AUTOMATED DETECTION OF VITRITIS USING ULTRAWIDE-FIELD FUNDUS PHOTOGRAPHS AND DEEP LEARNING

BACKGROUND/PURPOSE

Evaluate the performance of a deep learning algorithm for the automated detection and grading of vitritis on ultrawide-field imaging.

METHODS

Cross-sectional noninterventional study. Ultrawide-field fundus retinophotographs of uveitis patients were used. Vitreous haze was defined according to the six steps of the Standardization of Uveitis Nomenclature classification. The deep learning framework TensorFlow and the DenseNet121 convolutional neural network were used to perform the classification task. The best fitted model was tested in a validation study.

RESULTS

One thousand one hundred eighty-one images were included. The performance of the model for the detection of vitritis was good with a sensitivity of 91%, a specificity of 89%, an accuracy of 0.90, and an area under the receiver operating characteristics curve of 0.97. When used on an external set of images, the accuracy for the detection of vitritis was 0.78. The accuracy to classify vitritis in one of the six Standardization of Uveitis Nomenclature grades was limited (0.61) but improved to 0.75 when the grades were grouped into three categories. When accepting an error of one grade, the accuracy for the six-class classification increased to 0.90, suggesting the need for a larger sample to improve the model performances.

CONCLUSION

A new deep learning model based on ultrawide-field fundus imaging that produces an efficient tool for the detection of vitritis was described. The performance of the model for the grading into three categories of increasing vitritis severity was acceptable. The performance for the six-class grading of vitritis was limited but can probably be improved with a larger set of images.

Ophthalmic Emergency Visits in the Wake of the COVID 19 Pandemic: Our Experience at a Tertiary Hospital in Israel

BACKGROUND

In response to the coronavirus disease-2019 (COVID-19) pandemic, routine clinical visits to the ophthalmic emergency department (OED) were deferred, while emergency cases continued to be seen.

OBJECTIVES

To assess the consequences of the COVID-19 pandemic for ophthalmic emergencies.

METHODS

A retrospective chart analysis of patients who presented to the OED during the peak of the COVID-19 pandemic was conducted. The proportions of traumatic, non-traumatic-urgent, and non-traumatic-non-urgent presentations in 2020 were compared to those of the same time period in 2019. Duration of chief complains and best-corrected visual acuity were also assessed.

RESULTS

There were 144 OED visits in 2020 compared to 327 OED visits during the same 3-week-period in 2019. Lower mean age of OED patients was present in 2020. Logarithmic expression (LogMAR) best corrected visual acuity (BVCA) was similar in both years. In 2020 there was a reduction in traumatic, non-traumatic-urgent, and non-traumatic-non-urgent cases compared to 2019 (15.4% reduction, P = 0.038; 57.6% reduction, P = 0.002; 74.6% reduction, P = 0.005, respectively). There was a higher proportion of same-day presentations at commencement of symptoms in 2020 compared with 2019 (52.8% vs. 38.8%, respectively P = 0.006).

CONCLUSIONS

During the COVID-19 pandemic, the number of OED visits at a tertiary hospital dropped by more than half. Although the drop in visits was mostly due to decrease in non-traumatic-non-urgent cases, there was also decrease in non-traumatic-urgent presentations with possible important visual consequences. Additional studies should elucidate what happened to these patients.

Ocular Involvement in Hereditary Amyloidosis

The term amyloidosis describes a group of rare diseases caused by protein conformation abnormalities resulting in extracellular deposition and accumulation of insoluble fibrillar aggregates. So far, 36 amyloid precursor proteins have been identified, and each one is responsible for a specific disease entity. Transthyretin amyloidosis (ATTRv) is one of the most common forms of systemic and ocular amyloidosis, due to the deposition of transthyretin (TTR), which is a transport protein mainly synthesized in the liver but also in the retinal pigment epithelial cells. ATTRv amyloidosis may be misdiagnosed with several other conditions, resulting in a significant diagnostic delay. Gelsolin and keratoepithelin are other proteins that, when mutated, are responsible for a systemic amyloid disease with significant ocular manifestations that not infrequently appear before systemic involvement. The main signs of ocular amyloid deposition are in the cornea, irido-corneal angle and vitreous, causing complications related to vasculopathy and neuropathy at the local level. This review aims at describing the main biochemical, histopathological and clinical features of systemic amyloidosis associated with eye involvement, with particular emphasis on the inherited forms. We discuss currently available treatments, focusing on ocular involvement and specific ophthalmologic management and highlighting the importance of a prompt treatment for the potential sight-threatening complications derived from amyloid deposition in ocular tissues.

New Highlights of Resveratrol: A Review of Properties against Ocular Diseases

Eye diseases are currently a major public health concern due to the growing number of cases resulting from both an aging of populations and exogenous factors linked to our lifestyles. Thus, many treatments including surgical pharmacological approaches have emerged, and special attention has been paid to prevention, where diet plays a preponderant role. Recently, potential antioxidants such as resveratrol have received much attention as potential tools against various ocular diseases. In this review, we focus on the mechanisms of resveratrol against ocular diseases, in particular age-related macular degeneration, glaucoma, cataract, diabetic retinopathy, and vitreoretinopathy. We analyze, in relation to the different steps of each disease, the resveratrol properties at multiple levels, such as cellular and molecular signaling as well as physiological effects. We show and discuss the relationship to reactive oxygen species, the regulation of inflammatory process, and how resveratrol can prevent ocular diseases through a potential epigenetic action by the activation of sirtuin-1. Lastly, various new forms of resveratrol delivery are emerging at the same time as some clinical trials are raising more questions about the future of resveratrol as a potential tool for prevention or in therapeutic strategies against ocular diseases. More preclinical studies are required to provide further insights into RSV's potential adjuvant activity.

Identifying fallers among ophthalmic patients using classification tree methodology

PURPOSE

To develop and validate a tool aiming to support ophthalmologists in identifying, during routine ophthalmologic visits, patients at higher risk of falling in the following year.

METHODS

A group of 141 subjects (age: 73.2 ± 11.4 years), recruited at our Eye Clinic, underwent a baseline ophthalmic examination and a standardized questionnaire, including lifestyles, general health, social engagement and eyesight problems. Moreover, visual disability was assessed by the Activity of Daily Vision Scale (ADVS). The subjects were followed up for 12 months in order to record prospective falls. A subject who reported at least one fall within one year from the baseline assessment was considered as faller, otherwise as non-faller. Different tree-based algorithms (i.e., C4.5, AdaBoost and Random Forests) were used to develop automatic classifiers and their performances were evaluated by the cross-validation approach.

