Stereoscopic Fundus Photographs Research Articles

2247-PUB: Comparative Analysis of the Thickness of Inner Retinal Layers among African Immigrants Based on Their Status of Glucose Tolerance

Inner retinal neurodegeneration was found, independent of the severity of retinopathy in persons with diabetes (DM). However, it is unknown whether the inner retinal neurodegeneration is evident in people with prediabetes (preDM) or asymptomatic people with newly diagnosed DM. In this cross-sectional study, we prospectively enrolled African immigrants who self-identified as being healthy with no prior history of diabetes. Each participant was tested for diabetes with an OGTT and underwent a comprehensive eye exam with spectral-domain optical coherence tomography and stereoscopic fundus photographs. The thickness of parafoveal (PA) retinal nerve fiber layer (RNFL), perifoveal (PE) RNFL, PA ganglion cell + inner plexiform layers (G+I), and PE G+I were measured using an automated segmentation software. A total of 211 African immigrants enrolled in the study. After excluding participants with a history or signs of glaucoma and other conditions that could affect retinal structural integrity, there were 21 DM participants (76% male, age 46 (28-61y) (mean (range))), 72 preDM participants (61.1% male, age 42.4 (23-65)), and 91 normal glucose tolerant (NGT) participants (58% male, age 36 (20-62y)). From the 91 NGT control subgroup, 52 age-sex-matched participants were selected for comparative analyses (64% male, age 43 (32-62y)). Among participants in the 3 subgroups (DM, preDM, NGT), there was no significant difference in the mean thickness of PA RNFL (24.7 (2.4) (mean (SD)), 24.9 (2.1), 24.6 (2.8), respectively, P=0.863), PE RNFL (35.9 (3.8), 36.7 (4.1), 35.4 (3.2), P=0.794), PA G+I (88.8 (5.6), 90.6 (10.3), 89.7 (7.2), P=0.415), or PE G+I (65.0 (5.0), 67.2 (5.6), 67.4 (4.2), P=0.194). With this limited sample size, we were unable to find in fircan an association of neurodegeneration in persons with PDM and NDM. Future studies with larger sample size may provide further supporting evidence for such an association. Disclosure C.K. Hwang: None. E. Agron: None. A.E. Sumner: None. S.M. Briker: None. J.Y. Aduwo: None. C. DuBose: None. E. Chew: None.

599-P: Diabetic Retinopathy (DR) Screening Performance of General Ophthalmologists, Retina Specialists, and Artificial Intelligence (AI): Analysis from a Pivotal Multicenter Prospective Clinical Trial

A prospective study (NCT03112005) evaluated DR screening using the EyeArt AI eye screening system and dilated ophthalmoscopy by board-certified ophthalmologists against the ETDRS clinical reference standard (CRS) of adjudicated expert grading of 4-wide field stereoscopic fundus photographs. A total of 497 subjects with diabetes from 10 U.S. clinical centers underwent undilated 2-field fundus photography for analysis by the EyeArt system, dilated ophthalmoscopy, and dilated 4-wide field stereo fundus photography for the CRS. Performance (Table) of dilated ophthalmoscopy against CRS for identifying referable DR [moderate non-proliferative or higher on the International Clinical Diabetic Retinopathy severity scale or clinically significant macular edema] indicates significant variability across retina specialists and general ophthalmologists. In a previous study, this AI system has been shown to achieve sensitivity 89.0% [95% CI: 87.7-90.2%] and specificity 91.6% [95% CI: 91.0-92.2%] against 7-field ETDRS reference standard. We await the results of the EyeArt system in this multicenter study to verify its ability to provide a more consistent performance for detection of referable DR to facilitate DR screening in primary care and endocrinology clinics. Disclosure E. Ipp: Research Support; Self; Eyenuk Inc., Novartis Pharmaceuticals Corporation. V.N. Shah: Advisory Panel; Self; Sanofi US. Consultant; Self; Dexcom, Inc. B.W. Bode: Consultant; Self; ADOCIA, Lexicon Pharmaceuticals, Inc., Novo Nordisk Inc. Research Support; Self; Becton, Dickinson and Company, Dexcom, Inc., Diasome Pharmaceuticals, Inc., Eli Lilly and Company, Eyenuk Inc., Insulet Corporation, National Institutes of Health, Novo Nordisk Inc., Sanofi Research & Development, Senseonics, Xeris Pharmaceuticals, Inc. Speaker's Bureau; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Janssen Pharmaceuticals, Inc., Novo Nordisk Inc., Sanofi US, Senseonics. Stock/Shareholder; Self; AgaMatrix, Glytec, LLC. S.R. Sadda: Consultant; Self; Carl Zeiss Meditec, Centervue, Heidelberg Engineering, Optos. Other Relationship; Self; Nidek. Other Relationship; Spouse/Partner; Topcon. Funding Eyenuk Inc.

