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1.
Ocul Immunol Inflamm ; : 1-6, 2020 Apr 10.
Artigo em Inglês | MEDLINE | ID: mdl-32275186

RESUMO

Purpose: To determine the incidence of contralateral eye involvement and retinal detachment in HIV-infected patients with cytomegalovirus retinitis treated with repeated intravitreous ganciclovir.Methods: In a prospective cohort study in Northern Thailand, HIV-infected patients with cytomegalovirus retinitis were treated with antiretroviral therapy and intravitreous ganciclovir injections and followed for 3 months for contralateral cytomegalovirus retinitis and retinal detachment.Results: Of 49 participants with unilateral cytomegalovirus retinitis at enrollment, 7 developed contralateral eye involvement (4.8/100 person-months, 95% CI 1.9-9.8). Of 105 eyes without a retinal detachment at enrollment, 6 developed a retinal detachment (2.0/100 eye-months, 95% CI 0.7-4.3). Baseline clinical factors were not associated with the development of either outcome.Conclusion: Eyes treated with intravitreous ganciclovir experienced retinal detachment at a rate similar to other populations treated with systemic antivirals. The risk of contralateral eye involvement was relatively high during the first 3 months after initial diagnosis despite the institution of antiretroviral therapy.

3.
PLoS One ; 14(8): e0220362, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31393904

RESUMO

PURPOSE: Glaucoma screening can be performed by assessing the vertical-cup-to-disk ratio (VCDR) of the optic nerve head from fundus photography, but VCDR grading is inherently subjective. This study investigated whether computer software could improve the accuracy and repeatability of VCDR assessment. METHODS: In this cross-sectional diagnostic accuracy study, 5 ophthalmologists independently assessed the VCDR from a set of 200 optic disk images, with the median grade used as the reference standard for subsequent analyses. Eight non-ophthalmologists graded each image by two different methods: by visual inspection and with assistance from a custom-made publicly available software program. Agreement with the reference standard grade was assessed for each method by calculating the intraclass correlation coefficient (ICC), and the sensitivity and specificity determined relative to a median ophthalmologist grade of ≥0.7. RESULTS: VCDR grades ranged from 0.1 to 0.9 for visual assessment and from 0.1 to 1.0 for software-assisted grading, with a median grade of 0.4 for each. Agreement between each of the 8 graders and the reference standard was higher for visual inspection (median ICC 0.65, interquartile range 0.57 to 0.82) than for software-assisted grading (median ICC 0.59, IQR 0.44 to 0.71); P = 0.02, Wilcoxon signed-rank test). Visual inspection and software assistance had similar sensitivity and specificity for detecting glaucomatous cupping. CONCLUSION: The computer software used in this study did not improve the reproducibility or validity of VCDR grading from fundus photographs compared with simple visual inspection. More clinical experience was correlated with higher agreement with the ophthalmologist VCDR reference standard.

4.
Am J Ophthalmol ; 197: 136-144, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30268865

RESUMO

PURPOSE: To evaluate the efficacy, safety, and quality of life (QOL) of transdermal androgen in treatment of dry eye patients associated with androgen deficiency. DESIGN: Randomized controlled trial. METHODS: Fifty patients with dry eye from a tertiary eye center in northern Thailand were randomized to receive transdermal androgen (AndroGel; Besins Healthcare, Brussels, Belgium) or placebo for 4 weeks. Main outcome measures were symptoms and signs of dry eye. Serum level of sex hormone and QOL questionnaires were also evaluated at the baseline and after treatment. RESULTS: After 4 weeks, the Ocular Surface Disease Index decreased significantly in the AndroGel group compared to the placebo (-14.36 ± 7.76 vs 0.14 ± 14.60, P < .001). Significant improvements of tear break-up time (7.40 ± 3.37 vs -1.14 ± 1.68 seconds, P < .001), corneal fluorescein staining (-0.62 ± 0.30 vs 0.19 ± 0.37, P < .001), and Schirmer test (6.84 ± 5.10 vs -0.48 ± 2.14 mm, P < .001) were observed in the AndroGel group compared to the placebo. Serum testosterone in female patients significantly increased in the AndroGel group compared to the placebo (P < .001), while no different change was observed in serum testosterone in male subjects and the sex hormone-binding globulin in both groups. In the AndroGel group, 20% of patients had oily skin and 4% had acne. No serious adverse effects were reported. The menopause rating score improved significantly in the AndroGel group compared to the placebo (P < .001), while the aging male symptoms were not different in both groups (P = .589). CONCLUSIONS: Transdermal androgen was effective in relieving symptoms and signs of dry eye as well as improving QOL in aging patients. There were no serious side effects during a short-term treatment.


