Fundus Examination In Patients Research Articles

Advanced ring melanoma of the choroid and ciliary body with extrascleral extension

Introduction: Ring melanoma is a rare form of uveal melanomas that is characterized by circumferential growth pattern. The diagnosis of ring melanomas may be delayed because of their initial hidden location and non-specific symptoms. In addition, ring melanomas may be misdiagnosed and treated as refractory glaucoma or retinal detachment because of their atypical presentation. Such tumours are usually large and extensive at the time of diagnosis, thus associated with worse prognosis.Patient presentation: This case report presents a case of a 70-year-old female presenting with blurring of vision of 1 month duration. Examination revealed a pigmented subconjunctival mass just inferior to the lower limbus that the patient reported to appear 1 year before. Dilated fundus and ultrasonographic examination were suggestive of ciliochoroidal melanoma with associated retinal detachment.Management and outcome: The patient underwent enucleation, and histopathology confirmed the diagnosis of ciliochoroidal melanoma of mixed cell type.Conclusion and Contribution: This article aims to report a rare and advanced case of a deadly tumour emphasizing on the importance of routine fundus examination in patients over the age of 40 years.

Preoperative fundus examination in patients with diabetes scheduled for surgery.

This study aimed to show the proportion of fundus examinations in patients with diabetes who were scheduled for surgery. We retrospectively analyzed 455 consecutive patients with diabetes admitted for surgery. Just 49% had fundus examinations before hospitalization. The decision tree analysis showed that the type of family doctor was the first split associated with fundus examination; patients treated by a diabetes specialist were more likely to receive the examination. In this subgroup, glycated hemoglobin levels ≥8.0% and age ≥71 years were associated with a lower proportion of receiving the examination. In patients whose family doctor was not a diabetes specialist, glycated hemoglobin levels <7.2% and body mass index <27.4 kg/m2 without severe comorbidities were associated with a higher proportion of receiving the examination. In conclusion, half of patients scheduled for surgery did not receive fundus examinations. A high‐risk population for not receiving the examination varied with the consultation setting.

Idiopathic Epiretinal Membrane in Young: A Rare Entity

Epiretinal membrane is usually seen commonly in older age group individuals secondary to intra ocular surgery, trauma, retinal vascular diseases and diabetes mellitus. Here in this case report we describe an unusual case of idiopathic Epiretinal membrane in young individual and importance of fundus examination in patients of microtropia to rule out any macular pathology.

Factors Influencing Fundus Examination in Patients with Diabetes

Factors Influencing Fundus Examination in Patients with Diabetes

Influence of comorbidities on the implementation of the fundus examination in patients with newly diagnosed type 2 diabetes.

To investigate the influence of comorbidities on undergoing a diabetic eye examination in patients with newly diagnosed type 2 diabetes mellitus (T2DM). Retrospective cohort study METHODS: This was a retrospective cohort study using data from health insurance claims made between January 2005 and March 2013 in Japan. The primary outcome was implementation of the fundus examination that includes fundus photography, ophthalmoscopy and optical coherence tomography by a doctor within one year of initial drug therapy for Type2 Diabetes Mellitus (T2DM). We used multivariable logistic regression models with adjustment for demographic parameters to investigate the influence of comorbidities (hypertension and/or hyperlipidemia) on patients with T2DM receiving fundus examinations. We conducted an additional analysis to investigate whether the site of treatment might influence the performance of fundus examinations in patients with T2DM. A total of 6,492 patients were eligible for this analysis, of which 1,044 (16.1%) had comorbidities and 2,212 (34.1%) received the fundus examination. In the multivariable analysis, there was a significant association between comorbidities and a lower proportion of examination implementation (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.48-0.68; P<0.001). The implementation proportion for patients treated for comorbidities and T2DM in the same facility was also low (OR, 0.52; 95% CI, 0.43-0.63; P<0.001). These results suggest that the proportion of taking fundus examination is low among patients with comorbidities, especially in patients treated at the same facility for comorbidities and T2DM. This may help to increase the proportion of T2DM patients receiving fundus examinations.