RESULTS

Over the follow-up, 25 falls were referred by 13 patients. The logistic regression analysis showed the following variables as significant predictors of prospective falls: pseudophakia and use of prescribed eyeglasses as protective factors, recent worsening of visual acuity as risk factor. Random Forest ranked best corrected visual acuity, number of sleeping hours and job type as the most important features. Finally, AdaBoost enabled the identification of subjects at higher risk of falling in the following 12 months with a sensitivity rate of 69.2% and a specificity rate of 76.6%.

CONCLUSIONS

The current study proposes a novel method, based on classification trees applied to self-reported factors and health information assessed by a standardized questionnaire during ophthalmological visits, to identify ophthalmic patients at higher risk of falling in the following 12 months. The findings of the current study pave the way to the validation of the proposed novel tool for fall risk screening on a larger cohort of patients with visual impairment referred to eye clinics.

Ocular pyoderma gangrenosum: A systematic review

BACKGROUND

Pyoderma gangrenosum (PG) is a rare, ulcerative cutaneous disorder. Ophthalmic involvement in PG is atypical, but can have devastating consequences.

OBJECTIVE

We sought to characterize ocular PG to allow for earlier diagnosis and therapy. To our knowledge, this is the first systematic review summarizing this clinical variant.

METHODS

A systematic review was conducted using PubMed and Web of Science. Data were extracted and studies were qualitatively assessed and analyzed.

RESULTS

We identified all 34 cases of PG involving the eye and periorbital area, and categorized them into 4 different subtypes. Common presenting signs include ulceration, peripheral ulcerative keratitis, and decreased visual acuity. Although it is often difficult to biopsy ocular PG, histologic features are nonspecific. Combined therapy using corticosteroids and further surgical reconstruction as needed is the mainstay of treatment. Cases of the eye/orbit in particular should be treated aggressively, as these are more likely to relapse compared with cases of the periorbital area.

LIMITATIONS

Use of case reports, paucity of ocular PG cases, and heterogeneity of studies are limitations.

CONCLUSION

PG should be considered in the differential diagnosis of ulceration of ocular/periocular tissues. An aggressive, early, multimodal treatment strategy should be used to prevent relapse, especially in cases of the eye/orbit.

Complications of retinal xenon-arc photocoagulation

The perioperative complications of xenon-arc photocoagulation of 245 eyes of 165 patients were reviewed. The follow-up ranged from 5 days in case of no complication to 5-30 days in case of complications. In 210 eyes (approximately 86%) photocoagulation could be carried out without any complication. Severe complications occurred in only 8 cases (approximately %). Among these were retrobulbar hematoma, keratopathy, secondary glaucoma, and persistent choroidal detachment. The number of burns per eye was of minor influence to the occurrence of complications.

Vitreomacular traction syndrome: postoperative functional and anatomic outcomes

BACKGROUND AND OBJECTIVE

To analyze a variety of vitreomacular traction (VMT) morphologies to establish a major classification that better reflects the preoperative predictive factors of postoperative visual and anatomic outcomes.

PATIENTS AND METHODS

Thirty-six eyes submitted to vitrectomy surgery were categorized with a VMT pattern (V- or J-shaped) and diameter (focal < 1,500 µm or broad > 1,500 µm) based on optical coherence tomography.

RESULTS

The researchers compared different classifications of VMT. Despite similar postoperative best corrected visual acuity (BCVA) values (P = .393), cases with focal VMT had greater visual improvement (P = .027) because the preoperative BCVA was significantly lower in the focal group (P = .007). However, the BCVA improvements did not differ between the groups regarding the classic VMT morphologic patterns (P = .235).

CONCLUSION

Postoperative outcomes and macular disorders are closely related to VMT size. The adhesion diameter (focal or broad VMT) and not the classic VMT morphologic pattern (V- or J-shaped) may better predict the postoperative anatomic and functional outcomes.

Eyeballing expertise

'Tacit' and 'explicit' knowledge, and their relation to expertise, have a long-standing importance within social studies of science and technology. At the centre of the development of thinking about these topics has been the work of Harry Collins and Robert Evans. In this article, we bring to bear observations of the work of people involved in grading eye disease, and their seeming display of expertise, tacit and explicit knowledge, on three thrusts identified in the work of Collins, and Collins and Evans. These thrusts are the following: (1) a concern with the appearance of tacit knowledge in the activities of experts, (2) a commitment to studying expertise as 'real' and substantive rather than attributed, and (3) a commitment to promoting the recognition and fostering the management of expertise by providing analytical distinctions regarding expertise and its reliance on tacit knowledge. By considering what is involved in the work of grading eyes, we relocate the interest in tacit and explicit knowledge, and their bearing on expertise, in how expert knowledge is displayed and made recognizable in and through courses of action and interaction.

[Ophthalmic pathology in tubalars of the Altai Republic]

PURPOSE

To study the prevalence and structure of ophthalmic pathology in Tubalars, rural indigenes of the Altai Republic, for the benefit of the eye care system.

MATERIAL AND METHODS

A total of 673 indigenes (67% of the whole population) aged from 1 month to 88 years, 521 Russians and 316 people of mixed parentage were examined.

RESULTS

The general prevalence of eye diseases appeared to be higher in Russian newcomers (2481.75 per thousand) than in Tubalars (1965.82 per thousand), while the lowest proportion was found in the group of mixed parentage (1319.62 per thousand). The structure of ophthalmic pathology in Tubalars was as follows: refractive errors and accommodative disorders (799.40 per thousand), diseases of the conjunctiva (390.79 per thousand), retinal diseases (212.48 per thousand), lens diseases (164.93 per thousand), other ocular pathology and tumors of the auxiliary structures (124.81 per thousand), disorders of the lacrimal system (112.93 per thousand), corneal diseases (87.67 per thousand), strabismus (20.80 per thousand), congenital ocular anomalies (10.40 per thousand), glaucoma (8.91 per thousand), diseases of the vascular tract (8.91 per thousand), and eye injury (2.97 per thousand).

