The COMS randomized trial of iodine 125 brachytherapy for choroidal melanoma, III: initial mortality findings. COMS Report No. 18

OBJECTIVES

To report initial mortality findings from the Collaborative Ocular Melanoma Study (COMS) randomized clinical trial of iodine 125 brachytherapy vs enucleation for treatment of choroidal melanoma.

METHODS

Patients were evaluated for eligibility at 43 participating clinical centers in the United States and Canada. Eligible consenting patients were assigned randomly at the time of enrollment to enucleation or 125I brachytherapy. Patients were examined at specified intervals after enrollment for data collection purposes. Findings presented herein are based on data received by September 30, 2000. Data for each patient were analyzed with the treatment group to which the patient was assigned randomly at the time of enrollment.

RESULTS

During the 11(1/2)-year accrual period, 1317 patients enrolled; 660 were assigned randomly to enucleation and 657 to 125I brachytherapy. Only 2 patients in the enucleation arm were found to have been misdiagnosed when histopathology was reviewed centrally. All but 17 patients (1.3%) received the assigned treatment. Adherence to the brachytherapy protocol was excellent, with 91% of patients treated per protocol. Based on time since enrollment, 1072 patients (81%) had been followed for mortality for 5 years and 416 (32%) for 10 years. A total of 364 patients had died: 188 (28%) of 660 patients in the enucleation arm and 176 (27%) of 657 patients in the brachytherapy arm. The unadjusted estimated 5-year survival rates were 81% and 82%, respectively; there was no clinically or statistically significant difference in survival rates overall (P =.48, log-rank test). The adjusted estimated risk ratio for 125I brachytherapy vs enucleation was 0.99 (95% confidence interval [CI], 0.80-1.22). Five-year rates of death with histopathologically confirmed melanoma metastasis were 11% and 9% following enucleation and brachytherapy, respectively; after adjustment, the estimated risk ratio was 0.91 (95% CI, 0.66-1.24).

CONCLUSIONS

Mortality rates following 125I brachytherapy did not differ from mortality rates following enucleation for up to 12 years after treatment of patients with choroidal melanoma who enrolled in this COMS trial. The power of the study was sufficient to indicate that neither treatment is likely to increase or decrease mortality rates by as much as 25% relative to the other.

The COMS randomized trial of iodine 125 brachytherapy for choroidal melanoma, II: characteristics of patients enrolled and not enrolled. COMS Report No. 17

OBJECTIVES

To describe characteristics of patients evaluated for the Collaborative Ocular Melanoma Study (COMS) randomized clinical trial of iodine 125 brachytherapy for choroidal melanoma by enrollment status, and to compare characteristics of patients enrolled with those of patients with tumors of eligible size who did not enroll in order to assess the extent to which findings from the clinical trial can be generalized to future patients.

METHODS

For all patients diagnosed with choroidal melanoma and evaluated for the clinical trial at COMS centers from November 1986 through July 31, 1998, selected data were transmitted to the COMS Coordinating Center, Baltimore, Md, where they were integrated and analyzed. Data included ophthalmic and medical history, examination findings, and visual acuity measurements recorded prior to enrollment; standardized A- and B-scan echographic examination findings; and wide-angle fundus photographs and fluorescein angiograms.

RESULTS

Of 8712 patients with choroidal melanoma, 5046 had tumors of eligible size; of these, 2882 (57%) were eligible for enrollment, and 1317 (46% of eligible patients, 26% of patients with tumors of eligible size) enrolled. Most differences between eligible and ineligible patients corresponded to eligibility and exclusion criteria. However, ineligible patients were older and had thicker tumors than eligible patients. Eligible patients who enrolled were slightly older and had larger tumors than those who did not enroll. Nearly half (48%) of enrolled patients had choroidal melanoma with the apex located temporal to the fovea, compared with 40% of eligible patients not enrolled and 29% of ineligible patients.

CONCLUSIONS

This trial was designed to yield internally valid treatment comparisons through random assignment to treatment at time of enrollment. Information from this and other studies document that enrolled patients were similar to other patients with choroidal melanoma who were treated with 125I brachytherapy. These findings support the external validity of the trial and applicability of treatment findings to all patients who meet the criteria used to judge eligibility for the trial.

Adult-onset foveomacular pigment epithelial dystrophy: clinicopathologic correlation of three cases

PURPOSE

The authors describe the clinicopathologic features of three patients with adult onset foveomacular pigment epithelial dystrophy (AOFPED).

METHODS

The eyes of three patients were studied ophthalmoscopically and by fluorescein angiography, and obtained postmortem and studied by light and electron microscopy.

RESULTS

Histopathologic study of the three patient's eyes disclosed central loss of the retinal pigment epithelium and photoreceptor cell layer with a moderate number of pigment-containing macrophages present in the subretinal space and outer retina. To either side, the retinal pigment epithelium was distended with much lipofuscin. Basal laminar and basal linear deposits were present throughout the central area. No discontinuities of Bruch membrane were present.

CONCLUSION

The findings in the eyes of three patients with AOFPED included marked aging changes that are similar to those seen in age-related macular degeneration. Pigmented cells with lipofuscin in the subretinal space account for the vitelliform appearance.

Macular translocation: unifying concepts, terminology, and classification

PURPOSE

To describe some unifying concepts, terminology, and classification of macular translocation so as to facilitate communication within the scientific community.

METHODS

A panel of ophthalmologists with expertise in macular translocation reviewed available data and developed some unifying concepts, terminology, and classification of macular translocation.

RESULTS

Macular translocation may be defined as any surgery that has a primary goal of relocating the central neurosensory retina or fovea intraoperatively or postoperatively specifically for the management of macular disease. It may be classified according to the size of the retinotomy and, where applicable, the technique of chorioscleral shortening used. The direction of macular translocation is denoted by the movement of the neurosensory macula relative to the underlying tissues. Effective macular translocation may be defined as successful intraoperative or postoperative relocation of the fovea overlying a subfoveal lesion to an area outside the border of the lesion. The concepts of minimum desired translocation and median postoperative foveal displacement can give some useful idea of the likelihood of effective macular translocation before surgery.

CONCLUSIONS

Use of a common standardized terminology for macular translocation will facilitate communication within the scientific community and enhance further research in this area. However, the definitions, terms, classification, and concepts concerning macular translocation are likely to continue to evolve as macular translocation undergoes further modifications and refinements.

Collaborative ocular melanoma study (COMS) randomized trial of I-125 brachytherapy for medium choroidal melanoma. I. Visual acuity after 3 years COMS report no. 16

OBJECTIVE

To report visual acuity during the first three years after iodine 125 (I(125)) brachytherapy for medium-sized choroidal melanoma and to identify important baseline and treatment factors associated with posttreatment visual acuity in a group of patients who were treated and observed prospectively as part of a large, randomized clinical trial.

DESIGN

Observational case series within a randomized, multicenter study.

PARTICIPANTS

Patients enrolled in the Collaborative Ocular Melanoma Study randomized trial of I(125) brachytherapy versus enucleation had choroidal melanoma of at least 2.5 mm but no more than 10.0 mm in apical height, and no more than 16.0 mm in largest basal dimension. One thousand three hundred seventeen patients enrolled from February 1987 through July 1998; 657 patients were assigned to I(125) brachytherapy. Visual acuity data for 623 patients who received I(125) brachytherapy as randomly assigned and who have been observed for at least 1 year were analyzed for this report.