Assuntos
Androgênios/uso terapêutico , Síndromes do Olho Seco/tratamento farmacológico , Idoso , Androgênios/deficiência , Método Duplo-Cego , Síndromes do Olho Seco/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Soluções Oftálmicas/uso terapêutico , Qualidade de Vida , Adesivo Transdérmico
5.
Br J Ophthalmol ; 102(12): 1607-1610, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30206157

RESUMO

AIMS: To determine if early dilated fundus examination for cytomegalovirus (CMV) retinitis leads to better visual outcomes in areas with limited HIV care, where patients may have long-standing retinitis before they are diagnosed with HIV. METHODS: Twenty-four eyes of 17 patients with CMV retinitis who were seen at an urban HIV clinic in Chiang Mai, Thailand, were included in this retrospective cohort study. Participants were divided into two groups based on the amount of time from the first documented CD4 count below 100 cells/mm3 to the first eye examination for CMV retinitis. Average visual acuity in each group was calculated at the time CMV retinitis was first detected, and then at 3, 6 and 12 months after diagnosis. RESULTS: The group of patients who received an eye examination within approximately 4 months of the initial low CD4 count measurement had better baseline visual acuity (median 20/30,IQR 20/20 to 20/60) compared with patients who presented later (median 20/80, 20/60 to hand motion); p=0.03). Visual acuity did not change significantly during the 12-month study period in either the early group (p=0.69) or late group (p=0.17). CONCLUSION: In this study, patients who were examined sooner after a low CD4 count had better vision than patients who were examined later. Routine early screening of patients with CD4 counts under below 100 cells/mm3 may detect earlier disease and prevent vision loss.


Assuntos
Retinite por Citomegalovirus/diagnóstico , Diagnóstico Tardio , Diagnóstico Precoce , Oftalmoscopia/estatística & dados numéricos , Adulto , Retinite por Citomegalovirus/fisiopatologia , Diagnóstico Tardio/efeitos adversos , Diagnóstico Tardio/estatística & dados numéricos , Progressão da Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Encaminhamento e Consulta/estatística & dados numéricos , Estudos Retrospectivos , Tailândia , Acuidade Visual
6.
Open Ophthalmol J ; 12: 63-71, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29872485

RESUMO

Purpose: To evaluate the efficacy, predictability, stability and safety of laser in situ keratomileusis (LASIK) using the FS200 femtosecond laser and EX500 excimer laser platform. Methods: The outcomes of 254 eyes of 129 consecutive patients with myopia or myopic astigmatism who underwent full correction femtosecond laser-assisted LASIK at CMU LASIK Center were assessed. Pre-operative and post-operative parameters including manifest refraction, Uncorrected Distance Visual Acuity (UDVA), Best Corrected Distance Visual Acuity (BDVA), corneal topography and tomography were analyzed. The results between low to moderate myopia and high myopia were compared up to 12 months. Results: Mean pre-operative Spherical Equivalent (SE) was -5.15±2.41 Diopters (D) (range -0.50 to -11.50 D) and -0.13±0.28 D, -0.13±0.27 D, -0.13±0.28 D and -0.14±0.30 D at 1, 3, 6, and 12 months, post-operatively. At 12 months, the propor¬tion of eyes achieving UDVA ≥ 20/20 was 90.0% and ≥20/40 was 98.8%. The proportion of eyes achieving post-operative mean SE ±0.5 D, and ±1 D was 91.3%, and 98.5%. No eyes lost more than two lines of BDVA. The low to moderate myopic group had a statistically significant better UDVA at one (p=0.017) and three months (p=0.014) but no difference at six (p=0.061) and 12 months (p=0.091). The mean post-operative SE was better in low to moderate myopic group at every follow-up visit (p=0.001, 0.007, <0.001 and <0.001). Conclusion: One-year clinical results of LASIK with the FS200 femtosecond laser and EX500 excimer laser showed high efficacy, predictability, stability and safety.

