Adherence of patients with diabetic macular oedema to intravitreal injections: A systematic review.

The purpose of this study was to review adherence rates to intravitreal injections in the treatment of diabetic macula oedema and to identify factors associated with adherence. A systematic search of Embase, Medline, PsycINFO and CINAHL was conducted up to May 2020. Two authors independently screened, selected and appraised the studies. Seven articles on anti-VEGF treatment were found to meet the inclusion criteria. No studies were found on intravitreal corticosteroids or dexamethasone implants. Attendance rates varied between studies from 35% to 85%. The rate of missed or delayed attendance ranged from 14% to 51%, whereas 25% of patients were lost to follow-up at 12 months. Non-adherence was found to be multifactorial and included patient related reasons, demographic characteristics and clinical factors. Enablers to adherence included patient understanding of the disease and treatment. Further research in this area is warranted in order to better understand adherence in these patients and to improve patient outcomes.

Experiences and perceptions of patients undergoing treatment and quality of life impact of diabetic macular edema: a systematic review.

Diabetic macular edema (DME) is a common cause of visual impairment. Current treatments for DME include laser photocoagulation, corticosteroids and Vascular Endothelial Growth Factor (VEGF) antagonists, which are administered via intravitreal injection. The purpose of this systematic review is to explore the experiences and perceptions of patients undergoing laser, corticosteroid implants and intravitreal injection treatment for DME and the impact on Quality of Life (QoL). A systematic search of the Embase, Medline, PsycINFO and Cinahl electronic databases was conducted to identify all studies with an unlimited date range, published in the English language, full text and incorporating human participants. Hand searching identified two articles. Following the application of the Critical Appraisal Skills Programme (CASP) Quantitative and Qualitative Research Checklist 21 articles were selected for inclusion, as they were deemed pertinent for the purpose of this review. Limited studies have examined DME patients' experiences and perceptions of treatment and QoL. The outcomes of these studies lack agreement on the effectiveness of treatment, treatment preferences and impact of QoL in patients with DME. Future research which enhances current knowledge will therefore serve to improve treatment outcomes and QoL in these patients.

Experiences of patients undergoing repeated intravitreal anti-vascular endothelial growth factor injections for neovascular age-related macular degeneration.

Current therapy to slow disease progression in patients with neovascular age-related macular degeneration (AMD) entails regular intravitreal anti-vascular endothelial growth factor (VEGF) injections, often indefinitely. Little is known about the burden imposed on patients by this repetitive treatment schedule and how this can be best managed. The aim of this study was to explore the psychosocial impact of repeated intravitreal injections on patients with neovascular AMD. Forty patients (16 males, 24 females) with neovascular AMD undergoing anti-VEGF treatment were recruited using purposive sampling from a private ophthalmology practice and public hospital in Melbourne. Patients were surveyed using the Macular Disease Treatment Satisfaction Questionnaire (MacTSQ; Bradley, Health Psychology Research Unit, Surrey, England) and underwent semi-structured, one-on-one interviews. Interview topics were: treatment burden and satisfaction; tolerability; barriers to adherence; treatment motivation; and patient education. Interviews were audio recorded and thematic analysis performed using NVivo 10 (QSR International, Doncaster, Australia). Patients recognised the importance of treatment to preserve eyesight, yet experienced significant psychosocial and practical burden from the treatment schedule. Important issues included treatment-related anxiety, financial considerations and transport burden placed on relatives or carers. Many patients were restricted to sedentary activities post-injection owing to treatment side effects. Patients prioritised treatment, often sacrificing family, travel and social commitments owing to a fear of losing eyesight if treatment was not received. Whilst anti-VEGF injections represent the current mainstay of treatment for neovascular AMD, the ongoing treatment protocol imposes significant burden on patients. An understanding of the factors that contribute to the burden of treatment may help inform strategies to lessen its impact and assist patients to better manage the challenges of treatment.