METHODS

Under study protocol, an ophthalmic evaluation, including best-corrected visual acuity measurement of each eye, was performed at baseline, every 6 months thereafter for 5 years, and once yearly thereafter. Two poor vision outcomes, visual acuity of 20/200 or worse that was confirmed at the next follow-up examination and loss of six lines or more of visual acuity from baseline that was confirmed at the next follow-up examination, were analyzed to identify baseline and treatment characteristics that were associated with posttreatment visual acuity.

RESULTS

At baseline, median visual acuity in the eye with choroidal melanoma was 20/32, with 70% of eyes having 20/40 or better and 10% of eyes having 20/200 or worse visual acuity. Three years after I(125) brachytherapy, median visual acuity was 20/125, with 34% having 20/40 or better and 45% having 20/200 or worse visual acuity, including eyes that were enucleated within 3 years of treatment. Life-table estimates of percentages of patients who lost six or more lines of visual acuity from baseline, a quadrupling of the minimum angle of resolution, with this finding confirmed at the next 6-month follow-up examination, were 18% by 1 year, 34% by 2 years, and 49% by 3 years after treatment. Life-table estimates of percentages of patients with baseline visual acuity better than 20/200 whose visual acuity decreased to 20/200 or worse, confirmed at the next follow-up examination, were 17% by 1 year, 33% by 2 years, and 43% by 3 years after treatment. As soon as a poor vision outcome was observed, improvement of visual acuity to a level that no longer met the definition for a poor vision outcome was rare. Greater baseline tumor apical height and shorter distance between the tumor and the foveal avascular zone (FAZ) were the factors most strongly associated with loss of six or more lines of visual acuity after treatment. These two factors and baseline visual acuity also were strongly associated with visual acuity 20/200 or worse after treatment. Patient history of diabetes, presence of tumor-associated retinal detachment, and tumors that were not dome shaped also were associated with greater risk for both of the poor vision outcomes.

CONCLUSIONS

Forty-three percent to 49% of treated eyes had substantial impairment in visual acuity by 3 years after I(125) brachytherapy, defined as a loss of six or more lines of visual acuity from the pretreatment level (49% of eyes) or visual acuity of 20/200 or worse (43% of eyes) that was confirmed at the next 6-month examination. Patients with a history of diabetes and patients whose eyes had thicker tumors, tumors close to or beneath the FAZ, tumor-associated retinal detachment, or tumors that were not dome shaped were those most likely to have a poor visual acuity outcome within 3 years after I(125) brachytherapy.

Initial experience of inferior limited macular translocation for subfoveal choroidal neovascularization resulting from causes other than age-related macular degeneration

PURPOSE

To report our initial experience of inferior limited macular translocation in patients with subfoveal choroidal neovascularization resulting from causes other than age-related macular degeneration.

METHODS

We conducted a retrospective study of 23 eyes of 22 patients with choroidal neovascularization involving the foveal center secondary to pathologic myopia (11 eyes), ocular histoplasmosis syndrome (four eyes), angioid streaks (four eyes), idiopathic neovascularization (three eyes), and multifocal choroiditis (one eye), in which the fovea was moved inferiorly by means of limited macular translocation surgery. The mean preoperative best-corrected visual acuity was 20/150, and in five of 23 eyes (21.7%) the visual acuity was 20/80 or better. The major outcome measures were preoperative and postoperative visual acuity, postoperative foveal displacement, and complications related to the surgery.

RESULTS

The mean postoperative follow-up was 10.82 months (range, 6 to 18 months). Postoperative best-corrected visual acuity improved by 2 or more Snellen lines of visual acuity in 11 of 23 eyes (47.82%), remained within 1 line in seven of 23 eyes (30.43%), and worsened 2 or more lines of vision in five of 23 eyes (21.74%). The mean postoperative best-corrected visual acuity was 20/100, and in 12 of the 23 eyes (52.17%) the visual acuity achieved was 20/80 or better. Retinal detachment was the most frequent complication and occurred in six eyes (26%).

CONCLUSIONS

Our initial experience with limited macular translocation shows that this treatment modality offers the potential to improve visual function in some eyes with subfoveal choroidal neovascularization secondary to myopia, ocular histoplasmosis syndrome, angioid streaks, idiopathic neovascularization, and multifocal choroiditis. Although longer and more complete follow-up is needed, the results of this initial series warrant further studies to define the precise role of macular translocation in the management of these conditions.

Complications associated with limited macular translocation

PURPOSE

To report the ocular complications associated with the limited macular translocation procedure.

METHODS

Retrospective review of 153 consecutive eyes of 151 patients that had the limited macular translocation procedure for subfoveal choroidal neovascularization between April 1996 and February 1999. The major study variables investigated included the incidence of specific ocular complications and their impact on visual acuity at 3 months after the surgery. In addition, baseline patient characteristics and operative factors were evaluated to determine whether they were significant risk factors for the development of an ocular complication. The existence of a surgical procedure learning process was investigated.

RESULTS

One hundred forty-one (92.15%) of 153 eyes achieved at least 3-month follow-up. At least one complication occurred in 53 of 153 eyes (34.6%) and in 51 of these 53 eyes (96. 22%) the complications occurred before 3 months of postoperative follow-up. The intraoperative and postoperative complications included retinal detachment (17.4%), retinal breaks (13.4%), macular holes (7.8%), macular fold (4.6%), and intraocular hemorrhage (vitreous, subretinal, or choroidal; 9.2%). Eyes that developed retinal detachment, subretinal hemorrhage, and macular fold had significantly more loss of visual acuity than eyes without each of these complications (P =.0001, P =.038, and P =.027, respectively). The presence of predominantly classic choroidal neovascularization, the occurrence of an intraoperative retinal break, any intraocular hemorrhage, or macular fold formation were significantly associated with retinal detachment (P =.021, P =.025, P =.013, and P =.014, respectively). The incidence of any complication, retinal detachment, and hemorrhage significantly decreased during the study period, suggesting a learning process (P =.03, P =.006, P =.027, respectively).

CONCLUSIONS

A variety of ocular complications can occur during or after limited macular translocation, and some are associated with reduced postoperative visual acuity. Improved surgical techniques and experience may significantly reduce the incidence of these complications.

Limited inferior macular translocation for the treatment of subfoveal choroidal neovascularization secondary to age-related macular degeneration

PURPOSE

To review a series of patients with age-related macular degeneration undergoing limited macular translocation for the treatment of subfoveal choroidal neovascularization, to determine short-term visual acuity outcomes, to measure amounts of attainable retinal movement, and to identify prognostic factors.

METHODS

A retrospective review was conducted on a consecutive series of patients undergoing inferior limited macular translocation with scleral imbrication for the treatment of subfoveal choroidal neovascularization secondary to age-related macular degeneration. The main outcome measures investigated were distance of macular translocation, visual acuity at 3 and 6 months after surgery, change in visual acuity from baseline, and the development of intraoperative and postoperative complications. Univariate and multivariate analyses of a number of potential prognostic factors were undertaken.