7.
PLoS One ; 13(2): e0193161, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29466424

RESUMO

Human immunodeficiency virus (HIV) causes impairment to the human immune system which leads to immunocompromised conditions, including ocular complications. Several important HIV-associated disorders may involve the anterior segment, ocular surface, and adnexae organ such as dry eye, blepharitis which reduce quality of life of patients. In present, potent antiretroviral therapies HAART (highly active antiretroviral therapy) has improved the length and quality of life which may lead to an increased prevalence of anterior segment ocular disorders. Hence, this study has been undertaken to identify the prevalence and associated factors of anterior segment and external ocular disorder in HIV infected patients in the era of HAART. A prospective descriptive cross sectional study was carried out in HIV positive patients conducted at the Department of Ophthalmology, Chiang Mai University Hospital, from February 2014 to October 2015. Detail history and ocular examination was carried out to examine for anterior segment and external ocular disorders. A total number of 363 patients were included for this prospective cross-sectional study. From the total of 363 patients, 123 patients had an anterior segment and external ocular disorder which account as the prevalence of 33.9%. The most common anterior segment manifestations was dry eye seen in 36 patients (9.9%), followed by posterior blepharitis (Meibomian gland dysfunction) seen in 23 patients (6.3%) and anterior blepharitis seen in 12 patients (3.3%). Other ocular complications included microvasculopathy, immune recovery uveitis, conjunctivitis, papilloma, anterior uveitis, corneal ulcer, nevus, trichiasis, molluscum contangiosum, Kaposi sarcoma, interstitial keratitis, conjunctival lymphangiectasia, dacryocystitis, vernal keratoconjunctivitis and eyelid penicilosis. In this study, the prevalance of anterior segment disorders was higher than in the preHAART era. Dry eye, blepharitis and uveitis were the top three most common anterior segment disorders in the HAART era. The statistical analysis showed no association between age, sex, CD4 count, duration of infection or receiving HAART and anterior segment disorders. Anterior segment abnormalities reduce the quality of life of patients, so ophthalmologists have to be aware and complete ocular examination should be performed in all HIV infected patients.


Assuntos
Oftalmopatias , Infecções por HIV , HIV-1 , Adolescente , Adulto , Idoso , Terapia Antirretroviral de Alta Atividade/efeitos adversos , Criança , Estudos Transversais , Oftalmopatias/induzido quimicamente , Oftalmopatias/epidemiologia , Oftalmopatias/patologia , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Infecções por HIV/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Prospectivos
8.
Br J Ophthalmol ; 101(6): 691-694, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28450377

RESUMO

AIM: The aim of this study was to determine the frequency of fundus abnormalities among patients who are undergoing or have recently completed treatment for extrapulmonary tuberculosis (eTB). METHODS: This is a prospective cross-sectional study conducted in a TB clinic of a tertiary hospital in northern Thailand. All patients who had eTB between January 2014 and August 2015 were invited by telephone to return to the clinic for fundus photography. Three uveitis specialists reviewed all photographs to identify posterior segment lesions that were consistent with ocular TB. RESULTS: A total of 265 patients were diagnosed with eTB during the specified period, of which 118 (44.5%) were reached by telephone and 60 (50.8%) participated in the study. A total of 7 eyes from six patients (10.0% of participants, 95% CI 2.2% to 17.8%) had lesions consistent with ocular TB. The group with possible ocular TB lesions was on average 16.8 years older than those without ocular lesions (p=0.01), but the two groups were otherwise not significantly different. CONCLUSION: Ocular lesions consistent with TB were not rare in a group of patients who were undergoing or had recently completed treatment for eTB. Fundus examination may provide diagnostic information that could influence a clinician's beliefs when diagnosing eTB. Given the low costs and immediate results of eye examination, this diagnostic test should be considered in patients suspected for eTB, especially when other tests are negative.


Assuntos
Técnicas de Diagnóstico Oftalmológico , Retina/diagnóstico por imagem , Tuberculose Ocular/diagnóstico , Adulto , Estudos Transversais , Feminino , Seguimentos , Fundo de Olho , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Tailândia/epidemiologia , Tuberculose Ocular/epidemiologia
9.
Int Ophthalmol ; 37(6): 1289-1298, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27914026

