@book{miller, title = {Walsh and Hoyt's clinical neuro-ophthalmology}, editor = {Miller, NR and Newman, NJ and Biousse, V and Kerrison, JB}, publisher = {Lippincott Williams \& Wilkins}, address = {Philadelphia}, edition = {6th}, keywords = {Neuroophthalmology. Eye Diseases. Neurologic Manifestations.}, year = 2005 } @article{ang, author = {Ang, GS and Dhillon, B}, title = {Do junior house officers routinely test visual acuity and perform ophthalmoscopy}, annotate = {?}, journal = {Scott Med J}, volume = {47}, number = {3}, pages = {60--63}, note = {NLM MEDLINE Journal Article}, abstract = {Our objective was to assess junior house officer (JHO) practice of visual acuity testing and ophthalmoscopy in clerking patients. DESIGN: Cross-sectional questionnaire-based study using a standardised structured interview technique. SETTING: A Scottish university teaching hospital employing 65 JHOs. PARTICIPANTS: All medical and surgical JHOs from this hospital were interviewed over a three month period. MAIN OUTCOME MEASURES: Questionnaire-based data on the subjective responses studying current practice of visual acuity testing, and direct ophthalmoscopy with and without topical mydriatics. RESULTS: 18.5\% and 4.6\% of participants perform daily ophthalmoscopy and visual acuity testing respectively. Most do not routinely use the Snellen chart (80.0\%) or topical mydriatics during ophthalmoscopy (75.4\%). JHOs claimed these were not easily available in the wards. CONCLUSIONS: The majority of JHOs fail to test visual acuity or perform ophthalmoscopy in clerking patients. This study highlights the poor availability of Snellen charts, functioning ophthalmoscopes, and topical mydriatics in the wards. This warrants further investigation.}, keywords = {Hospitals, Teaching Humans Medical Staff, Hospital/*standards Ophthalmoscopy/*standards Questionnaires Scotland Vision Tests/standards *Visual Acuity EDAT- 2002/08/24 10:00}, year = {2002} } @article{baker, author = {Baker, ML and Larsen, EK and Kuller, LH and Klein, R and Klein, BE and Siscovick, DS and Bernick, C and Manolio, TA and Wong, TY}, title = {Retinal Microvascular Signs, Cognitive Function, and Dementia in Older Persons. The Cardiovascular Health Study}, journal = {Stroke}, note = {1524--4628 (Electronic) Journal article}, abstract = {BACKGROUND AND PURPOSE: Cerebral microvascular disease may be a risk factor for the development of dementia in elderly persons. We describe the association of retinal microvascular signs with cognitive function and dementia among older individuals. METHODS: In the population-based Cardiovascular Health Study, 2211 persons aged 69 to 97 years at recruitment had retinal photography. Photographs were evaluated for retinopathy (eg, microaneurysms, retinal hemorrhages), focal arteriolar narrowing, arteriovenous nicking, and retinal arteriolar and venular caliber. Cognitive status was determined from the Digit-Symbol Substitution Test and Modified Mini-Mental State Examination. Participants were also further evaluated for the presence of dementia with detailed neuropsychological testing. Persons with a prior stroke or taking antipsychotic or antidepressant medications were excluded. RESULTS: After adjusting for age, gender, race, field center, education level, internal carotid intima-media thickness, body mass index, hypertension, diabetes, and cigarette smoking status, persons with retinopathy had lower mean Digit-Symbol Substitution Test scores but not Modified Mini-Mental State Examination than those without retinopathy (39 versus 41, P=0.002). In hypertensive persons, retinopathy (multivariable-adjusted OR, 2.10; 95\% CI, 1.04 to 4.24) and focal arteriolar narrowing (OR, 3.02; 95\% CI, 1.51 to 6.02) were associated with dementia. These associations were not present in individuals without hypertension. CONCLUSIONS: In older persons, our study shows a modest cross-sectional association between retinopathy signs with poorer cognitive function and, in persons with hypertension, with dementia. These data support a possible role of cerebral microvascular disease in the pathogenesis of impaired cognitive function and dementia in older hypertensive persons.}, year = {2007} } @article{ball, author = {Ball, AK and Clarke, CE}, title = {Idiopathic intracranial hypertension}, journal = {Lancet Neurol}, volume = {5}, number = {5}, pages = {433--442}, note = {Journal Article Review England}, abstract = {Idiopathic intracranial hypertension is common in obese women and can lead to significant visual impairment. First described more than 100 years ago, the cause of the disorder remains unknown. Despite a multitude of proposed links, the aetiology has never been established. Impairment of cerebrospinal-fluid reabsorption is the most likely underlying pathophysiological cause of the raised pressure, but this notion has yet to be proven. Cerebral venous sinus abnormalities associated with the disorder need further exploration. Although the major symptoms of headache and visual disturbance are well documented, most data for disease outcome have been from small retrospective case series. No randomised controlled trials of treatment have been done and the management is controversial. The importance of weight loss needs clarification, the role of diuretics is uncertain, and which surgical intervention is the most effective and safe is unknown. Prospective trials to examine these issues are urgently needed.}, keywords = {Adolescent Adult Aged Cerebrospinal Fluid/*metabolism Diuretics/therapeutic use Female Headache/etiology Humans Incidence Intracranial Hypertension/complications/epidemiology/*physiopathology Intracranial Pressure Middle Aged Obesity/*complications Sex Factors Vision Disorders Weight Loss}, year = {2006} } @article{bar, author = {Bar-Sela, SM and Glovinsky, Y}, title = {A feasibility study of an Internet-based telemedicine system for consultation in an ophthalmic emergency room}, journal = {J Telemed Telecare}, volume = {13}, number = {3}, pages = {119--124}, note = {NLM In-Process Journal Article Research Support, Non-U.S. Gov't}, abstract = {We examined the feasibility of a low-bandwidth, Internet-based tele-ophthalmology system for consultation in an ophthalmic emergency room. Forty-nine patients (98 eyes) with complicated cases were seen during night shifts in the ophthalmic emergency room. Ocular images were taken using a slit-lamp connected to a video camera, processed and transmitted to a senior physician by email. A telephone was used for real-time audio communication. Each case was re-examined by the same senior physician the following day. The time needed to capture and to process the images was 5 min (SD 2). Each case was given a feasibility score (0--100\%), which was defined as the contribution made by the transmitted images in presenting clinical details which could not have been described verbally. High feasibility scores (mean scores ranging from 85 to 90) were found for the following images: ocular surface, anterior chamber, anterior chamber angle, pupils, lens, optic nerve and macula. In contrast, images of vitreous and peripheral retina received low feasibility scores (mean score 65). There was 100\% agreement between the diagnosis made during consultation and the on-site examination made by the senior ophthalmologist later on. Ninety-eight percent of the patients stated that they would prefer being examined under the telemedicine system on their next emergency room visit, rather than the traditional resident on-site examination.