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PubMed2004

A retrospective review of the associations between amblyopia type, patient age, treatment compliance and referral patterns.

AIM: To review presenting ages, referral sources, amblyopia type and treatment compliance in children attending a typical public hospital ophthalmology clinic with no formal amblyopia screening program in place. METHODS: One hundred and twenty-seven children attending the outpatients clinics of The Children's Hospital at Westmead for amblyopia management between January 2001 and May 2003 were reviewed. Presenting age, amblyopia type, referral source, treatment prescribed and compliance achieved were analysed using means, 95% confidence intervals (CI), and Mantel-Haenszel chi2 statistic. RESULTS: General practitioners and paediatricians provided most referrals. The mean presenting age was 32.9 (95% CI 29.0-36.9) months. There was no significant association between presenting age and amblyopia type (chi2 = 6.00, P = 0.11, d.f. = 3), but a trend was found with deprivation amblyopia identified earliest, and pure anisometropic amblyopia identified latest (chi2 = 5.65, P = 0.02, d.f. = 1). Compliance to patching did not differ significantly between sexes, with calculated aggregate compliance of 67.3% (95% CI: 59-75%) for boys and 66.3% (95% CI: 60-73%) for girls. Compliance to patching also did not differ significantly between amblyopia types (chi2 = 3.61, P = 0.3, d.f. = 3). Compliance was best among younger and older children, and worst among those aged 15-30 months. There was no association between patching compliance and treatment duration. CONCLUSION: Amblyopia is a preventable form of blindness. A multidisciplinary approach must be taken. Resources and education should be targeted at general practitioners and paediatricians who have the greatest opportunities to perform amblyopia screening. Teachers are an important resource in identifying cases missed at previous informal screening opportunities. Amblyopia treatment must be intensified and individualized between the ages of 15-30 months when compliance is poorest.

Age Distribution↗
PubMed2006

Pattern of presentation of primary open-angle glaucoma in Benin City, Nigeria.

Late presentation is a major problem in the management of patients with primary open-angle glaucoma. The aim of this study was to determine the clinical features and the degree of visual disability of glaucoma patients at initial presentation. This was a prospective study of new patients with a diagnosis of primary open-angle glaucoma seen between January 2001 and August 2002 at the University of Benin Teaching Hospital, Nigeria. The patients were analysed in the context of age, gender, geographical abode, educational and socioeconomic status and clinical presentation. The patients were examined using the Snellen's chart, pen torch, slit lamp biomicroscopy, ophthalmoscopy, tonometry, perimetry and gonioscopy. Over a 20-month period 154 patients were studied; the mean age was 52.73 years (standard deviation +/- 15.98) and the highest incidence was in the seventh decade. The male to female ratio was 2.1:1. In all, 119 patients (77.3%) presented with subjective visual loss in one or both eyes, while 57.1% dated the onset of their symptoms to 1-5 years before presentation. Overall, 38 patients (24.7%) were blind when using visual acuity as the criteria, while 87 patients (56.5%) were blind when using visual fields as the criteria. The problem of late presentation has not improved over the last two and a half decades. More measures towards early detection by extensive health education, screening programmes and training of more eye care providers need to be put in place.

Adolescent↗
PubMedDate not supplied

Polaroid photorefractive screening of infants.

We modified a Polaroid SE camera for use as a photoretinoscope. A total of 187 infants between 2 and 18 months of age were photographed using this device. About half of these infants (97) participated in a double blind study in which the results of photorefraction were compared with those of standard cycloplegic retinoscopy. Eighty-three infants were photographed without cycloplegia. Thirty-four infants were photographed while cyclopleged. Photographs were evaluated for significant refractive errors and other ocular abnormalities. The effectiveness of the camera system to screen for significant refractive errors without the use of cycloplegia was assessed. Infants were identified to be at risk by photorefraction if, in any photograph, a hyperopic bright crescent calculated to be greater than or equal to +1.25 D was present in the pupil. Clinically significant refractive errors were defined by the results of cycloplegic retinoscopy: "at-risk" infants had either 3.5 D or more hyperopia in either eye, or astigmatism in either eye greater than or equal to 2.5 D, or anisometropia greater than or equal to 1.5 D. With these clinical criteria and the above photographic screening criterion, the camera's sensitivity and specificity were 83% and 69%, respectively. The present system compares favorably with earlier, more sophisticated units in alerting practitioners to potentially significant refractive errors in infants. Additionally, as a screening tool, this device offers the benefits of being inexpensive and easy to use, and of providing immediate feedback.

