David A. Quillen

Central serous chorioretinopathy in women

BACKGROUND Central serous chorioretinopathy is a disorder that typically affects young and middle-aged men. Although extensive information is available pertaining to the clinical features of central serous chorioretinopathy in men, little is known about this condition in women. MATERIALS AND METHODS The authors reviewed the medical records and photographic files of women who received a diagnosis of central serous chorioretinopathy. The women were divided into three groups for data analysis: idiopathic, exogenous corticosteroid use, and pregnancy. RESULTS Fifty-one women with active central serous chorioretinopathy were evaluated. These findings in women with idiopathic serous chorioretinopathy were similar to those described in men, with the exception that women tend to be older at the time of onset. Central serous chorioretinopathy in women taking exogenous corticosteroids more likely was characterized by bilateral involvement and subretinal fibrin. Central serous chorioretinopathy in pregnant women typically developed in the third trimester and resolved spontaneously within 1-2 months after delivery. CONCLUSION Idiopathic central serous chorioretinopathy is similar in women and men, with the exception that women tend to be more older at the time of onset. The finding of exogenous corticosteroid use in a significant number of women in our study provides further support that cortisol may play a role in the development of central serous chorioretinopathy. The mechanism by which cortisol influences the development of central serous chorioretinopathy is unclear.

Inner retinal visual dysfunction is a sensitive marker of non-proliferative diabetic retinopathy.

Aims To determine the effect of diabetes on inner and outer retinal function in persons with diabetes and no clinically detectable retinopathy or with non-proliferative diabetic retinopathy (NPDR). Methods Visual function was assessed in 18 adults with normal retinal health, 23 adults with diabetes and 35 adults with NPDR and normal visual acuity. Contrast sensitivity and frequency doubling technology (FDT) sensitivity were used to assess ganglion cell function. Acuity, dark adaptation, light-adapted visual sensitivity and dark-adapted visual sensitivity were measured to evaluate cone and rod photoreceptor visual function. The presence and severity of diabetic retinopathy was determined by grading of 7-field stereoscopic fundus photographs using the Early Treatment Diabetic Retinopathy Study grading system. Results Participants with NPDR exhibited impairment of all measured visual functions in comparison with the normal participants. Inner retinal function measured by FDT perimetry was the most impaired visual function for patients with NPDR, with 83% of patients exhibiting clinically significant impairment. Rod photoreceptor function was grossly impaired, with almost half of the patients with NPDR exhibiting significantly impaired dark-adapted visual sensitivity. Conclusion Both inner retinal and outer retinal functions exhibited impairment related to NPDR. FDT perimetry and other visual function tests reveal an expanded range of diabetes induced retinal damage even in patients with good visual acuity.

Visual Outcomes and Incidence of Vitreous Loss for Residents Performing Phacoemulsification Without Prior Planned Extracapsular Cataract Extraction Experience

PURPOSE Phacoemulsification cataract surgery is one of the most important surgical procedures learned by ophthalmology residents during their residency training. We evaluated the visual outcomes and incidence of vitreous loss of phacoemulsification cataract surgeries performed by ophthalmology residents without prior planned extracapsular cataract extraction experience. DESIGN Interventional case series. METHODS A retrospective review was performed on 332 consecutive phacoemulsification cataract surgeries performed by third-year ophthalmology residents from July 1999 through June 2001. Data included are preoperative and postoperative best-corrected visual acuity, preexisting ocular comorbidities, and intraoperative and postoperative complications. RESULTS Postoperative best-corrected visual acuity was 20/40 or better in 89% of eyes. After excluding the cases with preexisting ocular comorbidities, the percentage increased to 97.7%. Vitreous loss occurred in 4.8% of cases. CONCLUSIONS Ophthalmology residents can learn to perform phacoemulsification cataract surgery safely and effectively without prior planned extracapsular cataract extraction experience.

