Noel C. Wheeler

A clinical and demographic profile of a sample of adults with attention deficit hyperactivity disorder, residual state.

It is becoming increasingly recognized that one third to one half of children diagnosed as having attention deficit/hyperactivity disorder (ADHD) continue to exhibit symptoms of the disorder into adulthood. The nature of the clinical picture is not well understood by a substantial number of clinicians. The purpose of this study is to report on the demographic and clinical profile of 56 adults, age 19 to 65 years (48 men, eight women) who present with adult ADHD and meet DSM-III-R criteria for the disorder. Patients underwent a diagnostic work-up consisting of medical and psychiatric evaluation, a structured interview Schedule for Affective Disorders and Schizophrenia-Lifetime Version [SADS-L]), the Symptoms Checklist Revised (SCL-9OR), Conners Attention Deficit Disorder With Hyperactivity (ADDH) scale, structured interview of ADDH, the Global Assessment of Functioning Scale (GAF), and, when available, information from parents was obtained. Ninety-one percent of our sample met the Utah Criteria for adult ADHD. The majority of the sample had additional DSM-III-R diagnoses and only seven had ADHD diagnosis alone. Fifty-three percent of the sample met the criteria for generalized anxiety disorder, 34% alcohol abuse or dependence, 30% drug abuse, 25% dysthymic disorder, and 25% cyclothymic disorder. These findings were similar to those reported in the literature.

Vitreoretinal Juncture: Synchysis Senilis and Posterior Vitreous Detachment

A quantitative study of synchysis senilis of vitreous and a statistical evaluation of its relationship to posterior vitreous detachment (PVD) was performed in eyes of 2,246 autopsied subjects (4,492 eyes); cases in which there was any cause for synchysis or PVD except senescence were excluded. Synchysis was graded 0 through 6 according to degree of destruction as judged by the technique of suspension-in-air; synchysis increased with age (P less than 0.00005). PVD was also age-related, becoming notable in the seventh decade (27%) and reached a zenith in the eighth (63%). When the rate of PVD for each grade of synchysis was plotted, there was a significant upturn between synchysis grades 3 (50% destruction) and 4 (67%) (P less than 0.00005); this trend was also evident when age was considered. These quantitative data reaffirm the role of synchysis in rhegmatogenous PVD and suggest that the vitreous of human eye can tolerate only a given degree of synchysis before some event, possibly related to vitreous instability, initiates PVD.

Reliability coefficients of three corneal pachymeters

We compared the accuracy and reproducibility of a hand-held portable ultrasound pachymeter, the Pach-Pen (Bio-Rad, Ophthalmic Division, Santa Ana, California); another ultrasound pachymeter, the DGH 1000 (DGH Technology, Inc., Frazer, Pennsylvania); and the Pro-Cem 4 endothelial specular microscope (Alcon-Surgical, Inc., Irvine, California). Each eye of 18 healthy human subjects was examined to determine corneal thickness using the three different instruments. For each instrument, five repeated measurements were obtained at each of five corneal locations (one central, four peripheral), for a total of 25 measurements per eye. The accuracy of the two ultrasound pachymeters was tested by comparing measurements obtained on specially designed test blocks of known thickness. The Pach-Pen was the more accurate of the two ultrasound pachymeters, with measurements within the range of 0.003 to 0.065 mm from the true thickness. The three instruments were most consistent in mean thickness in the center of the cornea. All three instruments showed excellent intraobserver reproducibility, as measured by reliability coefficients over 90%. Overall, the Pach-Pen pachymeter had high reproducibility, and produced more accurate measurements than the DGH 1000 pachymeter.

