Direct Ophthalmoscopic Examination Research Articles

Association of Mean Platelet Volume with Grades of Hypertensive Retinopathy.

Hypertension is the most prevalent non communicable disease causing deaths even before evidence of target organ damage. Platelet activation is associated with risk of vascular events. Identification of mean platelet volume (MPV) values in patients with hypertensive retinopathy (HR) can help in prognostication and risk stratification of possible complications. Patients presenting to the outpatient department over a period of 18 months underwent clinical examination, blood sampling, direct ophthalmoscopic examination, and two-dimensional echocardiography. Out of 104 subjects, there were a total of 25 females and 79 males. Patients with grade 1HR had a mean MPV value of 9.4, those with grade 2 HR had a mean MPV of 9.8, among people with grade 3 HR the mean MPV was 10.1, and those with grade 4 HR had a mean MPV of 10.9. In our study, we have seen that MPV increases with increasing severity of HR, thus implying that MPV probably plays a role in HR. Testing of MPV can be used to decide whether preventative treatments should be instituted to the prevent the severe complications of retinopathy and thus decrease the risk and occurrence of cardiovascular and cerebrovascular events.

A study on the prevalence of retinopathy in newly diagnosed Type 2 diabetes mellitus in a tertiary care center of Tamil Nadu

Background: Type 2 diabetes mellitus (Type 2 DM) is one of the leading risk factors for cardiovascular diseases. Although the awareness of the need for screening and treatment for Type-2 DM is widely prevalent, the awareness of complications arising out of it is not widespread. This article highlights the occurrence of diabetic retinopathy (DR) among newly detected diabetic patients. Aims and Objectives: The aim of the study was to study the prevalence of DR in patients who are diagnosed as having Type 2 diabetes mellitus for the first time. Materials and Methods: The present study involved 501 newly diagnosed Type 2 DM patients. Their history was recorded and the investigations done included haemoglobin (Hb), glycated Hb percent (HbA1c), fasting blood sugar, and post-prandial blood sugar. These patients underwent fundus examination through direct ophthalmoscope and slitlamp examination. Results: Out of the 501 patients in the study, 59.5% (298) had good knowledge about diabetes, but only 3.8% knew about retinopathy. A total of 71.5% of patients did not have periodic eye examination; the most common barrier identified was lack of awareness about the necessity for this (58.5%), 5.6% among the total population had an eye disease. Mild non-proliferative DR (NPDR) was found among 10 females and it was observed in eight males. Moderate NPDR was identified in three males and two females and while no severe cases were reported among the men, two were noted among the women. Conclusion: The study highlights the prevalence of retinopathy in newly diagnosed Type 2 DM population in tertiary care center hospital in Salem district. The study also highlights the importance of detection of Type 2 DM before the occurrence of complications which arise due to diabetes and screening for microvascular complications is necessary at the time of diagnosis of DM and periodically.

Prevalence of Ophthalmic Manifestations in COVID-19 Positive Indoor Patients during Second Wave at Rural Tertiary Care Hospital of Gujarat: A Prospective Observational Study