Calibration↗
PubMed1998

Pigment gene expression in protan color vision defects.

We screened 150 male eye donors and identified four who did not have or express L pigment genes, consistent with each of them having a congenital protan color vision defect. One donor was identified as a protanope because he had and expressed a single X-chromosome photopigment gene that encoded an M pigment. Three were categorized as protanomalous because each expressed significant levels of genes specifying two spectrally different M pigments. The first gene in each of the protanomalous arrays was expressed the most and encoded an M pigment that differed in amino acid sequence from M pigments in color normal men.

Base Sequence↗
PubMed1994

Attacking the backlog of India's curable blind. The Aravind Eye Hospital model.

The number of individuals in developing nations with preventable blindness from cataract and other disorders is increasing. New programs incorporating local customs and efficiently using available resources must be created to prevent the escalation of blindness and to rehabilitate patients already disabled with cataracts. We describe a system of high-quality, high-volume, cost-effective cataract surgery, using screening eye camps and a resident hospital. This has enabled us to provide efficient low-cost cataract surgery and overcome barriers of adequate eye care in southern India. We have been successful in locating patients with treatable eye problems, educating them about the availability of ophthalmic care, and providing free eye care. Our structure stresses the following: community involvement, identification of individuals most likely to benefit from screening, efficient utilization of both medical and paramedical personnel, and a streamlined approach to screening patients. This system may be capable of modification for use in other developing areas to decrease the backlog of cataract blindness.

Blindness↗
PubMed1999

Barriers to compliance with screening guidelines for diabetic retinopathy.

OBJECTIVE: To identify barriers to compliance with guidelines for diabetic retinopathy screening. METHODS: The population studied included 4410 adults, aged 31 to 64, enrolled in an Independent Practice Association (IPA) plan in Upstate New York, who were diagnosed with diabetes, and their Primary Care Physicians (408 PCPs). Claims data were used to calculate variables characterizing patients and their PCPs. Logistic regression models were estimated to identify factors associated with higher probability of screening. RESULTS: 34% of patients were screened in 1993. The probability of screening was significantly higher for older patients, for women, for patients who visit their PCPs more often and for those living in areas of higher average education and lower percentage of blacks. However, only 16% of diabetic patients received an annual screen in two consecutive years (1992 and 1993). The probability of consecutive annual screening was significantly associated only with gender and patient expenditures per month. CONCLUSION: The very low rate of diabetic retinopathy screening has implications for quality of life of patients with diabetes, long term costs of caring for them and social costs due to lost productivity. Interventions to increase screening rates are needed and should target both patients and their Primary Care Physicians.

Adult↗
PubMed2006

Do infants of birth weight less than 1500 g require additional long term ophthalmic follow up?

AIM: To survey existing ophthalmic follow up protocols in the United Kingdom for very low birthweight (VLBW) children. In addition, relative risk analysis was performed using data from a cohort study to assess which factors (birth weight, gestational age, retinopathy of prematurity (ROP) status) led to a high risk of developing amblyogenic factors. METHODS: Questionnaires were sent to every orthoptic department in the United Kingdom (n = 288) for information on their policy on the follow up of VLBW children. RESULTS: Responses were received from 125 departments (43%). There was a large variation in criteria used for follow up; 21% of respondents using birth weight (BW) and gestational age (GA), 22% using stage 3 or treated ROP, the remainder using a combination of these factors. There was no consensus regarding when follow up should commence (from 3 months to 3 years) or cease (1-8 years). Relative risk analysis revealed that birth weight under 1500 g, GA under 33 weeks, and the presence of severe ROP were significant risk factors for developing one or more amblyogenic factors. CONCLUSION: There is no consensus on whether VLBW children need to be reviewed. There is a greatly increased risk of ophthalmic deficits in those with severe ROP or severe neurological disorders, and also in those with mild or no ROP. Children in the latter group who are not routinely followed up, have a high risk of developing treatable refractive errors and strabismus. This raises the question of whether an additional screening examination is merited.

