Age-related macular degeneration: diagnosis and management.

BACKGROUND: Age-related macular degeneration (AMD) is a leading cause of blind registration in Western Europe and the third leading cause of blindness worldwide. METHODS: The management of AMD is discussed with a review of current and new treatments. RESULTS: Although there is no treatment for advanced dry AMD (geographic atrophy), there have been considerable advances in the management of neovascular AMD (nAMD). Established therapies for nAMD include laser photocoagulation and photodynamic therapy (PDT), but these have largely been superseded by agents which block the action of vascular endothelial growth factor (anti-VEGF agents). Current preventative strategies involve cessation of smoking and use of specific nutritional supplements to reduce the risk of developing nAMD. CONCLUSIONS: There have been exciting advances in the treatment of nAMD and increased understanding of the genetics and pathogenic mechanisms involved will hopefully lead to the development of new therapies in the future.

Entonox as an analgesic agent during panretinal photocoagulation.

BACKGROUND/AIMS: Panretinal photocoagulation (PRP) reduces the risk of visual loss in proliferative diabetic retinopathy but some patients cannot tolerate PRP because of pain. Inhaled Entonox was evaluated as an analgesic during PRP. METHODS: A randomised, crossover, double masked pilot study was performed. Patients inhaled either air or Entonox and half the PRP was applied. The treatment was completed with the alternate inhaled gas. Patients graded pain experienced during both stages of the treatment using a visual analogue scale. Pain scores were compared using a paired t test. RESULTS: 20 patients participated. Mean pain scores from the Entonox and air treatments were 2.94 (SD 2.73) versus 3.73 (SD 3.20) respectively (p<0.03). CONCLUSION: Entonox can be used as a safe and effective analgesic agent during PRP treatment.

Automated detection of diabetic retinopathy on digital fundus images.

AIMS: The aim was to develop an automated screening system to analyse digital colour retinal images for important features of non-proliferative diabetic retinopathy (NPDR). METHODS: High performance pre-processing of the colour images was performed. Previously described automated image analysis systems were used to detect major landmarks of the retinal image (optic disc, blood vessels and fovea). Recursive region growing segmentation algorithms combined with the use of a new technique, termed a 'Moat Operator', were used to automatically detect features of NPDR. These features included haemorrhages and microaneurysms (HMA), which were treated as one group, and hard exudates as another group. Sensitivity and specificity data were calculated by comparison with an experienced fundoscopist. RESULTS: The algorithm for exudate recognition was applied to 30 retinal images of which 21 contained exudates and nine were without pathology. The sensitivity and specificity for exudate detection were 88.5% and 99.7%, respectively, when compared with the ophthalmologist. HMA were present in 14 retinal images. The algorithm achieved a sensitivity of 77.5% and specificity of 88.7% for detection of HMA. CONCLUSIONS: Fully automated computer algorithms were able to detect hard exudates and HMA. This paper presents encouraging results in automatic identification of important features of NPDR.

Detection of retinal lesions after telemedicine transmission of digital images.

PURPOSE/BACKGROUND: To assess whether loss of image resolution or colour and subsequent telemedicine transmission of digital images affects the accuracy of retinal lesion detection by ophthalmologists when compared with the original transparencies. METHODS: Fifteen ophthalmologists of different experience independently scored 11 retinal images for pathological signs. The images were presented as either transparencies or colour and monochrome digital images, which had been transmitted via telephone lines to a geographically remote location. One patient's eye was also imaged using scanning laser ophthalmosocopy (SLO) which produced a dynamic black and white digital image. ANOVA analysis was performed. RESULTS: Total scores were higher for transparencies than colour (p = 0.0003) or black and white digital images (p = 0.00006). Expert observers (n = 5) considered separately showed no significant difference of accuracy between transparencies and either colour digital (p = 0.09) or monochrome digital images (p = 0.11). Experts were better than trainees at detecting pathology from less familiar images: total score (p = 0.02), colour digital (p = 0.03), monochrome digital (p = 0.02) and SLO images (p = 0.004). CONCLUSION: Experienced observers can identify sight-threatening retinal pathology from poorer-resolution digital images that have been transmitted by telemedicine. They can also adapt to viewing less familiar images such as black and white digital or SLO images.

Automated localisation of the optic disc, fovea, and retinal blood vessels from digital colour fundus images.

AIM: To recognise automatically the main components of the fundus on digital colour images. METHODS: The main features of a fundus retinal image were defined as the optic disc, fovea, and blood vessels. Methods are described for their automatic recognition and location. 112 retinal images were preprocessed via adaptive, local, contrast enhancement. The optic discs were located by identifying the area with the highest variation in intensity of adjacent pixels. Blood vessels were identified by means of a multilayer perceptron neural net, for which the inputs were derived from a principal component analysis (PCA) of the image and edge detection of the first component of PCA. The foveas were identified using matching correlation together with characteristics typical of a fovea-for example, darkest area in the neighbourhood of the optic disc. The main components of the image were identified by an experienced ophthalmologist for comparison with computerised methods. RESULTS: The sensitivity and specificity of the recognition of each retinal main component was as follows: 99.1% and 99.1% for the optic disc; 83.3% and 91.0% for blood vessels; 80.4% and 99.1% for the fovea. CONCLUSIONS: In this study the optic disc, blood vessels, and fovea were accurately detected. The identification of the normal components of the retinal image will aid the future detection of diseases in these regions. In diabetic retinopathy, for example, an image could be analysed for retinopathy with reference to sight threatening complications such as disc neovascularisation, vascular changes, or foveal exudation.

