Clinical classification of age-related macular degeneration.

OBJECTIVE: To develop a clinical classification system for age-related macular degeneration (AMD). DESIGN: Evidence-based investigation, using a modified Delphi process. PARTICIPANTS: Twenty-six AMD experts, 1 neuro-ophthalmologist, 2 committee chairmen, and 1 methodologist. METHODS: Each committee member completed an online assessment of statements summarizing current AMD classification criteria, indicating agreement or disagreement with each statement on a 9-step scale. The group met, reviewed the survey results, discussed the important components of a clinical classification system, and defined new data analyses needed to refine a classification system. After the meeting, additional data analyses from large studies were provided to the committee to provide risk estimates related to the presence of various AMD lesions. MAIN OUTCOME MEASURES: Delphi review of the 9-item set of statements resulting from the meeting. RESULTS: Consensus was achieved in generating a basic clinical classification system based on fundus lesions assessed within 2 disc diameters of the fovea in persons older than 55 years. The committee agreed that a single term, age-related macular degeneration, should be used for the disease. Persons with no visible drusen or pigmentary abnormalities should be considered to have no signs of AMD. Persons with small drusen (<63 µm), also termed drupelets, should be considered to have normal aging changes with no clinically relevant increased risk of late AMD developing. Persons with medium drusen (≥ 63-<125 µm), but without pigmentary abnormalities thought to be related to AMD, should be considered to have early AMD. Persons with large drusen or with pigmentary abnormalities associated with at least medium drusen should be considered to have intermediate AMD. Persons with lesions associated with neovascular AMD or geographic atrophy should be considered to have late AMD. Five-year risks of progressing to late AMD are estimated to increase approximately 100 fold, ranging from a 0.5% 5-year risk for normal aging changes to a 50% risk for the highest intermediate AMD risk group. CONCLUSIONS: The proposed basic clinical classification scale seems to be of value in predicting the risk of late AMD. Incorporating consistent nomenclature into the practice patterns of all eye care providers may improve communication and patient care.

Proposed international clinical diabetic retinopathy and diabetic macular edema disease severity scales.

PURPOSE: To develop consensus regarding clinical disease severity classification systems for diabetic retinopathy and diabetic macular edema that can be used around the world, and to improve communication and coordination of care among physicians who care for patients with diabetes. DESIGN: Report regarding the development of clinical diabetic retinopathy disease severity scales. PARTICIPANTS: A group of 31 individuals from 16 countries, representing comprehensive ophthalmology, retina subspecialties, endocrinology, and epidemiology. METHODS: An initial clinical classification system, based on the Early Treatment Diabetic Retinopathy Study and the Wisconsin Epidemiologic Study of Diabetic Retinopathy publications, was circulated to the group in advance of a workshop. Each member reviewed this using e-mail, and a modified Delphi system was used to stratify responses. At a later workshop, separate systems for diabetic retinopathy and macular edema were developed. These were then reevaluated by group members, and the modified Delphi system was again used to measure degrees of agreement. MAIN OUTCOME MEASURES: Consensus regarding specific classification systems was achieved. RESULTS: A five-stage disease severity classification for diabetic retinopathy includes three stages of low risk, a fourth stage of severe nonproliferative retinopathy, and a fifth stage of proliferative retinopathy. Diabetic macular edema is classified as apparently present or apparently absent. If training and equipment allow the screener to make a valid decision, macular edema is further categorized as a function of its distance from the central macula. CONCLUSIONS: There seems to be a genuine need for consistent international clinical classification systems for diabetic retinopathy and diabetic macular edema that are supported with solid evidence. The proposed clinical classification systems provide a means of appropriately categorizing diabetic retinopathy and macular edema. It is hoped that these systems will be valuable in improving both screening of individuals with diabetes and communication and discussion among individuals caring for these patients.

Vitrectomy for retained lens material after cataract extraction: the relationship between histopathologic findings and the time of vitreous surgery.

PURPOSE: To report the histopathologic features of vitreous specimens obtained after vitrectomy for retained lens material and to correlate these findings with the time after cataract surgery at which vitreous surgery was performed. DESIGN: Observational case series. PARTICIPANTS: All 135 patients who had vitreous specimens submitted to the pathology laboratory after vitreous surgery for retained lens material after elective senile cataract surgery. METHODS: A review of histopathologic reports of 135 consecutive vitreous specimens that were obtained during vitreous surgery for retained lens material after surgery for senile cataract. MAIN OUTCOME MEASURES: Identification of lens material, macrophages, phacolytic cells, and giant cells in the vitrectomy specimens. RESULTS: Lens material was observed in 100% of cases. Macrophages without ingested lens material were present in 48% (65 of 135), phacolytic cells in 24% (32 of 135), and a mixture of neutrophils and multinucleated giant cells in 8% (11 of 135). No cells were discovered in eyes in which vitrectomy was performed within 3 days of cataract extraction. The percentages of eyes with macrophages increased from 35% when vitrectomy was performed 4 to 7 days after cataract surgery to 80% when this time interval was 61 to 90 days. CONCLUSION: Lens-induced inflammatory reaction seems to increase with time that retained lens material remains in the eye.