RESUMO

PURPOSE: To evaluate the results of cultivated limbal epithelial and oral mucosal epithelial transplantation (CLET and COMET) in limbal stem cell deficiency (LSCD)-induced rabbit model. MATERIALS AND METHODS: Six New Zealand white rabbits were divided into two groups of three rabbits each. Limbal tissue was harvested from the first group, and oral mucosal biopsy was obtained from the second group. The tissues were cultured using an explant technique with amniotic membrane as a substrate and co-culture with the 3T3 fibroblast and air-lifting method. The right eye of each rabbit was induced to have LSCD using alkali burns. After three weeks, the LSCD-induced rabbit eyes were transplanted with the cultivated limbal and oral mucosal epithelial sheet in the first and second group, respectively. The transplanted eye was evaluated weekly post-operation. After 2 months, all transplanted eyes were enucleated and the epithelial morphology and phenotype of ocular surfaces were studied and compared with normal corneal and oral mucosal tissue. RESULTS: At 2-month post-transplantation, the eyes of four animals recovered with corneal transparency, one partially recovered, and one failed. The histology of the majority of transplanted eyes was stratified layers of corneal epithelia similar to normal rabbit cornea with some different findings such as goblet cells in the limbal region. Corneal epithelial thickening and stromal vascularization in two animals were observed. Phenotypic characterization of transplanted eyes showed a similar pattern of marker expression with the absence of p63 expression in the limbal or corneal epithelium in the COMET group. CONCLUSIONS: The histology and phenotype of transplanted eyes after CLET and COMET were most likely to have similar characteristics as a normal healthy rabbit eye even though the COMET eyes have some inferior characteristics to the CLET eyes.


Assuntos
Transplante de Células/métodos , Lesões da Córnea/cirurgia , Células Epiteliais/transplante , Limbo da Córnea/citologia , Mucosa Bucal/citologia , Transplante de Células-Tronco , Âmnio/transplante , Animais , Queimaduras Químicas/terapia , Técnicas de Cultura de Células/métodos , Modelos Animais de Doenças , Queimaduras Oculares/terapia , Procedimentos Cirúrgicos Oftalmológicos , Coelhos
10.
PLoS One ; 11(10): e0165564, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27788232

RESUMO

PURPOSE: Cytomegalovirus (CMV) retinitis remains a leading cause of blindness in countries with a high burden of AIDS. Although dilated fundus examinations are recommended for those with CD4 counts below 100 cells/µL, in practice only those with poor vision and/or symptoms are routinely referred for screening. Therefore, the predictive value of this common practice should be assessed. METHODS: This is a prospective cross-sectional study. Patients with known HIV and a CD4 count of less than 100 cells/µL attending an HIV clinic in Chiang Mai, Thailand completed a standardized questionnaire about visual symptoms and underwent visual acuity testing and dilated fundus examination. Participants without CMV retinitis were invited for repeated examinations every 3 months until their CD4 count exceeded 100 cells/µL. Patient-level statistical analyses were conducted to calculate diagnostic test characteristics, with bootstrapping to account for correlated data. RESULTS: Of 103 study participants, 16 had CMV retinitis diagnosed at some point during the study. Participants with CMV retinitis were more likely to complain of visual symptoms compared to those without CMV retinitis (p = 0.01), including scotoma (p = 0.0002), itchy or watery eyes (p < 0.0001), and eye pain (p = 0.003); they were also more likely to have visual acuity worse than Counting Fingers (p = 0.0003). However, the absence of eye symptoms and the absence of poor vision did not strongly affect the probability that a patient did not have disease (negative likelihood ratio 0.56 and 0.76, respectively). CONCLUSIONS: Ocular symptoms and poor visual acuity were poor diagnostic indicators for the presence of CMV retinitis. Systematic screening of HIV patients with CD4 counts below 100 cells/µl should be carried out to detect disease at an early stage, when blindness can still be prevented.


Assuntos
Retinite por Citomegalovirus/diagnóstico , Adulto , Estudos Transversais , Retinite por Citomegalovirus/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Tailândia , Acuidade Visual
11.
Br J Ophthalmol ; 100(8): 1017-21, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-27297217

RESUMO

AIM: To determine if poor access to healthcare is associated with increased cytomegalovirus (CMV) retinitis risk among patients with HIV with CD4 counts of <100 cells/µL screened in a resource-limited setting. METHODS: This is a prospective cross-sectional study. Patients with known HIV and a CD4 count of <100 cells/µL attending an HIV clinic in Chiang Mai, Thailand, completed a standardised questionnaire and underwent dilated fundus examination. Participants without CMV retinitis were invited for repeated examinations every 3 months until their CD4 count exceeded 100 cells/µL. The relationship between various potential risk factors and CMV retinitis was assessed with logistic regression. RESULTS: 103 study participants were enrolled. At enrolment, the mean age was 37.5 (95% CI 35.7 to 39.2) years, 61.2% (95% CI 51.6% to 70.7%) were male and the mean CD4 count was 29.5 (95% CI 25.9 to 33.1) cells/µL. 21 eyes from 16 (15.5%) participants were diagnosed with CMV retinitis. In multivariate analyses, CMV retinitis was significantly associated with lower CD4 count (OR 1.42 per 10-cell decrement, 95%CI 1.05 to 1.93), longer travel time to clinic (OR 3.85 for those with >30-min travel time, 95% CI 1.08 to 13.8) and lower income (OR 1.22 per US$50 less income, 95% CI 1.02 to 1.47). CONCLUSIONS: CD4 count, low income and longer travel time to clinic were significant risk factors for CMV retinitis among patients with HIV in a resource-limited setting. These results suggest that reducing blindness from CMV retinitis should focus on increasing accessibility of screening examinations to poor and hard-to-reach patients.