RESULTS

Macular translocation was achieved in all 102 eyes (101 patients) included in this study. The range of movement varied from 200 to 2,800 microm with a median movement of 1, 200 microm. Nearly 33% of the study group achieved a visual acuity better than 20/100 at 3 months, and 49% achieved this vision at 6 months. At 3 and 6 months, 37% and 48% of the study group, respectively, experienced 2 or more lines of improvement on visual acuity testing, and by 6 months 16% experienced greater than 6 lines of visual improvement. Good baseline vision, achieving the desired amount of macular translocation, a greater amount of macular translocation, and recurrent choroidal neovascularization at baseline were associated with better visual acuities at 3 and 6 months. Poor preoperative vision and the development of complications were associated with worse vision at 3 and 6 months.

CONCLUSIONS

Limited macular translocation is a technically feasible procedure that can lead to significant visual improvement and good visual acuity in some patients presenting with subfoveal choroidal neovascularization associated with age-related macular degeneration. A randomized prospective clinical trial of this surgical technique is warranted.

Initial two years of experience with the AAO National Eyecare Outcomes Network (NEON) cataract surgery database

PURPOSE

To report the results of the first 2 years of experience with an American Academy of Ophthalmology (AAO) cataract surgery registry; to compare patient characteristics, operative procedures, and patient outcomes observed in the registry to those observed in the Cataract PORT study; and to discuss the current shortcomings and potential benefits of a national cataract surgery registry.

DESIGN

Observational study of episodes of cataract surgery reported by a self-selected sample of 249 ophthalmologists.

PARTICIPANTS

Seven thousand six hundred twenty-six patients undergoing cataract surgery during 1996 and 1997.

METHODS

Beginning in January 1996, participation in the AAO cataract surgery registry was offered to all ophthalmologists. Participants could use software or paper data collection forms to submit a common set of data regarding patients' demographics, preoperative ophthalmologic history, physical examination and test results, functional status and symptoms, intraoperative procedures and events, and postoperative outcomes for all patients undergoing first or second eye cataract surgery. Data were transmitted to a central database, where they were aggregated and analyzed. Findings were compared with those observed in the Cataract PORT study, which was conducted in 1991 and 1992.

RESULTS

Between January 1, 1996, and February 28, 1998, 249 ophthalmologists submitted data on at least one patient who underwent cataract surgery. A total of 7626 patients undergoing first or second eye surgery were enrolled, with all preoperative, intraoperative, and postoperative data forms submitted for 3342 patients (44%). The preoperative characteristics of patients reported to National Eyecare Outcomes Network (NEON) were similar to those of patients enrolled in the Cataract PORT study except for a higher reported prevalence of ocular comorbidity in NEON patients. Use of retrobulbar anesthesia was reported far less commonly, and use of topical anesthesia, phacoemulsification, and foldable intraocular lenses was reported far more often for NEON than for Cataract PORT study patients. Patient outcomes reported to NEON were similar to those observed in the Cataract PORT study.

MAIN OUTCOME MEASURES

Visual acuity, VF-14, Cataract Symptom Score, surgical complications.

CONCLUSIONS

During the first 2 years of NEON, ophthalmologist participation in the NEON cataract surgery database was low and consisted of a self-selected and likely nonrepresentative sample of ophthalmologists. The representativeness of patients for whom data were reported is unknown. In addition, complete data were submitted on only a minority of patients who were enrolled. Even so, the preoperative characteristics of patients on whom data were submitted to NEON were similar to those of patients enrolled in the Cataract PORT study. The initial experience with NEON demonstrates that it is technically possible to collect clinical data from, and report aggregated results to, practicing clinicians' offices. In addition, at least some practicing clinicians are willing to spend the time required to participate in the NEON registry. The NEON cataract surgery database thus has the potential to provide a practical means for tracking practice patterns and patient outcomes in real time. If a representative sample of physicians was willing to contribute data systematically and accurately over time, initiatives such as NEON could provide a means for professional societies and physicians to play a leadership role in defining and monitoring quality of care.

Hypertension, cardiovascular disease, and age-related macular degeneration. Age-Related Macular Degeneration Risk Factors Study Group

OBJECTIVES

To describe a case-control study of risk factors for neovascular and non-neovascular age-related macular degeneration (AMD) and to present findings on associations with systemic hypertension and cardiovascular disease.

METHODS

Participants with and without neovascular and non-neovascular AMD were recruited from 11 ophthalmology practices in the New York, NY, metropolitan area. Comprehensive data collection included (1) a standardized interview, (2) blood pressure measurements, and (3) blood samples. Cases and controls were classified from fundus photograph gradings. Polychotomous logistic regression analyses were used to evaluate associations.

RESULTS

Classification of 1222 sets of available photographs resulted in the inclusion of a neovascular case group (n = 182), a non-neovascular case group (n = 227), and a control group (n = 235). Neovascular AMD was positively associated with diastolic blood pressure greater than 95 mm Hg (odds ratio [OR] = 4.4), self-reported use of potent antihypertensive medication (OR = 2.1), physician-reported history of hypertension (OR = 1.8), use of antihypertensive medication (OR = 2.5), combinations of self-reported and physician-reported data on hypertension and its treatment (OR = 1. 7), high-density lipoprotein level (OR = 2.3), and dietary cholesterol level (OR = 2.2). Non-neovascular AMD was unrelated to hypertension or cholesterol level. No associations were found between either AMD type and other definitions of hypertension or other cardiovascular disease.

CONCLUSIONS

These findings suggest that neovascular AMD is associated with moderate to severe hypertension, particularly among patients receiving antihypertensive treatment. They also support the hypotheses that neovascular and non-neovascular AMD may have a different pathogenesis and that neovascular AMD and hypertensive disease may have a similar underlying systemic process.

Diabetic retinopathy in a black population: the Barbados Eye Study

OBJECTIVE

The distribution of diabetic retinopathy in black populations is largely unknown. The authors present retinopathy data from the predominately black participants of the Barbados Eye Study (BES).

DESIGN AND PARTICIPANTS

Prevalence study of 4631 participants based on a random sample of the Barbados population 40 to 84 years of age (84% participation).

MAIN OUTCOME MEASURES

Diabetes was defined as self-reported history of physician-diagnosed diabetes or glycosylated hemoglobin greater than 10% (>2 standard deviations above the population mean of persons without a diabetes history). Retinopathy was assessed by independent gradings of 30 degrees color stereo fundus photographs of the disc and macula.

RESULTS

Diabetes was present in 19.4% of black (n = 4314), 15.2% of mixed (black and white; n = 184), and 7.5% of white/other (n = 133) self-reported racial groups. In the black/mixed population, regardless of diabetes status, the prevalence of retinopathy was 5.9%. In the 636 black and mixed participants with diabetes, the prevalence of retinopathy was 28.5%: 19.8% had minimum changes, 7.7% had moderate changes, and 0.9% had severe retinopathy. Clinically significant macular edema (CSME) was found in 8.6% of those with diabetes.

CONCLUSIONS

In the population of African origin, approximately 1 in 17 persons had retinopathy. Among those with diabetes, 28.5% had retinopathy and 8.6% had CSME. These results highlight the clinical and public health relevance of diabetic retinopathy in the black population.

Ketorolac treatment of pseudophakic cystoid macular edema identified more than 24 months after cataract extraction

OBJECTIVE

To evaluate whether ketorolac ophthalmic drops prescribed four times a day can be associated with improved visual acuity and prompt resolution of edema for patients with pseudophakic cystoid macular edema identified more than 24 months after cataract surgery.

DESIGN

Prospective, nonrandomized, comparative (subject self-controlled) trial.

PARTICIPANTS

The records of nine patients who had pseudophakic cystoid macular edema more than 24 months after cataract surgery at the time treatment commenced were identified at the Wilmer Retinal Vascular Center from September 1, 1996, through March 1, 1997.

