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PubMed1998

Predictive value of floaters in the diagnosis of posterior vitreous detachment.

PURPOSE: To evaluate Weiss ring and floaters as indexes of posterior vitreous detachment. METHODS: Using biomicroscopy and indirect ophthalmoscopy, we examined the posterior vitreous in 200 consecutive eyes with posterior vitreous detachment. RESULTS: In 200 eyes with posterior vitreous detachment, biomicroscopy disclosed complete, incomplete, and no Weiss ring in 102 (51%), 72 (36%), and 26 (13%) eyes, respectively. Indirect ophthalmoscopy showed the glial ring in 58 (56.9%) and 16 (22.2%) of the eyes, with a complete (102 eyes) and incomplete (72 eyes) Weiss ring, respectively. Although the incidence of floaters was significantly correlated with the presence of the glial ring (P = .0014), 60 (58.8%) and 49 (68.1%) of the eyes with a complete (102 eyes) and incomplete (72 eyes) glial ring, respectively, had no floaters. CONCLUSION: Detecting the detached posterior vitreous cortex by biomicroscopy is essential regardless of the presence of Weiss ring or floaters.

Aged↗

PubMed2001

Assessment of the retinal nerve fiber layer in clinical trials of glaucoma neuroprotection.

Assessment of the retinal nerve fiber layer (RNFL) is appealing for use in clinical trials of glaucoma neuroprotection, as it is directly correlated with loss of ganglion cells, which is assumed to be a primary event in glaucomatous damage. Qualitative assessment of the RNFL includes ophthalmoscopy, color stereophotography, and red-free monochromatic photography. In contrast, confocal scanning laser ophthalmoscopy (CSLO), scanning laser polarimetry (GDx), optical coherence tomography (OCT), and retinal thickness analysis (RTA) objectively and quantitatively measure the RNFL thickness. These latter techniques are still in evolution. Continuing meticulous objective validation is necessary to assess the usefulness and limitations of these powerful tools. Nevertheless, there are excellent prospects for using longitudinal assessment of the RNFL in clinical trials of glaucoma neuroprotection.

Cell Survival↗

PubMedDate not supplied

Current approaches to the diagnosis and management of choroidal melanomas.

Although malignant melanoma of the uveal tract is well known as the most common primary intraocular malignancy, many questions exist regarding the best approach to its diagnosis and treatment. In the past, diagnosis has been made by direct ophthalmoscopy alone and errors resulting in unnecessary enucleation have been frequent. However, recent studies have shown that the adequate use of new techniques such as indirect ophthalmoscopy, fluorescein angiography, ultrasonography, and the 32P test can reduce the incidence of error substantially. A 12-step procedure for diagnosis utilizing these aids is outlined. Traditionally, enucleation has been accepted as the treatment of choice. However, with earlier and more accurate diagnosis, alternative treatments are being applied in selected cases. Although photocoagulation, irradiation, cryotherapy, diathermy and local resection of choroidal melanomas have been used with some success, these methods require further trial and followup before their value can be established. Techniques and indications for use of these procedures are discussed, and the complications and potential effectiveness of each is evaluated.

Choroid Neoplasms↗

PubMed2002

Assessment of optic disc anatomy and nerve fiber layer thickness in ocular hypertensive subjects with normal short-wavelength automated perimetry.

PURPOSE: To compare optic disc topography and nerve fiber layer thickness in ocular hypertensive eyes and normal subjects. DESIGN: Prospective, case-controlled study. PARTICIPANTS AND CONTROLS: One eye in each of 20 normal and 27 ocular hypertensive patients was enrolled. METHODS: Consecutive normal and ocular hypertensive patients were enrolled. Each patient underwent complete ophthalmic examination, achromatic automated perimetry, short-wavelength automated perimetry, confocal scanning laser ophthalmoscopy, confocal scanning laser polarimetry, and optical coherence tomography. The intraocular pressure was 21 mmHg or less for normal subjects and at least 25 mmHg on two separate occasions in ocular hypertensive eyes. Structural parameters were compared between the two groups. Eyes with evidence of glaucomatous optic neuropathy, achromatic visual field loss, or evidence of focal visual field injury during short-wavelength automated perimetry were excluded. MAIN OUTCOME MEASURES: Optic nerve head topography and nerve fiber layer thickness. RESULTS: The three imaging technologies could not detect differences in optic disc or nerve fiber layer anatomy between the two groups. Ocular hypertensive eyes had a greater corrected pattern standard deviation than normal eyes during short-wavelength automated perimetry (P = 0.04). CONCLUSIONS: Ocular hypertensive eyes with normal achromatic automated perimetry and short-wavelength automated perimetry could not be distinguished from normal subjects with confocal scanning laser ophthalmoscopy, confocal scanning laser polarimetry, and optical coherence tomography.