Introduction: Coronavirus Disease-2019 (COVID-19) can affect multiple system of body including eye. In eye, it can cause mild conjunctivitis, posterior segment involvement, neurosensory involvement and lethal opportunistic infection like mucormycosis. Associated co-morbidities, severity of COVID19 infection and corticosteroids used in its management can affect ophthalmic involvement. Aim: To determine the frequency and various types of ophthalmic manifestation of patients with COVID-19. Materials and Methods: This prospective observational study was conducted on indoor patients of Shree Krishna Hospital, a rural, tertiary care hospital affiliated with Pramukh Swami Medical College, Karansad, Gujarat, India, from 1st May 2021 to 1st January 2022. Second wave of COVID-19 was from 13th March 2021 to 19th June 2021. Patients’ demographic data, details of COVID-19 infection severity score, oxygen requirement, use of corticosteroids, history of various co-morbidities and stages of Rhino-Orbital-Cerebral Mucormycosis (ROCM) (if present) were noted. Bedside ophthalmic examination was done with torch light, fluorescent strip, cobalt blue light of direct ophthalmoscope and fundus examination with indirect ophthalmoscopy under institutional COVID-19 guidelines. Descriptive Statistics {Mean, (SD), Frequency, (%)} were used for analysis of the collected data. Results: Out of 649 COVID-19 patients, 368 were male and 281 were female with mean age of 52.58 (±15.38) years. All over prevalence of ophthalmic manifestations was 9.86% (n=64 out of 649 patients). A total of 63 patients (9.71%) did not require any oxygen supplement, 352 patients (54.24%) required nasal prongs, 201 patients (30.97%) required non invasive ventilator support and 33 patients (5.08%) required mechanical ventilation. The 378 patients (58.24%) received cortico-steroids in oral or intravenous form. A total of 325 patients (50.1%) had diabetes,267 patients (41.1%) had hypertension, 29 patients (4.5%) had chronic kidney disease and 15 patients (2.3%) had thyroid disease. A total of 52 patients (8.01%) had conjunctivitis. Mean age of patients with conjunctivitis was 50.04 (±15.28) with male preponderance (n=30, 57.7%). Most common systemic presentation was fever (n=29,55.8%). Patients with conjunctivitis had high D-dimer (>500 ng/mL) (n=42;80.8%) and C-Reactive Protein (CRP) values (>3 mg/L) (n=39;75%). A total of 144 patients (22.2%) were vaccinated with COVID-19 vaccine first dose while ten patients (19.23%) out of 52 patients having conjunctivitis were vaccinated. Out of 649 patients, prevalence of ROCM was 1.85% (n=12) with mean age 58.58 years (±9.71 years) and male preponderance (n=8, 66.66%). Nine out of twelve patients had high blood sugar levels (mean level 340 mg/ dL) at the time of admission. Out of twelve, eight patients had received corticosteroids for management of COVID-19 infection. Six patients of ROCM (50%) did not require any oxygen support while two patient (16.7%) required nasal prongs for mean 7.50 days and four patient (33.3%) required non invasive ventilator support for mean 7.33 days (±2.5 days). One patient had stage 2C disease, one had stage 3B, five patients had stage 3C while five patients had stage 4C disease. Conclusion: Ocular manifestations of COVID-19 range from conjunctivitis to ROCM. Conjunctivitis has mild and self-limited course while ROCM is sight threatening and life-threatening condition, if not treated appropriately.

Relationship of mean platelet volume in predicting severity in hypertensive retinopathy – A cross sectional study

Background: Hypertension is a major health issue in India and it has led to increasing incidences of target organ damage including hypertensive retinopathy (HR). Many factors like platelet activation show influence in levels of HR. Mean platelet volume (MPV) being an indicator of platelet activation can help in predicting the severity of HR. The present study was planned to find a correlation of levels of MPV with the severity of HR. Methodology: Data of 100 cases of hypertensive retinopathy aged 31 to 80 years diagnosed by direct and indirect ophthalmoscopic examination in the outpatient department of ophthalmology was recorded and reviewed. Complete clinical and demographic data (age, gender, weight, body mass index and socioeconomic status) was noted. Mean platelet volume was obtained from fully automated haematology analyser Horiba medical Yumizen H550. Results: The mean age (years ± standard deviation) of cases with grade 1 HR was 59.448±11.642, grade 2 HR was 56.166±10.0377 and grade 3 HR was 58±19.37. The mean value of MPV in the study population for grade 1 HR was 8.55±0.576, for grade 2 HR was 9.17±0.8224, for grade 3 was 9.6±1.5594. The comparison between grades of HR and levels of MPV was done by one way analysis of variance. Conclusion: We established a significant relationship between mean platelet volume and severity grades of hypertensive retinopathy. MPV a cheap and easily available biomarker can be used for predicting severity in hypertensive retinopathy.

Relationship between insulin-sensitive obesity and retinal microvascular abnormalities.

Obesity and insulin resistance (IR) are risk factors for microvascular disease (MVD). Whether insulin-sensitive obese individuals are at higher risk for MVD is still debated. We aimed to investigate whether insulin-sensitive obesity is associated with retinal microvascular abnormalities. This cross-sectional study recruited a total of 8,313 participants (3,604 males and 4,709 females) aged 21 years or older from 13 villages in rural area and 8 communities in urban area in Fujian province in China between 2011 to 2012. Participants were categorized by insulin-sensitive/-resistant and general/ abdominal obese status. IR was defined as homeostasis model assessment of IR >1.99 (75% percentile). Direct ophthalmoscopic examination was used to diagnose MVD, which was defined as the presence of retinal microvascular abnormalities. Among the older subjects (aged 65-79 years), those who were obese had a markedly higher risk for MVD, both in insulin-sensitive [odds ratio (OR): 2.259, 95% confidence interval (CI): 1.041-4.904, P=0.039] and insulin-resistant (OR: 2.356, 95% CI: 1.064-5.218, P=0.035) individuals. Additionally, insulinsensitive/-resistant abdominal obesity in middle-aged people showed an increased risk for prevalent MVD in women (OR: 2.061, 3.322; 95% CI: 1.004-4.233, 1.645-6.709; P values: 0.049, <0.001). In this study, obesity was closely related to an elevated higher risk of MVD, regardless of IR, especially in older people and abdominally obese middle-aged women. Obesity may be similar to diabetes mellitus, with chronic complications that not only cause cardiovascular diseases but also MVD. Direct ophthalmoscopy may be a noninvasive and meaningful method of early screening for obesity-related MVD. Insulin-sensitive obesity, like impaired glucose tolerance, is a pre-existing state of insulin resistant obesity.