Diagnostic Sensitivity and Specificity of Dark Adaptometry for Detection of Age-Related Macular Degeneration

PURPOSE Difficulty with night vision is a common complaint of patients with age-related macular degeneration (AMD). Consistent with this complaint, dark adaptation (DA) is substantially impaired in these patients. Because of the severity of the deficit, measurement of DA has been suggested as a means for the diagnosis of AMD. Previous methods for measurement of DA were time intensive (>30 minutes), which made them unsuitable for clinical use. This study evaluated a rapid DA test (≤ 6.5 minutes) for the detection of AMD. METHODS Dark adaptation was measured by using the AdaptDx dark adaptometer in two groups: subjects with normal retinal health and subjects with AMD. Subjects were assigned to their group by clinical examination and grading of fundus photographs. Subjects were classified as having DA consistent with normal retinal health (rod intercept ≤ 6.5 minutes) or having dark adaptation consistent with AMD (rod intercept > 6.5 minutes). RESULTS The eligible sample for analysis included 21 normal adults and 127 AMD patients. The rapid test was found to have a diagnostic sensitivity of 90.6% (P < 0.001) and specificity of 90.5% (P < 0.027). Thus, abnormal DA was detected in 115 of 127 AMD patients, and normal DA was found in 19 of 21 normal adults. CONCLUSIONS The high diagnostic sensitivity and specificity compared favorably to long-duration research methods for the measurement of DA, and slit lamp biomicroscopy performed by a retina specialist. These results suggest that a rapid DA test is useful for the detection of AMD.

The essential value of projects in faculty development.

Projects--planned activities with specific goals and outcomes--have been used in faculty development programs to enhance participant learning and development. Projects have been employed most extensively in programs designed to develop faculty as educators. The authors review the literature and report the results of their 2008 study of the impact of projects within the Pennsylvania State University College of Medicine Junior Faculty Development Program, a comprehensive faculty development program. Using a mixed-methods approach, the products of project work, the academic productivity of program graduates, and the impact of projects on career development were analyzed. Faculty who achieved the most progress on their projects reported the highest number of academic products related to their project and the highest number of overall academic achievements. Faculty perceived that their project had three major effects on their professional development: production of a tangible outcome, development of a career focus, and development of relationships with mentors and peers. On the basis of these findings and a review of the literature, the authors conclude that projects are an essential element of a faculty development program. Projects provide a foundation for future academic success by enabling junior faculty to develop and hone knowledge and skills, identify a career focus and gain recognition within their community, generate scholarship, allocate time to academic work, and establish supportive relationships and collaborative networks. A list of best practices to successfully incorporate projects within faculty development programs is provided.

Comparison of retinal vasodilator and constrictor responses in type 2 diabetes

Purpose:  The retinal blood vessels provide a unique way to directly examine the human microvasculature, which is frequently damaged in individuals with diabetes. Previous studies have demonstrated that retinal flickering light‐induced vasodilation and hyperoxia‐induced vasoconstriction may operate by enhancing or reducing similar vasoregulatory factor(s), but a comparison between these two provocative stimuli in individuals with diabetes has not been studied. The purpose of the study was to examine the association between retinal flickering light‐induced vasodilation and retinal hyperoxia‐induced vasoconstriction in type 2 diabetic subjects and in healthy controls.

Impaired retinal vasodilator responses in prediabetes and type 2 diabetes

Purpose:  In diabetes, endothelial dysfunction and subsequent structural damage to blood vessels can lead to heart attacks, retinopathy and strokes. However, it is unclear whether prediabetic subjects exhibit microvascular dysfunction indicating early stages of arteriosclerosis and vascular risk. The purpose of this study was to examine whether retinal reactivity may be impaired early in the hyperglycaemic continuum and may be associated with markers of inflammation.

An extension of the Early Treatment Diabetic Retinopathy Study (ETDRS) system for grading of diabetic macular edema in the Astemizole Retinopathy Trial.