Assuntos
Infecções Oportunistas Relacionadas com a AIDS/epidemiologia , Linfócitos T CD4-Positivos/patologia , Retinite por Citomegalovirus/epidemiologia , HIV , Acesso aos Serviços de Saúde , Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Adulto , Contagem de Linfócito CD4 , Estudos Transversais , Retinite por Citomegalovirus/diagnóstico , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Tailândia/epidemiologia
12.
JAMA Ophthalmol ; 133(2): 198-205, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25412344

RESUMO

IMPORTANCE: Cytomegalovirus (CMV) retinitis is a leading cause of blindness in many developing countries, likely the result of inadequate screening. Telemedicine screening for CMV retinitis instituted at the point of care for human immunodeficiency virus (HIV) infection may allow for earlier detection. OBJECTIVES: To determine the diagnostic accuracy of retinal photography in detecting CMV retinitis at the point of HIV care and to characterize the clinical manifestations of CMV retinitis detected through the screening program. DESIGN, SETTING, AND PARTICIPANTS: We enrolled 103 participants from a population of 258 patients with HIV and a CD4 level of less than 100/µL treated at an HIV clinic in Thailand from June 2010 through June 2012. We captured mosaic fundus photographs through a dilated pupil using a digital fundus camera. An experienced on-site ophthalmologist masked to the results of the fundus images subsequently examined each eye with indirect ophthalmoscopy and recorded the clinical findings on a standardized form. Three remote graders evaluated each image for CMV retinitis. INTERVENTION: Fundus photography and indirect ophthalmoscopy. MAIN OUTCOMES AND MEASURES: Sensitivity and specificity of telemedicine relative to indirect ophthalmoscopy for diagnosis of CMV retinitis and clinical features of CMV retinitis lesions. RESULTS: Sixteen patients (15.5%) were diagnosed as having CMV retinitis, of whom 5 (31%) had bilateral disease. Of the 21 eyes (10.2%) with CMV retinitis, 7 (33%) had visual symptoms. Retinitis lesions occupied less than 10% of the total retinal surface area in 13 of 21 eyes (62%) and did not involve the posterior pole (ie, zone 1) in 15 of 21 eyes (71%). Mean logMAR visual acuity in affected eyes was 0.41 (95% CI, 0.11-0.71; Snellen equivalent, 20/50 [95% CI, 20/25-20/100]). The mean sensitivity for the 3 remote graders in detecting CMV retinitis on fundus photography was 30.2% (95% CI, 10.5%-52.4%), and mean specificity was 99.1% (95% CI, 97.8%-100.0%). The CMV retinitis lesions missed by the remote graders (false-negative findings) were more likely to be small (P = .001) and located in the peripheral retina (P = .04). CONCLUSIONS AND RELEVANCE: Patients undergoing screening at a clinic for HIV treatment had less extensive retinitis than patients in recent reports from an ophthalmology clinic. Retinal photography with the camera used in this study was not highly sensitive in detecting CMV retinitis but may identify disease with an immediate threat to vision. Improved accuracy will require a camera that can more easily image the peripheral retina.


Assuntos
Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Retinite por Citomegalovirus/diagnóstico , Programas de Rastreamento/métodos , Sistemas Automatizados de Assistência Junto ao Leito , Retina/patologia , Telemedicina/métodos , Infecções Oportunistas Relacionadas com a AIDS/epidemiologia , Adulto , Retinite por Citomegalovirus/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Reprodutibilidade dos Testes , Estudos Retrospectivos , Tailândia/epidemiologia , Acuidade Visual
13.
Am J Ophthalmol ; 159(1): 185-92, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25448999