}, year = {2007} } @article{biousse, author = {Biousse, V and Ameri, A and Bousser, MG}, title = {Isolated intracranial hypertension as the only sign of cerebral venous thrombosis}, journal = {Neurology}, volume = {53}, number = {7}, pages = {1537--42}, note = {Journal Article United states}, abstract = {BACKGROUND: Cerebral venous thrombosis (CVT) is often overlooked when intracranial hypertension (ICH) is isolated, hence mimicking idiopathic intracranial hypertension (IIH). OBJECTIVE: To describe the characteristics of patients with CVT and ICH. METHODS: We examined 160 consecutive patients with CVT between 1975 and 1998. They were separated into two groups according to their clinical presentation--isolated ICH and other neurologic symptoms and signs. RESULTS: Fifty-nine patients with CVT (37\%) presented with isolated ICH. Neuroimaging showed involvement of more than one sinus in 35 patients (59\%). Brain CT was normal in 27 of 50 patients (54\%). Lumbar puncture was performed in 44 patients and showed elevated opening pressure in 25 of 32 (78\%) and abnormal CSF content in 11 (25\%). Etiologies and risk factors included local causes in 7 of 59 (12\%), surgery in 1, inflammatory diseases in 18 (30.5\%), infection in 2, cancer in 1, postpartum state in 1, coagulopathies in 11 (19\%), oral contraception in 7 (12\%), and remained unknown in 11 (19\%). Anticoagulants were used in 41 of 59 patients (69.5\%), steroids or acetazolamide in 26 (44\%), therapeutic lumbar puncture in 44 (75\%), and surgical shunt in 1. Three patients had optic atrophy with severe visual loss, 1 died from carcinomatous meningitis, and 55 (93\%) had complete recovery. CONCLUSIONS: Central venous thrombosis (CVT) can present with all the classical criteria for idiopathic intracranial hypertension (IIH), including normal brain CT with normal CSF content. Because the recognition of CVT has crucial prognostic and therapeutic implications, MRI, with magnetic resonance venography when necessary, should be performed in patients with isolated intracranial hypertension. The outcome of CVT is unpredictable, and management of patients with CVT should not differ whether they present with isolated raised intracranial pressure or with other neurologic symptoms and signs. Therefore, isolated raised intracranial pressure from CVT differs in management from IIH and should be classified neither as "IIH" nor "pseudotumor cerebri."}, keywords = {Adolescent Adult Aged *Cerebral Veins Child Diagnosis, Differential Female Humans Intracranial Hypertension/*etiology Magnetic Resonance Imaging Male Middle Aged Phlebography Venous Thrombosis/*complications/diagnosis}, year = {1999} } @article{cheung1, author = {Cheung, N and Rogers, S and Couper, DJ and Klein, R and Sharrett, AR and Wong, TY}, title = {Is diabetic retinopathy an independent risk factor for ischemic stroke}, annotate = {?}, journal = {Stroke}, volume = {38}, number = {2}, pages = {398--401}, note = {1524--4628 (Electronic) Comparative Study Journal Article Research Support, N.I.H., Extramural Validation Studies}, abstract = {BACKGROUND AND PURPOSE: The relationship between diabetic retinopathy and ischemic stroke is uncertain and examined in this study. METHODS: A population-based, prospective cohort study of 1617 middle-aged persons with diabetes. Diabetic retinopathy signs were ascertained from retinal photographs, and incident ischemic stroke events were prospectively identified and validated. RESULTS: Over an average follow-up of 7.8 years, there were 75 ischemic stroke events. After adjustment for age, gender, race, center, 6-year mean arterial blood pressure, anti-hypertensive treatment use, fasting glucose, insulin treatment, duration of diabetes, high-density lipoprotein and low-density lipoprotein cholesterol levels and cigarette smoking status, diabetic retinopathy was associated with an increased risk of ischemic stroke (hazard rate ratio, 2.34; 95\% CI, 1.13 to 4.86). CONCLUSIONS: Diabetic retinopathy predicts incident ischemic stroke in people with diabetes, independent of other risk factors.}, keywords = {Brain Ischemia/*epidemiology/etiology Cerebrovascular Accident/*epidemiology/etiology Cohort Studies Diabetic Retinopathy/complications/*epidemiology Female Follow-Up Studies Humans Male Middle Aged Prospective Studies Risk Factors}, year = {2007} } @article{razminia, author = {Razminia, M and Trivedi, A and Molnar, J and Elbzour, M and Guerrero, M and Salem, Y and Ahmed, A and Khosla, S and Lubell, DL}, title = {Validation of a new formula for mean arterial pressure calculation: the new formula is superior to the standard formula.}, journal = {Catheter Cardiovasc Interv}, volume = {63}, number = {4}, pages = {419--425}, year = {2004} } @article{cheung2, author = {Cheung, N and Wang, JJ and Klein, R and Couper, DJ and Richey Sharrett, AR and Wong, TY}, title = {Diabetic Retinopathy and the Risk of Coronary Heart Disease: The Atherosclerosis Risk in Communities Study}, journal = {Diabetes Care}, volume = 30, number = 7, pages = {1742--1746}, note = {1935--5548 (Electronic) Journal article}, abstract = {Objective: To examine the relation of diabetic retinopathy to incident coronary heart disease (CHD). Research Design and Methods: A population-based, prospective cohort study consisting of 1,524 middle-aged persons with type 2 diabetes without prevalent CHD and stroke at baseline. Diabetic retinopathy signs were graded from retinal photographs according to the Early Treatment for Diabetic Retinopathy Severity Scale. Incident CHD events (myocardial infarction, fatal CHD or coronary revascularization) were identified and validated following standardized protocols. Results: In our study, 214 (14.7\%) participants had diabetic retinopathy. Over an average follow-up of 7.8 years, there were 209 (13.7\%) incident CHD events. After controlling for age, gender, race, study center, fasting glucose, glycosylated hemoglobin, duration of diabetes, blood pressure, anti-hypertensive treatment, cigarette smoking, body mass index and lipid profile, the presence of diabetic retinopathy was associated with a two-fold higher risk of incident CHD events (Hazard rate ratios [HR] 2.07, 95\% confidence interval [CI]: 1.38--3.11) and a three fold higher risk of fatal CHD (HR 3.35; 95\% CI: 1.40--8.01). Further adjustments for inflammatory markers, carotid artery intima-media thickness or nephropathy had minimal impact on the association. The increased risk of CHD was significant in both men (HR 1.89; 95\% CI: 1.08--3.31) and women (HR 2.16; 95\% CI: 1.16--4.02) with diabetic retinopathy. Conclusions: In persons with type 2 diabetes, the presence of retinopathy signifies an increased CHD risk, independent of known risk factors. Our data support the role of microvascular disease in the pathogenesis of CHD in diabetes.}, year = 2007 } @article{chow, author = {Chow, SP and Aiello, LM and Cavallerano, JD and Katalinic, P and Hock, K and Tolson, A and Kirby, R and Bursell, SE and Aiello, LP}, title = {Comparison of nonmydriatic digital retinal imaging versus dilated ophthalmic examination for nondiabetic eye disease in persons with diabetes}, journal = {Ophthalmology}, volume = {113}, number = {5}, pages = {833--840}, note = {NLM MEDLINE Comparative Study Journal Article Research Support, U.S. Gov't, Non-P.H.S.