Remote image based retinopathy of prematurity diagnosis: a receiver operating characteristic analysis of accuracy.

BACKGROUND/AIMS: Telemedicine offers potential to improve the accessibility and quality of diagnosis of retinopathy of prematurity (ROP). The aim of this study was to measure accuracy of remote image based ROP diagnosis by three readers using receiver operating characteristic (ROC) analysis. METHODS: 64 hospitalised infants who met ROP examination criteria underwent two consecutive bedside procedures: dilated examination by an experienced paediatric ophthalmologist and digital retinal imaging with a commercially available wide angle camera. 410 images from 163 eyes were reviewed independently by three trained ophthalmologist readers, who classified each eye into one of four categories: no ROP, mild ROP, type 2 prethreshold ROP, or ROP requiring treatment. Sensitivity and specificity for detection of mild or worse ROP, type 2 prethreshold or worse ROP, and ROP requiring treatment were determined, compared to a reference standard of dilated ophthalmoscopy. ROC curves were generated by calculating values for each reader at three diagnostic cut-off levels: mild or worse ROP (that is, reader was asked whether image sets represented mild or worse ROP), type 2 prethreshold or worse ROP (that is, reader was asked whether image sets represented type 2 prethreshold or worse ROP), and ROP requiring treatment. RESULTS: Areas under ROC curves ranged from 0.747-0.896 for detection of mild or worse ROP, 0.905-0.946 for detection of type 2 prethreshold or worse ROP, and 0.941-0.968 for detection of ROP requiring treatment. CONCLUSIONS: Remote interpretation is highly accurate among multiple readers for the detection of ROP requiring treatment, but less so for detection of mild or worse ROP.

Intravitreal triamcinolone for the treatment of refractory diabetic macular oedema with hard exudates: an optical coherence tomography study.

AIM: To investigate the use of intravitreal triamcinolone acetonide (IVTA) for the treatment of diabetic macular oedema (DMO) unresponsive to previous laser photocoagulation. METHOD: A retrospective, interventional, non-comparative case series. There were 30 eyes of 22 consecutive patients with refractory DMO. An intravitreal injection of triamcinolone acetonide at the dose of 4 mg in 0.1 ml was administered. Best corrected visual acuity was measured at each examination. In addition the central macular thickness was quantitatively measured by optical coherence tomography (OCT) examination at each visit. The amount of hard exudates deposition in the macula was subjectively evaluated using colour fundus photographs. RESULTS: 30 eyes of 22 patients completed 6 months or more of follow up and were included in the study. Mean (SD) visual acuity improved from 0.17 (0.12) at baseline to 0.34 (0.18), 0.36 (0.16), and 0.31 (0.17) at the 1, 3, and 6 month follow up respectively. Mean (SD) OCT macular thickness decreased from 476 (98.32) microm at baseline to 277.46 (96.77) microm, 255.33 (95.73) microm, and 331.25 (146.76) microm at the 1, 3, and 6 month follow up period respectively. 18 and seven eyes completed 12 months and 18 months of follow up, respectively. Mean (SD) visual acuity was 0.36 (0.15) and 0.35 (0.16) at the 12 and 18 month follow up period respectively. 12 eyes received two, seven eyes received three, and two eyes received four IVTA injections. The mean (SD) interval between the first and second IVTA injection was 5.7 (2.67) months and between the second and third was 5.7 (3.25) months. Hard exudates were present in the macula at baseline in all eyes. Progressive reduction in the number and size of the hard exudates was noted after IVTA in all cases. Intraocular pressure was raised above 21 mm Hg in 12 (40%) of 30 eyes. Two eyes developed posterior subcapsular cataract and two developed vitreous haemorrhage. CONCLUSIONS: IVTA is a promising treatment for patients with DMO refractory to laser treatment. IVTA is effective in improving vision, reducing macular thickness, and inducing reabsorption of hard exudates. Further investigation is warranted to assess the safety of IVTA for the treatment of DMO.

