplitude and phase/latency.

A comparison of cup-to-disc ratio estimates by fundus biomicroscopy and stereoscopic optic disc photography in the Tema Eye Survey.

PurposeTo determine if there are systematic differences in cup-to-disc ratio (CDR) grading using fundus biomicroscopy compared to stereoscopic disc photograph reading.MethodsThe vertical cup-to-disc ratio (VCDR) and horizontal cup-to-disc ratio (HCDR) of 2200 eyes (testing set) were graded by glaucoma subspecialists through fundus biomicroscopy and by a reading center using stereoscopic disc photos. For validation, the glaucoma experts also estimated VCDR and HCDR using stereoscopic disc photos in a subset of 505 eyes that they had assessed biomicroscopically. Agreement between grading methods was assessed with Bland-Altman plots.ResultsIn both sets, photo reading tended to yield small CDRs marginally larger, but read large CDRs marginally smaller than fundus biomicroscopy. The mean differences in VCDR and HCDR were 0.006±0.18 and 0.05±0.18 (testing set), and -0.053±0.23 and -0.028±0.21 (validation set), respectively. The limits of agreement were ~0.4, which is twice as large as the cutoff of clinically significant CDR difference between methods. CDR estimates differed by 0.2 or more in 33.8-48.7% between methods.ConclusionsThe differences in CDR estimates between fundus biomicroscopy and stereoscopic optic disc photo reading showed a wide variation, and reached clinically significance threshold in a large proportion of patients, suggesting a poor agreement. Thus, glaucoma should be monitored by comparing baseline and subsequent CDR estimates using the same method rather than comparing photographs to fundus biomicroscopy.

Long-term outcomes of neovascular glaucoma treated with and without intravitreal bevacizumab.

AIMS: To compare the outcomes of neovascular glaucoma (NVG) treated with and without intravitreal bevacizumab in a large case comparison study. METHODS: The study is a retrospective, comparative, case series of 163 eyes of 151 patients with NVG, including 99 treated without and 64 treated with intravitreal bevacizumab. Medical and surgical treatments for NVG were assessed. The main outcome measures were visual acuity (VA) and intraocular pressure (IOP). RESULTS: At the time of NVG diagnosis, the median VA was count fingers (CF) in the non-bevacizumab group and 2/300 in the bevacizumab group. IOP (mean±SD) was 43.1±13.0 mm Hg in the non-bevacizumab group and 40.8±11.5 mm Hg in the bevacizumab group. IOP (mean±SD) decreased to 18.3±13.8 mm Hg in the non-bevacizumab group and 15.3±8.0 mm Hg in the bevacizumab group, and the median VA was CF in both treatment groups at a mean follow-up of 12 months. Panretinal photocoagulation (PRP) substantially reduced the need for glaucoma surgery (P<0.001) in bevacizumab treated NVG eyes. CONCLUSIONS: Although bevacizumab delayed the need for glaucoma surgery, PRP was the most important factor that reduced the need for surgery. Vision and IOP in eyes with NVG treated with bevacizumab showed no long-term differences when compared with eyes that were not treated with bevacizumab. Thus, intravitreal bevacizumab serves as an effective temporizing treatment, but is not a replacement for close monitoring and definitive treatment of NVG. PRP remains the treatment modality that affects the course of NVG in terms of decreasing the need for surgery to control IOP.

Outcomes of treatment of neovascular glaucoma with intravitreal bevacizumab.