Perceived usefulness and ease of use of fundoscopy by medical students: a randomised crossover trial of six technologies (eFOCUS 1)

BackgroundFundoscopy outside ophthalmology is in decline, and the technical demands of the traditional direct ophthalmoscope examination are likely contributing. Alternative fundoscopy technologies are increasingly available, yet valid comparisons between fundoscopy technologies are lacking. We aimed to assess medical students’ perceptions of usefulness and ease of use of traditional and contemporary fundus-viewing technologies including smartphone fundoscopy.MethodsOne hundred forty-six second-year medical students participated in a cross-sectional, randomised, cross-over study of fundoscopy methods. Medical students completed small group training sessions using six current fundoscopy technologies including: a non-mydriatic fundus camera; two types of direct fundoscopy; and three types of smartphone fundoscopy. A novel survey of perceived usefulness and ease of use was then completed by students.ResultsRepeated-measures ANOVA found students rated both the perceived usefulness (p< 0.001) and ease of use (p< 0.001) of smartphone fundoscopy significantly higher than both the non-mydriatic camera and direct fundoscopy.ConclusionsSmartphone fundoscopy was found to be significantly more useful and easier to use than other modalities. Educators should optimise student access to novel fundoscopy technologies such as smartphone fundoscopy which may mitigate the technical challenges of fundoscopy and reinvigorate use of this valuable clinical examination.

The relationship between vertical cup–disc ratio and body mass index in a population of adult Saudi females

Purpose: The vertical cup–disc (C/D) ratio is useful clinically in optic-disc assessment in glaucoma suspects and diagnosing glaucomas and is thought to also be influenced by many ocular and systemic factors. The body mass index (BMI) is said to be an important parameter which influences vertical C/D ratio and different studies have shown different correlation between these two variables. The aim of the study was to assess the relationship of vertical C/D ratio with BMI in a population of Saudi adult females. Methods: One hundred and one female participants in the age group 18 to 40 years were included in a cross-sectional study after obtaining information regarding demographic data, ocular/systemic diseases, and surgeries by an oral interview. The BMI was calculated as ratio of body weight divided by the square of the body height. C/D ratio was recorded with direct ophthalmoscopic examination and examination with 90-D (Volk) lens. Analysis of variance was used to examine the BMI on vertical C/D ratio. A P-value <0.05 was considered to be statistically significant with confidence interval of 95%. Results: The mean BMI was 22.7 (±4.49) and the mean C/D ratio was 0.22 (±0.14). No significant relationship between increasing vertical C/D ratio and BMI P-value 0.154 was found. Conclusion: This study, conducted as a pilot study to investigate the relationship between C/D ratio and BMI in a young female Saudi population, found no significant relationship between vertical C/D ratio and BMI. This relationship is important as it helps to rule out effect of BMI on C/D ratio parameters in this population.

Platelet Aggregation as a Predicting Factor of Normal-Tension Glaucoma

Objective: To determine the odds ratio of platelet aggregation as a risk factor of normal-tension glaucoma. Methods: This is a case control study with consecutive sampling technique. Samples were divided into 2 groups: (1) individuals with normal-tension glaucoma (case group) and (2) individuals without normal-tension glaucoma (control group). Each group consists of 30 individuals. Inclusion criteria for case groups: (1) Normal-tension glaucoma patient, (2) Age ≤ 50 years old, and (3) Provided written informed consent. Inclusion criteria for control group: (1) Subjects with age ≤ 50 years old, (2) No glaucomatous optical nerve papilla found in direct ophthalmoscope examination, (3) Intraocular pressure < 21 mmHg, (4) Provided written informed consent. Exlusion criteria includes normal-tension glaucoma or a non-glaucoma patient but with a tendency of platelet hyperaggregation such as in thrombotic stroke, myocard infarct, diabetes mellitus; or platelet hypoaggregation such as in uremia, liver diseases, myeloproliferative diseases, dengue fever; or drug use (aspirin, sulphinpyrazone, dipiridamol, thienopyridine, clopidogrel, glycoprotein blockers). Association between platelet aggregations with normal-tension glaucoma was evaluated with odds ratio, while association between platelet aggregation values with confounding factors was measured with multivariate analysis with coefficient of regression. Results: Three reagents were used to measure risk factors of normal-tension glaucoma. ADP 10 μM was shown to be stronger in predicting hyperaggregation in normal-tension glaucoma than ADP 5 μM or ADP 2 μM. However, no statistically significant difference (p>0.05) among effects of each reagents on platelet hyperaggregation in normal-tension glaucoma patients were found. Conclusion: Normal-tension glaucoma risk factor was found in the utilization of ADP 10 μM and ADP 5 μM. Higher platelet aggregation results in higher risk of normal-tension glaucoma.