Adult↗

PubMed2002

Retinal pigment epithelium translocation after choroidal neovascular membrane removal in age-related macular degeneration.

PURPOSE: To test the feasibility of a new surgical technique and to assess visual function over the translocated retinal pigment epithelium (RPE) cells in patients operated on for subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (ARMD). DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: Nine patients with previously untreated exudative ARMD underwent surgical excision of the subfoveal CNV with RPE translocation and were observed for 12 to 32 months. METHODS: The surgery consisted of a standard three-port pars plana vitrectomy, excision of the CNV, and RPE translocation. Pre- and postoperative ocular examination included best-corrected visual acuity measurement, fundus color stereo photography, and fundus fluorescein angiography. Optical coherence tomography and confocal laser scanning ophthalmoscopy (cLSO) were performed after surgery. A crossfixation target and a single-point flashing light were projected on different areas of the posterior pole using a cLSO. Photopic 10 to 2 perimetry, photopic fine matrix mapping, and cLSO microperimetry were also performed after surgery in six patients. MAIN OUTCOME MEASURES: Optical coherence tomography cross-sectional scans and cLSO RPE autofluorescence were recorded to detect the presence of viable translocated RPE. Visual acuity, fixation, photopic 10 to 2 perimetry, photopic fine matrix mapping, and cLSO microperimetry were used to test central visual function. RESULTS: Retinal pigment epithelium was translocated successfully at the time of CNV removal from the edge of the RPE defect to a subfoveal location in seven of nine patients. One patient experienced proliferative vitreoretinopathy, but significant hemorrhage was not a feature. Optical coherence tomography showed the translocated RPE as an area of increased optical reflectivity with optical shadowing external to it. Confocal laser scanning ophthalmoscopy showed autofluorescence of the translocated RPE. The crossfixation target was seen when projected on the translocated RPE. During eccentric fixation, the patients could see a flashing point-target projected on the translocated RPE. Photopic 10 to 2 perimetry, photopic fine-matrix mapping, and cLSO microperimetry showed the presence of central visual function. CONCLUSIONS: The authors propose that translocation of RPE at the time of CNV removal, from the edge of the RPE defect to a subfoveal location, may have a role in the surgical management of ARMD.

Aged↗

PubMed1981

The natural history of retinopathy in insulin-dependent juvenile-onset diabetes.

We determined the cross-sectional natural history of retinopathy by prospective study of 461 insulin-dependent juvenile-onset diabetics. In so doing, we compared the sensitivity of ophthalmoscopy, photography, and fluorescein angiography in detecting retinopathy. Photography was far more reliable than ophthalmoscopy in detecting early retinopathy and equivalent to angiography. Retinopathy was not present at diagnosis of diabetes. After a lag period, the prevalence of retinopathy rose in sigmoidal fashion, reaching 50% at just over seven years duration, and asymptotically approaching 90% at 17--50 years. Proliferative retinopathy was first seen at 13 years duration, and its prevalence rose to 26% at 26--50 years. From the natural history we computed the dimensions of a proposed clinical trial to test the effect of tight metabolic control in prevention of retinopathy.

Diabetes Mellitus, Type 1↗

PubMed1986

Fundus lesions in malignant hypertension. IV. Focal intraretinal periarteriolar transudates.

