James L. Kinyoun

Prevalence of diabetes mellitus and impaired glucose tolerance among second-generation Japanese-American men.

We describe the initial findings from a multidisciplinary, epidemiologic study of diabetes mellitus conducted in a population of secondgeneration Japanese-American (Nisei) men born between 1910 and 1939 who reside in King County, Washington (n = 1746). From this study population, 487 volunteered, and 229 were enrolled to comprise the study sample. A random sample of Nisei men was also drawn from the population to develop a reference sample of 189 men. All subjects participated in a 75-g oral glucose tolerance test; the National Diabetes Data Group (NDDG) and World Health Organization (WHO) diagnostic criteria as well as a modification of the WHO criteria were used to classify individuals with normal glucose tolerance, impaired glucose tolerance (IGT), or diabetes. Within the study sample, 79 men were found to have normal glucose tolerance, 72 had IGT, and 78 had type II diabetes. The mean age of the study sample was 61.4 yr. Based on comparison of the study sample to the reference sample, the study sample was ascertained to be representative of Nisei men in King County. Extrapolating from our observations in the reference sample and in the study sample, we have estimated that ∼56% of Nisei men in the study population have abnormal glucose tolerance. Much of this is undiagnosed because only ∼13% of the reference sample of Nisei men reported a prior diagnosis of diabetes. Of the men who enrolled in the study as nondiabetic subjects, 11.1% had diabetes and 39.2% had IGT; i.e., 50.3% had previously unknown abnormalities in glucose tolerance. We estimate that ∼20% of Nisei men have diabetes (both previously diagnosed and undiagnosed) and ∼36% have IGT.

Detection of diabetic macular edema. Ophthalmoscopy versus photography - early treatment diabetic retinopathy study report number 5

Clinical and photographic methods were used to assess retinopathy during the examinations of diabetic patients enrolled in the Early Treatment Diabetic Retinopathy Study (ETDRS). In analyzing available data from eyes randomly selected for deferral of treatment, the authors compare the clinical detection (including contact lens biomicroscopy) with photographic detection (30 degrees stereoscopic color fundus photographs) of diabetic macular edema. Based on clinical detection, 53% (1778 patients) had hard exudates within 1 disc diameter (DD) of the center of macula, 56% (1868 patients) had retinal thickening within this region, and 31% (1027 patients) had thickening at the center of macula. These analyses show agreements of 83, 78, and 83% between retinal specialists and photographic graders when assessing these three characteristics, respectively. Agreement was 81% in the detection of macular edema for which treatment is indicated (clinically significant macular edema). Each method has its advantages but in general there was close agreement between these methods, particularly for clinically significant macular edema, which supports the reliability of each method.

Prevalence of Complications Among Second-Generation Japanese-American Men With Diabetes, Impaired Glucose Tolerance, or Normal Glucose Tolerance

In a study sample of 229 second-generation Japanese- American (Nisei) men, 79 with normal glucose tolerance, 72 with impaired glucose tolerance (IGT), and 78 with non-insulin-dependent diabetes, we have determined prevalence rates for certain conditions (ischemic heart disease, peripheral vascular disease, hypertension, retinopathy, neuropathy, and nephropathy) associated with diabetes. All subjects participated in a 75-g oral glucose tolerance test. World Health Organization (WHO) diagnostic criteria and information from the subjects medical history and personal physician were used to classify the subjects. Retinopathy was observed only in diabetic men in the study sample (11.5% of diabetic men). Furthermore, it was observed only in men who were receiving drug treatment for diabetes—40.0% of insulin-treated and 17.2% of sulfonylurea-treated men. Electrophysiologic evidence of peripheral neuropathy was observed in 46.2% of diabetic men and in 4.0% of nondiabetic (normal and IGT) men. For diabetic men with fasting serum glucose ≥140 mg/dl, 63.8% had peripheral neuropathy and 19.1% had retinopathy, whereas for diabetic men with fasting serum glucose <140 mg/dl, 19.4% had neuropathy and none had retinopathy. For diabetic men with a diabetes duration of 2:10 yr, 72.7% had neuropathy and 31.8% had retinopathy; with a diabetes duration of 5-9 yr, 70.6% had neuropathy and 11.8% had retinopathy; and with a diabetes duration of <5 yr, 20.5% had neuropathy and none had retinopathy. Nephropathy was distinctly uncommon, and among the measurements of kidney function, only proteinuria was clearly abnormal with diabetes. Prevalence rates of hypertension, peripheral vascular disease, and ischemic heart disease were highest in Nisei men with diabetes, lowest in men with normal glucose tolerance, and intermediate in men with IGT. None of these conditions appeared to be strongly related to the degree of fasting hyperglycemia. Hypertension occurred in 53.8% of diabetic men, 51.4% of men with IGT, and 29.1% of men with normal glucose tolerance (blood pressure > 140/90 and/or treatment with medication for hypertension). Arteriosclerosis obliterans of the lower leg vessels was determined by Doppler technique to occur in 24.4% of diabetic men, 16.7% of men with IGT, and 8.9% of men with normal glucose tolerance. Ischemic heart disease, as determined from a resting electrocardiogram and the Minnesota Code criteria for ischemic heart disease, occurred in 29.5% of diabetic men, 23.6% of men with IGT, and only 6.3% of men with normal glucose tolerance.