Evaluation of choroidal thickness in different stages of diabetic retinopathy

Purpose: to assess changes of choroidal thickness (CT) in diabetic patients in different stages of diabetic retinopathy and diabetic macular edema using spectral domain optical coherence tomography. Patients and methods: One hundred and sixty three subjects were enrolled: 113 diabetic patients (186 eyes) and 50 normal individuals as controls. Eyes were divided into two groups according to age; group A from 35 to 50 years and group B from 51 to 65 years. Both groups classified according to retinopathy grade: DR1 (no DR), DR2 (mild- moderate nonproliferative diabetic retinopathy (NPDR)), DR3 (severe NPDR), DR4 (untreated proliferative diabetic retinopathy (PDR)) and DR5 (previously treated PDR). All participants underwent full ophthalmic examination, stereoscopic color fundus photography, and spectral domain optical coherence tomography (RS-3000; Nidek). Spectral domain optical coherence tomography examination consisted of linear scans, 6 mm in length, centered onto the fovea, and macula multi scans. Choroidal thickness was measured manually at the fovea and at 500, 1000, and 1500 um distance along all scans in the macula. Results: Mean age was not significantly different between patients with diabetes and controls. In the macular area, CT was significantly lower in the nasal quadrant versus all other quadrants (P, 0.0001), in both groups. No significant CT difference was found between controls and diabetic eyes without detectable DR. Diabetic macular edema did not influence CT. In early NPDR (mild and moderate) and treated PDR the mean choroidal thickness was significantly decreased than control. In severe NPDR and treated PDR, the mean subfoveal choroidal thickness was not different than control. There was a statistically significant increase in choroidal thickness in PDR when compared with the mild NPDR group (P=0.027). DME was associated with a non-statistically significant increase in choroidal thickness compared with eyes without DME (P=0.13). Conclusion: Choroidal thickness is reduced in diabetic eyes. Subfoveal choroidal thickness increased with the severity of diabetic retinopathy but showed no statistically significant association with the presence of DME. Spectral domain optical coherence tomography clearly confirms in vivo previously reported histopathologic observations. The role of choroid in the pathophysiology of DR needs to be adequately investigated.

Natural History of Drusenoid Pigment Epithelial Detachment Associated with Age-Related Macular Degeneration: Age-Related Eye Disease Study 2 Report No. 17

To investigate the natural history and genetic associations of drusenoid pigment epithelial detachment (DPED) associated with age-related macular degeneration (AMD). Retrospective analysis of a prospective cohort study. Of the 4203 Age-Related Eye Disease Study 2 (AREDS2) participants, 391 eyes (325 participants) had DPED without late AMD at the time of DPED detection. Genetic analyses included 120 white AREDS2 participants and 145 Age-Related Eye Disease Study (AREDS) participants with DPED. Baseline and annual stereoscopic fundus photographs were graded centrally to detect DPED, a well-defined yellow elevated mound of confluent drusen ≥433 μm in diameter, and to evaluate progression rates to late AMD: geographic atrophy (GA) and neovascular (NV)-AMD. Five single nucleotide polymorphisms (CFH [rs10611670], C3 [rs2230199], CFI [rs10033900], C2/CFB [rs114254831], ARMS2 [rs10490924]) and genetic risk score (GRS) group were investigated for association with DPED development. Kaplan-Meier analyses and multivariable proportional hazard regressions were performed. Progression rates to late AMD and decrease of ≥3 lines in visual acuity (VA) from the time of DPED detection; association of rate of DPED development with genotype. Mean (standard deviation [SD]) follow-up time from DPED detection was 4.7 (0.9) years. DPED was associated with increased risk of progression to late AMD (hazard ratio [HR], 2.36; 95% confidence interval [CI], 1.98-2.82; P < 0.001); 67% of eyes progressed to late AMD 5 years after DPED detection. Drusenoid pigment epithelial detachment was associated with increased risk of ≥3 lines of VA loss (HR, 3.08; CI, 2.41-3.93; P < 0.001) with 46% of eyes experiencing vision loss at 5 years (with or without progression to late AMD). ARMS2 risk alleles (1 vs. 0: HR, 2.72, CI, 1.58-4.70; 2 vs. 0: HR, 3.16, CI, 1.60-6.21, P < 0.001) and increasing GRS group (4 vs. 1) (HR, 12.17, CI, 3.66-40.45, P < 0.001) were significantly associated with DPED development in AREDS. There were no significant genetic results in AREDS2. This study replicates the results of previous natural history studies of eyes with DPED including the high rates of progression to late AMD and vision loss (regardless of progression to late AMD). The genetic associations are consistent with genes associated with AMD progression.