Experimental renovascular malignant arterial hypertension was produced in 57 rhesus monkeys by a modified Goldblatt's procedure and their eyes were studied by serial ophthalmoscopy, by stereoscopic color fundus photography, and by fluorescein fundus angiography over a period of months or years. A very common, and one of the earliest, lesions in hypertensive retinopathy was focal intraretinal periarteriolar transudates (FIPTs). In the past, FIPTs have been described erroneously as "cotton-wool spots." The two types of lesions differ very much in shape, size, color, location, fluorescein fundus angiographic pattern, resolution pattern, life cycle, and pathogenesis. FIPTs, on ophthalmoscopy, usually are pinpoint to pinhead size, round or oval, dull white in color, and situated in deeper layers of the retina and beside the major retinal arteries and their main branches. On fluorescein angiography, FIPTs show multiple punctate foci of fluorescein leakage from dilated precapillary retinal arterioles, and there is no focal retinal capillary obliteration. They usually last for two to three weeks, and on resolution leave no ophthalmoscopic, angiographic, or microvascular abnormality. Cotton-wool spots are seen in a variety of retinopathies; FIPTs, however, are a specific retinal lesion of malignant arterial hypertension only. They develop due to breakdown of blood-retinal barrier in pre-capillary retinal arterioles, due to dilatation of the arterioles from failure of autoregulation (caused by severe rise of blood pressure).

Animals↗

PubMed1992

Visual field testing in the management of cytomegalovirus retinitis.

BACKGROUND: Sequential visual field testing is an extremely helpful adjunct to ophthalmoscopy and fundus photography in the management of cytomegalovirus (CMV) retinitis with the antiviral agents ganciclovir or foscarnet in patients with the acquired immune deficiency syndrome (AIDS). The authors studied the visual field defects found in a series of 110 patients with AIDS and CMV retinitis. METHODS: Ophthalmoscopy and fundus photography were performed on all patients. Visual field analysis was performed with either tangent screen, Goldmann kinetic, or Humphrey automated static perimetry. RESULTS: Of 166 eyes in 110 patients with CMV retinitis, visual field defects were present initially in 92 (55%) eyes of 78 (70%) patients, and ultimately in 97 (53%) eyes of 90 patients in whom follow-up was available. Stabilization of visual field defects was indicative of controlled retinitis. CONCLUSION: Sequential visual field testing will confirm ophthalmoscopic evidence of successful antiviral treatment of CMV retinitis and will corroborate very early progression of previously controlled retinitis.

AIDS-Related Opportunistic Infections↗

PubMed1992

Retinal pigment epithelium lesions as a biomarker of disease in patients with familial adenomatous polyposis. A follow-up report.

BACKGROUND: The sensitivity of retinal pigment epithelium (RPE) lesions as a predictive congenital marker for the development of familial adenomatous polyposis (FAP) is evaluated. METHODS: In a prospective study, 34 patients at 50% risk of inheriting FAP were examined. Based on the presence or absence of four or more RPE lesions, patients were categorized as those who had inherited or those who lacked the FAP genes. All patients received dilated fundus examinations with binocular indirect ophthalmoscopy and all RPE lesions were documented with fundus photography. All patients underwent annual sigmoidoscopy to determine the presence or absence of polyps. RESULTS: A 3-year follow-up analysis showed that 8 of 14 patients who were positive for RPE lesions later developed polyps. Of the 20 patients considered negative for FAP based on normal fundus examination, none has developed polyps. CONCLUSION: The authors urge all patient at risk of inheriting FAP to undergo dilated fundus examination with binocular indirect ophthalmoscopy and wide-angle fundus photography at the earliest age possible. All patients with 4 or more RPE lesions should undergo annual sigmoidoscopic examinations beginning before 10 years of age.

Adenomatous Polyposis Coli↗

PubMed1995

Ophthalmoscopic measurement of the optic disc.

