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Performance of glaucoma mass screening with only a visual field test using frequency-doubling technology perimetry.

PURPOSE: To report the performance of glaucoma mass screening with only a visual field test utilizing frequency- doubling technology (FDT) perimetry in general populations. DESIGN: Hospital and population-based cross-sectional study. METHODS: This study took place in a multicenter setting. One hundred three consecutive glaucomatous patients and 14,814 persons were randomly selected. We had created a glaucoma screening protocol (GSP) using FDT perimetry (FDT-GSP). Frequency-doubling technology-glaucoma screening protocol was tested on consecutive glaucoma patients diagnosed with Humphrey visual field analyzer (30-2 SITA standard), and then FDT-GSP was applied to general populations. Frequency-doubling technology-glaucoma screening protocol positive subjects were ophthalmologically diagnosed. Detection ability of FDT-GSP was determined in consecutive patients, and the positive predictive value (PPV) of FDT-GSP to detect definitive glaucoma was estimated in general populations. RESULTS: Frequency-doubling technique-glaucoma screening protocol detected 83.3% and 100% of definitive glaucoma patients with an early (mean deviation [MD] > -6 dB) and more advanced stage (MD < or = -6 dB), respectively. In the population-based screening, there were 660 (4.5%) subjects who had positive FDT-GSP, including 512 in whom no visual field abnormalities (VFA) had been pointed out previously. Of them, 370 subjects underwent ophthalmologic diagnosis. Then, 266 (71.9%, 266/370) subjects had a glaucomatous disk and 167 had definitive glaucomatous VFA. Fifty-five (14.9%) and 39 (10.5%) subjects were diagnosed as having other diseases and as normal, respectively. The PPV of FDT-GSP ranged from 32.6% (167/512)-45.1% (167/370). CONCLUSIONS: Frequency-doubling technology-based screening with only a visual field test showed reasonable performance on mass screening for detection of definitive glaucoma in this study population, considering the glaucoma prevalence.

Aged↗

Screening for diabetic retinopathy. Initiation and frequency.

A screening program for diabetic eye disease was established in Iceland in 1980. Diabetics involved in the screening program have a low prevalence of blindness, 1% in type 1 and 1.6% in type 2. We examined ways to make the screening program more efficient by identifying subgroups at low risk of developing eye disease that require treatment and therefore need less frequent screening. We studied whether diabetic eye disease screening programs may be trimmed by excluding children and examining diabetics without retinopathy biannually. Our results indicate that diabetic children under the age of 12 years do not need regular screening for eye disease. Biannual examinations seem to suffice in type 1 and 2 diabetic patients without retinopathy. However, in a setting where the eye clinic is located apart from the diabetes clinics, biannual examinations present practical problems which could result in a less effective screening for diabetic eye disease.

Adolescent↗

The dexamethasone provocative test: a predictive tool for glaucoma?

A retrospective follow-up study of 134 patients (84 women and 50 men) tested for their responsiveness to topically administered corticosteroids was carried out. Of the 134 patients tested, 34 (25.4%) had a high response (IOP rise greater than or equal to 16 mmHg), 66 (49.3%) an intermediate (IOP rise 6-15 mmHg) and 34 (25.4%) a low response (IOP rise less than or equal to 5 mmHg) to topically administered 0.1% dexamethasone eye drops. Follow-up time varied from 5 to 15 years (mean 7.1 years). During the follow-up period 29 (21.6%) patients developed glaucoma. Of these, 9 (31.0%) were high responders and 7 (24.0%) had a low response to corticosteroids. Log-linear analysis showed no correlation between corticosteroid response and development of glaucoma in the study eye (SD = 0.232, DF = 2, P = 0.890), the control eye (SD = 1.234, DF = 2, P = 0.540) or both eyes (SD = 0.618, DF = 2, P = 0.734). At the final examination 75 patients (56%) had an IOP of greater than or equal to 22 mmHg. Of these ocular hypertensive patients 28 (37.3%) were high responders, and 15 (20%) had a low response to corticosteroids. Of the whole material of 134 patients 44 had a family history of glaucoma. Eleven (25.1%) of these were high responders and 14 (31.8%) low responders. Of the 29 patients who developed glaucoma 8 had a family history of glaucoma. Of these 3 were high responders and 3 low responders. The results indicate that the dexaprovocative test yielded relatively limited value in the screening of patients for glaucoma.

Administration, Topical↗

Contrast sensitivity changes in background diabetic retinopathy.

Previous reports of contrast sensitivity in diabetic patients have shown conflicting results. We evaluated contrast sensitivity using Cambridge low-contrast sensitivity charts in 22 diabetic patients (22 eyes without retinopathy and 16 eyes with background retinopathy on fluorescein angiography) and 10 control subjects (20 eyes) matched for age and sex. The mean contrast threshold values at a spatial frequency of 4 cycles/degree were 0.46%, 0.60% and 0.43% in the three groups of eyes respectively. Contrast sensitivity was significantly lower in the diabetic eyes with retinopathy than in the normal eyes (p = 0.011) or the diabetic eyes without retinopathy (p = 0.033). This test may be of value in screening diabetic patients for retinopathy in primary care facilities.

