Charles P. Wilkinson

Proposed international clinical diabetic retinopathy and diabetic macular edema disease severity scales

PURPOSE To develop consensus regarding clinical disease severity classification systems for diabetic retinopathy and diabetic macular edema that can be used around the world, and to improve communication and coordination of care among physicians who care for patients with diabetes. DESIGN Report regarding the development of clinical diabetic retinopathy disease severity scales. PARTICIPANTS A group of 31 individuals from 16 countries, representing comprehensive ophthalmology, retina subspecialties, endocrinology, and epidemiology. METHODS An initial clinical classification system, based on the Early Treatment Diabetic Retinopathy Study and the Wisconsin Epidemiologic Study of Diabetic Retinopathy publications, was circulated to the group in advance of a workshop. Each member reviewed this using e-mail, and a modified Delphi system was used to stratify responses. At a later workshop, separate systems for diabetic retinopathy and macular edema were developed. These were then reevaluated by group members, and the modified Delphi system was again used to measure degrees of agreement. MAIN OUTCOME MEASURES Consensus regarding specific classification systems was achieved. RESULTS A five-stage disease severity classification for diabetic retinopathy includes three stages of low risk, a fourth stage of severe nonproliferative retinopathy, and a fifth stage of proliferative retinopathy. Diabetic macular edema is classified as apparently present or apparently absent. If training and equipment allow the screener to make a valid decision, macular edema is further categorized as a function of its distance from the central macula. CONCLUSIONS There seems to be a genuine need for consistent international clinical classification systems for diabetic retinopathy and diabetic macular edema that are supported with solid evidence. The proposed clinical classification systems provide a means of appropriately categorizing diabetic retinopathy and macular edema. It is hoped that these systems will be valuable in improving both screening of individuals with diabetes and communication and discussion among individuals caring for these patients.

Clinical Classification of Age-related Macular Degeneration

OBJECTIVE To develop a clinical classification system for age-related macular degeneration (AMD). DESIGN Evidence-based investigation, using a modified Delphi process. PARTICIPANTS Twenty-six AMD experts, 1 neuro-ophthalmologist, 2 committee chairmen, and 1 methodologist. METHODS Each committee member completed an online assessment of statements summarizing current AMD classification criteria, indicating agreement or disagreement with each statement on a 9-step scale. The group met, reviewed the survey results, discussed the important components of a clinical classification system, and defined new data analyses needed to refine a classification system. After the meeting, additional data analyses from large studies were provided to the committee to provide risk estimates related to the presence of various AMD lesions. MAIN OUTCOME MEASURES Delphi review of the 9-item set of statements resulting from the meeting. RESULTS Consensus was achieved in generating a basic clinical classification system based on fundus lesions assessed within 2 disc diameters of the fovea in persons older than 55 years. The committee agreed that a single term, age-related macular degeneration, should be used for the disease. Persons with no visible drusen or pigmentary abnormalities should be considered to have no signs of AMD. Persons with small drusen (<63 μm), also termed drupelets, should be considered to have normal aging changes with no clinically relevant increased risk of late AMD developing. Persons with medium drusen (≥ 63-<125 μm), but without pigmentary abnormalities thought to be related to AMD, should be considered to have early AMD. Persons with large drusen or with pigmentary abnormalities associated with at least medium drusen should be considered to have intermediate AMD. Persons with lesions associated with neovascular AMD or geographic atrophy should be considered to have late AMD. Five-year risks of progressing to late AMD are estimated to increase approximately 100 fold, ranging from a 0.5% 5-year risk for normal aging changes to a 50% risk for the highest intermediate AMD risk group. CONCLUSIONS The proposed basic clinical classification scale seems to be of value in predicting the risk of late AMD. Incorporating consistent nomenclature into the practice patterns of all eye care providers may improve communication and patient care.

Evidence-based analysis of prophylactic treatment of asymptomatic retinal breaks and lattice degeneration.