PURPOSE: The authors evaluated whether the optic disc dimensions can be measured directly by ophthalmoscopy without the use of a fundus camera or special ophthalmoscope. MATERIALS AND METHODS: The horizontal and vertical disc diameters were measured ophthalmoscopically in 158 eyes of 95 subjects using a standard Goldmann three-mirror contact lens and a commercial slit lamp with adjustable length of the beam. The refractive error ranged from -7.25 to 3.5 diopters. Based on these direct measurements, the authors calculated the disc area by applying a modified formula for an ellipse, where area = pi/4 x the horizontal diameter x the vertical diameter. Additionally, the authors determined by planimetry the diameters and area of the disc on color photographs after correcting the ocular and photographic magnification. RESULTS: The values of the disc diameters as determined by photography were x1.27 larger than those measured with the Goldmann contact lens. Taking into account this constant correction factor of 1.27 for all eyes examined, the disc diameters, as measured by the Goldmann lens, varied by 0.11 +/- 0.06 mm or 5.8% +/- 3.5% from the values measured on the photographs. This error decreased slightly (P = 0.04) with increasing disc size. It was independent of the refractive error. The calculated disc area based on the ophthalmoscopically determined disc diameters differed by 9.4% +/- 6.6% from the disc area as measured by planimetry on the photographs. CONCLUSIONS: For clinical purposes, the optic disc and other structures of the posterior fundus can be measured by ophthalmoscopy using a Goldmann contact lens and a slit lamp with adjustable beam length. The optic disc area can be calculated by the formula: horizontal disc diameter x vertical disc diameter x pi/4.

Adult↗

PubMed1999

Heidelberg retina tomography and optical coherence tomography in normal, ocular-hypertensive, and glaucomatous eyes.

PURPOSE: To evaluate optic disc and retinal nerve fiber layer (RNFL) appearance in normal, ocular-hypertensive, and glaucomatous eyes undergoing confocal scanning laser ophthalmoscopy and optical coherence tomography (OCT). DESIGN: Prospective, cross-sectional study. PARTICIPANTS: Seventy-eight eyes of 78 consecutive normal (n = 17), ocular-hypertensive (n = 23), and glaucomatous subjects (n = 38) were enrolled. METHODS: Each patient underwent complete ophthalmic examination, achromatic automated perimetry, confocal scanning laser ophthalmoscopy (Heidelberg Retinal Tomography [HRT]), and OCT. Topographic HRT parameters (disc area, cup-disc ratio, rim area, rim volume, cup shape measure, mean RNFL thickness, and cross-sectional area) and mean OCT-generated RNFL thickness were evaluated in each group. MAIN OUTCOME MEASURES: OCT and HRT assessment of optic disc and RNFL anatomy. RESULTS: OCT RNFL thickness showed no difference between normal and ocular-hypertensive eyes (P = 0.15) but was significantly less in glaucomatous eyes (P < 0.001). HRT measurements of rim area, cup-disc ratio, cup shape measure, RNFL thickness, and RNFL cross-sectional area were significantly less in glaucomatous eyes (all P < 0.005) and were correlated with mean OCT RNFL thickness (all P < 0.02). RNFL thickness using OCT or HRT was highly correlated with visual field mean defect during achromatic perimetry (P < 0.0001). CONCLUSION: Both HRT and OCT can differentiate glaucomatous from nonglaucomatous eyes. RNFL thickness measurements using OCT correspond to disc topographic parameters using HRT.

Adult↗

PubMedDate not supplied

Mouse models of ocular diseases.

The Jackson Laboratory, having the world's largest collection of mouse mutant stocks and genetically diverse inbred strains, is an ideal place to discover genetically determined eye variations and disorders. In this paper, we list and describe mouse models for ocular research available from Mouse Eye Mutant Resource at The Jackson Laboratory. While screening mouse strains and stocks at The Jackson Laboratory (TJL) for genetic mouse models of human ocular disorders, we have identified numerous spontaneous or naturally occurring mutants. We characterized these mutants using serial indirect ophthalmoscopy, fundus photography, electroretinography (ERG) and histology, and performed genetic analysis including linkage studies and gene identification. Utilizing ophthalmoscopy, electroretinography, and histology, to date we have discovered 109 new disorders affecting all aspects of the eye including the lid, cornea, iris, lens, and retina, resulting in corneal disorders, glaucoma, cataracts, and retinal degenerations. The number of known serious or disabling eye diseases in humans is large and affects millions of people each year. Yet research on these diseases frequently is limited by the obvious restrictions on studying pathophysiologic processes in the human eye. Likewise, many human ocular diseases are genetic in origin, but appropriate families often are not readily available for genetic studies. Mouse models of inherited ocular disease provide powerful tools for rapid genetic analysis, characterization, and gene identification. Because of the great similarity among mammalian genomes, these findings in mice have direct relevance to the homologous human conditions.