Relationship of Hypertensive Retinopathy with Mean Platelet Volume Among Hypertensive Patients.

Background The pathophysiological mechanism of hypertensive retinopathy (HR) is not fully understood, although it is thought that increased platelet activation may have a pivotal role. This study was designed to investigate this possibility by determining the frequency and magnitude of mean platelet volume (MPV), a marker of platelet activation, in HR.Methods One hundred and thirty-eight patients, aged 31 to 80 years, who had essential hypertension with HR were enrolled in the study. The patients who presented at the emergency and outpatient medical department of the Capital Development Authority (CDA) Hospital, Islamabad, Pakistan, from March 2013 to February 2014 were selected for this study. All patients were analyzed for grading of HR according to the Keith-Wagener-Barker (KWB) classification criteria. A direct ophthalmoscopic examination was performed in all the subjects, together with an assessment of MPV.Results The mean age of the patients was 54.1 ± 11.7 years. Normal MPV was found in 97 (70.2%) patients, 53 males and 44 females. Elevated levels of MPV were found in 41 (29.7%) patients, 19 males and 22 females. In patients with Grade 1 HR, the MPV was 10.6 ± 0.6 femtoliters (fl). In Grades 2, 3, and 4 HR, the values of MPV were 11.1± 0.5 fl, 11.6 ± 0.3 fl, and 12.2 ± 0.6 fl, respectively, which were greater than the normal range (> 10 fl) of MPV values. In addition, the frequency of elevated MPV significantly (P < 0.001) and linearly (r = 0.998) increased with increasing HR grade.Conclusion It is concluded that the frequency of elevated MPV is increased in patients with HR and strongly correlates to grade. In addition, the magnitude of the elevated MPV increased with the severity of the retinopathy. Thus, abnormally elevated MPV may be an etiological factor for HR in hypertensive patients.

Retrobulbar Optic Nerve Cysticercosis.

Sir, Cysticercosis is the most common parasitic disease involving the central nervous system (CNS). It is caused by infestation of the larval form of Taenia solium, with humans being the primary host. Intraocular cysticercosis occurs in 3% of the cases. Optic nerve involvement by cysticercosis is extremely rare, with very few cases in the literature.[1] A 21-year-old man was referred to our department for computed tomography (CT). He complained of dull headache of the left frontal and temporal region and left ocular pain and mild left orbital swelling and small nodular swelling in left temporal region. The ocular pain was exacerbated with eye movement (ophthalmoplegia). The patient also noted a gradual progressive diminished vision in the left eye since 1 month. The patient had been treated at an outside hospital with painkillers and steroids, but had experienced no improvement in his symptoms. Direct ophthalmoscopic examination revealed features suggestive of left optic disk edema and congestion. The examination of the right eye was normal. Initial CT was performed in the axial plane with 5-mm contiguous sections followed by 1.25-mm sections. The study revealed an approximately 9-mm cyst located in the mid portion of the left optic nerve [Figures 1 and 2]. A magnetic resonance imaging (MRI) study revealed the lesion to have high T2 signal and to expand the mid portion of the optic nerve in a fusiform manner [Figure 3]. The T1-weighted sequence showed the lesion to be of low signal. The cystic lesion was causing expansion of the nerve with margins of the nerve clearly noted around the cyst. Another small cyst was noted in left temporalis muscle [Figure 4].Figure 1: Axial CT section in a 21-year-old patient at the level of optic nerve showing a cyst with mural nodule in the mid portion of left optic nerve (arrow). CT: Computed tomographyFigure 2: Sagittal CT reformations in a 21-year-old patient showing a cyst with mural nodule in the left optic nerve mid portion (arrow)Figure 3: Axial MRI T2W image in 21-year-old patient showing hyperintense cystic lesion in mid portion of left optic nerve (arrow). MRI: Magnetic resonance imaging, T2W: T2-weightedFigure 4: Axial CT in a 21-year-old patient at the level of temporalis muscle showing a cyst with mural nodule in the left temporalis muscle (arrow)Based on the above CT and MRI findings a possibility of cysticercosis was considered. The other possible differential diagnosis of optic nerve glioma, or optic nerve coloboma were also considered. However, the presence of scolex and another similar cystic lesion in temporalis muscle a diagnosis of cysticercosis was considered. The patient was treated conservatively without histologic confirmation, thereby avoiding a surgical procedure. The patient was treated with a 2-week course of albendazole and prednisolone. There was a substantial improvement in the retinal congestion and edema. A repeat CT done on 30th day showed complete resolution of the lesion. The diagnosis of cysticercosis is based on clinical, serologic, and imaging findings. The clinical findings and serologic results may occasionally be nondiagnostic. Thus, imaging studies are often helpful in establishing the diagnosis of cysticercosis.[2] Four stages are noted in the evolution of cysticercosis: Vesicular, colloidal vesicular, granular nodular, and the nodular calcified stage. The CT and MRI appearances differ with the stage of the disease.[3] Identification of the cyst and associated scolex is seen in the vesicular stage.[4] This appearance is strongly suggestive of cysticercosis, especially in endemic regions of the world. The vesicular stage was probably present in our case; our imaging studies revealed a cyst with a mural nodule (scolex). The optic nerve receives its blood supply from a branch of the central retinal artery a branch of ophthalmic artery. Hematogenous spread along the branches of this artery may result in isolated involvement of the optic nerve.

