Cardiometabolic risks during anabolic hormone supplementation in older men

OBJECTIVE

To determine the cardiometabolic risks of testosterone and growth hormone (GH) replacement therapy to youthful levels during aging.

DESIGN AND METHODS

A double-masked, partially placebo controlled study in 112 men 65-90 years-old was conducted. Transdermal testosterone (5 g vs. 10 g/day) using a Leydig Cell Clamp and subcutaneous recombinant GH (rhGH) (0 vs. 3 vs. 5 μg/kg/day) were administered for 16-weeks. Measurements included testosterone and IGF-1 levels, body composition by DEXA, and cardiometabolic risk factors (upper body fat, blood pressure, insulin sensitivity, fasting triglycerides, HDL-cholesterol, and serum adiponectin) at baseline and after 16 weeks of treatment.

RESULTS

Some cardiometabolic factors improved (total and trunk fat, triglycerides, HDL-cholesterol) and others worsened (systolic blood pressure, insulin sensitivity index [QUICKI], adiponectin). Cardiometabolic risk composite scores (CRCSs) improved (-0.69 ± 1.55, P < 0.001). In multivariate analyses, QUICKI, triglycerides, and HDL-cholesterol contributed 33%, 16%, and 14% of the variance in CRCS, respectively. Pathway analyses indicated that changes in fat and lean mass were related to individual cardiometabolic variables and CRCS in a complex manner. Changes in BMI, reflecting composite effects of changes in fat and lean mass, were more robustly associated with cardiometabolic risks than changes in fat mass or LBM individually.

CONCLUSIONS

Testosterone and rhGH administration was associated with diverse changes in individual cardiometabolic risk factors, but in aggregate appeared not to worsen cardiometabolic risk in healthy older men after 4-months. The long-term effects of these and similar anabolic therapies on cardiovascular events should be investigated in populations with greater functional limitations along with important health disabilities including upper body obesity and other cardiometabolic risks.

Whole-body and muscle protein metabolism are not affected by acute deviations from habitual protein intake in older men: the Hormonal Regulators of Muscle and Metabolism in Aging (HORMA) Study

BACKGROUND

Acute deviations in protein intake before the quantification of protein kinetics in older humans may explain the controversy over the effects of older age on muscle protein synthesis and proteolysis rates.

OBJECTIVE

We hypothesized that an acute decrease in protein intake from the habitual intake is associated with lower muscle protein synthesis and higher proteolysis rates, whereas an acute increase in protein intake from the habitual intake is associated with higher muscle protein synthesis and lower proteolysis rates.

DESIGN

In 112 community-dwelling healthy men aged 65-90 y, we quantified resting whole-body [1,2-(13)C(2)]leucine kinetics, muscle mixed protein fractional synthesis rates (FSRs), and muscle proteasome proteolytic enzyme activities after participants consumed for 3 d controlled research meals (0.9-1.1 g protein · kg(-1) · d(-1)) that contained more or less protein than that habitually consumed and that induced alterations in nitrogen balance.

RESULTS

Protein kinetic parameters were not significantly different between the groups, despite controlled research protein intakes that were lower (-0.2 to -0.3 g · kg(-1) · d(-1)) or higher (+0.2 g · kg(-1) · d(-1)) than habitual intakes and that induced negative (-22 to -25 mg · kg(-1) · d(-1)) or positive (22-25 mg · kg(-1) · d(-1)) nitrogen balance. Within these acutely altered protein intake and nitrogen balance boundaries, a reduction in protein intake from habitual intake and induction of negative nitrogen balance were not associated with higher proteolysis or lower muscle FSR, and an acute increase in protein intake from habitual intake and induction of positive nitrogen balance were not associated with lower proteolysis or higher muscle FSR. A higher quantitative insulin sensitivity check index was associated with lower whole-body proteolysis rates.

CONCLUSIONS

The practice of acutely controlling protein intake, even at intakes lower than habitual intakes that induce negative nitrogen balance, before quantifying human protein kinetics does not significantly reduce muscle protein synthesis or increase proteolysis. Factors other than protein intake explain lower muscle protein synthesis rates with advanced age. This trial is registered at clinicaltrials.gov as NCT00183040.

How can statistical approaches enhance transdisciplinary study of drug misuse prevention?

Application of statistical techniques in transdisciplinary research includes statistical model selection and model specification. This paper presents statistical models used in drug misuse prevention research. The historical roots of these models are discussed to illustrate the numerous disciplines from which different techniques originated. Single and multilevel approaches are described to illustrate methods of synthesizing perspectives from different scientific arenas. Using single-level approaches in transdisciplinary research, these models can easily incorporate broader theoretical considerations and more integrated hypotheses by representing each discipline with a set of variables. Simultaneous testing of every set of variables obtained from different disciplines may provide more comparable results to identify critical factors associated with substance-use behavior. Using multilevel approaches, more powerful syntheses across disciplines can be achieved by representing each discipline at a different level.

Long term visual outcome of patients with cytomegalovirus retinitis treated with highly active antiretroviral therapy

BACKGROUND

Healed cytomegalovirus (CMV) retinitis in the setting of highly active antiretroviral therapy (HAART) is complicated by inflammatory sequelae and vision loss.

AIM

To determine the long term visual outcome of AIDS patients with CMV retinitis who received HAART.

METHODS

90 eyes of 63 consecutive AIDS patients with extramacular CMV retinitis were studied prospectively.

RESULTS

Immune recovery status was related to time to onset of epiretinal membrane (p=0.05) and cystoid macular oedema (p=0.06) as well as to the incidence of cataract (p=0.001) and moderate vision loss (p<0.0001). Severe vision loss was associated with retinal detachment (p<0.001).

CONCLUSION

AIDS patients with extramacular CMV retinitis lose vision while on HAART. HAART related immune recovery is associated with increased frequencies of epiretinal membrane, cystoid macular oedema, cataract, and retinal detachment with resultant vision loss in AIDS patients with healed CMV retinitis.

Estrogen in the prevention of atherosclerosis. A randomized, double-blind, placebo-controlled trial

BACKGROUND

Although observational studies suggest that estrogen replacement therapy (ERT) reduces cardiovascular morbidity and mortality in postmenopausal women, use of unopposed ERT for prevention of coronary heart disease in healthy postmenopausal women remains untested.

OBJECTIVE

To determine the effects of unopposed ERT on the progression of subclinical atherosclerosis in healthy postmenopausal women without preexisting cardiovascular disease.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

University-based clinic.

PATIENTS

222 postmenopausal women 45 years of age or older without preexisting cardiovascular disease and with low-density lipoprotein cholesterol levels of 3.37 mmol/L or greater (>/=130 mg/dL).

INTERVENTION

Unopposed micronized 17beta-estradiol (1 mg/d) or placebo. All women received dietary counseling. Women received lipid-lowering medication if their low-density lipoprotein cholesterol level exceeded 4.15 mmol/L (160 mg/dL).

MEASUREMENTS

The rate of change in intima-media thickness of the right distal common carotid artery far wall in computer image processed B-mode ultrasonograms obtained at baseline and every 6 months during the 2-year trial.

RESULTS

In a multivariable mixed-effects model, among women who had at least one follow-up measurement of carotid intima-media thickness (n = 199), the average rate of progression of subclinical atherosclerosis was lower in those taking unopposed estradiol than in those taking placebo (-0.0017 mm/y vs. 0.0036 mm/y); the placebo-estradiol difference between average progression rates was 0.0053 mm/y (95% CI, 0.0001 to 0.0105 mm/y) (P = 0.046). Among women who did not receive lipid-lowering medication (n = 77), the placebo-estradiol difference between average rates of progression was 0.0147 mm/y (CI, 0.0055 to 0.0240) (P = 0.002). Average rates of progression did not differ between estradiol and placebo recipients who took lipid-lowering medication (n = 122) (P > 0.2).

CONCLUSIONS

Overall, the average rate of progression of subclinical atherosclerosis was slower in healthy postmenopausal women taking unopposed ERT with 17beta-estradiol than in women taking placebo. Reduction in the progression of subclinical atherosclerosis was seen in women who did not take lipid-lowering medication but not in those who took these medications.

Duration of vitrectomy and postoperative cataract in the vitrectomy for macular hole study

PURPOSE

To report the association between duration of vitrectomy, as well as other risk factors, and the progression of nuclear sclerosis and posterior subcapsular cataract in the Vitrectomy for Macular Hole Study.

DESIGN

A cohort study nested within a randomized controlled clinical trial.

METHODS

Using a system similar to the Lens Opacities Classification System II, nuclear sclerosis (NS) and posterior subcapsular cataract (PSC) were scored in the vitrectomy and fellow eye of 74 patients at baseline and at 6, 12, and 24 months postoperatively. Age, baseline blood pressure and refractive power, and duration of surgery were evaluated as risk factors for NS or PSC progression and cataract extraction.

RESULTS

The incidence of NS progression in the surgical group of vitrectomy eyes was 81% at 6 months, 98% at 1 year, and 100% at 2 years of follow-up. In contrast, NS progression in the control group of fellow eyes was only 18% at 6 months, 20% at 1 year, and 8% at 2 years. The incidence of PSC progression in the surgical group remained at approximately 11% throughout follow-up, which was not significantly higher than the 3% to 5% incidence in the control group. Vitrectomy was significantly related to progression of NS cataract (P <.001) and cataract extraction (P <.01). No statistically significant differences were found for NS scores, PSC scores, or progression rates between eyes that had less than median surgical duration (60 min.) or more than the median surgical duration. Additionally, no significant differences were found when eyes that experienced 45 minutes or less surgical duration were compared with eyes that endured more than 75 minutes surgical duration. Age, blood pressure, and refractive power were not found to be predictors for NS and PSC progression.

