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PubMed1993

Use of ophthalmologic services by diabetic patients in Nova Scotia.

To evaluate the possible public health consequences of diabetic retinopathy in Nova Scotia, we investigated the number and frequency of ophthalmologic examinations in patients with diabetes mellitus. A total of 36,683 people (4.2%) were identified from the administrative database of the provincial health department as having a diagnostic code of diabetes during the period March 1987 to February 1990. All billings by ophthalmologists for these patients during the same period were then identified. Of the 36,129 patients aged 10 years or more, 17,518 (48.5%) had seen an ophthalmologist at least once during the study period, and 5218 (14.4%) had seen an ophthalmologist approximately annually. Increased age and being female were associated in univariate logistic regression analysis with higher use of ophthalmologic services. The medical insurance system is free of direct costs to patients, and there are enough ophthalmologists to meet patient needs (4.35 per 100,000 population). The findings indicate that most diabetic patients in Nova Scotia are not seen at least once a year, as recommended by the Expert Committee of the Canadian Diabetes Advisory Board, despite ready availability of ophthalmologic care.

Adolescent↗

PubMed1996

Can medical students design their ophthalmology programme?

Students are major participants in the ophthalmology programme but it is usually designed solely by faculty. This study investigated whether a student-designed programme would differ from the existing one in our department. Fifty final- year medical students and the seven ophthalmologists in the study town completed questionnaires on the relevance of ophthalmology at undergraduate level, learning objectives, timing, length and content of the ophthalmology programme. The student-designed programme required more frequent postings and greater correlation of ocular with systemic disease. It was concluded that students can make a very meaningful contribution to programme design.

Curriculum↗

PubMed1998

The Baylor survey of Ophthalmology Residency graduates: rationale for reform in residency training.

BACKGROUND AND OBJECTIVE: To survey graduates of an ophthalmology residency training program regarding skills necessary for a well-trained ophthalmologist. METHODS: Two survey instruments were mailed to the graduates of the Baylor College of Medicine Department of Ophthalmology Residency Training Program. RESULTS: Specific skills were identified that were rated as clinically important and for which training was considered adequate, and, conversely, skills that were rated as less important but for which training was adequate. CONCLUSION: This survey instrument may allow ophthalmology residency training programs to identify perceived and real deficiencies in the prioritization of changes in curriculum or the skills transfer process.

Clinical Competence↗

PubMed1998

Alfred Bielschowsky's 1940 legacy for neuro-ophthalmology.

OBJECTIVES: The author was stimulated to write this article by a 1996 visit to the University where Professor Alfred Bielschowsky was Chairman of Ophthalmology in the 1930s. Dr. Bielschowsky was one of the founders of neuro-ophthalmology. This review, with biographical notes, is presented in his honor. Dr. Bielschowsky and the author had similar disruptive experiences, of historic interest, during the Hitler regime in Nazi Germany. REVIEW: Professor Bielschowsky's legacy begins with his contributions to ocular physiology. For instance, his after-image test establishes the presence of retinal correspondence, important for stereoscopic vision. Alfred Bielschowsky taught how an ocular examination is critical for neuro-ophthalmologic diagnosis, localization, prognostication, and treatment. Much of our knowledge is linked with his name. Examples include "Bielschowsky's Phenomenon", explaining dissociated vertical movements, and "Bielschowsky's Doll's Head Phenomenon" (Doll's Eyes), describing proprioceptive reflexes important for localizing intracranial lesions. Dr. Bielschowsky emphasized many pitfalls in the differential diagnosis of oculomotor anomalies. For example, he cautioned against mistaking the compensatory head position in congenital fourth cranial nerve paresis for neck muscle disease. CONCLUSION: Dr. Bielschowsky's emphasis on the clinical examination remains critical despite today's advanced diagnostic equipment. His legacy is the application of physiology to patient care.

Germany↗

PubMed2003

Physicians' liability in ophthalmology practice.