BACKGROUND/AIMS: To evaluate the course of treatment and outcomes of neovascular glaucoma (NVG) treated with intravitreal bevacizumab. METHODS: The study is a retrospective, non-comparative, consecutive, interventional case series. Demographic data, past ocular history, cause of NVG and anterior chamber angle status were recorded. Visual acuity (VA), intraocular pressure (IOP), number of IOP-lowering medications and type of treatment administered were recorded at the time of NVG diagnosis and at follow-up intervals. Treatment-related complications and reasons for vision loss were recorded. RESULTS: The study included 56 eyes of 52 patients. At the time of NVG diagnosis, the median VA was count fingers, and the mean IOP (SD) was 40 (11) mm Hg. At 6 months after initial bevacizumab injection, the median VA was 1/200, and the mean IOP (SD) was 18 (15) mm Hg. Seventy-one per cent of eyes underwent panretinal photocoagulation after NVG diagnosis. Sixty-one per cent of eyes received a glaucoma drainage implant (GDI). The Kaplan-Meier cumulative proportion of eyes with open angles receiving a GDI after initial bevacizumab injection was not statistically significantly different from that of eyes with closed angles. Forty-six per cent of eyes received repeat bevacizumab injections. Eleven eyes had hyphaema after both bevacizumab injection and GDI surgery, while three eyes had hyphaema after GDI surgery but prior to initial bevacizumab injection. CONCLUSIONS: Intravitreal bevacizumab is now a frequently used adjunct for the treatment of NVG. Eyes must be monitored closely after initial injection of intravitreal bevacizumab, regardless of initial angle status, as many may still require surgery to lower IOP or repeat injections of intravitreal bevacizumab.

Lack of effect of SU1498, an inhibitor of vascular endothelial growth factor receptor-2, in a transgenic murine model of retinoblastoma.

SU1498, a tyrosine kinase inhibitor of vascular endothelial growth factor receptor 2 (VEGFR-2), has activity against retinal neovascular diseases. To determine if this drug might have clinical utility against retinoblastoma, we evaluated the effects of SU1498, as well as the expression of VEGFR-2, in a transgenic animal model of retinoblastoma. Optical coherence tomography (OCT) was evaluated as a technology to measure retinal tumors in vivo, in response to treatment. Immunofluorescence analysis was performed to evaluate the distribution and expression of VEGFR-2 in enucleated eyes from LHbetaTag transgenic mice and controls at 4, 8, 12, and 16 weeks of age. VEGFR-2 and phosphorylated (p)VEGFR-2 levels were quantitated by Western blot. OCT was used to pair 10-week-old animals based on tumor volume (n=10), and these animals were treated with 6 periocular injections of SU1498 (50mg/kg, given twice weekly) or vehicle for 3 weeks. Tumor burden was determined by histology and in vivo imaging by OCT. VEGFR-2 and pVEGFR-2 expression levels were upregulated during tumorigenesis. However, SU1498 did not significantly reduce tumor burden compared to vehicle (p=0.29). OCT imaging of one matched pair demonstrated equivalent, linear tumor growth despite treatment with SU1498. Retinal tumors can be followed non-invasively and quantitatively measured with OCT. VEGFR-2 is strongly upregulated during tumorigenesis in transgenic retinoblastoma; however, SU1498 does not decrease tumor volume in transgenic murine RB at the studied dose and route of administration.

Estimating visual acuity by character counting using the Snellen visual acuity chart.

PURPOSE: This study examines visual acuity estimation with character counting, which can be used in subjects with nonorganic visual loss. METHODS: The right eyes of 35 healthy subjects were fogged with plus lenses and tested with the Snellen visual acuity chart (Reichert 11180). Visual acuity and counting level were assessed under various degrees of fogging, up to a maximal fogged acuity of 20/200. Counting level was defined as the smallest line that subjects could count the number of characters correctly. For each counting level, the visual acuity that 95% of subjects could see equal to or better than was determined. RESULTS: A counting level of 20/10 estimates (ie 95% chance) a visual acuity equal to or better than 20/30. Counting levels 20/15, 20/20, and 20/25 estimate visual acuities of at least 20/50, 20/80, and 20/80, respectively. Counting levels 20/30-20/60 estimate a visual acuity of at least 20/200. CONCLUSIONS: Character counting appears to be a useful technique of obtaining a rough estimate of visual acuity in subjects unable to be tested by standard methods, such as those with non-organic visual loss.

Relationships between laser flare photometry values and complications of uveitis.

