Stereo Fundus Photography Research Articles

Visual fields correlate better than visual acuity to severity of diabetic retinopathy

We compared the outcomes of perimetric and visual acuity tests in patients with diabetic retinopathy. We examined 59 diabetic patients with different degrees of retinopathy using stereo fundus photography in accordance with the Early Treatment of Diabetic Retinopathy Study (ETDRS) and fluorescein angiography. Conventional white-on-white perimetry (WWP) and short wavelength automated perimetry (SWAP) were performed and analysed with reference to normal values. Visual acuity was measured with ETDRS charts. Regression analysis revealed that visual acuity was significantly associated with increasing severity of retinopathy according to the ETDRS scale when visual acuity was estimated by counting logarithm of minimum angle of resolution (LogMar) scores, but not when visual acuity was measured by the conventional reading of the smallest line that could be seen. Visual acuity decreased by 0.02 LogMar per ETDRS step (p=0.03). The degree of visual field loss was significantly associated with increasing severity of retinopathy according to the ETDRS scale, perimetric sensitivity decreasing by 0.44 dB per ETDRS step (p=0.0001) using WWP, and by 0.40 dB per ETDRS step (p=0.04) with SWAP. The size of the area of the foveal avascular zone and adjacent perifoveal intercapillary areas (PIAs) also affected the central visual field as obtained both by WWP (-2.6 dB/mm2, p=0.03), and by SWAP (-7.9 dB/mm2, p=0.002), but did not affect visual acuity. The regression model fit for peripheral retinopathy according to the ETDRS scale was better using WWP than SWAP or visual acuity, while SWAP testing was superior to both WWP and visual acuity when measuring effects caused by enlarged foveal avascular zones and PIAs. Perimetry can provide more useful information than visual acuity on functional loss in diabetic retinopathy, particularly when the perifoveal capillary network is damaged.

Feasibility of Screening for High-Risk Age-Related Macular Degeneration With an Internet-Based Automated Fundus Camera

The objective of this pilot study was to determine whether a new screening system, the DigiScope (EyeTel Imaging, Inc., Columbia, MD), can detect the presence of age-related macular degeneration (AMD) at a level requiring referral to an ophthalmologist for further evaluation and possible treatment. The DigiScope is an Internet-based semi-automated digital imaging system designed to be in primary care physicians' offices. Forty-two eyes of 21 patients with different categories of AMD were imaged with both the DigiScope and a standard color fundus camera. The imaging capability of the two modalities was compared for identification of lesions associated with AMD and classification into stages. There was good agreement for low-risk lesions and excellent agreement for high-risk lesions. Thirty-five of 36 eyes with intermediate or advanced disease were correctly identified with DigiScope images. Choroidal neovascularization was identified in all cases with the DigiScope due to the presence of subretinal hemorrhage or subretinal fibrosis. The DigiScope was found less capable of detecting subretinal fluid than standard stereo fundus photographs. This pilot study suggests that the DigiScope may be a useful screening tool for AMD.

Sankara Nethralaya—Diabetic Retinopathy Epidemiology and Molecular Genetic Study (SN—DREAMS 1): Study Design and Research Methodology