PURPOSE To assess the quality of information in the literature regarding the benefits of prophylactic treatment of asymptomatic retinal tears and lattice degeneration. CLINICAL RELEVANCE Asymptomatic retinal breaks occur in approximately 7% of patients over age 40, and lattice degeneration is present in approximately 8% of the general population. Because retinal breaks cause retinal detachment and lattice degeneration is associated with approximately 30% of retinal detachments, prophylactic treatment of these lesions has sometimes been recommended. LITERATURE REVIEWED A panel of vitreoretinal experts performed a literature review of all publications regarding prevention of retinal detachment that have been published in English. These articles were then used to prepare recommendations for patient care in an American Academy of Ophthalmology Preferred Practice Pattern (PPP). Each recommendation was rated according to: (1) its importance in the care process and (2) the strength of evidence supporting the given recommendation. RESULTS Most recommendations were rated as A (most important to patient care). Only a single publication was graded as I (providing strong evidence in support of a recommendation), and this was not a prospective trial. Of the few publications rated as II (substantial evidence), most were studies documenting a lack of treatment benefit. Because of an absence of level I and level II studies in the literature, level III (consensus of expert opinion) was the basis for most recommendations in the PPP. CONCLUSIONS The current literature regarding prevention of retinal detachment does not provide sufficient information to support strongly prophylactic treatment of lesions other than symptomatic flap tears. Prospective randomized trials of prophylactic therapy are indicated. Eyes highly predisposed to retinal detachment should be considered for such studies.

Goldmann-Favre maculopathy.

A healthy 17-year-old girl presented with typical symptoms and physical features of Goldmann- Favre vitreoretinal degeneration. She had reduced visual acuity in both eyes and night blindness. Her parents were first cousins. Striking fundus features included typical maculopathy with a radiating stellate pattern surrounded by tiny vacuole-like pockets of retinoschisis throughout the posterior pole within the temporal vascular arcades. The fundus features were quite typical and permitted a firm diagnosis when combined with the other features of night blindness, gender, and electroretinogram (ERG) abnormalities.

Enlargement of circumscribed choroidal hemangiomas.

Abstract: The authors describe five patients with circumscribed choroidal hemangiomas. Fundus photography, fluorescein angiography, and ultrasound examinations showed progressive enlargement of these hemangiomas. In all cases, the extent of lesion enlargement was slight: the mean change in tumor size was 1.6 mm x 1.5 mm in basal diameters by 0.9 mm in thickness during a median interval of 52 months (range 33 to 100 months) between initial tumor diagnosis and detection of lesion enlargement. This series of cases demonstrates that circumscribed choroidal hemangiomas can enlarge slightly during long intervals between observations.

Comparison of standardized clinical classification with fundus photograph grading for the assessment of diabetic retinopathy and diabetic macular edema severity.

Purpose: To compare evaluation by clinical examination with image grading at a reading center for the classification of diabetic retinopathy and diabetic macular edema. Methods: Action to Control Cardiovascular Risk in Diabetes (ACCORD) and Family Investigations of Nephropathy in Diabetes (FIND) had similar methods of clinical and fundus photograph evaluation. For analysis purposes, the photographic grading scales were condensed to correspond to the clinical scales, and agreement between clinicians and reading center classification were compared. Results: Six thousand nine hundred and two eyes of ACCORD participants and 3,638 eyes of FIND participants were analyzed for agreement (percent, kappa) on diabetic retinopathy on a 5-level scale. Exact agreement between clinicians and reading center on diabetic retinopathy severity category was 69% in ACCORD and 74% in FIND (kappa 0.42 and 0.65). Sensitivities of the clinical grading to identify the presence of mild nonproliferative retinopathy or worse were 0.53 in ACCORD and 0.84 in FIND. Specificities were 0.97 and 0.96, respectively. Diabetic macular edema agreement in 6,649 eyes of ACCORD participants and 3,366 eyes of FIND participants was similar (kappa 0.35 and 0.41). Sensitivities of the clinical grading to identify diabetic macular edema were 0.44 and 0.53 and specificities were 0.99 and 0.94, respectively. Conclusion: The results support the use of clinical information for defining broad severity categories but not for documenting small-to-moderate changes in diabetic retinopathy over time.