Direct Ophthalmoscopic Examination in the Emergency Department: Is It Really Vital?

Introduction: Hypertensive retinopathy, an important marker of target organ damage in high blood pressure, is a very important guide in the management of hypertension. Therefore, detection of retinopathy in those patients has vital importance. Emergency physicians can easily identify hypertensive retinopathy using direct ophthalmoscopic examination. Here, we present a renal failure case that was diagnosed late because of neglect of the ophthalmoscopy. Case Report: A 26-year-old male was admitted to an emergency physician with complaint of a foreign body, visual acuity loss in the left eye, and fatigue 2 weeks earlier. However, the first doctor of the patient had not performed an ophthalmoscopy. The patient’s visual loss had worsened in the following 2 weeks. On our examination, the best corrected visual acuity was 20/30 (Snellen chart) in the right eye and 20/400 in the left. On ophthalmoscopic examination, both eyes showed signs of hypertensive retinopathy. The patient was referred to a nephrology clinic because of high arterial blood pressure values and higher-than-normal urea and creatinine levels. Bilateral renal failure due to chronic glomerulonephritis was detected by nephrologists. Conclusion: Emergency physicians should accept ophthalmoscopy as a part of the physical examination and use it to prevent skipping vitally important diseases, such as hypertension and renal failure.

High-resolution in vivo imaging of regimes of laser damage to the primate retina.

Purpose. To investigate fundamental mechanisms of regimes of laser induced damage to the retina and the morphological changes associated with the damage response. Methods. Varying grades of photothermal, photochemical, and photomechanical retinal laser damage were produced in eyes of eight cynomolgus monkeys. An adaptive optics confocal scanning laser ophthalmoscope and spectral domain optical coherence tomographer were combined to simultaneously collect complementary in vivo images of retinal laser damage during and following exposure. Baseline color fundus photography was performed to complement high-resolution imaging. Monkeys were perfused with 10% buffered formalin and eyes were enucleated for histological analysis. Results. Laser energies for visible retinal damage in this study were consistent with previously reported damage thresholds. Lesions were identified in OCT images that were not visible in direct ophthalmoscopic examination or fundus photos. Unique diagnostic characteristics, specific to each damage regime, were identified and associated with shape and localization of lesions to specific retinal layers. Previously undocumented retinal healing response to blue continuous wave laser exposure was recorded through a novel experimental methodology. Conclusion. This study revealed increased sensitivity of lesion detection and improved specificity to the laser of origin utilizing high-resolution imaging when compared to traditional ophthalmic imaging techniques in the retina.

Association between glucose variability as assessed by continuous glucose monitoring (CGM) and diabetic retinopathy in type 1 and type 2 diabetes