Purpose: To describe the methodology of the Sankara Nethralaya—Diabetic Retinopathy Epidemiology and Molecular Genetic Study (SN—DREAMS 1), an ongoing population-based study to estimate the prevalence of diabetes and diabetic retinopathy in urban Chennai, Tamil Nadu, South India, and also to elucidate the clinical, anthropometric, biochemical and genetic risk factors associated with diabetic retinopathy. Methods: In this ongoing study, we anticipate recruiting a total of 5830 participants. Eligible patients, over the age of 40 years, are enumerated using the multistage random sampling method. Demographic data, socioeconomic status, physical activity, risk of sleep apnea, dietary habits, and anthropometric measurements are collected. A detailed medical and ocular history and a comprehensive eye examination, including stereo fundus photographs, are taken at the base hospital. Biochemical investigations (total serum cholesterol, high-density lipoproteins, serum triglycerides, hemoglobin, glycosylated hemoglobin HbA1c) and genetic studies of eligible subjects are conducted. A computerized database is created for the records. Conclusion: The study is expected to result in an estimate of the prevalence of diabetes and diabetic retinopathy and a better understanding of biochemical and genetic risk factors associated with diabetic retinopathy in an urban South Indian population. Worldwide, the prevalence of diabetes mellitus, in particular type II diabetes, is rising at an alarming rate. The World Health Organization (WHO) and International Diabetes Federation (IDF) have predicted that the number of cases of adult-onset diabetes would more than double by 2030 from the present level of 171 million to 366 million—an increase of 214%. In developed countries, this increase in diabetic population would be around 42% and in developing countries, particularly in India, it is even higher; i.e. 150%. In India, the prevalence of diabetes mellitus in the urban population is around 12.1%, as reported by the national urban diabetes study conducted in six major cities. Studies have shown the prevalence of diabetes to be higher among the high-income groups (25.5%) as compared to low-income groups (12.6%). The assessment of socioeconomic status was based on income, education, occupation or caste—which are not representative of the actual socioeconomic status. In the present study, however, the sample was stratified on socioeconomic scoring. This scoring was calculated on the basis of several parameters such as the residence being rented or owned, the number of rooms in the house, the highest educational status, the highest salary, the highest occupation, material possessions (cycle, TV, audio, car, etc.) and house/land value. To the best of our knowledge, this kind of comprehensive socioeconomic scoring has not been done before for prevalence studies on diabetic retinopathy in the general population.

5-year incidence of age-related maculopathy in the Reykjavik Eye Study

To examine the age- and gender-specific 5-year incidence of age-related maculopathy (ARM) and age-related macular degeneration (AMD) in citizens of Reykjavik. Population-based, prospective cohort study. The cohort was a population-based random sample of citizens 50 years and older. Of 1379 eligible subjects, 1045 had a baseline examination in 1996; 846 of the 958 survivors (88.2%) had a 5-year follow-up examination in 2001. The incidence of various characteristics of drusen and pigmentary changes that are typical of ARM were determined using the international classification and grading system for ARM and AMD. Early ARM and AMD were assessed by masked grading of stereo fundus photographs. Hypopigmentation developed at 5 years in 10.7% of people 50 to 59 years of age (95% confidence interval [CI], 6.9-14.4) and in 25.7% those 70 to 79 years of age (95% CI, 18.4-33.0) at baseline. Age-related macular degeneration developed in no one who was 50 to 59 years of age at baseline. Geographic atrophy (GA) developed in 4.6% (95% CI, 1.2-7.9) and exudative AMD in none of those who were 70 years and older at baseline. Geographic atrophy is the predominant type of AMD in Iceland, and the ratio of GA to neovascular AMD is higher than in racially similar populations.

Local multifocal oscillatory potential abnormalities in diabetes and early diabetic retinopathy.

To study retinal dysfunction in diabetes and early nonproliferative diabetic retinopathy (NPDR) using a new method to analyze local multifocal electroretinogram oscillatory potentials (mfOPs). One eye of each of 26 normal subjects, 16 diabetic subjects without retinopathy (NoR), and 16 diabetic subjects with early NPDR was examined. Slow-flash multifocal electroretinograms (sf-mfERGs) were recorded from the central 45 degrees, and stereo fundus photographs of the diabetic eyes were taken. The first-order (K1), induced first-order (K1i), and second-order (K2) response components were extracted from each retinal location, and K1i and K2 were added to create Ks2. Responses from 35 contiguous areas were digitally filtered 90 to 225 Hz to isolate the mfOPs. The signal-to-noise ratio (SNR) of the mfOPs was calculated, and abnormality was defined as SNR below the fifth percentile of the normal subjects. Combining the K1i and K2 components to form Ks2 before isolation of the mfOPs by digital filtering increased the SNR. Mean Ks2 and K1 mfOP SNRs were abnormal in 25% and 19% of the NoR eyes, respectively, and both were abnormal in 62% of the NPDR eyes. The retinal distributions of the local Ks2 and K1 mfOP abnormalities overlapped, but they differed. Furthermore, local Ks2 mfOP abnormalities were preferentially associated with retinal sites containing NPDR but K1 mfOP abnormalities were not. The cells that contribute to the generation of local mfOPs are affected by diabetes and, to a greater degree, by early NPDR. The results suggest that fast adaptive mechanisms influencing the mfOPs are most abnormal at retinal sites containing NPDR.