Acute annular outer retinopathy: report of four cases.

PURPOSE: To describe the clinical findings and course in four patients with acute annular outer retinopathy. METHODS: Four patients were evaluated during the course of acute annular outer retinopathy, and the historical and clinical findings were retrospectively collected. RESULTS: Four healthy patients developed the acute onset of visual field loss associated with a localized, white annular outer retinopathy. All patients were caucasian; two were women, aged 29 and 32 years, and two were men, aged 71 and 79 years. The mean follow-up was 3.9 years (range, 1 to 6 years). On presentation, four eyes had an irregular, incomplete, peripapillary, annular band of gray-white, deep retinal opacification with visual CONCLUSIONS: These four cases of acute annular outer retinopathy expand our knowledge of this disorder. Acute annular outer retinopathy may be a distinct entity or it may represent a variant of acute zonal occult outer retinopathy retinopathy. As more cases are recognized, the characteristic features of the disease spectrum, the etiology, and treatment options may be better elucidated.

Evidence-based analysis of prophylactic treatment of asymptomatic retinal breaks and lattice degeneration.

PURPOSE: To assess the quality of information in the literature regarding the benefits of prophylactic treatment of asymptomatic retinal tears and lattice degeneration. CLINICAL RELEVANCE: Asymptomatic retinal breaks occur in approximately 7% of patients over age 40, and lattice degeneration is present in approximately 8% of the general population. Because retinal breaks cause retinal detachment and lattice degeneration is associated with approximately 30% of retinal detachments, prophylactic treatment of these lesions has sometimes been recommended. LITERATURE REVIEWED: A panel of vitreoretinal experts performed a literature review of all publications regarding prevention of retinal detachment that have been published in English. These articles were then used to prepare recommendations for patient care in an American Academy of Ophthalmology Preferred Practice Pattern (PPP). Each recommendation was rated according to: (1) its importance in the care process and (2) the strength of evidence supporting the given recommendation. RESULTS: Most recommendations were rated as A (most important to patient care). Only a single publication was graded as I (providing strong evidence in support of a recommendation), and this was not a prospective trial. Of the few publications rated as II (substantial evidence), most were studies documenting a lack of treatment benefit. Because of an absence of level I and level II studies in the literature, level III (consensus of expert opinion) was the basis for most recommendations in the PPP. CONCLUSIONS: The current literature regarding prevention of retinal detachment does not provide sufficient information to support strongly prophylactic treatment of lesions other than symptomatic flap tears. Prospective randomized trials of prophylactic therapy are indicated. Eyes highly predisposed to retinal detachment should be considered for such studies.

Evidence-based medicine regarding the prevention of retinal detachment.

PURPOSE: To assess the quality of information in the literature regarding the prevention of retinal detachment in an effort to establish appropriate practice guidelines. METHODS: A panel of vitreoretinal experts performed a literature review of all publications in the English language for articles about prevention of retinal detachment. These article were then used to prepare recommendations for patient care in an American Academy of Ophthalmology "Preferred Practice Pattern" (PPP). Each recommendation was rated according to its importance in the care process and the strength of evidence supporting the given recommendation. RESULTS: Most recommendations were given a rating of "A" (most important to patient care). Only a single publication was graded as Level I (providing strong evidence in support of a recommendation), and this was not a prospective trial. Of the few publications rated as Level II (substantial evidence), most were studies documenting a lack of treatment benefit. Because of an absence of Level I and Level II studies in the literature, Level III (consensus of expert opinion) was the basis for most recommendations in the PPP. CONCLUSION: The current literature regarding prevention of retinal detachment does not provide sufficient information to strongly support prophylactic treatment of lesions other than symptomatic flap tears. Prospective randomized trials of prophylactic therapy are indicated. Eyes highly predisposed to retinal detachment should be considered for such studies.

Phakic retinal detachments in the elderly.

PURPOSE: To discover if clinical nontraumatic phakic retinal detachments in the elderly possess characteristics that distinguish them from similar cases in younger persons. METHODS: A retrospective study of 100 consecutive cases in patients aged 70 years and older was performed. Recorded data included patient age and sex, type and location of retinal break, extent of detachment, and associated vitreoretinal pathology. RESULTS: Approximately 90% of retinal breaks were horseshoe tears, and the majority were located in the superior temporal quadrant. Horseshoe tears confined to the posterior margin of the vitreous base were responsible for retinal detachments in 30% of cases, and an additional 36% of breaks were located anterior to the equator. CONCLUSION: The incidence of this type of anterior break is higher than that previously described for phakic retinal detachments, although previous studies have not discussed break types as a function of old age. Anterior horseshoe tears, which cause many phakic retinal detachments in the elderly, may not be caused by acute posterior vitreous detachment, but rather to persistent chronic traction on the vitreous base after posterior vitreous detachment.

