James C. Folk

Factors Prognostic of Visual Outcome in Patients With Subretinal Hemorrhage

We reviewed the charts of 29 patients with large subretinal hemorrhages involving the center of the fovea to evaluate factors that might be prognostic of visual outcome. The average final visual acuity was 20/480 with a mean follow-up of three years. Patients with thick hemorrhages (causing an obvious elevation of the fovea) had worse final visual acuity than patients with thin hemorrhages (P = .02). The diameter of the hemorrhage was not a significant predictor of outcome. Patients with aging macular degeneration had poorer final visual acuity (mean, 20/1,700, P = .002), and patients with choroidal ruptures had better final visual acuity, (mean 20/35, P less than .001) than the remainder of the patients. We found that the presence of aging macular degeneration was a more important predictor of the outcome of legal blindness than the thickness of the hemorrhage (P = .03). Although the prognosis in patients with subfoveal blood is generally poor, some patients have excellent return of vision.

Punctate inner choroidopathy

Ten moderately myopic women had blurred vision, light flashes, or paracentral scotomas associated with small yellow-white lesions of the inner choroid and pigment epithelium. Most lesions had an overlying serous detachment, were hyperfluorescent, and leaked fluorescein during the acute phase. The lesions healed into atrophic scars and became progressively more pigmented with time. Subretinal neovascular membranes later developed from scars in six patients. Vision was usually only minimally affected unless the lesions were subfoveal or unless choroidal neovascular membranes subsequently occurred. Extensive laboratory studies were noncontributory.

Long-term Visual Outcome and Complications Associated with Pars Planitis

PURPOSE To identify the ocular complications and to statistically evaluate the possible association of pars planitis with multiple sclerosis (MS) in a homogeneous population of pars planitis patients. METHODS The authors reexamined 36 patients and reviewed the records of an additional 18 patients (total: 54 patients, 108 eyes) with idiopathic pars planitis. RESULTS The initial mean visual acuity of 20/46 (logMAR: 0.36 +/- 0.50) was not statistically different from the final mean visual acuity of 20/44 (logMAR: 0.34 +/- 0.45; P = 0.73), after a mean follow-up of 89.2 months. Complications included neovascularization with or without associated vitreous hemorrhage (7 eyes, 6.5%), moderate to severe cellophane retinopathy (7 eyes, 6.5%), chronic cystoid macular edema (CME) (9 eyes, 8.3%), visually significant cataracts (16 eyes, 14.8%), and retinal detachment (9 eyes, 8.3%). Significant lens opacification was associated with a greater risk of retinal detachment (P = 0.004). In four patients (7.4%), optic neuritis developed, and in an additional eight patients (14.8%) MS developed. Kaplan-Meier analysis of these data showed a 16.2% +/- 6.2% risk of MS solely developing in patients, and a 20.4% +/- 6.7% risk of either MS or optic neuritis developing, after 5 years of disease. The presence of periphlebitis at the time of pars planitis diagnosis increased the rate of development of these conditions (P = 0.002). Six patients (11.1%) had a family history positive for MS in a first-degree relative. CONCLUSIONS This study demonstrates the overall favorable visual prognosis in patients with pars planitis. Patients with significant cataract formation appear to be at greater risk for retinal detachment. Periphlebitis at the time of diagnosis of pars planitis increases the risk of development of optic neuritis or MS. The strong association demonstrated between pars planitis and MS in this study further supports a link between the two disease states.

Visual Prognosis of Multifocal Choroiditis, Punctate Inner Choroidopathy, and the Diffuse Subretinal Fibrosis Syndrome