Contrast Sensitivity↗

Two-field photography can identify patients with vision-threatening diabetic retinopathy: a screening approach in the primary care setting.

OBJECTIVE: To compare the effectiveness of two 45 degrees photographic fields per eye in the screening for diabetic retinopathy with the routine ophthalmologist's examination and to study the effectiveness of visual acuity measurement in the detection of diabetic macular edema. RESEARCH DESIGN AND METHODS: Type 1 and 2 diabetic patients without a known history of more than minimal retinopathy (n = 469) had a routine examination by an ophthalmologist, including visual acuity measurement, indirect retinoscopy, and biomicroscopy. At the same time, two-field nonstereoscopic retinal photographs were made of both eyes and assessed in a masked fashion by a retinal specialist. The results were compared. RESULTS: The prevalence was 4.3% for vision-threatening retinopathy and 24% for any retinopathy. The sensitivity of two-field photography in identifying diabetic patients with sight-threatening retinopathy was 95% (specificity 99%) and sensitivity for detecting any retinopathy was 83% (specificity 88%). The percentage of referrals to an ophthalmologist was 6.2%. All patients with macular edema detected by biomicroscopy were classified as having vision-threatening retinopathy on the photographs. CONCLUSIONS: Two-field retinal photography is a promising alternative to the routine ophthalmologist's examination in the screening for diabetic retinopathy. Visual acuity measurement is not a sensitive tool for the detection of macular edema. Screening for diabetic retinopathy using two-field retinal photography is feasible in a primary care setting and can substantially lower the number of ophthalmic referrals.

Adult↗

Helping the elderly stay active: a technique for detecting disability in the primary care office.

The inability to perform essential activities of daily living such as cooking, shopping, dressing and bathing is termed functional disability. These deficits can prevent elders from enjoying independent, active lifestyles. The development of functional disability is a gradual process. Early identification and intervention by the primary care physician can often reduce functional decline. Screening for functional decline has traditionally been performed by either questionnaire or direct observation of tasks. This paper reviews methods which have been proposed to integrate functional disability screening into office practice. A method which incorporates both questionnaire and direct observation is recommended by the authors. The method of screening proposed targets specific areas prone to dysfunction. It focuses on simple screens of vision, hearing, arm and leg function, urinary incontinence, mental status, depression, nutrition, activities of daily living, environmental hazards, and social support systems. Appropriate methods of follow up evaluation and treatment are provided. This fifteen minute technique is a practical and applicable means of screening elderly patients for functional deficits in the primary care office.

Activities of Daily Living↗

Do optometrists screen for glaucoma?

A survey of optometrists practising in Nottingham was undertaken to identify their methods of screening for glaucoma in the community. There was found to be great variation in all parameters examined including referral criteria. Although all of the respondents screened for glaucoma, 50% appeared not to be aware of subtle optic disc signs of the disease, 8% never measured intra-ocular pressures and 19% never performed visual field analysis. In a general practice population age 50 and over, 73% of patients had visited their optician within the last two years, 67% knew glaucoma was an eye disease, but only 15% remembered being screened for glaucoma.

False Positive Reactions↗

Calculating the predictive power of the Henson field screener in a population at risk of glaucomatous field loss.

Suprathreshold field screeners are in common use for the detection of glaucomatous field loss. The predictive power of a positive result (PP+) depends on the sensitivity and specificity of the screener in the population in which it is to be used. Using data from 755 normal individuals (1510 eyes), we calculated the PP+ of the Henson CFS2000 screening programme for a population aged 50 and over. 4.3% of normal eyes failed the screening programme. Ignoring one or two misses on the screening programme immediately adjacent to the disc reduced this figure to 1.3% and significantly improved the PP+ of the programme. Calculations of the PP+ at increasing glaucoma prevalence levels indicates this to be particularly relevant at low levels such as those encountered when screening middle aged and elderly populations. Optometrists should perform routine field analysis when screening for glaucoma provided they adhere to strict protocols.

Aged↗

Visual field screening and the development of a new screening program.

The diagnosis of chronic open-angle glaucoma requires diligent and careful screening. Intraocular pressure measures and disc evaluations, when used in isolation, give unacceptably high numbers of false positives and false negatives, while full visual field analysis, as conducted with kinetic or full threshold static perimetry, takes too long for routine use. Screening of the visual field may offer a viable alternative. The effect of changing certain parameters of a visual field screening test are evaluated. These include the location of the stimuli, the number of stimuli and their suprathreshold increment. The results of an optimized visual field screening test are then evaluated with respect to the theoretical predictions. The results indicate that high levels of sensitivity and specificity can be achieved with visual field screening tests which are short enough to be included as part of the routine optometric examination.