PURPOSE: The aims of this paper are to point out the importance of coherence in established guidelines in daily practice, highlight the value of signed patient informed consent forms and stress the value of a good understanding of the law, while focusing on issues related to malpractice in ophthalmology. METHODS: Search of the current relevant literature. RESULTS: The most common causes of medical litigation in ophthalmology are related to LASIK surgery, cataract surgery, glaucoma care, radial keratotomy for myopia reduction and failure to diagnose binocular vision anomalies in children and adults in a timely fashion. The litigation raised in most cases is driven by unfavourable outcomes and not by malpractice. CONCLUSION: Maintenance of high standards in daily practice, with continuous training and clear communication along with the appropriate documentation of any procedure carried out, may improve the professional safety of practising eye specialists in the event of medical litigation. Although the use of patient informed consent varies substantially among European countries, it may serve as useful evidence in the physician's defence.

Consent Forms↗

PubMed2002

[Analytic management in ophthalmology: towards a cost per hospital out- and in-patient].

PURPOSE: To determine the total annual cost of the activities in the Ophthalmology Department at the Hospital La Mancha-Centro, Homogeneous functional group (HFG) of the INSALUD, and to estimate the cost per patient/process of both ambulatory patients and hospital in-patients. METHODS: The study was designed over 1 year period, from January to December 1997, and applied by using analytic accounting in 17,857 patients seen at the out-patient ophthalmology clinic and 973 hospital in-patients who were classified by diagnosis-related groups (DRG) and sorted out by analysis of Case Mix index. RESULTS: We have determined the annual cost of our activity in both the ambulatory patient group and the hospital in-patient group classified by DRG and obtained the cost per process. CONCLUSIONS: To know systematically the annual cost of our medical and surgical activity is nowadays a necessary tool in the framework of the Total Quality Plan developed by the INSALUD's SIGNO Group since 1991. This leads us to the analytic management area and places us in the never ending search for the ideal model of cost per process determination.

Ambulatory Care↗

PubMed1985

Feeding intolerance following ophthalmologic examination.

Reports of isolated cases of necrotizing enterocolitis following administration of mydriatric medication and ophthalmologic examination prompted a comparison of the incidence of feeding difficulties 24 hours before and 24 hours after the ophthalmologic examination of 50 newborns. All infants had received cyclopentolate hydrochloride and phenylephrine hydrochloride before the examination. A critical review of the nursing notes showed more abdominal distention and gastric aspirates in the period following the examination than in the period preceding the examination. One infant developed necrotizing enterocolitis during the 24-hour postexamination period. This study demonstrates the risk of feeding intolerance following the ophthalmologic examination of neonates. These risks may be due to the known side effects of the mydriatics, to the physical stress of the examination, or to a combination of both factors.

Animals↗

PubMed1998

[Night driving capacity of ophthalmologically healthy persons of various ages].

UNLABELLED: In 1970 Aulhorn and Harms made fundamental recommendations for the night driving ability of motorists as well as for the corresponding examination methods. Reduced night driving ability of persons over the age of 60, as well the established limits for twilight vision and glare sensitivity, and their relevance to night-time collisions has been re-examined. PATIENTS AND METHODS: A total of 117 normal volunteers between 10 and 79 years of age underwent ophthalmological examinations including measurement of contrast acuity and glare sensitivity by means of the Mesotest II (Oculus, Germany). RESULTS: Contrast acuity and glare sensitivity deteriorate in an age-dependent fashion. Thus, night driving ability decreased with increasing age. The majority part of persons over the age of 60 were not able to fulfill the actual criteria for night driving ability according to the recommendations of the German Ophthalmological Society (DOG). CONCLUSIONS: In the present population, nearly 40% of persons over the age of 60 have reduced night driving ability. Since Lachenmayr showed in the BAST study the correlation of reduced night driving ability and car accidents, this emphasizes the importance of ophthalmological check-ups for motorists at this age.