}, abstract = {OBJECTIVE: To evaluate the ability of stereoscopic nonmydriatic digital retinal imaging to detect ocular pathologic features other than diabetic retinopathy (DR) in patients with diabetes mellitus (DM) compared with dilated retinal examination by retinal specialist ophthalmologists. DESIGN: Clinic-based comparative instrument study and retrospective chart review. PARTICIPANTS: Two hundred eighty Joslin Diabetes Center outpatients (560 eyes) with type 1 or type 2 DM. METHODS: Nonsimultaneous stereoscopic nonmydriatic digital retinal images (640 x 480 pixels) of three 45 degrees retinal fields were acquired and graded for clinical level of DR and other ocular pathologic features by certified readers according to Joslin Vision Network (JVN) protocol. Retrospective chart review compared findings from JVN digital images with findings from dilated retinal examination by retinal specialists performed within an average of 39.6 days of digital imaging. An independent senior retinal specialist adjudicated disagreements by review of 7 standard field 35-mm Early Treatment Diabetic Retinopathy Study protocol fundus photographs and JVN images. MAIN OUTCOME MEASURES: Detection of non-DR ocular pathologic features by digital imaging as compared with clinical examination. RESULTS: Nonmydriatic digital evaluation identified at least 1 non-DR ocular finding in 40.7\% of patients (114/280). Non-diabetes mellitus ocular pathologic features identified by digital images, clinical examination, or both included cataract (n = 100); age-related maculopathy (n = 52); suspicion of glaucoma (n = 18); choroidal lesions (n = 18); evidence of systemic disorder (e.g., hypertension or renal disease; n = 15); epiretinal membrane (n = 11); chorioretinal atrophy, scar, or both (n = 6); retinal emboli (n = 3); retinitis pigmentosa (n = 1); and asteroid hyalosis (n = 1). Agreement of nonmydriatic imaging with clinical examination for presence and absence of these findings was 95.4\%, 91.3\%, 98.2\%, 98.6\%, 98.2\%, 99.6\%, 100\%, 100\%, 100\%, and 100\%, respectively. Kappa values for all non-DR lesions demonstrated near perfect agreement (kappa> or =0.80) except for age-related maculopathy (kappa = 0.71) and choroidal lesions (kappa = 0.73), where agreement was substantial. Overall, only 55 eyes (9.8\%) were ungradable for level of DR and 85 eyes (15.2\%) were ungradable for macular edema. CONCLUSIONS: Joslin Vision Network nonmydriatic digital imaging demonstrated excellent agreement with dilated ophthalmic examination by retinal specialists in the detection of ocular disease other than DR, suggesting a potential role for this technology in evaluating non-DR disorders and highlighting the extent of findings other than retinopathy in patients with diabetes.}, keywords = {0 (Mydriatics) Adult Aged Aged, 80 and over Diabetes Mellitus, Type 1/*complications Diabetes Mellitus, Type 2/*complications Female Humans Male Middle Aged Mydriatics/*administration & dosage Observer Variation Ophthalmology/standards Ophthalmoscopy Photography/*methods Pupil/*drug effects Retina/*pathology Retinal Diseases/*diagnosis Retrospective Studies Sensitivity and Specificity Signal Processing, Computer-Assisted EDAT- 2006/05/03 09:00}, year = {2006} } @article{christiaans, author = {Christiaans, MH and Kelder, JC and Arnoldus, EP and Tijssen, CC}, title = {Prediction of intracranial metastases in cancer patients with headache}, journal = {Cancer}, volume = {94}, number = {7}, pages = {2063--2068}, note = {NLM MEDLINE Journal Article}, abstract = {BACKGROUND: The current study was conducted to investigate the diagnostic value of neurologic evaluation for the prediction of intracranial metastases in cancer patients with new or changed headache. METHODS: Between February 1997 and February 2000, general practitioners and specialists referred cancer patients with new or changed headache to the Department of Neurology at the study institution. All patients underwent a structured history and neurologic examination. Magnetic resonance imaging (MRI) of the brain was used as the gold standard for determining the presence of intracranial metastases. The association between baseline patient characteristics, history variables, and variables from the neurologic examination in patients with intracranial metastases was evaluated by univariate and multivariate logistic regression analyses in combination with receiver operating characteristic (ROC) curve analyses. RESULTS: Sixty-eight consecutive patients were included in the current study (48 females and 20 males). The mean age of the patients was 57 years (range, 24--88 years; standard deviation +/- 13.3 years). Breast carcinoma was the primary tumor in 32 patients (47.1\%) and lung carcinoma was the primary tumor in 12 patients (17.6\%). Intracranial metastases occurred in 22 patients (32.4\%). The occurrence of intracranial metastases was predicted in the multivariate logistic regression analyses by one baseline patient characteristic variable and 2 history variables (i.e., headache duration of < or =10 weeks [odds ratio (OR) of 11.0; 95\% confidence interval (95\% CI), 1.1--108.2], emesis [OR of 4.0; 95\% CI, 1.1--14.3], and pain not of tension- type [OR of 6.7; 95\% CI, 1.8--25.1]). No variable from the neurologic examination was found to add information to the prediction model. When at least one of the three predictors was present, all patients with intracranial metastases could be identified with this prediction model. MRI could be omitted in 12 patients (26\%) without intracranial metastases. The ROC area under curve of this model was 0.83. CONCLUSIONS: Intracranial metastases were found in 32.4\% of the cancer patients with headache as the presenting symptom. Although 3 significant clinical predictors were found (headache duration < or =10 weeks, emesis, and pain not of tension- type), few patients could be excluded from undergoing MRI because of a low specificity. Therefore, MRI of the brain was considered to be warranted in all patients in the current study.}, keywords = {Adult Aged Aged, 80 and over Brain Neoplasms/*secondary Breast Neoplasms/*pathology Female Headache/*diagnosis Humans Lung Neoplasms/*pathology Magnetic Resonance Imaging Male Middle Aged Neurologic Examination Pain/etiology Prognosis Prospective Studies ROC Curve Vomiting/etiology EDAT- 2002/04/05 10:00}, year = {2002} } @incollection{workforce, author = {Committee on the Future of Emergency Care in the United States Health System, Board on Health Care Services}, title = {The Emergency Care Workforce}, booktitle = {Hospital-based emergency care: at the breaking point.}, publisher = {National Academies Press}, address = {Washington}, pages = {209--258}, year = {2007} } @article{corbett, author = {Corbett, JJ and Savino, PJ and Thompson, HS and Kansu, T and Schatz, NJ and Orr, LS and Hopson, D}, title = {Visual loss in pseudotumor cerebri. Follow-up of 57 patients from five to 41 years and a profile of 14 patients with permanent severe visual loss}, journal = {Arch Neurol}, volume = {39}, number = {8}, pages = {461--474}, note = {Rr59/rr/ncrr Journal Article Research Support, U.S. Gov't, P.H.S. United states}, abstract = {The prognosis for vision in most patients with pseudotumor cerebri is excellent; however, visual loss, which is the only serious complication, may occur either early or late in the course of the disease. A group of 57 patients was followed up five to 41 years with visual fields, visual acuity, and fundus photographs. Blinding visual loss or severe visual impairment in one or both eyes occurred in 14 patients, and in seven patients, this occurred months to years after the initial symptoms. Systemic hypertension was a significant risk factor for visual loss in patients with pseudotumor cerebri, and blindness occurred in eight of 13 patients who were hypertensive. Despite suggestions that blind spot measurement is useful for following up patients with this condition, we believe that sequential quantitative perimetry gives more complete information and is essential to rational decision making in the treatment of pseudotumor cerebri.