MAIN OUTCOME MEASURES

Best-corrected visual acuities measured on a retroilluminated Bailey-Lovie chart approximately every 3 months, contact lens biomicroscopy, and fluorescein angiography following ketorolac.

INTERVENTION

Commercially available ketorolac ophthalmic drops 0.5% were prescribed for the affected eye four times a day for at least 3 months and continued until edema resolved.

RESULTS

Ten eyes of nine patients were identified more than 24 months after cataract extraction (median, 59 months). Seven eyes (70%) improved (mean, +3.2 lines; range, +1 to +13 lines), including six by 2 or more lines 3 months after treatment initiation. Two eyes (20%) were unchanged, and one eye (10%) was 1 line worse. All seven eyes that improved 1 line or more had some or complete angiographic resolution of fluorescein dye leakage. In these seven eyes, ketorolac was discontinued when dye leakage completely resolved or failed to continue to improve on periodic 3-month follow-up examinations. In all seven eyes, recurrence of edema was noted within 3 months after ketorolac was stopped.

CONCLUSIONS

Chronic pseudophakic cystoid macular edema identified more than 24 months after cataract surgery can improve with topical ketorolac but probably requires persistent use.

Tracers for imaging melanin with positron emission tomography

The melanin binding properties of six radioligands were determined in vivo in the eyes of pigmented mice. Binding in the eyes of nonpigmented mice was used to assess nonmelanin binding characteristics. Of these radioligands, 3H-N-methylspiperone showed the best uptake and gave the best signal-to-noise ratio at all time points examined. Its binding appeared essentially irreversible. A PET study with 11C-N-methylspiperone was therefore carried out in a patient with a small ocular melanoma. Increased uptake of 11C-N-methylspiperone was observed in the melanoma. Our studies indicate that PET and radiolabeled NMSP might be used for imaging melanin and for the detection of pigmented melanoma. These results suggest that with a high resolution PET camera it may be feasible to image the melanin-containing cells (dopaminergic neurons) of the substantia nigra in the central nervous system, which could be of interest for the study of Parkinson's disease.

Availability of color fundus photographs from previous visit affects practice patterns for patients with diabetes mellitus

OBJECTIVE

To determine whether access to color fundus photographs from a patient's previous visit would alter the recommendations rendered to a cohort with diabetic retinopathy.

PATIENTS AND METHODS

One hundred sixty patients with diabetic retinopathy returning for a follow-up visit and who had color fundus photographs obtained at a previous visit were evaluated by trained retina specialists. Their clinical impression and recommendations regarding management of diabetic retinopathy were recorded without reference to previous photographs. Color fundus photographs from the patient's most recent visit were then reviewed and new recommendations with regard to appropriate treatment and follow-up were recorded.

RESULTS

In 21% of cases, after reviewing the patient's most recent color fundus photographs, the clinical recommendation changed. In 14% of cases, photographs clearly demonstrated that the patient's condition was stable or improved, resulting in a change from recommending treatment to recommending deferral of treatment. In 4% of cases, photographs clearly demonstrated clinical worsening and the recommendation was changed from observation to treatment. In 3% of cases, review of photographs prompted a change in the recommended follow-up interval.

CONCLUSION

Access to color fundus photographs from a patient's previous visit frequently changed the clinical recommendations made to patients with diabetic retinopathy regarding appropriate treatment and follow-up. Availability of color fundus photographs therefore has implications about quality of care and may affect the cost of care.

Diabetic retinopathy

Nonproliferative diabetic retinopathy may cause visual loss when associated with macular edema or macular ischemia (secondary to retinal capillary nonperfusion). Proliferative diabetic retinopathy may cause severe visual loss if complicated by vitreous hemorrhage or traction detachment of the macula. Patients with diabetes benefit from collaboration between the internist and ophthalmologist. Tighter control of blood glucose levels and lower blood pressure reduce the risk of progression of diabetic retinopathy. Regular dilated eye examinations and appropriate intervention with laser or vitrectomy surgery help to preserve vision in patients with established macular edema or proliferative diabetic retinopathy.

Lens opacities, demographic factors and nutritional supplements in the Barbados Eye Study

BACKGROUND

This study evaluated the association of age-related lens opacities with the use of nutritional supplements and demographic factors among 4314 black participants (> or = 40 years) in the population-based Barbados Eye Study.

METHODS

Lenses were classified at the slit lamp by the Lens Opacities Classification System II (LOCS II); a score > or = 2 was used to define the presence of gradable lens opacities, by type. Lens changes also included prior cataract surgery or cataract too advanced to grade. Associations with risk factors were evaluated by logistic regression analyses.

RESULTS

The study identified 1800 individuals with lens changes in at least one eye; 229 had nuclear opacities only; 851 had cortical opacities only. Older age and indicators of lower socioeconomic status (low education and/or non-professional occupation), were positively associated with both nuclear (odds ratio [OR] = 1.90) and cortical (OR = 1.47) opacities. Women had an increased risk of cortical opacities (OR = 1.41). Regular users of nutritional supplements were less likely to have lens changes (OR = 0.78) and, specifically, cortical opacities (OR = 0.77). The association with nutritional supplements was present in those < 70 years, but not at older ages.

CONCLUSIONS

The study supports the association of lower socioeconomic status with lens changes, including nuclear and cortical lens opacities. The findings also suggest that regular users of nutritional supplements have a one-fourth lower risk of lens changes and particularly, of cortical opacities; a result seen at ages under 70 years. The associations with potentially modifiable factors indicate the need for further evaluations, given the high prevalence of lens opacities.

Distribution of intraocular pressure. The Barbados Eye Study

OBJECTIVE

To provide data on the distribution of intraocular pressure (IOP) in a predominantly black population, which has a high prevalence of open-angle glaucoma.

DESIGN

Population-based prevalence study.

SETTING AND PARTICIPANTS

Participants (N = 4601) (age range, 40-84 years) who had undergone applanation tonometry measurements in the Barbados Eye Study. Self-reported race was 93% black, 4% mixed (black and white), and 3% white or other.

DATA COLLECTION

A standardized protocol included applanation tonometry and other ocular measurements, fundus photography, demographic data, and an interview.

MAIN OUTCOME MEASURES

The average of 3 IOP measurements at the Barbados Eye Study visit was used to compare IOP by self-reported race. Descriptive data on IOP by age, sex, glaucoma status, and cup-disc ratio were examined in the black population.

RESULTS

The IOP was highest in the population of African origin. The mean (+/-SD) IOP values for black, mixed, and white participants were 18.7 +/- 5.2, 18.2 +/- 3.8, and 16.5 +/- 3.0 mm Hg, respectively. An IOP greater than 21 mm Hg was present in 18.4%, 13.6%, and 4.6% of the black, mixed, and white participants, respectively. In analyses that were adjusted for age, sex, and glaucoma status, such values were 5 times as likely in black than white participants and 3.5 times as likely in mixed race participants (P < .01). Among the black participants, the mean IOP increased approximately 1 mm Hg for every increase in 10 years of age. After excluding persons with any type of glaucoma, suspected glaucoma, or a history of glaucoma treatment, women had significantly (P < .01) higher IOP values; however, no significant IOP trends by sex were evident in the group with glaucoma. The IOP was also positively associated (P < .05) with vertical cup-disc ratios. After 2 visits, the IOP remained 21 mm Hg or less in 21% of the persons with glaucoma vs 64% of those without glaucoma.