Survival of Patients with the Acquired Immune Deficiency Syndrome after Development of Cytomegalovirus Retinopathy

Abstract To study the survival of patients with acquired immune deficiency syndrome (AIDS) who develop cytomegalovirus (CMV) retinopathy, the medical records of 100 consecutive patients with AIDS and CMV retinopathy were reviewed. Dates of AIDS diagnosis, CMV retinopathy diagnosis, and death were determined for each patient. The median interval from CMV retinopathy diagnosis to death for patients whose infection was diagnosed between May 1984 and September 1987 was 5 months. The interval had increased significantly since 1981. The interval from AIDS diagnosis to CMV retinopathy diagnosis (median, 9 months) did not increase. Based on extent and location of retinal lesions at the time patients were first examined, increased survival could not be attributed to earlier diagnosis of CMV retinopathy. Patients treated with ganciclovir lived longer after diagnosis of CMV retinopathy (median, 7 months) than untreated patients (median, 2 months; P

Diabetes Mellitus and Intraocular Lens Implantation

Prospective evaluation of extracapsular cataract extraction with posterior chamber intraocular lens (ECCE-posterior chamber IOL) in 234 eyes of 20 diabetics, with and without nonproliferative retinopathy, and 209 nondiabetics demonstrated no statistically significant difference in operative or postoperative complications. A postoperative final visual acuity of 20/40 or better was achieved in 65% of diabetic surgical eyes and in 90% of nondiabetic surgical eyes, a difference that was statistically significant (P = 0.0049). When eyes with diabetic retinopathy or other pre-existing ophthalmic disease responsible for decreased vision were excluded, postoperative visual acuity of 20/40 or better was obtained in 93% of diabetic eyes and 96% of nondiabetic eyes, a difference that was not statistically significant (P = 0.5045). Therefore, the relatively less favorable outcome of ECCE-posterior chamber IOL surgery in diabetics, with or without nonproliferative retinopathy, is due to greater frequency of retinopathy or other ophthalmic disease responsible for decreased vision. Based on this study and all available information, guidelines regarding diabetes mellitus and intraocular lens implantation are presented.

Demographic Factors in a Population-Based Survey of Hospitalized, Work-Related, Ocular Injury

PURPOSE To obtain population-based estimates of the incidence of severe work-related ocular trauma and to identify demographic factors related to increased risk of this type of injury. METHODS A statewide population-based survey of severe work-related ocular injury was performed using hospital discharge data. These data were derived from all inpatient admissions to nonfederal, acute-care hospital facilities in the state of California during 1988. Workers compensation was used as the principal payor code to establish the work-relatedness of a given ocular injury. Census data for the state of California were used to obtain population denominators. RESULTS Two hundred sixty-nine (approximately 14.3%) of all admissions for which ocular trauma was the principal diagnosis (1,876) were work related. Annual incidence for severe work-related ocular injury was 1.76 per 100,000 employed persons when ocular trauma was the principal diagnosis and 2.98 per 100,000 employed persons when ocular trauma was a principal or secondary diagnosis. Projected to the working-age United States population (128 million) these annual rates correspond to an estimated 2,165 acute hospitalizations for work-related ocular trauma as the principal diagnosis, and an estimated 3,745 acute hospitalizations for work-related ocular trauma as a principal or secondary diagnosis. Incidence of severe work-related ocular injury was highest among men, Hispanics, and individuals 20 to 24 years of age (5.02, 3.72, and 4.64 per 100,000 employed per year, respectively). CONCLUSIONS The workplace accounts for a substantial proportion of severe ocular injury. Demographic groups at highest risk for this type of injury are men, Hispanics, and young adults.

Results of Inpatient and Outpatient Cataract Surgery: A Historical Cohort Comparison