Progression of Geographic Atrophy in Age-related Macular Degeneration: AREDS2 Report Number 16

To analyze the prevalence, incidence, and clinical characteristics of eyes with geographic atrophy (GA) in age-related macular degeneration (AMD), including clinical and genetic factors affecting enlargement. Prospective cohort study within a controlled clinical trial. Age-Related Eye Disease Study 2 (AREDS2) participants, aged 50-85 years. Baseline and annual stereoscopic color fundus photographs were evaluated for GA presence and area. Analyses included GA prevalence and incidence rates, Kaplan-Meier rates, mixed-model regression, and multivariable analysis of the square root of GA, area adjusted for covariates, including clinical/imaging characteristics and genotype. (1) Presence or development of GA; (2) change in the square root of GA area over time. At baseline, 517 eyes (6.2%) of 411 participants (9.8%) had pre-existing GA (without neovascular AMD), with the following characteristics: 33% central, 67% noncentral; and the following configurations: 36% small, 26% solid/unifocal, 24% multifocal, 9% horseshoe/ring, and 6% indeterminate. Of the remaining 6530 eyes at risk, 1099 eyes (17.3%) of 883 participants developed incident GA without prior neovascular disease during mean follow-up of 4.4 years. The Kaplan-Meier rate of incident GA was 19% of eyes at 5 years. In eyes with incident GA, 4-year risk of subsequent neovascular AMD was 29%. In eyes with incident noncentral GA, 4-year risk of central involvement was 57%. GA enlargement rate (following square root transformation) was similar in eyes with pre-existing GA (0.29 mm/year; 95% confidence interval 0.27-0.30) and incident GA (0.28 mm/year; 0.27-0.30). In the combined group, GA enlargement was significantly faster with noncentrality, multifocality, intermediate baseline size, and bilateral GA (P < 0.0001 for interaction in each case) but not with AREDS2 treatment assignment (P= 0.33) or smoking status (P= 0.05). Enlargement was significantly faster with ARMS2 risk (P < 0.0001), C3 non-risk (P= 0.0002), and APOE non-risk (P= 0.001) genotypes. Analyses of AREDS2 data on natural history of GA provide representative data on GA evolution and enlargement. GA enlargement, which was influenced by lesion features, was relentless, resulting in rapid central vision loss. The genetic variants associated with faster enlargement were partially distinct from those associated with risk of incident GA. These findings are relevant to further investigations of GA pathogenesis and clinical trial planning.

The Relationship of Retinal Vessel Geometric Characteristics to the Incidence and Progression of Diabetic Retinopathy

To examine the relationships of retinal vessel geometric characteristics (RVGCs) to the incidence and progression of diabetic retinopathy (DR). Observational, prospective cohort study. Nine hundred ninety-six persons with type 1 diabetes mellitus (T1DM) and 1370 persons with type 2 diabetes mellitus (T2DM) seen at a baseline examination who were eligible for follow-up examinations at subsequent 5-year intervals. A total of 3846 person-interval data from these follow-up examinations are the basis for the analyses. Diabetic retinopathy and macular edema were assessed by grading of 30° stereoscopic color fundus photographs. Retinal vessel geometric characteristics were assessed using the Singapore I Vessel Assessment program from a digitized copy of 1 of the field 1 fundus photographs obtained at baseline and follow-up. The 5-year incidence of any DR, progression of DR, and incidence of proliferative diabetic retinopathy (PDR) and clinically significant macular edema (CSME) in right eyes. Incident DR occurred in 45%, progression in 32%, PDR in 10%, and CSME in 5%. While adjusting for glycated hemoglobin, duration of diabetes, and other factors, retinal arteriolar simple tortuosity was associated significantly with the incidence of any DR (odds ratio [OR], 1.17; 95% confidence interval [CI], 1.01-1.35). Retinal venular branching angle was associated significantly with progression of DR (OR, 1.18; 95% CI, 1.03-1.36), retinal venular curvature tortuosity was associated significantly with the incidence of PDR (OR, 1.15; 95% CI, 1.01-1.30), and retinal venular branching angle (OR, 1.41; 95% CI, 1.10-1.82) was associated significantly with the incidence of CSME. There were no significant associations of other RVGCs with any of the DR outcomes in the full multivariate model. Inclusion of all possible RVGCs did not improve the predictive value of the models that already included retinal vessel diameter and baseline DR severity level. Retinal vessel geometric characteristics of the retinal venules were associated with progression of DR; however, most of the RVGCs measured from digitized fundus photographs added little to the assessment of risk of incidence and progression of DR when other risk factors were considered in T1DM and T2DM.

Retinal Nerve Fiber Layer Protrusion Associated with Tilted Optic Discs.

This study resulted in the identification of an optic nerve head (ONH) feature associated with tilted optic discs, which might potentially contribute to ONH pathologies. Knowledge of such findings will enhance clinical insights and drive future opportunities to understand disease processes related to tilted optic discs. The aim of this study was to identify novel retinal nerve fiber layer (RNFL) anomalies by evaluating tilted optic discs using optical coherence tomography. An observed retinal nerve fiber protrusion was further investigated for association with other morphological or functional parameters. A retrospective review of 400 randomly selected adult patients with ONH examinations was conducted in a referral-only, diagnostic imaging center. After excluding other ONH pathologies, 215 patients were enrolled and evaluated for optic disc tilt and/or torsion. Gross anatomical ONH features, including size and rim or parapapillary region elevation, were assessed with stereoscopic fundus photography. Optical coherence tomography provided detailed morphological information of individual retinal layers. Statistical analysis was applied to identify significant changes between individual patient cohorts. A dome-shaped hyperreflective RNFL bulge, protruding into the neurosensory retina at the optic disc margins, was identified in 17 eyes with tilted optic discs. Available follow-up data were inconclusive regarding natural changes with this ONH feature. This RNFL herniation was significantly correlated with smaller than average optic disc size (P = .005), congenital disc tilt (P < .0001), and areas of rim or parapapillary elevation (P < .0001). This study reports an RNFL protrusion associated with tilted optic discs, which has not previously been assessed as an independent ONH structure. The feature is predominantly related to congenital crowded, small optic discs and variable between patients. This study is an important first step to elucidate diagnostic capabilities of tilted disc morphological changes and understanding associated functional deficits.