PURPOSE To characterize the visual prognosis of patients with multifocal choroiditis and panuveitis (MCP), punctate inner choroidopathy (PIC), and the diffuse subretinal fibrosis (DSF) syndrome. METHODS Forty-one patients with MCP, 16 with PIC, and 5 with DSF syndrome were evaluated. The mean follow-up was approximately 39 months for patients with MCP, 51 months for patients with PIC, and 59 months for patients with DSF syndrome. Complete ophthalmic examinations were performed, and photofiles were reviewed. RESULTS The final average visual acuity for patients with MCP was 20/50. Forty-five of the 68 involved eyes (66%) had 20/40 visual acuity or better. Choroidal neovascularization (CNV) developed within choroiditis lesions in 22 (19 patients) of 68 eyes, causing visual acuity poorer than 20/50 in 14 eyes. The final average visual acuity in patients with PIC was 20/39; 23 (77%) of the 30 involved eyes had visual acuity of 20/40 or better. Six of the seven eyes with 20/50 or poorer vision had CNV. Six other eyes had CNV within the macula that regressed spontaneously with good resultant vision. Seven of the ten involved eyes with DSF syndrome had 20/200 or poorer vision. Poor vision was due to fibrosis and atrophy within the macula. CONCLUSION Most patients with MCP and PIC retained visual acuity of 20/40 or better. In nearly one third of patients with MCP and PIC, CNV developed. Severe visual loss in these diseases was usually due to subfoveal CNV. Patients with DSF syndrome had a poor prognosis due to fibrosis and atrophy involving the macula.

Automated Early Detection of Diabetic Retinopathy

PURPOSE To compare the performance of automated diabetic retinopathy (DR) detection, using the algorithm that won the 2009 Retinopathy Online Challenge Competition in 2009, the Challenge2009, against that of the one currently used in EyeCheck, a large computer-aided early DR detection project. DESIGN Evaluation of diagnostic test or technology. PARTICIPANTS Fundus photographic sets, consisting of 2 fundus images from each eye, were evaluated from 16670 patient visits of 16,670 people with diabetes who had not previously been diagnosed with DR. METHODS The fundus photographic set from each visit was analyzed by a single retinal expert; 793 of the 16,670 sets were classified as containing more than minimal DR (threshold for referral). The outcomes of the 2 algorithmic detectors were applied separately to the dataset and were compared by standard statistical measures. MAIN OUTCOME MEASURES The area under the receiver operating characteristic curve (AUC), a measure of the sensitivity and specificity of DR detection. RESULTS Agreement was high, and examination results indicating more than minimal DR were detected with an AUC of 0.839 by the EyeCheck algorithm and an AUC of 0.821 for the Challenge2009 algorithm, a statistically nonsignificant difference (z-score, 1.91). If either of the algorithms detected DR in combination, the AUC for detection was 0.86, the same as the theoretically expected maximum. At 90% sensitivity, the specificity of the EyeCheck algorithm was 47.7% and that of the Challenge2009 algorithm was 43.6%. CONCLUSIONS Diabetic retinopathy detection algorithms seem to be maturing, and further improvements in detection performance cannot be differentiated from best clinical practices, because the performance of competitive algorithm development now has reached the human intrareader variability limit. Additional validation studies on larger, well-defined, but more diverse populations of patients with diabetes are needed urgently, anticipating cost-effective early detection of DR in millions of people with diabetes to triage those patients who need further care at a time when they have early rather than advanced DR.

Retained Nuclei after Cataract Surgery

The authors reviewed the medical records of 36 patients in whom the nucleus or nuclear fragments were retained in the eye after cataract surgery. In 4 patients, there was no further surgery, and visual acuity deteriorated to counting fingers or worse (mean follow-up time, 14 months). Thirty-two patients underwent vitrectomy to remove the retained, unencapsulated nuclear material. Sixty percent (6 of 10) of patients in whom vitrectomy was performed after 3 weeks had chronic glaucoma on long-term follow-up, whereas this complication developed in only 18% (4 of 22) of patients in whom vitrectomy was performed in less than 3 weeks. Sixty-three percent (21 of 32) of vitrectomy patients had final visual acuity of 20/200 or better after removal of the retained nuclear fragments. The causes of the poorest visual outcome (less than 20/200) included 1 or more of the following: corneal decompensation, chronic inflammation, chronic glaucoma with optic atrophy, and retinal detachment.

