Screening for diabetic retinopathy in rural areas: the potential of telemedicine.

Diabetic retinopathy is a common cause of blindness, and screening can identify the disease at an earlier, more treatable stage. However, rural individuals with diabetes may have limited access to needed eye care. The objective of this project was to demonstrate the feasibility of a diabetic retinopathy screening program using a state-of-the-art nonmydriatic digital fundus imaging system. The study involved a series of patients screened in primary care and public health locations throughout seven predominantly rural counties in eastern North Carolina. Images of each fundus were obtained and sent to a retinal specialist. The retinal specialist reviewed each image, recorded image quality, diagnosed eye disease and made recommendations for subsequent care. Of 193 volunteers with a history of diabetes mellitus, 96.3 percent reported that they were very comfortable or comfortable with the camera. Eighty-five percent of images were rated as good or fair by the retinal specialist. The retinal specialist also reported being very certain or certain of the diagnosis in 84 percent of cases. Image quality correlated highly with the certainty of diagnosis (Spearman's rank order correlation coefficient = 0.79; P < 0.001). The average time since the previous examination by an eye care specialist for diabetic subjects was two years. Approximately 62 percent of diabetic patients had diagnosable eye conditions, the most common of which was diabetic retinopathy (40.9 percent). In this convenience sample, African Americans, despite similar age and disease duration, were more likely to have retinopathy. Digital imaging is a feasible screening modality in rural areas, may improve access to eye care, and may improve compliance with care guidelines for individuals with diabetes mellitus.

Visual loss caused by choroidal ischemia preceding anterior ischemic optic neuropathy in giant cell arteritis.

Three patients with visual loss and normal fundi were discovered to have choroidal ischemia on fluorescein angiography. Each patient had a markedly increased Westergren erythrocyte sedimentation rate, but only one described symptoms of polymyalgia rheumatica, neck pain, and jaw claudication. Biopsy of the temporal artery confirmed giant cell arteritis in the two patients without constitutional symptoms. In one patient, typical anterior ischemic optic neuropathy developed the following day, whereas in the other two, anterior ischemic optic neuropathy later occurred despite the prompt administration of intravenous high-dose corticosteroids. Choroidal ischemia may be the first sign of giant cell arteritis in elderly patients with visual loss. Early diagnosis and treatment are mandatory in an attempt to forestall the development of anterior or posterior ischemic optic neuropathy, or central retinal artery occlusion in the affected or fellow eye.

Acute retinal necrosis after chickenpox in a healthy adult.

A healthy man had acute retinal necrosis (ARN) two weeks after diffuse varicella eruption. Treatment with acyclovir and corticosteroids was associated with a favorable clinical outcome. To our knowledge, there are no reported occurrences of permanent visual loss or retinal detachment in healthy patients with postvaricella ARN.

Controlled trial of laser photocoagulation of pigment epithelial detachments in the elderly: 4 year review.

Patients who were enrolled in a controlled treatment trial of laser grid photocoagulation for retinal pigment epithelial detachment as part of age-related maculopathy were reviewed 4 years after entry into the trial. The data imply that the original conclusion that this form of treatment did not improve the visual prognosis at 18 months was also justified at 4 years. It has become clear that lesions with evidence of subpigment epithelial new vessels were included in the trial. In a retrospective study the lesions were separated into those in which there was evidence of subretinal neovascularisation and those in which no such evidence existed. A difference was identified in the behaviour of the treated and untreated lesions designated avascular in that the treated eyes had a poorer visual outcome. These cases accounted for the different behaviour between two management groups in the initial study such that the original conclusion that grid photocoagulation of avascular pigment epithelial detachments in the elderly does not improve the visual prognosis is justified.

Detection of subpigment epithelial neovascularisation in cases of retinal pigment epithelial detachments: a review of the Moorfields treatment trial.

The entry angiograms of 42 eyes with detachment of the retinal pigment epithelium in a treatment trial of laser photocoagulation were reviewed in a masked fashion by three observers in order to assess the possible presence of subpigment epithelial neovascularisation. Vascularity or avascularity was designated with reference to a list of clues believed to imply the presence of subpigment epithelial neovascularisation. As a predictor of outcome the initial assessment achieved a sensitivity and specificity of 77% and 82% respectively. Despite notable parity of the degree of sensitivity and specificity among the three observers, full agreement on the initial assessments was reached in only 23 eyes (55%), 10 with vascular and 13 with avascular outcome. Of these, only one eye which developed new vessels after 4 years had an outcome which differed from that predicted by classification of the entry angiograms.

Drusen as risk factors in age-related macular disease.

In a study of 150 consecutive patients with age-related macular disease and unilateral visual loss, the drusen in the better eye were analyzed for size, number, density, and fluorescein angiographic appearance, and these characteristics were compared with the type of the lesion causing visual loss in the contralateral eye. In the fellow eye of an eye with avascular detachment of the retinal pigment epithelium, the drusen were more densely packed, larger, and less fluorescent than in the fellow eye of an eye with primary neovascularization. The characteristics of drusen in fellow eyes of those eyes with pigment epithelial detachments and evidence of subpigment epithelial new vessels were intermediate between the other two groups. Because there is significant symmetry of drusen between fellow eyes, these data imply that the characteristics of drusen are important in the determination of the form of the lesion complicating age-related macular disease.

Peripheral retinal neovascularization in birdshot retinochoroidopathy.

A 69-year-old black woman had ocular findings consistent with birdshot retinochoroidopathy; these included cream-colored depigmented spots at the level of the retinal pigment epithelium and vitreitis. She also had peripheral retinal neovascularization with localized vitreous hemorrhage. There were no laboratory or systemic findings consistent with other disease entities.

Optic disc neovascularization in dominant exudative vitreoretinopathy.

Dominant exudative vitreoretinopathy (DEVR) is inherited retinal vascular disorder which is characterized by peripheral retinal neovascularization, tractional retinal detachment, subretinal, exudation, and vitreous fibrosis. A milder form of involvement characterized by capillary nonperfusion and straightening of the retinal vessels may be present in asymptomatic individuals. We describe a 15-year-old patient who presented with optic disc neovascularization, a finding not previously reported in association with DEVR. Angiographic evidence of DEVR in successive generations confirmed the diagnosis. The findings in mild and advanced DEVR are reviewed, and the pathogenesis of the capillary nonperfusion is discussed.