Experiences of patients undergoing anti-VEGF treatment for neovascular age-related macular degeneration: a systematic review.

Current therapy to slow disease progression in patients with neovascular age-related macular degeneration (AMD) often entails intra-vitreal injection of an anti-vascular endothelial growth factor (VEGF) agent, that begins with a three-month loading phase of four weekly injections followed by regular monthly visits with clinician-determined re-treatment. The effects of AMD on quality of life and visual function have been extensively reported in the literature, however, less is known about the burden imposed on patients by the arduous and often indefinite treatment schedule which habitually follows a diagnosis of wet AMD. To date, no systematic review has been conducted of research investigating patients' experiences of anti-VEGF treatment for AMD. A systematic search of the Embase, Medline, PsycINFO and PubMed electronic databases was undertaken to identify all studies between January 2004 and December 2013, published in the English language and involving human participants. A hand-search of an additional four journals was conducted. Ten articles were identified for inclusion in this review. A critical appraisal was undertaken using the Critical Appraisal Skills Programme Qualitative Research Checklist and the results synthesised to form a narrative review. Few studies to date have investigated patients' experiences of treatment for AMD. These studies have focused primarily on patients' experiences of the injection procedure with respect to pain and anxiety. Anticipated discomfort is often greater than actual discomfort experienced during intra-vitreal injection. However, different stages of the treatment procedure produce varying levels of patient discomfort. No one method of anaesthesia has consistently been shown to be more effective in reducing discomfort associated with treatment. Common reasons underlying patient apprehension surrounding treatment include the thought of having an injection, fear of losing eyesight and fear of the unknown. Whilst these studies have not been without their methodological limitations, they provide a platform for further exploration of the patient experience.

'Poppers Maculopathy' and the adverse ophthalmic outcomes from the recreational use of alkyl nitrate inhalants: a systematic review.

OBJECTIVE: The aim of this systematic review and meta-analysis was to provide an overview of reported cases of poppers maculopathy and a statistical analysis of the clinical presentations, anatomical changes and treatment and follow-up of the rare disease. METHODS: A systematic search of CINAHL, Embase and PubMed databases was conducted, including a search of the grey literature. Data were pooled to provide a summary of the clinical characteristics and outcomes of poppers maculopathy. Studies were critically appraised using the Joanna Briggs Institute or the Authority, Accuracy, Coverage, Objectivity, Date, Significance checklists. RESULTS: Of the 493 articles obtained, 32 were included, consisting of 113 participants with a mean age of 40.2. Most patients were male with bilateral maculopathy and presented with either vision loss or a visual disturbance. Cessation of popper use was the most common form of management prescribed. The mean VA at baseline was 0.22 (logMAR units). For those followed-up, the mean VA significantly improved from 0.24 to 0.11 (Z = -5.800, p = <0.001). Bilateral yellow foveal spots were viewed on fundoscopy in 53 patients, and a sub-foveal disturbance of the ellipsoid layer was reported on spectral domain optical coherence tomography in 89 patients. By 6 months, SD-OCT anatomical changes mostly improved or resolved. CONCLUSION: Recreational users of poppers who develop maculopathy generally present with vision loss or a visual disturbance secondary to foveal disruption. Patients have a good visual prognosis, with cessation of poppers potentially having a role in improved outcomes. With the high prevalence of use among gay and bisexual men, awareness of related maculopathy and presenting symptoms by clinicians is important to mitigate side effects.

Effectiveness of visual and acoustic biofeedback eccentric viewing training in conjunction with home exercises on visual function: a retrospective observational review.

