Natasha V. Nayak

Ocular telehealth screenings in an urban community.

The current U.S. economic recession has resulted in a loss of income, housing, and healthcare coverage. Our major goal in this socioeconomic setting was to provide ophthalmic remote health screenings for urban soup kitchen and homeless populations in order to identify and refer undetected vision-threatening disease (VTD). We assessed visual acuity, blood pressure, pulse/oxygen saturation, body mass index, and intraocular pressure for 341 participants at soup kitchens as part of the homeless outreach program in Newark, NJ. History of diabetes, hypertension, and smoking, last ocular examination, and ocular history were noted. Imaging was performed with an 8.2 megapixel non-mydriatic retinal camera with high-speed Internet ready for off-site second opinion image evaluation. Positive VTD findings were identified in 105 participants (31%) (mean age, 53.6 years), of whom 78% were African American, 73% males, and 62% smokers. We detected glaucoma in 34 participants (32%), significant cataract in 22 (21%), diabetic retinopathy in 5 (5%), optic atrophy in 1 (1%), age-related macular degeneration in 1 (1%), and other retinal findings in 43 (41%). The incidence of VTDs was higher among this cohort than among study groups in previous screenings (31% vs. 12%). This finding shows an increase in ocular morbidity in a younger, at-risk population with elevated rates of hypertension, diabetes, and smoking. Functional visual impairment was 2.5 times higher than the national average (16% vs. 6.4%). Comprehensive, community-based screenings can provide more sensitive detection of VTDs in high-risk groups with low access to ophthalmic care and can be an integral part of recession solutions for improving healthcare.

Topical cyclosporine a 1% for the treatment of chronic ocular surface inflammation.

Objective: To evaluate the use of topical cyclosporine A (CsA) 1% emulsion in the treatment of chronic ocular surface inflammation (OSI). Methods: We conducted a retrospective chart review of patients with various forms of OSI treated with topical CsA 1% from 2001 to 2012. Results: Twenty-nine patients (52 eyes) with various forms of OSI, including epidemic keratoconjunctivitis (n=14), chronic follicular conjunctivitis (n=12), Thygeson superficial punctate keratopathy (n=2), and vernal keratoconjunctivitis (n=1), were included. Twenty-seven patients had inflammation refractory to prior therapies. Twenty-four patients received concurrent medications with CsA 1%. Twenty-three of 24 patients on concurrent corticosteroids (CS) were able to taper their use while receiving CsA 1%. Thirteen patients experienced ocular discomfort with CsA 1%; one patient discontinued therapy all together as a result of these side effects; another switched to CsA 0.5% with improvement of adverse symptoms. Inflammation was controlled in 22 (92%) of the 24 patients who received CsA 1% for at least 2 months in duration. Conclusion: Topical CsA 1% helps to control inflammation and spares CS use in patients with chronic OSI.

Effect of age and disc size on rim order rules by Heidelberg Retina Tomograph.

Purpose:The ISNT rule for nonglaucomatous eyes suggests that the neuroretinal rim is thickest at the inferior quadrant (I), followed by the superior (S), nasal (N), and temporal (T) quadrants. This study aimed to use Heidelberg Retina Tomograph (HRT III) measurements to assess (a) fulfillment of the ISNT rule and its derivatives in a large normative database and (b) effect of disc size and age on rule fulfillment. Patients and Methods:A multicenter, prospective, cross-sectional study of a Caucasian normative database consisting of 280 subjects with normal comprehensive biomicroscopic examination, intraocular pressure <21 mm Hg, and normal automated visual field testing was conducted. Right eye neuroretinal rim and disc area, measured by HRT III, for each of the 4 quadrants were analyzed. Compliance of the rim area to the ISNT rule (I≥S≥N≥T) and its derivates was determined. Effect of age and disc area on rule compliance was further determined. Results:Only 18% of normal eyes had rim areas that complied with the ISNT rule; however, a majority complied to IS (77%) and IST (73%) rules. The temporal quadrant had the smallest rim area [(I,S,N)>T] in 91% of patients. The likelihood of ISNT rule violation was increased in larger discs (&khgr;2, P=0.003) but was not affected by age. Conclusions:The ISNT rule does not apply to neuroretinal rim area as measured by HRT, as only 18% of the eyes complied with the ISNT rule in this normative database. Although the ISNT rule may be more applicable to normal eyes with a smaller disc area, the IS and IST rules seem to better represent the normative database.