This issue of ACTA

The cover illustration shows a prolene thread inserted into Schlemm′s canal as reported by Grieshaber et al. in this issue of Acta. Klemp et al. in Copenhagen describe exudative retinal detachment, cataract formation and melanocytic tumours as the characteristic ocular findings in uveal melanocytic proliferation. Campos et al. in Portugal consider the role of the choroid in diabetic macular oedema and how OCT studies of the choroid advance this field of research. Jørstad et al. in Oslo found positive results with aflibercept in AMD eyes which were resistant to ranibizumab and bevacizumab injections. Many eyes required more than bimonthly aflibercept injections. Vujosevic et al. in Italy emphasize inflammatory biomarkers in diabetic macular oedema such as hyperreflective retinal spots, subfoveal neuroretinal detachment and increased foveal autofluorescence. These biomarkers improved with dexamethasone treatment. Subhi and Lykke Sørensen in Denmark correlated systemic leucocyte activity with onset and size of neovascular lesions in AMD. They suggest that inflammation plays a role in the pathophysiology. Sauer et al. in Germany used fluorescence lifetime imaging to map pigment distribution and evaluate its role in macular hole formation. Hamoudi et al. in Denmark found no difference in corneal endothelial density between combined and separated phacoemulsification and vitrectomy for epiretinal membrane. Makdoumi et al. in Sweden and the USA used blue light and riboflavin to kill resistant staphylococci and suggest this approach may work in corneal infections. Margulis et al. in the Netherlands, Spain and Denmark examined use of nonsteroidal anti-inflammatory eye drops. These were used with cataract surgery and for allergic conjunctivitis. Pärssinen and Kauppinen in Finland found astigmatism to increase with myopia. Corneal astigmatism predominates. Grieshaber et al. in South Africa and Switzerland recommend the Stegmann Schlemm′s canal expander to lower intraocular pressure in patients with moderate to advanced open angle glaucoma. Quérat and Chen in Sweden recommend ICARE® self-tonometry. Day-to-day variations are seen in most patients. Mrowicka et al. in Poland propose that insufficient antioxidant capacity may play a role in age related macular degeneration. This hypothesis is based on study of enzymes and genes related to antioxidant activity. Pilat et al. in UK used hand-held OCT to image anterior segment dysgenesis in children. The following articles are published electronically only and are accessible on www.actaophtalmologica.com, where you can also access the printed articles. Nitta et al. in Japan report an increase in retinal oximetry readings in retinal venules following glaucoma surgery and lowering of intraocular pressure. Tanito et al. in Japan recommend microhook trabeculotomy in glaucoma patients. It lowers IOP and reduces need for glaucoma medications. Mansouri and Shaarawy in the USA and Switzerland fond similar outcomes with scanning laser trabeculoplasty and selective laser trabeculoplasty. Lanza et al. in Italy used light backscattering with in vivo corneal confocal microscopy to evaluate changes in corneal layers in patients with Sjögren syndrome and dry eyes. Shimada et al. in Japan found reduced anterior chamber bacterial contamination with either 0.025% povidone-iodine or 0.0025% polyvinyl alcohol iodine irrigation of ocular surface. Peiretti et al. in Italy, the Netherlands, Saudi Arabia and the USA examined retinal folds following retinal detachment repair. This was not influenced by use of heavy liquids in surgery or postoperative positioning. Chan et al. in Hong Kong, Singapore and UK seek ways to measure and control emulsification of intraocular silicone oil. Kang et al. in Korea measured greater choroidal thickness in eyes with vitreoretinal traction. This was reversed following epiretinal membrane surgery and release of the traction. Jonas et al. in India and Germany found myopic retinopathy to be rare in rural India. It was associated with open angle glaucoma. Carreño et al. in Spain, USA and UK measured several inflammatory cytokines in tear fluid in uveitis patients. Bray et al. in UK suggest that portable electronic vision enhancement systems are cost-effective to improve near vision. However, it may not provide cost-effective improvement in quality of life. Babeau et al. in France comment on an article on using adaptive optics for screening chloroquine retinopathy. Parrovano et al. in Italy used OCT angiography to monitor reduction in neovascular lesions. Van Asten et al. in the Netherlands found positive outcomes with aflibercept in AMD patients unresponsive to bevacizumab. Lytvynchuk in Ukraine surgically removed a retinal branch artery embolus. Dimopoulos et al. in Germany used autologous thrombocyte serum for macular hole surgery. Grewal et al. in USA used intraoperative OCT to guide placement of Argus II retinal prosthesis. Huynh et al. in the USA found no benefit from dilated fundus examination in patients with spontaneous subconjunctival haemorrhage. Qu-Knafo et al. in France suggest that eyes with DME and serous retinal detachment may show greater improvement with ranibizumab than eyes without serous detachment. I hope you are enjoying a pleasant summer and Acta fits into your summer reading schedule.

