The value of routine dilated pupil screening examination.

We evaluated the cost-effectiveness of routine dilated fundus examination in improving visual outcomes. The cost of routine dilated fundus examination was related to the number of preventable cases of vision-threatening peripheral retinal disease. Patients with these diseases who had no risk factors were ascertained in a population of 1.75 million adults for a period of 6 months. Those whose last examination had been undilated were identified because only for them could routine dilated examination (RDE) have been substituted for undilated examination. The number of preventable cases was calculated for multiples of a 10% probability of prevention. The cost of RDE was determined from the number of undilated examinations in the same population and period and the cost of a single RDE. The number of patients who underwent undilated examination was estimated by random medical record review. The additional cost of a single RDE was determined from estimated examination times and payroll costs. Among patients without risk factors, 38 were identified for whom undilated examination rather than RDE had been performed. If prevention had been 10% effective, the substitution of 50,000 RDEs for undilated examinations costing the provider $433,000 would have been required per prevented case. These results suggest that most peripheral retinal diseases cannot be prevented by RDE. Routine dilated examination is an expensive test per prevented case. Published clinical guidelines lack evidence to recommend its use.

Synergism between diabetic and radiation retinopathy: case report and review.

It is suspected that radiation retinopathy is more likely to develop in an eye with preexisting diabetic retinopathy than in a normal eye. However, there is only one report of this occurring, at a radiation dose of 4500 rads. We present a woman with minimal diabetic retinopathy who had breast carcinoma which was treated with chemotherapy but metastasised to the choroid. Within nine months of external beam radiation (3000 rads in fractions of 200 rads) a fulminant retinopathy evolved in that eye, while the non-radiated eye showed no change. The histopathology of radiation and diabetic retinopathy and causes for possible synergism are discussed. As this case report shows, radiation oncologists and ophthalmologists need to be aware of the risk that patients with minimal diabetic retinopathy who have undergone chemotherapy may suffer a dramatic visual loss from radiation therapy despite a radiation dose which is considered adequate, safe, and properly fractionated.

Extended retinal tamponade in the treatment of retinal detachment with proliferative vitreoretinopathy.

We have used intraocular sulphur hexafluoride or liquid silicone as an adjunct to vitreous surgery in the treatment of a non-randomised sequential series of 19 eyes with retinal detachment complicated by proliferative vitreoretinopathy. We have studied the surgical results and complications of these two tamponades and drawn preliminary conclusions on their use in retinal reattachment surgery. After a seven-month minimum follow-up 13 (68%) of the eyes have reattached retinas. Six (60%) of 10 eyes treated only with silicone have reattached retinas, and four (67%) of six eyes treated only with sulphur hexafluoride gas tamponade have reattached retinas. An additional three eyes treated initially with silicone oil subsequently developed retinal detachments; all were successfully reattached with sulphur hexafluoride tamponade after silicone oil removal. Intraoperative pneumatic retinal reattachment to assess relief of retinal traction combined with the production of widespread chorioretinal adhesions to wall off persistent anterior traction and detachment, as well as extended postoperative gas tamponade of the retina, appears to enhance the surgical results in retinal detachment complicated by proliferative vitreoretinopathy. Silicone oil tamponade of the retina appears to be useful in cases where retinal traction cannot be entirely relieved and in patients who are unable to tolerate the head positioning required for effective gas tamponade of the retina. A controlled clinical study recently begun will be required to define further the precise role of these methods of retinal tamponade.

Functional visual effects of lesions located near the optic nerve head.

Three patients with retinal lesions near or impinging on the optic nerve head are presented. Three different functional disruptions are demonstrated by quantitative layer-by-layer perimetry. In one, a patient who primarily exhibited subretinal neovascularization, inner retinal functions were anomalous; but the overlying nerve fiber bundle was as yet not affected. In the second patient, an individual with possible histoplasmosis causing an outer retinal/choroidal lesion, the overlying nerve fiber bundle was affected causing apparent retrograde changes in inner retinal function at remote visual field locations; but another aspect of optic nerve function (time-dependent response) was not anomalous. These apparently retrograde changes were essentially identical to functional changes previously demonstrated in patients with established open-angle glaucoma. In the third patient, with presumed toxoplasmosis, there were clear-out time-dependent anomalous responses consistent with optic nerve involvement, as previously reported in patients with optic neuritis. There were also modest, time-stable, nerve fiber bundle defects present in this third patient. Together, these results demonstrate that lesions in the area of the disc can have very different functional consequences, and that quantitative psychophysical techniques can elucidate these differences.

Joint application of hyperacuity perimetry and gap tests to assess visual function behind cataracts: initial trials.

We have developed two related clinical tests that offer potential in better assessing visual function behind an ocular opacity. The tests are resistant to the effects of opacities because they utilize a localization task (vernier acuity) rather than a resolution task. In this paper we report the initial trials in which we apply the two tests together. Results from six case studies (some with actual opacities and some with simulated opacities) illustrate both the conduct of the tests and their potential capabilities in detecting even very modest retinal dysfunction in the presence of opacities. These techniques offer considerable potential in the separation of a given acuity loss observed in the presence of cataract into a portion due to the opacity and a portion due to retinal dysfunction.