Animals↗

PubMed2001

Acute posterior multifocal placoid pigment epitheliopathy and ulcerative colitis: a possible association.

PURPOSE: To report a case of Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE) in the course of Ulcerative Colitis (UC). METHODS: A complete ophthalmologic evaluation, including fluorescein and indocyanine green angiography, was performed. RESULTS: A patient with exacerbation of UC was referred to our department for sudden visual loss in RE. Ophthalmoscopy disclosed multifocal yellow-white placoid lesions typical of APMPPE in RE. There were no lesions in the fellow eye. On fluorescein angiography (FA), the active lesions showed early hypofluorescence, followed by late staining. Indocyanine green angiography (ICGA) revealed early and late hypofluorescence corresponding to the lesions observed clinically, and late anular staining surrounding a hypofluorescent lesion at the posterior pole. On LE ICGA revealed lesions not detected with ophthalmoscopy and FA. After corticosteroid therapy the lesions healed. CONCLUSION: Ulcerative Colitis may be responsible for the onset of AMPPPE by an immunological mechanism of delayed type hypersensitivity reaction.

Acute Disease↗

PubMed2001

What optic disc parameters are most accurately assessed using the direct ophthalmoscope?

PURPOSE: It has been suggested that over-reliance on the cup-to-disc ratio is a major factor in the misinterpretation of the optic disc. In spite of this optometrist assessment of the optic disc tends to be restricted to measurement of the cup-to-disc ratio and cup depth only. Would interpretation of the disc improve if optometrists were to evaluate other parameters? The aim of this study was to evaluate the accuracy of optometrist assessment of nine parameters of the optic nerve head using direct ophthalmoscopy. METHODS: Eight optometrists evaluated nine parameters of the optic nerve head (vertical disc diameter, vertical cup-to-disc ratio, neuroretinal rim configuration, cup shape, neuroretinal rim colour, vessel path, presence/ absence of haemorrhage, extent and location of peripapillary atrophy and classification of health status of the disc) in 50 eyes of 50 patients using direct ophthalmoscopy. Intensive training in optic nerve head assessment was given prior to assessing the patients. Criteria for evaluation were discussed. The 'gold standard' reference was the classification of the parameters by a consultant ophthalmologist with a special interest in glaucoma. RESULTS: Interobserver agreement for vertical cup-to-disc ratio was almost perfect (mean weighted kappa 0.84). Agreement for neuroretinal rim configuration, cup shape, haemorrhage and final classification of the disc was good (mean kappa 0.62-0.67). There was moderate agreement for vessel configuration (mean kappa 0.53). For assessment of peripapillary atrophy, disc size and neuroretinal rim colour, agreement was fair (mean kappa 0.22-0.34). CONCLUSIONS: Accuracy of assessment was greatest for vertical cup-to-disc ratio, neuroretinal rim configuration and cup shape. Improved agreement has been demonstrated for the final classification of the disc compared with previous reports. The combination of training and assessment of additional disc parameters appears to improve interpretation of the optic nerve head by optometrists.

Clinical Competence↗

PubMed2002

Imaging vitreous.

Purpose Imaging vitreous is a quest to view what is, by design, invisible. This treatise will review significant historical aspects, past and present imaging methodologies, and imaging techniques that are currently in development for future research and clinical applications. Methods Classic and modern histologic techniques, dark-field slit microscopy, clinical slit lamp biomicroscopy, standard and scanning laser ophthalmoscopy, ultrasonography, optical coherence tomography, magnetic resonance and raman spectroscopy, and dynamic light scattering methodologies are presented. Results The best available histologic techniques for imaging vitreous are those that avoid rapid dehydration of vitreous specimens. Dark-field slit microscopy enables in vitro imaging without dehydration or tissue fixatives. Optical coherence tomography enables better in vivo visualization of the vitreo-retinal interface than scanning laser ophthalmoscopy and ultrasonography but does not image the vitreous body. Dynamic light scattering can determine the average sizes of vitreous macromolecules within the vitreous body as well as possibly image the posterior vitreous cortex once detached, while Raman spectroscopy can detect altered vitreous molecules, such as glycated collagen and other proteins in diabetic vitreopathy. Conclusions The inability to adequately image vitreous hinders a more complete understanding of its normal structure and how this changes in aging and disease. The combined use of more than one technique could provide better imaging of vitreous for future investigational and clinical purposes.