Effect of an intervention to reduce procedural pain and distress for children with HIV infection.

OBJECTIVE: To evaluate a multicomponent pain management intervention, including cognitive behavioral strategies, for children with human immunodeficiency virus (HIV) infection undergoing routine venipuncture. METHODS: Following a baseline venipuncture, children were exposed to an intervention including preparation, relaxation, distraction, reinforcement, parent involvement, and EMLA (eutectic mixture of local anesthetics) cream, and followed for three additional venipuncture procedures. After each procedure, child distress was rated on the Procedure Behavior Checklist (PBCL), child self-report of pain was obtained using the FACES scale, and parent anxiety was reported on the State Trait Anxiety Inventory-State Scale (STAI). RESULTS: Significant reductions in child distress and pain were found by the second postintervention procedure and maintained at the third. Parent anxiety was significantly reduced by the second postintervention procedure, but many parents chose not to participate in the third postintervention procedure. CONCLUSIONS: With repeated exposure, a multicomponent pain management intervention, including cognitive behavioral strategies and EMLA, appears effective at reducing pain, distress, and parent anxiety for children with HIV.

Pars plana vitrectomy for persistent, visually significant vitreous opacities.

PURPOSE: To evaluate the role of vitrectomy in patients with persistent, visually disabling vitreous opacities. METHODS: Six consecutive eyes of five men (age 58-66 years) with pseudophakia or aphakia and vitreous opacities resulting in visual symptoms for more than 1 year that underwent vitrectomy were retrospectively reviewed. Postoperative questionnaires regarding functional performance and quality-of-life issues were completed by the participants to assess subjective patient satisfaction. RESULTS: Postoperative Snellen visual acuity was improved or equal to preoperative acuity in all cases (8-44 month follow-up) and there were no surgical complications. All patients expressed high satisfaction with overall visual function. Analysis of the National Eye Institute Visual Function Questionnaire-39 indicated that general vision, near activities, distance activities, mental health, role difficulties, and peripheral vision were significantly improved (P < 0.05) following surgical intervention. CONCLUSIONS: Vitrectomy may be indicated in a select group of patients with visually disabling vitreous floaters, although objective assessment of visual dysfunction from vitreous floaters requires further evaluation.

Soluble cellular adhesion molecules in proliferative vitreoretinopathy and proliferative diabetic retinopathy.

PURPOSE: To measure vitreous levels of soluble intercellular adhesion molecule-1 (sICAM-1) and soluble vascular cellular adhesion molecule-1 (sVCAM-1) in the eyes of patients with retinal detachment (RD) due to proliferative diabetic retinopathy (PDR) or proliferative vitreoretinopathy (PVR) and to determine whether the levels of these mediators correlated with clinical parameters of disease. METHODS: Undiluted vitreous specimens were collected from 50 eyes of 48 patients undergoing vitrectomy for traction RD due to PDR (21 specimens) and recurrent RD due to PVR (19 specimens). Control vitreous specimens were obtained from patients undergoing macular hole repair (10 specimens). The levels of sICAM-1 and sVCAM-1 were measured in each sample by specific enzyme-linked immunoadsorbent assays. RESULTS: Vitreous levels of sICAM-1 were significantly increased in vitreous specimens from both PVR (median +/- SD; 12.0 +/- 76.3 ng/ml; P < 0.01) and PDR (8.4 +/- 24.0 ng/ml; P < 0.01) when compared to vitreous from eyes with macular holes (0. 3 +/- 4.2 ng/ml). Vitreous levels of sVCAM-1 were significantly increased in both PVR (36.5 +/- 255.2 ng/ml; P < 0.001) and PDR (26. 2 +/- 93.5 ng/ml; P < 0.01) when compared to control vitreous (17.7 +/- 7.8 ng/ml). The vitreous levels of sICAM-1 were higher in cases of PDR which developed recurrent proliferative disease (P < 0.01) and recurrent RD (P = 0.01), whereas the levels of sICAM-1 in PVR and sVCAM-1 in PDR and PVR did not significantly correlate with these clinical parameters. CONCLUSIONS: Soluble forms of ICAM-1 and VCAM-1 are increased in the vitreous cavity of patients with RD due to PDR or PVR, reflecting the inflammatory nature of these conditions and suggesting a possible role for these mediators in the pathogenesis of proliferative retinal disease. The vitreous levels of these sCAMs at the time of surgery may serve as a marker of inflammation, but their specific levels do not predict the likelihood of recurrent proliferation or surgical anatomic success in most cases of PVR and PDR.