Purpose: To compare the effects of astemizole, an antihistamine, versus placebo on the 1-year course of diabetic macular edema (DME) and to illustrate use of a modified ETDRS system for grading areas of retinal thickening and hard exudates that may be useful in clinical trials of treatments for this disorder. Methods: Between June 1994 and September 1997, at 2 clinics, 63 patients who had, in at least one eye (the study eye), DME that had not previously been treated with macular photocoagulation, and for which photocoagulation was not currently recommended by the investigator, were enrolled and randomly assigned to astemizole or placebo. Fifty-four of the 63 patients (86%, 26 in Clinic 1 and 28 in Clinic 2) completed 1 year of followup and had adequate 7-field stereoscopic film-based color fundus photographs of the study eye at the baseline and 1-year visits. DME was > 0.33 disc diameters (DD) from the center of the macula in 48% of study eyes and involved the center in 13%. Photographs were graded using the ETDRS protocol modified to allow estimates of areas of retinal thickening (RT) and hard exudate (HE) to be made on continuous scales in disc area (DA) units. Principal outcome measures were mean change in the square root of RT area (the average diameter of the area in DD), mean change in area of HE, and change in the degree to which RT involved or threatened the center of the macula. Results: At baseline, RT area in the 54 study eyes ranged from 0.09 to 4.0 DA (median 1.1). At the 1-year visit the square root of RT area (RTdd) had decreased by ≥ 0.3 DD in 10 eyes, increased by ≥ 0.3 DD in 19 and was about the same in 25. Mean change at 1 year was +0.09 DD (SD 0.57) for astemizole versus +0.19 DD (SD 0.48) for placebo, for a difference of −0.10 DD (95% CI −0.38, +0.19; p = 0.51). Adjustments for baseline and time-dependent risk factors did not change this result appreciably, although there was a trend towards a difference in favor of astemizole in the subgroup of patients with more severe retinopathy. Other morphologic outcomes paralleled change in RTdd. Change in RTdd did vary by clinic: −0.03 DD in Clinic 2, versus + 0.32 DD in Clinic 1, for a difference of −0.35 DD (95% CI −0.62, −0.07; p = 0.014). Clinic 1 is a tertiary retinal referral center in Pennsylvania and Clinic 2 a retinal clinic closely affiliated with a large diabetes clinic in Copenhagen. The unexpected clinic difference in outcome provided an opportunity for further analyses using the modified ETDRS system. In comparison to Clinic 1, Clinic 2 patients were more often male, were younger at diagnosis of diabetes, and had less severe retinopathy and better visual acuity, but these differences did not appear to explain the trend for lesser increase in RTdd. Conclusion: No effect of astemizole was found, but the confidence interval for the principal outcome, mean change in RTdd, included both a modest beneficial effect and a small harmful effect. This outcome measure did demonstrate a small difference in outcome by clinic, which could not be explained by baseline characteristics but may reflect differences in access to and/or continuity of care or other unmeasured differences associated with different referral patterns. Although optical coherence tomography may supplant photography as a measure of central RT, photographic assessments of change in RT and HE areas analyzed with the methods described herein may be useful outcomes in trials assessing treatment of early stages of DME. Application of these methods to other data sets is needed to confirm this conclusion.

Patient attitudes toward resident involvement in cataract surgery.

OBJECTIVE To assess how patients in an academic ophthalmology practice feel regarding the involvement of residents in their cataract surgery. METHODS Using an anonymous survey, we asked patients with cataracts about issues related to resident involvement in cataract surgery, including informed consent, how likely they were to agree to resident involvement in their surgery, and the likelihood that they would seek care elsewhere if residents were to be involved in their surgery. RESULTS Participants indicated they should be asked in advance if a resident may assist in (83%) or perform (96%) their surgery. The person asking permission should be the attending surgeon. Most participants would agree to resident assistance (83%), and nearly half would agree to resident performance (49%) of their cataract surgery. Participants indicated that they would be upset if the resident assisted in (45%) or performed (74%) their surgery without their expressed permission. Few would seek treatment in a setting without residents if a resident were to assist in (7%) or perform (26%) their cataract surgery. CONCLUSIONS Most individuals would accept resident involvement in their cataract surgery provided full disclosure was provided by their attending surgeon.

Twelve-month natural history of dark adaptation in patients with AMD.

Purpose A sensitive endpoint is required for clinical trials evaluating preventative therapies for early age-related macular degeneration (AMD). Dark adaptation (DA) is a sensitive marker of AMD and has been proposed as a potential endpoint. This study evaluated whether significant changes in DA speed could be detected in participants with early to intermediate AMD at 12 months following baseline DA measurement. Methods Dark adaptation, visual acuity (VA), and fundus photography were obtained at baseline and at 6 and 12 months in 26 subjects with AMD and in 6 subjects with normal retinal health. Disease severity was assessed by the Nine-Step Age-Related Eye Disease Study AMD severity scale. Results At 12 months, significant progression of DA impairment occurred in 5 of 26 (19%) participants with AMD. None of the participants with AMD exhibited a significant worsening of fundus grade or decrease of acuity related to disease progression. The normal group exhibited stable DA and VA during the observation period. Conclusions Significant worsening of DA was observed in 19% of subjects with AMD in 12 months of observation, despite stable VA and fundus appearance. This study suggests that DA may be a suitable functional endpoint for early clinical studies evaluating novel treatments for early to intermediate AMD.