Choroidal Cavitary Disorders.

The structure and functions of the choroid have been long acknowledged but the pathophysiology behind various anomalies has been difficult to understand until the advent of optical coherence tomography (OCT). With OCT imaging, choroidal cavitations appear as optically empty spaces between the outer retinal and choroidal layers with attenuation or loss of outer retinal layers. Choroidal cavitations are found in the posterior pole and seen in conditions such as pathologic myopia, north carolina macular dystrophy (NCMD), focal choroidal excavation (FCE), and torpedo maculopathy (TM). To date, these disorders have not been linked. A commonality they all share is malformation of the RPE-photoreceptor-choroid complex. The following report describes the differences and similarities of choroidal cavitation amongst the different retinal disorders and emphasizes the importance of multimodal imaging in the detection and management of potential complications.

Visual dysfunctions and symptoms during the subacute stage of blast-induced mild traumatic brain injury.

The purpose of the present study was to assess the occurrence of visual dysfunctions and associated symptoms in active duty warfighters during the subacute stage of blast-induced mild traumatic brain injury (mTBI). A comprehensive visual and oculomotor function evaluation was performed on 40 U.S. military personnel, 20 with blast-induced mTBI and 20 without. In addition, a comprehensive symptom questionnaire was used to assess the frequency of visual, vestibular, and neuropsychiatric-associated symptoms. The most common mTBI-induced visual dysfunctions were associated with near oculomotor deficits, particularly large exophoria, decreased fusion ranges, receded near point of convergence, defective pursuit and saccadic eye movements, decreased amplitude of accommodation, and monocular accommodative facility. These were associated with reduced reading speed and comprehension and an increased Convergence Insufficiency Symptom Survey score. Photosensitivity was a common visual dysfunction along with hearing, balance, and neuropsychiatric symptoms. The oculomotor testing for warfighters suspected of blast-induced mTBI should include, at a minimum, the assessment of near lateral and vertical phorias, positive fusional vergence, stereoacuity, near point of convergence, amplitude of accommodation, monocular accommodative facility, saccades, and pursuit eye movements. A reading test should be included in all routine exams as a functional assessment of the integration of oculomotor functions.

Effectiveness of computerized oculomotor vision screening in a military population: pilot study.

The prevalence of oculomotor dysfunctions associated with blast-induced mild traumatic brain injury (mTBI) in warfighters has increased as a consequence of recent conflicts. This study evaluated the effectiveness of computerized oculomotor vision screening (COVS) in a military population. Oculomotor functions were assessed with COVS and by conventional methods in 20 U.S. military personnel with and 20 without mTBI. The validity of COVS was determined by Pearson correlation and Bland-Altman method or the kappa coefficient. The repeatability of the COVS was assessed with the coefficient of repeatability or the kappa coefficient. The results showed that COVS had high sensitivity and specificity for screening near oculomotor functions. Overall, the COVS showed excellent validity and repeatability for assessing near lateral and vertical phorias, Worth 4 Dot, and fixation, as well as pursuit and saccadic eye movements. Despite the strong Pearson correlation, the Bland-Altman analysis identified minor to moderate discrepancies for both positive and negative fusional vergence and their associated recovery as well as for the monocular accommodative facility measurements. This study demonstrated that non-eye-care professionals may be able to use the COVS as a tool to efficiently screen oculomotor functions in a military population with or without mTBI.

The use of optical coherence tomography to determine the effect of thiazolidinediones on retinal thickness in patients with type 2 diabetes.

OBJECTIVE: Thiazolidinediones (TZDs) are insulin-sensitizing agents that are associated with peripheral edema and have been reported to be associated with diabetic macular edema (DME). We hypothesized that TZDs produce subclinical increases in retinal thickness that may be detected by optical coherence tomography (OCT) but are not seen on routine dilated funduscopic examination. RESEARCH DESIGN AND METHODS: We used OCT to screen for subclinical DME in a cross-sectional study of patients with type 2 diabetes; 29 patients were taking TZDs and 58 were not taking TZDs. We analyzed data using multiple linear regression analysis to investigate associations of retinal thickness with clinical characteristics. RESULTS: There was no significant difference between the central subfield retinal thickness in the non-TZD group (206.4 ± 28.0 microns; n = 59) and TZD group (204.1 ± 26.1 microns; n = 29) (p = .72) nor were there significant differences in any other retinal subfield. There was no significant correlation of retinal thickness with laboratory results studies--peripheral edema, gender, age, duration of diabetes, individual, or combinations of medications. Retinal thickness differences between regions displayed normal anatomical variation. However, ethnic differences were found in which African-Americans had thinner retinas in all regions than Caucasians regardless of whether or not they used TZDs. CONCLUSIONS: These data suggest that TZDs do not cause subclinical DME in a demographically diverse patient population with diabetes. The established normal ranges for macular thickness may require adjustment based on ethnicity.