}, keywords = {Adolescent Adrenal Cortex Hormones/adverse effects Adult Blindness/diagnosis/*etiology/physiopathology Empty Sella Syndrome/complications Follow-Up Studies Humans Intraocular Pressure Middle Aged Optic Disk/physiopathology Papilledema/physiopathology Pseudotumor Cerebri/cerebrospinal fluid/*complications/diagnosis/physiopathology/surgery Risk Visual Acuity Visual Fields}, year = {1982} } @article{cordeiro, author = {Cordeiro, MF and Jolly, BC and Dacre, JE}, title = {The effect of formal instruction in ophthalmoscopy on medical student performance}, journal = {Med Teach}, volume = {15}, number = {4}, pages = {321--325}, note = {NLM MEDLINE Journal Article}, abstract = {Ophthalmoscopy is an essential part of a complete clinical examination of a patient. However specific formal instruction in fundoscopy is rarely given to medical students. We decided to determine the value of explicit teaching of ophthalmoscopy and devised and validated a rating scale for assessing performance which was used to evaluate 29 first year clinical medical student volunteers at St. Bartholomew's Hospital Medical College, before and after formal instruction in fundoscopy. The competence of this group at ophthalmoscopy was then compared to the rest of their year (109 medical students) during the objective structured clinical end-of-year examination. Students formally instructed in ophthalmoscopy showed an improved score after instruction (from 53\% to 77\%). They also performed better at fundoscopy than the rest of their year (mean average score 64\%), when tested 2 months later, suggesting persistence of the training effect. However as a group they performed no better than their peers at clinical skills other than ophthalmoscopy. We suggest that as fundoscopy is such an important clinical skill, medical students should be given specific teaching, preferably in their ophthalmology firm attachment, as we have shown that it results in a persistent improvement in performance.}, keywords = {Clinical Competence/*standards Education, Medical, Undergraduate/*standards Educational Measurement Evaluation Studies Humans Ophthalmology/*education Ophthalmoscopy/*standards EDAT- 1993/01/01}, year = {1993} } @article{ells, author = {Ells, AL and Holmes, JM and Astle, WF and Williams, G and Leske, DA and Fielden, M and Uphill, B and Jennett, P and Hebert, M}, title = {Telemedicine approach to screening for severe retinopathy of prematurity: a pilot study}, journal = {Ophthalmology}, volume = {110}, number = {11}, pages = {2113--2117}, note = {NLM MEDLINE Evaluation Studies Journal Article Research Support, Non-U.S. Gov't Research Support, U.S. Gov't, P.H.S.}, abstract = {PURPOSE: To evaluate the use of remote reading of digital retinal photographs in the diagnosis of severe (referral-warranted) retinopathy of prematurity (ROP) during longitudinal screening for ROP. STUDY DESIGN: Prospective, longitudinal cohort study. SUBJECTS: Forty-four consecutive premature infants at risk for ROP. METHODS: All infants were examined longitudinally, over a series of examinations, by indirect ophthalmoscopy (gold standard) and digital photography using the RetCam-120 Digital Retinal Camera (Massie Research Laboratories Inc., Dublin, CA) equipped with an ROP lens. Images were stored and read remotely by a masked reader. Referral-warranted ROP was defined as ROP in zone 1, the presence of plus disease or the presence of any stage 3 ROP. We determined whether and when referral-warranted ROP was diagnosed for each eye, of each infant, on each examination, during the course of each of the infant's screening. RESULTS: Severe (referral-warranted) ROP was diagnosed in 23 eyes by indirect ophthalmoscopy during their series of examinations. Digital photography had a sensitivity of 100\% and a specificity of 96\% in detecting referral-warranted ROP. The positive predictive value of digital photography was 92\%, and the negative predictive value was 100\%. In 87\% of eyes, referral-warranted ROP was diagnosed by digital photography before or at the same time as indirect ophthalmoscopy. CONCLUSIONS: Longitudinal remote reading of digital photographs using the RetCam-120 system has excellent specificity and sensitivity in detecting referral-warranted ROP. This pilot study has shown that remote reading of digital photographs has promise for telemedicine strategies in ROP screening.}, keywords = {Cohort Studies False Positive Reactions Feasibility Studies Humans Image Processing, Computer-Assisted Infant Infant, Newborn Ophthalmoscopy Photography/*methods Pilot Projects Predictive Value of Tests Prospective Studies Remote Consultation/*methods Reproducibility of Results Retinopathy of Prematurity/*diagnosis Sensitivity and Specificity EDAT- 2003/11/05 05:00}, year = {2003} } @article{hubbard, author = {Hubbard, LD and Brothers, RJ and King, WN and Clegg, LX and Klein, R and Cooper, LS and Sharrett, AR and Davis, MD and Cai, J}, title = {Methods for evaluation of retinal microvascular abnormalities associated with hypertension/sclerosis in the Atherosclerosis Risk in Communities Study}, journal = {Ophthalmology}, volume = {106}, number = {12}, pages = {2269--2280}, note = {NLM MEDLINE Journal Article Research Support, U.S. Gov't, P.H.S.}, abstract = {OBJECTIVE: To develop protocols to photograph and evaluate retinal vascular abnormalities in the Atherosclerosis Risk in Communities (ARIC) Study; to test reproducibility of the grading system; and to explore the relationship of these microvascular changes with blood pressure. DESIGN: Population-based, cross-sectional study. PARTICIPANTS: Among 4 examination centers, 11,114 participants (48--73 years of age) at their third triennial examination, after excluding persons with diabetes from this analysis. METHODS: One eye of each participant was photographed by technicians with nonmydriatic fundus cameras. Reading center graders evaluated focal arteriolar narrowing, arteriovenous (AV) nicking, and retinopathy by examining slides on a light box and measured diameters of all vessels in a zone surrounding the optic disc on enhanced digitized images. To gauge generalized narrowing, vessel diameters were combined into central arteriolar and venular equivalents with formulas adjusting for branching, and the ratio of equivalents (A/V ratio) was calculated. MAIN OUTCOME MEASURES: Retinal vascular abnormalities, mean arteriolar blood pressure (MABP). RESULTS: Among 11,114 participants, photographs were obtained of 99\%, with quality sufficient to perform retinal evaluations in 81\%. In the 9040 subjects with usable photographs, A/V ratio (lower values indicate generalized arteriolar narrowing) ranged from 0.57 to 1.22 (median = 0.84, interquartile range = 0.10), focal arteriolar narrowing was found in 7\%, AV nicking in 6\%, and retinopathy in 4\%. Because of attrition of subjects and limitation of