Neovascular complications associated with rubeosis iridis and peripheral retinal detachment after retinal detachment surgery.

PURPOSE: To report clinical features and surgical management of neovascular complications associated with rubeosis iridis and peripheral retinal detachment after retinal detachment surgery in nondiabetic patients. METHODS: Seven consecutive eyes of seven nondiabetic patients who developed neovascular complications associated with rubeosis iridis and peripheral retinal detachment after scleral buckling and vitrectomy procedures were retrospectively reviewed. None of the eyes had clinical evidence of anterior segment ischemia or retinal vascular disease, but each eye developed rubeosis iridis and neovascular complications. RESULTS: Of the seven eyes with rubeosis iridis and peripheral retinal detachment, six developed recurrent or progressive vitreous hemorrhage, and three developed progressive neovascular glaucoma. Four eyes underwent a revision procedure to repair the peripheral retinal detachment, and anterior proliferative vitreoretinopathy was found in each of these cases. Rubeosis iridis regressed in all three eyes in which surgery resulted in complete reattachment of the retina. In one eye with persistent peripheral retinal detachment and in the three remaining eyes that did not undergo revision surgery, rubeosis iridis persisted and was associated with long-term neovascular complications. Final corrected visual acuity was 20/70 to 20/400 in three eyes with total retinal reattachment and no light perception to hand motions in four eyes with persistent peripheral retinal detachment and rubeosis iridis. CONCLUSION: Visually significant neovascular complications may occur in eyes that develop rubeosis iridis associated with peripheral retinal detachment after retinal detachment surgery in nondiabetic patients. Successful repair of the peripheral retinal detachment may induce regression of rubeosis iridis, reduce associated complications, and improve the long-term prognosis of these eyes.

Rifabutin-associated uveitis in an immunosuppressed pediatric patient without acquired immunodeficiency syndrome.

PURPOSE: To describe a case of bilateral, symptomatic rifabutin-associated uveitis with hypopyon and vitreal opacities in an immunosuppressed pediatric patient without acquired immunodeficiency syndrome (AIDS). METHOD: Case report. An 8-year-old boy presented with bilateral uveitis 24 months after a bilateral lung transplant. RESULTS: Our patient, whose medications included rifabutin, clarithromycin, and immunosuppressive agents, responded to discontinuation of the rifabutin and initiation of intensive topical corticosteroid therapy with complete resolution of the uveitis. CONCLUSION: Rifabutin-associated uveitis may occur in a non-AIDS pediatric patient.

Optic coherence tomography of optic disk pit maculopathy.

PURPOSE: To define the structure of optic disk pit maculopathy. METHODS: A patient was examined with optic coherence tomography before and after an intravitreal gas tamponade. RESULTS: Before intravitreal gas injection, optic coherence tomography defined a separation between the inner and outer layers of the retina that connected with the optic disk pit. An outer retinal layer detachment that centered on the fovea was also present. After pneumatic displacement of the intraretinal and subretinal fluid, optic coherence tomography disclosed that the two layers were opposed and in contact with the retinal pigment epithelium. CONCLUSIONS: Optic coherence tomography confirmed the two-layer structure of optic disk pit maculopathy and demonstrated the positive effect of pneumatic displacement.