There is a growing debate in the literature on whether glucose variability contributes, as well as high HbA1c levels and longstanding diabetes, to the onset and progression of diabetic retinopathy (DR) in patients with diabetes types 1 (DM1) and 2 (DM2). Few data, obtained only by self-monitoring of blood glucose, support this hypothesis. We used continuous glucose monitoring (CGM) to investigate the association between DR and glucose variability parameters (SD, CONGA 2, MAGE), acute hyperglycemia (HBGI) and chronic exposure to glucose (AG and AUC tot). We studied 68 patients from 19 to 69 years old, 35 with DM1 and 33 with DM2. The prevalence of retinopathy was 43 % in DM 1 patients and 39 % in DM 2 patients. The values of all indicators were obtained by CGM for 72 h. DR was diagnosed on direct or indirect ophthalmoscopic examination, after inducing mydriasis with tropicamide. HbA1c was measured at the baseline and 6 weeks after CGM to test the stability of the patients' glycemic control. Univariate analysis showed a close association between DR and duration of diabetes (OR 1.11; 1.04-1.19), intensive insulin therapy (OR 5.6, CI 1.14-27.30), SD (OR 1.03; CI 1.01-1.06) and CONGA 2 (OR 1.02; CI 1.00-1.04)-both indicators of variability and HBGI (OR 1.1, CI 1.01-1.18)-a parameter reflecting acute hyperglycemia. There was no significant correlation with HbA1c (p = 0.070). Multivariate regression analysis showed that disease duration is the parameter most significantly correlating with DR (OR 1.05; 1.01-1.15). These results reinforce the evidence that longstanding disease is the factor most closely associated with DR. Our data also suggest, however, that glucose variability-regardless of HbA1c-may also have a role as a risk factor for DR, particularly in the case of acute fluctuations (as represented by CONGA 2 and SD) and acute hyperglycemia (as represented by HBGI).

Canine ocular thelaziosis caused by Thelazia callipaeda in Portugal

Ocular thelaziosis caused by Thelazia callipaeda is a vector-borne disease affecting dogs and humans. We report a case of thelaziosis in a 10-year-old German Shepherd dog from Vila Real city (Portugal). Ophthalmological examination revealed bulbar and nictitating membrane conjunctival hyperemia with serous discharge noted at the left medial canthus and blepharitis. Schirmer tear test value and intraocular pressure were within the reference ranges in both eyes, and biomicroscopy showed a transparent cornea without lesions or edema and no inflammatory reaction in the anterior chamber. No funduscopic alterations were detected by direct and indirect ophthalmoscopic examination. When testing the nasolacrimal patency, two white worms were observed on the caruncle conjunctival surface with undulating movements that increased with light intensity. In total, eight worms were collected and morphologically identified as T. callipaeda (seven mature females and one male). PCR amplification of a 689 sequence of partial cytochrome c oxidase subunit 1 target gene confirmed the nematodes were T. callipaeda, haplotype 1. The dog was treated with a single subcutaneous injection of ivermectin combined with additional topical application of ophthalmic fusidic acid drops and oral milbemycin oxime. One week after treatment, no worms were detected and the ocular clinical signs resolved. The most recent reports of canine thelaziosis in the Iberian Peninsula should alert local health authorities to the zoonotic potential of infestation with T. callipaeda, which should be included in the differential diagnosis of conjunctivitis in dogs and humans.

Emergent vitrectomy combined with lensectomy, silicone oil temponade for endogenous endophthalmitis

Objective To observe the effect of emergent vitrectomy combined with lensectomy,silicone oil temponade for endogenous endophthalmitis. Methods The clinical data of 28 patients (30 eyes)with endogenous endophthalmitis were analyzed retrospectively. All patients had no history of ocular trauma and intraocular surgery history. There were 21 patients without systemic symptoms, three patients with fever, two patients with eye pain and headache, and two patients with abdominal pain when presentation.All patients diagnosed by best corrected visual acuity, intraocular pressure, slit-lamp microscopy, direct and indirect ophthalmoscope examination and intraocular B-ultrasound examination. Emergent surgery (vitrectomy, lensectomy, silicone oil temponade) was performed in all 30 patients, those with fever or abdominal pain was also treated by relevant clinical departments. Vitreous purulence was taken in all patients before vitrectomy for bacterial, fungal culture and drug sensitivity test. The follow-up was 18 to 30 months. The preoperative and postoperative visual acuity, intraocular pressure and eye retention situation were observed. Results Endophthalmitis was controlled in 28/30 eyes (93.3%) after surgery, recurrent vitreous empyema occurred in 2/30 eyes (6.7%). Evisceration was performed on those two eyes as uncontrolled intraocular pressure. The visual acuity improved significantly at one month and 18 months after surgery (x2 = 19.87, 32. 44; P ＜ 0.01). Postoperative intraocular pressure was normal in 24 eyes (80.0%), transient elevated and controlled in six eyes (x2 = 7.43; P＜0. 05). 12/28 (42.9%) vitreous samples were positive for pathogen culture, including 7/12 (58. 3%) positive for bacteria, 5/12 (41.7%)positive for fungi. There are 18/28 patients (64.3%) also had hepatobiliary system infections. Conclusion Emergent vitrectomy combined with lensectomy, silicone oil temponade is effective for endogenous endophthalmitis. Key words: Endophthalmitis/surgery; Endophthalmitis/etiology; Vitrectomy; Silicone oils/therapeutic use