Visual Field Defects After Macular Hole Surgery

Purpose To describe a group of patients with dense visual field defects following macular hole surgery. Methods Nine (7%) of 125 patients reviewed noted onset of dense visual field defects following uncomplicated vitrectomy with gas-fluid exchange for the treatment of macular hole. Patient records were reviewed to investigate the etiology of these defects. Results Eight (89%) of nine eyes that had surgery for macular hole developed dense, wedgeshaped visual field defects in the temporal periphery. One eye had an inferonasal wedge-shaped defect extending to fixation. Seven (78%) of nine eyes had generalized or focal narrowing of the retinal arteriole extending into the area of retina corresponding to the visual field defect, and five (56%) of nine eyes developed mild to moderate segmental nasal optic disk pallor. Postoperative fluorescein angiography disclosed one eye with delayed filling of the retinal arteriole extending into the area of retina corresponding to the visual field defect. Vitrectomy specimens showed no evidence of nerve fiber layer or internal limiting membrane in eight (89%) of nine eyes. Conclusions Visual field defects can occur following vitrectomy and gas-fluid exchange for macular hole. The most common visual field defect is dense and wedge-shaped and involves the temporal visual field. Although unclear, the etiology may involve trauma to the peripapillary retinal vasculature or nerve fiber layer during elevation of the posterior hyaloid or during aspiration at the time of air-fluid exchange, followed by compression and occlusion of the retinal peripapillary vessels during gas tamponade.

Long-term visual outcome in patients with optic nerve pit and serous retinal detachment of the macula.

Serous detachment of the macula is a well-known complication in patients with an optic nerve pit. Despite the many descriptions of this condition and possible treatment options, the long-term natural history is not well known. The authors identified 15 eyes of 15 consecutive patients seen over 21 years who were diagnosed with a serous detachment of the macula arising from an optic nerve pit. Average length of follow-up was 9 years. Twelve eyes lost three or more lines of vision, two eyes remained unchanged, and only one eye improved. All of the 12 eyes losing three or more lines of vision experienced this decrease within the first 6 months of follow-up. Although only two patients had a visual acuity of 20/200 or less initially, 12 of 15 patients had a visual acuity of 20/200 or less at the time of their last examination. The appearance of the macula at last examination included cystic changes of the neurosensory retina, full-thickness hole formation, retinal pigment epithelial mottling, and lamellar hole formation in the outer retinal layer. The long-term visual prognosis in patients with optic nerve pit and untreated serous retinal detachment of the macula is poor, and visual loss occurs within 6 months of the serous detachment.

Automated Measurement of the Arteriolar-to-Venular Width Ratio in Digital Color Fundus Photographs

A decreased ratio of the width of retinal arteries to veins [arteriolar-to-venular diameter ratio (AVR)], is well established as predictive of cerebral atrophy, stroke and other cardiovascular events in adults. Tortuous and dilated arteries and veins, as well as decreased AVR are also markers for plus disease in retinopathy of prematurity. This work presents an automated method to estimate the AVR in retinal color images by detecting the location of the optic disc, determining an appropriate region of interest (ROI), classifying vessels as arteries or veins, estimating vessel widths, and calculating the AVR. After vessel segmentation and vessel width determination, the optic disc is located and the system eliminates all vessels outside the AVR measurement ROI. A skeletonization operation is applied to the remaining vessels after which vessel crossings and bifurcation points are removed, leaving a set of vessel segments consisting of only vessel centerline pixels. Features are extracted from each centerline pixel in order to assign these a soft label indicating the likelihood that the pixel is part of a vein. As all centerline pixels in a connected vessel segment should be the same type, the median soft label is assigned to each centerline pixel in the segment. Next, artery vein pairs are matched using an iterative algorithm, and the widths of the vessels are used to calculate the AVR. We trained and tested the algorithm on a set of 65 high resolution digital color fundus photographs using a reference standard that indicates for each major vessel in the image whether it is an artery or vein. We compared the AVR values produced by our system with those determined by a semi-automated reference system. We obtained a mean unsigned error of 0.06 (SD 0.04) in 40 images with a mean AVR of 0.67. A second observer using the semi-automated system obtained the same mean unsigned error of 0.06 (SD 0.05) on the set of images with a mean AVR of 0.66. The testing data and reference standard used in this study has been made publicly available.

Results and Complications of Pneumatic Retinopexy

Fifty-one patients with primary rhegmatogenous retinal detachment (RD) were treated by pneumatic retinopexy. The overall success rate for reattachment with one operation was 63%. Of the 34 phakic eyes, 25 (74%) were reattached; of the 17 aphakic or pseudophakic eyes, seven (41%) were reattached (P less than 0.05). Postoperative complications included the development of new tears (22%), inadequate closure of the original tear, shifting and delayed absorption of subretinal fluid, and opening of previously closed tears. Pneumatic retinopexy is a valuable new technique; however, careful patient selection and postoperative management is required.