RESUMO

PURPOSE: To determine risk factors predictive of retinal detachment in patients with cytomegalovirus (CMV) retinitis in a setting with limited access to ophthalmic care. DESIGN: Case-control study. METHODS: Sixty-four patients with CMV retinitis and retinal detachment were identified from the Ocular Infectious Diseases and Retina Clinics at Chiang Mai University. Three control patients with CMV retinitis but no retinal detachment were selected for each case, matched by calendar date. The medical records of each patient were reviewed, with patient-level and eye-level features recorded for the clinic visit used to match cases and controls, and also for the initial clinic visit at which CMV retinitis was diagnosed. Risk factors for retinal detachment were assessed separately for each of these time points using multivariate conditional logistic regression models that included 1 eye from each patient. RESULTS: Patients with a retinal detachment were more likely than controls to have low visual acuity (odds ratio [OR], 1.24 per line of worse vision on the logMAR scale; 95% confidence interval [CI], 1.16-1.33) and bilateral disease (OR, 2.12; 95% CI, 0.92-4.90). Features present at the time of the initial diagnosis of CMV retinitis that predicted subsequent retinal detachment included bilateral disease (OR, 2.68; 95% CI, 1.18-6.08) and lesion size (OR, 2.64 per 10% increase in lesion size; 95% CI, 1.41-4.94). CONCLUSION: Bilateral CMV retinitis and larger lesion sizes, each of which is a marker of advanced disease, were associated with subsequent retinal detachment. Earlier detection and treatment may reduce the likelihood that patients with CMV retinitis develop a retinal detachment.


Assuntos
Infecções Oportunistas Relacionadas com a AIDS/complicações , Retinite por Citomegalovirus/complicações , Descolamento Retiniano/etiologia , Adulto , Estudos de Casos e Controles , Retinite por Citomegalovirus/etiologia , Retinite por Citomegalovirus/fisiopatologia , Feminino , Infecções por HIV/complicações , Recursos em Saúde/provisão & distribução , Humanos , Modelos Logísticos , Masculino , Descolamento Retiniano/diagnóstico , Fatores de Risco , Tailândia , Acuidade Visual
15.
JAMA Ophthalmol ; 132(9): 1052-8, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24945306

RESUMO

IMPORTANCE: Cytomegalovirus (CMV) retinitis continues to be a leading cause of blindness in many developing countries. Telemedicine holds the potential to increase the number of people screened for CMV retinitis, but it is unclear whether nonophthalmologists could be responsible for interpreting fundus photographs captured in a telemedicine program. OBJECTIVE: To determine the accuracy of nonophthalmologist photographic graders in diagnosing CMV retinitis from digital fundus photographs. DESIGN, SETTING, AND PARTICIPANTS: Fifteen nonexpert graders each evaluated 182 mosaic retinal images taken from the eyes of patients with AIDS who were evaluated at the Ocular Infectious Diseases Clinic at Chiang Mai University in Chiang Mai, Thailand. MAIN OUTCOMES AND MEASURES: Graders diagnosed each image as CMV retinitis present, CMV retinitis absent, or unknown. The results from each grader were compared with those of an indirect ophthalmoscopic examination from an experienced on-site ophthalmologist as well as with the consensus grade given by a panel of CMV retinitis experts. RESULTS: Relative to the on-site ophthalmologist, the sensitivity of remote CMV retinitis diagnosis by nonexpert graders ranged from 64.0% to 95.5% (mean, 84.1%; 95% CI, 78.6%-89.6%)), and the specificity ranged from 65.6% to 92.5% (mean, 82.3%; 95% CI, 76.6%-88.0%)). Agreement between nonexpert and expert graders was high: the mean sensitivity and specificity values of nonexpert diagnosis using expert consensus as the reference standard were 93.2% (95% CI, 90.6%-95.8%) and 88.4% (95% CI, 85.4%-91.1%), respectively. Mean intrarater reliability also was high (mean Cohen κ, 0.83; 95% CI, 0.78-0.87). CONCLUSIONS AND RELEVANCE: The sensitivity and specificity of remote diagnosis of CMV retinitis by nonexpert graders was variable, although several nonexperts achieved a level of accuracy comparable to that of CMV retinitis experts. More intensive training and periodic evaluations would be required if nonexperts are to be used in clinical practice.


