Barriers to compliance with screening guidelines for diabetic retinopathy.

OBJECTIVE: To identify barriers to compliance with guidelines for diabetic retinopathy screening. METHODS: The population studied included 4410 adults, aged 31 to 64, enrolled in an Independent Practice Association (IPA) plan in Upstate New York, who were diagnosed with diabetes, and their Primary Care Physicians (408 PCPs). Claims data were used to calculate variables characterizing patients and their PCPs. Logistic regression models were estimated to identify factors associated with higher probability of screening. RESULTS: 34% of patients were screened in 1993. The probability of screening was significantly higher for older patients, for women, for patients who visit their PCPs more often and for those living in areas of higher average education and lower percentage of blacks. However, only 16% of diabetic patients received an annual screen in two consecutive years (1992 and 1993). The probability of consecutive annual screening was significantly associated only with gender and patient expenditures per month. CONCLUSION: The very low rate of diabetic retinopathy screening has implications for quality of life of patients with diabetes, long term costs of caring for them and social costs due to lost productivity. Interventions to increase screening rates are needed and should target both patients and their Primary Care Physicians.

Fusion after surgical alignment of longstanding strabismus in adults.

BACKGROUND: Fusion and the development of the monofixation syndrome are well recognized after surgical alignment of congenital esotropia to within 8 delta of orthotropia. However, in adults with longstanding strabismus and a history of congenital esotropia who are not surgically aligned within the first few years of life, the prognosis for the development of fusion is believed to be poor. METHODS AND RESULTS: Twenty-four adults, 12 with a history of congenital esotropia (onset before 6 months age), 1 of congenital exotropia, and 11 with the onset of esotropia between 6 months and 2 years, were included in this study. All patients had longstanding strabismus, and none had been surgically aligned within the first 2 years of life. No patient had visual acuity worse than 20/30 in the worse eye. Preoperatively, no patient demonstrated fusion with the red glass test, Worth four-dot, or Titmus test. Postoperatively, all were aligned to within 8 delta of orthotropia, and all demonstrated peripheral fusion with the Worth four-dot at near. Twelve patients (50%), 8 of whom were in the congenital group, achieved stereopsis of 200 seconds of arc or better using the Titmus stereo test. CONCLUSION: These findings suggest that surgery in this group of patients not only eliminates the ocular alignment deformity but can confer the functional benefits of fusion and increased field of binocular vision.

Treatment of unilateral acute sixth-nerve palsy with botulinum toxin.

We studied 29 consecutive patients with acute unilateral sixth-nerve palsy, who received botulinum toxin injection to the antagonist medial rectus muscle. The average interval between onset of palsy and treatment was 40 days and the mean follow-up from the last injection was 14 months. Before treatment, esotropia in the primary position ranged from 12 to 45 prism diopters and limitation to abduction in the affected eye ranged from -2 (approximately 15 degrees lateral to midline) to -6 (15 degrees nasal to midline). After treatment, 22 of 29 patients (76%) had complete recovery of motility as determined by version testing. Of the seven patients with a residual abduction deficit, two had fusion in the primary position, three had fusion with prismatic correction, and two patients required subsequent surgery. Botulinum toxin injection seems to be an effective treatment option in cases of acute unilateral sixth-nerve palsy.

The diagnosis of amblyopia in cross-fixation.

Customarily, it is taught that cross-fixation, in a patient with congenital esotropia, obviates the development of amblyopia. However, our clinical experience has shown significant amblyopia in 50% of cross-fixators. In our hands, the diagnosis of amblyopia is made based on the point at which alternation of fixation takes place. By this method, if there is equal visual acuity, alternation will occur at the midline with each eye. If amblyopia exists, the sound eye will continue to follow the target beyond midline, into abduction, before the poorer seeing eye picks up fixation. In order to test the reliability of this method, using Teller acuity cards as the standard, we compared estimates of objective and subjective vision in 25 consecutive patients with congenital esotropia and cross-fixation. Our findings suggest that there may be a significant prevalence of amblyopia in cross- fixating patients and that the point at which alternation of fixation occurs is a reliable means of detecting a difference in visual acuity between the two eyes.

Oblique muscle palsies fixating with the paretic eye.

Palsy of the superior oblique muscle is one of the most commonly occurring entities in strabismus; the clinical characteristics are easily recognizable. Isolated inferior oblique muscle palsy, although anatomically enigmatical, is also known to ophthalmologists. When a patient with an oblique muscle palsy chooses to fixate with the paretic eye, characteristic patterns of motility may be obscured. Patients with superior oblique muscle palsy or isolated inferior oblique muscle palsy who habitually fixate with the paretic eye, may present with limited elevation or depression respectively. In each case, limited motility exists secondary to decreased innervational input to the contralateral antagonist of the paretic muscle, or to a mechanical restriction caused by prolonged contracture of the yoke of the paretic muscle. Inhibitional palsy of the contralateral antagonists and the fallen and rising eye syndromes may present diagnostic dilemmas unless the underlying oblique muscle palsy is recognized. Proper diagnosis may be obtained with three clinical tests; the 3-step test, the comparison of ductions to versions, and forced ductions.

The deterioration of accommodative esotropia: frequency, characteristics, and predictive factors.

A number of patients with accommodative esotropia who are initially well controlled in their spectacle correction will deteriorate. To obtain an overall estimate of the prevalence of deterioration and to examine the associated clinical features for an indication of which factors may influence deterioration, 114 charts of patients with the diagnosis of accommodative esotropia, who were followed for a period of at least 10 years, were reviewed. Results of this review showed that 15 of the 114 patients (13%) deteriorated. Overall, 73 patients had a normal AC/A ratio (viz less than 5:1 by the gradient method) and 41 patients had a high AC/A ratio; deterioration occurred in statistically identical proportions in each group. There was an increasing frequency of deterioration the longer the delay between the onset of esodeviation and prescription of optical correction. In addition, deterioration was found to be most prevalent in patients for whom the age of onset was 24 months or younger. Other parameters were consistent with features typically reported in cases of accommodative esotropia.

Stability of visual acuity in amblyopic patients after visual maturity.

One hundred thirty patients with strabismic amblyopia who underwent full-time occlusion therapy (FTO) and were followed through to at least 9 years of age were evaluated to determine the stability of visual acuity after visual maturity (after 9 years of age). Of these 130 patients, 89 are included in this review. At the conclusion of the FTO therapy, 92% (82/89) had attained a visual acuity of 20/40 or better, 6% (5/89) had attained 20/50-20/100, and 2% (2/89) remained at 20/200 or less. Of the nine patients in this series in whom patching was initiated between the ages of 6 and 9 years of age, a good visual result was seen in 89% (8/9), with 63% (5/8) of those attaining 20/20 vision. The final visual acuity in this group of patients was taken at an average patient age of 15.9 years. In 75% of the patients (67/89) there was no change in visual acuity over time, while 17% (15/89) showed a one- or two-line decrease, and in 8% (7/89) vision dropped more than two lines. Of those patients who had greater than or equal to 20/40, 88% (56/64) who had a posttreatment visual acuity of 20/20 showed no change at the final evaluation, but only 50% (9/18) of those whose posttreatment vision was between 20/25 and 20/40 were stable. In those patients who needed part-time occlusion (PTO) to maintain equal visual acuity, their stability appeared to be the same as the vision of those whose vision was maintained without PTO.