OBJECTIVE: To determine whether relationships exist between elevated laser flare photometry values and common abnormalities and complications associated with uveitis. METHODS: We retrospectively studied all patients with uveitis on whom laser flare photometry measurements ("flare") were obtained (N = 111) at 2 academic medical centers. The first laser flare photometry values obtained for each patient were compared with the presence or absence of the following abnormalities or complications associated with uveitis: keratic precipitates, posterior synechiae, cataract, macular edema, optic disc edema, and glaucoma. In bilateral cases, the eye with the higher flare was used in primary analyses. RESULTS: Flare was significantly higher in patients with posterior synechiae (P<.001) and in those with macular edema (P =.02) than in patients with uveitis who did not have these complications. Flare was significantly higher in patients with prior cataract surgery or cataract at the study visit than in those without cataracts (P =.001). There was no significant difference in flare between patients with and without keratic precipitates, optic disc edema, or glaucoma. No relationships were found between abnormalities or complications and the level of inflammatory cells or flare as determined by clinical assessment. We also identified an inverse relationship between flare and visual acuity that was not completely explained by the presence of complications in a stepwise regression model. CONCLUSIONS: Although causal relationships were not established, associations between flare and some complications of uveitis suggest that aqueous humor protein may be an important factor in the development of these problems. Consequently, laser flare photometry could play a role in predicting outcomes or monitoring therapy for patients with uveitis.

Prognosis and risk factors for early postoperative wound leaks after trabeculectomy with and without 5-fluorouracil.

PURPOSE: To evaluate the prognosis of patients who develop early postoperative wound leaks after trabeculectomy, to determine risk factors for these leaks, and to document adverse outcomes. DESIGN: Multicenter randomized clinical trial. METHODS: Two-hundred thirteen patients with previous cataract surgery or failed filtering surgery were randomized to either trabeculectomy (standard group) or trabeculectomy with postoperative subconjunctival 5-fluorouracil injections (5-FU group). Masked measurements of intraocular pressure were performed throughout 5 years of follow-up. Failure was defined as a reoperation to control intraocular pressure or an intraocular pressure greater than 21 mm Hg with or without medication at or after the 1-year examination. An early postoperative wound leak was defined as one that developed within 2 weeks postoperatively, determined by daily topical fluorescein testing. RESULTS: At 1 year (5 years), the success rate for the 5-FU group was 80% (54%) in eyes without a leak, and 60% (28%) in those with a leak. The 1-year (5-year) success rate in the standard group was 50% (24%) in those without a leak and 44% (15%) with a leak. (P =.018, log-rank test, adjusted for treatment). Leaks were more common in the 5-FU group, 34/105 (32%), than in the standard treatment group, 22/108 (20%), (P =.066, chi(2)). More eyes with one-layer conjunctiva-Tenon capsule closure developed leaks 40/115 (35%) than those with two-layer closure 16/95 (17%) (P =.006, chi(2)). More eyes with a trabeculectomy located inferiorly 29/76 (38%) developed leaks than those done superiorly 27/137 (20%) (P =.006, chi(2)). Patients with leaks were older (66 years) than those without leaks (60 years) (P =.011, t test). CONCLUSION: An early postoperative wound leak was a risk factor for trabeculectomy failure. We recommend that trabeculectomy be performed in a superior location with a two-layer closure.

Corneal graft survival and intraocular pressure control after penetrating keratoplasty and glaucoma drainage device implantation.

OBJECTIVE: To investigate corneal graft survival rates and intraocular pressure (IOP) control in eyes after penetrating keratoplasty (PK) and glaucoma drainage device (GDD) implantation. DESIGN: Retrospective, comparative, consecutive case series. PARTICIPANTS: All patients who underwent PK and GDD implantation at the Bascom Palmer Eye Institute between January 1, 1993 and October 31, 1998. MAIN OUTCOME MEASURES: Graft clarity and IOP control. RESULTS: Of the 72 eyes in 72 patients identified, 47 (65%) underwent combined PK and GDD implantation, and 25 (35%) underwent GDD placement after PK (2-30 months after PK; median, 13 months). The GDD type was Baerveldt 350 mm(2) in 57 eyes, Ahmed in 9, Krupin in 2, and other in 4 eyes. The GDD was placed in the anterior chamber in 54 eyes (75%) and in the vitreous cavity in 18 eyes (25%). Preoperative IOP was 11 to 53 mmHg with or without antiglaucoma medications in 16 eyes (30%) with the GDD implanted in the anterior chamber and in 4 eyes (22%) with the GDD placed in the vitreous cavity (P = 0.76). At 1 year after GDD implantation, the graft was clear in 26 eyes (48%) with the GDD in the anterior chamber compared with 15 eyes (83%) with the GDD in the vitreous cavity (P = 0.013). Forty-eight eyes (89%) with the GDD in the anterior chamber and 18 eyes (100%) with the GDD in the vitreous cavity had IOP between 5 and 21 mmHg with or without antiglaucoma medications (P = 0.33). The mean reduction in IOP, 1 year after surgery, was 12 mmHg among eyes with the GDD in the anterior chamber, compared with 17 mmHg among eyes with the GDD in the vitreous cavity (P = 0.13) CONCLUSIONS: Corneal graft survival at 1 year is significantly higher among eyes with the GDD implanted in the vitreous cavity compared with those in which the GDD is implanted in the anterior chamber. The IOP was significantly lower at 1 year after surgery compared with before surgery in both groups, and there was no significant difference between the groups in IOP control and amount of IOP reduction. There was no significant difference in corneal graft survival or IOP control between eyes with the GDD implanted concurrently with the PK versus after the PK.