CONCLUSIONS

In the black participants, the IOP was higher than in the white participants. The IOP was also associated with age and cup-disc ratios. The results showed that open-angle glaucoma and a high IOP alone have a different distribution by sex; although open-angle glaucoma was more frequent in men, ocular hypertension was more frequent in women. These data have implications for the detection and causation of open-angle glaucoma in this high-risk population.

Occult choroidal neovascularization in age-related macular degeneration. A natural history study

OBJECTIVE

To explore morphological and vision changes in untreated eyes with subfoveal choroidal neovascularization (CNV) that have poorly demarcated boundaries.

DESIGN

Analysis of photographs of untreated patients with poorly demarcated occult CNV participating in a prospective clinical trial evaluating laser treatment compared with observation.

SETTING

Two tertiary retinal referral centers.

PATIENTS

Symptomatic individuals with poorly demarcated subfoveal occult CNV associated with age-related macular degeneration.

MAIN OUTCOME MEASURES

Change in size of lesion, development of classic CNV, change in vision, and development of subretinal fibrosis.

RESULTS

During follow-up (9-12 months), 32% of the occult choroidal neovascular lesions more than doubled their original size. Classic CNV developed in 52% of eyes that started without it. The median loss in visual acuity was 2.5 lines. Eyes with classic CNV or subretinal blood or both at baseline developed subretinal fibrosis more frequently and lost more visual acuity, but not to a statistically significant degree.

CONCLUSIONS

The morphological changes of eyes with subfoveal occult CNV in which the boundaries are poorly demarcated in variable; the presence of subretinal blood or a component of classic CNV may influence the prognosis for further loss of vision.

Macular scatter ('grid') laser treatment of poorly demarcated subfoveal choroidal neovascularization in age-related macular degeneration. Results of a randomized pilot trial

OBJECTIVES

To determine the effects of macular scatter ("grid") laser photocoagulation compared with observation on the visual function of eyes with subfoveal choroidal neovascularization (CNV) that has poorly demarcated boundaries and to provide preliminary data for the evaluation of the feasibility and design of a larger, definitive trial.

DESIGN

Randomized pilot clinical trial.

SETTING

Two tertiary care retinal referral practices.

PATIENTS

Symptomatic individuals with subfoveal CNV secondary to age-related macular degeneration in whom fluorescein angiography showed occult CNV with poorly demarcated boundaries; classic CNV was allowed but did not need to be present for entry into the study.

MAIN OUTCOME MEASURE

Change in visual acuity from baseline to specified time periods.

RESULTS

Fifty-two eyes were assigned to observation. Fifty-one eyes were assigned randomly to treatment consisting of macular scatter ("grid") laser photocoagulation to the area of CNV. The treatment protocol for 8 of these eyes also included confluent laser photocoagulation to areas of classic CNV. The average visual acuity decrease from baseline was greater in the treated than in the observed group. The difference between these groups was greatest within the first year after study enrollment. At 24 months, slightly more than 40% of the eyes in each group had lost 6 or more lines of visual acuity. Similar results were noted for the subgroup of eyes initially with angiographic features of occult CNV but no classic CNV.

CONCLUSIONS

These short-term study results suggest that macular scatter ("grid") laser treatment is not beneficial and is possibly harmful compared with observation for symptomatic subfoveal CNV with poorly demarcated boundaries in age-related macular degeneration. With or without treatment, a significant proportion of these patients are at risk of severe visual loss within 2 years of seeking treatment, even when the eye initially has occult CNV and no classic CNV.

Detection of diabetic macular edema: Nidek 3Dx stereophotography compared with fundus biomicroscopy

PURPOSE

To assess the use of the Nidek 3Dx simultaneous stereophotography camera in diabetic patients, comparing the detection of clinically significant macular edema by fundus biomicroscopy to detection by the Nidek 3Dx simultaneous fundus stereophotograph.

METHODS

Two hundred eight eyes of 123 diabetic patients at the Wilmer Retinal Vascular Center were examined for this prospective study between August 1993 and October 1993. Each patient was examined by one of three retina specialists by contact lens biomicroscopy for clinically significant macular edema and foveal center thickening. Nidek 3Dx fundus stereophotographs were obtained and graded independently for clinically significant macular edema and foveal center thickening by a fourth ophthalmologist masked from the clinical examination findings. Percent agreement, kappa statistic, and weighted kappa statistic were determined for the two diagnostic methods.

RESULTS

One hundred eighty-four (88%) of the 208 stereophotographs were of sufficient quality to detect clinically significant macular edema; 175 (84%) of the 208 stereophotographs detected foveal center thickening. The agreement between the clinician and the photographic grading, measured by weighted kappa, was 0.52 for clinically significant macular edema and 0.58 for foveal center thickening, representing fair to good agreement beyond chance. Agreement was improved when normal fundus Nidek stereophotographs were available as standards for comparison.

CONCLUSIONS

The Nidek 3Dx camera is suitable for photographic detection of clinically significant macular edema and may have a potential advantage over conventional cameras by achieving good-quality, gradable stereophotographs in a large proportion of photographed eyes.

Rhegmatogenous retinal detachment in eyes with uveal melanoma

PURPOSE

To describe the clinical features, surgical management, and outcome of patients with uveal melanoma who presented with or later developed a rhegmatogenous retinal detachment.

METHODS

We retrospectively identified four patients who presented with uveal melanoma and rhegmatogenous retinal detachment simultaneously and six patients in whom a rhegmatogenous retinal detachment developed 11-100 months (mean, 44.8 months) after radiotherapy for a choroidal melanoma.

RESULTS

All four patients with simultaneous presentation of uveal melanoma and retinal detachment underwent successful retinal detachment repair (cases 1 and 4, scleral buckle; case 2, pars plana vitrectomy, and case 3, pneumatic retinoplexy). Rhegmatogenous retinal detachment occurring after proton beam or plaque radiotherapy of uveal melanoma was repaired successfully in five of six patients with scleral buckling alone or in combination with pars plana vitrectomy. In the short follow-up period of this study, we did not observe tumor recurrence either before or after retinal detachment repair.

CONCLUSION

Rhegmatogenous retinal detachment associated with uveal melanoma may be treated successfully using conventional retinal surgical techniques. The benefits of retinal detachment repair must be weighed against any theoretical increased risk of extra-scleral extension of the melanoma. Long-term follow-up evaluation will be required to determine the safety of various retinal detachment repair techniques in these eyes.

Angiographic features and outcome of questionable recurrent choroidal neovascularization

PURPOSE

We sought to identify specific fluorescein angiographic patterns that may have led to the diagnosis of questionable recurrent choroidal neovascularization. We evaluated follow-up information to determine whether any specific angiographic patterns could be used to identify patients at high risk for definite recurrence.

METHODS

We identified fluorescein angiograms graded as questionable for recurrent choroidal neovascularization that were taken from a previous prospective study involving 401 consecutive follow-up visits of patients treated with photocoagulation for choroidal neovascularization. We reviewed these angiograms to identify specific angiographic patterns that might have led to the classification of questionable recurrent choroidal neovascularization. Angiograms from visits subsequent to a questionable recurrence were reviewed to determine which patterns, if any, were associated with an increased risk for a definite recurrence to develop later.