CONCLUSIONS

Although vitrectomy is a risk factor for NS progression, the duration of vitrectomy does not increase the risk.

Coincident linkage of fasting plasma insulin and blood pressure to chromosome 7q in hypertensive hispanic families

BACKGROUND

Insulin resistance (IR) and hyperinsulinemia are phenotypically associated with hypertension. We have previously provided evidence that blood pressure (BP) and IR cosegregate in Hispanic families, suggesting that this association has a genetic component. In the present study, we provide further support for the hypothesis of a genetic basis for the BP-IR relationship from a genetic linkage study.

METHODS AND RESULTS

A 10-cM genome scan was conducted in 390 Hispanic family members of 77 hypertensive probands. Detailed measurements of BP, glucose, insulin levels, and insulin sensitivity (euglycemic clamp) were performed in adult offspring of probands. Multipoint variance component linkage analysis was used. A region on chromosome 7q seemed to influence both IR and BP. The greatest evidence for linkage was found for fasting insulin (lod score=3.36 at 128 cM), followed by systolic BP (lod score=2.06 at 120 cM). Fine mapping with greater marker density in this region increased the maximum lod score for fasting insulin to 3.94 at 125 cM (P=0.00002); lod score for systolic BP was 2.51 at 112 cM. Coincident mapping at this locus also included insulin sensitivity measured by the homeostasis assessment model (HOMA) and serum leptin concentrations. Insulin sensitivity by euglycemic clamp did not map to the same locus.

CONCLUSIONS

Our results demonstrate that a major gene determining fasting insulin is located on chromosome 7q. Linkage of BP, HOMA, and leptin levels to the same region suggests this locus may broadly influence traits associated with IR and supports a genetic basis for phenotypic associations in IR syndrome.

Immune recovery vitritis and uveitis in AIDS: clinical predictors, sequelae, and treatment outcomes

PURPOSE

To determine 1) clinical predictors of an inflammatory syndrome associated with cytomegalovirus (CMV) retinitis (immune recovery vitritis or uveitis [IRV or IRU]); 2) clinical sequelae of IRV; and 3) the effect of corticosteroid treatment on visual acuity.

METHODS

A cohort study from the AIDS Ocular Research Unit of the University of California, San Diego, and a case series from the Cleveland Clinic consisted of patients who had acquired immunodeficiency syndrome and inactive CMV retinitis who responded to highly active antiretroviral therapy (HAART) with CD4 T-lymphocyte levels >60 cells/mm3. The cohort was followed for a median of 13.5 months following increase in CD4 count. The authors studied the occurrence of IRV, defined as symptomatic (vision decrease and/or floaters) vitritis of 1+ or greater severity associated with inactive CMV retinitis. Macular edema or epiretinal membrane formation was determined by clinical examination and fluorescein angiography. Five eyes were treated with sub-Tenon corticosteroid injections.

RESULTS

In the cohort study, 19 (63%) of 30 HAART responders developed IRV (26 eyes). The clinical spectrum of inflammation included vitritis, papillitis, macular edema, and epiretinal membranes. Eyes with CMV surface area >30% of the retina were at the highest risk (relative risk = 4.5) of developing IRV (P = 0.03). During follow-up, inflammation persisted without treatment for a median of 20 weeks and 14 patients (16 eyes) developed macular changes. Treatment resulted in vision improvement without reactivation of retinitis. Histology and immunohistochemistry of associated epiretinal membranes showed evidence of chronic inflammation with a predominant T-lymphocyte cell population. In the case series, 3 (38%) of 8 HAART responders developed IRV (4 eyes). All four eyes were treated and resulted in visual acuity improvement of one line.

CONCLUSIONS

Symptomatic IRV or IRU develops in a significant number of patients with CMV retinitis following successful HAART. Eyes with CMV surface area >30% of the retina are at the greatest risk. Eyes with IRV respond favorably to antiinflammatory therapy without reactivation of retinitis. Immune recovery vitritis may be the result of an immunologic reaction to latent CMV antigens in the eye in which T-lymphocytes play a role.

Retinal nerve fiber layer evaluation in human immunodeficiency virus-positive patients

PURPOSE

To determine the effect of human immunodeficiency virus (HIV) infection on topographic measures of the optic disk and the retinal nerve fiber layer.

METHODS

A cross-sectional study at the Acquired Immunodeficiency Syndrome (AIDS) Ocular Research Unit at the University of California, San Diego. Retinal nerve fiber layer thickness at the optic nerve head was evaluated using the Heidelberg Retinal Tomograph, a confocal scanning laser tomograph in 38 HIV-positive and 24 age-matched HIV-negative subjects.

RESULTS

HIV-positive patients without CMV retinitis showed significant differences from HIV-negative normal controls in a number of measures of the retinal nerve fiber layer. This indicated a loss of retinal ganglion cells in HIV-positive patients without retinitis. HIV-positive patients with CMV retinitis were worse in most measurements than both HIV-negative controls and HIV-positive patients without CMV.

CONCLUSIONS

Significant thinning of the retinal nerve fiber layer occurs in HIV-positive patients without infectious retinopathy, and there are further changes in the optic disk associated with CMV retinitis. Confocal scanning laser tomography may be of use in the diagnosis of early HIV-associated visual function loss.

Evidence for joint genetic control of insulin sensitivity and systolic blood pressure in hispanic families with a hypertensive proband

BACKGROUND

The clustering of hypertension, insulin resistance, and obesity remains unexplained. We tested for genetic and nongenetic influences on the association among these traits in Hispanic families with hypertension.

METHODS AND RESULTS

Blood pressure and body mass index (BMI) were measured in 331 members of 73 Hispanic families in which an index case (proband) had hypertension. Insulin sensitivity (S(I)) was measured by euglycemic clamp in 287 probands and their spouses (parents' generation) or their adult offspring. Correlation analysis examined relationships among traits within and between generations. Path analysis estimated genetic and nongenetic contributions to variability in systolic blood pressure (SBP), S(I), and the correlation between them. In the offspring, there was a significant correlation between individuals for each trait, as well as significant correlations within and between individuals for all possible pairs of traits. Between generations, SBP, S(I), and BMI in parents correlated with the same traits in their offspring; BMI in parents correlated with S(I) and SBP in offspring; and S(I) in parents correlated with SBP in offspring. Path analysis estimated that among offspring, genetic effects unrelated to BMI accounted for 60.8% of the variation in SBP, 36.8% of the variation in S(I), and 31.5% of the correlation between SBP and S(I) after adjustment for age and sex. Heritable effects related to BMI accounted for an additional 14.0% of variation in SBP, 26.8% of variation in S(I), and 56.3% of variation in their correlation.

CONCLUSIONS

Clustering of hypertension and insulin resistance in Hispanic Americans is accounted for in part by heritable factors both associated with and independent of BMI.

Embedding health-promoting changes into the daily lives of independent-living older adults: long-term follow-up of occupational therapy intervention

The Well Elderly Study was a randomized trial in independent-living older adults that found significant health, function, and quality of life benefits attributable to a 9-month program in preventive occupational therapy (OT). All participants completing the trial were followed for an additional 6 months without further intervention and then reevaluated using the same battery of instruments. Long-term benefit attributable to preventive OT was found for the quality of interaction scale of the Functional Status Questionnaire and for six of eight scales on the RAND SF-36: physical functioning, role functioning, vitality, social functioning, role emotional, and general mental health (p<.05). Approximately 90% of the therapeutic gain observed following OT treatment was retained in follow-up. The finding of a sustained effect for preventive OT is of great public health relevance given the looming health care cost crisis associated with our nation's expanding elderly population.

First operation anatomic success and other predictors of postoperative vision after complex retinal detachment repair with vitrectomy and silicone oil tamponade

PURPOSE

To evaluate the role of first operation anatomic success compared with success after reoperation and preoperative characteristics in achieving ambulatory vision (>/=4/200) and good vision (>/=20/100) after repair of complex retinal detachment with vitrectomy and silicone oil tamponade.

METHODS

A prospective, observational, multicenter study of patients who underwent vitrectomy with silicone oil for retinal detachments associated with cytomegalovirus necrotizing retinitis or a non-cytomegalovirus necrotizing retinitis etiology, including proliferative diabetic retinopathy, giant retinal tear, proliferative vitreoretinopathy, and ocular trauma.

RESULTS

A higher rate of ambulatory vision was achieved in the first operation anatomic success cases, compared with the reoperation cases, for eyes with cytomegalovirus necrotizing retinitis (72% vs 50%, P < 0.01) and eyes without cytomegalovirus necrotizing retinitis (51% vs 38%, P = 0.04). For eyes with cytomegalovirus necrotizing retinitis, preoperative ambulatory vision (RR = 2.3, P < 0.0001) and reoperation (RR = 0.4, P = 0.05) were independent predictors of postoperative ambulatory vision. For eyes without cytomegalovirus necrotizing retinitis, preoperative ambulatory vision (RR = 4.0, p < 0.0001) and retinal detachment etiology (P = 0.02) were prognostic factors. Compared to eyes with trauma, eyes with giant retinal tear, proliferative vitreoretinopathy and proliferative diabetic retinopathy were 2.8 (P < 0.003), 2.2 (P = 0.01) and 1.6 (P = 0.17) times as likely to achieve postoperative ambulatory vision, respectively. Within the giant retinal tear group, a higher rate of ambulatory vision was achieved in the first operation anatomic success cases compared with the reoperation cases (66% vs 31%, P = 0.03). Although not statistically significant, similar outcomes occurred in the proliferative diabetic retinopathy (48% vs 25%) and proliferative vitreoretinopathy groups (54% vs 45%). Similar prognostic relationships were found for good visual acuity outcomes.