methods, prevalence of abnormality was likely underestimated. Controlling for gender, race, age, and smoking status, these retinal changes were associated with higher blood pressure. For every 10-mmHg increase in MABP, A/V ratio decreased by 0.02 unit (P < 0.0001), focal arteriolar narrowing had an odds ratio (OR) of 2.00 (95\% confidence interval [CI] = 1.87--2.14), AV nicking had an OR of 1.25 (95\% CI = 1.16--1.34), and retinopathy had an OR of 1.25 (95\% CI = 1.15--1.37). For any degree of generalized narrowing, individuals with focal narrowing had MABP approximately 8 mmHg higher than those without (P < 0.0001). Masked replicate assessment of a sample found the following reproducibility: for A/V ratio, correlation coefficient = 0.79 and median absolute difference = 0.03; for focal arteriolar narrowing, kappa = 0.45; for AV nicking, kappa = 0.61; and for retinopathy, kappa = 0.89. CONCLUSION: Protocols have been developed for nonmydriatic fundus photography and for evaluation of retinal vascular abnormalities. Several microvascular changes were significantly associated with higher blood pressure; follow-up will show whether these are predictive of later cerebrovascular or cardiovascular disease independently of other known risk factors.}, keywords = {Aged Blood Pressure Capillaries/pathology Coronary Arteriosclerosis/*complications/epidemiology Cross-Sectional Studies *Diagnostic Techniques, Ophthalmological Female Fundus Oculi Humans Hypertension/*complications Image Processing, Computer-Assisted/methods Male Middle Aged Photography/methods Reproducibility of Results Retinal Diseases/classification/*diagnosis/etiology Retinal Vessels/*pathology Risk Factors Sclerosis/complications United States/epidemiology EDAT- 1999/12/22}, year = {1999} } @article{liew, author = {Liew, G and Mitchell, P and Wang, JJ and Wong, TY}, title = {Fundoscopy: to dilate or not to dilate?}, journal = {BMJ}, volume = {332}, number = {7532}, pages = {3}, note = {1468--5833 (Electronic) Editorial}, keywords = {Diabetic Retinopathy/*diagnosis Dilatation/*adverse effects Glaucoma/*etiology Humans Ophthalmoscopy/*methods}, year = {2006} } @article{lin, author = {Lin, DY and Blumenkranz, MS and Brothers, RJ and Grosvenor, DM}, title = {The sensitivity and specificity of single-field nonmydriatic monochromatic digital fundus photography with remote image interpretation for diabetic retinopathy screening: a comparison with ophthalmoscopy and standardized mydriatic color photography}, journal = {Am J Ophthalmol}, volume = {134}, number = {2}, pages = {204--213}, note = {NLM MEDLINE Comparative Study Journal Article}, abstract = {PURPOSE: To evaluate single-field digital monochromatic nonmydriatic fundus photography as an adjunct in the screening of diabetic retinopathy. DESIGN: Prospective, comparative, observational case series. METHODS: Patients with type I and type II diabetes mellitus (n = 197) were sequentially evaluated by three different techniques: single-field digital monochromatic nonmydriatic photography; dilated ophthalmoscopy by an ophthalmologist; and seven Early Treatment Diabetic Retinopathy Study (ETDRS) standardized 35-mm color stereoscopic mydriatic images. The seven stereoscopic color photographs served as the reference standard and were compared with either ophthalmoscopy or a single digital photograph transmitted electronically to a reading site. Levels of agreement were determined by kappa analyses. The sensitivity and specificity of the three methods were compared based on a threshold for referral to further ophthalmologic evaluation (ETDRS level > or =35). RESULTS: There was highly significant agreement (kappa = 0.97, P =.0001) between the degree of retinopathy detected by a single nonmydriatic monochromatic digital photograph and that seen in seven standard 35-mm color stereoscopic mydriatic fields. The sensitivity of digital photography compared with color photography was 78\%, with a specificity of 86\%. Agreement was poor (kappa = 0.40, P =.0001) between mydriatic ophthalmoscopy and the seven-field standard 35-mm color photographs. Sensitivity of ophthalmoscopy compared with color photography was 34\%, with a specificity of 100\%. CONCLUSION: A single nonmydriatic monochromatic wide-field digital photograph of the disk and macula was more sensitive for diabetic retinopathy screening than mydriatic ophthalmoscopy, the currently accepted screening method. When adjudicated by standard seven-field color photographs, the higher sensitivity of digital photography primarily reflected the reduced sensitivity of ophthalmoscopy in detecting early retinopathy.}, keywords = {0 (Mydriatics) Adult Aged Aged, 80 and over Diabetes Mellitus, Type 1/complications Diabetes Mellitus, Type 2/complications Diabetic Retinopathy/*diagnosis Female Fundus Oculi Humans Male Middle Aged Mydriatics/administration & dosage Ophthalmoscopy/*methods Photography/*methods Prospective Studies Pupil/drug effects Remote Consultation Reproducibility of Results Sensitivity and Specificity EDAT- 2002/07/26 10:00}, year = {2002} } @article{maberley, author = {Maberley, D and Walker, H and Koushik, A and Cruess, A}, title = {Screening for diabetic retinopathy in James Bay, Ontario: a cost-effectiveness analysis}, journal = {CMAJ}, volume = {168}, number = {2}, pages = {160--164}, note = {NLM MEDLINE Journal Article}, abstract = {BACKGROUND: Retinopathy is a common complication of diabetes mellitus that if detected early by regular retinal examinations can be treated; thus, blindness can be delayed or prevented. Providing high-quality retinal screening is difficult, especially in rural and remote areas. Canada's First Nations population has a higher prevalence of diabetes and is, in general, more geographically isolated than the broader Canadian population. We modelled the cost-effectiveness of retinopathy screening by travelling retina specialists versus retinal photography with a portable digital camera in an isolated First Nations cohort with diabetes. METHODS: The 2 screening programs were modelled to run concurrently for 5 years, with outcomes evaluated over 10 years. To construct economic models for the population of Cree individuals living in the western James Bay area of northern Ontario, we used available data on the prevalence of diabetes in the area and estimates of the incidence of retinopathy derived from the published literature. We compared the screening models and calculated total costs, visual outcome, costs per sight-year saved and costs per quality-adjusted life year (QALY). We also estimated the costs of implementing a screening program for all First Nations individuals in Ontario with diabetes and no access to an ophthalmologist. RESULTS: From the perspective of the health care system the camera program was preferable to the specialist-based program. Over 10 years, 67 v. 56 sight years were saved, compared with no screening, at costs of 3900 Canadian dollars v. 9800 Canadian dollars per sight year and 15,000 Canadian dollars v. 37,000 Canadian dollars per QALY. Generalizing these results to the province of Ontario, the camera system could allow most isolated First Nations people with diabetes to be screened for 5 years for approximately 1.2 million Canadian dollars. INTERPRETATION: A portable retinal camera is a cost-effective means of screening for diabetic retinopathy in isolated communities of at-risk individuals.