David J. Weissgold

Accuracy of retinopathy of prematurity diagnosis by retinal fellows.

Purpose:The purpose of this study was to measure the accuracy of retinopathy of prematurity (ROP) diagnosis by retinal fellows. Methods:An atlas of 804 retinal images was captured from 248 eyes of 67 premature infants with a wide-angle camera (RetCam-II, Clarity Medical Systems, Pleasanton, CA). Images were uploaded to a study Web site, from which an expert pediatric retinal specialist and 7 retinal fellows independently provided a diagnosis (no ROP, mild ROP, type 2 ROP, or treatment-requiring ROP) for each eye. The sensitivity and specificity of each retinal fellow were calculated and subsequently compared with a reference standard of diagnosis by an expert pediatric retinal specialist. Results:For detection of type 2 or worse ROP by fellows, mean (range) sensitivity was 0.751 (0.512-0.953), and specificity was 0.841 (0.707-0.976). For detection of treatment-requiring ROP, mean (range) sensitivity was 0.914 (0.667-1.000), and specificity was 0.871 (0.678-0.987). Conclusion:In general, fellows showed high accuracy for detecting ROP. However, 3 of 7 fellows achieved <80% sensitivity for diagnosis of type 2 or worse ROP, and 2 of 7 achieved <90% sensitivity for diagnosis of treatment-requiring ROP. This could lead to undermanagement and undertreatment of clinically significant disease and raises potential concerns about the quality of ROP screening examinations performed by less-experienced examiners.

Telemedical diagnosis of retinopathy of prematurity: accuracy of expert versus non-expert graders

Background/aims To assess accuracy of telemedical retinopathy of prematurity (ROP) diagnosis by trained non-expert graders compared with expert graders. Methods Eye examinations (n=248) from 67 consecutive infants were captured using wide-angle retinal photography (RetCam-II, Clarity Medical Systems, Pleasanton, California, USA). Non-expert graders attended two 1-h training sessions on image-based ROP diagnosis. Using a web-based telemedicine system, 14 non-expert and three expert graders provided a diagnosis for each eye: no ROP, mild ROP, type 2 pre-threshold ROP or treatment-requiring ROP. All diagnoses were compared with a reference standard of dilated indirect ophthalmoscopy by an experienced paediatric ophthalmologist. Results For detection of type 2 or worse ROP, the mean (range) sensitivities and specificities were 0.95 (0.94–0.97) and 0.93 (0.91–0.96) for experts, 0.87 (0.71–0.97) and 0.73 (0.39–0.95) for resident non-experts, and 0.73 (0.41–0.88) and 0.91 (0.84–0.96) for student non-experts, respectively. For detection of treatment-requiring ROP, the mean (range) sensitivities and specificities were 1.00 (1.00–1.00) and 0.93 (0.88–0.96) for experts, 0.88 (0.50–1.00) and 0.84 (0.71–0.98) for resident non-experts, and 0.82 (0.42–1.00) and 0.92 (0.83–0.97) for student non-experts, respectively. Conclusions Mean sensitivity and specificity of trained non-experts were lower than that of experts, although several non-experts had high accuracy. Development of methods for training non-expert graders may help support telemedical ROP evaluation.

Accuracy of retinopathy of prematurity image-based diagnosis by pediatric ophthalmology fellows: Implications for training

PURPOSE To measure the accuracy of image-based retinopathy of prematurity (ROP) diagnosis by pediatric ophthalmology fellows. METHODS This was a comparative case series of expert versus nonexpert clinicians in image-based ROP diagnosis. An atlas of 804 retinal images was captured from 248 eyes of 67 premature infants with a wide-angle camera (RetCam-II, Clarity Medical Systems, Pleasanton, CA). Images were uploaded to a study website from which an expert pediatric retinal specialist and five pediatric ophthalmology fellows independently provided a diagnosis (no ROP, mild ROP, type 2 ROP, or treatment-requiring ROP) for each eye. Two different retinal specialists experienced in ROP examination served as additional controls. Primary outcome measures were sensitivity and specificity of image-based ROP diagnosis by fellows compared to a reference standard of image-based interpretation by the expert pediatric retinal specialist. Secondary outcome measure was intraphysician reliability. RESULTS For detection of mild or worse ROP, the mean (range) sensitivity among the five fellows was 0.850 (0.670-0.962) and specificity was 0.919 (0.832-0.964). For detection of type 2 or worse ROP by fellows, mean (range) sensitivity was 0.527 (0.356-0.709) and specificity was 0.938 (0.777-1.000). For detection of treatment-requiring ROP, mean (range) sensitivity was 0.515 (0.267-0.765) and specificity was 0.949 (0.805-1.00). CONCLUSIONS Pediatric ophthalmology fellows in this study demonstrated high diagnostic specificity in image-based ROP diagnosis; however, sensitivity was lower, particularly for clinically significant disease.