CONCLUSIONS

First operation anatomic success, preoperative visual acuity, and giant retinal tear or proliferative vitreoretinopathy as the retinal detachment etiology are important factors that predict visual outcome.

Blood Pressure and Insulin Resistance Cosegregate at Two Distinct Regions on Chromosome 7

P137

Purpose: Insulin resistance (IR) and hyperinsulinemia precede hypertension in Mexican Americans and may be a preclinical phenotype for hypertension. We tested the hypothesis that IR and blood pressure (BP) share genetic regulation by conducting a genome scan in healthy adult offspring of hypertensive probands, chosen so that the traits would not have been influenced by either the disease process or treatment. Methods: A total of 390 Mexican-Americans in 77 nuclear hypertension families were genotyped with 386 microsatellite markers. We performed two-point (by SIBPAL) and multipoint linkage analysis (by SOLAR) for BP, IR, and related traits. Results: In direct support of our hypothesis, we observed evidence for two loci on chromosome 7 that influenced both IR and BP. Two-point analysis showed evidence for linkage of a locus on 7p (∼18cM) with diastolic BP (DBP), systolic BP (SBP), mean arterial pressure (MAP), and two-hour insulin (p=0.01-0.05), with a LOD of 1.44 for SBP. More impressively, the locus on 7q (∼133cM) showed lod scores of 1.78 for SBP, and 2.97 for fasting insulin. Additional quantitative traits mapping to the 7q locus are plasma levels for leptin (LOD=1.5) and apoAII (LOD=2.0). This region overlaps with the diabesity locus reported in the Pima (Hanson et al. 1998). Two candidate genes exist in the region: PPP1R3 (∼135cM), which regulates skeletal muscle glycogenesis and has a role in type 2 diabetes (Xia et al. 1998), and leptin (∼126cM). Of particular interest, it appears that the two loci interact. Thus, the 7p locus lod score for MAP increases from 0.90 to 2.37 when an interaction with 7q is introduced Conclusions: 1) The coincident mapping of loci for BP and insulin supports the role of IR in the pathogenesis of hypertension in this population. 2) There appear to be at least two different genes on chromosome 7 responsible for BP and IR. 3) There is an interaction of these two genes, suggesting they are part of a common pathway for the IR-BP syndrome.

Correlation between static automated and scanning laser entoptic perimetry in normal subjects and glaucoma patients

OBJECTIVE

To compare the effectiveness of scanning laser entoptic perimetry with static automated perimetry as a noninvasive instrument for screening for glaucomatous damage in visually asymptomatic subjects within the central 60 degrees (diameter) of vision.

DESIGN

A masked cross-sectional study comparing entoptic perimetry to achromatic threshold perimetry.

PARTICIPANTS

Twenty-three subjects and controls from the Sharp Rees-Stealy Hospital and the Shiley Eye Center at the University of California, San Diego.

TESTING

Virtual reality-based entoptic perimetry was compared with achromatic threshold perimetry.

MAIN OUTCOME MEASURES

For each testing session, we compared the presence of a disturbance in the entoptic perimetry stimulus with the presence of defects in visual function as measured by Humphrey automated visual field perimetry.

RESULTS

Scanning laser entoptic perimetry reasonably estimates the overall visual field loss for moderate-to-severe scotomas as measured by the pattern deviation in standard visual field perimetry. Scanning laser entoptic perimetry has a sensitivity from 27% to 90% and a specificity from 50% to 100% for screening moderate-to-severe visual field defects caused by glaucoma within the central 60 degrees diameter of vision.

CONCLUSIONS

Scanning laser entoptic perimetry may be an effective and inexpensive screening test in hospitals and community clinics for diagnosing visual field loss caused by glaucoma.

Scanning laser entoptic perimetry for the screening of macular and peripheral retinal disease

OBJECTIVE

To determine the effectiveness of scanning laser entoptic perimetry as a noninvasive platform for screening for retinal damage in visually asymptomatic patients within the central 120 degrees (diameter) of vision.

DESIGN

A masked study comparing entoptic perimetry with fundus photographs.

SETTING

The Shiley Eye Center and the AIDS Ocular Research Unit at the University of California, San Diego.

PATIENTS

Fifty-eight patients recruited during ophthalmologic visits for treatment or follow-up of ocular disease.

MEASUREMENTS

For each testing session, we compared the presence of a disturbance in the entoptic stimulus with the presence of retinal disease within the central 120 degrees of vision, centered on the fovea.

RESULTS

Scanning laser entoptic perimetry has a sensitivity and specificity of more than 90%, a positive predictive value of 100%, and a negative predictive value of 89% for screening retinal lesions within the central 120 degrees diameter of vision.

CONCLUSION

Scanning laser entoptic perimetry may be an effective and inexpensive screening test for diagnosing retinal disease in hospitals and community clinics. Arch Ophthalmol. 2000;118:1205-1210

Efficacy of two lipid-lowering treatments on quantitative coronary angiographic endpoints

This study contrasts the sensitivity of four quantitative coronary angiography (QCA) measures (percent diameter stenosis [%S], minimum lumen diameter, average segment diameter, and percent involvement) in detecting 2-year treatment effects of two lipid-lowering therapies and reports on the longitudinal pattern after 4 years of treatment on the primary QCA trial endpoint (%S) for all, mild/moderate (<50%S), and severe lesions (> or =50%S). Patient cohorts were followed up from two randomized, placebo-controlled clinical trials of lipid-lowering therapies-colestipol/niacin in the Cholesterol Lowering Atherosclerosis Study (CLAS) and lovastatin in the Monitored Atherosclerosis Regression Study (MARS). Identical QCA methodology was used. In CLAS, the largest 2-year treatment effect size (=0.60) was noted for %S. In MARS, equivalent 2-year effect sizes (=0.15) were noted for three QCA measures. The largest 2-year effect size in %S was found in CLAS for mild/moderate lesions (=0.55) and in MARS for severe lesions (=0.31). Treatment in CLAS led to regression of disease in the first 2 years; treatment in MARS slowed progression of disease in the first 2 years and led to regression of disease after 4 years. Colestipol/niacin reduced progression of mild/moderate and severe lesions over the first 2 years of therapy; lovastatin reduced the progression of severe lesions over the last 2 years of therapy. We conclude that reducing the progression of atherosclerosis is not a simple proposition; maximal therapy for reducing and stabilizing atherosclerosis most likely will result from the selection of agents targeted at specific lesions.

Derivation and pilot assessment of a health promotion program for Mandarin-speaking Chinese older adults

As the percentage of older adults of diverse ethnicities increases in the United States, the call for culturally sensitive health care service strategies that target the special needs of older people grows. The present report describes methods used to adapt a health care program so that it would better meet the needs of a group of well, older Mandarin-speaking Chinese residents of Los Angeles. The specific qualitative research procedures that we used to adapt the treatment program are described, along with the particular adaptations that emerged. Additionally, outcomes from a randomized pilot experiment are presented that are consistent with the notion that the adapted program was effective in reducing health-related declines among older Mandarin-speaking men and women. The overall outcome of this project is in agreement with other reports in the health care literature that address the importance of providing culturally sensitive health care service for elders.

Prevalence, correlates, and natural history of epiretinal membranes surrounding idiopathic macular holes. Virectomy for Macular Hole Study Group

OBJECTIVE

To report on the prevalence, correlates, and natural history of epiretinal membranes (ERM) in eyes with stage II or III/IV macular holes.

DESIGN

A subgroup analysis arising from a multicentered, controlled, randomized clinical trial.

SETTING

Community and university-based ophthalmology clinics.

PATIENTS

Two hundred twenty four eyes with stage II or III/IV macular holes.

INTERVENTIONS

No intervention for 100 eyes randomly assigned to observation.

OUTCOME MEASURES

Grade of ERM determined by stereoscopic examination of fundus photographs at baseline and at 3, 6, 12, and 24 months of follow-up.

RESULTS

The prevalence of ERM was 65% (145 of 224 eyes), was greater in pseudophakic than in phakic eyes (80% vs. 63%, P = 0.10), and increased with increasing severity of the hole (P < 0.0001). Stage III/IV eyes with ERM had a significantly larger hole size than did eyes without ERM (P < 0.01); however, no association between presence of ERM and visual acuity was found (P > 0.5). In the 100 phakic eyes that were randomly assigned to observation, there was a significant increase in the severity of ERM over follow-up (P < 0.0001).

CONCLUSIONS

ERM are common in eyes with full-thickness idiopathic macular holes. Although ERM prevalence increases with severity and size of the macular hole, the presence of ERM are not closely correlated with visual acuity. These factors may be important in considering the removal of ERM during vitrectomy for macular hole.