RESULTS

Forty-four eyes (44 patients) with questionable recurrences (of which 40 had at least four months of follow-up) were categorized into six angiographic patterns. The three most common patterns included the following: (1) focal staining along the edge of the laser lesion (20 cases, 15 subsequently recurred); (2) blocked fluorescence from subretinal hemorrhage not documented at the previous visit (eight cases, five subsequently recurred); (3) speckled hyperfluorescence noted beyond the edge of the laser lesion (eight cases, six subsequently recurred).

CONCLUSIONS

Questionable recurrent choroidal neovascularization may be identified by specific angiographic patterns. Focal staining along the edge of the laser lesion and speckled hyperfluorescence were the patterns that were most likely to progress to definite recurrence.

Risk factors for open-angle glaucoma. The Barbados Eye Study

OBJECTIVE

To evaluate risk factors for open-angle glaucoma among black participants in the Barbados Eye Study.

DESIGN

Population-based study of demographic, medical, ocular, familial, and other factors possibly related to open-angle glaucoma.

SETTING AND PARTICIPANTS

The Barbados Eye Study included 4709 Barbados residents identified by a simple random sample of Barbadian-born citizens, 40 to 84 years of age; participation was 84%. This report is based on the 4314 black participants examined at the study site; 302 (7%) met the Barbados Eye Study criteria for open-angle glaucoma.

DATA COLLECTION

A standardized protocol included applanation tonometry, Humphrey perimetry, fundus photography, blood pressure, anthropometry, and an interview. An ophthalmologic examination was performed for participants who met specific criteria.

MAIN OUTCOME MEASURES

Open-angle glaucoma was defined by the presence of both characteristic visual field defects and optic disc damage. Association of open-angle glaucoma with specific factors was evaluated in logistic regression analyses.

RESULTS

Age, male gender, high intraocular pressure, and family history of open-angle glaucoma were major risk factors; the latter association was stronger in men than women. Lean body mass and cataract history were the only other factors related to open-angle glaucoma. Although hypertension and diabetes were common in Barbados Eye Study participants, they were unrelated to the prevalence of open-angle glaucoma. However, associations were found with low diastolic blood pressure-intraocular pressure differences and low systolic and diastolic blood pressure/intraocular pressure ratios.

CONCLUSIONS

In the Barbados Eye Study black population, persons most likely to have open-angle glaucoma were older men and had a family history of open-angle glaucoma, high intraocular pressure, lean body mass, and cataract history. These results suggest the importance of possible genetic or familial factors in open-angle glaucoma. The role of vascular risk factors is consistent with our finding of low blood pressure to intraocular pressure relationships, but the results could be explained by the high intraocular pressure in open-angle glaucoma.

Features of age-related macular degeneration in a black population. The Barbados Eye Study Group

OBJECTIVE

To report on the frequency of features of age-related macular degeneration in a black population based on fundus photograph gradings.

DESIGN

Population-based study.

SETTING

Barbados, West Indies.

STUDY POPULATION

Residents of Barbados, selected by a random sample of Barbados-born citizens, aged 40 to 84 years.

MAIN OUTCOME MEASURE

Gradings from 30 degrees stereoscopic macular photographs.

RESULTS

Black participants (n = 3444) completed examinations at the study site and had gradable macular photographs in both eyes. Drusen larger than 63 microns occurred with comparable frequency in men and women. The frequency of small drusen decreased with age, while medium and large drusen were more common in older participants. Frequencies of all age-related macular degeneration-related characteristics were similar for men and women except for small drusen, which occurred more commonly in women. Confluent drusen and pigment atrophy also increased significantly with age. Exudative features occurred in 0.5% of the participants.

CONCLUSIONS

This study provides population-based data on the frequency of features of age-related macular degeneration based on photographic gradings of a black population. Features of early age-related macular degeneration were common, but appeared at a lower frequency than has been reported for white populations. Exudative disease was infrequent, occurring in about one of 200 participants.

Evaluating quality of care in the new health care environment

Today's health care environment explicitly emphasizes quality monitoring and improvement systems. To better understand the new concepts of quality, the quality systems currently used and under development at the Doheny Eye Institute, Los Angeles, Calif, and The Wilmer Ophthalmological Institute, Baltimore, Md, were reviewed and the underlying principles and pertinent examples extracted. In the future, quality monitoring will require measurement of rates of conformance with indicators of each of the three components of quality of care, ie, structures, processes, and outcomes. As such, significant changes in the philosophy of quality monitoring and development of newer and more advanced measures and indicators will be needed to meet the challenges of quality review in the new health care environment.

Detecting recurrent choroidal neovascularization. Comparison of clinical examination with and without fluorescein angiography

OBJECTIVE/DESIGN

To evaluate prospectively the ability of three retina specialists to detect recurrent choroidal neovascularization (CNV) after clinical examination alone and then with fluorescein angiography at 3 and 6 weeks and at 3, 6, 9, and 12 months after laser photocoagulation.

SETTING

Single tertiary retinal referral center.

PATIENTS

All patients who had laser treatment for CNV within 14 months of their study visit. One hundred thirty-seven eyes of 134 patients were evaluated during 401 visits.

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive predictive value, and negative predictive value of clinical examination with biomicroscopy to detect recurrent CNV when defined as leakage on the periphery of the laser-treated area on the fluorescein angiogram.

RESULTS

Ninety-seven definite or probable recurrences in 56 eyes were identified on the fluorescein angiogram. Clinical examination had a sensitivity of 59%, specificity of 94%, positive predictive value of 76%, and negative predictive value of 88%. These figures varied somewhat by underlying cause, age, time since treatment, and lesion location. Using either a reported or measured loss of vision with the results of biomicroscopy as an indication of recurrence increased the sensitivity to 77% but reduced the specificity to 81%.

CONCLUSIONS

Clinical examination probably cannot replace fluorescein angiography in detecting all recurrent CNV after laser treatment. However, for follow-up visits in which recurrent CNV was not suspected on biomicroscopy, definite or questionable recurrent CNV was identified on the fluorescein angiogram only 12% of the time, while the absence of recurrent CNV using this method was confirmed 88% of the time.

Outcome of cataract operations performed to permit diagnosis, to determine eligibility for laser therapy, or to perform laser therapy of retinal disorders

Cataract operations may be recommended when retinal disease is suspected but cannot be adequately diagnosed or treated because of lens opacity. We evaluated the outcome of cataract operations performed under those circumstances. We reviewed the records of 119 patients who were examined at the Wilmer Retinal Vascular Center and within three months underwent a cataract operation. We identified 17 patients (20 eyes) who underwent a cataract operation at the recommendation of a retinal specialist, to permit diagnosis, to determine eligibility for laser therapy, or to perform laser therapy. After the cataract operation, eight (40%) of the 20 eyes were found to have a retinal disease for which laser therapy was recommended, and six (30%) of the 20 eyes underwent laser therapy that, before the cataract operation, had been impossible. These results indicate that a cataract operation may be useful when lenticular opacity prevents diagnosis or treatment in a patient with a suspected retinal disorder.

Choroidal neovascularization in black patients

OBJECTIVE

To characterize choroidal neovascularization (CNV) in black patients examined at a retinal disease referral center.

DESIGN

Retrospective review of the medical records of all patients diagnosed as having CNV to identify black patients with CNV.

SETTING

Single tertiary retinal referral center that included four ophthalmologists.

PATIENTS

All patients diagnosed as having CNV between April 1990 and October 1992.