Surgical management of secondary glaucoma after pars plana vitrectomy and silicone oil injection for complex retinal detachment.

OBJECTIVE: To evaluate the outcomes of surgical intervention for secondary glaucoma after pars plana vitrectomy and silicone oil injection for repair of complex retinal detachment. DESIGN: Retrospective noncomparative interventional case series. PARTICIPANTS: Forty-three eyes of 43 patients who underwent incisional surgery for secondary glaucoma after pars plana vitrectomy and silicone oil injection for repair of complex retinal detachment over a 9-year period. MAIN OUTCOME MEASURES: Intraocular pressure (IOP), intraoperative and postoperative complications, visual acuity, and the need for further surgical intervention for glaucoma. Success was defined as IOP < or =21 mmHg and > or =5 mmHg with or without medication but without surgical reoperation for glaucoma. RESULTS: Findings associated with elevated IOP included emulsified oil in the anterior chamber (n = 14), pupillary block from silicone oil (n = 13), open-angle glaucoma without silicone oil in the anterior chamber (n = 9), and angle-closure glaucoma without pupillary block (n = 7). The mean (+/- standard deviation) IOP was 41.4 +/- 15.1 mmHg before surgery for glaucoma and 17.2 +/- 10.2 mmHg after an average follow-up of 19.6 months (P < 0.001). Cumulative success was 69%, 60%, 56%, and 48% at 6, 12, 24, and 36-months respectively. In patients who underwent silicone oil removal alone for surgical management of glaucoma (n = 32), 11 of 12 IOP failures (92%) were due to uncontrolled IOP, whereas most IOP failures in the group who underwent silicone oil removal plus glaucoma surgery (n = 8) failed because of hypotony (3 of 4, 75%, P = 0.027). Of three patients who underwent glaucoma surgery alone to control IOP, one failed because of hypotony. There was no significant change in visual function at last follow-up (logarithm of the minimum angle of resolution [logMAR] 2.01) compared with preoperative visual function (logMAR 2.07, P = 0.74). CONCLUSION: Surgical management of secondary glaucoma after silicone oil injection for complex retinal detachment may achieve good IOP control and stabilization of visual function in most patients. Patients who undergo silicone oil removal alone to control IOP are more likely to have persistent elevation of IOP and possibly undergo reoperation for glaucoma, whereas patients who undergo concurrent silicone oil removal and glaucoma surgery are more likely to have hypotony.

Incidence of nonarteritic anterior ischemic optic neuropathy associated with cataract extraction.