Paradoxic pupillary constriction in a patient with congenital stationary night blindness.

Paradoxic pupillary constriction to an "off-step" of light was studied in a 35-year-old woman with congenital stationary night blindness. ERG was of the Schubert-Bornschein type (scotopic B-wave absent); fundi were normal for a high myope. Paradoxic constrictions were larger in response to full field and peripheral off-steps from low photopic levels than from higher photopic levels. The patient's "on response" was smaller in magnitude and slower in both latency and dynamics than the on-response of normal subjects. Pupillary hippus was larger in magnitude and more peaked in the patient than in normal subjects. Steady-state (tonic) pupil size increased paradoxically with increased light level over the range 1-2 log fL.

Degenerative retinoschisis with giant outer layer breaks and retinal detachment.

Five unusual cases of retinal detachment were caused by giant (more than 90 degrees) posterior breaks in the outer layer of degenerative retinoschisis. All retinas were successfully reattached by a variety of surgical techniques. The two cases managed with scleral buckling required subsequent buckle removal because of macular distortion. Treatment with cryotherapy or laser, together with intraocular air and postoperative positioning, gave better anatomic results.

Hyperacuity perimetry. Assessment of macular function through ocular opacities.

"Hyperacuity perimetry" provides localized measures of visual performance across the central visual field that are resistant to the retinal image degradation caused by media opacities. A normal observer, viewing a vernier stimulus through an artificial opacity (ground glass), exhibits a pronounced performance improvement with foveal viewing, relative to viewing at visual field points just 2 degrees to 4 degrees parafoveal. Patients with central lesions exhibit anomalous hyperacuity perimetric profiles, even in the presence of a simulated ocular opacity. We conclude that in patients with media opacities, hyperacuity perimetry can preoperatively evaluate the distribution and size of areas of visual loss across the central visual field and the stability and location of primary fixation. This potentially powerful test of macular function behind media opacities is as easy to apply as any static visual field measurement.

Helium ion therapy for choroidal melanoma.

Eighty-two patients with choroidal melanomas were treated with helium ion charged particle irradiation. Seventy-eight of 82 patients have either remained stable or demonstrated tumor shrinkage. Forty-five of 46 patients followed for at least 1 year after therapy have demonstrated tumor regression with a mean tumor shrinkage of approximately 31%. No tumor-related mortality has been observed. The most effective method of choroidal melanoma management is unclear. Charged particle external beam irradiation may be more applicable and have less ocular morbidity than either radioactive plaques or photocoagulation.

Paradoxical pupil in congenital achromatopsia.

Children with congenital achromatopsia possess an interesting paradoxical pupillary constriction to darkness that has not been previously described. This paper describes three children in whom this paradoxical pupillary reaction was documented with infrared pupillometry. The literature on the pupil in achromatopsia is reviewed and a tentative testable model of the reaction is hypothesized.

Helium ion charged particle therapy for choroidal melanoma.

Nine patients with choroidal melanomas were treated with helium ion charged particle irradiation. No patient demonstrated tumor enlargement, and most lesions followed for more than five months have demonstrated tumor shrinkage. The most effective method of choroidal melanoma management is unclear. Heavy charged particle irradiation may be more applicable and have less ocular morbidity associated with it in either radioactive plaques or photocoagulation.

Bare sclera closure in retinal detachment surgery.

Our modification of the limbal peritomy technique in retinal detachment surgery involved recession of the confunctiva 3 mm posterior to the corneoscleral limbus as the conjunctiva was closed. This recession offered some advantages over the standard nonrecessed method: fewer sutures were required; postoperative ophthalmoscopy was not impaired by conjunctiva swelling over the cornea; the eye was comfortable and quiet in appearance because there was no suture material or inflamed conjunctiva adjacent to the corneoscleral limbus. We have not encountered any disadvantages in several hundred cases.

A technique for improving corneal clarity during retinal surgery.

To maintain corneal clarity during scleral buckling operations, the surgeon firmly rolls a dry cotton applicator across the edematous corneal surface, and the epithelial edema fluid is pressed out and absorbed by the applicator. This technique, which may be repeated a number of times, reduces the number of cases that require removal of the epithelium.

Paradoxical pupillary responses in congenital stationary night blindness.

Three unrelated boys, ages 2, 6, and 10 years, who have congenital stationary night blindness with myopia and a Schubert-Bornschein-type electroretinogram finding, were found to show a "paradoxical" pupillary constriction in darkness. When examining room lights are turned out, the patient's pupils briskly constrict and slowly dilate. Older night blind male relatives of these boys did not show this abnormal constriction to darkness.

Vitelliform lesions developing in normal fundi.

Two patients with Best's macular dystrophy, photographically documented, developed vitelliform lesions in previously normal or nearly normal fundi. The patients were studied prospectively because their brother had Best's disease. The first patient, a 6-year-old boy, had normal-appearing fundi in February 1974, but in October 1974 he had developed a vitelliform lesion in the left macula. His electro-oculogram (EOG) was severely abnormal in both eyes. His 12-year-old syster had an essentially normal fundus appearance and an abnormal EOG in both eyes in November 1971. In October 1975, she had an extramacular vitelliruptive lesion in the right eye and a typical Best's lesion in the left macula.