Adolescent↗

PubMedDate not supplied

Sensitivity and specificity of new eye check chart for neuro-ophthalmological diseases.

PURPOSE: To determine the sensitivity and specificity of a new Eye Check Chart (ECC) for screening neuro-ophthalmological patients with lesions in the visual pathways. METHODS: The Humphrey perimeter (HP) with the 30-2 SITA Fast program was used to confirm the visual field defects found in 65 eyes of 35 neuro-ophthalmological patients. Forty eyes had pregeniculate lesions, and 25 eyes had postgeniculate lesions. As controls, 22 eyes of 12 patients without visual field defects were also examined. All subjects were then examined using the eye check chart (ECC) to determine whether comparable visual field defects were detected. The eyes were separated into those in which the ECC findings agreed with the HP findings, and those in which they did not agree. Based on HP results, the sensitivity and specificity of the ECC results were calculated. RESULTS: The sensitivity of ECC was 87% in patients with pregeniculate lesions and 80% in patients with postgeniculate lesions. The overall specificity of ECC was 91%. CONCLUSION: This high sensitivity and specificity indicate that ECC can give reliable results in screening neuro-ophthalmological patients for lesions in the visual pathways.

Adult↗

PubMed2006

Asthenopia in schoolchildren, orthoptic and ophthalmological findings and treatment.

The aim of this study was to describe the orthoptic and ophthalmological findings in schoolchildren with asthenopia, to correlate them with asthenopic symptoms and to evaluate the effect of treatment. One hundred and twenty schoolchildren, aged 6-16 years, were included in the study. They were all referred by school nurses, for asthenopic symptoms. An orthoptic and ophthalmological assessment was performed. The main diagnoses were accommodative insufficiency, convergence insufficiency, refractive errors, and latent strabismus. Reading glasses could help 98% of the schoolchildren with reduced accommodation, and 94% of the children with refractive errors and heterophorias were helped with appropriate spherical, cylindrical and prism correction. Convergence exercise reduced the symptoms in all patients with convergence insufficiency. Ninety-three percent of all 120 schoolchildren were symptom free 3-6 month after treatment had started. By an orthoptic and ophthalmological examination abnormalities in schoolchildren with asthenopia related to visual problems can be identified. Most of the children were relieved from their symptoms by giving adequate glasses, convergence exercises and surgery.

Accommodation, Ocular↗

PubMed1986

Visual evoked responses and ophthalmological examination in optic neuritis. A follow-up study.

Ophthalmological examination and visual evoked responses (VERs) were repeated at 6-120 (mean 46) months after the first attack of acute optic neuritis in 80 patients who had abnormal VERs in 98 symptomatic eyes at the initial examination. The wide field VER returned to within the normal range in 19/98 (19%) symptomatic eyes. Fifteen percent of patients had completely normal VERs at follow-up. The yield of VER abnormalities was increased by the use of central field in addition to wide field stimulation. One or more components of the ophthalmological examination were abnormal in 91% of symptomatic eyes at final review. Although the ophthalmological examination was a more sensitive index than the VER of past optic neuritis in symptomatic eyes, the reverse was the case in asymptomatic eyes.

Acute Disease↗

PubMed2005

Neuro-ophthalmologic and electroretinographic findings in pantothenate kinase-associated neurodegeneration (formerly Hallervorden-Spatz syndrome).