Age Factors↗

PubMed2006

Cup-to-disc ratio: agreement between slit-lamp indirect ophthalmoscopic estimation and stratus optical coherence tomography measurement.

PURPOSE: To determine agreement between slit-lamp indirect ophthalmoscopy and Stratus optical coherence tomography (OCT) when assessing cup-to-disc ratios (CDRs). METHODS: Twenty-five ocular hypertensive subjects and 56 patients with primary open-angle glaucoma were included. Estimation of vertical (VCDR) and horizontal (HCDR) cup-to-disc ratio with slit-lamp ophthalmoscopy was made by three glaucoma specialists along with OCT scanning of optic nerve head. Agreement between OCT and specialists was measured by intraclass correlation coefficients (ICC), Bland and Altman's scatterplots, and a regression coefficient of the average difference. RESULTS: The mean VCDR and HCDR was significantly higher (P<0.001) with OCT than that estimated by the specialists, with the difference ranging from 0.08 to 0.11, and from 0.13 to 0.18, respectively, depending on the specialist. Difference was higher (P<0.001) for cuppings below 0.3, and looses significance for larger VCDR cuppings (above 0.7). ICC for VCDR was 0.87 among specialists, and ranges from 0.82 to 0.75 when comparing OCT and specialists. ICC for HCDR was 0.83 among specialists and 0.74 between OCT and specialists. When data were plotted according to the Bland-Altman method, as the cupping increased, the agreement also increased. CONCLUSIONS: There is very good agreement among the specialists when estimating CDRs by stereoscopic slit-lamp biomicroscopy. OCT shows higher values than the specialists; the greatest differences occurred when assessing small CDRs and the differences diminished as the cupping increased. These two methods of measurement are not interchangeable, and the difference must be considered, especially in discs with smaller CDRs.

Early Diagnosis↗

PubMed1999

A simple eye model to objectively assess ophthalmoscopic skills of medical students.

OBJECTIVES: Ophthalmoscopy is an important clinical skill that is essential for medical students to master. Competency in the performance of this skill needs to be assessed objectively. DESIGN: The development of a simple, cheap eye model for objective assessment of ophthalmoscopic skills of medical students is described. SETTING: University of Liverpool. SUBJECTS: Undergraduate medical students. RESULTS: The model was used in 803 assessments and showed a high level of student performance, based on both checklist marking of the general approach to the examination and objective marking of the ability of students to manipulate the light beam, focus the lens and systematically examine the model's fundus. CONCLUSIONS: The method described provides a simple, cost-effective, objective assessment of the performance of ophthalmoscopy.

Audiovisual Aids↗

PubMed2002

[Normal fundus and abnormal electroretinogram: differential diagnosis].

PURPOSE: To assess retinal dysfunction when ophthalmoscopy reveals normal features. METHODS: Ganzfeld electroretinography of the rod and of the cone systems was used to detect congenital or acquired retinal dysfunction. In infants under 5 years of age ERG was performed using inhalational anaesthesia. In addition, multifocal ERG techniques detect discrete local retinal dysfunctions. The ERG results are evaluated in comparison to normative data and to ophthalmoscopic as well as perimetric results. Patient data were selected to demonstrate typical ERG changes and the corresponding differential diagnosis. RESULTS: Abnormalities in ERG results and normal ophthalmoscopic features are shown in 8 typical examples. They were observed in the following conditions: (1) stationary congenital dysfunctions, (2) early stages of the hereditary tapetoretinal degenerations, and (3) toxic or cancer-associated retinopathies. In these disorders the ERG complemented visual field testing by detecting isolated dysfunction of the rod- and cone-systems. CONCLUSION: In the context of making crucial diagnostic decisions ERG complements ophthalmoscopy and psychophysical testing of the retinal function. This diagnostic test facilitates differential diagnosis, helps to establish prognosis, and provides a basis for genetic counselling.

Anesthesia, Inhalation↗