Efficacy and safety of memantine treatment for reduction of changes associated with experimental glaucoma in monkey, II: Structural measures.

To determine, using anatomic measurements, whether daily oral dosing with memantine is both safe and effective to reduce the injury associated with experimental glaucoma in primates. Argon laser treatment of the anterior chamber angle was used to induce chronic ocular hypertension (COHT) in the right eyes of 18 macaque monkeys. Nine animals were daily orally dosed with 4 mg/kg memantine while the other nine animals received vehicle only. Measurements of intraocular pressure (IOP) from both eyes of all animals were made at regular intervals. Appearance of the optic nerve head, retinal vessels, and surrounding retina was documented with stereo fundus photographs obtained at multiple time points throughout the study. Measurements of optic nerve head topography were obtained from confocal laser scans made from animals with the highest IOPs at approximately 3, 5, and 10 months after elevation of IOP. At approximately 16 months after IOP elevation, animals were killed and histologic counts of cells in the retinal ganglion cell (RGC) layer were made. Histologic measurements showed that, for animals with moderate elevation of IOP, memantine treatment was associated with an enhanced survival of RGCs in the inferior retina. Measurements of optic nerve head topography showed less IOP-induced change in memantine-treated animals. This effect was seen in measurements of both the cup and the neuroretinal rim. A comparison of these same histologic and morphologic measurements in normotensive eyes from the two treatment groups showed that memantine treatment was not associated with any significant effects on these eyes. Histologic measurements of RGC survival as well as tomographic measurements of nerve head topography show that systemic treatment with memantine, a compound which does not lower intraocular pressure, is both safe and effective to reduce changes associated with experimental glaucoma.

Five-year incidence of age-related maculopathy: The Visual Impairment Project

Purpose To describe the 5-year incidence of age-related maculopathy (ARM) and the progression of the early stages of ARM lesions in Melbourne, Australia. Design Population-based cohort study. Participants A total of 3271 participants aged 40 years and older from Melbourne, Victoria, Australia. Main outcome measures The 5-year incidence and progression of ARM lesions. Methods Participants were recruited through a cluster random sampling from 9 urban clusters. Baseline examinations were conducted from 1992 through 1994, and the follow-up data were collected from 1997 through 1999. Presence of ARM lesions was graded from color stereo fundus photographs according to the International Classification and Grading System. Results The overall cumulative 5-year incidence of age-related macular degeneration (AMD) was 0.49% (95% confidence interval [CI], 0.2–0.8) and that of early ARM was 17.3% (95% CI, 8.7–26.0). The incidence of all ARM lesions increased with age (all P<0.001). The 5-year incidence of AMD was 0%, 0.69%, 1.7%, and 6.3% and that of early ARM was 13%, 22.7%, 29.8%, and 20% for participants aged 60 years and younger, aged 60 to 69 years, aged 70 to 79 years, and aged 80 years and older at baseline, respectively. People with soft indistinct drusen with pigmentary abnormalities had a 9.5 times (95% CI, 1.9–45.6) higher risk of developing AMD compared with people with soft drusen or pigmentary abnormalities. After adjusting for age, people with unilateral early ARM at baseline were 3 times (95% CI, 0.98–8.0) as likely to have early ARM in their second eye when compared with people with no ARM in both eyes. Conclusions These data suggest that 1 in 3 persons aged 70 years or older will have ARM lesions over a 5-year period and that the disease will progress to a more severe form after the age of 80 years. The presence of soft indistinct drusen with pigmentary abnormalities significantly increased the risk for development of AMD.

Assessment of multifocal electroretinogram abnormalities and their relation to morphologic characteristics in patients with large drusen.