}, keywords = {Cost-Benefit Analysis Diabetic Retinopathy/diagnosis/ethnology/*prevention & control Humans *Indians, North American Monte Carlo Method Ontario Ophthalmology/economics/methods Photography Quality-Adjusted Life Years Vision Screening/*economics/methods EDAT- 2003/01/23 04:00}, year = {2003} } @article{mohanty, author = {Mohanty, SA and Washington, DL and Lambe, S and Fink, A and Asch, SM}, title = {Predictors of on-call specialist response times in {California} emergency departments}, journal = {Acad Emerg Med}, volume = {13}, number = {5}, pages = {505--512}, note = {NLM MEDLINE Evaluation Studies Journal Article Research Support, Non-U.S. Gov't DEP - 20060411}, abstract = {OBJECTIVES: To assess waiting times in emergency departments (EDs) for on-call specialist response and how these might vary by facility or neighborhood characteristics. Limited availability of on-call specialists is thought to contribute to ED overcrowding. METHODS: Direct observational data from a random sample of 1,798 patients visiting 30 California EDs during a six-month period provided specialist waiting times. The authors used multivariate logistic regression and survival analysis to analyze predictors of time to on-call specialists' telephone response. RESULTS: Eighty-six percent of on-call specialists who were paged responded by telephone within 30 minutes. Ten percent of specialists did not respond at all. After controlling for the annual percentage of nonurgent ED patients at each facility, near closure status, and hospital ownership status, for every 10,000 dollars increase in hospital zip code income, the odds of on-call specialist response within 30 minutes increased by 123\% (adjusted odds ratio = 2.23; 95\% confidence interval = 1.24 to 4.02; p = 0.01). CONCLUSIONS: Although the majority of on-call specialists met the federal recommendation of a 30-minute response, those in poor neighborhoods were less likely to do so. One in ten on-call specialists did not respond at all. State and federal policies should focus on making more funding available for on-call specialist panels in poor areas.}, keywords = {California Emergency Service, Hospital/*statistics & numerical data Health Care Surveys Hospitals, Private/statistics & numerical data Hospitals, Public/statistics & numerical data Hospitals, Teaching/statistics & numerical data Hospitals, Urban/statistics & numerical data Humans Insurance, Health/statistics & numerical data Logistic Models Models, Statistical Multivariate Analysis Outcome Assessment (Health Care) Socioeconomic Factors Specialties, Medical/*statistics & numerical data Survival Analysis Telephone/statistics & numerical data *Time Trauma Centers/statistics & numerical data Waiting Lists EDAT- 2006/04/13 09:00}, year = {2006} } @article{morad, author = {Morad, Y and Barkana, Y and Avni, I and Kozer, E}, title = {Fundus anomalies: what the pediatrician's eye can't see}, journal = {Int J Qual Health Care}, volume = {16}, number = {5}, pages = {363--365}, note = {NLM MEDLINE Journal Article}, abstract = {BACKGROUND: With increasing workloads for hospital doctors, routine funduscopy may be abandoned. It is not known how often pediatricians perform funduscopy and how skilled they are in performing it. OBJECTIVE: To assess hospital pediatricians' ability to diagnose abnormalities of the ocular fundi and to determine whether a short tutorial can improve their skills. METHODS: Physicians working at the pediatric division of a university-affiliated hospital participated in the study. All participants completed an anonymous questionnaire regarding their experience and skills in performing funduscopy. A pictorial quiz containing 20 fundus pictures of common findings in children was given. After completing the quiz, a 45-minute tutorial on common fundus anomalies was given. At the end of the lecture, the same quiz was given again. The percentage of correct answers for each quiz was scored. RESULTS: Sixteen physicians completed the study (11 pediatric residents and five senior pediatricians). Most participants did not feel competent at performing a fundus examination [mean score on a visual analog scale 1.96; range 0 (not competent at all) to 7]. The mean score for the fundus pictures quiz given before the tutorial was 48\% (range 37--58\%). The average score of the residents (47\%) did not differ significantly from that of the senior pediatricians (42\%). After the tutorial the mean grade increased significantly to 60\% (P = 0.002). This was true both for residents (63\%; P = 0.001) and seniors (55\%; P = 0.004). CONCLUSIONS: Our study shows that funduscopy is being neglected by pediatricians. Even a short tutorial may significantly improve the diagnostic value of this test.}, keywords = {Child Clinical Competence/*statistics & numerical data Diagnostic Tests, Routine Education, Medical, Continuing/methods Eye Abnormalities/*diagnosis *Fundus Oculi Humans Israel Medical Staff, Hospital/education/statistics & numerical data Ophthalmoscopy/*utilization Pediatrics/education/*standards EDAT- 2004/09/18 05:00}, year = {2004} } @misc{orbis, author = {ORBIS}, title = {Cyber-Sight [online], Available at: http://www.orbis.org}, number = {3/1/2010}, } @article{roberts, author = {Roberts, E and Morgan, R and King, D and Clerkin, L}, title = {Funduscopy: a forgotten art}, annotate = {?}, journal = {Postgrad Med J}, volume = {75}, number = {883}, pages = {282--284}, note = {001001title_3817009255 3 MEDLINE MEDLINE/PubMed UID - 10533632 NLM PubMed MEDLINE Journal Article 2 c3d5ae5a9cee45e5b29035f1992db929 DCOM- 19991109}, abstract = {Funduscopy is an integral part of the physical examination, especially in older patients in whom visual problems and systemic diseases affecting the fundi (e.g., diabetes mellitus) are more common. We have assessed the views of hospital doctors to funduscopy via a questionnaire survey, reviewed the case notes to see whether or not funduscopy is carried out on older patients, and assessed the views of older patients on vision via a questionnaire survey. Review of the case notes showed only three of 100 patients had had funduscopy. Most patients reported a visual problem on specific enquiry. Whilst most hospital doctors believed funduscopy was important, many felt they had insufficient training in this procedure and felt their skills could be improved. We conclude that older patients are missing out on routine funduscopy. Hospital doctors should be aware that not all patients complain of visual problems and specific enquiry should be made. The issue of training and encouragement to perform funduscopy needs to be addressed before funduscopy becomes a forgotten art.}, keywords = {Diabetic Retinopathy/diagnosis Fundus Oculi Humans Medical Audit Medical Staff, Hospital Ophthalmoscopes Ophthalmoscopy/*methods Retinal Diseases/*diagnosis}, year = {1999} } @article{rudkin, author = {Rudkin, SE and Oman, J and Langdorf, MI and Hill, M and Bauche, J and Kivela, P and Johnson, L}, title = {The state of {ED} on-call coverage in {California}}, journal = {Am J Emerg Med}, volume = 22, number = 7, pages = {575--581}, note = {NLM MEDLINE Comparative Study Journal Article}, abstract = {The ED provides initial treatment, but failure of specialists to respond unravels the safety net. To assess the scope of problems with on-call physicians in {California}. A mailed anonymous survey to all {CAL/ACEP} physician members (1876) asking patient, physician and {ED} demographics, specialist availability for consultation, insurance profile, and availability of follow-up care. 608/1876 physicians responded (32.4\%), representing 320/353 California EDs (90.6\%). The seven specialties in which the greatest proportion of EDs reported trouble with specialty response were: plastic surgery (37.5\%), ENT (35.9\%), dentistry (34.9\%), psychiatry (26.0\%), neurosurgery (22.9\%), ophthalmology (18.4\%) and orthopedics (18.0\%). 