Plus disease in retinopathy of prematurity: Quantitative analysis of vascular change

PURPOSE To examine the relationship between rate of vascular change and plus disease diagnosis. DESIGN Retrospective observational case-control study. METHODS Wide-angle images were taken bilaterally from 37 infants at 31 to 33 weeks and 35 to 37 weeks postmenstrual age (PMA). The semi-automated Retinal Image multiScale Analysis system was used to measure parameters for all arteries and veins: integrated curvature, diameter, and tortuosity index. A reference standard diagnosis (plus vs not plus) was defined for each eye by consensus of 5 experts at 35 to 37 weeks PMA. Weekly rate of change in parameters was compared in eyes with plus vs not plus disease. Receiver operating characteristic area under the curve (AUC) was calculated for plus disease detection based on 1) weekly rates of parameter change between 31 to 33 weeks and 35 to 37 weeks PMA and 2) parameter values at 35 to 37 weeks only. RESULTS Weekly rates of change in all venous parameters were significantly different in eyes with plus vs not plus disease, particularly for tortuosity index (P < .0004) and diameter (P = .018). Using weekly rate of change, AUC for plus disease detection was highest for venous tortuosity index (0.819) and venous diameter (0.712). Using the 35 to 37-week PMA image only, AUC was highest for venous integrated curvature (0.952) and diameter (0.789). CONCLUSION Rate of change in venous, but not arterial, parameters is correlated with plus disease development in this data set. This did not appear to contribute information beyond analysis of an image at 35 to 37 weeks PMA only.

Rescue of exposed scleral buckles with cadaveric pericardial patch grafts.

PURPOSE To describe a new method for salvaging externally exposed silicone scleral exoplants (buckles) to avoid removal and the consequent risk of retinal redetachment. DESIGN A retrospective, noncomparative, interventional case series. PARTICIPANTS Four patients with exposed, clinically uninfected scleral buckles after initial surgery for the treatment of rhegmatogenous retinal detachment. INTERVENTION Processed human donor pericardium patch grafts (Tutoplast; Innovative Ophthalmic Products, INC:, Costa Mesa, CA) were used to cover exposed areas of scleral buckles in concert with conjunctivoplasty. MAIN OUTCOME MEASURES Scleral buckle preservation was the goal of this new treatment strategy. RESULTS In four eyes treated with pericardial patch grafts to cover segments of exposed scleral buckles, three (75%) were managed successfully with one surgery. One eye (25%) had this treatment method fail and required scleral buckle removal. CONCLUSIONS Processed human donor pericardium patch grafting is one useful way to avoid removing exposed scleral buckles, and consequently, sparing patients the risk of recurrent retinal detachment.

Acute postoperative Alcaligenes xylosoxidans endophthalmitis.

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Delayed-onset fungal keratitis after endophthalmitis