PURPOSE The transition from inpatient to outpatient cataract surgery during the last decade was not accompanied by prospective investigation of its effect on visual outcomes or surgical complications. The authors performed this study to assess the impact of this transition on surgical results. METHODS The authors reviewed 600 extracapsular cataract extractions performed by 4 experienced ophthalmic surgeons during a 36-month period; in 300 cases, patients were hospitalized after surgery (inpatient group), and, in 300 cases, patients were never hospitalized (outpatient group). The same surgical techniques were used in all cases. Visual outcome and rates for operative and postoperative complications were compared. RESULTS There were no statistically significant differences between the inpatient and outpatient groups for visual acuity. Excluding patients with pre-existing nonlenticular ocular disease, a best-corrected visual acuity of 20/40 or better was achieved in 93.1% of inpatient cases and in 97.2% of outpatient cases 6 months after surgery. Postoperative, clinically apparent cystoid macular edema was more common in the inpatient group (P = 0.03); however, after exclusion of patients with diabetes, hypertension, age younger than 65 years, and eyes with pre-existing nonlenticular disease, there was no statistically significant difference between groups. No significant differences in rates for other operative and postoperative complications were identified, including wound dehiscence, unplanned postoperative filtering blebs, infectious endophthalmitis, retinal detachment, persistent iridocyclitis, glaucoma, and corneal edema. CONCLUSION This study does not demonstrate that the transition to outpatient cataract extractions has had an adverse effect on surgical outcomes.

Transfer of tuberculin immunity from mother to infant.

ABSTRACT:: The purpose of our study was to investigate transfer of tuberculin immunity from mother to infant via breast milk by studying newborn lymphocyte blastogenesis induced by purified protein derivative antigen at 1-5 days of age, 4-6 wk of age, and 3 months of age. Our study consisted of four mother-infant groups: breast-feeding and bottle-feeding infants of tuberculin-positive and tuberculinnegative mothers. A difference in the groups was found only at 4-6 wk of age where 17% (4/23) of breast-feeding infants and 13% (2/15) of bottle-feeding infants of tuberculin positive mothers had lymphocyte blastogenesis to purified protein derivative. None of the infants of tuberculin negative mothers had purified protein derivative-induced blastogenesis. Analysis of covariance with tests for equality of slopes showed that the responses of tuberculin-positive mothers were significantly different from the responses of tuberculin-negative mothers (p < 0.05). These studies suggest transplacental transfer of tuberculin immunity evident at 4-6 wk of age which wanes by 3 months of age. We could not find evidence of transfer via human milk.

Cytomegalovirus retinopathy as the initial manifestation of the acquired immunodeficiency syndrome.

Of 100 consecutive patients with human immunodeficiency virus infection and cytomegalovirus retinopathy, 15 did not have a previous diagnosis of the acquired immunodeficiency syndrome before the ocular infection. All had other HIV-related disorders that would place them in Group IV of the Centers for Disease Control hierarchical classification system for HIV infections. In nine patients, cytomegalovirus retinopathy was the only disorder that fulfilled the Centers for Disease Control criteria for diagnosis of AIDS. In the other six, examination disclosed additional preexistent or concurrent nonocular disorders that were also diagnostic of AIDS. No demographic, medical, or ophthalmic characteristics distinguished the nine patients for whom cytomegalovirus retinopathy was initially the only manifestation of AIDS. On the basis of published figures for the prevalence of cytomegalovirus retinopathy in patients with AIDS, and the incidence with which HIV-infected persons develop AIDS, it is estimated that approximately 1.8% of patients with AIDS have cytomegalovirus retinopathy as the first manifestation and that less than 1% of HIV-infected persons will develop cytomegalovirus retinopathy as the initial manifestation of AIDS during the first seven years after infection with HIV.

Comparison of Lesions Predisposing To Rhegmatogenous Retinal Detachment By Race of Subjects

Because rhegmatogenous retinal detachments are thought to be much less common in blacks than in whites, we compared the incidence of various lesions known to cause or predispose to this condition (synchysis senilis, posterior vitreous detachment, breaks, tears, and holes of the peripheral fundus, and lattice degeneration of the retina) in a series of postmortem eyes on the basis of race. Our statistical analysis also included trauma, myopia, and chorioretinitis. The series included 322 black subjects and 2,012 white subjects. The subjects ranged in age from 20 to 93 years at the time of death. Although the initial data showed a racial difference in the incidence of synchysis senilis of grade 3 (50% destruction) or higher and posterior vitreous detachment (P = .033 and P = .021, respectively), we found no difference when the data were age-corrected.