OBJECTIVES: To determine the incidence of nonarteritic anterior ischemic optic neuropathy (NAION) after cataract extraction and to use the incidence to evaluate the causal relationship between cataract extraction and NAION. DESIGN: Cohort study. PARTICIPANTS: Five thousand seven hundred eighty-seven cataract extraction cases at the Bascom Palmer Eye Institute (BPEI) in a 5-year period between January 1, 1993 and December 31, 1997. METHODS: During the study period, an estimated 5787 cataract extraction cases were identified that met the following criteria: (1) the patient was 50 years of age or older, (2) surgery was performed by phacoemulsification or phacofracture techniques and not planned in combination with another procedure, and (3) follow-up was at BPEI. Charts of patients diagnosed with NAION from January 1, 1993 to December 31, 1998 were reviewed to detect the occurrence of NAION within 1 year of surgery. The diagnosis of NAION was based on the following: (1) an acute decrease in vision, (2) associated nerve fiber layer defect on visual field testing, (3) associated relative afferent pupillary defect, and (4) observed optic nerve edema. The exact binomial test was used to compare the incidence of NAION after cataract extraction against the expected incidence. MAIN OUTCOME MEASURE: Occurrence of NAION within 1 year after cataract extraction. RESULTS: Of the 5787 cataract extraction cases, three patients experienced NAION within 1 year of the procedure. Each case occurred after surgery on days 29, 36, and 117, giving an estimated 6-month incidence of 51.8 in 100,000 and a 6-week incidence of 34.6 in 100,000. Both were statistically higher than the previously reported overall incidence of NAION. Two of the three patients had a history of NAION in the contralateral eye. CONCLUSIONS: Cataract extraction is associated with an increased incidence of NAION, which is higher than the reported overall incidence. However, the risk of NAION after cataract extraction is low, with approximately one occurrence in every 2000 cases. A history of NAION in the fellow eye may be a risk factor.

Pseudomonas aeruginosa in vitro corneal isolate sensitivity to ofloxacin, ciprofloxacin, and trovafloxacin: a comparative study.

PURPOSE: To compare sensitivity of Pseudomonas aeruginosa corneal isolates to ofloxacin, ciprofloxacin, and trovafloxacin. METHODS: Sensitivities of P. aeruginosa corneal isolates to each antibiotic from the periods 1985 to 1987 (n = 32) and 1995 to 1999 (n = 85) were evaluated in vitro with E tests (AB Biodisk; Remel, Lenexa, Kansas). RESULTS: Overall, the percent of P. aeruginosa corneal isolates sensitive in vitro to ofloxacin (106/117, 90.6%) was significantly less than to ciprofloxacin (113/117, 96.6%, P =.016) and trovafloxacin (113/117, 96.6%, P =.016). We observed trends of decreasing sensitivity to ciprofloxacin and trovafloxacin, which were not statistically significant. Sensitivity to ofloxacin remained unchanged; however, sensitivity to ofloxacin was always less than sensitivity to ciprofloxacin and trovafloxacin. CONCLUSION: Although in vitro susceptibilities may not correlate with in vivo efficacy, our data suggest that ciprofloxacin and trovafloxacin are superior to ofloxacin in the treatment of P. aeruginosa keratitis.

Echography of retinoblastoma: histopathologic correlation and serial evaluation after globe-conserving radiotherapy or chemotherapy.

PURPOSE: To assess the sensitivity of echography in detecting retinoblastoma, compare tumor features observed by echography with histopathology data, and assess the usefulness of echography in serially following retinoblastoma tumors after globe-conserving treatments. METHODS: The medical and echography records of all patients treated for retinoblastoma at the Bascom Palmer Eye Institute between 1991 and 1997 were reviewed. All eyes underwent pretreatment echographic evaluation, and eyes treated with external beam radiotherapy, brachytherapy, or chemotherapy underwent serial follow-up echography. RESULTS: Sixty-nine eyes of 48 patients were identified. Echography demonstrated evidence of retinoblastoma in 69 of 69 (100%) eyes and calcification in 63 (91.3%) eyes. Histopathology was superior to echography in detecting optic nerve invasion, extraocular extension, and presence of calcification. CONCLUSION: Echography is a useful adjunct to indirect ophthalmoscopy in establishing the diagnosis of retinoblastoma. While not as specific as histopathology, echographic evaluation before and after treatment of retinoblastoma permits monitoring of treatment response and may aid in detecting recurrent tumor growth or failure to respond to treatment.

Emotional distress in patients with retinal disease.