CONCLUSION

The prevalence of eye diseases in the three ethnic groups proves interethnic differences. Tubalars demonstrated intermediate results between Russians (higher rates) and the group of mixed parentage (lower rates), which indicates unequal adaptation of these populations to harsh climatic conditions of the area. The obtained data are fundamental for informed management decision-making on rational distribution of health institutions and allocation of medical personnel and funds among the regions of the country.

Visual acuity of commercial motor drivers in Ogun State of Nigeria

AIMS AND OBJECTIVES

To objectively assess the visual acuity of commercial motor drivers (CMD) in 3 Local Government Areas (LGA) of Ogun State of Nigeria in order to determine their eligibility to drive.

SUBJECTS AND METHODS

The visual acuities of CMDs in 3 LGAS of Ogun state in Nigeria (selected using a multistage sampling technique) were tested with Snellens acuity charts and the eyes examined with bright pen torches and ophthamoscopes. Visual acuity 6/12 or better in the worse eye was taken as adequate to obtain a driving license. The drivers with worse visual acuities were further examined to find the cause of decreased vision.

RESULTS

The visual acuities of 524 drivers were determined and analyzed. Their ages ranged from 19-66 years with a mean of 46.8 ±7.2 years. Two hundred and twenty (41.9%) of the drivers were between 40 and 49 years old. Four hundred and four (77.1%) did not have any form of eye test prior to this study. Four hundred and sixty three drivers (88.4%) were eligible to drive while 61 drivers (11.6%) were not eligible. Decreased visual acuity was caused by refractive error in 22(36.1%), cataract in 19(31.2%), glaucoma in 12(19.7%), corneal scar in 5(8.2%) and posterior segment lesions in 3(4.9%).

CONCLUSION

Objective assessment of vision should be an essential component of licensure. Middle aged and elderly drivers are prone to age related ocular diseases and require reassessment of visual status every 3 years when licenses are renewed.

One month outcome of ocular related emergencies in a tertiary hospital in Central Saudi Arabia

OBJECTIVE

To investigate the number and characteristics of patients attending the Accident/Emergency (A/E) Department of a tertiary care hospital in Riyadh, and to determine their route of referral, and pattern of ocular emergency cases.

METHODS

A retrospective study was carried out using the records and history of all patients attending the A/E at King Abdulaziz University Hospital (KAUH) in Riyadh, Kingdom of Saudi Arabia in July 2010. Data collected included time of arrival, age, gender, source of referral, principal diagnosis, attending doctor, action taken, and discharge plan.

RESULTS

A total of 1,412 patients were recruited in our study with an average daily attendance of 47 patients. A total of 863 (61%) patients were male, and their mean age was 28.2 years. The most frequent diagnosis in patients was trauma (382, 27%), followed by conjunctivitis (211, 14.9%), lids and lacrimal system (133, 9.4%), retina problems (51, 3.6%), glaucoma (30, 2.1%), neuro-ophthalmology (22, 1.6%), keratitis (20, 1.4%), uveitis (10, 0.7%), and episcleritis (5, 0.35%). Most cases (77.5%) seen were self-referrals. Additionally, 712 (50.4%) of cases were considered as non-emergency, which are visiting the A/E for dry eye, chalazion, blepharitis, and allergy.

CONCLUSION

Most cases seen at our ophthalmic A/E had non-urgent conditions that could be managed satisfactorily by trained ophthalmic assistants under supervision of an ophthalmologist.

Validation of a photographic vitreous haze grading technique for clinical trials in uveitis

PURPOSE

To validate a photographic vitreous haze grading technique using a 9-step logarithmic scale in patients enrolled in a randomized, controlled clinical trial in uveitis.

DESIGN

Retrospective study of clinical trials methodology.

METHODS

SETTING

University-based department of ophthalmology.

STUDY POPULATION

Baseline fundus photographs of patients with intermediate uveitis, posterior uveitis, or panuveitis enrolled in the Multicenter Uveitis Steroid Treatment (MUST) trial.

OBSERVATIONAL PROCEDURE

Grading of vitreous haze using a previously described photographic scale. Regrading of a subset of photographs to assess intraobserver agreement.

MAIN OUTCOME MEASURES

Interobserver and intraobserver intraclass correlation for photographic haze grading, and correlation between photographic and clinical vitreous haze scores, assessment of the clinical findings that significantly affect the photographic haze score.

RESULTS

Vitreous haze was graded in 271 eyes (142 patients) by 3 postgraduate ophthalmologists. The interobserver and intraobserver intraclass correlations were excellent, with correlation coefficients between 0.84 and 0.93. There was moderately strong correlation between the photographic and clinical vitreous haze scores (r=0.51; P<.001), with significant differences among the mean and median photographic haze scores for the 3 lowest clinical grades of haze, 0, 1+, and 2+. Other parameters that correlated with photographic vitreous haze score included visual acuity of 20/50 or worse (P=.003), degrees of posterior synechiae (P<.001), lens abnormality (P=.023) or posterior capsule obscuration (P=.001), and amount of anterior vitreous cell (P=.002).

CONCLUSIONS

Photographic grading of vitreous haze with a 9-step logarithmic scale is a highly reproducible methodology that may be adaptable to use in future clinical trials.

Survey of pediatric ophthalmic diagnoses in a teaching hospital in Nigeria

BACKGROUND

A review of pediatric cases seen over one year in the eye clinic of the University of Port Harcourt teaching hospital, Rivers state is presented.

AIM

To ascertain the different diagnoses made in children who attend the eye clinic and the most common with a view to establish guidelines for equipping a functional pediatric ophthalmic clinic to address the problems if any.

METHODOLOGY

Records of all patients aged 0-18 years who attended the clinic in the year 2004 were extracted from the outpatient register. The information was analyzed manually with a simple scientific calculator.

RESULTS

Atotal number of 846 pediatric patients were seen in the one year period under review. Newly diagnosed patients were 671 in number. Male female ratio was 1:1.07. The largest number of patients seen was between the ages of 13-18 years (n = 320). Refractive error was the most common condition seen with 248 diagnosed with the condition and a percentage of(28.95%) of the total number of patients seen. Vernal conjunctivitis followed with a percentage of 17.96% (n=152). Sixty-two (7.33%) were diagnosed with iritis while 52 were diagnosed to have cataract (6.15%). Thirty-five had glaucoma as the primary diagnosis (4.14%) while 14 children presented with conjunctivitis (1.65%). Other patients had pterygium (n=9, 1.06%), chalazion (n=4, 0.47%) and corneal opacity (n=6, 0.71%). The patients with refractive error and vernal conjunctivitis were mainly girls 56.5% and 25% respectively. Glaucoma mainly affected boys (57.1%) Cataracts were mainly seen in girls (53.8%).