PURPOSE: The onset of pantothenate kinase-associated neurodegeneration (PKAN) occurs in the first and second decade of life and a pigmentary retinal degeneration is a feature of the disorder. Since the neuro-ophthalmologic and electroretinographic (ERG) features have never been well delineated, we describe them in 16 patients with PKAN. DESIGN: Observational case series. METHODS: Sixteen patients with genetic and neuroimaging-confirmed PKAN were examined. Ten underwent neuro-ophthalmologic examination and all had ERGs. RESULTS: Of the 10 who underwent neuro-ophthalmologic examination, all showed saccadic pursuits and eight showed hypometric or slowed vertical saccades. Seven of eight had inability to suppress the vestibulo-ocular reflex; two patients could not cooperate. Two had square wave jerks and four had poor convergence. Vertical optokinetic responses were abnormal in five, and two patients had blepharospasm. Eight patients had sectoral iris paralysis and partial loss of the pupillary ruff consistent with Adie's pupils in both eyes. Only four of 10 examined patients showed a pigmentary retinopathy, but 11 of 16 had abnormal ERGs ranging from mild cone abnormalities to severe rod-cone dysfunction. No patient had optic atrophy. The PANK2 mutations of all of the patients were heterogeneous. CONCLUSIONS: Adie's-like pupils, abnormal vertical saccades, and saccadic pursuits were very common. These findings suggest that mid-brain degeneration occurs in PKAN more frequently than previously thought. ERG abnormalities were present in approximately 70% and no patient had optic atrophy. Although genotype-ocular phenotype correlations could not be established, allelic differences probably contributed to the variable clinical expression of retinopathy and other clinical characteristics in these patients.

Adolescent↗

PubMed2006

Ophthalmologic findings and long-term course in patients with neurofibromatosis type 2.

PURPOSE: To evaluate ophthalmologic findings and long-term course in patients with neurofibromatosis type 2 (NF2). DESIGN: Retrospective observational case series. METHODS SETTING: Single-center institutional practice. STUDY POPULATION: Thirty referred patients with NF2 were enrolled from 1991 to 2003 and underwent at least one thorough neuroophthalmologic examination. Follow-up of 23 patients ranged from 4.3 to 12.5 years. MAIN OUTCOME MEASURES: Visual function, structural ocular abnormalities, onset and type of presenting NF2-related symptoms, and number of central nervous system tumors. RESULTS: Initial symptoms for patients with early-onset NF2 mostly comprised ophthalmologic symptoms (n = 7) and lower motor neuron extremity weakness (n = 6), as opposed to eighth nerve impairment (n = 11) in late disease onset. NF2-specific ocular findings were noted in 83% of all patients (94% childhood onset; 67% adult onset): 67% had cataracts, 40% epiretinal membranes, 3% hamartoma, 13% disk gliomas, and 27% optic nerve sheath meningiomas. Only 14% in the childhood-onset group-as opposed to 78% in the adult-onset group-sustained visual acuity of 1.0 in both eyes at final examination. Significantly more patients with early onset of symptoms developed multiple central nervous system tumors (P = .004) and showed a higher amount of NF2-specific findings (P = .015). CONCLUSIONS: Initial manifestations of NF2 differ between children and adults. NF2-specific ophthalmologic findings can help establish the diagnosis. Symptom onset at a young age is clearly a risk factor for marked disease progression. These patients should be carefully followed because survival rates have increased, and vision becomes increasingly important as the disease progresses.

Adolescent↗

PubMed2005

Ophthalmologic disorders in minority populations.