Natural history of diabetic macular streak exudates: evidence from a screening programme.

BACKGROUND/AIMS: Diabetic retinopathy screening guidelines recommend referral to an ophthalmologist if there is exudate within one disc diameter of the fovea. Many of these patients, however, have resolution of small amounts of exudate without treatment. This study aimed to assess whether patients with minimal streak or dot exudates within one disc diameter of the fovea can be monitored in a screening programme without compromising visual acuity. METHODS: A retrospective review of records and Polaroid photographs obtained by one screening centre over a 10 year period was performed. Outcomes measured were referral rates, alteration of Snellen visual acuity, and the need for macular photocoagulation treatment. RESULTS: 55 patients (74 eyes) fulfilled entry criteria (37 streak and 37 dot exudates). Mean follow up was 56.1 months (range 12-127 months). Twenty five patients (30 eyes) were referred to an ophthalmologist. 13 eyes (17.6%) required macular photocoagulation treatment. Four eyes (5.4%) lost two or more lines of Snellen acuity over the follow up period (three from macular oedema and one from macular ischaemia). There was no relation between the presence or resolution of minimal exudate and visual loss (p>0.2). CONCLUSION: It is appropriate to monitor eyes with streak or dot macular exudates at 6-9 monthly intervals in a screening programme.

Meaning in the use of unconventional arthritis therapies.

PURPOSE: To determine the meanings that rural adults have for 11 different unconventional arthritis remedies. METHODS: Interviews were conducted with 219 adults from a nonmetropolitan North Carolina county. Open-ended responses to questions surrounding the use of 11 unconventional arthritis therapies were tape recorded and transcribed verbatim. A variable-based approach was used to analyze and interpret these qualitative data. RESULTS: Several themes were present for the different unconventional therapies. The most extensive set of themes was present for religion, which included faith, transformation, communion, self-help, and spiritual healing. The mechanical aspect of rubbing used in the application of several therapies (ointments as well as turpentine) was also an important theme. Skepticism about the effectiveness of the unconventional therapies was another pervasive theme. CONCLUSIONS: The respondents had a consistent set of meanings about the unconventional therapies that transcended gender and ethnic groups. Understanding the meanings or belief systems of rural adults is essential to the development of culturally appropriate health education and intervention.

Gender and ethnic differences in alternative and conventional arthritis remedy use among community-dwelling rural adults with arthritis.

OBJECTIVE: To examine the frequency of, and the ethnic and gender differences in, the use of arthritis remedies among rural adults. METHODS: Interviews were conducted with 219 adults from a nonmetropolitan North Carolina county. Participants reported whether they ever used and still used 19 remedies. Participants were evaluated for the actual presence of arthritis and functional capacity. Analysis included descriptive statistics and multivariate logistic regression. RESULTS: Participants used a variety of alternative and conventional remedies, with prayer (92%) being most widely used. Prescription medicine was used by 60%. Differences in remedy use included European-Americans making greater use of conventional remedies and African-Americans making greater use of some alternative remedies. Those with greater functional disability have used alternative remedies, but they still used prescription medicine. CONCLUSIONS: Rural individuals use a variety of remedies, with differences by gender, ethnicity, and functional capacity. Future research must examine the role of gender, culture, residence, and disease severity in arthritis remedy use decisions.

Continuing education for health professionals.

Although continuing education in the health professions is an important endeavor, it has been largely neglected in the professional literature. Few studies have been done on (a) conceptual models to guide the design and implementation of continuing education and (b) the use of such models in continuing education. To fill this gap, two such models are described in this article: (a) instructional development and (b) community development. Combining and using these models can lead to more effective continuing education with more enduring effects. Principles to guide the implementation of these models are presented. An arthritis continuing education project based on the instructional and community development models is used to illustrate these principles. This continuing education project focused on occupational and physical therapists in clinical practice.

Development and validation of the Attitude Toward Arthritis Patients Scale (ATAPS).

The development and validation of a four-item scale, the ATAPS, measuring attitude toward working with arthritis patients is described. Three separate samples of occupational and physical therapists were surveyed. Data from the first random sample were used to select a reliable subset of items from a larger pool and to provide a baseline for comparison with the second sample. The second sample comprised arthritis workshop attendees and confirmed the scale's reliability and its ability to differentiate between therapists with an active interest in arthritis and a group with no special interest in the disorder. The third stratified random sample further confirmed the scale's reliability and demonstrated that the ATAPS scores were associated with the number of arthritis patients in therapists' practices but not with measures of professional experience unrelated to arthritis.