Age Factors↗
PubMed2002

Screening for retinopathy of prematurity: evaluation and modification of guidelines.

AIMS: To evaluate current screening guidelines for ROP (retinopathy of prematurity) and to determine whether they can be modified. METHODS: In accordance with the authors' present criterion, infants born in Stockholm County, Sweden, from 1 August 1998 to 31 July 2000, with a gestational age of < or =32 weeks, were screened for ROP. The effectiveness of screening was studied. RESULTS: The incidence of ROP was 25.5% in this study. A dropout group comprising almost 20% of the population studied (< or =32 weeks), was never referred, were lost to follow up, or died before screening was completed. No infant with a gestational age of >31 weeks at birth developed severe ROP (stages 3-5) and no infant with a gestational age of >29 weeks was treated for ROP. CONCLUSION: 80% of infants in this population with a gestational age at birth of < or =32 weeks, the current screening criterion, were effectively screened for ROP. The authors recommend that the screening criterion be lowered to </=31 weeks since no infant with severe ROP would have been missed.

Birth Weight↗
PubMed1995

Sensitivity and specificity of photography and direct ophthalmoscopy in screening for sight threatening eye disease: the Liverpool Diabetic Eye Study.

OBJECTIVE: To evaluate different methods for community based screening for sight threatening diabetic eye disease. DESIGN: Prospective study. SETTING: Mobile screening unit visiting inner city community clinics; hospital assessment clinic (tertiary centre). SUBJECTS: 395 diabetic patients registered with four general practices in an inner city location. INTERVENTIONS: Community based photography with mydriasis and direct ophthalmoscopy through dilated pupils by an experienced ophthalmologist, both compared with reference standard of slit lamp biomicroscopy by a consultant specialist in medical retinal disease. MAIN OUTCOME MEASURES: Sensitivity and specificity of screening method and prevalence of sight threatening diabetic eye disease (moderate preproliferative retinopathy, circinate maculopathy, exudate within 1 disc diameter of fixation, other diabetes related eye disease). RESULTS: 358 subjects underwent photography, 326 attended hospital clinic for ophthalmoscopy, and six were ungradable on photographs and biomicroscopy, leaving 320 for analysis. Of these 295 (91%) attended clinic within four months of photography. Sensitivity of detection of eye disease by photography was 89% (95% confidence interval 80% to 98%), significantly better than for direct ophthalmoscopy (65% (51% to 79%)). Analysis of patients with false negative results indicated possible improvement of photographic sensitivity to 93% by addition of stereoscopic macular pair photographs. Specificity of detection of sight threatening eye disease was 86% (82% to 90%) for photography and 97% (95% to 99%) for direct ophthalmoscopy. CONCLUSIONS: Since high sensitivity is essential for an effective screening programme, a photographic method should be considered as preferred option in national, community based screening programmes. Even in the hands of an experienced ophthalmologist, direct ophthalmoscopy is limited by weaknesses inherent to the instrument.

Ambulatory Care↗
PubMed1999

Photoscreening for refractive errors in children and young adults with severe learning disabilities using the MTI photoscreener.