PURPOSE: To investigate the prevalence of, and potential risk factors for, emotional distress among patients with retinal disease. DESIGN: Cross-sectional study. METHODS: Cases consisted of 86 consecutive patients at Wilmer Eye Institute Retinal Vascular Center. Fifty-one controls with normal visual acuity and no known ocular disease were frequency-matched to the cases by age, sex, and race. Subjects were interviewed using the Community Disability Scale, a functional status questionnaire, and the General Health Questionnaire, a questionnaire assessing emotional distress. RESULTS: The prevalence of probable (General Health Questionnaire score 4 or greater and less than 10) or definite (General Health Questionnaire score 10 or greater) emotional distress was 59.3% among ophthalmic patients and 2.0% among controls. There were significant relationships between emotional distress, as assessed by General Health Questionnaire score, and degree of 1) visual impairment, as assessed by weighted bilateral average logarithm of minimal angle of resolution (logMAR), and 2) functional impairment, as assessed by Community Disability Scale score (P =.001). Univariate analyses identified significant predictors of emotional distress: shorter duration of ocular disease (P =.019), worse visual acuity (P =.001), increased systemic comorbidities (P =.001), and increased functional impairment (P <.001). Multiple regression analysis demonstrates that worse visual acuity, increased systemic comorbidities, and shorter duration of ocular disease each explain over 10% of the variability in General Health Questionnaire score (r(2) = 0.15, 0.12, and 0.11, respectively). Addition of Community Disability Scale score to the regression model eliminates the significance of visual acuity and systemic comorbidities; Community Disability Scale score explains nearly 30% of the variability in emotional distress, as assessed by General Health Questionnaire score (r(2) = 0.29). CONCLUSIONS: Emotional distress is prevalent among patients with retinal disease; potential risk factors for emotional distress among such patients include shorter duration of ocular disease, worse visual acuity, increased systemic comorbidities, and increased functional impairment.

Visual hallucinations in patients with retinal disease.

PURPOSE: To investigate the prevalence and phenomenologic nature of visual hallucinations among patients with retinal disease and to investigate whether presence of hallucinations is a significant predictor of functional status, quality of life, and/or emotional distress after adjusting for visual acuity. DESIGN: Cross-sectional study. METHODS: Eighty-six consecutive patients at the Wilmer Ophthalmologic Institute Retinal Vascular Center were interviewed using the Sickness Impact Profile, Community Disability Scale, General Health Questionnaire, Visual Phenomena Interview, Eysenck Personality Questionnaire, and Telephone Interview for Cognitive Status. RESULTS: The prevalence of visual hallucinations was 15.1%. Most were formed hallucinations in clear consciousness that lasted for seconds to minutes. The majority of patients had been experiencing visual hallucinations for less than 1 year (61.5%) or for 1 to 2 years (23.1%). Only two of the 13 patients with hallucinations had informed a physician of their hallucinations. Univariate analyses revealed that variables significantly associated with experiencing hallucinations were female sex, worse visual acuity, bilateral visual impairment, emotional distress, decreased functional status, and decreased quality of life. Regression analysis demonstrated that among patients with relatively good vision, those who experienced hallucinations were more emotionally distressed and had a lower quality of life than patients without hallucinations. CONCLUSIONS: Visual hallucinations among patients with retinal disease are common, underdiagnosed, and not associated with cognitive deficits, abnormal personality traits, or a family or personal history of psychiatric morbidity. Among patients with relatively good vision, hallucinations are associated with increased emotional distress and decreased quality of life.

The effect of punctal occlusion on tear production, tear clearance, and ocular surface sensation in normal subjects.