Management of Ocular Injuries and Emergnencies.

Common emergent scenarios - recommended guidelines for timing of ophthalmologic and other specialized evaluation the epidemiology of ocular trauma - a preventable ocular emergency ocular evaluation evaluation of paediatric ocular trauma radiographic and echographic imaging studies timing guidelines for emergent surgery preoperative preparation and anaesthesia injuries of the lid and lacrimal system orbital trauma infection of the lacrimal system, eyelids and orbit ocular and periocular inflammatory syndromes ocular burns non-infectious disorders of the conjunctiva and cornea infectious conjunctivitis and keratitis corneoscleral lacerations and ruptures injuries of the anterior segment.

Retinal detachment surgery: management 25 years ago.

The history of surgery for rhegmatogenous retinal detachment is rich but short. Almost 90 years ago, Jules Gonin began disseminating his message claiming a successful procedure for a previously untreatable disorder. Gonin first provided an oral report regarding the success of his technique of “ignipuncture” to the Swiss Ophthalmologic Society in 1919,1 although his successes were not clearly substantiated by others until 1928.2 Many authorities cite 1929 as the year during which news of his achievements reached the world,3 and his first publication in English did not appear until 1930, only 76 years ago.2 Gonin’s essential steps for successful surgery have remained as follows: locate the retinal breaks and functionally close the breaks. The detection of retinal beaks was first performed with a monocular reflecting ophthalmoscope, and one of the most critical surgical advances in ophthalmology was the introduction of the binocular indirect ophthalmoscope by Schepens in the late 1940s.4 Closure of retinal breaks with Gonin’s ignipuncture technique was quickly superseded by the introduction of several diathermy techniques,3 and these in turn were replaced in most instances by the introduction of cryotherapy by Lincoff and coworkers.5 Although pneumatic retinopexy and primary vitrectomy have been employed in retinal surgery for much longer than 20 years, their use was restricted to relatively unusual cases until more recently, and the first articles on these techniques for routine retinal detachments did not appear until 206 and 237 years ago. Twenty-five years ago, the usual method of repairing rhegmatogenous detachments was with a scleral buckle. These techniques were initially introduced as temporary devices by Jess,8 but Custodis9 deserves credit as the first contemporary scleral buckler, although his initial efforts were largely unappreciated in the United States. In our country, Schepens and coworkers introduced scleral buckling.10,11 This was initially performed on only cases with a poor prognosis, and an encircling polyethylene tube was employed; hard silicone materials for buckling were introduced a few years later. Segmental nondrainage procedures introduced by Custodis were popularized in the United States by Lincoff, who also developed improved models of suturing needles.12 In summary, 22 years ago, in 1984, retinal surgeons were primarily performing scleral buckles. Vitrectomies were reserved for particularly difficult or unusual cases, and pneumatic retinopexy was employed as an intraor postoperative maneuver. Scleral buckling reduces flow through and functionally closes retinal breaks in a variety of nonexclusive ways, including the following: 1) shortening the distance between the retinal pigment epithelium and sensory retina; 2) displacing subretinal fluid; 3) reducing vitreous traction; 4) altering subretinal fluid currents; and 5) creating a functional vitreous plug. Interestingly, a permanent scleral buckle usually functionally closes retinal breaks even if a chorioretinal adhesion is not created. Fetkenhour and Hauch13 performed scleral buckling on a consecutive series of 175 cases and applied no thermal adhesive modalities. Their success rate and incidence of proliferative vitreoretinopathy (PVR) was comparable to series in which a chorioretinal adhesion had been created, and PVR remained the most common cause of failure. Contemporary scleral buckling 25 years ago included a fundamental decision about the relative value of encircling versus segmental procedures and the necessity of draining subretinal fluid, although the From the Departments of Ophthalmology, Greater Baltimore Medical Center and The Johns Hopkins University, Baltimore, Maryland. Presented at the annual meeting of the American Academy of Ophthalmology; New Orleans, Louisiana; October 26, 2004. Reprint requests: Charles P. Wilkinson, MD, 6569 N. Charles St., #505, Baltimore, MD 21204.