PURPOSE: To test the potential ability of the MTI photoscreener to facilitate screening for significant refractive errors in children and young adults with severe learning disabilities. METHODS: Thirty-eight patients with severe learning disabilities from a special school were examined with the photoscreener, and underwent cycloplegic refraction, an ophthalmological and an orthoptic examination. The age at examination, the cause of learning disability, the pupil size, the number of photographs required for accurate interpretation, the co-operation of the subject and the presence or absence of strabismus were recorded. An educational psychologist had performed a psychological assessment on all the children. The results of the cycloplegic retinoscopy were compared with the photorefraction results. RESULTS: A photorefraction was possible in 37 patients and cycloplegic refraction in all the patients. The patients had severe learning difficulties with an intelligence quotient of less than 50. All the patients had behavioural problems, 9 patients had associated cerebral palsy, 8 had chronic epilepsy, 1 patient was brain damaged from a non-accidental injury and 1 from a road traffic accident. The mean age of the patients was 10.0 +/- 4.9 years (range 3-18 years), the average pupil diameter during photoscreening was 6.1 +/- 0.9 mm (range 4-8 mm) and the average number of photographs required for each subject was 2.1 +/- 0.9 (range 1-4). The photoscreener detected 10 patients with a manifest strabismus. There was one false positive and one false negative result giving a sensitivity of 92.8% and a specificity of 90%. CONCLUSION: The examination of children with severe learning disabilities for refractive errors can be extremely difficult. The MTI photoscreener is an effective means of screening such children and young adults for refractive errors and strabismus so that the children with these abnormalities may be targeted for a more detailed evaluation.

Adolescent↗
PubMed2004

Automated detection of diabetic retinopathy in digital retinal images: a tool for diabetic retinopathy screening.

AIMS: To develop a system to detect automatically features of diabetic retinopathy in colour digital retinal images and to evaluate its potential in diabetic retinopathy screening. METHODS: Macular centred 45 degrees colour retinal images from 1273 patients in an inner city diabetic retinopathy screening programme. A system was used involving pre-processing to standardize colour and enhance contrast, segmentation to reveal possible lesions and classification of lesions using an artificial neural network. The system was trained using a subset of images from 500 patients and evaluated by comparing its performance with a human grader on a test set of images from 773 patients. RESULTS: Maximum sensitivity for detection of any retinopathy on a per patient basis was 95.1%, accompanied by specificity of 46.3%. Specificity could be increased as far as 78.9% but was accompanied by a fall in sensitivity to 70.8%. At a setting with 94.8% sensitivity and 52.8% specificity, no cases of sight-threatening retinopathy were missed (retinopathy warranting immediate ophthalmology referral or re-examination sooner than 1 year by National Institute for Clinical Excellence criteria). If the system was implemented at 94.8% sensitivity setting over half the images with no retinopathy would be correctly identified, reducing the need for a human grader to examine images in 1/3 of patients. CONCLUSION: This system could be used when screening for diabetic retinopathy. At 94.8% sensitivity setting the number of normal images requiring examination by a human grader could be halved.

Color↗
PubMed2003

Wave-front analysis as screening technique for amblyogenic ametropia with and without cycloplegia.

INTRODUCTION: For many years, attempts have been made to find an easy, efficient and inexpensive method to screen children for amblyogenic ametropia. Wave-front analysis is a new way to determine the refractive state of the eye from a distance. This technique could be a useful tool for infant screening. PURPOSE: The purpose of the study was the evaluation of the efficacy of a commercially available wave-front analyzing autorefractometer (SureSight, software version 2.0, Welch Allyn, Skaneateles Falls, NY 13153, U.S.A.) in detecting amblyogenic ametropia in patients with and without cycloplegia. METHODS: 256 eyes (-28.25 D to +7.88 D spherical equivalent) of 128 patients (1-81 years) were examined with the wave-front autorefractometer under cycloplegia. Prior to this investigation, 108 eyes (-21.38 D to 75 D) of 54 of these patients (1-76 years) were refracted without cycloplegia. The readings of the wave-front autorefractometer were compared with the results of retinoscopy under cycloplegia. RESULTS: Without cycloplegia, the sensitivity in detecting any amblyogenic ametropia such as anisometropia, astigmatism, myopia or hyperopia was 94%, while the specificity was 63%. Following cycloplegia, the sensitivity decreased to 87% and the specificity increased to 80%. CONCLUSION: Wave-front analyzing refractometry is highly applicable for infant screening. At the present state of development, the efficacy in detecting amblyogenic ametropia is similar to that of other screening techniques and instruments that operate from distance. Cycloplegia enhances the sensitivity in detecting hyperopia and decreases the sensitivity in detecting astigmatism.