PURPOSE: To evaluate the effect of temporary punctal occlusion on tear production, tear clearance, and ocular surface sensation in normal subjects. METHODS: Noncomparative interventional case series. Punctal occlusion with silicone punctal plugs was performed on nine normal subjects without complaints of ocular irritation and no known history of ocular surface disease. The lower punctum of both eyes was occluded in five subjects. The upper and lower puncta of only one eye were occluded in four subjects. Corneal and conjunctival sensations were measured with the Cochet-Bonnet anesthesiometer. Tear fluorescein clearance was evaluated with a CytoFluor II fluorophotometer by measuring the fluorescein concentration in minimally stimulated tear samples collected from the inferior tear meniscus 15 minutes after instillation of fluorescein. Schirmer test was performed without anesthesia. The tests were performed at days 0, 1, 3, 7, and 14 to 17 after punctal occlusion. Relationships were analyzed with linear regressions, and a quadratic term was used to model a return to preocclusion levels. Paired t test was used to study the change in tear fluorescein concentration. RESULTS: In subjects who had the lower puncta of both eyes occluded, conjunctival sensation decreased in both eyes (right eye, P =.008; left eye, P =.003), but there was no change in corneal sensation. Their tear fluorescein clearance did not show a significant change from baseline (P =.90). However, a decrease in Schirmer test scores approached statistical significance (P =.056). In subjects with both puncta of only one eye occluded, we noted a decrease in corneal sensation (occluded eye, P =.042; nonoccluded eye, P =.036), conjunctival sensation (occluded, P =.001; nonoccluded, P =.060), and Schirmer scores (occluded, P =.022; nonoccluded, P =.011). Linear regression did not show a significant change in tear fluorescein clearance for either eye (occluded, P =.28; nonoccluded, P =.44). However, paired t test showed a significant worsening of tear clearance in the occluded eye from day 0 to day 3 (P =.001) followed by a subsequent improvement in tear clearance from day 3 to the end of the study period (P =.045). Paired t test did not reveal any significant changes in tear clearance in the nonoccluded eye. The quadratic term of the linear regression model demonstrated an increase toward preocclusion levels that approached statistical significance for corneal sensation (occluded, P =.053; nonoccluded, P =.099). It was statistically significant for conjunctival sensation (occluded, P =.001; nonoccluded, P =.045) and Schirmer scores (occluded, P =.047; nonoccluded, P =.044). CONCLUSIONS: Temporary punctal occlusion in normal subjects decreases tear production and ocular surface sensation. Our findings suggest that in addition to blocking tear drainage, punctal occlusion may affect the ocular surface/lacrimal gland interaction. These effects were more pronounced in subjects with both upper and lower puncta occluded. In normal subjects, there appears to be an autoregulatory mechanism to return tear production, tear clearance, and ocular surface sensation to preocclusion levels 14 to 17 days after punctal occlusion.

Outcomes of vitreoretinal surgery for complications of branch retinal vein occlusion.

OBJECTIVE: To investigate outcomes of vitreoretinal surgery for complications of branch retinal vein occlusion (BRVO). DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: The medical records of all patients who underwent vitreoretinal surgery for complications of BRVO at Bascom Palmer Eye Institute between January 1, 1991 and December 31, 1998 were reviewed. Thirty-six eyes from 36 consecutive patients were identified. MAIN OUTCOME MEASURES: Visual acuity outcomes include preservation of preoperative visual acuity and visual acuity greater than or equal to 20/40, 20/200 and 5/200. When preoperative retinal detachment was present, the anatomic outcome assessed was complete retinal attachment. Postoperative event rates of retinal detachment, vitreous hemorrhage, epiretinal membrane (ERM), and cataract were tabulated. All outcomes were assessed at 6 months. RESULTS: Surgical indications included nonclearing vitreous hemorrhage (17 patients), traction retinal detachment involving the macula (15), and ERM (4). Mean follow-up was 19 months. Preoperatively, best-corrected vision was greater than or equal to 20/200 in 19/36 (53%) eyes. Six months postoperatively, best-corrected vision was greater than or equal to 20/40 in 12/36 (33%) eyes, greater than or equal to 20/200 in 27/36 (75%) eyes, and greater than or equal to 5/200 in 31/36 (86%) eyes. Postoperative complications included retinal detachment (2/36; 6% eyes), ERM (3; 8%), vitreous hemorrhage (2; 6%), suprachoroidal hemorrhage (1; 3%), central retinal vein occlusion (1; 3%), and central retinal artery occlusion (1; 3%). Clinical features associated with better visual outcome include better preoperative visual acuity (P: = 0.05), absence of preoperative afferent pupillary defect (P: = 0.01), and absence of preoperative macular edema (P: = 0.08). CONCLUSIONS: Following surgery, retinal attachment and improved visual acuity were achieved in the majority of patients. Pre-existing pathology and postoperative complications may limit final vision in eyes with BRVO.

Screening for retinopathy of prematurity employing the retcam 120: sensitivity and specificity.