Response of pancreatic beta-cells to improved insulin sensitivity in women at high risk for type 2 diabetes

The purpose of this study was to examine the response of pancreatic beta-cells to changes in insulin sensitivity in women at high risk for type 2 diabetes. Oral glucose tolerance tests (OGTTs) and frequently sampled intravenous glucose tolerance tests (FSIGTs) were conducted on Latino women with impaired glucose tolerance and a history of gestational diabetes before and after 12 weeks of treatment with 400 mg/day troglitazone (n = 13) or placebo (n = 12). Insulin sensitivity was assessed by minimal model analysis, and beta-cell insulin release was assessed as acute insulin responses to glucose (AIRg) and tolbutamide (AIRt) during FSIGTs and as the 30-min incremental insulin response (30-min dINS) during OGTTs. Beta-cell compensation for insulin resistance was assessed as the product (disposition index) of minimal model insulin sensitivity and each of the 3 measures of beta-cell insulin release. In the placebo group, there was no significant change in insulin sensitivity or in any measure of insulin release, beta-cell compensation for insulin resistance, or glucose tolerance. Troglitazone treatment resulted in a significant increase in insulin sensitivity, as reported previously. In response, AIRg did not change significantly, so that the disposition index for AIRg increased significantly from baseline (P = 0.004) and compared with placebo (P = 0.02). AIRt (P = 0.001) and 30-min dINS (P = 0.02) fell with improved insulin sensitivity during troglitazone treatment, so that the disposition index for each of these measures of beta-cell function did not change significantly from baseline (P > 0.20) or compared with placebo (P > 0.3). Minimal model analysis revealed that 89% of the change from baseline in insulin sensitivity during troglitazone treatment was accounted for by lowered plasma insulin concentrations. Neither oral nor intravenous glucose tolerance changed significantly from baseline or compared with placebo during troglitazone treatment. The predominant response of beta-cells to improved insulin sensitivity in women at high risk for type 2 diabetes was a reduction in insulin release to maintain nearly constant glucose tolerance.

A multicentered clinical study of serum as adjuvant therapy for surgical treatment of macular holes. Vitrectomy for Macular Hole Study Group

OBJECTIVE

To evaluate and compare the risks and benefits of autologous serum as an adjuvant therapy in macular hole surgery for stage 3 or 4 macular holes.

METHODS

Comparison of 2 consecutive (nonrandomized) cohorts using standardized methods for the determination of hole size and for surgical procedures, and using the same study surgeons. The serum cohort consisted of 106 eyes using autologous serum as an adjuvant, and the no serum cohort consisted of 58 eyes without adjuvants. The primary end point was the closure of the macular hole as determined by the 6-month fundus photographs. Secondary end points included the number and types of postoperative complications. Comparison in outcomes between the 2 cohorts used chi2 and logistic regression procedures, adjusting for preoperative differences between the study cohorts.

RESULTS

At 6 months, the (unadjusted) rate of hole closure was significantly greater for the eyes treated with serum than for the eyes not treated with serum (90 [85%] of 106 vs. 40 [69%] of 58, P = .04). However, after adjusting for preoperative differences in hole diameter and the prevalence of epiretinal membranes, no overall difference in hole closure rates due to serum was found (P = .44). In contrast, benefit due to serum for large holes (diameter >573 microm) was seen (12 [75%] of 16 vs 13 [57%] of 23, P = .04). No differences in complication rates were found between the cohorts.

CONCLUSIONS

Any beneficial effect of serum used as an adjuvant to macular hole surgery is small, and, if present, the beneficial effect may be limited to larger holes. A randomized, prospective, controlled study in larger macular holes is needed.

Silicone oil in the repair of pediatric complex retinal detachments: a prospective, observational, multicenter study

OBJECTIVE

To report anatomic and visual acuity outcomes, as well as complications, after using 1000-centistoke silicone oil as a retinal tamponade for the treatment of complex retinal detachments in a pediatric population.

DESIGN

A prospective, observational, multicenter study.

PARTICIPANTS

The study cohort consisted of 205 patients 16 years of age or younger (211 eyes) treated at community and university-based ophthalmology clinics for complex retinal detachments associated with trauma, proliferative vitreoretinopathy (PVR), giant retinal tear (GRT), or retinopathy of prematurity (ROP).

INTERVENTION

Vitrectomy surgery for complex retinal detachment with 1000-centistoke silicone oil as the retinal tamponade.

MAIN OUTCOME MEASURES

Anatomic outcomes include complete retinal attachment and macular attachment. Visual acuity outcomes include ambulatory vision (> or = 4/200) and preservation of preoperative visual acuity. Complications include rates of secondary intraocular pressure (IOP) elevation (> or = 30 mmHg), hypotony (< or = 5 mmHg), corneal opacification (including band keratopathy, corneal edema, and corneal abrasions), oil emulsification, and cataract. All outcome measures were assessed 6, 12, and 24 months after surgery and at last examination.

RESULTS

At the 6-month examination, the retina was completely attached in 43 (57%) of 76 eyes in the trauma group, 24 (63%) of 38 PVR eyes, 23 (68%) of 34 GRT eyes, and 6 (33%) of 18 ROP eyes. The macula was attached in 60 (79%), 33 (87%), 26 (76%), and 8 (44%) eyes, respectively. Ambulatory vision was achieved in 19 (25%) eyes in the trauma group, 18 (47%) PVR eyes, 19 (56%) GRT eyes, and 4 (22%) ROP eyes. Visual acuity was preserved in 53 (70%), 26 (68%), 28 (82%), and 9 (50%) eyes, respectively. The corresponding rates of complications for traumatic, PVR, GRT, and ROP eyes were: elevated IOP-3 (4%) of 76, 1 (3%) of 38, 1 (3%) of 34, and 0 (0%) of 18; hypotony--9 (12%), 3 (8%), 2 (6%), and 2 (11%); corneal opacity--25 (33%), 8 (21%), 15 (44%), and 5 (28%); emulsification--4 (5%), 1 (3%), 3 (9%), and 1 (6%); and cataract in phakic eyes--1 (33%) of 3, 2 (67%) of 3, 2 (50%) of 4, and 1 (33%) of 3.

CONCLUSIONS

Retinal reattachment and preserved visual acuity were achieved in the majority of eyes using vitrectomy and silicone oil retinal tamponade. Complete retinal and macular attachment was achieved less frequently in ROP eyes than in eyes in the other diagnostic groups. Use of 1000-centistoke silicone oil can be considered in the management of pediatric complex retinal detachments associated with multiple etiologies.

Neural networks in outcomes research

Neural networks (NNs) are being used in the areas of prediction and classification of outcomes in medicine--areas in which regression models have traditionally been used. In this report, we summarize the steps in developing and testing an NN. Through applications in clinical research, we present several examples of NN development and evaluation. Through these applications we show that the performance of the NNs matched or exceeded the performance of traditional methods. We then discuss the advantages and disadvantages of NN models in comparison to traditional regression methods.

Ethnicity and attitudes towards life sustaining technology

The ethical and legal implications of decisions to withhold and withdraw life support have been widely debated. Making end-of-life decisions is never easy, and when the cultural background of doctor and patient differ, communication about these issues may become even more difficult. In this study, we examined the attitudes of people aged 65 and older from different ethnic groups toward foregoing life support. To this end, we conducted a survey of 200 respondents from each of four ethnic groups: European-American, African-American, Korean-American and Mexican-American (800 total), followed by in-depth ethnographic interviews with 80 respondents. European-Americans were the least likely to both accept and want life-support (p < 0.001). Mexican-Americans were generally more positive about the use of life-support and were more likely to personally want such treatments (p < 0.001). Ethnographic interviews revealed that this was due to their belief that life-support would not be suggested if a case was truly hopeless. Compared to European-Americans, Korean-Americans were very positive regarding life-support (RR = 6.7, p < 0.0001); however, they did not want such technology personally (RR = 1.2, p = 0.45). Ethnographic interviews revealed that the decision of life support would be made by their family. Compared to European-Americans, African-Americans felt that it was generally acceptable to withhold or withdraw life-support (RR = 1.6, p = 0.06), but were the most likely to want to be kept alive on life-support (RR = 2.1, p = 0.002). Ethnographic interviews documented a deep distrust towards the health care system and a fear that health care was based on one's ability to pay. We concluded that (a) ethnicity is strongly related to attitudes toward and personal wishes for the use of life support in the event of coma or terminal illness, and (b) this relationship was complex and in some cases, contradictory.

Psychometric properties of a Chinese translation of the SF-36 health survey questionnaire in the Well Elderly Study

OBJECTIVES

To evaluate the psychometric properties of a Chinese translation of the 36-item Short Form Health Survey (SF-36) in the Well Elderly Study--a randomized clinical trial designed to evaluate the effectiveness of preventive occupational therapy services specifically tailored for multiethnic, independent-living, older adults.

METHODS

Translation and back-translation procedures were used to obtain appropriate meanings for the SF-36 survey questions and to ensure face, functional, and conceptual equivalence.

RESULTS

Statistical analyses demonstrated satisfactory reliability and validity, with the results generally similar to those reported for older Anglo adults.

DISCUSSION

As the percentage of older adults of diverse ethnicity increases, the need for health care research and service strategies that can effectively include multiple ethnicities becomes paramount. The results of this study suggest that a Chinese-translated SF-36 can be used to assess multiple dimensions of health in a Mandarin-speaking population of older adults.

Fluorophotometry in patients with human immunodeficiency virus with and without cytomegalovirus retinitis

OBJECTIVE

To study the aqueous humor dynamics in subjects with human immunodeficiency virus (HIV) with and without cytomegalovirus (CMV) retinitis.

DESIGN

Prospective cross-sectional study.

PARTICIPANTS

Fourteen HIV-positive subjects (27 eyes, 19 with CMV retinitis and 8 without CMV retinitis), and a control group of 9 HIV-negative subjects (17 eyes).

TESTING

Fluorophotometry.

MAIN OUTCOME MEASURES

Aqueous flow rates as measured by fluorophotometry and intraocular pressure (IOP).

RESULTS

Analysis of variance of the mean corrected aqueous flow rate revealed that both HIV-positive groups had significantly lower aqueous flow rates than did the control group (P < 0.03). No difference in mean aqueous flow rates was found between the HIV-positive eyes with or without CMV retinitis. Comparison of mean IOP revealed that HIV-positive eyes with CMV retinitis had significantly lower IOP than did the HIV-positive eyes without CMV retinitis (P = 0.03) and HIV-negative subjects (P = 0.002). There was no correlation between aqueous flow rate and IOP in HIV-positive subjects (P > 0.5).

