The impact of national diabetic retinopathy screening on ophthalmology: the need for urgent planning.
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Diabetic Retinopathy↗
Biomedical subjects
V Chong
Publications and source records attributed to V Chong.
Screening for age-related macular degeneration using nonstereo digital fundus photographs.
UNLABELLED: Age-related macular degeneration (AMD) is a disease with significant visual morbidity and accounts for the majority of blind registrations in the developed world including the UK. Certain forms of neovascular AMD are amenable to treatment but require expeditious referral to a retinal specialist. AIM: To evaluate the possibility of using nonstereo fundus photographs as a low-cost screening tool for neovascular AMD. DESIGN: Retrospective review of patients referred to the macular clinic of a teaching hospital in London. METHODS: A total of 198 randomised digital fundus photographs, without any other clinical information, were presented to two independent ophthalmic interns who graded them into one of the three categories: normal, age-related maculopathy (ARM), or neovascular age-related macular degeneration (AMD) to determine the urgency of referral to clinic. The results were compared with the known diagnosis for each patient and sensitivities and specificities for each diagnostic category calculated. RESULTS: The intraobserver Kappa statistic was 0.75 and 0.91 for grader 1 and 2, respectively. The interobserver Kappa was 0.54. The mean sensitivity and specificity for the identification of ARM was 60.5 and 76.3%, respectively The mean sensitivity and specificity for the identification of AMD was 85.7 and 78.8%, respectively. CONCLUSION: Nonstereo digital fundus photograph is a reasonable screening tool for CNV and may aid in decreasing the visual morbidity it causes by enabling timely referrals and treatment.
Choroidal Neovascularization↗
Evolving European guidance on the medical management of neovascular age related macular degeneration.
BACKGROUND: Until recently, only two options were available for the treatment of choroidal neovascularisation (CNV) associated with age related macular degeneration (AMD)-thermal laser photocoagulation and photodynamic therapy with verteporfin (PDT-V). However, new treatments for CNV are in development, and data from phase III clinical trials of some of these pharmacological interventions are now available. In light of these new data, expert guidance is required to enable retina specialists with expertise in the management of AMD to select and use the most appropriate therapies for the treatment of neovascular AMD. METHODS: Consensus from a round table of European retina specialists was obtained based on best available scientific data. Data rated at evidence levels 1 and 2 were evaluated for laser photocoagulation, PDT-V, pegaptanib sodium, and ranibizumab. Other treatments discussed are anecortave acetate, triamcinolone acetonide, bevacizumab, rostaporfin (SnET2), squalamine, and transpupillary thermotherapy. RESULTS: PDT-V is currently recommended for subfoveal lesions with predominantly classic CNV, or with occult with no classic CNV with evidence of recent disease progression and a lesion size <or=4 Macular Photocoagulation Study (MPS) disc areas (DA). The new classes of anti-angiogenic agents-namely, pegaptanib sodium and ranibizumab (the latter when peer reviewed phase III data become available) are recommended for subfoveal lesions with any proportion of classic CNV or occult with no classic CNV. For juxtafoveal classic CNV, PDT-V or anti-angiogenic therapy should be considered if the new vessels are so close to the fovea that laser photocoagulation would almost certainly extend under the centre of the foveal avascular zone. For all other well demarcated juxtafoveal lesions and for extrafoveal classic lesions, laser photocoagulation remains the standard treatment. Therapy should be undertaken within 1 week of the fluorescein angiogram on which the clinical decision to treat is based. At each follow up, fluorescein angiography should be performed and best corrected visual acuity measured as a minimum requirement. CONCLUSIONS: These recommendations provide evidence based guidance for the choice and use of non-surgical therapies for the management of neovascular AMD. Revisions of the recommendations may be required as new data become available.
Antibodies, Monoclonal↗
Choroidal translocation with a pedicle following excision of a type 1 choroidal neovascular membrane.
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Aged↗
Radiotherapy for neovascular age-related macular degeneration.
BACKGROUND: Radiotherapy has been proposed as a treatment to prevent new vessel growth in people with neovascular age-related macular degeneration (AMD). OBJECTIVES: The aim of this review was to examine the effects of radiotherapy on neovascular AMD. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group trials register) on The Cochrane Library Issue 2, 2004, MEDLINE (1966 to May 2004), EMBASE (1980 to June 2004) and LILACS (Latin American and Caribbean Health Sciences Literature Database) (May 2004). We also wrote to investigators of trials included in the review to ask if they were aware of any other studies. SELECTION CRITERIA: We included all randomised controlled trials in which radiotherapy was compared to another treatment, sham treatment, low dosage irradiation or no treatment in people with subfoveal choroidal neovascularisation secondary to AMD. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted the data. Relative risks were combined using a random effects model. The percentage of the variability in effect estimates that was due to heterogeneity, rather than sampling error, was estimated using I2. MAIN RESULTS: Eleven trials randomising a total of 1078 people were included in this review. All trials used a similar method of delivering the radiotherapy treatment (external beam). Dosage ranged from 7.5 to 24 Gy. Most trials found effects (not always significant) that favoured treatment. However, there was considerable inconsistency in the results between trials (I2 > 50%). As only 11 trials were included in the review and only some of these trials provided data for each outcome our ability to determine the causes of the heterogeneity between trials was limited. Subgroup analyses did not reveal any statistically significant interactions although with small numbers of trials in each subgroup (range two to four) this was not surprising. There was some indication that trials with no sham irradiation reported a greater effect of treatment as did trials with a greater percentage of participants with classic choroidal neovascularisation. REVIEWERS' CONCLUSIONS: This review currently does not provide evidence that external beam radiotherapy is an effective treatment for neovascular AMD. If further trials are to be considered to evaluate radiotherapy in AMD then adequate masking of the control group must be considered. Given the recent evidence that most lesions are amenable to treatment with photodynamic therapy if identified at a small lesion size, trials evaluating radiotherapy against photodynamic therapy are warranted.