Glaucoma, Open-Angle↗

Impact of diabetes on glaucoma screening using frequency-doubling perimetry.

PURPOSE: To determine whether diabetes is a potential source of abnormal test results in glaucoma screening by use of frequency-doubling perimetry. DESIGN: Observational case series. PARTICIPANTS AND CONTROLS: Twenty-five patients with diabetes and 25 nondiabetic normal controls, all without cataract or glaucoma. METHODS: Frequency-doubling perimetry using the C-20-5 screening mode was performed in 1 randomly selected eye of each participant. Abnormal test results were immediately repeated to reduce artifacts caused by test inexperience. Frequency-doubling technology (FDT) results were assigned a numerical score between 0 (normal) and 87 (no stimuli detected). MAIN OUTCOME MEASURE: Abnormal FDT test scores. RESULTS: Overall, 7 of 25 (28%) patients with diabetes and 1 of 25 (4%) normal controls had an abnormal test; the 1 normal subject with an abnormal test was subsequently determined to have an abnormal glucose tolerance test. Four of the 7 patients with diabetes with abnormal FDT tests had no evidence of diabetic retinopathy on clinical examination. Patients with diabetes had higher test scores than normal controls (8.9+/-16.9 vs. 1.0+/-4.4, P = 0.028) and had longer test times than normal controls (66.4+/-35.5 seconds vs. 48.3+/-11.2 seconds, P = 0.019). CONCLUSIONS: Frequency-doubling perimetry is abnormal in some patients with diabetes, including some patients with diabetes without clinical evidence of diabetic retinopathy. Abnormal FDT testing in diabetic eyes may not represent glaucomatous visual field loss. Diabetes may be a source of "false-positive" test results when this technology is used for glaucoma screening.

Adult↗

Photoscreening for amblyogenic factors.

BACKGROUND: The Medical Technology Inc (MTI) Photoscreener is a new eccentric photoscreener that is being marketed as a device for the detection of amblyogenic factors in preverbal children. The purpose of this study was to evaluate the accuracy of the MTI Photoscreener in the target population of young, healthy children. METHODS: One thousand and three healthy children between the age of 6 months and 59 months were photoscreened with the MTI Photoscreener. Nine hundred and forty nine children were included in the study and their results were compared with a complete ophthalmologic examination with cycloplegia. RESULTS: The sensitivity of the MTI Photoscreener was determined to be 81.8% with a specificity of 90.6%. The overall agreement rate was 88.8%. The positive and negative predictive values were 68.9% and 95.2%, respectively. All cases of strabismus and media opacities were detected. CONCLUSION: The MTI Photoscreener is an accurate and reliable device designed to detect amblyogenic factors in young children. The camera offers promise as a useful mass-screening tool.

Amblyopia↗

Cost-effectiveness of orthoptic screening in kindergarten: a decision-analytic model.

PURPOSE: The purpose of this study was to analyze the cost-effectiveness of orthoptic screening for amblyopia in kindergarten. METHODS: A decision-analytic model was used. In this model all kindergarten children in Germany aged 3 years were examined by an orthoptist. Children with positive screening results were referred to an ophthalmologist for diagnosis. The number of newly diagnosed cases of amblyopia, amblyogenic non-obvious strabismus and amblyogenic refractive errors was used as the measure of effectiveness. Direct costs were measured form a third-party payer perspective. Data for model parameters were obtained from the literature and from own measurements in kindergartens. A base analysis was performed using median parameter values. The influence of uncertain parameters was tested in sensitivity analyses. RESULTS: According to the base analysis, the cost of one orthoptic screening test was 7.87 euro. One ophthalmologic examination cost 36.40 euro. The total cost of the screening program in all kindergartens was 3.1 million euro. A total of 4,261 new cases would be detected. The cost-effectiveness ratio was 727 euro per case detected. Sensitivity analysis showed considerable influence of the prevalence rate of target conditions and of the specificity of the orthopic examination on the cost-effectiveness ratio. CONCLUSIONS: This analysis provides information which is useful for discussion about the implementation of orthoptic screening and for planning a field study.

Amblyopia↗

Population-based screening versus case detection.

India has a large burden of blindness and population-based screening is a strategy commonly employed to detect disease and prevent morbidity. However, not all diseases are amenable to screening. This communication examines the issue of "population-based screening" versus "case detection" in the Indian scenario. Using the example of glaucoma, it demonstrates that given the poor infrastructure, for a "rare" disease, case detection is more effective than population-based screening.

Blindness↗

[Retinophotography--screening method in diabetic retinopathy].

The paper presents the modern screening method for diabetic retinopathy-the retino-photography. We present our experience on this issue, regarding the patients with diabetic retinopathy screened in Diabetic Eye Department, Ophthalmology Clinic Craiova, between October 2002-June 2005.

Diabetic Retinopathy↗