Prevalence and Characteristics of Myopic Degeneration in an Adult Chinese American Population: The Chinese American Eye Study

To characterize and provide population-based prevalence estimates of myopic degeneration (MD) among Chinese Americans, the fastest-growing minority population in the United States in the last decade. Population-based, cross-sectional study. A total of 1523 Chinese-American adults with myopia, aged 50 years and older, residing in the city of Monterey Park, California, underwent an interview and comprehensive eye examination, including subjective and objective refraction and stereoscopic fundus photography. For each participant, the eye with the worse myopic refractive error was included in this analysis. MD was assessed in a masked manner by an expert grader. The prevalence of any MD was 44.9% among myopic subjects, based on the presence of any degenerative lesion secondary to myopia. The prevalence was 32.2% when MD was defined by a modified version of the Meta-Analysis for Pathologic Myopia. The prevalence of specific lesions included tessellation (31.7%), tilted disc (28.1%), peripapillary atrophy (7.0%), staphyloma (5.7%), diffuse atrophy (6.4%), lacquer cracks (2.6%), intrachoroidal cavitation (2.2%), patchy atrophy (0.9%), and end-stage MD (0.2%). The prevalence of MD was higher among older myopic subjects and among participants with more severe myopia and longer axial length (P < .001). These data provide the first population-based estimates of MD in Chinese Americans and indicate that a high proportion of Chinese Americans might be at risk for MD and associated visual complications. Prevalence of MD in this cohort of Chinese Americans was higher than that observed in other East Asian populations and in people of other ethnicities.

Lack of Longitudinal Association Between Thiazolidinediones and Incidence and Progression of Diabetic Eye Disease: The ACCORD Eye Study

To report the longitudinal association between use of thiazolidinediones (TZDs), visual acuity (VA) change, and diabetic eye disease incidence and progression. Cohort study ancillary to a randomized clinical trial. We analyzed baseline and 4-year follow-up data of 2856 ACCORD trial participants with no history of proliferative diabetic retinopathy. Based on stereoscopic fundus photographs, we evaluated diabetic macular edema (DME) progression and DR progression. We also evaluated 10- and 15-letter change on the ETDRS visual acuity chart. Main outcome measures were incidence or progression of DME or DR and change in visual acuity. TZD use was not associated with DME incidence in either the analysis of any use (adjusted odds ratio [aOR] [95% CI]: 1.22 [0.72-2.05]) or duration of use (aOR: 1.02 [0.99-1.04]). Diabetic retinopathy (DR) incidence/progression was more common in patients with no or mild DR at baseline who were ever treated with TZDs (aOR: 1.68 [1.11-2.55]), but this association disappeared when adjusting for the time on TZD (aOR: 1.02 [1.00-1.04]). DR progression among those with moderate or worse DR at baseline was no different between TZD users and non-users. TZD usage had no effect on the ultimate visual acuity outcome. In this longitudinal study of patients with type 2 diabetes, we found no association between TZD use and visual acuity outcomes or DME progression, and no consistent evidence of increased DR progression in patients ever treated with TZDs vs those never treated with TZDs.

Skin Intrinsic Fluorescence and Age-Related Macular Degeneration: The Beaver Dam Eye Study.

PurposeTo determine if skin intrinsic fluorescence (SIF), a noninvasive measure of advanced glycation endproducts and oxidative stress in skin is associated with AMD.MethodsSIF was measured with the SCOUT DS skin fluorescence spectrometer in a cross-sectional cohort study of 969 persons aged 68 to 102 years from the 1181 who participated in the 25-year follow-up examination in the Beaver Dam Eye Study (BDES) in 2014 to 2016. The SCOUT DS skin fluorescence spectrometer uses five light-emitting diodes, centered at 375 nm to 456 nm. AMD was assessed by grading of digital color 45° stereoscopic fundus photographs of the macula using the Wisconsin Age-Related Maculopathy grading scheme. Analyses included logistic regression with generalized estimating equations to account for correlation between the eyes of a person.ResultsThere were data for 1827 eyes for analyses. Early AMD was present in 22% and late AMD in 4% of the eyes. While adjusting for age, sex, smoking status, and history of cardiovascular disease, there were no significant associations of any SIF measure with any AMD or exudative AMD. SIF01 (odds ratio per 1 SD difference on the log scale, 95% confidence interval) (1.66, 1.00–2.74, P = 0.05) and SIF03 (1.81, 1.16–2.81, P = 0.008) were associated with geographic atrophy.ConclusionsThere was a suggestive relationship of two SIF measures, SIF01 and SIF03, using different correction factors from the excitation centered at 375 nm, with the prevalence of geographic atrophy in the BDES. Longitudinal follow-up is indicated to assess a temporal relationship.