To determine the extent of functional changes in the first-order kernel multifocal electroretinogram (mfERG) responses in patients with large drusen by means of a localized analysis and to determine correlations between mfERG responses and morphologic changes. Thirty-one eyes from 20 patients ages 58 to 84 years with large drusen (> or =5 drusen > or =63 microm diameter) were studied. The mfERGs were recorded with a stimulus of 103 hexagons and a flash intensity of 2.67 candela (cd).s-1.m-2. Each of the 103 single first-order kernel mfERG responses was analyzed and compared with those of age-matched healthy control subjects. Imaging studies, including color stereo fundus photography, red-free fundus photography, and fluorescein angiography, were performed in all patients, and morphologic changes (drusen in red-free fundus photography, staining or window defect in fluorescein angiography) were determined with a digital measurement tool. The mfERG responses were correlated to areas with and without morphologic changes. Reduced responses were found in 10.0% (scalar products) and 4.0% (response densities) and delayed implicit times in 13.8% (N1), 18.9% (P1), and 23.8% (N2) of all mfERGs. Abnormal mfERG responses extended up to 25 degrees in radius. Significant morphologic-functional relations were detected in only a few patients. Abnormal mfERG variables were present in areas without morphologic changes. Patients with large drusen exhibit functional changes in the cone-driven pathways evaluated by the mfERG, indexed particularly by implicit times. Morphologically visible changes do not predict retinal function. Large drusen are associated with a more general retinal dysfunction.

Incidence of diabetic retinopathy in the Barbados Eye Studies

Purpose To examine the 4-year incidence and risk factors for diabetic retinopathy (DR) among black participants with diabetes in the Barbados Eye Studies (BES). Design Population-based incidence study. Setting and participants Four hundred ten persons with diabetes mellitus (DM) from the BES cohort, which was based on a simple random sample of Barbadians, 40 to 84 years of age at baseline. Main outcome measures Development of DR, assessed by independent gradings of 30° color stereo fundus photographs of the disc and macula. Associations were evaluated by logistic regression analyses. Results After 4 years, DR developed in 92 of 306 (30.1%; 95% confidence interval, 25.0%, 35.5%) persons unaffected at baseline. The incidence of DR was 31.9% in those with known DM at baseline and 20.9% in newly diagnosed DM. Clinically significant macular edema developed in 16 (4.5%) of 353 individuals at risk. Seven (6.9%) of the 101 persons with minimum or moderate DR at baseline progressed to proliferative DR. Age-specific incidence declined from 36.2% at age 40 to 49 years to 28.8% and 24.2% over the subsequent two decades, increasing to 38.2% among those ≥70 years. Risk factors for DR were increased systolic blood pressure (relative risk [RR], 1.16 [1.03, 1.31]/10 mmHg increase); use of oral hypoglycemics (RR, 2.4 [1.3, 4.2]); and use of insulin (RR, 6.1 [1.7, 22.1]) (vs. no treatment or diet only); and elevated glycated hemoglobin (GHb; RR, 6.4 [2.5, 16.0]); GHb >11.5% vs. GHb ≤8%). Conclusions High rates of incident DR were evident in the black BES population, also known to have high rates of DM. Prevention of visual loss caused by DR in this population has high priority, including optimal glycemic and blood pressure control.

Circulating anti-pericyte autoantibodies are present in Type 2 diabetic patients and are associated with non-proliferative retinopathy.

This study aims to determine the prevalence of anti-pericyte autoantibodies in Type 2 diabetes and to characterize these autoantibodies as new markers of disease activity in diabetic retinopathy. A total of 299 patients with Type 2 diabetes participated in this study. Retinopathy was assessed by 7-field stereo fundus photography and was graded according to the ETDRS scale. Serum anti-pericyte autoantibodies were detected by immunofluorescence on tissue cultured bovine retinal pericytes. The prevalence of anti-pericyte autoantibodies in Type 2 diabetic patients was 54% and was approximately equal in men and women. The prevalence was approximately 55% with retinopathy at grades from 10 to 53. At grades above 53 the prevalence declined to 23% ( p<0.0001). The highest prevalence by duration of diabetes, 70%, was found at 0 to 5 years and the lowest, 25% at more than 25 years duration ( p<0.0001). Anti-pericyte autoantibodies are present at high prevalence in Type 2 diabetes. Their presence during earlier stages of retinopathy could be due to a reaction with antigens expressed by "activated" pericytes. The decline in antibody prevalence in advanced retinopathy could mark pericyte loss and progression to an angiogenic retinal milieu.