Assuntos
Pessoal Técnico de Saúde/normas , Retinite por Citomegalovirus/diagnóstico , Oftalmologia/normas , Fotografação/classificação , Retina/patologia , Telemedicina/normas , Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Antivirais/uso terapêutico , Países em Desenvolvimento , Reações Falso-Positivas , Humanos , Masculino , Pessoa de Meia-Idade , Oftalmoscopia , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Tailândia , Acuidade Visual
16.
Int J Ophthalmol ; 7(1): 145-51, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24634881

RESUMO

AIM: To determine healthcare resource utilization and the economic burden associated with wet age-related macular degeneration (AMD) in Thailand. METHODS: This study included patients diagnosed with wet AMD that were 60 years old or older, and had best corrected visual acuity (BCVA) measured at least two times during the follow-up period. We excluded patients having other eye diseases. Two separate sub-studies were conducted. The first sub-study was a retrospective cohort study; electronic medical charts were reviewed to estimate the direct medical costs. The second sub-study was a cross-sectional survey estimating the direct non-medical costs based on face-to-face interviews using a structured questionnaire. For the first sub-study, direct medical costs, including the cost of drugs, laboratory, procedures, and other treatments were obtained. For the second sub-study, direct non-medical costs, e.g. transportation, food, accessories, home renovation, and caregiver costs, were obtained from face-to-face interviews with patients and/or caregivers. RESULTS: For the first sub-study, sixty-four medical records were reviewed. The annual average number of medical visits was 11.1±6.0. The average direct medical costs were $3 604±4 530 per year. No statistically-significant differences of the average direct medical costs among the BCVA groups were detected (P=0.98). Drug costs accounted for 77% of total direct medical costs. For direct non-medical costs, 67 patients were included. Forty-eight patients (71.6%) required the accompaniment of a person during the out-patient visit. Seventeen patients (25.4%) required a caregiver at home. The average direct non-medical cost was $2 927±6 560 per year. There were no statistically-significant differences in the average costs among the BCVA groups (P=0.74). Care-giver cost accounted for 87% of direct non-medical costs. CONCLUSION: Our study indicates that wet AMD is associated with a substantial economic burden, especially concerning drug and care-giver costs.

17.
Ophthalmic Epidemiol ; 20(5): 267-73, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24070100

RESUMO

PURPOSE: The World Health Organization (WHO) recommends that Southeast Asian countries have ≥ 1 ophthalmologist per 100,000 persons, equally distributed in urban and rural areas. However, regional patterns of eye care have been poorly characterized. This study investigates the distribution of ophthalmologists in Thailand and provides regional estimates of access to ophthalmologists. METHODS: We geocoded the work address of ophthalmologists listed in the 2008 directory of the Royal College of Ophthalmologists of Thailand. We determined the number of ophthalmologists per 100,000 persons at the national, provincial, and district levels using data from the 2000 Thai Population Census, and assessed demographic factors associated with meeting the WHO recommendation of ≥ 1 ophthalmologist per 100,000 persons. RESULTS: In 2008, Thailand had 1.52 ophthalmologists per 100,000 persons; however, only 20 of 76 provinces (26%) and 134 of 926 districts (14%) met the WHO recommendation of ≥ 1 ophthalmologist per 100,000 persons. District factors associated with not meeting the WHO recommendation included a high proportion of children, a high proportion of elderly, and a high proportion of rural residents. CONCLUSION: Thailand meets the WHO's goal for access to ophthalmologic care, but the distribution of ophthalmologists is uneven, with less access to ophthalmologic care in rural areas.


Assuntos
Acesso aos Serviços de Saúde/estatística & dados numéricos , Mão de Obra em Saúde/estatística & dados numéricos , Oftalmologia , Médicos/provisão & distribução , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oftalmologia/estatística & dados numéricos , População Rural/estatística & dados numéricos , Tailândia/epidemiologia , População Urbana/estatística & dados numéricos , Organização Mundial da Saúde , Adulto Jovem
18.
JAMA Ophthalmol ; 131(5): 638-45, 2013 May.
Artigo em Inglês | MEDLINE | ID: mdl-23494002