CONCLUSION

The commonest causes of childhood ocular morbidity in this study were refractive error and allergic conjunctivitis accounting for almost 50% of pediatric patients presenting at the ophthalmology clinic of UPTH. These require prompt pediatric ophthalmic consultation for effective treatment and prevention of avoidable sequelae. Therefore facilities need to be made available to adequately detect these conditions early particularly for refractive errors before amblyopia develops through training of teachers in all schools and public awareness campaigns. It may be important to ensure that legislation be passed to ensure compulsory eye checks before parents enroll their wards in school.

Ocular emergencies presenting to Menelik II Hospital

BACKGROUND

Ocular conditions such as trauma, painful red eye of any cause, painless sudden visual loss and others are commonly seen as ocular emergencies, and can lead to ocular morbidity and visual loss.

OBJECTIVE

To determine types and causes of ocular emergencies seen at Menelik II hospital.

METHODS

A cross-sectional study was conducted from April to October, 2007. Consecutive patients who presented with ocular emergencies at any time of the day were prospectively evaluated and registered on a formatted questionnaire. Evaluation of the patients included history of presenting illness, visual acuity testing intraocular pressure measurement on non-perforated and non-infected eyes, and complete eye examination in order to arrive at the diagnosis.

RESULTS

A total of 26,400 patients attended Menelik II hospital during the study period. Of these, 758 (3%) were persons with an ocular emergency. The majority of patients (n=551; 72.7%) were male, with a male to female ratio of 2.7:1. The age group of 16 to 30 years was the most affected (47.9%), followed by those aged 15 years or younger (27.3%). Ocular trauma and ocular infections accounted for 75.6% and 13.1% of cases, respectively. Of the total ocular emergencies, open globe injuries constituted 171 (22.6%), corneal foreign bodies and abrasion 125 (16.5%), and open adnexal injuries 119 (15.7%). Metal and wood were the commonest work-related causes of ocular injuries in adults, with both together accounting for 60% of all ocular injuries. Children, on the other hand, sustained ocular injury while playing with others in 128 (22.3%) of cases.

CONCLUSION

This study was able to provide a more complete picture to improve understanding of the nature and circumstances of ocular emergencies in Ethiopia. Ocular emergencies were dominated by ocular trauma, particularly affecting males and working-age adults. Public education and use of protective safety measures are recommended to alleviate the problem.

Eye diseases in patients with sleep apnea syndrome: a rewiew

Sleep apnea syndrome (SAS) is characterized by recurrent episodes of apnea during sleep. Mechanical upper airway obstruction is by far the most frequent form of SAS, and is named obstructive sleep apnea (OSA). Besides giving rise to a reduced quality of life, OSA is associated with important cardiovascular morbidity and mortality if left untreated. OSA has also been associated with several ophthalmic manifestations. The purpose of this paper is to review the most important features of OSA, and to highlight the ophthalmic abnormalities recognized in these patients. Ophthalmologists should be familiar with the possibility of sleep disorders in their patients as the cause of certain eye pathologies. The ophthalmologist can often identify a patient with OSA and refer him for a sleep study. Sleep physicians, on the other hand, should be alert for the possibility of eye disorders, inform their patients and refer them for a check up.

Childhood eye diseases in southwestern Nigeria: a tertiary hospital study

BACKGROUND

Eye diseases are important cause of medical consultation in children, with the spectrum varying in different localities. This study aimed to determine the spectrum of childhood eye diseases in a tertiary hospital serving rural and semi-rural communities.

METHODS

We conducted a retrospective review of all patients less than 15 years old who presented to the eye clinic of Wesley Guild Hospital Ilesa, Nigeria between January 2001 and December 2006. Data on age at presentation, age at onset of disease, sex and diagnosis were collected and analyzed using SPSS. A p value less than 0.05 was considered statistically significant.

RESULTS

We evaluated the reports of 286 children, with a male:female ratio of 1:1.1. Children aged 11-15 years made up the largest group (p=0.013). Ocular trauma (21.7%), allergic conjunctivitis (17.8%), infections of the eye and its adnexa (15.4%) and refractive errors (14.3%) were the most common conditions. Ocular injury was more common in males (p=0.002) and children aged 6-10 years, and 87.1% of these cases were a closed globe injury. Infections were seen more commonly among females and children aged 0-5 years, with keratitis representing 40.9% of these cases. Congenital eye disease represented 13.3% of childhood eye diseases.

CONCLUSION

The prevalent childhood eye diseases recorded here can lead to absenteeism from school and are potentially blinding. Health education aimed at the prevention of ocular trauma and prompt presentation for the management of other eye diseases should be encouraged.

[Epidemiology of ocular diseases--a review of medical examinations from The Area of Military Medical Commission in Lodz]

PURPOSE

To determine the prevalence of ocular diseases among candidates and members of Military Service.

MATERIAL AND METHODS

A retrospective review of medical examinations for entry to the military service from The Area of Military Medical Ophthalmic Commission in Lodz. We used statistic analysis to review the results.

RESULTS

Statistic analysis revealed that the commonest ocular diseases are in order: refractive errors, color vision disturbances and strabismus.

CONCLUSIONS

1. The prevalence of ocular diseases among candidates and members of Polish Military Service is the same as discovered in other ophthalmologic researches. 2. Commonest ocular diseases were refractive errors (21.63% in total).

Schedule for rating disabilities; eye. Final rule

This document amends the Department of Veterans Affairs (VA) Schedule for Rating Disabilities (Rating Schedule) by updating the portion of the schedule that addresses disabilities of the eye. These amendments ensure that the schedule uses current medical terminology, provides unambiguous criteria for evaluating disabilities, and incorporates pertinent medical advances.