Eye↗
Relation of surgical volume to outcome in eight common operations: results from the VA National Surgical Quality Improvement Program.
OBJECTIVE: To examine, in the Veterans Health Administration (VHA), the relation between surgical volume and outcome in eight commonly performed operations of intermediate complexity. SUMMARY BACKGROUND DATA: In multihospital health care systems such as VHA, consideration is often given to closing low-volume surgical services, with the assumption that better surgical outcomes are achieved in hospitals with larger surgical volumes. Literature data to support this assumption in intermediate-complexity operations are either limited or controversial. METHODS: The VHA National Surgical Quality Improvement Program data on nonruptured abdominal aortic aneurysmectomy, vascular infrainguinal reconstruction, carotid endarterectomy (CEA), lung lobectomy/pneumonectomy, open and laparoscopic cholecystectomy, partial colectomy, and total hip arthroplasty were used. Pearson correlation, analysis of variance, mixed effects hierarchical logistic regression, and automatic interaction detection analysis were used to assess the association of annual procedure/specialty volume with risk-adjusted 30-day death (and stroke in CEA). RESULTS: Eight major surgical procedures (68,631 operations) were analyzed. No statistically significant associations between procedure or specialty volume and 30-day mortality rate (or 30-day stroke rate in CEA) were found. CONCLUSIONS: In VHA hospitals, the procedure and surgical specialty volume in eight prevalent operations of intermediate complexity are not associated with risk-adjusted 30-day mortality rate from these operations, or with the risk-adjusted 30-day stroke rate from CEA. Volume of surgery in these operations should not be used as a surrogate for quality of surgical care.
Adolescent↗
The Department of Veterans Affairs' NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program.
OBJECTIVE: To provide reliable risk-adjusted morbidity and mortality rates after major surgery to the 123 Veterans Affairs Medical Centers (VAMCs) performing major surgery, and to use risk-adjusted outcomes in the monitoring and improvement of the quality of surgical care to all veterans. SUMMARY BACKGROUND DATA: Outcome-based comparative measures of the quality of surgical care among surgical services and surgical subspecialties have been elusive. METHODS: This study included prospective assessment of presurgical risk factors, process of care during surgery, and outcomes 30 days after surgery on veterans undergoing major surgery in 123 medical centers; development of multivariable risk-adjustment models; identification of high and low outlier facilities by observed-to-expected outcome ratios; and generation of annual reports of comparative outcomes to all surgical services in the Veterans Health Administration (VHA). RESULTS: The National VA Surgical Quality Improvement Program (NSQIP) data base includes 417,944 major surgical procedures performed between October 1, 1991, and September 30, 1997. In FY97, 11 VAMCs were low outliers for risk-adjusted observed-to-expected mortality ratios; 13 VAMCs were high outliers for risk-adjusted observed-to-expected mortality ratios. Identification of high and low outliers by unadjusted mortality rates would have ascribed an outlier status incorrectly to 25 of 39 hospitals, an error rate of 64%. Since 1994, the 30-day mortality and morbidity rates for major surgery have fallen 9% and 30%, respectively. CONCLUSIONS: Reliable, valid information on patient presurgical risk factors, process of care during surgery, and 30-day morbidity and mortality rates is available for all major surgical procedures in the 123 VAMCs performing surgery in the VHA. With this information, the VHA has established the first prospective outcome-based program for comparative assessment and enhancement of the quality of surgical care among multiple institutions for several surgical subspecialties. Key features to the success of the NSQIP are the support of the surgeons who practice in the VHA, consistent clinical definitions and data collection by dedicated nurses, a uniform nationwide informatics system, and the support of VHA administration and managerial staff.
Hospitals, Veterans↗
Isolated sphenoethmoid recess polyps.
Isolated sphenoethmoid recess (SER) polyps are rare. They usually arise from the sphenoid sinus. We report six patients with SER polyps as the only abnormal clinical finding at initial presentation. All cases were investigated with outpatient biopsy and computed tomography (CT) or magnetic resonance (MR) imaging. Pre-operative histology revealed three cases of inflammatory disease, two cases with inverted papilloma, and one case of an ectopic pituitary adenoma arising from the sphenoid sinus. One of the inflammatory polyps arose directly from the mucosa around the sphenoid ostium. The other five cases involved the sphenoid sinus. Except for the ectopic pituitary adenoma all the polyps were managed by transnasal endoscopic surgery. We emphasize that isolated SER polyps may signify existing sphenoid pathology and a pre-operative biopsy is valuable for planning surgery.
Adenoma↗