Adolescent↗
PubMed2004

Examination of preschool children for ametropia: first experiences using a new hand-held autorefractor.

INTRODUCTION: Over the last decades, various methods have been investigated for preschool screening for amblyogenic ametropia. The SureSight is a new hand-held wavefront-analyzing autorefractor designed for screening. METHODS: A total of 338 children (3 1/2 - 4 1/2 years-old) were examined in their kindergartens without cycloplegia using the new instrument. Of these, 56 had a cycloplegic retinoscopy as a reference measurement. Hyperopia > or =3 dpt, myopia > or =1 dpt, astigmatism > or =1 dpt and anisometropia > or =1 dpt were considered amblyogenic ametropia. RESULTS: Testability was 99.4%. Accuracy was high for cylinder power and axis but poor for the spherical equivalent. Sensitivity was 41% for the detection of amblyogenic hyperopia, 95% for astigmatism and 75% for anisometropia, with specificity values of 92, 79 and 73%. CONCLUSION: The high testability and accuracy for cylinder power and axis are the strong points. The poor accuracy for the spherical equivalent is probably caused by the lack of cycloplegia. At present, non-cycloplegic autorefractor screening cannot be recommended due to the low specificity. Our findings support the advice that objective refraction in childhood must be performed with cycloplegia.

Child, Preschool↗
PubMed2000

Glaucoma screening using the scanning laser polarimeter.

PURPOSE: To determine the ability of scanning laser polarimetry (GDx Nerve Fiber Analyzer; Laser Diagnostic Technologies, Inc., San Diego, CA) to separate normal eyes and those considered likely to have glaucoma in a public glaucoma screening. METHODS: A 2-day public glaucoma screening program was held at two different institutions. Each subject underwent ophthalmologic examination, Humphrey perimetry (24-2 Fastpac program), and imaging using scanning laser polarimetry (GDx) in each eye for allocation into a diagnostic category: normal, ocular hypertensive, glaucoma suspect, or glaucoma. Results from the normal and glaucoma groups were analyzed, using modulation parameters calculated from a measurement band located 1.8 disc diameters from the disc, and selected parameters provided automatically by GDx software. Receiver operating characteristic curves were used to depict the sensitivity/specificity relationship at different GDx parameter cutoff levels. RESULTS: Of 200 subjects, 197 were classified; 122 were classified as normal, 23 were classified with ocular hypertension, 30 were classified as glaucoma suspects, and 22 were classified with definite glaucoma. Three subjects had ocular diseases other than glaucoma. The maximum area under the receiver operating characteristic curve for modulation parameters was 0.935, and for the GDx software parameters was 0.901. CONCLUSIONS: Scanning laser polarimetry may be useful in glaucoma screening.

Diagnostic Techniques, Ophthalmological↗
PubMed1997

Hydroxychloroquine and visual screening in a rheumatology outpatient clinic.

OBJECTIVE: To review 10 years' data relating to visual screening of patients taking hydroxychloroquine. METHODS: Following baseline visual assessment, ophthalmic monitoring was carried out at six monthly intervals on 758 patients while on hydroxychloroquine. This consisted of corrected visual acuity, central field screening with a red Amsler grid, slit lamp examination, and retinoscopy. RESULTS: None of the patients suffered visual impairment from retinal toxicity, though 12 reported visual disturbance. This was related to ocular muscle imbalance in four. In the remainder, none of the ocular findings was directly attributable to hydroxychloroquine. Ten patients reported defects when tested with a red Amsler grid. None was related to retinal toxicity. Seven patients developed corneal drug deposits which cleared on stopping or reducing the dose of hydroxy-chloroquine. CONCLUSIONS: The findings support the view that following baseline ophthalmic examination for patients receiving hydroxychloroquine, regular ophthalmic screening is not required if the daily dose is less than 6.5 mg kg-1 and the cumulative dose is less than 200 g.