Diabetes and diabetes risk factors in second- and third-generation Japanese Americans in Seattle, Washington

In Seattle, Washington, the prevalence of diabetes was 20% in second-generation (Nisei) Japanese-American men and 16% in Nisei women 45-74 years old, while the prevalence of impaired glucose tolerance (IGT) was 36% in Nisei men and 40% in Nisei women. Hyperglycemia was less and duration of diabetes shorter in women. Related to diabetes and IGT in Nisei were higher fasting plasma insulin levels and central (visceral) adiposity. Prevalence of diabetes was low among the younger (34-53 years old) third-generation (Sansei) men and women. Among self-reported non-diabetic Sansei, however, prevalence of IGT was 19% in men and 29% in women, and IGT was associated with both increased fasting plasma insulin levels and more visceral fat, suggesting that many Sansei are at risk of future diabetes. An important lifestyle factor in the development of NIDD in Japanese Americans appeared to be dietary saturated (animal) fat. Another factor may be physical inactivity. In Japanese-American women, menopause also appeared to be an important risk factor. These risk factors may be related to fostering the accumulation of visceral fat and the development of insulin resistance. Five-year follow-up examinations performed in non-diabetic Nisei men and women have yielded additional information concerning the prognosis of IGT. Of those women who were IGT at baseline, 34% were diabetic at follow-up while 17% returned to normal. In men who had been IGT at baseline, 18% were diabetic at follow-up while 36% returned to normal. Over the 5-yr follow-up interval, proportionally more women progressed from normal to IGT (54%) then went from IGT to normal (17%). For men, roughly equal proportions went from normal to IGT (37%) as from IGT to normal (36%). It would therefore appear that greater proportions of Nisei women are progressing to IGT and to NIDD than are Nisei men. This observation may be related to the increased risk of developing central obesity and insulin resistance following menopause. Prevalence of cardiovascular disease (hypertension, peripheral vascular disease, and/or coronary heart disease) was increased in Japanese Americans with IGT and NIDD. Neuropathy and retinopathy were associated only with NIDD.

Glucose intolrrance and diabetic complications among Japanese-American women

The prevalence of glucose intolerance and diabetic complications was determined in second-generation Japanese-American (Nisei) women and compared to previously obtained results in Nisei men. A volunteer study sample of 191 Nisei women 45-74 years old was enrolled from a study population of 1489 Nisei women born 1913-1942, raised and educated in the U.S., and residing in King County, Washington. The enrolled sample included 72 with normal glucose tolerance, 67 with impaired glucose tolerance (IGT), and 52 with non-insulin-dependent diabetes. A random sample was also drawn from the study population to form a reference sample of 157 women. Based upon observations in the reference and enrolled samples, an estimated 16% of Nisei women in the study population have diabetes and 40% IGT. These rates compare to 20% diabetes and 36% IGT previously estimated for Nisei men 45-74 years old. The prevalence of cardiovascular disease (hypertension, peripheral vascular disease, and/or coronary heart disease) was highest among diabetic women, lowest in those with normal glucose tolerance, and intermediate in women with IGT. In comparison to diabetic men, there was a significantly lower frequency of neuropathy, peripheral vascular disease, and coronary heart disease in diabetic women. However, hypertension occurred equally often in both. Thus Japanese-American men and women 45-74 yr old have a similar prevalence of glucose intolerance, although less severe in women, and complications, except for hypertension, are reduced in women.