The aim of this study is to evaluate the effectiveness of an eccentric viewing training program that combines biofeedback training using micro-perimetry with home exercises on multiple visual function parameters and to explore potential relationships between post-treatment visual function parameters. A retrospective observational review of 27 participants who underwent the training program was performed. Eligible participants were diagnosed with bilateral central scotomas secondary to age-related macular degeneration. All participants undertook up to 15 visual and acoustic biofeedback training sessions and were required to partake in traditional home exercises between sessions. The biofeedback training was conducted in the better eye using the Macular Integrity Assessment microperimeter (MAIA). Distance and near acuity, contrast sensitivity and fixation stability quantified by the P1 and P2 values and the 63% and 95% bivariate contour ellipse area (BCEA) before and after the rehabilitation program were recorded. Significant improvement was noted post-training for distance visual acuity (t(26) = 4938 p = .000), near visual acuity (Z = -4.461 p = .000), contrast sensitivity (Z = -3.647 p = .000) and fixation stability for all measures, including P1 (t(26) = -9.490 p = .000), P2 (t(26) = -7.338 p = 0.000), 63% BCEA (Z = 3.569 p = .000) and 95% BCEA (t(26) = 4.687 p = .000). Significant medium-to-large correlations were also found between most visual function variables. Visual and acoustic biofeedback in conjunction with home exercises has the potential to improve visual function parameters in patients with age-related macular degeneration and irreversible central vision loss.

COVID-19 and sudden-onset ocular neurogenic palsy in prior healthy patients: a systematic review.

BACKGROUND: The aim of this systematic review is to identify cases of neurogenic ocular palsy in the presence of COVID-19 and to document patient characteristics, type of palsy and possible aetiologies. METHODS: A systematic search of PubMed, Medline and CINAHL databases was conducted on the 6th of January 2023 to identify cases of neurogenic ocular palsy in patients with current or previous COVID-19 infection. Data were pooled to summarise the neurogenic palsy, patient clinical characteristics and proposed palsy mechanisms. RESULTS: The combined database search yielded 1197 articles. Of these, 23 publications consisting of 25 patients met the inclusion criteria. Most patients were male (68%) and ranged in age from 2 to 71 years (median=32.7, SD=21.4). Seven patients (28%) were children aged 2 to 10 years old. Abducens palsies were most common (68%) and the most common ocular presentation was diplopia (76%) with an average time of onset 15 days from testing positive to COVID-19 or having symptoms of the virus. Proposed mechanism of development of a neurogenic palsy secondary to COVID-19 infection was classified into one of three categories: vascular/thrombotic, a viral neuro-invasive or inflammatory virus-mediated immune response. DISCUSSION: This study suggests that COVID-19 infection may be linked to oculomotor, trochlear and abducens nerve palsies and the underlying mechanisms may vary but are difficult to definitively establish. Further studies investigating the onset of neurogenic palsy secondary to COVID-19 infection is required.

Real-World Investigation of Impact of Retinal Fluid in Treatment Naïve Eyes Treated with Anti-VEGF for Neovascular Age-Related Macular Degeneration.

BACKGROUND: Traditionally, visual acuity gain and central retinal thickness have been used to measure outcomes when investigating the efficacy of vascular endothelial growth factor (VEGF) inhibitors for patients with neovascular age-related macular degeneration (nARMD). However, localization of retinal fluid may offer additional prognostic value for treatment. The primary aim of this retrospective clinical audit was to investigate whether the presence and location of subretinal fluid has an effect on the visual outcomes of treatment naïve patients with nARMD treated in the real-world setting with VEGF inhibitors. Secondary aims included investigation of change to visual and anatomical outcomes and investigation of the dosing schedule. METHODS: Retrospective observational study of patients attending one suburban and one regional ophthalmology clinic requiring treatment with VEGF inhibitors for nARMD using single-user non-identifiable data from the Fight Retinal Blindness! Registry from 2014 to 2020. Visual acuity (VA) and central subfield thickness (CST) were recorded at baseline, 3, 6, 12 and 24 months. RESULTS: Forty-nine eyes of 42 treatment naïve patients were included for analysis (aged 62-89 years). Almost half (49%) presented with a combination of intra- and subretinal fluid at baseline. Intraretinal fluid was present in 75% of eyes but decreased to 22.7% of eyes by 24 months. VA at baseline was 55 letters, and this improved by 6 letters. The change in VA from baseline to 3, 6 and 12 months was statistically significant (p < .05). The mean change in CST from baseline to 3 months was significant (-76 µm). This change was also observed at the other milestones (p < .001). CONCLUSIONS: The findings of this study suggest that allowing some subretinal fluid to remain will not affect treatment outcomes.