Increased disk size in glaucomatous eyes vs normal eyes in the reykjavik eye study

Purpose To evaluate the use of disk diameter as an indicator in the identification of glaucomatous optic neuropathy. Methods We evaluated all available stereofundus photographs for 1,040 right eyes obtained in the Reykjavik Eye Study. Horizontal and vertical disk diameters were determined in a masked manner by a glaucoma specialist (K.F.D.). All disk diameters were corrected for refractive error. Results There were significant differences ( P < .05) between the corrected vertical disk diameters of normal subjects (0.189 ± 0.018 inches) and those suspected of having glaucoma (0.202 ± 0.020 inches) as well as between the normal and the glaucoma groups (0.206 ± 0.029 inches). The corrected horizontal measurement showed the same pattern. Conclusions In the Reykjavik Eye Study, optic disks meeting structural criteria for glaucoma are significantly larger than normal nerves.

眼底写真撮影

Techniques for photography including stereo fundus photography, fundus photography with filters, the scanning laser ophthalmoscopy and angiographic photography are described.The advantages and disadvantages of digital photography are also discussed in comparison with among photographic techniques.

Risk factors for type ii diabetes and diabetic retinopathy in a mexican-american population: proyecto ver

PURPOSE: Risk factors for type II diabetes and diabetic retinopathy were determined in a population-based study of Mexican-Americans. DESIGN: Proyecto VER (Vision, Evaluation, and Research) is a cross-sectional study in a random sample of the self-described Hispanic populations in Tucson and Nogales, Arizona, age 40 and older. METHODS: Of 6,659 eligible subjects, 4,774 (72%) participated in the home questionnaire and clinic visit. Diabetes was defined as self-report of a physician diagnosis or hemoglobin A 1c value of ≥ 7.0%. Only type II diabetes was included. Diabetic retinopathy was assessed on stereo fundus photographs of all persons with diabetes. Questions were asked about demographic, personal, socioeconomic, and diabetes related variables. RESULTS: 1023 (21.4%) of the sample had type II diabetes, and 68% were in the low-income group (annual income less than $20,000). Diabetes was associated with Native-American ancestry, higher acculturation, low income, less education, and increasing body mass index after age and gender adjustment. Persons with previously undiscovered diabetes were more likely to have no regular source of care, no insurance, and currently smoke compared with persons with known diabetes. Only low income was related to proliferative retinopathy, once adjusted for other factors (odds ratio [OR] = 3.93, 95%, confidence limitations [CL] = 1.31–11.80). CONCLUSIONS: Several socioeconomic and other factors were associated with diabetes, but few were related to diabetic retinopathy. Persons in the low-income group appeared to be at greater risk of diabetes and the ocular complications of diabetes compared with those with more income. Further longitudinal studies in this population are needed to confirm the associations.

Is one 60 degrees fundus photograph sufficient for screening of proliferative diabetic retinopathy?

To compare one 60 degrees fundus photograph to seven field stereo fundus photographs in identifying proliferative diabetic retinopathy. A total of 44 eyes in 23 patients with moderate/severe nonproliferative diabetic retinopathy were included. Evaluation of each eye was based on one 60 degrees fundus photograph. Eyes were re-examined using seven field 30 degrees stereo fundus photographs according to the protocol of the Early Treatment Diabetic Retinopathy Study, and the photographs were examined independently by three ophthalmologists to identify retinal neovascular lesions. In addition, fluorescein angiography was performed in all patients to verify the presence of the lesions. In four eyes of three patients (11.1% of eyes) evaluated based on seven field stereo photographs, retinal neovascularization was found. This condition was not found on examination of 60 degrees fundus photographs. Examination of one 60 degrees fundus photograph was found to be insufficient as a screening procedure in patients with moderate/severe nonproliferative diabetic retinopathy.