Adolescent↗
PubMed2005

An evaluation of the change in activity and workload arising from diabetic ophthalmology referrals following the introduction of a community based digital retinal photographic screening programme.

AIMS: To determine how the workload of an ophthalmology department changed following the introduction of an organised retinal screening programme. METHODS: Information was collected from the hospital medical record of people with diabetes attending eye clinics over 4 years. The first year was before screening, the next 2 years the first round, and the fourth year the second round. RESULTS: The total number of people with diabetes referred each year over the 4 year period was 853, 954, 974, 1051 consecutively. The number of people with diabetes in the county rose by 1400 per annum. The total number of referrals for an opinion about diabetic retinopathy was 227, 333, 363, 368, for cataract was 64, 57, 77, 93, and for glaucoma was 57, 62, 61, 68. The total number of patients referred for laser treatment over the 4 years was 77, 124, 111, and 63 CONCLUSION: This study suggests that the workload in the eye clinic increases in the first round of screening but in subsequent rounds it does not fall below the pre-screening level, except for laser treatment. This may be partly because of increasing numbers of people with diabetes. With the introduction of a national screening programme, this has significant workload implications for the National Health Service.

Adolescent↗
PubMed1992

Screening for diabetic retinopathy: a relative cost-effectiveness analysis of alternative modalities and strategies.

Diabetic retinopathy is the most common cause of blindness among adults of working age in the UK. If the disease is detected early effective treatment can be provided and this has resulted in calls for a systematic national screening programme. Using data on the screening of 3423 diabetics collected as part of an experimental programme in three UK centres, the relative cost-effectiveness of various screening options is assessed. The paper utilises direct evidence on a number of single modality screening options, including ophthalmoscopy undertaken by general practitioners or ophthalmic opticians, and non-mydriatic photography. With the objective of increasing the sensitivity of screening and using data collected in the study, options based on two further potential screening strategies are modelled and evaluated: combined screening using both ophthalmoscopy and non-mydriatic photography; and selective screening where high-risk diabetics are directly referred to an ophthalmologist and low-risk cases are either left unscreened or are screened by one of the single or combined modality screening options. Given the objective of early detection, effectiveness is assessed in terms of the sensitivity and specificity of the referral decisions of screening options. Both health service and private resource costs of the various screening options are estimated, the latter in terms of travel and the opportunity cost of time. Cost effectiveness is evaluated in terms of the expected cost per true positive case of diabetic retinopathy referred by the screening options. To narrow the choice between the options, those subject to three-way domination with respect to the three choice variables of sensitivity, specificity and expected cost per true positive are excluded. Amongst the remaining options, the choice is dependent on the trade-off between the higher specifics of unselective single modality screening options and the higher sensitivities and lower expected costs per true positive case detected of combined modality and selective screening options.

Adult↗
PubMed2003

Ocular morbidity in schoolchildren in Kathmandu.

BACKGROUND/AIMS: Any information on eye diseases in schoolchildren in Nepal is rare and sketchy. A programme to provide basic eye screening to schoolchildren with an aim to provide services as well as gather information on ocular morbidity has been started. METHODS: All the children in the schools visited are included in the study. This programme is targeted at poor government schools, which are unable to afford this service. A complete eye examination is given to all the children including slit lamp examination, fundus evaluation and retinoscopy, and subjective refraction. RESULTS: A total of 1100 children from three schools are included in this report. 11% of our schoolchildren have ocular morbidity, 97% (117 out of 121) of which is preventable or treatable. Refractive error is the commonest type of ocular morbidity (8.1%). Myopia is the commonest type of refractive error (4.3%) as opposed to hypermetropia (1.3%). 12.4% of children with refractive error have already developed amblyopia. Strabismus is the second commonest type of ocular disability (1.6%). Alternate divergent squint is the commonest type of strabismus (1.4%). Traumatic eye injuries (0.54%), xerophthalmia (0.36%), and congenital abnormalities (0.36%) are much less common. CONCLUSION: A school eye screening cum intervention programme with periodic evaluation seems to be appropriate for countries like Nepal as most of the eye diseases found are preventable or treatable.

Adolescent↗