CONCLUSION

The lack of correlation between the aqueous flow rate and IOP suggests that there may be some disassociation between these parameters in HIV-positive patients. Further studies are needed to better understand the mechanism of aqueous formation and in the management of disorders affecting IOP in this population.

Incidence of immune recovery vitritis in cytomegalovirus retinitis patients following institution of successful highly active antiretroviral therapy

This study was conducted to determine the likelihood of the development of a new ocular inflammatory syndrome (immune recovery vitritis, IRV), which causes vision loss in AIDS patients with cytomegalovirus (CMV) retinitis, who respond to highly active antiretroviral therapy (HAART). We followed 30 HAART-responders with CD4 cell counts of >/=60 cells/mm3. Patients were diagnosed with IRV if they developed symptomatic vitritis of >/=1+ severity associated with inactive CMV retinitis. Symptomatic IRV developed in 19 (63%) of 30 patients and in 26 (59%) of 44 eyes over a median follow-up from HAART response of 13.5 months. The annual incidence of IRV was 83/100 person-years. Excluding patients with previous cidofovir therapy did not significantly alter the time course of IRV (P=.79). These data suggest that IRV develops in a significant number of HAART-responders with CMV retinitis and is unrelated to previous cidofovir therapy.

The utility of entoptic perimetry as a screening test for cytomegalovirus retinitis

OBJECTIVE

To determine the sensitivity and specificity of entoptic perimetry as a noninvasive test for detecting retinal damage due to peripheral cytomegalovirus (CMV) retinitis.

DESIGN

A masked study comparing entoptic perimetry with fundus photography under 4 experimental conditions (determined by increasing pixel sizes) on 2 separate testing sessions.

SETTING

Acquired immunodeficiency syndrome Ocular Research Unit at the University of California, San Diego.

PATIENTS

Twenty-four human immunodeficiency virus-positive and 8 human immunodeficiency virus-negative subjects; 21 eyes with documented CMV retinitis, and 26 eyes that were retinitis free.

MEASUREMENTS

For each testing session, screening method, and condition, the presence of CMV retinitis was determined for each meridian (i.e., clock hour), each quadrant (consisting of 3 meridians), and each eye (consisting of all meridians); the amount of retinitis was defined as the percentage of meridians or quadrants with CMV retinitis.

RESULTS

Entoptic perimetry was as sensitive and specific as fundus photography in determining the presence of CMV retinitis. Determination of the amount of CMV retinitis tended to be underestimated by perimetry for larger pixel sizes.

CONCLUSION

Entoptic perimetry may be an effective and inexpensive alternative to fundus photography for CMV retinitis in hospitals and community clinics.

A discourse of relationships in bioethics: patient autonomy and end-of-life decision making among elderly Korean Americans

A two-year, multidisciplinary study (N = 800) was conducted on attitudes about end-of-life decision making among elderly individuals in four ethnic groups (African American, European American, Korean American, and Mexican American). On a quantitative survey, Korean Americans reported negative attitudes about the use of life-sustaining technology for themselves but positive attitudes about its use in general. This article reports on an interview with a 79-year-old typical Korean American respondent to explain the contradiction in the survey data. Expectations among elderly Korean Americans include protecting family members with a life-threatening illness from being informed of their diagnosis and prognosis, and doing everything to keep them alive. Two conclusions, one substantive and the other methodological, are drawn: First, the bioethics discourse on individual rights (patient autonomy) is insufficient to explain the preferences of many Korean Americans and must be supplemented with a discourse on relationships. Second, the rigorous use of qualitative, narrative methods clarifies quantitative data and should not be dismissed as "anecdotal."

Silicone oil in the repair of complex retinal detachments. A prospective observational multicenter study

OBJECTIVE

This study aimed to report anatomic and visual acuity outcomes and complications after 1000-centistoke silicone oil was used as a retinal tamponade for the treatment of complex retinal detachments.

DESIGN

Prospective observational multicenter study conducted at community and university-based ophthalmology clinics.

PARTICIPANTS

The study cohort consisted of 2439 patients (2573 eyes) treated for complex retinal detachments associated with cytomegalovirus (CMV) necrotizing retinitis or a non-CMV etiology, including proliferative diabetic retinopathy, giant retinal tears, proliferative vitreoretinopathy, or ocular trauma.

INTERVENTION

Vitrectomy surgery was performed for complex retinal detachment with 1000-centistoke silicone oil as the retinal tamponade.

MAIN OUTCOME MEASURES

Anatomic outcomes were complete retinal attachment and macular attachment. Visual acuity outcomes were ambulatory vision (> or = 4/200) and preservation of preoperative visual acuity. Complications were rates of secondary intraocular pressure elevation (> or = 30 mmHg), hypotony (< or = 5 mmHg), corneal opacification (including band keratopathy, corneal edema, and corneal abrasions), oil emulsification, and cataract. Outcomes were assessed 6, 12, and 24 months after surgery.

RESULTS

At the 6-month examination, the retina was completely attached in 178 (78%) of 228 CMV eyes and in 855 (70%) of 1219 non-CMV eyes. The macula was attached in 216 (95%) of 228 and 1062 (89%) of 1189 CMV and non-CMV eyes, respectively. Ambulatory vision was noted in 151 (65%) of 234 CMV eyes and in 480 (38%) of 1251 non-CMV eyes. Visual acuity was preserved in 106 (46%) of 230 and 1035 (84%) of 1229 CMV and non-CMV eyes, respectively. The corresponding rates of complications for CMV and non-CMV eyes were: elevated intraocular pressure, 0 (0%) of 196 and 35 (3%) of 1196; hypotony, 11 (6%) of 196 and 228 (19%) of 1196; corneal opacity, 13 (6%) of 229 and 326 (26%) of 1248; emulsification, 3 (1%) of 211 and 29 (3%) of 959; and cataract in phakic eyes, 118 (64%) of 185 and 50 (63%) of 80.

CONCLUSIONS

Retinal reattachment was achieved in the majority of eyes using vitrectomy and silicone oil retinal tamponade. Complication rates generally were less frequent in CMV eyes, but follow-up was shorter in this group of patients, largely because of reduced life expectancy. Cataract frequently developed in phakic eyes of study patients. Use of 1000-centistoke silicone oil can be considered in the management of complex retinal detachments associated with multiple etiologies.

TRIPOD (TRoglitazone In the Prevention Of Diabetes): a randomized, placebo-controlled trial of troglitazone in women with prior gestational diabetes mellitus

The TRoglitazone In the Prevention Of Diabetes (TRIPOD) trial is a single-center, randomized, placebo-controlled, double-masked study. The primary aim of the TRIPOD trial is to test the hypothesis that chronic administration of troglitazone to nondiabetic women with prior gestational diabetes mellitus (GDM) will improve whole-body insulin sensitivity and reduce the incidence of non-insulin-dependent diabetes (NIDDM). Because troglitazone is already known to lower blood glucose concentrations in persons who have developed NIDDM, an additional aim of the project will be to determine whether early intervention with troglitazone will achieve better final glycemic control than can be achieved by later intervention. In addition, since troglitazone treatment is expected to improve insulin sensitivity and may prevent or delay a decline in glucose tolerance, we also plan to determine whether long-term troglitazone treatment alters the development or progression of atherosclerosis. In this article we describe the experiment's design, the study's endpoints and methods for determining those endpoints, methods for assessing quality of life, and proposed methods for statistical analyses. The unique two-phase study design of the TRIPOD trial will permit testing not only of the biological question about reversal of insulin resistance and prevention of diabetes, but also of the clinical question about whether early intervention is superior to late intervention. Results from this trial will have an important impact on the monitoring and treatment of patients at high risk for NIDDM.

The role of carotid arterial intima-media thickness in predicting clinical coronary events

BACKGROUND

Carotid arterial intima-media thickness is used as a noninvasive surrogate end point to measure progression of atherosclerosis, but its relation to coronary events has not been fully explored.

OBJECTIVE

To determine whether carotid arterial intima-media thickness predicts coronary events.

DESIGN

Long-term follow-up (average, 8.8 years) of a previously assembled cohort of persons who completed the 2-year Cholesterol Lowering Atherosclerosis Study, a randomized arterial imaging trial designed to study the effects of lipid lowering on progression of atherosclerosis.

SETTING

University-based ultrasonography laboratory.

PATIENTS

146 men 40 to 59 years of age who had previously had coronary artery bypass graft surgery.

MEASUREMENTS

Preintrusive atherosclerosis in the common carotid artery was evaluated every 6 months with B-mode ultrasonography, and intrusive atherosclerosis in the coronary arteries was evaluated at baseline and at 2 years with quantitative coronary angiography. After the trial, the incidences of coronary events (nonfatal acute myocardial infarction, coronary death, and coronary artery revascularization) were documented.

RESULTS

For each 0.03-mm increase per year in carotid arterial intima-media thickness, the relative risk for nonfatal myocardial infarction or coronary death was 2.2 (95% CI, 1.4 to 3.6) and the relative risk for any coronary event was 3.1 (CI, 2.1 to 4.5) (P < 0.001). Absolute intima-media thickness was also related to risk for clinical coronary events (P < 0.02). Absolute thickness and progression in thickness predicted risk for coronary events beyond that predicted by coronary arterial measures of atherosclerosis and lipid measurements (P < 0.001).

CONCLUSION

Noninvasive B-mode ultrasonographic measurement of progression of intima-media thickness in the distal common carotid artery is a useful surrogate end point for clinical coronary events.

Evaluation of an expert system on lymph node pathology

BACKGROUND

Pathfinder is an Expert System that assists pathologists in making accurate diagnoses in the domain of lymph-node pathology. Pathfinder provides a differential diagnosis based on the initial histological feature(s) observed by the pathologist, and suggests to the user additional histological features for observation that are likely to narrow the differential diagnosis.