Pars plana vitrectomy, subretinal injection of tissue plasminogen activator, and fluid–gas exchange for displacement of thick submacular hemorrhage in age-related macular degeneration

PURPOSE: To evaluate a new procedure for displacement of large, thick submacular hemorrhage in patients with age-related macular degeneration. METHODS: Retrospective review of 11 eyes of 11 patients with age-related macular degeneration and thick submacular hemorrhage (defined as causing retinal elevation detectable on stereo fundus photographs) treated with vitrectomy, subretinal injection of tissue plasminogen activator (25 or 50 μg), and fluid–gas exchange with postoperative prone positioning. Outcome measures included displacement of hemorrhage from the fovea, best postoperative visual acuity, and final postoperative visual acuity. RESULTS: In the 11 affected eyes of 11 patients (seven men and four women; mean age, 76 years), preoperative visual acuity ranged from 20/200 to hand motions. With surgery, subretinal hemorrhage was displaced from the fovea in all 11 cases. Mean postoperative follow-up was 6.5 months (range, 1 to 15 months). Best postoperative visual acuity varied from 20/30 to 5/200, with improvement in nine (82%) cases and no change in two cases. Eight eyes (73%) measured 20/200 or better, with four of these eyes (36%) 20/80 or better. Final postoperative visual acuity ranged from 20/70 to light perception, with improvement in eight (73%) cases, no change in one case, and worsening in two cases. A statistically significant difference was found between preoperative and best postoperative visual acuity ( P = .004) but not between preoperative and final visual acuity ( P = .16). Hemorrhage recurred in three (27%) eyes, causing severe visual loss in one eye. CONCLUSIONS: This technique displaces submacular hemorrhage from the fovea and can improve vision in patients with age-related macular degeneration. However, recurrence of hemorrhage occurred in 27% of eyes and caused severe visual loss in one eye. A randomized, prospective clinical trial is necessary to determine the efficacy of this technique in comparison with other proposed treatments.

The prevalence of age-related maculopathy: The visual impairment project

Purpose To determine the prevalence of age-related maculopathy (ARM) lesions in residents of the state of Victoria, Australia. Design Population-based cross-sectional study. Participants Total of 5147 residential and institutionalized persons aged 40 years and older, living in Victoria. Methods Participants were recruited through a cluster, stratified, random sampling from nine urban clusters and four rural clusters. The presence of ARM lesions was graded from color stereo fundus photographs as well as slit-lamp stereo biomicroscopy according to the International Classification and Grading System. Main outcome measures The presence of ARM lesions. Results The mean age of participants was 60.2 years, and 55% were females. Gradable fundus photographs were available for at least one eye in 4345 (92%) of the participants. The weighted prevalence of neovascular age-related macular degeneration (AMD) was 0.39% (95% confidence limits [CL] = 0.20, 0.58), atrophic AMD was 0.27% (95% CL = 0.04, 0.50), and total AMD was 0.68% (95% CL = 0.30, 1.1). Prevalence of AMD was strongly related to age ( P < 0.001). Prevalence of early ARM was 15.1% (95% CL = 13.7, 16.4). Large drusen, 125 μm or more, were present in 6.3% of the participants. There was a higher prevalence of soft distinct drusen (7.5%) than soft indistinct drusen (4.3%). Retinal pigmentary abnormalities were present in 8.2% (95% CL = 7.2, 9.2). The prevalence of large drusen, soft drusen, and pigmentary abnormalities increased with age ( P < 0.001). Prevalence of retinal pigmentary abnormalities increased with increasing drusen size ( P < 0.001). Soft indistinct drusen were more common in women aged 70 years or older ( P < 0.001). Bilaterality of any ARM was strongly age related, and women appeared to have a higher risk of both bilateral early ARM and AMD. Conclusions These data provide age- and gender-specific prevalence of ARM and its component lesions in an ethnically diverse Australian population. Early ARM and AMD prevalence rates increased sharply from ages 70 and 80 years, respectively, in all ethnic groups. These higher rates will continue to increase the importance of AMD as our population ages.