Photocoagulation treatment of radiation retinopathy

We studied the visual and anatomic effects of focal photocoagulation for clinically significant radiation macular edema in five eyes of four patients and panretinal photocoagulation for proliferative radiation retinopathy in six eyes of three patients. Focal and limited scatter photocoagulation was successful in preventing further vision loss in all five eyes treated for macular edema. Three eyes treated with panretinal photocoagulation had regression of neovascularization. The other three eyes treated for proliferative retinopathy subsequently had dense vitreous hemorrhages that required vitrectomy for restoration of useful vision.

Photocoagulation treatment for clinically significant radiation macular oedema.

Macular oedema is a leading cause of vision loss in patients with radiation retinopathy. In an effort to find an effective treatment for this vision threatening complication, 12 eyes (eight patients) were treated with photocoagulation for clinically significant radiation macular oedema (CSRMO) defined as central macular thickening, exudates threatening the macular centre, or one disc area of thickening in the macula. Median visual acuity improved from 20/100 preoperatively to 20/90 at the initial postoperative examination (mean follow up 5 months) and to 20/75 at the final postoperative examination (mean follow up 39 months). At the final postoperative examination, visual acuity had improved in eight (67%) eyes and six (50%) eyes had complete resolution of the CSRMO; two (17%) other eyes had improved anatomically in that fewer CSRMO criteria were present. These results suggest that macular photocoagulation is effective in decreasing macular oedema and improving vision in eyes with CSRMO.

Endogenous Aspergillus endophthalmitis after lung transplantation

PURPOSE/METHODS By fundus photography and histopathologic examination, we documented a case of early endogenous Aspergillus endophthalmitis in a 29-year-old man after lung transplantation. RESULTS/CONCLUSIONS The clinical and histopathologic features of this case are consistent with those of previous case reports of endogenous Aspergillus endophthalmitis. Endogenous Aspergillus endophthalmitis represents a manifestation of disseminated aspergillosis, usually a fatal infection. This diagnosis should be considered in immunocompromised patients with visual disturbances, as early recognition of the fundus appearance may aid in systemic treatment.

Wide-field optical coherence tomography based microangiography for retinal imaging

Optical coherence tomography angiography (OCTA) allows for the evaluation of functional retinal vascular networks without a need for contrast dyes. For sophisticated monitoring and diagnosis of retinal diseases, OCTA capable of providing wide-field and high definition images of retinal vasculature in a single image is desirable. We report OCTA with motion tracking through an auxiliary real-time line scan ophthalmoscope that is clinically feasible to image functional retinal vasculature in patients, with a coverage of more than 60 degrees of retina while still maintaining high definition and resolution. We demonstrate six illustrative cases with unprecedented details of vascular involvement in retinal diseases. In each case, OCTA yields images of the normal and diseased microvasculature at all levels of the retina, with higher resolution than observed with fluorescein angiography. Wide-field OCTA technology will be an important next step in augmenting the utility of OCT technology in clinical practice.

Visual Loss from Choroidal Ischemia

Six patients with visual loss showed decreased perfusion of the choroid during fluorescein angiography. The most commonly associated systemic abnormality in these patients was severe hypertension. Other associated diseases included toxemia of pregnancy, renal failure, systemic lupus erythematosus, disseminated intravascular coagulation, and thrombotic thrombocytopenic purpura. Two patients had permanently decreased vision in one or both eyes whereas the other four regained normal vision. Known anatomic and physiologic differences between the retinal and choroidal vessels explained the pronounced choroidal vascular disturbances in the presence of minimal or no observed retinal vascular abnormalities in these patients.