Clinical practice patterns for assessing children with learning difficulties: survey of eye health care professionals.

CLINICAL RELEVANCE: Understanding what aspects of vision or binocular vision may affect learning, and how these are assessed, is important for the eye health care professional assessing children with learning difficulties. It is vital that visual dysfunction is identified or excluded in these patients to ensure targeted and timely intervention. BACKGROUND: The aim of this study was to investigate similarities and differences between eye care professionals in the knowledge, attitudes and practice patterns, when evaluating children with learning difficulties. METHODS: This study was a cross-occupational, cross-sectional, predominantly quantitative internet-based survey. Ophthalmologists, optometrists, and orthoptists working in Australia were eligible to participate. A questionnaire comprising of 31 multiple-choice questions with up to 19 additional branching questions was distributed using REDCap in September 2022. RESULTS: A total of 130 responses were analysed (6 ophthalmologists, 84 orthoptists and 40 optometrists of whom 9 were practicing behavioural vision care). Most respondents assessed distance visual acuity (95%), near stereoacuity (85%), presence of strabismus (88%) and ocular movements (91%). Near vision was assessed less often (65%). Optometrists were most likely to measure colour vision (p < 0.002), accommodation and undertake a subjective refraction (each p < 0.001). Ophthalmologists were least likely to measure convergence (p = 0.041) but more likely to undertake a cycloplegic refraction (p = 0.044). More optometrists practicing behavioural vision care reported testing binocular vision (p = 0.026), fusional vergence (p < 0.001), saccades (p = 0.066), and smooth pursuit (p = 0.050) than other professions. There was a positive correlation between frequency and confidence level when assessing children with learning difficulties (ρ = 0.64). Respondents referred to paediatricians (39%), speech pathologists (30%), educational psychologists (29%) and general practitioners (29%). CONCLUSION: Despite similarities across occupations, there were differences in testing the vision and binocular functions of children with learning difficulties. Future research should aim to establish minimum standards for assessing this patient cohort to ensure consistent and relevant assessment.

Prevalence of optical coherence tomography-diagnosed postoperative cystoid macular oedema in patients following uncomplicated phaco-emulsification cataract surgery.

BACKGROUND: Postoperative cystoid macular oedema is a complication of uneventful cataract surgery. Whereas improved surgical techniques have decreased the incidence of cystoid macular oedema, it remains a cause of unfavourable visual outcome following surgery. Fundus fluorescein angiography has been the 'gold standard' for diagnosing subclinical cystoid macular oedema; however, non-invasive cross-sectional imaging of the retina with optical coherence tomography may be equally effective at detecting the condition and offers the ability to quantify and repeat results over time. DESIGN: Prospective pre-post case series of patients undergoing routine phaco-emulsification surgery. PARTICIPANTS: Eighty consecutive patients (100 eyes) with cataracts and an age range of 40 to 90 years (mean 76.18). METHODS: Macular thickness of participants was determined using time-domain optical coherence tomography preoperatively and after surgery at 1 day, 1 week, 4 weeks and 6 months. Optical coherence tomography was used to diagnose postoperative cystoid macular oedema. MAIN OUTCOME MEASURES: Presence of cysts at the macula, identified by optical coherence tomography, in addition to foveal and macular thickness (µm). RESULTS: Cystoid macular oedema was present in 5% of eyes. Macular thickness increased after surgery and central foveal thickness increased by almost 7% but returned to preoperative levels after 6 months. Findings also indicate that patients who developed postoperative cystoid macular oedema had significantly thicker central foveal thickness of approximately 5% compared with those that did not. CONCLUSIONS: Optical coherence tomography is a useful, non-invasive diagnostic tool in determining subclinical cystoid macular oedema in uncomplicated cataract surgery patients and detects the presence of retinal thickening and intra-retinal cysts very soon after surgery, thereby facilitating earlier diagnosis and treatment of postoperative cystoid macular oedema.