Aging persons' estimates of vehicular motion.

Estimated arrival times of moving autos were examined in relation to viewer age, gender, motion trajectory, and velocity. Direct push-button judgments were compared with verbal estimates derived from velocity and distance, which were based on assumptions that perceivers compute arrival time from perceived distance and velocity. Experiment 1 showed that direct estimates of younger Ss were most accurate. Older women made the shortest (highly cautious) estimates of when cars would arrive. Verbal estimates were much lower than direct estimates, with little correlation between them. Experiment 2 extended target distances and velocities of targets, with the results replicating the main findings of Experiment 1. Judgment accuracy increased with target velocity, and verbal estimates were again poorer estimates of arrival time than direct ones, with different patterns of findings. Using verbal estimates to approximate judgments in traffic situations appears questionable.

The collagen shield as a collagenase inhibitor and clinical indicator of collagenase activity on the ocular surface.

Collagen shields applied to the corneas of patients with bacterial keratitis degrade rapidly, often within a few hours. Once treatment brings the infection under control, subsequently applied collagen shields degrade more slowly. In vitro models were established to evaluate the significance of these observations. Twenty-four and 72-hour collagen shields were incubated with collagenase from Clostridium histolyticum. The in vitro rate of digestion of the shields was directly proportional to the concentration of collagenase, with the rate of digestion of the 24-hour shields being greater than that of the 72-hour shields. Therefore, the rate of collagen shield degradation may be a clinically useful index of collagenase activity on the ocular surface. Ultrastructural studies of collagen shields from patients with acute bacterial keratitis revealed irregular degradation of shield matrix with no evidence of adherence of microorganisms or inflammatory cells. Co-incubation of deepithelialized rabbit corneas and collagen shields resulted in inhibition of the digestion of the rabbit corneas when the weight:weight ratio of collagen shield:rabbit cornea was increased to greater than or equal to 2:1. Collagen shields may inhibit corneal collagen degradation in infectious ulceration and melting disorders by effectively competing for collagenase on the ocular surface.

Accuracy of judging time to arrival: effects of modality, trajectory, and gender.

Observers' accuracy in using time-to-arrival (Ta) information was examined in 4 experiments. The issues included use of visual vs. acoustic Ta information, use of acoustic Ta information by blind Ss, use of Ta information controlling for velocity, and effects of angle of approach and arrival time on judgment accuracy. Visual information was used more efficiently than audiovisual and auditory information. Blind Ss used acoustical approach information as accurately as sighted Ss used visual information. Radial, oblique, and transverse orientations were used to examine effects of approach trajectory. Radial events were underestimated, whereas the more accurate transverse approach was likely to be overestimated. Oblique angle events yielded intermediate accuracies implying a spatiotemporal anisotropy. Women underestimated Ta more than did men. Possible reasons for Ss' judgment accuracy, including linear vs. nonlinear optical changes and relation to spatial skills and experience, were discussed.

Prospective study of metabolic abnormalities in patient with continent Kock pouch urinary diversion.

Metabolic alterations as a result of bowel being employed in the urinary tract are well documented. To investigate this phenomenon in the continent ileal reservoir urinary diversion, 106 patients who had undergone Kock pouch surgery were followed in a prospective study at the University of Southern California between 1985 and 1987. Serum chemistries and urine osmolality determinations were performed approximately every three months for a year. Mean patient values for each time period were then compiled and compared with the norms and with the preoperative values. The mean serum electrolyte values were found to be within normal limits during all follow-up periods. Fourteen patients were identified, however, as having values falling intermittently outside of the normal range. These patients were investigated and found to be abnormal during episodes of acute renal failure usually secondary to dehydration or obstruction at which time they usually became acidotic and occasionally hyperchloremic. These problems disappeared when the renal failure was corrected. This study corroborated our previously reported findings that hyperchloremic acidosis or other metabolic alterations requiring replacement therapy do not routinely occur in this population.