Race- and ethnicity-related differences in prevalence of a number ofophthalmologic disorders have been documented. More importantly, blackand Hispanic Americans share a disproportionate share of morbidity, asmeasured by visual impairment and blindness, when compared with whiteAmericans. The reasons for this health disparity are complex andmultifactorial. If the unequal, individual, and societal burden of avoidable vision lossamong black and Hispanic Americans is to be decreased, it is essential tounderstand the apparent barriers to accessing timely and appropriateophthalmologic monitoring and care for these minority populations. Forthose who do gain access to ophthalmologic care, it is important tounderstand better the determinants leading to different treatment of blackand Hispanic Americans compared with white Americans. Opportunities for decreasing vision-related morbidity caused by cataract,diabetic retinopathy, and glaucoma for these minority groups clearly exist. Strategies for each of these ophthalmologic disorders may differ. Cataract isa reversible cause of visual impairment and removal of cataract improvesquality of life. Cataract surgery should be offered to all who can potentiallybenefit from this treatment. Earlier diagnosis, before the disease hasprogressed to loss of vision, should be a goal in both glaucoma and diabeticretinopathy. Strategies for screening high-risk groups may be particularlyrelevant in this regard. Additionally, with diabetic retinopathy, improvedmanagement of contributing risk factors, such as blood glucose control andblood pressure control, is important. Asian Americans are increasingly becoming a sizable minority group inthe United States. It is projected that by 2070, the Asian population willreach 11% of the total population of the United States. Virtually all of thepopulation-based data relating to ophthalmologic disorders in Asians havebeen performed in Asia. The reported relative proportion of PACG versusPOAG, however, among some Asian populations and of normal-tensionglaucoma versus high-tension glaucoma among the Japanese seems to applyto the United States Asian population. This assertion is based onwidespread clinical impression and analysis of Medicare claims data [56]. Understanding the differences is important for optimal treatment of theseminority populations as the proportion of Asians in the United Statescontinues to grow. The common denominator in all of these diseases is the role of thephysician and patient. Educational programs aimed at the physician tofacilitate cultural competence and at the patient to increase level of knowledgeabout their disease are appropriate and enthusiastically endorsed.

Eye Diseases↗

PubMed2004

Neuro-ophthalmologic diagnosis and therapy of central nervous system trauma.

Although direct injury to the orbit and globes can easily result in ophthalmologic disorders, it is less appreciated that distant head injury can similarly result in injury to the retrobulbar afferent visual pathways or cranial nerves. The physician must be suspicious of latent and manifest injuries to the neuro-ophthalmologic system after head trauma and maintain an awareness of the need for timely intervention in a subset of these disorders. Even patients with injuries removed from the eyes should be checked for visual problems, and if any are detected, a careful neuro-ophthalmologic examination should be performed. In most cases, examination and judicious use of neuroimaging will help in choosing the appropriate management for injuries to the afferent and efferent visual systems.

Craniocerebral Trauma↗

PubMed2006

Ophthalmologic findings in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy: a cross-sectional study.

OBJECTIVE: To determine the ophthalmologic findings, especially the nature of retinal vascular changes, and their clinical significance in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), a disease that causes migraine, recurrent strokes, and finally subcortical vascular dementia. DESIGN: Cross-sectional study. PARTICIPANTS: Thirty-eight CADASIL patients (19 to 61 years old; 20 in a prestroke group, 15 in a stroke group, and 3 in a dementia group), all with the R133C NOTCH3 mutation and including one homozygous patient, underwent a detailed ophthalmologic examination. METHODS: Common cardiovascular risk factors were evaluated. Ophthalmologic examination included best-corrected visual acuity, anterior- and posterior-segment biomicroscopy, and measurement of intraocular pressure. In 33 patients and 16 healthy controls (20-64 years old), retinal fundus photographs were taken. Diameters of all arterioles and venules located in the area from 0.5 to 1.0 disc diameters from the optic disc margin were measured with a computer-based program and arteriole-to-venule (A/V) ratios were calculated from digitized photographs. RESULTS: General arterial narrowing and arteriovenous nickings were common. Straightening of the retinal arterioles and a marked wall reflex (n = 6) occurred. The A/V ratio of CADASIL patients was significantly (P< 0.001) lower than that of controls. One patient had one retinal microinfarct and hemorrhages. The homozygous patient had a chorioretinal scar as a sign of circulatory deficiency. Anterior-segment changes included mild iris atrophy (n = 5) and various degrees of lens opacities. Visual acuity was normal in all but 2 patients, who had cataract and amblyopia. CONCLUSIONS: The generalized arteriopathy of CADASIL causes a wide variety of changes in retinal arterioles but only minimal functional disturbances. These findings are consistent with alterations in arterioles in the cerebral cortex with which the retina and its arterioles are analogous, but contrast with the severe damage of cerebral white matter arterioles.