Butterflies and black lacy patterns: the prevalence and characteristics of Charles Bonnet hallucinations in an Australian population.

BACKGROUND: Charles Bonnet Syndrome (CBS) is characterized by vivid, elaborate and recurrent visual hallucinations in psychologically normal people. It most often occurs in older, visually impaired persons. The prevalence of the syndrome has been reported at 1-40% in Asia, Europe and North America. The aim of this study was to examine the prevalence and characteristics of CBS in the older aged, visually impaired population in Australia. METHODS: Two hundred consecutive patients attending ophthalmology clinics aged more than 60 years with best-corrected visual acuity of 6/12 or less were screened for CBS. Those who reported experiencing visual hallucinations were asked to participate in the project. They were then interviewed and asked demographic, general health and visual hallucination-related questions. A group of 30 non-hallucinating participants was chosen for comparison of demographic data. RESULTS: The prevalence was found to be 17.5%. Participants experiencing hallucinations were predominantly female with a mean age of 77.7 years. Correlations were found between the living situation, level of education and characteristics of the hallucinations such as the duration, length of time the participant had been experiencing them and their frequency. CONCLUSION: The prevalence of CBS in the older-aged, low-vision population is 17.5%. Several demographic and syndrome-specific characteristics were found to be consistent enabling a profile of a CBS sufferer in this group of participants to be compiled.

Retinal Vascular Caliber and Kidney Function in Children and Adolescents with Type 1 Diabetes.

PURPOSE: To evaluate the relationship between retinal vascular caliber and kidney function in a cohort of Australian children and adolescents with type 1 diabetes. METHODS: This was a cross-sectional study of 483 children and adolescents with type 1 diabetes, aged 7-18 years. An audit of medical files of participants who attended the Royal Children's Hospital, Melbourne, between January 2009 and March 2014 was performed. Albumin to creatinine ratio (ACR) was acquired through spot urine samples and microalbuminuria was classified as ACR >3.5 mg/mmol in females and >2.5 mg/mmol in males. Retinal vascular caliber was measured using a standardized protocol and later summarized as central retinal arteriolar equivalent (CRAE) and central retinal venular equivalent (CRVE). RESULTS: CRAE was significantly narrower in participants with microalbuminuria compared to those with normo-albuminuria in crude analysis (mean ± standard deviation 159.07 ± 9.90µm vs 164.49 ± 12.45 µm; p = 0.006). After adjustment for key confounders and known or potential mediators of microalbuminuria (age, sex, ethnicity, hemoglobin A1c, systolic blood pressure, total cholesterol, body mass index, duration of diabetes and CRVE) the association between narrower CRAE and microalbuminuria was attenuated and was no longer significant (95% confidence interval 0.94-1.02, p = 0.222). No significant associations between CRVE or arteriole-to-venule ratio and microalbuminuria were observed in univariate or multivariate models. CONCLUSIONS: After adjustment for potential confounding variables, retinal vascular caliber was not significantly associated with microalbuminuria in this sample of children and adolescents with type 1 diabetes. Future prospective longitudinal research is warranted to further evaluate these findings.

Vascular risk factors are associated with retinal arteriolar narrowing and venular widening in children and adolescents with type 1 diabetes.