PURPOSE

To evaluate the diagnostic accuracy of pathologists with and without the Pathfinder.

METHODS

Thirty H&E stained slides from 30 lymph node biopsy specimens on which a Consensus diagnosis was made by two experts were reviewed by 19 pathologists to evaluate Pathfinder. After a period of training, 10 pathologists using Pathfinder (Interactive Computer Method) and 9 pathologists using the Routine Method (diagnosis without computer) determined a differential diagnosis for 15 slides (Test 1). Pathologists were then crossed over, trained, and evaluated the remaining 15 slides (Test 2). For each test, the proportion of "correct" diagnoses was compared between methods. In addition, the information integration attributes (making logical diagnosis given a set of specific histologic features) of Pathfinder and pathologists were compared. Finally, feature identification and quantification skills of pathologists were determined and correlated with the percent correct diagnosis.

RESULTS

The diagnostic accuracy using Pathfinder was greater than that using the Routine Method (40% v 32%, P = .02). Diagnostic accuracy for the group of pathologists who made diagnosis using the Routine Method in Test 1 increased when they made diagnosis using Pathfinder in Test 2 (27% to 44%, P < .0001). The proportion of correct diagnosis for the group of pathologists who used Pathfinder in Test 1 remained virtually unchanged when they gave up Pathfinder in Test 2 (35% to 37%). The percentage of incompatible feature identification ("atypical proliferation" diagnosis) was significantly lower after using Pathfinder (P < .0001). In addition, information integration attributes of Pathfinder were significantly superior than that of the pathologists (P < .0001).

CONCLUSIONS

Pathfinder is a valuable tool that assists pathologists in making accurate diagnosis because it has superior attributes than pathologists to integrate information and to screen for observations incompatible with any specific disease.

Vision-threatening complications of surgery for full-thickness macular holes. Vitrectomy for Macular Hole Study Group

OBJECTIVE

To study complications of vitrectomy surgery for full-thickness macular holes.

DESIGN

A multicentered, randomized, controlled clinical trial.

PARTICIPANTS

Community and university-based ophthalmology clinics.

INTERVENTION

Standardized macular hole surgery versus observation.

MAIN OUTCOME MEASURES

Assessment of anatomic and visual outcomes and determination of postoperative complications at 12 months after randomization.

RESULTS

Posterior segment complications were noted in 39 eyes (41%). The incidence of retinal pigment epithelium (RPE) alteration and retinal detachment (RD) were 33% and 11%, respectively. One RD due to a giant retinal tear resulted in a visual acuity of light perception. Other complications included a reopening of the macular hole in 2 eyes (2%), cystoid macular edema in 1 eye (1%), a choroidal neovascular membrane in 1 eye (1%) and endophthalmitis in 1 eye (1%). Eyes with complications had significantly worse visual acuity outcomes as determined by the Early Treatment Diabetic Retinopathy Study, Word Reading, and Potential Acuity Meter charts (P < 0.01 for all comparisons). Eyes with macular holes greater than 475 microns were more than twice as likely to have complications than eyes with holes less than 475 microns (odds ratio [OR] = 2.2, P = 0.07). Before surgery, the stage of the hole was related to postoperative RPE changes (P < 0.0001) and the occurrence of postoperative RD (P = 0.0002). Intraoperative trauma was related to the occurrence of these complications (P < 0.0001 for RPE changes, P = 0.02 for RDs). Epiretinal membrane removal was related to RPE changes (P = 0.02) but not RDs.

CONCLUSIONS

The RPE alterations and RDs are common after macular hole surgery and result in significantly reduced postoperative visual acuity. The RPE changes may be related to surgical trauma or light toxicity. Further efforts to reduce complications associated with macular hole surgery are indicated.

Post-traumatic proliferative vitreoretinopathy. The epidemiologic profile, onset, risk factors, and visual outcome

PURPOSE

The purpose of the study was to characterize the clinical development of proliferative vitreoretinopathy (PVR) after trauma in the human eye.

METHODS

A chart review was performed on the records of 1564 patients with ocular trauma seen at a large metropolitan hospital. The frequency, type of ocular trauma, time to onset, potential risk factors, and visual outcome for PVR were evaluated.

RESULTS

Proliferative vitreoretinopathy occurred in 71 (4%) of 1654 injured eyes. Of these 71 injured eyes, 30 (42%) resulted from rupture, 15 (21%) from penetration, 13 (18%) from perforation, and 7 (10%) from confusion. Six (9%) were associated with an intraocular foreign body (IOFB). The frequency of PVR following perforation, rupture, penetration, IOFB, and contusion was 43%, 21%, 15%, 11%, and 1%, respectively. Overall, those eyes that developed PVR had a poorer visual outcome, with PVR being the primary reason for visual loss. The time from injury to onset of PVR was shortest after perforation (median, 1.3 months), followed by rupture (2.1 months), IOFB (3.1 months), penetration (3.2 months), and contusion (5.7 months). Vitreous hemorrhage was the strongest independent predictive factor for the development of PVR. A long, posteriorly located wound and persistent intraocular inflammation were also important risk factors for PVR.

CONCLUSIONS

These results suggest that PVR is a common complication following a variety of ocular injuries, and that it is associated with a poor visual outcome. Its frequency, onset, and outcome are strongly dependent on the nature of the trauma. Specific high-risk groups are identified as candidates for more aggressive therapy.

Influence of lifestyle modification on atherosclerotic progression determined by ultrasonographic change in the common carotid intima-media thickness

The Monitored Atherosclerosis Regression Study (MARS) was a randomized, double-blind, placebo-controlled angiographic trial of lipid-lowering therapy in subjects with coronary artery disease. Subjects were counseled to follow a low-fat, low-cholesterol diet. At every clinic visit, data were obtained on body weight, dietary intake, alcohol consumption, and tobacco use. Semiannual determinations of early preintrusive atherosclerosis were made with high-resolution B-mode ultrasonography of the carotid artery intima-media thickness (IMT). We evaluated the effects of lifestyle modification (diet, alcohol, smoking, and weight loss) on the rate of carotid artery IMT progression on the 94 subjects randomly assigned to the placebo group. Dietary cholesterol, insoluble fiber, body mass index, and smoking were significant predictors of the annual rate of carotid artery IMT progression (P < 0.05). For subjects experiencing IMT progression, increased intakes of monounsaturated fat relative to saturated fat and stearic acid (18:0) consumption were significant predictors of a reduction in the annual rate of carotid artery IMT progression; for subjects experiencing IMT regression, male sex was a significant predictor of a reduction in the annual rate of carotid artery IMT regression. Modifications reducing body mass index by 5 kg/m2, quitting a 10 cigarette/d smoking habit, and reducing dietary cholesterol intake by 100 mg/d on average would reduce the annual rate of carotid wall IMT progression by 0.13 mm/y, which is equivalent to the maximum rate of IMT progression observed in the MARS placebo group. Progression of early preintrusive atherosclerosis can be reduced and overall regression can occur with dietary and lifestyle modification.

A comparison of quantitative computerized and human panel coronary endpoint measures: implications for the design of angiographic trials

The Monitored Atherosclerosis Regression Study was a double-blind, 2-year, placebo-controlled, randomized, serial angiographic trial which tested reduction of low density lipoprotein-cholesterol with monotherapy using lovastatin on the progression of coronary atherosclerosis. Angiographic outcome was evaluated both by a panel of human readers who visually inspected matched film pairs to arrive at a global change score and by automated computerized vessel edge finding and lesion measurement (quantitative coronary angiography, QCA). In this paper, we model the association between QCA measures of coronary artery lesion change and the panel-based global change score. QCA measures included: per-patient changes in percent diameter stenosis and minimum lumen diameter averaged over all lesions; per-patient changes in average diameter and percent involvement averaged over all segments; the numbers of progressing and regressing lesions and new total occlusions; and the development of any new lesions. We found that when evaluating coronary artery lesion change, panelists evaluate changes in percent diameter stenosis for both low grade (< 50% diameter stenosis at baseline) and high grade (> or = 50% diameter stenosis at baseline) lesions as well as new total occlusions and the number of progressing lesions. Although computerized quantification of the size of a lesion at baseline and as an endpoint may be a more precise measure than that by human panel interpretation, QCA fails to incorporate many other important aspects of coronary angiographic change visualized over the entire coronary artery tree by a panel of human interpreters. Thus, the global change score provides a "multiple endpoint" for coronary angiographic trials which does not suffer from the problems of statistical analysis and interpretation of multiple hypothesis tests which usually accompany true multiple endpoint measures. Choice of either or both endpoints in preparing angiographic trials depends on careful consideration of the desired information as well as the cost of carrying out the endpoint analysis.

Vitrectomy with silicone oil or long-acting gas in eyes with severe proliferative vitreoretinopathy: results of additional and long-term follow-up. Silicone Study report 11

BACKGROUND

The Silicone Study evaluated the outcomes of vitreoretinal surgery for retinal detachment with proliferative vitreoretinopathy (PVR).

OBJECTIVE

To evaluate short-term (up to 36 months) outcomes in eyes randomized to silicone oil or perfluoropropane gas and long-term (up to 72 months) outcomes in eyes with attached maculas at 36 months.

DESIGN

Prospective, randomized, multicentered surgical trial.

SETTING

Community- and university-based vitreoretinal practices.