OBJECTIVES: To compare the method of photographic screening using the RetCam 120 to the standard method of screening for retinopathy of prematurity (ROP) by ophthalmologic examination. METHODS: A total of 100 RetCam 120 photoscreening examinations of the retina were performed on 32 premature infants. These were stored in a separate file from which all identifying information was removed. At this same examination, a detailed ophthalmological evaluation, employing the indirect ophthalmoscope with scleral depression, was performed by an experienced examiner. Masked examiners performed an evaluation of the fundus photographs to identify presence or absence of ROP, the location and extent of the disease, and the presence or absence of plus disease. These data were then compared with the results of the ophthalmological examination to determine the specificity, sensitivity, and the positive and negative predictive value (PPV and NPV) of the method. RESULTS: Retinopathy of prematurity was detected in 68 of 100 subjects by ophthalmologic examinations and in 58 of 100 subjects' photoscreening examinations. No ROP was detected in 32 of 100 subjects. The sensitivity of the method was 56 (82.4%) of 68 and the specificity was 30 (93.8%) of 32. The PPV was 96.6%; NPV, 76.9%. CONCLUSIONS: The sensitivity of the method was low. The ROP that was missed was peripheral stage 1 or stage 2 disease in peripheral zone 2 or zone 3. This was largely due to the technical limitations of the speculum-camera interface preventing a better view of the periphery. The ROP cases that were missed by the photographic examination regressed spontaneously on follow-up. No disease more posterior to peripheral zone 2 was overlooked. These results detail the accuracy of the method employing the technique of photoscreening as a potential substitute for detailed ophthalmological examination. At present there are clear technical limitations to such a substitution. The study is part of an ongoing project to determine the feasibility of employing neonatal nurses trained to take digitized images of the premature infant's retina and telemeter the results to be read by an experienced ophthalmologist remote from the site.

The outcome of retinopathy of prematurity: screening for retinopathy of prematurity using an outcome predictive program.

PURPOSE: The purpose of this study was to compare the calculated risk of progression to threshold retinopathy of prematurity (ROP) and risk of an unfavorable structural outcome using the computer program, RM-ROP, with the observed incidence for infants born at Jackson Memorial Hospital (JMH) and to determine how many children would have been treated unnecessarily if the threshold criteria for treatment were lowered on the basis of the clinical findings and RM-ROP risk calculations. DESIGN: Noncomparative interventional case series. PARTICIPANTS: All 292 surviving premature infants weighing 1250 g or less at birth and born at JMH between January 1, 1997, and December 31, 1998, were included in the study. METHODS: Baseline demographic factors and data from sequential ophthalmic examinations were entered into the RM-ROP program for risk calculation. Infants reaching threshold disease received diode laser indirect photocoagulation of the avascular retina. Three-month follow-up was obtained for infants receiving laser treatment. MAIN OUTCOME MEASURES: The development of threshold ROP and an unfavorable structural outcome, defined as a posterior retinal fold or posterior retinal detachment occurring within 3 months of threshold disease. RESULTS: Thirty-eight eyes were diagnosed with threshold ROP, with 18 of 20 subjects having bilateral disease. Three-month posttreatment follow-up was obtained on all 20 children, with 19 having good structural outcomes. Thirty-two percent of eyes (12 of 38) reaching threshold never had a risk estimate greater than 0.10. However, only 6% of eyes (35 of 546) that did not reach threshold ever had a model predicted risk greater than 0.15. All right eyes with zone 1 prethreshold disease, 60% of those with zone 2 stage 2+ disease, and 23% with zone 2 stage 3 disease progressed to threshold ROP. CONCLUSIONS: The similarity between the risk distributions for the Miami and the Multicenter Trial of Cryotherapy for Retinopathy of Prematurity study indicates the similarity in the populations with respect to risk factors identified as important by the model. The Miami data validated the model, with eyes reaching threshold having higher risks than eyes that did not. Actual risk estimates for eyes reaching threshold can be small. Changing the threshold criteria for treatment on the basis of various clinical and computer-generated prethreshold risk levels in our population would have resulted in the unnecessary treatment of many infants who never progressed to threshold disease. In the Miami population, if the model were used to manage an individual subject, close attention would have to be paid to small differences in risk. Although the RM-ROP software program may be a useful tool for following premature infants with ROP, the clinical examination remains the "gold standard."