The diagnosis of diabetic retinopathy. Ophthalmoscopy versus fundus photography.

PURPOSE: To compare fundus photography with ophthalmoscopy in the detection of diabetic retinopathy. METHODS: Ophthalmoscopy and fundus photographs with a nonmydriatic camera, both performed through dilated pupils, were compared to diagnose retinopathy in a cohort of 410 Oklahoma Indians with noninsulin-dependent diabetes mellitus. A total of 795 eyes were examined using both methods. The mean age of participants was 60.3 years, with a mean duration of diabetes of 17.3 years. RESULTS: An overall agreement of 86.3% with a kappa statistic kappa of 0.74 was found between ophthalmoscopy and fundus photography with a nonmydriatic camera. For the diagnosis of proliferative diabetic retinopathy, kappa = 0.84 with an agreement of 98.1%. With a total of 61 cases of proliferative retinopathy diagnosed by either method in our study, ophthalmoscopy alone detected 88.5% and fundus photography, 78.7%. When compared on a lesion-by-lesion basis, agreement between the two diagnostic methods was highest for nonproliferative retinopathy, as well as fibrous proliferation. CONCLUSION: The fundus photography with a nonmydriatic camera, performed with mydriasis, is comparable to ophthalmoscopy for the detection of retinopathy. It may prove to be a suitable, cost-effective method for routine screening in diabetes clinics, provided ophthalmologic referral is ensured for those with a diagnosis of any form of retinopathy, questionable retinopathy, nondiabetic retinopathy, those with poor quality photographs, as well as those with acute changes in visual acuity.

Diabetic retinopathy in Oklahoma Indians with NIDDM. Incidence and risk factors.

OBJECTIVE: To determine the incidence rates and risk factors for development of diabetic retinopathy in Oklahoma Indians. RESEARCH DESIGN AND METHODS: Cohort follow-up study with baseline examination between 1972 and 1980 and follow-up examination between 1987 and 1991. Mean +/- SD follow-up time was 12.8 +/- 1.7 yr. Eleven Indian Health Service facilities (clinics and hospitals) in Oklahoma participated in the study. Study participants were a quasirandom sample of 1012 American Indians (379 men, 633 women) in Oklahoma with NIDDM, 927 of whom received a detailed eye examination at baseline. The mean age of participants was 52 yr with a duration of diabetes of 6.9 yr at baseline. The average quantum of Indian blood was 92% (77% full blood). At follow-up, 515 (55.6%) were alive, 408 (44.0%) were deceased, and 4 (0.4%) could not be traced. Of the living participants, 380 (73.8%) underwent an ophthalmoscopic examination. RESULTS: The incidence of retinopathy among the participants who were free of disease at baseline and who survived the follow-up interval was 72.3%. By multivariate analysis, significant independent predictors of retinopathy recorded at baseline were FPG level, therapeutic regimen, systolic blood pressure, and duration of diabetes. FPG levels > or = 11.1 mM (200 mg/dl) increased the risk of retinopathy 1.7 times that for levels < 7.8 mM (140 mg/dl). Insulin use was associated with a 20% greater incidence. Hypertension was a particularly significant risk factor for those with lower FPG levels. CONCLUSIONS: Given that NIDDM is reaching epidemic proportions in Oklahoma Indians and that most may be afflicted with retinopathy, frequent ophthalmological examinations are clearly indicated for this high-risk population. The role of intervention, namely glycemic and hypertensive control, deserves further study.

Cilioretinal artery occlusion in young adults with central retinal vein occlusion.

Ten patients, all younger than 50 years of age, had a temporal cilioretinal artery occlusion associated with a nonischemic central retinal vein occlusion. On fluorescein angiography, the cilioretinal artery eventually filled in all but one eye. The cilioretinal artery showed pulsations on fluorescein angiography in five eyes. The central retinal vein occlusion eventually resolved and the fundus assumed a normal appearance in all nine of the followed cases. Eight of nine eyes that underwent follow-up examination had final visual acuity of 20/30 or better. The occlusion of the central retinal vein produces an elevation of intraluminal capillary pressure because the central retinal artery continues to pump blood into the retina. Because the perfusion pressure of the cilioretinal artery is lower than the central retinal artery, it becomes relatively occluded. The prognosis for these patients is generally good unless the entire parafoveal capillary net is affected by the cilioretinal artery that is occluded.