BACKGROUND: The aim of the study was to describe the relationship of retinal arteriolar and venular calibre with vascular risk factors in children and adolescents with type 1 diabetes. METHODS: In this hospital-based cross-sectional study, the medical files of 483 children and adolescents with type 1 diabetes were audited to collect retinal images and relevant clinical data. Retinal vascular calibre was measured using standardised protocols. RESULTS: After multivariable adjustments, a vascular risk profile that included: older age, higher serum creatinine, higher systolic blood pressure (SBP), higher body mass index (BMI), abnormal estimated glomerular filtration rate (eGFR), lower high-density lipoproteins (HDL) cholesterol, longer duration of diabetes and higher serum sodium was associated with narrower central retinal artery equivalent (CRAE) (95% CI=-4.10/-0.76, p=0.004). A specific risk profile, including higher total cholesterol level, higher BMI, lower physical activity level, higher HbA1c, higher triglyceride levels, female gender and lower socio-economic status, was associated with wider central retinal vein equivalent (CRVE) (95% CI=1.14/5.62, p=0.003). CONCLUSIONS: In summary, these findings support evidence that cardiovascular disease may have its origins early in life. Prospective and/or intervention studies are required to confirm whether the observed associations are involved in the causal pathway for retinal vascular calibre.

Physical Activity, Sedentary Behaviors, and Retinal Vascular Caliber in Children and Adolescents With Type 1 Diabetes.

PURPOSE: The aim of this study was to investigate associations of physical activity and sedentary behaviors with retinal vascular caliber in children and adolescents with type 1 diabetes. DESIGN: This was a hospital-based cross-sectional study. METHODS: A study of 122 children and adolescents with type 1 diabetes was conducted over an 8-month period. Self-reported physical activity time and time spent watching TV or playing computer or video games were obtained using interviewer-administered questionnaires. Retinal vascular caliber was measured by a trained grader using a standardized protocol and later summarized as central retinal artery equivalent (CRAE) and central retinal vein equivalent (CRVE) using a semiautomated computer program. RESULTS: After adjusting for confounders (age, sex, ethnicity, body mass index, systolic blood pressure, HbA1c, maternal smoking status, age at which cow's milk was introduced, and CRVE/CRAE, respectively), narrower CRAE was independently related to more time spent playing computer/video games [ExpB = -3.85; 95% confidence interval (CI), -6.41 to -1.29; P = 0.004], whereas wider CRVE was independently related to lower physical activity level (ExpB = -1.08; 95% CI, -2.01 to -0.15; P = 0.03) and more time spent playing computer/video games (ExpB = 4.72; 95% CI, 0.52-8.92; P = 0.02). Television viewing time was not associated with retinal vascular caliber after adjustment. CONCLUSIONS: The results of this study suggest that physical activity and sedentary behaviors in the form of "screen viewing time" are associated with retinal vessel caliber early in life. These results suggest that retinal vascular caliber may provide prognostic information beyond current traditional cardiovascular risk factors. Future longitudinal and interventional studies are warranted to evaluate the relevance of these observations.

Prevalence and risk factors for diabetic retinopathy in a hospital-based population of Australian children and adolescents with type 1 diabetes.

BACKGROUND: The aim of this study was to investigate the prevalence of, and traditional and emerging risk factors associated with, retinopathy in a hospital-based population of Australian children and adolescents with type 1 diabetes. METHODS: This was a cross-sectional study of 483 children and adolescents with type 1 diabetes. Medical files were audited to collect all relevant clinical data. Diabetic retinopathy was assessed from colour retinal images by an ophthalmologist. RESULTS: Diabetic retinopathy was observed in 11 (2.3%) participants. Logistic regression revealed that the principal components analysis derived risk profile of: higher serum creatinine, older age, higher systolic blood pressures, higher body mass index, abnormal estimated glomerular filtration rate (eGFR) (<59 mL/min), lower high density lipoproteins (HDL) cholesterol, higher serum sodium, longer duration of diabetes and narrower retinal arteriolar calibre was associated with diabetic retinopathy (ExpB=2.60, 95% CI 1.36/4.96, p=0.004). CONCLUSIONS: These results support the concept that the pathogenesis of diabetic retinopathy is likely due to the combined influence of various risk factors, many already identified.

Dietary patterns and retinal vascular calibre in children and adolescents with type 1 diabetes.