Association of Mortality with Ocular Diseases and Visual Impairment in the Age-Related Eye Disease Study 2: Age-Related Eye Disease Study 2 Report Number 13

To evaluate the association of mortality with visual acuity (VA) impairment, age-related macular degeneration (AMD), and cataract surgery. Cohort study. Participants with at least intermediate AMD enrolled in a randomized controlled clinical trial of lutein/zeaxanthin and/or omega-3 fatty acids, the Age-Related Eye Disease Study 2 (AREDS2), for treatment of AMD and cataract. Baseline and annual eye examinations included best-corrected visual acuity (BCVA) assessments, slit-lamp examinations, and stereoscopic fundus photographs that were centrally graded for development of late AMD (central geographic atrophy or neovascular AMD) or pseudophakia. Cause-specific mortality was determined on the basis of the International Classification of Diseases 9th or 10th Revision codes. Risk of all-cause and cause-specific mortality was assessed with Cox proportional hazards models adjusted for age, sex, AMD severity, VA, history of cataract surgery, and assigned AREDS2 study treatment. Analyses included baseline covariates: race, education, smoking status, diabetes, and cardiovascular disease. During follow-up (median 5 years), 368 (9%) of the 4203 AREDS2 participants died. Participants with neovascular AMD in 1 eye at baseline had a statistically significant increased risk for mortality compared with participants with no or few drusen (hazard ratio [HR], 1.56; 95% confidence interval [CI], 1.21-2.01; P < 0.001). Poorer survival was associated with bilateral cataract surgery before enrollment compared with baseline bilateral phakia (HR, 1.63; 95% CI, 1.29-2.07; P < 0.001) and with BCVA of less than 20/40 compared with participants with 20/40 or better (HR, 1.56; 95% CI, 1.06-2.30; P= 0.024), adjusted for age, sex, and statistically significant covariates. Participants who received antivascular endothelial growth factor therapies for neovascular AMD had decreased mortality compared with those who did not (HR, 0.71; 95% CI, 0.57-0.88; P= 0.002). The association between all-cause mortality and AREDS2 treatment whether assessing the main or individual treatment effect was not significantly different (omega-3 fatty acids main effect HR, 1.18; 95% CI, 0.96-1.45; P= 0.12; lutein/zeaxanthin main effect HR, 1.04; 95% CI, 0.85-1.28; P= 0.71). In AREDS2, the presence of late AMD, bilateral cataract surgery, and VA less than 20/40 was associated with decreased survival. However, oral supplementation with omega-3 fatty acids, lutein plus zeaxanthin, zinc, or beta-carotene had no statistically significant impact on mortality.

The Nine-Step Minnesota Grading System for Eyebank Eyes With Age Related Macular Degeneration: A Systematic Approach to Study Disease Stages.

To refine the Minnesota Grading System (MGS) using definitions from the Age-Related Eye Disease Studies (AREDS) into a nine-step grading scale (MGS-9). A nine-step grading scale descriptive analysis using three key phenotypic features (total drusen area, increased, and decreased pigmentation) of human eyebank eyes that were graded according to definitions from the AREDS criteria in order to harmonize studies of disease progression for research involving human tissue. From 2005 through February 2017, we have analyzed 1159 human eyes, procured from two eyebanks. Each macula was imaged using high-resolution, stereoscopic color fundus photography with both direct- and transillumination. Fundus images were digitally overlaid with a grading template and triangulated for foveal centration. We documented and stratified risk for each globe by applying the AREDS nine-step grading scale to the key clinical features from the MGS-9. We found a good distribution within the MGS categories (1-9) with few level eight globes. Eyes were processed within 12.1 ± 6.3, hours from the time of death through imaging, dissection, and freezing or fixation. Applying the MGS-9 to 331 pairs (662 eyes were simultaneously graded), 84% were within one-grading step and 93% within two steps of the fellow eye. We also document reticular pseudodrusen, basal laminar drusen, and pattern dystrophy. The MGS nine-step grading scale enables researchers using human tissue to refine the risk assessment of donor tissue. This analysis will harmonize results among researchers when grading human tissue using MGS criteria. Most importantly, the MGS-9 links directly to the known risk for progression from the AREDS.