Surgical approach to retinal detachment with primary congenital glaucoma

We present the clinical features and treatment approach of a case with congenital glaucoma, trabeculectomy and rhegmatogenous RD, and other ophthalmic complications. A 41-year-old male patient with trabeculectomy due to congenital glaucoma in both eyes was admitted to our clinic due to decreased visual acuity for the past three days. Visual acuity was at the level of hand movement in the right eye, and his left eye was phthisic. The bleb on the upper nasal side of the right eye was well formed but cystic and avascular. Fundus examination revealed a patchy RD in the upper half including the macula. Phacoemulsification and intraocular lens (IOL) implantation combined with pars plana vitrectomy-liquid-perfluorocarbon-air-silicone oil change and endolaser application was performed under general anesthesia. Silicone oil tamponade was removed 2 months later, and IOL was implanted with optic capture in the same session. The final visual acuity was 1/10. There was non-functional, avascular and flat bleb due to bleb sclerosis. From the beginning to the last follow-ups, progressive shallowing of the bleb was observed in anterior OCT sections.In a patient with monocular buphthalmos, cataract surgery combined with RD surgery involves multiple risks. In this case, we achieved good visual and anatomic outcome of the retina, but we had bleb functional loss because of bleb sclerosis. We recommend periodic fundus examinations in patients with congenital glaucoma. Rhegmatogenous RD in patients with congenital glaucoma can be reattached, but full recovery may not be achieved.

Clinical characteristics of high grade foveal hypoplasia

To report clinical characteristics of high grade foveal hypoplasia. Patients with foveal hypoplasia of grade 3 or 4 on spectral domain optical coherence tomography according to a previously published scheme were enrolled. All patients underwent a full ophthalmologic assessment including visual acuity testing, slit lamp biomicroscopy, fundus examination, and evaluation of ocular alignment. The underlying causes of foveal hypoplasia were identified as albinism in five patients and aniridia in six patients. The mean logMAR visual acuity was 0.57±0.24 (range 0.22-1.00) in the right eyes and 0.58±0.21 (range 0.30-1.00) in the left eyes. On fundus examination in patients with albinism, two patients showed marked transparency, one patient showed moderate transparency, and two patients showed minimal transparency. Among six patients with aniridia, five patients showed normal macular pigmentation without macular reflex and one patient showed decreased macular pigmentation with no macular reflex. Patients with high grade macular hypoplasia tended to have poor visual acuities; however, the range of visual acuity was quite variable. Other factors associated with underlying disease could be the reason of this variability. Therefore, careful consideration should be given when assessing visual prognosis in foveal hypoplasia using optical coherence tomography.

Vitrectomy for proliferative retinopathy in patient with advanced duchenne muscular dystrophy.

Retinal vascular abnormalities are rare in patients with Duchenne muscular dystrophy. We present a patient with Duchenne muscular dystrophy who developed severe proliferative retinopathy for which vitrectomy was successfully performed in one eye. Case presentation. A 23-year-old Japanese man with Duchenne muscular dystrophy complicated by cardiac and respiratory insufficiency had reduced vision in both eyes. His best-corrected visual acuity was 0.01 in the right eye and hand movements in the left eye. Ophthalmoscopy showed vitreous hemorrhage and proliferative tissue attached to the optic disk bilaterally. Ultrasound echography showed tractional retinal detachment in the left eye. Because general anesthesia was considered to be a high risk, vitrectomy, lensectomy, neovascular membrane removal, endolaser photocoagulation, and silicone oil injection were performed under local anesthesia on the right eye. After removal of the silicone oil and intraocular lens implantation, the best-corrected visual acuity was 0.8 in the right eye. Vitrectomy was performed on the left eye, but the retina could not be attached. The etiology of the proliferative retinopathy in our case is not known. Because early treatment has the potential to improve and maintain vision, we recommend periodic fundus examinations in patients with Duchenne muscular dystrophy.