PURPOSE: To examine the association between dietary patterns and retinal vascular calibre in children and adolescents with type 1 diabetes. METHODS: A hospital-based cross-sectional study of 83 children and adolescents with type 1 diabetes was conducted over an 8-month period. Dietary patterns were extracted using principal components analysis from completed food frequency questionnaires. Retinal vascular calibre was measured by a trained grader using a standardized protocol and later summarized as central retinal artery equivalent (CRAE) and central retinal vein equivalent (CRVE) using a semi-automated computer program. RESULTS: Three major dietary patterns were identified as follows: (1) processed foods, (2) plant-based foods and (3) vegetable/fish avoidance pattern. The processed pattern had high component loadings for processed meats and high fat takeaway foods. The plant-based pattern had high component loadings for a number of fruits including, but not limited to, pineapple, grapes oranges and mangos as well as a smaller number of vegetables, including beans and leeks. The vegetable and fish avoidance pattern had high inverse component loadings for canned and fresh fish as well as a number of vegetables including, but not limited to, pumpkin, green beans, broccoli, sweet potato and cabbage. Adjusted regression analysis revealed the 'vegetable/fish avoidance' dietary pattern was associated with a wider CRVE (ExpB = 3.67, 95% CI = 0.11/7.24, p = 0.039). After multivariable adjustments, a vascular risk profile that included: older age, higher BMI, higher systolic blood pressure, greater gestational age, longer screen viewing time, lower maternal education level, lower physical activity levels and lower high-density lipoproteins concentrations were more likely to display narrower CRAE (ExpB = -2.43, 95% CI = -4.92/0.06, p = 0.041). CONCLUSIONS: This study provides the first evidence for a diet-calibre relationship in children and adolescents with type 1 diabetes. This outcome has potential public health implications, as promotion of healthy eating patterns in children and adolescents might attenuate changes in microvasculature that have been related to an increased risk of microvascular disease, such as retinopathy, in adulthood. Additional studies are warranted to explore and validate this novel finding.

Diabetes, Diabetic Retinopathy, and Retinal Vascular Alterations: A Systematic Review.

The aim of this review is to summarize the available findings from previous research that has focused on retinal vascular caliber characteristics in diabetes and diabetic retinopathy and identify any gaps that exist in the current literature. A systematic Medline, EMBASE, and PubMed search of relevant articles was conducted with coverage up to the 30th of September, 2012. The search was not restricted by language but was limited to studies conducted in humans. The majority of articles conducted on children and adolescents with type 1 diabetes have reported that arterioles with larger caliber were present in the early stages of diabetic retinopathy (n = 5). Only a few studies conducted on older individuals with type 1 diabetes (n = 2) suggest that smaller retinal arteriolar caliber is associated with increased severity of diabetic retinopathy. Much stronger trends have been identified between venular caliber and older individuals with diabetes, with the vast majority of studies reporting that retinal venular dilation represents a later sign of severe diabetic retinopathy (n = 6), with only 1 study highlighting associations with incident diabetes (n = 1). Significant developments have occurred to better understand the relationship between retinal vascular caliber and the onset and progression of diabetes and diabetic retinopathy. Recent evidence suggests that retinal arteriolar dilation may be a possible risk factor in the early development diabetic retinopathy and retinal venules are dilated in persons with severe diabetic retinopathy. Despite this, the clinical significance of these findings requires further evaluation.

Frightening visual hallucinations: atypical presentation of Charles Bonnet syndrome triggered by the Black Saturday bushfires.

Charles Bonnet syndrome (CBS) is a disorder in which psychologically normal people, often with vision impairment, experience complex visual hallucinations. The hallucinations are purely visual and do not occur in any other sensory modality, and people with CBS have full insight into the unreal nature of the hallucinations. This report describes the case of a CBS sufferer who experienced a distressing change in the nature of her visual hallucinations following a stressful event--the Black Saturday bushfires of February 2009.