Diabetic retinopathy in a black population: The Barbados eye study

Objective The distribution of diabetic retinopathy in black populations is largely unknown. The authors present retinopathy data from the predominately black participants of the Barbados Eye Study (BES). Design and participants Prevalence study of 4631 participants based on a random sample of the Barbados population 40 to 84 years of age (84% participation). Main outcome measures Diabetes was defined as self-reported history of physician-diagnosed diabetes or glycosylated hemoglobin greater than 10% (>2 standard deviations above the population mean of persons without a diabetes history). Retinopathy was assessed by independent gradings of 30° color stereo fundus photographs of the disc and macula. Results Diabetes was present in 19.4% of black (n = 4314), 15.2% of mixed (black and white; n = 184), and 7.5% of white/other (n = 133) self-reported racial groups. In the black/mixed population, regardless of diabetes status, the prevalence of retinopathy was 5.9%. In the 636 black and mixed participants with diabetes, the prevalence of retinopathy was 28.5%: 19.8% had minimum changes, 7.7% had moderate changes, and 0.9% had severe retinopathy. Clinically significant macular edema (CSME) was found in 8.6% of those with diabetes. Conclusions In the population of African origin, approximately 1 in 17 persons had retinopathy. Among those with diabetes, 28.5% had retinopathy and 8.6% had CSME. These results highlight the clinical and public health relevance of diabetic retinopathy in the black population.

Diabetic retinopathy in pediatric patients with type-1 diabetes: Effect of diabetes duration, prepubertal and pubertal onset of diabetes, and metabolic control

Objective: The objective of this study was to determine the contribution of prepubertal and pubertal onset and duration of diabetes to the development of diabetic retinopathy. Study design: A total of 1391 standardized fundus examinations (stereo fundus-photography) were performed in 441 children or adolescents with type-1 diabetes (median age 15.5 years, median duration of diabetes 6.3 years). Results: Mild nonproliferative retinopathy was present in 72 patients (median age 19.9 years). Life table analysis revealed a median duration of diabetes until retinopathy was first diagnosed at 16.6 years (95% confidence interval: 15.3 to 18.3). Patients were stratified according to diabetes onset before or in puberty (≥10.4 years in girls, ≥12.2 years in boys). In children with a prepubertal onset of diabetes, retinopathy occurred after a pubertal duration of 10.9 years compared with 15.1 years in children with onset of diabetes in puberty ( p < 0.01), demonstrating the additional risk conveyed by the prepubertal years of diabetes. Long-term metabolic control had a significant influence on the prevalence of retinopathy: patients with a median HbA 1c ≥7.5% had development of retinopathy on average after 15.5 years compared with 18.3 years in patients with lower HbA 1c values ( p < 0.05). Conclusion: Both prepubertal and pubertal duration of diabetes are relevant for the development of background retinopathy. Good metabolic control should be attempted irrespective of age. (J Pediatr 1998;132:790-4)

Clustering of long-term complications in families with diabetes in the diabetes control and complications trial. The Diabetes Control and Complications Trial Research Group