PATIENTS

Two-hundred sixty-five eyes with PVR randomized to perfluoropropane gas and silicone oil with follow-up through 3 years (cohort 1) and 249 eyes with attached maculas at 36 months (121 eyes randomized to long-acting gas [either sulfur hexafluoride or perfluoropropane] and 128 eyes randomized to silicone oil) with follow-up up to 6 years (cohort 2). Both cohorts consisted of eyes that had and had not undergone vitrectomy for PVR (groups 1 and 2, respectively) before randomization. Of the 265 eyes in cohort 1, 24-month follow-up data were available for 218 eyes (82%) and 36-month follow-up data were available for 196 eyes (74%). Of 208 eyes in cohort 2, 48-month follow-up data were available for 146 eyes (70%), 60-month follow-up data for 119 eyes (57%), and 72-month follow-up data for 73 eyes (35%).

INTERVENTIONS

Vitrectomy surgery for PVR with a long-acting gas or silicone oil as the intraocular tamponade.

MAIN OUTCOME MEASURES

Changes in visual acuity, recurrent retinal detachment, and incidence of complications.

RESULTS

In group 1 of cohort 1, compared with oil-treated eyes, gas-treated eyes had a higher rate of complete retinal reattachment from 18 to 36 months (P < .05). No other differences were found. In group 2 of cohort 1, no notable differences were found between treatment arms. In cohort 2, during 6 years of follow-up, attachment of the macula was maintained for all eyes. No notable differences in the rates of complete retinal attachment, visual acuity of 5/200 or better, or glaucoma were found between treatment groups. In contrast, gas-treated eyes had more hypotony (P < .001). Silicone oil-treated eyes that underwent subsequent surgery were more likely to have the oil retained (P = .02). Compared with oil-retained eyes, oil-removed eyes had higher rates of complete posterior attachment (P = .01) and of a visual acuity of 5/200 or better (P < .001) and less keratopathy (P < .05). Compared with oil-removed eyes, gas-treated eyes had a worse visual acuity outcome (P < .05) and more hypotony (P < .01).

CONCLUSION

The Silicone Study showed that silicone oil and perfluoropropane gas were equal in most respects for the management of retinal detachments with PVR. Success in the first surgery for PVR is paramount for obtaining better visual results. Overall, surgery for PVR had a high likelihood of retinal reattachment, and if anatomically and visually successful at 3 years, there is an excellent chance that the results will be maintained over the long-term.

Vitrectomy for the treatment of full-thickness stage 3 or 4 macular holes. Results of a multicentered randomized clinical trial. The Vitrectomy for Treatment of Macular Hole Study Group

OBJECTIVE

To prospectively assess the risks and benefits of vitrectomy surgery for eyes with stage 3 or 4 macular holes.

DESIGN

A multicentered, controlled, randomized clinical trial.

SETTING

Community- and university-based ophthalmology clinics.

PATIENTS

One hundred twenty patients (129 eyes) with stage 3 or 4 macular holes.

INTERVENTIONS

Standardized macular hole surgery vs observation alone.

MAIN OUTCOME MEASURES

Four measures of best-corrected visual function, standardized photographic evaluation of the extent of hole closure, evaluation of lens opacification, and determination of adverse events. Outcomes were determined at 6 months after randomization.

RESULTS

Compared with observation alone, a significant benefit due to surgery was found in the rate of hole closure (4% vs 69%, P < .001). After adjusting for baseline visual acuity, hole duration, and maximum hole diameter, a significant benefit due to surgery was found in visual acuity for the Bailey-Lovie Word Reading (P = .02) and the Potential Acuity Meter (P < .01) tests; a marginally significant benefit due to surgery was found in visual acuity for the Early Treatment Diabetic Retinopathy Study chart (P = .05). Although the proportion of eyes achieving a change in visual acuity of 2 or more lines on the Early Treatment Diabetic Retinopathy Study chart was significantly greater for the surgery group vs the observed group (11 [19%] of 59 eyes vs 3 [5%] of 58 eyes, adjusted P = .05), 20 (34%) of 59 eyes randomized to surgery had a loss in visual acuity of 1 or more lines. Compared with the observation group, eyes randomized to surgery had higher nuclear sclerosis scores (2.4 vs 1.3, P < .001). Fourteen adverse events were noted in the surgery group; none were noted in the observed group.

CONCLUSIONS

Some visual benefit of vitrectomy surgery for macular holes exists, despite a notable incidence of adverse events. The large variability in visual acuity outcome in the surgical group may be because of complications or progressive cataract. A study of the long-term outcome after macular hole surgery is needed.

Effect of supplementary antioxidant vitamin intake on carotid arterial wall intima-media thickness in a controlled clinical trial of cholesterol lowering

BACKGROUND

There is accumulating experimental, epidemiological, and clinical evidence of an association between anti-oxidant vitamin intake and reduced risk of coronary heart disease. Using data from the Cholesterol Lowering Atherosclerosis Study (CLAS), we explored the association of self-selected supplementary antioxidant vitamin intake on the rate of progression of early preintrusive atherosclerosis.

METHODS AND RESULTS

CLAS was an arterial imaging trial in which nonsmoking 40- to 59-year-old men with previous coronary artery bypass graft surgery were randomized to colestipol/niacin plus diet or placebo plus diet. The rate of progression of early preintrusive atherosclerosis was determined in 146 subjects using high-resolution B-mode ultrasound quantification of the distal common carotid artery far wall intima-media thickness (IMT). From the nutritional supplement database, 22 subjects had an on-trial average supplementary vitamin E intake of > or = 100 IU per day (high users) and 29 subjects had an average on-trial supplementary vitamin C intake of > or = 250 mg per day (high users). Within the placebo group, less carotid IMT progression was found for high supplementary vitamin E users when compared with low vitamin E users (0.008 versus 0.023 mm/y, P = .03). No effect of vitamin E within the drug group was found. No effect of vitamin C within the drug or placebo group was found.

CONCLUSIONS

Supplementary vitamin E intake appears to be effective in reducing the progression of atherosclerosis in subjects not treated with lipid-lowering drugs while the process is still confined to the arterial wall (early preintrusive atherosclerosis).

Sensitivity, specificity, and predictive values of screening tests for eye conditions in a clinic-based population

PURPOSE

To assess four commonly available visual function tests to detect visually disabling or vision-threatening eye conditions among new patients of a large, urban, public, general ophthalmology clinic.

METHODS

Three hundred seventeen patients were tested for contrast sensitivity, Amsler grid abnormalities, and visual acuity at near and at distance. A complete eye evaluation found the prevalence of serious eye diseases, allowing determination of the sensitivity (Sn), specificity (Sp), likelihood ratio (LR), and other characteristics of each test.

RESULTS

Of 317 patients, most were Hispanic (77%), women (60%), and middle-aged (44 +/- 17 years). Normal findings were reported in 18%; refractive error in 43%; cataracts in 16%; glaucoma in 7.3%; and macular degeneration in 4.1%. Near visual acuity of 20/40 or worse (Sn = 0.75; Sp = 0.74; LR = 2.8); and distance visual acuity testing of 20/30 or worse (Sn = 0.74; Sp = 0.73; LR = 2.7) correlated significantly with ocular disease, whereas contrast sensitivity testing (Sn = 0.62; Sp = 0.41; LR = 1.1) and Amsler grid test (Sn = 0.19; Sp = 0.92; LR = 2.4) did not. Test performance decreased when refractive errors were excluded and among those younger than 40 years of age relative to those 40 years of age or older.

CONCLUSION

Of the four screening tests studied, distance and near threshold visual acuities as defined above were judged to have the best correlations of an abnormal result with ocular disease, both including or excluding refractive error. Different combinations of tests did not result in more accurate detection of ocular disease. More efficient screening tools for detecting ocular disease need to be developed.

Treatment of cytomegalovirus retinitis with intravitreous cidofovir in patients with AIDS. A preliminary report

BACKGROUND

Cytomegalovirus retinitis remains a major cause of illness in patients with the acquired immunodeficiency syndrome (AIDS), and existing therapies for this condition are relatively ineffective and toxic.

OBJECTIVE

To evaluate the efficacy of intravitreous cidofovir injections alone for initial and maintenance therapy for cytomegalovirus retinitis.

DESIGN

Prospective, nonrandomized, consecutive case series.

SETTING

University ophthalmology referral clinic.

PATIENTS

22 patients with AIDS and cytomegalovirus retinitis. In 15 of 32 affected eyes, intravitreous cidofovir was administered as the initial treatment for cytomegalovirus retinitis (group A); 17 eyes had previously been treated with intravenous therapy (group B).

INTERVENTION

All eyes were intravitreously injected with 20 micrograms of cidofovir at 5- to 6-week intervals. No patient in either group received systemic anticytomegalovirus therapy at any time during the study period.

MEASUREMENTS

Healing of retinitis was defined as resolution of retinal opacification and cessation of border progression. Progression, the primary end point, was defined as 750 microns of border progression or development of a new lesion.

RESULTS

The mean duration of follow-up was 15.3 weeks (range, 5 to 44 weeks). Of the eyes with active retinitis, 100% (95% CI, 87% to 100%) healed in response to the initial injection. In two eyes (6%; CI, 0% to 15%), two episodes of retinitis progression occurred (one in each eye). Both of these eyes were in a patient with clinically resistant retinitis. In 3% of eyes (CI, 0% to 9%), the retina became detached. Mild iritis developed after 14% of the injections that had been preceded by prophylaxis with oral probenecid. Irreversible, visually significant hypotonia developed in one eye.

CONCLUSION

Treatment and subsequent maintenance of cytomegalovirus retinitis with 20 micrograms of intravitreously injected cidofovir, given at 5- to 6-week intervals, is safe and highly effective.

Intravitreal cidofovir for the maintenance treatment of cytomegalovirus retinitis

PURPOSE

To evaluate the efficacy and safety of multiple intravitreal cidofovir (HPMPC) injections given every 5 to 6 weeks for the maintenance treatment of cytomegalovirus (CMV) retinitis.