Ocular disorders in renal transplant patients

This cross-sectional study was performed to determine ocular findings in renal transplant recipients and to correlate them with certain clinical characteristics related to transplantation. The study was performed on 150 patients who had received a renal transplant at least three months earlier and had serum creatinine levels < 3 mg/dL. All patients underwent a complete ophthalmologic examination. Clinical variables studied related to the transplant included cause of renal failure, duration of hemodialysis prior to transplantation and immunosuppressive regimen. Overall, 91 male and 59 female subjects with a mean age of 39.9 +/- 17.7 years were included. At least one ocular abnormality could be detected in 89.3% including impaired visual acuity < or = 20/25 (48.6%), conjunctival degeneration in the palpebral fissure (36.6%), posterior sub-capsular cataracts (24%), pinguecula (17.3%), retinal pigment epitheliopathy (14%), arteriovenous crossing changes (8.6%), proliferative diabetic retinopathy (6%), central serous chorioretinopathy and retinal vein occlusions (each in 3.3%), and non-proliferative diabetic retinopathy, optic nerve atrophy and diabetic macular edema (each in 2.7%). Abnormal ocular findings were not correlated with the underlying renal disorder or use of cyclosporine and prednisolone; however, they were positively correlated with transplant duration, pre-transplant dialysis duration and usage of azathioprine or mycophenolate mofetil. Our study suggests that ocular disorders are frequent among renal transplant patients especially with older transplants and those with a longer period of pre-transplant hemodialysis.

Ophthalmology emergency room at the University of São Paulo General Hospital: a tertiary hospital providing primary and secondary level care

OBJECTIVE

To assess the need for emergency care in a tertiary hospital, in the Ophthalmology Emergency Room of the University of the São Paulo Medical School General Hospital.

MATERIALS AND METHODS

A cross-sectional analytic study of the treatment complexity level was carried out in a readily available sample, n = 574, of patients seen at the Ophthalmology Emergency Room of the University of São Paulo Medical School General Hospital, during a typical week.

RESULTS

Of the 574 treated patients, 69.0% of the cases were diagnosed as requiring a simple treatment for their problem. The most frequent diagnoses were related to ocular inflammation and infection (55.0%), mainly including conjunctivitis (29.4%) and eyelid inflammations (10.5%). Next in frequency were ocular trauma (19.2%), particularly foreign bodies on the cornea (7.5%) and blunt trauma (5.2%). Refractive errors (3.1%) was the most prevalent diagnosis in the "other ocular modifications" category.

CONCLUSION

Most of the cases (69.0%) treated at the Ophthalmology Emergency Room of the University of São Paulo Medical School General Hospital could have been diagnosed and treated in primary or secondary care units. Also, the fact that return visits to check recovery are seen in the ER demonstrates the lack of referral services. The fact that patients come to a tertiary hospital with rather simple cases shows the poor structure of the Brazilian Public Healthcare System, which overloads the tertiary care facilities, where costs for human resources, materials, and other items are higher.

Ocular disease at Lere local government outreach post in Kaduna State of northern Nigeria

OBJECTIVE

The aim of the study was to analyse the ocular diseases that were seen at the an outreach post.

PATIENTS AND METHODS

Data on 883 patients was collected from records of patients starting from January 2005 to August 2005 at the Saminaka outreach eye clinic. Information on age, sex occupation, visual acuity was analysed in addition to data on diagnosis of presenting condition after a full ocular examination.

RESULTS

Out of 883 patients seen, 397 (45 %) were female and 486 (55%) were male. The patients seen consisted of 258 (29 %) children between the ages of 1 day to 14 years old. And adults made up 625 (70.7%) of the patient population. The data for analysis of diagnosis was available for only 680(77 %) of the total patients seen within this period. Bacterial conjunctivitis was the most commonly occurring condition at (23.3%) of the total followed by cataracts constituting (16.3 %) of all diagnoses. This was closely followed by vernal and allergic conjunctivitis making up 11.6% and 11.3% respectively. Other conditions of note included refractive errors which made up 4.1% and consisted mainly of presbyopes with only two myopes, ophthalmia neonatorum (3.8 %), keratitis 3.8 % and blunt trauma making up 3.4%.

CONCLUSION

Preventable and curable eye conditions were th,main conditions found at the outreach post.

Application of genetic approaches to ocular disease

The human eye is a complex organ whose development requires extraordinary coordination of developmental processes. Multiple genes responsible for the proper development and maintenance of the vertebrate eye have been identified and shown to be involved in a variety of debilitating ocular conditions. Genetic diseases involving the eye represent a leading cause of blindness in children and adults. This article summarizes current genetic approaches and their application to studies of ocular disease.

[The reevaluation of categorization for ocular manifestation of sarcoidosis in the "Guidelines for Diagnosis of Ocular Sarcoidosis"]

PURPOSE

To increase the degree of specificity for nomenclature in the current "Guidelines for Diagnosis of Ocular Sarcoidosis" published in 1990 by the Diffuse Pulmonary Disease Research Committee of Japan.

SUBJECTS AND METHODS

We reviewed the records of patients with uveitis from the Uveitis Clinic in the Department of Ophthalmology at Yokohama City University. Subjects were selected from the records of uveitis patients with histologically proven sarcoidosis (78), and others with non-sarcoidosis uveitis (81). We examined the sensitivity and specificity of suspected characteristics of ocular sarcoidosis in the current "Guidelines for Diagnosis of Ocular Sarcoidosis".

RESULTS

The definition specificity was improved by changing anterior uveitis to granulomatous anterior uveitis, and by simplifying to cloudy mass (snowball, string of pearls) from the previous diffused/cloudy mass vitreous opacity (snowball, string of pearls), and also by changing from retinal peripheral vasculitis (in many cases retinal periphlebitis, also at times retinal peripheral arteritis) to retinal periphlebitis.

CONCLUSION

This newly proposed "Guidelines for Diagnosis of Ocular Sarcoidosis" gives a much clearer definition of sarcoidosis, as well as improved nomenclature for specific categories of ocular symptoms.

Approach to ophthalmologic emergencies

This article presents evaluation and treatment approaches to ophthalmologic conditions that are likely to be encountered in a primary care office. These conditions can be organized by diagnostic category, symptoms, and location of complaint. By using one ora combination of these categories, the practitioner can provide appropriate, timely, and effective ophthalmologic evaluation and treatment. Acute conditions are categorized according to urgency of intervention.