Six-year prevalence and incidence of diabetic retinopathy and cost-effectiveness of tele-ophthalmology in Manitoba

ObjectiveThe purpose of this study was to evaluate the diabetic retinopathy (DR) tele-ophthalmology screening program in Manitoba to determine prevalence and incidence of DR, as well as to estimate the program’s cost-effectiveness. DesignRetrospective chart review. ParticipantsA total of 4676 patients with type 2 diabetes examined 9334 times from 2007 to 2013. MethodsFocused ophthalmic histories were recorded and examinations were performed by trained nurses, including visual acuities, intraocular pressure, and mydriatic 7 standard field stereoscopic fundus photography. Images were evaluated by retinal specialists according to the Early Treatment of Diabetic Retinopathy Study criteria. DR prevalence and incidence were then calculated during the study period. Cost-effectiveness was estimated by comparing the cost of running the tele-ophthalmology program compared with the cost of screening the same volume of patients in-office. ResultsThe average prevalence of any DR in each year was 25.1%. The cumulative incidence of DR across 6 years was 17.1% (95% CI, 15.4%–18.7%). The average savings per tele-ophthalmology examination was $1007. ConclusionsDR is highly prevalent among the studied population. Tele-ophthalmology provides a cost-effective means of monitoring patients as well as identifying new or treatable disease.

Factors Associated with Age-Related Macular Degeneration in Chinese American Adults: The Chinese American Eye Study (CHES)

To assess associations between age-related macular degeneration (AMD) and multiple factors comprising a conceptual model of AMD risk in a population of Chinese Americans, and to draw comparisons with a similar risk assessment of a Latino population. A cross-sectional population-based study. We enrolled 4582 Chinese Americans aged ≥50 residing in Monterey Park, California. Participants completed a comprehensive eye examination, including stereoscopic fundus photography and ocular biometric measurements. Fundus images were graded using a modified version of the Wisconsin Age-Related Maculopathy Grading System. Odds ratios for factors significantly modifying the risk of AMD and its related retinal lesions. Of the eligible participants, 4172 (72%) had fundus photographs gradable for AMD. Early AMD was present in 375 eyes (4.6%), and late AMD was present in 17 (0.2%). Shorter axial length, male sex, older age, and family history of AMD were identified as independent risk factors for prevalent AMD and its characteristic retinal lesions using a conceptual model of potential AMD risk factors. Of 4 AMD risk factors identified for Latinos, 3 (older age, male sex, shorter axial length) overlapped with those identified for Chinese Americans, with an association similar in magnitude and direction. Lower levels of education were a risk factor specific to Latinos. Based on a multivariable logistic regression model, the predicted probability of early AMD was 31% lower among Chinese Americans relative to Latinos (95% confidence interval [CI], 17%-43%). Chinese Americans also had statistically significantly lower odds of any AMD and 2 types of early retinal lesions symptomatic of AMD. Factors associated with prevalent AMD are similar for Chinese Americans and Latinos. Chinese Americans who were older, were male, had a family history of AMD, and had a shorter axial length were at an increased risk for AMD compared with those without these risk factors. We observed a significantly lower predicted prevalence of AMD among Chinese Americans compared with Latinos, even after controlling for all relevant covariates, suggesting that additional genetic or lifestyle differences may play an important role in determining AMD risk.

Ophthalmological Evaluation of Integrated Resistance and Aerobic Training During 70-Day Bed Rest.

We evaluated ophthalmic changes in healthy individuals who underwent integrated resistance and aerobic training (iRAT) during 70-d 6° head-down tilt (HDT) bed rest (BR). Participants were selected using NASA standard screening procedures. Standardized NASA BR conditions were implemented. Subjects were randomly assigned to the iRAT protocol or no exercise during HDTBR. Weekly ophthalmic examinations were performed in the sitting (pre/post-BR only) and HDT (BR only) positions. Mixed-effects linear models compared pre- and post-HDTBR intraocular pressure (IOP), Spectralis OCT circumpapillary retinal nerve fiber layer (cpRNFL) thickness, and peripapillary retinal thickness observations between groups. Six controls and nine exercisers completed the study. There was an overall effect of BR on our outcomes. Except Goldmann IOP (mean pre/post difference in controls and exercisers: -0.47 mmHg vs. +1.14 mmHg), the magnitude of changes from baseline was not significantly different between groups. There was a +1.38 mmHg and a +1.63 mmHg iCare IOP increase during BR in controls and exercisers, respectively. Spectralis OCT detected a +1.33 μm average cpRNFL thickness increase in both groups, and a +9.77 μm and a +6.65 μm peripapillary retinal thickening post-BR in controls and exercisers, respectively. Modified Amsler grid, red dot test, confrontational visual field, color vision, and stereoscopic fundus photography were unremarkable. HDTBR for 70 d induced peripapillary retinal thickening and cpRNFL thickening without visible signs of optic disc edema. The magnitude of such changes was not different between controls and exercisers. A slight IOP increase during BR subsided post-BR. Further study should evaluate whether different physical exercise paradigms may prevent/mitigate the risk of space-related visual impairment.Taibbi G, Cromwell RL, Zanello SB, Yarbough PO, Ploutz-Snyder RJ, Godley BF, Vizzeri G. Ophthalmological evaluation of integrated resistance and aerobic training during 70-day bed rest. Aerosp Med Hum Perform. 2017; 88(7):633-640.