A Comparative Cost Analysis of Digital Fundus Imaging and Direct Fundus Examination for Assessment of Diabetic Retinopathy

The objective of this study was to compare the cost between two procedures for fundus examination in patients with diabetes. In our setting, two alternatives for fundus examination are available for patients with diabetes. In the first alternative, a digital image is taken with a nonmydriatic fundus camera when the patient is at the endocrinology consultation, and the image is then examined by an ophthalmologist. In the second alternative, a direct fundus examination is made by an ophthalmologist. We calculated the costs of both procedures from both Public Healthcare System (PHS) and patient perspectives using the official scales to compute personnel, consumables, capital cost of equipment, travel expenses, and time loss of the patient caused by attending the consultation. The first alternative (digital fundus image) required 2.69, 0.03, and 1.62 Euros per patient for personnel, consumables, and capital cost of the equipment, respectively. A direct fundus examination was needed in 31% of patients that had an additional cost of 0.97 Euros per patient for the PHS plus 14.97 Euros per patient because of travel cost and loss of income. The second alternative (direct fundus examination) required 2.69, 0.11, and 0.33 Euros per patient for personnel, consumables, and capital cost, respectively. All patients in this second alternative had to attend a consultation that implied travel and loss of income costs. Attending a consultation represented a cost of 48.29 Euros per patient. From the PHS perspective, direct fundus examination is less costly than using digital fundus images. The higher cost of the digital fundus option is a consequence of the higher capital costs required by the equipment needed to obtain the digital image. However, from a global perspective, the digital image alternative is more convenient because the travel cost and loss of income of the patient are lower.

Rhegmatogenous retinal detachment associated with primary congenital glaucoma

The development of rhegmatogenous retinal detachments (RRDs) in eyes with a history of congenital glaucoma (CG) is very rare. We present the characteristics and surgical outcomes of three cases with a RRD who had CG and had undergone surgery many years earlier. Three men, ages 14, 43, and 48 years of age, each with a history of surgery for primary CG, presented with a RRD. All of the eyes were highly myopic. The retinal tears were located at the equator in all cases. The degree of RRD were superior half, total, and total (proliferative vitreoretinopathy). Vitrectomy was performed and the retinas were reattached in all cases. However, the visual acuity in all cases remained poor. Our findings indicate that a posterior vitreous detachment due to advanced vitreous liquefaction in the highly myopic eyes may have been the cause of the RRD. We recommend periodic fundus examinations in patients with CG, because while the RRD in patients with CG can be reattached the functional recovery may not be good.

Autosomal-dominant familial hematuria with retinal arteriolar tortuosity and contractures: A novel syndrome

Autosomal-dominant forms of hematuria have been mostly related to mutations in the COL4A3/COL4A4 genes. Patients with thin basement membrane (BM) disease do not have extrarenal manifestations, while those with Alport syndrome often present with hearing loss, anterior lenticonus, and dot-and-fleck retinopathy. We performed a phenotypic study and a candidate gene approach in a four-generation family presenting with autosomal-dominant hematuria associated with extrarenal manifestations. Renal biopsy was analyzed for determination of BM thickness and expression of chains of type IV collagen. Linkage to 18 candidate genes/loci was investigated using polymorphic microsatellite markers. In all affected patients, hematuria without proteinuria was associated with muscular contractures and retinal arterial tortuosities responsible for retinal hemorrhages. Cardiac arrhythmia, Raynaud phenomena, and brain MRI abnormalities were also observed. Despite the presence of red cells in tubule sections, no glomerular abnormalities were found by electron microscopy. Expression of type IV collagen chains and glomerular BM thickness was normal. We searched for a molecular defect affecting either BM or angiogenesis. Linkage analyses of genes encoding BM components (COL4A3/COL4A4, COL6A1, COL6A2, COL6A3, FBLN1), and angiogenic factors or their receptors (VHL, ANPT1, ANPT2, TIE, TEK, NOTCH2, NOTCH3, NOTCH4, DLL4, JAG1, JAG2) and of the facio-sapulo-humeral dystrophy and 3q21 loci failed to show segregation of the disease with those gene loci. We have identified a new inherited hematuria syndrome associated with retinal vessel tortuosities and contractures. We recommend performing a fundus examination in patients with familial hematuria and episodes of visual impairment, as well as a urinary analysis in patients with retinal arterial tortuosity or congenital muscular contractures.