RESUMO

IMPORTANCE: Little attention has been paid to clinical features of cytomegalovirus (CMV) infections in individuals without human immunodeficiency virus (HIV). OBJECTIVE: To describe the clinical manifestations and comorbidities of patients without HIV infection who have CMV-associated posterior uveitis or panuveitis. DESIGN AND SETTING: Retrospective observational case series in an academic research setting. PARTICIPANTS: The medical records were reviewed of 18 patients (22 affected eyes) diagnosed as having posterior uveitis or panuveitis who had aqueous positive for CMV by polymerase chain reaction techniques. MAIN OUTCOME MEASURES: Demographic data, clinical manifestations, and associated systemic diseases were recorded. RESULTS: Ocular features included focal hemorrhagic retinitis (n = 13) and peripheral retinal necrosis (n = 7). Two eyes had no focal retinal lesions but manifested vasculitis and vitritis. All patients exhibited vitreous inflammation. Inflammatory reactions in anterior segments developed in 14 of 22 eyes (64%). Retinal vasculitis was observed in 16 of 22 eyes (73%) and included mostly arteries (in 13 of 16 eyes [81%]). Eleven of 18 patients were taking immunosuppressive medications (5 for hematologic malignant diseases, 4 for systemic autoimmune diseases, and 2 following organ transplants). One additional patient was diagnosed as having non-Hodgkin lymphoma 3 months after the onset of CMV-associated panuveitis, and another patient had primary immunodeficiency disorder. Of the remaining 5 patients, 2 had diabetes mellitus, and 3 had no associated systemic diseases and exhibited no evidence of immune deficiency. CONCLUSIONS AND RELEVANCE: Cytomegalovirus-associated infections of posterior eye segments can develop in patients without HIV infection who have compromised immune function of variable severity but may occur also in individuals who have no evidence of immune insufficiency. Cytomegalovirus infections located in posterior eye segments in patients without HIV infection caused intraocular inflammatory reaction in all cases and demonstrated more variable clinical presentation than classic CMV retinitis observed in patients with HIV infection.


Assuntos
Infecções por Citomegalovirus/diagnóstico , Infecções Oculares Virais/diagnóstico , Infecções por HIV/complicações , Pan-Uveíte/diagnóstico , Uveíte Posterior/diagnóstico , Adulto , Idoso , Humor Aquoso/virologia , Contagem de Linfócito CD4 , Infecções por Citomegalovirus/imunologia , Infecções por Citomegalovirus/virologia , DNA Viral/análise , Infecções Oculares Virais/imunologia , Infecções Oculares Virais/virologia , Feminino , Humanos , Imunossupressão , Imunossupressores/uso terapêutico , Masculino , Pessoa de Meia-Idade , Pan-Uveíte/imunologia , Pan-Uveíte/virologia , Reação em Cadeia da Polimerase em Tempo Real , Estudos Retrospectivos , Uveíte Posterior/imunologia , Uveíte Posterior/virologia , Corpo Vítreo/patologia , Corpo Vítreo/virologia
19.
J Med Assoc Thai ; 95 Suppl 4: S129-35, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-22696865

RESUMO

OBJECTIVE: To quantify the frequencies of the common causes of visual acuity loss for HIV-infected patients with cytomegalovirus retinitis (CMVR) in the era of highly active antiretroviral therapy(HAART). MATERIAL AND METHOD: The present prospective observational study comprised 113 patients (184 eyes) with newly diagnosed CMVR, from May 2008-March 2010. Each patient was followed-up every 3 months with medical history and ophthalmologic examination. Patients were divided as visual impairment and legal blindness. RESULTS: The majority of the patients were native Thai (91%), while the rest was of hill tribe origin. 55% were females with age ranged between 14-57 years (average of 39). The main cause of HIV infection was heterosexual contact (90%), followed by homosexual contact (7%). It was found that 68% had CD4 T-cell count less than 50 cells/microl and that 46% had bilateral CMVR. Major causes of visual impairment were CMVR zone 2&3, CMVR zone 1 and cataract, respectively. Major causes of legal blindness were CMVR zone 2&3, CMVR zone 1 and retinal detachment, respectively Retinal detachment was a major risk factor in both groups. Even when surgery was successful, the visual acuity was not significantly improved, indicating a permanent loss of vision. CONCLUSION: In the HAART era, immune recovery of HIV patients also helps restoring specific anti-CMVimmunity. HAART reduces occurrence of visual impairment to 0.10/eye-year (EY) and legal blindness to 0.15/EY, compared to the pre-HAART figures of 0.94-0.98/EY and 0.47-0.49/EY respectively. However, it did not completely eliminate the occurrence. CMVR and cataract remain the most common causes of visual acuity loss followed by retinitis-related retinal detachment, and optic nerve atrophy respectively.


Assuntos
Terapia Antirretroviral de Alta Atividade , Retinite por Citomegalovirus/complicações , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Transtornos da Visão/etiologia , Adolescente , Adulto , Estudos de Coortes , Retinite por Citomegalovirus/diagnóstico , Retinite por Citomegalovirus/terapia , Feminino , Hospitais Universitários , Humanos , Masculino , Pessoa de Meia-Idade , Tailândia , Transtornos da Visão/diagnóstico , Transtornos da Visão/terapia , Adulto Jovem
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