Evaluating choroidal neovascularization in exudative age-related macular degeneration by fluorescein angiography combined with frequency-domain optical coherence tomography

Objective To evaluate the diagnostic value of Heidelberg retinal angiography(HRA) combined with optical coherence tomography (OCT) to detect neovascularization (CNV) in exudative age-related macular degeneration (AMD) patients. Methods This is a cross-sectional study of a series of clinical cases. AMD diagnosis was established by international standard vision chart, Slit lamp microscope, direct or indirect ophthalmoscope examination. A total of 50 eyes (42 cases) of exudative AMD received HRA and frequency domain OCT scan. All 50 eyes received fundus fluorescein angiography (FFA) and frequency-domain OCT simultaneously, and among them 15 eyes also received indocyanine green angiography (ICGA) at the same time. FFA and ICGA were carried out by conventional methods, CNV was localized by real-time Localization technology of frequency domain OCT. In the radial and grid-like section from the areas with strong fluorescence, image acquisition settings are 7 μm fault for each frame, 30° intervals for radialsection, 10 vertical and 10 horizontal scan lines for grid-like section. CNV can be divided into 4 types (typical CNV, partial typical CNV, occult CNV, CNV scarring) according to their boundaries demonstrated in FFA. Based on the features of the OCT images, there were 3 types of integrated image (sub-RPE type, sub-retinal type and mixed type). Results CNV was detected in all 50 eyes. There were 4 eyes (8%) of typical CNV, 11 eyes (22%) of partial typical CNV, 32 eyes (64 %, including 27 eyes of RPE detachment and 5 eyes of passive late leakage) of occult CNV and 3 eyes (6%) of CNV scarring. There were 4 eyes (8%) of sub-RPE type (CNV under the RPE light band) , 16 eyes (32%) of sub-retinal type(interrupted light band of RPE and choroid capillary layer) and 30 eyes (60%) of mixed type of integrated image. Conclusion The image integration technology of the HRA and frequency domain OCT system provide a valuable tool to classify and measure CNV, which will benefit the clinical treatment of AMD patients. Key words: Macular Degeneration/ diagnosis; Choroidal Neovascularization/ diagnosisTomography, optical coherence; Fluorescein angiography; Diagnostic imaging

Hypertensive Retinopathy

At the end of the 19th century, hypertensive retinopathy was first described by Markus Gunn in hypertensive patients with renal disease. Nearly 50 years later, Keith and colleagues documented the prognostic value of funduscopic abnormalities in hypertensive patients and categorized hypertensive nephropathy into 4 groups of increasing severity that since then have been taught in medical university schools. In 1966, the ophthalmoscopic changes were confirmed to be predictive of death in patients with essential hypertension.1,2 The usefulness of the classification system and its relevance to current clinical practice, however, have been questioned repeatedly.3 The direct ophthalmoscopic examination has been shown to be unreliable, with high rates of interobserver (20% to 40%) and intraobserver (10% to 33%) variability.4 The criticism refers to stages 1 and 2 of the Keith-Wagner-Barker classification. Only hemorrhages and exudates can be reliably assessed in retinal photographs. A systematic review identified 6 studies that provided data on interobserver agreement for hypertensive retinopathy using retinal photographs.3 In these studies interobserver agreement was modest and fair for focal arterial narrowing and arteriovenous nicking, good for the arteriovenous ratio, and excellent only for hemorrhages and exudates. Most current guidelines for the management of arterial hypertension, therefore, do not recommend funduscopy as a routine diagnostic test, but advanced retinopathy (hemorrhages, exudates, or papilledema) is accepted as a factor influencing prognosis in hypertensive patients.5 Hypertensive retinopathy is generally considered to be a marker and/or …

ULTRASONOGRAPHIC AND COMPUTED TOMOGRAPHIC EXAMINATIONS OF THE AVIAN EYE: PHYSIOLOGIC APPEARANCE, PATHOLOGIC FINDINGS, AND COMPARATIVE BIOMETRIC MEASUREMENT