Feasibility of retinal screening in a pediatric population with type 1 diabetes mellitus.

PURPOSE To study the feasibility of using a nonmydriatic camera to screen children with type 1 diabetes mellitus (DM1) as young as 2 years for diabetic retinopathy. METHODS Prospective pilot imaging study involving children with DM1 aged 2 to 17 years. The screening consisted of: (1) intake form; (2) measurement of blood pressure, pulse, and oximetry; (3) assessment of visual acuity (SIMAV, Padova, Italy); and (4) nonmydriatic color imaging (Canon CX-1 45° 15.1 megapixel camera; Canon Corp., Tokyo, Japan). Images were assessed for signs of diabetic retinopathy and graded for quality on a scale of 1 to 5 by two clinicians. Kappa coefficient was calculated to determine inter-observer agreement. RESULTS One hundred four of 106 (98%) children underwent imaging (mean age: 11.1 years, 51% male, 88% white). One (1%) child had nonproliferative diabetic retinopathy and 2 (1.9%) had incidental findings. Only 62% of children had an eye examination within the past year, with children with DM1 for more than 5 years significantly more likely to have done so (P = .03). Children who had an eye examination within the past year were significantly older than their counterparts (P = .01). Images of high quality (grades 4 and 5) were acquired in 178 (86%) eyes, and images of some clinical value (grades ≥ 2) were obtained in 207 (99.5%) eyes. Inter-observer agreement for image quality was 0.896. CONCLUSIONS The feasibility of using a nonmydriatic camera to screen children as young as 2 years for changes related to diabetic eye disease was demonstrated. Nonmydriatic imaging may supplement standard dilated clinical ophthalmology examinations for select patient populations.

Topical Cyclosporine A 1% for the Treatment of Chronic Follicular Conjunctivitis.

Objective: To evaluate the use of topical cyclosporine A (CSA) 1% in the treatment of chronic follicular conjunctivitis (CFC). Methods: Retrospective chart review from 2001 to 2012 identified 12 patients (22 eyes) with CFC (mean±standard deviation [SD] age, 50.2±15.4 years; 75% female; 92% white) treated with CSA. Main outcome measures included inflammation grade, visual acuity, concurrent corticosteroid (CS) therapy, effect on CS taper, and adverse effects. Results: Mean±SD follow-up time was 11.7±9.7 months. Mean±SD time from diagnosis to CSA treatment initiation was 2.4±3.2 months. Mean±SD duration of CSA treatment was 5.8±2.8 months. Four patients (33%) complained of irritation (n=2), redness (n=1), itching (n=1), and burning (n=1) but none discontinued treatment. Concurrent CSs were tapered off in all patients after a mean±SD of 5.0±2.5 weeks. Mean±SD initial vision was 0.078±0.093 logMAR, whereas vision at final examination was 0.056±0.081 logMAR (P=0.02). Mean±SD initial inflammation grade of 1.9±1.0 was significantly reduced to final grade of 0.7±0.9 (P=0.0002). Mean±SD time to initial inflammation control in 9 patients (75%) was 33.2±24.5 days. Two patients (17%) switched to oral CSA because of lack of inflammation control. Conclusions: Topical CSA 1% is an effective and well-tolerated therapy that decreased chronic inflammation and tapered topical CS in patients with CFC. The use of CSA in such patients warrants further investigation.

Complimentary imaging technologies in blunt ocular trauma

We describe complimentary imaging technologies in traumatic chorioretinal injury. Color and fundus autofluorescence (FAF) images were obtained with a non-mydriatic retinal camera. Optical coherence tomography (OCT) helped obtain detailed images of retinal structure. Microperimetry was used to evaluate the visual function. A 40-year-old man sustained blunt ocular trauma with a stone. Color fundus image showed a large chorioretinal scar in the macula. Software filters allowed detailed illustration of extensive macular fibrosis. A 58-year-old man presented with blunt force trauma with a tennis ball. Color fundus imaging showed a crescentric area of macular choroidal rupture with fibrosis. FAF imaging delineated an area of hypofluorescence greater on fundus imaging. OCT showed chorioretinal atrophy in the macula. Microperimetry delineated an absolute scotoma with no response to maximal stimuli. Fundus imaging with digital filters and FAF illustrated the full extent of chorioretinal injury, while OCT and microperimetry corroborated the structure and function correlations.