PURPOSE This study aimed to present two patients with delayed-onset, endogenous fungal keratitis after treatment for fungal endophthalmitis after cataract surgery. METHODS The authors retrospectively reviewed the clinical course of two patients in whom deep stromal fungal keratitis developed 2 weeks and 3 months, respectively, after apparent successful aggressive therapy for fungal endophthalmitis. Before the onset of the keratitis, both patients underwent vitrectomies with intraocular injection of 7.5 to 10.0 mcg amphotericin B, as well as treatment with systemic fluconazole and topical antifungal therapy. In case 1, a pre-existing prosthetic intraocular lens and lens capsular bag were removed at the time of vitrectomy, whereas in case 2, the intraocular lens was left in place and a posterior capsulectomy was performed. RESULTS The keratitis worsened in both patients, despite intensive systemic and topical antifungal therapy. Both patients underwent therapeutic penetrating keratoplasties. In case 1, this resulted in successful resolution of the infection and no recurrences 3 months after the transplant. The corneal transplant was complicated by an expulsive choroidal hemorrhage in the other patient. Fusarium solani was cultured from the initial vitrectomy specimen in patient 1, and although it was not cultured from the keratitis, septate hyphal elements were present on histopathologic examination. The causative organism in case 2 was Acremonium kiliense, which was cultured from both the original vitrectomy specimen and the deep corneal stromal infiltrate. CONCLUSIONS Fungal organisms may not be eradicated completely from eyes with endophthalmitis despite aggressive therapy and apparent initial successful treatment. These patients need to be monitored for prolonged periods, and treatment should be reinitiated at the earliest sign of recrudescence of infection.

Retinopathy of Prematurity Management using Single-Image vs. Multiple-Image Telemedicine Examinations

PURPOSE To compare performance of single-image vs multiple-image telemedicine examinations for retinopathy of prematurity (ROP) diagnosis. DESIGN Prospective comparative study. METHODS A total of 248 eyes from 67 consecutive infants underwent wide-angle retinal imaging by a trained neonatal nurse at 31 to 33 weeks and/or 35 to 37 weeks postmenstrual age (PMA) at a single academic institution. Data were uploaded to a web-based telemedicine system and interpreted by three masked retinal specialists. Diagnoses were provided based on single images, and subsequently on multiple images, from both eyes of each infant. Findings were compared to a reference standard of indirect ophthalmoscopy by a pediatric ophthalmologist. Primary outcome measures were recommended follow-up interval, presence of plus disease, presence of type-2 or worse ROP, and presence of visible peripheral ROP. RESULTS Among the three graders, mean sensitivity/specificity for detection of infants requiring follow-up in less than one week were 0.85/0.93 by single-image examination and 0.91/0.88 by multiple-image examination at 35 to 37 weeks PMA. Mean sensitivity/specificity for detection of infants with type-2 or worse ROP were 0.82/0.95 by single-image examination and 1.00/0.91 by multiple-image examination at 35 to 37 weeks PMA. Mean sensitivity/specificity for detection of plus disease were 1.00/0.86 by single-image examination and 1.00/0.87 by multiple-image examination at 35 to 37 weeks PMA. There were no statistically-significant intragrader differences between accuracy of single-image and multiple-image telemedicine examinations for detection of plus disease. CONCLUSIONS Single-image and multiple-image telemedicine examinations perform comparably for determination of recommended follow-up interval and detection of plus disease. This may have implications for development of screening protocols, particularly in areas with limited access to ophthalmic care.

Central serous chorioretinopathy after inhaled steroid use for post-mycoplasmal bronchospasm

Central serous chorioretinopathy (CSR) is an uncommon cause of central visual loss, metamorphopsia, and dyschromatopsia, generally involving submacular and/or subretinal pigment epithelial (RPE) fluid blisters. While most cases of CSR are idiopathic, several associated risk factors have been implicated, such as so called type A personality, emotional stress, and male sex.1 Systemic steroid use has long been known to be associated with CSR.2 This case report demonstrates the development of CSR secondary to inhaled steroid use specifically for the management of post-mycoplasmal bronchospasm. We evaluated a 40 year old white woman for complaints of metamorphopsia and decreased visual acuity on the left side for approximately a 2 month period. She denied previous similar episodes in either eye. Four months earlier, treatment for bronchospasm following mycoplasmal pneumonia had been initiated …

Corneal complications of lid disease

Contributions to the literature concerning the interaction of the eyelids and the conjunctiva with the health of the cornea continue to stress this important relationship. Ocular cicatrizing disorders, as well as atopic and other hypersensitivity diseases are reviewed. In addition, the corneal manifestations, complications, and treatment of other infectious and dermatological lid and conjunctival diseases are discussed.