[Gaucher's disease--ocular manifestation and treatment]

Gaucher's disease is the most common lysosomal storage disorder due to a deficiency of glukocerebrosidase activity. It leads to an accumulation of glukosylceramide within the cells of the the reticuloendothelial system. Gaucher's disease is divided into three subtypes based on clinical symptoms. Type I--nonneuronopathic--chronically progressive in adulthood, type II--acute neuronopathic--infantile form lead up to the difficult damage nervous system, and type III--juvenile form--subacute neuronopathic. The aim of this paper is to present the typical ocular symptoms which occured in the disease. Gaucher's disease is the lysosomal storage disorder which is treated by enzyme replacement therapy.

[Changes in the G-DRG System from 2003 to 2005 in Ophthalmology--Ophthalmologic G-DRG 2003 to 2005]

BACKGROUND

The objective of the study was to illustrate the effect of the extensive changes of the German DRG System on reimbursement of clinical ophthalmology during the years 2003, 2004 and 2005.

METHODS

All ophthalmologic patients treated as in-patients at the Department of Ophthalmology at the University Munich during the year 2003 served as a reference data basis. By means of appropriate software those cases were then re-grouped according to the G-DRG classification of the years 2003, 2004 and 2005. This resulted in different reimbursements caused only by system changes for an exemplary hospital of maximum medical care. In addition, the same calculations were performed for four virtual, typical clinics based on the calculation data of the "Institut für Entgeltsysteme (InEK)". For those four clinics it was assumed that 80 % of the cases came from one of the subspecialties retina, glaucoma, cataract or strabismus surgery.

RESULTS

Changes in the G-DRG system caused the sample hospital of maximum care to loose 8.5 % case mix index (CMI) during the period of 2003 to 2005. For three of the four virtual, typical ophthalmological clinics the theoretic reimbursement conditions also deteriorated: retina surgery -- 10.6 %, glaucoma surgery - 15.8 % and cataract surgery -- 17.9 % CMI. Only strabismus surgery showed an increase of + 5.6 % in CMI during the period examined.

CONCLUSION

Over the years 2003 to 2005 the CMI clearly deteriorated for many ophthalmological subspecialties given otherwise identical conditions. To calculate the changes specifically for an individual hospital, the individual base rates have to be considered.

[Prevalence of ocular diseases in a population of elderly residents of the city of Veranópolis, Brazil]

PURPOSE

To evaluate the prevalence of diseases of the eye in a population aged 80 years and above in the city of Veranópolis, Rio Grande do Sul, Brazil.

METHODS

187 elderly people were submitted to ophthalmologic tests including external inspection, ocular motility examination, visual acuity determination for near and far distance, applanation tonometry, biomicroscopy, cycloplegia, direct fundus examination and static skiascopy.

RESULTS

The most prevalent disease was presbyopia in 173 (92.5%) patients, cataract in 160 (85.6%), age-related ectropion in 130 (69.5%), hypermetropia in 130 (69.5%) and age-related macular degeneration (ARMD) in 59 (31.5%) patients. 85 (45.4%) patients presented marked low vision whose main causes were cataract in 46 (54.1%) and refractive error in 16 (18.9%) of the studied population. The most prevalent complaint was due to presence of age-related ectropion.

CONCLUSIONS

Common diseases as cataract and retractive error are still a challenge to ophthalmologists because these diseases remain main causes of visual deficit in old age resulting in life quality losses.

Eye health and adolescence

Complete development of eyes occurs between 8 and 11 years, though longitudinal growth of axial length may occur up to 13 years (approximately). Except a few, most of the eye diseases affecting adolescence age group are similar to adult type. Diseases like myopia, keratoconus, vernal keratoconjunctivitis, juvenile diabetic retinopathy and injuries to eye are exclusively diseases of adolescence that are commonly encountered. Psychologically, impact of eye disease on adolescent mind may be profound, thinking they might lose their eyesight. Early detection of diseases, prevention of injuries, health education and frequent eye check-up are essential.

Ocular findings seen among the staff of an institution in Lagos, Nigeria

BACKGROUND

The degree to which ocular morbidity affects workers productivity in the developing countries has not been studied adequately. A federal government research institute based in Lagos introduced an annual health screen for all its workers, which included eye tests. This provided an opportunity to study the pattern of ocular conditions among workers who were 30 years and above, and to determine the effect of eye diseases on the workers productivity.

STUDY DESIGN

Detailed eye examination including refraction, was done on every respondent at the institution's clinic by an ophthalmologist. A questionnaire on ocular health status and occupational history was administered independently by an ophthalmic nurse. Sickness absenteeism, use of the clinic were obtained from clinic records, and the results were analysed.

RESULTS

The common ocular conditions were uncorrected or poorly corrected refractive error, uncorrected or poorly corrected presbyopia and allergic. conjunctivitis. Glaucoma, maculopathy and optic atrophy were causes of severe visual impairment or blindness in 1.9 % of the subjects. Absenteeism and clinic use were more common in subjects with ocular morbidity than those with non-ocular morbidity. Subjects with ocular morbidity had more illnesses, absenteeism and used the clinic more.

CONCLUSION

Ocular problems which reduce worker's productivity are prevalent among the staff of the institution studied. They are mostly unrecognised.

Ocular vasculitis: a multidisciplinary approach

PURPOSE OF REVIEW

The ophthalmologist has direct visual access to inflamed vessels when examining the retina, and "vasculitis" in ophthalmology has so far mainly referred to retinal vasculitis. In the past few years the means to explore vasculitis in the ocular sphere have improved. Indocyanine green angiography now enables the analysis of choroidal inflammatory vasculopathy as well as vasculitis of the sclera (scleritis) and episclera (episcleritis) in addition to retinal vasculitis. Because vasculitis detected by the ophthalmologist can be the presenting sign of a systemic disease and has to be approached in a multidisciplinary fashion, the emerging term "ocular vasculitis," instead of retinal vasculitis, should be used in the future. The term covers vasculitis affecting all structures of the eye and the periocular tissues as detailed in this article. The ocular findings have to be integrated within the established and accepted classification of systemic vasculitis, which is divided into primary vasculitides, where the vessel itself is the target of the inflammatory reaction, and secondary vasculitides, caused by other inflammatory processes. This review will deal with recently published articles on ocular vasculitis, including its clinical aspects, its link with systemic diseases, and its investigation and management. The discussion will be conducted within the framework of the new classification put forward here.