MAIN OUTCOME MEASURES

Prevalence, demographic information, fundus photographic and fluorescein angiographic characteristics, natural history, and response to laser photocoagulation of CNV in black patients.

RESULTS

Black patients comprise 15% of all patients seen at this center. Of 1725 patients identified as having CNV who were seen at the center during a 2.5-year period, only 25 were black (1.4%). In these patients, CNV was associated with a variety of retinal diseases, the most frequent being age-related macular degeneration. The average age of the study group was 54 years, women outnumbered men 2:1, and 13 of the patients developed bilateral lesions. Twelve of the 38 lesions were extrafoveal on presentation, and five of these were peripapillary. In the laser-treated eyes, recurrence of CNV was frequent and associated with visual loss.

CONCLUSIONS

Choroidal neovascularization seems to be rare in blacks among a retinal disease referral center population. The overall presentation, natural history, and response to laser treatment seems to be similar to that of white patients. No feature of CNV in black patients was identified that would suggest that results of randomized clinical trials of laser photocoagulation for CNV are not valid for these patients.

Diabetic retinopathy: a review

In the United States, diabetic retinopathy is the leading cause of new blindness in those of occupational age. We present an overview of risk factors, including renal disease, uncontrolled blood pressure, pregnancy, poor glucose control, elevated glycosylated hemoglobin, duration of disease, and age at time of diagnosis; pathogenesis, addressing the involvement of aldose reductase, nonenzymatic glycosylation of proteins, vasoproliferative factors, ischemia and vasodilation, systemic growth factors, and platelets and blood viscosity; pathology, including nonproliferative, preproliferative, and proliferative retinopathy; and the management of this condition.

The Barbados Eye Study. Prevalence of open angle glaucoma

OBJECTIVE

To describe the design of the Barbados Eye Study and report on the prevalence of open angle glaucoma (OAG) in a predominantly black study population.

DESIGN

Population-based prevalence study.

SETTING AND PARTICIPANTS

Residents of Barbados, West Indies, identified from a simple random sample of Barbadian-born citizens 40 through 84 years old.

DATA COLLECTION

Participants had a comprehensive study visit that included automated perimetry, applanation tonometry, and fundus photography; persons with specific examination findings, as well as a 10% sample of participants, were referred for an ophthalmologic examination and additional tests.

OUTCOME

A diagnosis of OAG required both visual field and optic disc criteria for glaucoma damage after excluding other causes.

RESULTS

The 4709 participants (83.5% of those eligible) had demographic characteristics that were similar to the census population. Of the 4631 participants who were tested at the study site, 95% completed Humphrey automated perimetry and 97% had photographic or clinical disc gradings; 93% of those referred completed the ophthalmologic examination. In this adult population, the prevalence of OAG by self-reported race was 7.0% (302/4314) in black, 3.3% (6/184) in mixed-race, and 0.8% (1/133) in white or other participants. In black and mixed-race participants, the prevalence reached 12% at age 60 years and older and was higher in men (8.3%) than in women (5.7%), with an age-adjusted male-female ratio of 1.4. In addition, over 3% of the participants were classified as having suspect OAG.

CONCLUSIONS

To our knowledge, the Barbados Eye Study is the largest glaucoma study ever conducted in a black population and identified more people with OAG than did any previous population study. The prevalence of OAG was high, especially at older ages and in men. Among participants 50 years old or older, one in 11 had OAG, and prevalence increased to one in six at age 70 years or older. The results highlight the public health importance of OAG in the Afro-Caribbean region and have implications for other populations.

Comparison of diabetic retinopathy detection by clinical examinations and photograph gradings. Barbados (West Indies) Eye Study Group

OBJECTIVE

To compare the use of clinical examination and fundus photograph gradings in detecting diabetic retinopathy in a population that includes persons with and without diabetes.

DESIGN

Population-based epidemiologic study.

SETTING

Sir Winston Scott Polyclinic, Bridgetown, Barbados, West Indies.

PARTICIPANTS

Subset of a random sample of the country's population aged 40 to 86 years.

RESULTS

Among 1168 black persons with fundus photograph evaluations, ophthalmologic examinations, diabetes history, and glycated hemoglobin data, 21% reported a history of diabetes; 9.5% had definite diabetes (glycated hemoglobin > 11.5%); and 13.3% had a diabetes history and glycated hemoglobin value less than or equal to 11.5%. The frequency of diabetic retinopathy in this group was 7.7% (90/1168) by clinical examination, 8.7% (102/1168) by photograph gradings, and 6.7% (78/1168) by both methods.

CONCLUSIONS

These results suggest that in certain populations that include diabetics and nondiabetics, a clinical examination by an ophthalmologist will detect most cases of diabetic retinopathy identified by disc and macula photographs read by skilled graders. However, it will lead to an underestimate of prevalence. Staff availability and cost, issues not examined in this study, should determine which approach is selected.

Diabetic retinopathy: a review

In the United States, diabetic retinopathy is the leading cause of new blindness in those of occupational age. We present an overview of risk factors, including renal disease, uncontrolled blood pressure, pregnancy, poor glucose control, elevated glycosylated hemoglobin, duration of disease, and age at time of diagnosis; pathogenesis, addressing the involvement of aldose reductase, nonenzymatic glycosylation of proteins, vasoproliferative factors, ischemia and vasodilation, systemic growth factors, and platelets and blood viscosity; pathology, including nonproliferative, preproliferative, and proliferative retinopathy; and the management of this condition.

Is informed consent needed for fluorescein angiography?

Fluorescein angiography is a common diagnostic procedure. Questions have been frequently raised as to whether explicit informed consent is needed for this procedure and what form such consent should take. Review of existing legal concepts indicates that the need for explicit consent varies from state to state, but that the trend is to require an explicit discussion of risks, benefits, and alternatives. Documentation of such information can adequately range from a brief, written notation in the patient's chart to a complete, separate form.

Retinal manifestations of ocular lymphoma (reticulum cell sarcoma)

BACKGROUND

Diagnosis and treatment of ocular large cell lymphoma may lessen visual loss and prolong life. Although reports in the literature have described retinal infiltrates in eyes with large cell lymphoma, they have focused on the more prominent vitreous and subretinal pigment epithelial findings. Eyes with retinal infiltrates and hemorrhagic retinal necrosis are usually believed to harbor a microbial infection. The authors describe 5 patients, aged 57 to 85 years, with ocular lymphoma in whom the most prominent initial findings were in the retina.

METHOD

Patients presented with findings suggestive of an infectious retinal necrosis. When the initial therapy failed, investigators performed a vitreous biopsy. Two patients had a concomitant retinal biopsy. Radiation therapy was given to four patients.

RESULTS

All five patients had vitreous cells. Three patients had prominent perivascular exudate. Four patients had grayish-white retinal infiltrates, and three patients had associated retinal hemorrhage. Three patients had subretinal small white spots. An edematous thickened retina developed in three patients, and hemorrhagic retinal necrosis developed in three patients. The initial diagnosis was believed to be acute retinal necrosis (ARN) in three patients, toxoplasmosis in one patient, and frosted branch angiitis in one patient. Vitreous biopsy was positive in two patients but negative in three patients. In two of these three patients, the diagnosis was established by retinal biopsy.

CONCLUSION

Ocular lymphoma should be considered in the differential diagnosis of retinal vasculitis or necrotizing retinitis in a middle-aged or older patient. Retinal biopsy may be helpful in establishing the diagnosis.