Inflatable penile prostheses in patients undergoing cystoprostatectomy with urethrectomy.

When urethrectomy is indicated in the male patient in combination with cystoprostatectomy for diffuse transitional cell carcinoma, an additional challenge to reconstruction and sexual rehabilitation will be encountered. Inflatable penile prostheses were implanted in 19 patients who had undergone cystoprostatectomy with prophylactic urethrectomy. Of the patients 13 underwent cystoprostatectomy with en bloc urethrectomy and delayed placement of an inflatable penile prosthesis. The remaining 6 patients required urethrectomy and simultaneous implantation of an inflatable penile prosthesis 6 to 12 weeks after radical cystectomy. All 19 patients healed appropriately and had an adequate functioning prosthesis. However, results in patients in whom the glandular urethra could be preserved safely were far superior to those in patients requiring total urethrectomy. This was so because of easier and improved cylinder placement with better support to the glans, increased glandular sensation and a more acceptable penile appearance. The inflatable penile prosthesis can be used successfully in the cystourethrectomy patient with gratifying results, especially when the glandular urethra remains intact.

Infant sensitivity to audiovisually coherent events.

We examined 5-month-old infants' sensitivity to audiovisually coherent and incoherent events. A person speaking and an automobile with engine running were filmed approaching and receding with corresponding (coherent) soundtracks. Infants were tested with a habituation paradigm in which they observed coherent or incoherent films, involving, respectively, acoustical radial motion in the direction seen or opposite to the direction seen. Infants habituated to both person and car films, but coherent events uniformly yielded more rapid habituation than did incoherent ones. In addition, infants treated silent events more like audiovisual coherence than like incoherence. Infants habituated more to cars than to people, suggesting that a speaking person may especially maintain infant attention.

The potency-sparing radical cystectomy: does it compromise the completeness of the cancer resection?

Anatomical radical cystectomies with en bloc pelvic lymph node dissections were performed post mortem on 10 male cadavers. The traditional technique of radical cystectomy was used on 1 side and the potency-sparing technique was used on the opposite side. The tissue responsible for the differences in the surgical margins with the 2 procedures was examined by routine surgical pathological techniques to determine if it contained lymph nodes. Lymph nodes were identified in the bundle of tissue left in the pelvis with the nerve-sparing radical cystectomy in 6 of the 10 dissections (60 per cent). Because these lymph nodes may represent the potential first site of metastatic disease leaving the bladder, the reader is cautioned about adopting the nerve-sparing radical cystectomy as part of the management of invasive bladder cancer until the long-term sequelae of the procedure are known.

Treatment of unusual Kock pouch urinary calculi with extracorporeal shock wave lithotripsy.

Since the establishment of extracorporeal shock wave lithotripsy for the treatment of upper urinary tract calculi, further potential applications have been explored. We report the successful use of extracorporeal shock wave lithotripsy for the treatment of obstructive calculi on staples within the afferent nipple of a Kock pouch ureteroileal urinary diversion.

Recognizing people seen in events via dynamic "mug shots".

This study examined effects of an event and dynamic mug shots on facial recognition. Witnesses saw either a film of a liquor store holdup staged by six perpetrators, slides of the same targets, or freeze-framed views from the filmed event. Slides of different facial views of targets among 12 foils, or dynamic 180 degrees mug shots of the same men, or multiple static views were administered 24 hr later in yes-no recognition tests. Recognition (d') was poorer for the same men seen in the event than in slides, but better for dynamic than for static mug shots. Nondynamic event characteristics were responsible for poor recognition of people seen in events, whereas dynamic aspects of facial transformations, not multiple views, seemed responsible for the superiority of dynamic mug shots. The implications of these results for issues of ecological validity of traditional face recognition methodology and for static feature models vs. dynamic transformation models of face recognition are discussed.