Ultrasonography (US) and computed tomography (CT) were performed after routine ophthalmologic and ophthalmoscopic examinations in 190 eyes of six various diurnal (common buzzard [Buteo buteo L., 1758], n = 20; common kestrel [Tinnunculus tinnunculus L., 1758], n = 20) and nocturnal raptor species (barn owl [Tyto alba L., 1758], n = 22; tawny owl [Strix aluco L., 1758], n = 8; long-eared owl [Asio otus L., 1758], n = 5; horned owl [Bubo bubo L., 1758], n = 1); and domestic pigeons (Columba livia, Gmel., 1789; n = 19), with a total of 95 individuals. Pathologic findings such as lens subluxation and luxation, intravitreal hemorrhage, detached retina, post-traumatic partial sequestration, or malformation of the pecten could be demonstrated with diagnostic imaging tools, while opacities of cornea or lens constrained direct ophthalmoscopic examination. The results proved US to be a quick noninvasive imaging technique for detailed ocular diagnoses. CT provided detailed information of the bony skull and bony scleral rings as well as adequate visualization of shape, size, and margination of the eye and lens. Nevertheless, CT was unable to differentiate subtle structures within the vitreous like the pecten oculi or hemorrhage. Biometric measurements were carried out to objectify imaging results. Results showed good correlation of depth and width of the anterior eye chamber, lens and vitreous, length of the bulbus, and the pecten but no correlation of cornea and posterior wall thickness was found.

Prevalence, Risk Factors and Associated Cardiovascular Complications of Peripheral Arterial Disease in Type 2 Diabetic Patients in Eastern Taiwan

Objective: The purpose of this study was to evaluate the risk factors, including albuminuria, for peripheral arterial disease (PAD), and associated complications in patients with type 2 diabetes. Materials and Methods: All patients with type 2 diabetes 40 years old and over, were recruited consecutively from diabetic clinics at a medical center in eastern Taiwan. Information regarding each participant's sociodemographic characteristics and medical history was gathered from the patients and their medical records. A clinical examination which included anthropometric measurements and a direct ophthalmoscope check-up was performed. After an overnight fast, serum lipids, uric acid, fasting plasma sugar, A1C and urinary albumin concentration were measured. The anklebrachial index (ABI) was calculated by Doppler examination in both legs. PAD was diagnosed if the ABI in one of the legs was less than 0.9. Results: A total of 309 patients were recruited. PAD was present in 38 of the 309 diabetic subjects studied (12.3%; 12.7% of the men and 11.9% of the women). Of all subjects with PAD, 92.1% had a history of hypertension, 15.8% had stroke, 13.2% had coronary heart disease, and 47.4% had albuminuria. For those who completed the direct ophthalmoscope examination, 41.9% of patients with PAD had diabetic retinopathy. In univariate analysis, the significant associative risk factors for PAD were age, tobacco smoking, history of hypertension/stroke, duration of diabetes, insulin therapy, usage of angiotension-converting enzyme inhibitors/angiotension-receptor blockers (ACEI/ARB) and albuminuria. Multiple logistic regression analysis identified age as the most significant risk factor for PAD. The higher the age of the patient, the greater the likelihood of PAD, with a 1.11-fold increase in risk incurred for every 1-year increment. Cigarette smoking was also a significant factor with smokers incurring a 4.77-fold higher risk than non-smokers. Individuals suffering from macroalbuminuria were more likely to have PAD compared to those without albuminuria. Other significant risk factors included insulin usage. Conclusions: The occurrence of PAD in type 2 diabetic patients is associated with the age of the patient, smoking, insulin usage and albuminuria. Incorporation of albuminuria assessment and a smokingcessation program are recommended in clinical practice.

Descriptive epidemiology of infantile cataracts in metropolitan Atlanta, GA, 1968-1998.

Infantile cataract is an important cause of childhood visual impairment. Surgery before 6 weeks of age is recommended for optimal visual outcome. Description of the epidemiologic characteristics of cataracts is important for an improved understanding of the condition. To identify at-risk populations and facilitate successful treatment of patients with infantile cataracts. Infants with cataracts diagnosed in the first year of life were identified using the Metropolitan Atlanta Congenital Defects Program, a birth defects surveillance program with active methods of case ascertainment, for the years 1968-1998. Several factors were analyzed, including year of birth, sex, race, maternal age, plurality (single vs multiple gestation), gestational age, birth weight, laterality, seasonality, and age at diagnosis. A total of 199 infants with cataracts were identified, for a rate of 2.03 per 10 000 births. In 117 infants (59%), cataracts occurred as an isolated defect; in 43 infants (22%), cataracts occurred as part of a syndrome; and in 39 infants (20%), additional, unrelated, major birth defects were also present. Rates were higher for low-birth-weight infants (those weighing <1500 g; risk ratio [RR], 6.01; 95% confidence interval [CI], 3.83-9.43) and preterm infants (RR, 1.70; 95% CI, 1.21-2.40). Of the cases that occurred as an isolated defect, 38% were diagnosed after 6 weeks. This population-based study provides 31 years of data from a diverse US population and allows identification of risk factors for infantile cataracts. The finding that a number of infants with cataracts continue to have their conditions diagnosed after 6 weeks of age emphasizes the need for direct ophthalmoscopic examination of the red reflex in the newborn period to facilitate early detection and improve outcomes.