The association of smokeless tobacco use and pack-years of smokeless tobacco with age-related macular degeneration in Indian population

Aim: To explore the association of use versus no use and the influence of pack-year use of smokeless tobacco with that of early and late age-related macular degeneration (AMD) in rural and urban south Indian population. We hypothesized that the use and pack-years of use would be significantly associated with both early and late AMD. We therefore sought to examine subjects who gave a history of using smokeless tobacco and we quantified the usage as pack-years, to examine the association with that of early and late AMD.Materials and methods: This was part of Sankara Nethralaya: Rural–Urban Age-related Macular degeneration study (SN-RAM study), which was conducted between 2007 and 2010. Subjects aged 60 years or older or those turning 60 in the present calendar year, with a history of using smokeless tobacco were noted along with duration and number of packs used per day. Smokeless tobacco was defined as chewed-tobacco (loose leaves) and/or snuff (finely chopped tobacco). Subjects underwent detailed ophthalmic evaluation including cataract grading using the Lens Opacities Classification System (LOCS III), 45° 4-field stereoscopic fundus photography and AMD evaluation. Pack-years of smokeless tobacco use was stratified as <15, 15–34 and ≥35 years; the association of tobacco use and pack-years of use with that of early and late AMD was examined. A p value of < 0.05 was considered statistically significant.Results: The number of smokeless tobacco users was significantly higher in rural (n = 767) than in urban groups (n = 281), p < 0.001. Of the 1048 users, 238 subjects (23%) provided details regarding quantification of use. There were no significant differences in the pack-years between rural and urban areas, p = 0.756 or that between AMD and no AMD, p = 0.562. Use of smokeless tobacco compared with no use was significantly associated with late AMD, OR= 3.178, 95%CI: 1.095, 9.227, p = 0.033, when adjusted for age, gender, rural-urban differences, presence of diabetes, socioeconomic status, systolic and diastolic blood pressure, total cholesterol, low-density and high-density lipoprotein levels. The association was not significant for early AMD, p = 0.582. The pack-years of use did not show a statistically significant association with early or late AMD. Furthermore, out of the 1048 subjects, 547 reported as using areca nut. Of which, 415 (75.8%) subjects had no AMD, 119 (21.7%) showed evidence of early AMD and 13 (2.4%) had late AMD. There was no significant association between the use of areca nut and early AMD, (X2 (1, N = 930) = 2.345, p = 0.126) or with that of late AMD (X2 (1, N = 761) = 0.075, p = 0.785).Conclusions: Smokeless tobacco use compared with no use, is associated with late AMD, regardless of the pack-years of use. Tobacco use is a modifiable risk factor. Efforts to reduce or stop the use of smokeless tobacco is indicated in an effort to prevent vision loss with respect to late AMD.

A Revised Approach for the Detection of Sight-Threatening Diabetic Macular Edema

Diabetic macular edema is one of the leading causes of vision loss among working-age adults in the United States. Telemedicine screening programs and epidemiological studies rely on monoscopic fundus photography for the detection of clinically significant macular edema (CSME). Improving the accuracy of detecting CSME from monoscopic images could be valuable while recognizing the limitations of such detection in an era of optical coherence tomography detection of diabetic macular edema. To evaluate the screening test accuracy of radially arranged sectors affected by hard exudates in the detection of CSME. This investigation was a cross-sectional study of CSME grading in monoscopic images using a sectors approach. The Early Treatment Diabetic Retinopathy Study criteria were used to confirm the presence of CSME by the following 2 methods: stereoscopic fundus photography (method 1) and dilated biomicroscopy in combination with optical coherence tomography (method 2). Participants were recruited at a university-based practice between June 14, 2014, and December 28, 2015. Area under the receiver operating characteristic curve, sensitivity, specificity, positive predictive value, and negative predictive value. A total of 207 eyes from an ethnically/racially diverse group of 207 patients (mean [SD] age, 53.6 [10.8] years; 58.9% [122 of 207] female) were included in the analysis. Twelve eyes (5.8%) were diagnosed as having CSME based on method 1. The intermethod and intergrader agreement for CSME diagnosis and sector count was substantial (κ range, 0.66 [95% CI, 0.47-0.85] to 0.75 [95% CI, 0.53-0.97]; P < .001 for all). Area under the receiver operating characteristic curve was 93.2% (95% CI, 84.2%-100%) when evaluating a sectors approach against method 1 as a reference test and offered up to an 8.6% (95% CI, 3.0%-14.3%) increase in specificity compared with the existing methods of detection. The positive predictive value was 33.3% (95% CI, 25.6%-45.5%), and the negative predictive value was 98.1% (95% CI, 96.9%-100%). The results were similar when comparing a sectors approach with method 2 as a reference test. A sectors approach shows good screening test characteristics for the detection of CSME. Its implementation in the existing telemedicine programs would require minimal resources. This approach will have the greatest effect in a setting where implementation of optical coherence tomography, a more objective and sensitive way to detect retinal thickening, is not feasible. The proposed method also may be easily incorporated in the automated diabetic retinopathy detection algorithms.