71.6\% of responder EDs reported that their medical staff rules required ED on-call coverage. However, the percentage of responders who stated that hospitals paid each specialty for call was low: neurosurgery (37.3\%), orthopedics (34.4\%), ENT (17.9\%), plastic surgery (15.1\%) and ophthalmology (13.1\%). On-call problems were more acute at night (77.2\%) or on weekends (72.4\%). Patient insurance negatively affected (69.9\%) willingness of on-call physicians to consult for at least a quarter of patients. Regarding follow-up, 91\% reported some trouble, whereas 64\% reported a problem at least half the time. Surgical sub-specialists are the most problematic on-call physicians. Insurance status has a major negative effect on ED and follow-up care. The on-call situation in California has reached crisis proportions.}, keywords = {After-Hours Care Aftercare Attitude of Health Personnel California Dentists *Emergency Medicine Emergency Service, Hospital/*manpower/organization & administration Follow-Up Studies Humans Insurance, Health/classification *Interprofessional Relations Medical Staff, Hospital/organization & administration Neurosurgery Ophthalmology Orthopedics Otolaryngology Psychiatry Referral and Consultation *Specialties, Medical Specialties, Surgical/manpower Surgery, Plastic EDAT- 2005/01/25 09:00}, year = 2004 } @article{shuttleworth, author = {Shuttleworth, GN and Marsh, GW}, title = {How effective is undergraduate and postgraduate teaching in ophthalmology}, annotate = {?}, journal = {Eye}, volume = {11}, number = {Pt 5}, pages = {744--750}, note = {NLM MEDLINE Journal Article}, abstract = {PURPOSE: To gain an insight into the adequacy of ophthalmic medical education for doctors in the primary care setting. METHODS: A short forced-choice questionnaire was set to 150 randomly selected primary care practitioners in and around Bristol. Information was collected in relation to undergraduate and postgraduate ophthalmic education, ophthalmic confidence, facilities and understanding. RESULTS: One hundred and thirty-three primary care doctors replied to the questionnaire of whom 35\% were fundholders and 47\% in training practices. Only 22\% of all respondents felt their undergraduate ophthalmic medical education to be adequate. However, 83\% of the 86 primary care doctors who had attended postgraduate update courses in ophthalmology felt these to be adequate. Despite the availability of an ophthalmoscope and distance vision chart, only 56\% felt confident with the ophthalmoscope and only 61\% reported that their distance chart was set up in accord with manufacturer's instructions. Seventy-one per cent of respondents reported having access to dilating agents but only 61\% felt confident using them. Understanding of two key ophthalmic terms was also poor. Despite the general satisfaction, attendance of postgraduate update courses did not appear to alter facilities, confidence or understanding. CONCLUSIONS: It is apparent that most primary care doctors view their undergraduate ophthalmic medical education as inadequate and this is reflected in their confidence and understanding. Postgraduate courses, although more favourably received, do not appear to after these findings. We strongly suggest, therefore that general ophthalmic education is aimed at teaching examination techniques and ophthalmological principles suitable for primary care practice.}, keywords = {Adult Age Factors Attitude of Health Personnel Education, Medical, Graduate/*standards Education, Medical, Undergraduate/*standards England Eye Diseases/diagnosis Family Practice/*education/instrumentation Humans Middle Aged Ophthalmology/*education/instrumentation Primary Health Care Questionnaires EDAT- 1997/01/01 00:00}, year = {1997} } @article{snyder, author = {Snyder, H and Robinson, K and Shah, D and Brennan, R and Handrigan, M}, title = {Signs and symptoms of patients with brain tumors presenting to the emergency department}, journal = {J Emerg Med}, volume = {11}, number = {3}, pages = {253--258}, note = {NLM MEDLINE Journal Article}, abstract = {This retrospective chart review was conducted to determine the presenting signs and symptoms of patients with primary brain tumors diagnosed in the emergency department. There were 101 patients (65 males and 36 females) identified with a hospital discharge diagnosis of primary brain tumor who were admitted through the emergency department. The presenting symptoms included headache (56 patients), altered mental status (51 patients), ataxia (41 patients), nausea or vomiting (37 patients), weakness (27 patients), speech deficits (21 patients), and sensory abnormalities (18 patients). The presenting signs included motor weakness (37 patients), ataxia (37 patients), papilledema (28 patients), cranial nerve palsies (26 patients), visual deficits (20 patients), and speech deficits (12 patients). The average age was 42.8 years, with a range of 3 days to 88 years. The majority of tumors were malignant astrocytomas. Tumor location was cortical in 68 patients, subcortical in 9 patients, and brainstem or cerebellum in 24 patients. In conclusion, patients of all ages may present to the emergency department with a variety of symptoms resulting from a primary brain tumor. Headache and altered mental status were common in our series of patients, but symptoms will depend on the size, location, and type of tumor. A complete neurologic examination is essential, including evaluation for papilledema.}, keywords = {Adolescent Adult Aged Aged, 80 and over Ataxia/etiology Brain Neoplasms/complications/*diagnosis Child Child, Preschool Cranial Nerve Diseases/etiology *Emergency Service, Hospital Female Headache/etiology Humans Infant Infant, Newborn Male Middle Aged Nausea/etiology Papilledema/etiology Retrospective Studies Vomiting/etiology EDAT- 1993/05/01}, year = {1993} } @article{sobri, author = {Sobri, M and Lamont, AC and Alias, NA and Win, MN}, title = {Red flags in patients presenting with headache: clinical indications for neuroimaging}, journal = {Br J Radiol}, volume = {76}, number = {908}, pages = {532--535}, note = {NLM MEDLINE Journal Article}, abstract = {Headache is a very common patient complaint but secondary causes for headache are unusual. Neuroimaging is both expensive and has a low yield in this group. Most patients with intracranial pathology have clinical features that would raise a "red flag". Appropriate selection of patients with headache for neuroimaging to look for secondary causes is very important. Red flags act as screening tools to help in identifying those patients presenting with headache who would benefit from prompt neuroimaging, and may increase the yield. The aim of this study is to evaluate clinical features in patients with headache using neuroimaging as a screening tool for intracranial pathology. 