Screening for diabetic retinopathy

PURPOSE

To determine the appropriate patients, methods, and timing for screening for diabetic retinopathy.

DATA SOURCES

Relevant articles were identified through prominent review articles, the authors' files, recommendations from experts, and a MEDLINE search (1986 to the present); additional references were selected from the bibliographies of identified articles.

STUDY SELECTION

Selection of articles on the natural history of retinopathy was limited to large clinical series and formal epidemiologic studies of defined populations. Selection of articles on the therapeutic effect of photocoagulation and of glycemic control was limited to randomized trials. Sources bearing on the accuracy of screening modalities were necessarily more varied.

DATA EXTRACTION

For important variables, individual estimates from multiple studies are presented rather than a single meta-analytic summary estimate.

RESULTS

Screening for retinopathy is justifiable if early detection leads to less vision loss at an acceptable cost. The evidence shows that 1) laser therapy reduces the rate of vision loss by 50% among patients with proliferative retinopathy and macular edema, conditions that are often asymptomatic; 2) duration of diabetes is the main risk factor for retinopathy; and 3) standard ophthalmoscopic examination has only moderate sensitivity (about 80% in research settings) and specificity (greater than 90% for proliferative retinopathy but lower for macular edema), making seven-field stereophotography a more accurate method. Estimates of cost effectiveness indicate that screening for retinopathy not only saves years of vision but may be cost saving from a societal perspective.

CONCLUSIONS

Screening for retinopathy in patients with diabetes, and subsequent photocoagulation therapy for those who have high risk macular edema or proliferative retinopathy, is clearly beneficial.

Sclerochoroidal calcification

We studied 19 patients with sclerochoroidal calcification. The findings were bilateral in 16 patients and unilateral in the remaining three patients. The lesions, which were usually multifocal, had two characteristic appearances, plaque-like and tumorlike. Eleven patients had relatively flat, irregularly shaped, plaque-like, yellow-white lesions located between the arcades and the equator. Eight patients had more elevated tumorlike lesions, ranging up to 6 mm in height. All showed patterns on echography consistent with calcification. The calcification was often documented in both the choroid and sclera; sometimes it appeared only in the choroid, but never only in the sclera. Calcium metabolism appeared to be normal in all but two of the nine patients in whom it was investigated. Idiopathic sclerochoroidal calcification has a characteristic echographic and ophthalmoscopic appearance and may be more common than has been realized.

A review of mortality from choroidal melanoma. II. A meta-analysis of 5-year mortality rates following enucleation, 1966 through 1988

With the use of data published during the period from 1966 through 1988, a pooled analysis (meta-analysis) of 5-year mortality rates among patients who had an eye enucleated for choroidal melanoma was performed to provide a more robust estimate of this rate than could be obtained from any single study. The literature concerning mortality following a diagnosis of choroidal melanoma has been reviewed systematically and described in a separate article. Of 76 reports published from 1966 through 1988, 29 were excluded from the meta-analysis because there were no cases treated by enucleation alone, mortality was not reported by time from enucleation, fewer than 10 cases were reported, or 5-year mortality rates were not reported or derivable from the data presented. Ten additional reports were excluded because they were based on data for the same set of patients as another article in the series. Of the remaining 37 reports, 29 contained data for patients with tumors of varying sizes that could not be separated into subgroups based on the size of the tumor at the time of treatment. The remaining eight articles reported 5-year mortality rates by tumor size, specifically for small, medium, or large tumors. The combined weighted estimates of 5-year mortality rates following enucleation were 16% for small tumors (95% confidence interval [CI]: [14%, 18%]), 32% for medium tumors (95% CI: [29%, 34%]), and 53% for large tumors (95% CI: [50%, 56%]). Different methods of pooling the data yielded consistent estimates for all three tumor size categories.(ABSTRACT TRUNCATED AT 250 WORDS)

A review of mortality from choroidal melanoma. I. Quality of published reports, 1966 through 1988

The literature concerning mortality after a diagnosis of choroidal melanoma was reviewed to identify relevant articles published from 1966 through 1988 and to select those with mortality rates presented separately by tumor size for inclusion in a pooled analysis (meta-analysis) of 5-year mortality after enucleation for choroidal melanoma. The quality of the published literature for our purposes was assessed. Candidate articles were identified from a search of the MEDLINE files by an information specialist. Altogether, of 217 candidate articles, 76 (70 from the MEDLINE search and six more from our files) qualified for review. All-cause mortality rates were reported in 80% of the articles. Among six aspects of design and methods for which information was sought, eligibility criteria were reported in 52 (68%) of the 76 articles and statistical methods were cited in 38 (50%); other information was reported with intermediate frequency. Quality scores based on completeness of reporting with respect to 16 factors ranged from 13.3 to 92.3 of a possible 100.0. Findings suggest that researchers, clinicians, journal editors, and reviewers should be more attentive to the completeness of reports from clinical research studies with respect to basic information regarding design and methods.

Frequency of adverse systemic reactions after fluorescein angiography. Results of a prospective study

Intravenous fluorescein angiography is a commonly performed and extraordinarily valuable diagnostic procedure. The frequency of adverse reactions after angiography has varied considerably in previous reports. In a prospective study of 2789 angiographic procedures in 2025 patients, the authors found that the percentage of adverse reactions depended strongly on the patient's angiographic history. Overall, adverse reactions followed 4.8% of the angiographic procedures. These reactions included nausea (2.9%), vomiting (1.2%), flushing/itching/hives (0.5%), and other reactions (dyspnea, syncope, excessive sneezing) (0.2%). No cases of anaphylaxis, myocardial infarction, pulmonary edema, or seizures occurred. The percentage of reactions was 1.8% for patients who had had previous angiography without ever having had an adverse reaction. In contrast, the percentage of reactions was 48.6% for patients who had had an adverse reaction to angiography previously.

Impact of enucleation for choroidal melanoma on the performance of vision-dependent activities

We report a functional outcome assessment of 71 patients who underwent enucleation for choroidal melanoma. Each was interviewed to evaluate his her self-reported ability to perform four vision-dependent activities--working, driving, reading, and television viewing--before enucleation and when interviewed. The interval between enucleation and the interview varied between 2 and 25 years. Eighty-seven percent (62/71) reported no change in their ability to perform these important vision-dependent tasks. At 15 years after enucleation, 90% (18/20) retained the ability to drive and 96% (25/26) retained the ability to read. These results are reassuring for those with choroidal melanoma who are faced with enucleation, because most of these patients seem likely to continue at a level of visual function comparable with their preenucleation status.

Transfer from ophthalmology to another service is a marker of high risk medical events

Of 3632 consecutive admissions to the Wilmer Ophthalmological Institute between July 1, 1987 and June 30, 1989, 27 patients required transfer to a medical or surgical service (0.74%). The major reasons for transfer included acute or decompensated cardiac disease (26%), poorly controlled diabetes mellitus (19%), acute renal failure (11%), coagulopathy, stroke, and hypertension (7% each). Only one transfer was a direct result of an anesthesia complication. The highest rates of transfers were associated with orbital (4.3%), enucleation/evisceration (3.1%), and glaucoma (2.3%) surgeries, while vitreoretinal surgery had the lowest rate of transfer (0.3%). Most of the transfers of patients with orbital disease were for management of related problems such as sinusitis or increased intracranial pressure.