Evidence of central and peripheral vestibular pathology in blast-related traumatic brain injury.

OBJECTIVE: To prospectively assay the vestibular and oculomotor systems of blast-exposed service members with traumatic brain injury (TBI). STUDY DESIGN: Prospective, nonblinded, nonrandomized descriptive study. SETTING: Tertiary care facility (Department of Defense Medical Center). PATIENTS: Twenty-four service members recovering from blast-related TBI sustained in Iraq or Afghanistan. INTERVENTIONS: Focused history and physical, videonystagmography (VNG), rotational chair, cervical vestibular-evoked myogenic potentials, computerized dynamic posturography, and self-report measures. RESULTS: Vestibular testing confirms a greater incidence of vestibular and oculomotor dysfunction in symptomatic (vestibular-like dizziness) personnel with blast-related TBI relative to asymptomatic group members. VNG in the symptomatic group revealed abnormal nystagmus or oculomotor findings in 6 of 12 subjects tested. Similarly, rotational chair testing in this group revealed evidence of both peripheral (4/12) and central (2/12) vestibular pathology. By contrast, the asymptomatic group revealed less vestibular impairment with 1 of 10 rotational chair abnormalities. The asymptomatic group was further characterized by fewer aberrant nystagmus findings (4/12 abnormal VNGs). Computerized dynamic posturography testing revealed no significant differences between groups. Self-report measures demonstrated differences between groups. CONCLUSION: Vestibular function testing confirms a greater incidence of peripheral vestibular hypofunction in dizzy service members with blast-related TBI relative to those who are asymptomatic. Additionally, oculomotor abnormalities and/or nystagmus consistent with central involvement were present in 10 of the 24 study participants tested. The precise cause of these findings remains unknown.

Efficiency of automation and electronic health records in optometric practice.

BACKGROUND: Health information technology (HIT) consists of technological advancements in health care instrumentation, integration, and documentation. It is now beginning to reach a level of consistency, and its benefits are being realized in clinical practice. Comparisons between paper and digital documentation have been conducted in various specialties. There have also been studies comparing manual and automated documentation. Our study was designed to compare the overall benefit of an electronic health record (EHR) and clinical automation accompanied with HIT advancements to traditional modes of practice within the Optometry Clinic at Walter Reed Army Medical Center. PATIENTS AND METHODS: All processes and procedures used in the study were equivalent to those used in patient visits common to most optometric practices. They included patient check-in, pretesting by an ophthalmic technician, and a comprehensive eye examination by an optometrist. In addition to the quantitative time measurements for these procedures, the frequency of certain events was recorded to ascertain the value of automation versus conventional methods of patient management, testing, treatment, and documentation. RESULTS: Although no process time showed any statistically significant difference, some trends were evident. There was a trend toward increased efficiency in the automated group during "Doctor Examination" and "Total Time" subsections. Also, there was a trend toward decreased efficiency with the automated group during the "Check-In" section. CONCLUSIONS: Automation and EHR technology will likely improve over time and surpass the medical efficiency of conventional modes of care. It is impressive that the early stage of HIT used in this study showed no detraction from clinical efficiency while potentially offering many patient, provider, and administrative benefits.

Attrition of military enlistees with a medical waiver for myopia, 1999-2001.

BACKGROUND: Military service requires physical fitness, including vision within set standards. Premature attrition inflicts a considerable manpower and fiscal burden upon the military. METHODS: We conducted a retrospective cohort survival analysis of newly enlisted military personnel who entered active duty with a medical waiver for myopia between January 1, 1999, and December 31, 2001. Premature attrition rates, both medical and overall, were compared with those for a matched, fully qualified, comparison group. RESULTS: New enlistees with a waiver for myopia had the same probability of remaining on active duty through the first 2 years of service as did fully qualified peers. Enlistees with a waiver for myopia also had a low probability of an early medical discharge for myopia. CONCLUSION: The results of this study tend to validate the current branch-specific myopia waiver processes. They also provide evidence that current myopia accession criteria may be too restrictive and in need of policy review.