RECENT FINDINGS

Novel imaging techniques such as indocyanine green angiography have made it possible to explore inflammation of choroidal vessels and of scleral vasculitis in addition to retinal vasculitis, contributing to the global concept of ocular vasculitis. It has been shown, in particular, that the choriocapillaris, a vascular structure adjacent to the retina, can be the site of a primary inflammatory vasculopathy unrecognized so far. Most of the recent articles cited, however, deal not so much with new findings but with the integration of ocular pathologic changes into the systemic diseases they are part of. New knowledge about disease mechanisms and novel therapeutic modalities with biologic agents cited in this review are coming from other fields but have contributed to progress in the management of ocular vasculitis.

SUMMARY

New investigational techniques of vasculitis in ocular structures other than the retina have contributed to the development of the global concept of ocular vasculitis. This review shows the importance of promoting a comprehensive and global classification of ocular vasculitis compatible with the concepts accepted for systemic vasculitis to contribute to its multidisciplinary approach.

Homogenit�t der G-DRGs in der Augenheilkunde

BACKGROUND

Since the year 2004 hospitals in Germany are obliged to participate in a payment system based on diagnosis-related groups (DRG), which bases hospital reimbursement on the diagnosis and treatment of patients. The aim of this study was to analyze the data of the first German national hospital cost data calculation for their homogeneity.

METHODS

The cases at the LMU hospital in Munich were calculated analogous to the national hospital cost data calculation for a period of 7 months. These exemplary data were then analyzed in detail for homogeneity.

RESULTS

For many DRGs, the numbers of cases in the analysis were within a range similar to those in the official nationwide calculation. The costs and lengths of stay were similar to those of the official national calculation.

CONCLUSIONS

Many ophthalmologic DRGs are quite inhomogeneous necessitating regrouping to avoid false incentives. For cases with high complexity the current system may lead to cost deficits especially for hospitals providing maximum care.

Ocular side effects associated with isotretinoin

Isotretinoin is used for severe recalcitrant nodular acne and has a variety of associated ocular side effects. This review classifies these ocular side effects according to World Health Organization (WHO) criteria and reviews the existing literature as well as 2449 spontaneous case reports collected from around the world. Ocular sicca, decreased dark adaptation and intracranial hypertension are identified as "certain" side effects from isotretinoin and clinicians are provided guidelines for care and follow-up.

The impact of managed eye care on use of vision services, vision costs, and patient satisfaction

OBJECTIVES

This study was designed to evaluate the impact of introducing a managed vision benefit program on the use and costs of vision services in a managed care setting and also to assess satisfaction with those services after the program was introduced.

METHODS

Utilization and costs were compared for two groups of patients. The comparison group (n = 36,168) included all patients enrolled for 18 months before implementation of the managed eye-care plan. The study group (n = 23,816) included those enrolled for 18 months following its implementation. Medical claims, survey, and administrative data were used to evaluate study outcomes.

RESULTS

The overall use of vision care was similar before and after the introduction of the managed eye-care programs, with 24% of each group receiving at least one vision service during the 18-month period. Nevertheless, an increase in the use of routine eye-care services and a decrease in medical eye-care services were observed following program implementation. The overall cost of providing eye-care services to patients decreased from 1.86 dollars to 1.36 dollars per member per month after the program started, largely owing to a reduction in spending associated with medical eye-care services. More than 90% of patients surveyed were satisfied with their vision care provided by the program.

CONCLUSIONS

Findings suggest that introducing routine and medical managed eye-care programs in a managed care setting allows for a reduction in medical costs while maintaining access to care and patient satisfaction.

Painful ophthalmologic disorders and eye pain for the neurologist

Neurologists should be aware of the following causes of eye pain: (1)ocular and orbital disorders with or without visible pathology of the eye (eg,redness, corneal opacity, or proptosis); (2) ophthalmologic syndromes associated with headache; and (3) headache syndromes associated with ophthalmologic findings.

Klassifikation der Erkrankungen der Augenoberfl�che

The ocular surface consists of the lid margin, conjunctiva and cornea which together with the tear system represent a functional entity. The diagnosis of ocular surface disease can be very difficult due to the similarity of various disease entities. The classification should be made on the pathological and pathophysiological characteristics of ocular surface disease. The first part of the classification comprises diseases of the lid margin, the tear system as well as diseases of the conjunctiva. Both the clinical presentation as well as the underlying pathophysiological and pathological characteristics of the most important ocular surface diseases are reviewed.

Incidence of Lung, Eye, and Skin Lesions as Late Complications in 34,000 Iranians With Wartime Exposure to Mustard Agent

Approximately 34,000 Iranians known to have sustained mustard agent exposure during the Iran-Iraq war of 1980-1988 and survived over a decade afterwards were screened for distribution of the most commonly occurring medical problems. In order of greatest incidence, these include lesions of the lungs (42.5%), eyes (39.3%), and skin (24.5%). Within each subpopulation, patients were ranked according to severity of lesions. Twenty-three percent to 37% of patients exhibited at least mild coverage, with 1.5% to 4.5% classed as moderate, and a much smaller population (0.023-1.0%) of the 34,000 patients exhibiting extensive (severe) lesional coverage. These results provide a comprehensive overview of the medical problem most common among mustard victims and could serve as a predictor of the likely impact of these weapons on health status of populations exposed to them during ongoing military conflicts.

The influence of health, social support quality and rehabilitation on depression among disabled elders

This study examined the influence of health, social support, disability, and vision rehabilitation services on depression among visually impaired older adults seeking vision rehabilitation services. Participants (n = 95) were interviewed at application and approximately two years later. The first hierarchical regression model focused on concurrent relationships at baseline. The second model used baseline health and social support variables, along with indicators of change in vision and use of rehabilitation services, in order to predict change in depression over time. Findings indicate that being unmarried, in poorer health, having lower quality of relationships with family, and lower stability in friendships were significant independent risk factors for initial depression, explaining 50% of the variance. Decline in depression over time was predicted by younger age, better self-rated health, stability of friendships, and use of rehabilitation services that, along with baseline depression, explained 61% of the variance in depressive symptomatology at the two-year follow-up. Findings highlight the importance of qualitative aspects of social support for older disabled adults, as well as the distinction that needs to be made between factors that predict concurrent mental health status and those predicting change in status over time.