We investigated familial clustering of diabetic retinopathy and nephropathy in the families of 372 subjects from the Diabetes Control and Complications Trial (DCCT). These subjects had 467 first-degree relatives with IDDM or NIDDM. Family sizes ranged from two to six. A complete data set was obtained from 241 relatives of 217 DCCT subjects. Among the DCCT subjects, 53% were in the intensive treatment group and 47% were in the conventional group; 44% were from the primary prevention cohort (no retinopathy or microalbuminuria at the DCCT baseline) and 56% were from the secondary intervention cohort (mild-to-moderate nonproliferative retinopathy and <200 mg/24 h albumin excretion rate [AER] at baseline). Retinopathy and nephropathy were assessed with seven-field stereo fundus photography and timed urinary AER measurements. Retinopathy was assessed using the Early Treatment Diabetic Retinopathy Study (ETDRS) scale. ETDRS scores and AERs were adjusted for the DCCT treatment group and for significant covariates from among sex, age, diabetes duration, HbA1c value, and body weight. Familial associations were assessed by comparing the prevalence of retinopathy and nephropathy in diabetic relatives of the respective positive versus negative DCCT subjects. To determine family clustering of the severity of retinopathy or nephropathy, the intraclass (familial) correlation was computed from the log-adjusted retinopathy and nephropathy scores of DCCT subjects and their relatives for all family members and sib-sib relationships. For parent-offspring, mother-child, and father-child relationships, the pairwise estimate of the correlations was computed. A correlation of 0.2 was considered to be biologically meaningful a priori. Among families of patients in the intensive and conventional groups combined, there was an increased risk of severe retinopathy (an ETDRS score > or =47, clinically significant macular edema, or laser treatment in either eye) among relatives of retinopathy-positive vs. retinopathy-negative DCCT subjects in the secondary intervention cohort (odds ratio [OR], 3.1; 95% CI 1.2-7.8; P < 0.05). There was no increase in the risk of retinopathy of any severity (microaneurysms or worse) in the relatives of retinopathy-positive vs. retinopathy-negative DCCT subjects of the primary prevention cohort. There was an increased risk of nephropathy (AER >40 mg/24 h) in relatives of nephropathy-positive versus nephropathy-negative DCCT subjects of the secondary intervention cohort (OR, 5.4; 95% CI 2.2-13.7; P < 0.001). The risk of severe retinopathy in the relatives of positive versus negative subjects from the conventional treatment group alone (OR, 4.3; 95% CI 1.01-18.6; P < 0.05) was statistically significant and somewhat greater than that among relatives of the subjects in intensive treatment group (OR, 2.4; 95% CI 0.7-8.1), which was not significant. Correlations for the severity of retinopathy were 0.187 (all family members), 0.327 (parent-offspring), 0.249 (father-child), 0.391 (mother-child), and 0.060 (sib-sib), using the combined treatment group families. All these correlations were statistically significant (P < 0.05), except for sib-sib. The results showed similar trends when the families from the conventional and intensive treatment groups were analyzed separately. Correlations for nephropathy in the combined treatment group families were 0.063 (all family members), 0.138 (parent-offspring), 0.170 (father-child), 0.103 (mother-child), and 0.107 (sib-sib). None of these correlations is statistically significant. The lack of significant correlation for the severity of nephropathy may reflect the relatively short duration of diabetes in the offspring of these families and the known high intrasubject variability of AERs. These data provide the first available evidence that the severity of diabetic retinopathy is influenced by familial (possibly genetic) factors and confirmatory evidence that such factors influence the development

Optical Coherence Tomography of Macular Lesions Associated with Optic Nerve Head Pits

Although optic pits were described more than a century ago, the pathogenesis and pathologic nature of the associated macular lesions remain controversial. The authors used the technique of optical coherence tomography (OCT) to further define the anatomic relation that exists between optic pits, macular schisis-like spaces, and macular detachments. Four eyes of three consecutive patients with optic pit-related macular pathology were evaluated. Cross-sectional OCT images were correlated with findings from slit-lamp biomicroscopy and stereo fundus photography. All eyes previously had undergone unsuccessful photocoagulation to the temporal juxtapapillary retina. One eye had undergone vitrectomy and intraocular gas tamponade, resulting in partial resorption and displacement of the submacular fluid. Retinal edema and cystic degeneration were present, overlying macular neurosensory detachments in all four eyes. The most prominent edema was present in the outer retina at the level of the outer plexiform layer. This mimicked a true retinoschisis cavity, although bridging retinal elements were identifiable. A lesser degree of edema was present in the inner retina, predominantly located between the disc and fovea. In one eye, a lamellar hole was shown to be a defect in the outer neurosensory retina. In another eye, a macular detachment developed under a pre-existing schisis-like cavity. The schisis-like cavity or edematous retina communicated with the optic disc in all eyes, whereas none of the eyes demonstrated a direct connection between the macular detachment and optic pit. These findings support the concept of a bilaminar structure in which a macular detachment develops secondarily to a pre-existing schisis-like lesion consisting of severe outer retinal edema. Fluid may enter from the optic pit into the retinal stroma and not directly into the subretinal space, explaining the prolonged recovery and frequency of treatment failure after photocoagulation to the juxtapapillary retina.