Adult↗

PubMed2000

Ophthalmologic findings in Cohen syndrome. A long-term follow-up.

OBJECTIVE: To determine the nature and course of ophthalmologic abnormalities and their clinical significance in Cohen syndrome. STUDY DESIGN: Observational case series. PARTICIPANTS: Twenty-two Cohen syndrome patients aged 2 to 57 years were examined, and a retrospective review of ophthalmologic records was carried out for 14 of them. All but one were part of the Finnish study of refined mapping of the Cohen syndrome gene by linkage disequilibrium in chromosome 8. MAIN OUTCOME MEASURES: Visual acuity (VA), cycloplegic refraction, biomicroscopy, lens opacitometry, ophthalmoscopy, and fundus photography. RESULTS: With the exception of the two youngest patients, all had symptoms such as nyctalopia, impaired vision, and visual field loss. Progressive, often high-grade myopia, astigmatism, and retinochoroidal dystrophy resembling retinitis pigmentosa occurred in all, except for the youngest patients. The earliest fundus changes were pale disc and pale fundus with or without pigment granularity, followed by narrowed vessels, pigment clumps, and bone spiculelike pigment accumulations by 10 to 20 years of age. Pigment deposits increased and approached the posterior pole by 35 to 40 years of age. Patients more than 45 years of age had severe retinochoroidal atrophy. A bull's-eye macula was seen in most patients. Teenagers had peripheral lens opacities, and young adults had early nuclear sclerosis confirmed by lens opacitometry. Older patients also had posterior subcapsular cataracts, iris atrophy, and iridophacodonesis. Vision started to deteriorate at the age of 6 to 10 years, but remained relatively good (VA 0.5-0.1) in most patients until 30 and, in one case, 46 years of age. Older patients were severely visually handicapped (VA hand motion to light perception), but none were completely blind. CONCLUSIONS: Progressive myopia and retinochoroidal dystrophy are essential features in Cohen syndrome and, together with early lens opacities, lead to deterioration of vision. Cohen syndrome patients need careful ophthalmologic follow-up at all ages. Nyctalopia and restricted visual fields should be considered when planning the patient's daily activities.

Adolescent↗

PubMed2002

Perinatal cortical and subcortical visual loss: mechanisms of injury and associated ophthalmologic signs.

PURPOSE: To determine whether term and preterm injuries to the retrogeniculate visual system are associated with recognizable patterns of ophthalmologic abnormalities and whether these patterns can be attributed to cortical (gray matter) or subcortical (white matter) injury. DESIGN: A retrospective case series. PARTICIPANTS: One hundred children with clinical and neuroimaging signs of perinatal posterior visual pathway injury who were examined at Arkansas Children's Hospital Eye Clinic between 1989 and 1999. METHODS: We reviewed magnetic resonance images or computed tomographic scans from 50 children with cortical (predominantly or exclusively involving cortical gray matter) and 50 children with subcortical (predominantly or exclusively involving subcortical white matter) perinatal injury to the retrogeniculate visual system. Ophthalmologic abnormalities were analyzed retrospectively in each group. MAIN OUTCOME MEASURES: Conjugate gaze deviation, type of strabismus, abnormal eye movements, and optic disc morphology. RESULTS: Horizontal conjugate gaze deviation, exotropia, and a normal optic disc appearance were significantly more common in cortical than in subcortical visual loss. Tonic downgaze, esotropia, and optic nerve hypoplasia (with or without coexisting pallor) were significantly more common in subcortical than in cortical visual loss. CONCLUSIONS: Perinatal cortical and subcortical visual loss produce differing profiles of ophthalmologic dysfunction. A reclassification of periventricular leukomalacia and other forms of retrogeniculate white matter injury as subcortical visual loss would increase diagnostic specificity.

Blindness, Cortical↗