Ocular side-effects associated with imatinib mesylate (Gleevec)

This retrospective case series describes ocular side-effects associated with imatinib mesylate (Gleevec) and the clinical characteristics of these adverse reactions. A chart review of 104 patients on imatinib mesylate therapy from Oregon Health & Science University's Cancer Center were studied with regard to ocular side-effects. In addition, spontaneous reports from the Food and Drug Administration, the World Health Organization, and the National Registry of Drug-Induced Ocular Side-Effects databases were reviewed, including a Medline literature search. Seventy-three (70%) of the patients at OHSU developed periorbital edema and 19 patients (18%) developed epiphora after receiving imatinib mesylate. Average dose was 407.5+/-60 mg. Periorbital edema occurred an average of 68+/-48 days after initiation of therapy. WHO classification of side-effects is as follows: certain: periorbital edema; probable: epiphora; possible: extraocular muscle palsy, ptosis, blepharoconjunctivitis; unlikely: glaucoma, papilledema, retinal hemorrhage, photosensitivity, abnormal vision, and increased intraocular pressure. Periorbital edema and epiphora are the two most common ocular side-effects related to imatinib mesylate therapy. Clinical characteristics of imatinib mesylate induced periorbital edema are described. Management of ocular side-effects is conservative except in very rare cases of visually significant periorbital edema.

T-cell characterization in chronic allergic eye disease

Chronic allergic eye disease encompasses several disorders, but it is vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC) that have sight-threatening sequelae. T cells, eosinophils, and mast cells are all found in the conjunctiva, and are thought to play a role in disease pathogenesis. Recently, the conjunctival epithelium has also been considered to play a key role. New and effective therapeutic strategies for the future for these patients depend on achieving a greater understanding of the roles and interactions of the cell populations in these sight-threatening disorders.

The clinical spectrum of the oculo-respiratory syndrome after influenza vaccination

Oculo-respiratory syndrome (ORS), a new influenza vaccine associated adverse event, was identified in 2000. The 2000 case definition (ORS-2000) required the presence of bilateral red eyes or respiratory symptoms or facial edema occurring between 2 and 24h following immunization and lasting <or=48 h. We compared clinical manifestations of cases outside these timelines. Cases were classified as ORS-early (onset <2 h after immunization), ORS-late (onset >24 h), ORS-persistors (duration >48 h).Overall, the distribution of symptoms was similar between ORS-2000 and other case categories. ORS-early and ORS-late had less ocular involvement, ORS-late and ORS-persistors had more cough and sore throat, ORS-early had more facial edema and ORS-late had less. In comparison to ORS-2000, ORS-early were younger whereas ORS-persistors and ORS-late were significantly older suggesting that clinical manifestations of ORS vary with age with a more rapid induction of symptoms in younger individuals and longer duration for older ones.

Neuro-ophthalmology of mitochondrial diseases

PURPOSE OF REVIEW

To review recent data on mitochondrial diseases with emphasis on their neuro-ophthalmic manifestations.

RECENT FINDINGS

Numerous studies have associated mitochondrial diseases with neuro-ophthalmic manifestations. Although there has been an explosion of studies on the genetics of mitochondrial diseases over the past few years, pathogenesis is only partly understood and therapy remains very limited. Over the past year, new mutations in Leber's hereditary optic neuropathy have been reported, and at least three genes associated with autosomal dominant chronic progressive external ophthalmoplegia have been described. These findings allow a better definition of the specific genetic mutations and gene products as well as pathophysiology of Leber's hereditary optic neuropathy and chronic progressive external ophthalmoplegia. The current development of animal models allows a better understanding of the pathophysiology of human mitochondrial diseases.

SUMMARY

The afferent and efferent visual pathways within the central nervous system are frequently involved in mitochondrial diseases. Neuro-ophthalmic signs figure prominently and may be the presenting or even sole manifestation of these disorders. The four most common neuro-ophthalmic abnormalities seen in mitochondrial disorders are bilateral optic neuropathy, ophthalmoplegia with ptosis, pigmentary retinopathy, and retrochiasmal visual loss.

Correlations between the severity of retinopathy in diabetic patients and whole blood and plasma viscosity

The aim of this study was to correlate the severity of retinopathy in diabetic patients with the whole blood and plasma viscosity. The studies were performed on 52 patients suffering from type II diabetes mellitus with non-proliferative retinopathy (25 men and 27 females, mean age of patients 64+/-6.5 years). The mean duration of diabetes treatment was 13.7 years. The control group consisted of 43 healthy persons (20 men and 23 women, the mean age of controls was 55.9+/-9.2 years). Blood samples were taken from patients immediately after ophthalmological examination from anticubital vein and anticoagulated with K2EDTA. The symptoms of retinopathy were: macular edemas, microaneurysms, hard and soft exudates and hemorrhagic focuses. The severity of particular signs of retinopathy was expressed in a three point scale. The total number of rank points was correlated with blood and plasma viscosity, moreover with eyes acuity. Blood viscosity measurements were performed with the use of cone-plate Brookfield's viscometer at shear rate 150 s(-1), and plasma viscosity with capillary Ubbelohd's viscometer. Besides the viscometric examinations hematocrit, fibrinogen, blood morphology, total cholesterol concentration, LDL-cholesterol, HDL-cholesterol, triglycerides, blood glucose concentration and glycosylated hemoglobin were examined. The whole blood viscosity, the corrected blood viscosity adjusted to 45% of hematocrit were significantly higher in diabetics (p<0.001). The whole blood relative viscosity was also significantly elevated in diabetic patients (p<0.002). The correlation between visual acuity and rank point of retinopathy severity was negative (r= -0.91, p<0.001). The retinopathy severity was positively correlated with whole blood and plasma viscosity (r=0.51; p<0.001 and r=0.4; p<0.005, respectively).

CONCLUSION

Elevated blood and plasma viscosity may play an additional and significant role in the development of diabetic retinopathy.

Hypertension and the eye: changing perspectives

Systemic hypertension is a common condition associated with significant morbidity and mortality. Hypertension confers cardiovascular risk by causing target-organ damage that includes retinopathy in addition to heart disease, stroke, renal insufficiency and peripheral vascular disease. The recognition of hypertensive retinopathy is important in cardiovascular risk stratification of hypertensive individuals. This review reevaluates the changing perspectives in the pathophysiology, classification and prognostic significance of fundal lesions in hypertensives.