Distribution of intraocular pressure, central corneal thickness and vertical cup-to-disc ratio in a healthy Iranian population: the Yazd Eye Study.

To determine the distribution of intraocular pressure (IOP), central corneal thickness (CCT) and vertical cup-to-disc ratio (VCDR) in the healthy Iranian population. This population-based, epidemiologic study evaluated Iranian aged 40-80years, residing in Yazd, Iran, in 2010-2011. Eligible subjects were selected by cluster random sampling. Each participant underwent an interview and ophthalmologic examination including slit lamp examination, Goldmann applanation tonometry, binocular optic disc evaluation, stereoscopic fundus photography, ultrasonic pachymetry and visual field testing. Of 2320 eligible individuals, 2098 subjects (response rate of 90.4%) participated in the study. One eye from 1159 subjects (total of 2262 normal eyes) were randomly selected for the purpose of the study. Mean age was 53.1±9.6years. Mean IOP, CCT and VCDR were 14.2±2.5mmHg, 543±37μm and 0.32±0.14, respectively. Multiple regression analysis showed a significant correlation between IOP and age (regression coefficient=0.02 per year, p=0.015), CCT (regression coefficient=0.02 per micron, p<0.001), Spherical equivalent (regression coefficient=-0.15 per dioptre, p=0.0.024) and smoking (regression coefficient=0.89 higher for smokers, p=0.009); it also showed a significant correlation between CCT with spherical equivalent (regression coefficient=3.6 per dioptre, p=0.002) and IOP (regression coefficient=3.6 per mmHG, p<0.001). There was no significant correlation with VCDR. Mean IOP, CCT and VCDR were 14.2±2.5mmHg, 543±35μm and 0.32±0.14, respectively, in healthy Iranians that is different from other ethnicities. It seems advisable to pay attention to ethnicity for interpretation of each person's variables.

Six-year prevalence and incidence of diabetic retinopathy and cost-effectiveness of tele-ophthalmology in Manitoba

ObjectiveThe purpose of this study was to evaluate the diabetic retinopathy (DR) tele-ophthalmology screening program in Manitoba to determine prevalence and incidence of DR, as well as to estimate the program’s cost-effectiveness. DesignRetrospective chart review. ParticipantsA total of 4676 patients with type 2 diabetes examined 9334 times from 2007 to 2013. MethodsFocused ophthalmic histories were recorded and examinations were performed by trained nurses, including visual acuities, intraocular pressure, and mydriatic 7 standard field stereoscopic fundus photography. Images were evaluated by retinal specialists according to the Early Treatment of Diabetic Retinopathy Study criteria. DR prevalence and incidence were then calculated during the study period. Cost-effectiveness was estimated by comparing the cost of running the tele-ophthalmology program compared with the cost of screening the same volume of patients in-office. ResultsThe average prevalence of any DR in each year was 25.1%. The cumulative incidence of DR across 6 years was 17.1% (95% CI, 15.4%–18.7%). The average savings per tele-ophthalmology examination was $1007. ConclusionsDR is highly prevalent among the studied population. Tele-ophthalmology provides a cost-effective means of monitoring patients as well as identifying new or treatable disease.

Morphological assessment of the retina in uveitis.

BackgroundThe objective of this study is to describe a system for color photograph evaluation in uveitis and report baseline morphologic findings for the Multicenter Uveitis Steroid Treatment (MUST) Trial.Four-hundred seventy-nine eyes of 255 subjects with intermediate, posterior, and panuveitis had stereoscopic color fundus photographs obtained by certified photographers and evaluated by certified graders using standardized procedures to evaluate morphologic characteristics of uveitis. The posterior pole was evaluated for macular edema, vitreoretinal interface abnormalities, and macular pigment disturbance/atrophy; the optic disk was assessed for edema, pallor, or glaucomatous changes. The presence of neovascularization, vascular occlusion, vascular sheathing, and tractional retinal changes was determined. A random subset of 77 images was re-graded to determine the percentage agreement with the original grading on a categorical scale.ResultsAt baseline, 437/479 eyes had images available to grade. Fifty-three eyes were completely ungradable due to media opacity. Common features of intermediate and posterior/panuveitis were epiretinal membrane (134 eyes, 35 %), and chorioretinal lesions (140 eyes, 36 %). Macular edema was seen in 16 %. Optic nerve head and vascular abnormalities were rare. Reproducibility evaluation found exact agreement for the presence of chorioretinal lesions was 78 %, the presence and location of macular edema was 71 %, and the presence of epiretinal membrane was 71 %. Vertical cup-to-disk ratio measurement had intra-class correlation of 0.75.ConclusionsThe MUST system for evaluating stereoscopic color fundus photographs describes the morphology of uveitis and its sequelae, in a standardized manner, is highly reproducible, and allows monitoring of treatment effect and safety evaluation regarding these outcomes in clinical trials.Electronic supplementary materialThe online version of this article (doi:10.1186/s12348-016-0103-2) contains supplementary material, which is available to authorized users.