METHODS

A prospective consecutive case series of 53 eyes in 35 patients with acquired immune deficiency syndrome and CMV retinitis was treated with maintenance intravitreal injections of cidofovir (20 micrograms) at one referral center between April 1994 and September 1995. Twenty-four eyes received intravitreal cidofovir as their initial treatment for CMV retinitis (group A), and 29 eyes previously had received systemic therapy (group B). None of the patients in either group received systemic anti-CMV therapy at any time during the study period. Progression of retinitis was the primary end point.

RESULTS

All eyes with active retinitis healed in response to treatment. None of the 24 eyes in group A demonstrated any progression during the study period. Four (14%) of the 29 eyes in group B had one episode each of retinitis progression (mean follow-up, 15 weeks; range, 0-58 weeks). In 1 (1.9%) of the 53 eyes, a retinal detachment developed. A mild iritis was observed after 14% of injections, which were prophylaxed with oral probenecid. Irreversible visually significant hypotony developed in two eyes (3.8%).

CONCLUSION

Treatment and subsequent maintenance therapy of CMV retinitis with 20 micrograms intravitreally injected cidofovir, given at 5- to 6-week intervals, is highly effective, with only rare episodes of re-activation and progression.

Anterior proliferative vitreoretinopathy in the silicone study. Silicone Study Report Number 10

BACKGROUND

As part of the design of the Silicone Study, a new classification of proliferative vitreoretinopathy (PVR) was developed that distinguishes the different types of contraction found in PVR. In contrast to the original Retina Society system that emphasized the post-equatorial retinal pathology (posterior PVR), the Silicone Study classification system included the characteristic types of contraction found in both the equatorial region and the pre-equatorial retina and vitreous base (anterior PVR).

METHODS

The authors contrast (1) preoperative and intraoperative findings and (2) vision and anatomic outcomes in the cohort of anterior PVR eyes with the cohort of posterior-only PVR eyes. For the cohort of eyes randomized to perfluoropropane gas (C3F8) or silicone oil, the authors carry out univariate and multivariate analyses to assess the predictive value of baseline and intraoperative parameters on vision and anatomic outcome.

RESULTS

Anterior PVR was present in 321 eyes (79%) and was more prevalent in eyes that had undergone an unsuccessful vitrectomy before study entry than in eyes that underwent a primary vitrectomy for PVR (88% versus 73%; P < 0.001). Compared with eyes that had posterior PVR at the preoperative examination, eyes that had anterior PVR tended to (1) be graded (Retina Society classification system) as D-1 or worse (86% versus 49%; P < 0.0001), (2) have worse (< 2/200) visual acuity (93% versus 86%; P = 0.003), (3) have more hypotony (24% versus 11%; P = 0.03), more edema (8% versus 2%; P = 0.04), more aqueous flare (P = 0.02), more macular pucker (69% versus 52%; P = 0.005), and more intravitreal contraction (21% versus 6%; P = 0.002). When compared with eyes that had anterior PVR, eyes with posterior PVR had a better outcome at the 6-month postoperative examination: complete attachment of the retina (76% versus 62%; P = 0.04), visual acuity of 5/200 or better (64% versus 45%; P = 0.006), and normal intraocular pressure (86% versus 71%; P = 0.04). For eyes with anterior PVR, significant predictors of poor (< 5/200) visual acuity were a preoperative PVR grade D-1 or worse and the use of C3F8 gas as the intraocular tamponade.

CONCLUSION

The Silicone Study classification of anterior PVR permits greater specificity in characterizing PVR and is prognostic of anatomic and vision outcome. Eyes with anterior PVR and clinically significant posterior PVR changes had a better visual prognosis if silicone oil was used. With the current understanding of the pathoanatomy of anterior PVR and the recent development of new surgical techniques, the incidence of anterior PVR in eyes that previously underwent vitrectomy may decline, and the prognosis in eyes with anterior PVR may improve.

Prospective randomized trial of vitrectomy or observation for stage 2 macular holes. Vitrectomy for Macular Hole Study Group

PURPOSE

To determine the risks and benefits of vitrectomy surgery in eyes with stage 2 macular holes.

METHODS

A multicentered, controlled, randomized clinical trial was performed with participation of 16 community and university-based ophthalmology clinics. Thirty-six eyes with stage 2 macular holes and 12 months of follow-up were studied. Pars plana vitrectomy with separation of the posterior hyaloid membrane and intraocular injection of perfluoropropane (C3F8) was followed by postoperative face-down positioning for two weeks. This protocol was compared with observation alone. Outcome variables included anatomic closure of the macular hole, macular hole size, and four standardized measures of vision.

RESULTS

At 12 months, 15 (71%) of 21 eyes randomly assigned to observation progressed to stages 3 or 4, compared with three (20%) of 15 eyes randomly assigned to surgery (P < .006). Compared with eyes randomly assigned to observation, eyes randomly assigned to surgery had significantly smaller hole diameters (P < .01) and significantly better visual acuity outcomes, as measured by the Word Reading (P = .02) and Potential Acuity Meter (P = .002) charts. No significant differences were found for the Early Treatment Diabetic Retinopathy Study chart and Contrast Sensitivity test.

CONCLUSION

Compared with observation alone, surgical intervention in stage 2 macular holes resulted in a significantly lower incidence of hole enlargement and appeared to be associated with better outcome in some measures of visual acuity.

Reduction in carotid arterial wall thickness using lovastatin and dietary therapy: a randomized controlled clinical trial

OBJECTIVE

To assess the effects of lipid-lowering therapy on the progression of early, preintrusive carotid arterial atherosclerosis.

DESIGN

Randomized, double-blind, placebo-controlled, serial carotid arterial imaging trial.

SETTING

University Atherosclerosis Research Unit.

PATIENTS

188 patients from the Monitored Atherosclerosis Regression Study who were 37 to 67 years of age and had angiographically defined coronary artery disease.

INTERVENTION

Cholesterol-lowering diet plus placebo or lovastatin, 80 mg/d.

MEASUREMENTS

High-resolution B-mode ultrasonographic quantification of the combined thickness of the distal common carotid arterial far wall intima-media complex (carotid arterial intima-media thickness) at baseline and every 6 months for as long as 4 years.

RESULTS

The annual rate of change in carotid arterial intima-media thickness differed significantly between the lovastatin group and the placebo group at 2 and 4 years (P < 0.001).

CONCLUSION

Lipid-lowering therapy reverses the progression of early, preintrusive atherosclerosis of the carotid artery. Both cholesterol-rich and triglyceride-rich lipoproteins correlate with the progression of early, preintrusive atherosclerosis of the carotid artery. These findings, together with earlier reports of the effects of lovastatin therapy on the progression of atherosclerosis of the coronary arteries, indicate that carotid arterial far wall intima-media thickness is a useful end point for anti-atherosclerosis trials.

The prognostic utility of the Silicone Study Classification System. Silicone Study Report 9. Silicone Study Group

OBJECTIVE

To evaluate the reproducibility and the prognostic utility of the Retina Society and Silicone Study Classification Systems in eyes after surgery for severe proliferative vitreoretinopathy (PVR).

DESIGN

Subgroup analysis of the Silicone Study--a randomized, multicentered, surgical trial.

SETTING

Community and university-based ophthalmology clinics.

MATERIALS

Three hundred forty eyes with preoperative and intraoperative evaluations using both systems of grading PVR (reproducibility study), and 287 eyes with preoperative and intraoperative evaluations using both systems of grading PVR and with a 24-month follow-up examination (prognosis study).

INTERVENTIONS

Vitrectomy for PVR with long-acting perfluoropropane gas or silicone oil as the intraocular tamponade.

OUTCOME MEASURES

Retinal reattachment, visual acuity ( > or = 5/200), intraocular pressure, corneal clarity, and the need for reoperation.

RESULTS

The reproducibility of the Silicone Study Classification System was 64% (type of contraction), 77% (number of clock hours), 67% (posterior PVR), 88% anterior and posterior PVR), and 94% (anterior, posterior, and subretinal PVR). The reproducibility of the Retina Society Classification System was 99%. Using the Silicone Study Classification System, location of PVR predicted visual acuity (P=.004, chi 2 test for trend) and hypotony (P=.03, chi 2 test for trend). Using the Retina Society Classification System, the grade of PVR predicted only visual acuity (P=.01, chi 2 test for trend). For eyes with anterior and posterior PVR, there was a decreasing trend in successful visual acuity outcome with increasing severity of PVR (from C-3 to D-3, P=.02, chi 2 test for trend).

CONCLUSIONS

Although the classification of PVR using the Silicone Study classification System was not reproducible for the type of contraction or for posterior PVR, identification of the anteroposterior extent of the PVR was prognostic of visual acuity and hypotony at 24 months. The joint knowledge of the location of PVR (using the Silicone Study Classification System) and the tightness of the funnel for retinas with 9 to 12 clock hours involved by fixed folds (using the Retina Society Classification System) has prognostic utility for eyes with anterior and posterior PVR.

Hyperacuity test to evaluate vision through dense cataracts; research preliminary to a clinical study. IV. Data on patients with macular degeneration and minimal media disorders obtained with and without a pseudo-nuclear cataract 6/60 (20/200) at the Aravind Eye Hospital, Madurai, India

Using a recently discussed three-point Vernier alignment test, data were obtained on patients with macular dysfunctions with and without a pseudo-nuclear cataract 6/60 (20/200) at the Aravind (Free) Eye Hospital, Madurai, India. The pseudo-cataract caused measurably and predictably reduced Vernier alignment thresholds, and necessary modifications deemed to be necessary in the protocol for later study are defined.