20 red flags were defined. A retrospective study of 111 patients was performed and the outcomes were divided into positive and negative. Abnormal neuroimaging was present in 39 patients. Results were analysed using the Logistic Regression model. Sensitivity and specificity of red flags were analysed to establish the cut-off point to predict abnormal neuroimaging and a receiver operating characteristic (ROC) curve plotted to show the sensitivity of the diagnostic test. Three red flag features proved to be statistically significant with the p-value of less than 0.05 on both univariate and multivariate analysis. These were: paralysis; papilloedema; and "drowsiness, confusion, memory impairment and loss of consciousness". In addition, if three or more red flags from the list were present, this showed strong indication of abnormal neuroimaging, from cut-off point of ROC curve (area under the curve =0.76).}, keywords = {Adolescent Adult Aged Child Female Headache Disorders/*etiology/pathology Humans Magnetic Resonance Imaging Male Memory Disorders/etiology Middle Aged Papilledema/etiology Paralysis/etiology Prognosis ROC Curve Retrospective Studies Sleep Stages Tomography, X-Ray Computed Unconsciousness/etiology EDAT- 2003/08/02 05:00}, year = {2003} } @article{solberg, author = {Solberg, KE}, title = {Telemedicine set to grow in India over the next 5 years}, journal = {Lancet}, volume = {371}, pages = {17--18}, year = {2008} } @article{thambisetty, author = {Thambisetty, M and Lavin, PJ and Newman, NJ and Biousse, V}, title = {Fulminant idiopathic intracranial hypertension}, journal = {Neurology}, volume = {68}, number = {3}, pages = {229--232}, note = {P30-ey06360/ey/nei Journal Article Multicenter Study Research Support, N.I.H., Extramural United States}, abstract = {OBJECTIVE: To describe the incidence and characteristics of acute and rapidly progressive visual loss in idiopathic intracranial hypertension (IIH). METHODS: We reviewed the medical records of all patients with IIH seen at two institutions. "Fulminant IIH" was defined as the acute onset of symptoms and signs of intracranial hypertension (less than 4 weeks between onset of initial symptoms and severe visual loss), rapid worsening of visual loss over a few days, and normal brain MRI and MR venography (or CT venogram). RESULTS: Sixteen cases with "fulminant IIH" were included (16 women, mean age 23.8 years [range 14 to 39 years]). All were obese. One patient had iron-deficiency anemia, four had systemic hypertension, and none had known sleep apnea syndrome. Acute or subacute headache, nausea and vomiting, and visual loss were present in all patients. The first lumbar puncture performed for the diagnosis showed a mean CSF opening pressure of 54.1 cm H(2)O (range 29 to 60 cm H(2)O). In addition to the initial lumbar puncture, medical treatment included acetazolamide (1 to 2 g/day) in all patients, and IV methylprednisolone in four patients. Repeat lumbar punctures were performed in 11 of the 16 patients. Surgical treatment (optic nerve sheath fenestration in five cases, lumboperitoneal CSF shunting procedure in nine cases, and ventriculoperitoneal shunting procedure in two cases) was performed because of ongoing visual loss in all cases. The median delay between evaluation in neuro-ophthalmology and surgery was 3 days (range a few hours to 37 days). All patients reported dramatic improvement of headaches and vomiting following surgery. Visual function improved in 14 cases, although 8 patients (50\%) remained legally blind. Visual fields remained severely altered in all cases. CONCLUSION: Severe and rapidly progressive visual loss suggests "fulminant idiopathic intracranial hypertension" and should prompt aggressive management. Urgent surgery may be required in these patients, and temporizing measures such as repeat lumbar punctures, lumbar drainage, and IV steroids considered.}, keywords = {Acute Disease Adolescent Adult Comorbidity Female Georgia/epidemiology Humans Incidence Intracranial Hypertension/*diagnosis/*epidemiology Male Middle Aged Prognosis Risk Assessment/*methods Risk Factors Severity of Illness Index Tennessee/epidemiology Vision, Low/*diagnosis/*epidemiology}, year = {2007} } @article{wong1, author = {Wong, T and Mitchell, P}, title = {The eye in hypertension}, journal = {Lancet}, volume = {369}, number = {9559}, pages = {425--435}, note = {1474--547X (Electronic) Journal Article Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov't Review}, abstract = {Hypertension has a range of effects on the eye. Hypertensive retinopathy refers to retinal microvascular signs that develop in response to raised blood pressure. Signs of hypertensive retinopathy are frequently seen in adults 40 years and older, and are predictive of incident stroke, congestive heart failure, and cardiovascular mortality--independently of traditional risk factors. Hypertension is also a major risk factor for the development of other retinal vascular diseases, such as retinal vein and artery occlusion, and ischaemic optic neuropathy. High blood pressure increases the risk of both development of diabetic retinopathy and its progression. Adequate control of blood pressure has been proven in randomised clinical trials to reduce vision loss associated with diabetic retinopathy. Finally, hypertension has been implicated in the pathogenesis of glaucoma and age-related macular degeneration. Recognition of the ocular effects of blood pressure could allow physicians to better manage patients with hypertension, and to monitor its end-organ effects.}, keywords = {Diabetic Neuropathies/*etiology/physiopathology Glaucoma/*etiology/physiopathology Humans Hypertension/*complications Macular Degeneration/*etiology/physiopathology Retinal Diseases/classification/*etiology/physiopathology Risk Factors}, year = {2007} } @article{wong2, author = {Wong, TY}, title = {Fred Hollows lecture: hypertensive retinopathy - a journey from fundoscopy to digital imaging}, journal = {Clin Experiment Ophthalmol}, volume = {34}, number = {5}, pages = {397--400}, note = {1442--6404 (Print) Lectures Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov't}, abstract = {Hypertensive retinopathy refers to a spectrum of retinal microvascular signs that develop in response to elevated blood pressure. These signs are broadly divided into localized signs (focal retinal arteriolar narrowing, arteriovenous nicking, retinal haemorrhages, cotton wool spots, hard exudates and microaneurysms) and diffuse signs (generalized retinal arteriolar narrowing, arterial wall opacification and optic disc oedema). Although their association with systemic morbidity was recognized more than a century ago, the prognostic significance of hypertensive retinopathy has not received much attention. In large part, this is because clinical assessment of hypertensive retinopathy signs with the direct fundoscopy has proven imprecise. Data from large population-based studies in the past decade, using retinal photographic methods to define hypertensive retinopathy signs, have provided new insights into the epidemiology, systemic associations and clinical significance of hypertensive retinopathy. These studies show that hypertensive retinopathy signs are common (up to 14\% of adults aged 40 years and older, even in those without clinical diabetes or hypertension) and are strongly associated with blood pressure. Various retinopathy signs predict the risk of stroke, congestive heart failure and cardiovascular mortality, independent of blood pressure and other risk factors. These data suggest that patients with hypertensive retinopathy signs may benefit from a careful cardiovascular evaluation, and appropriate risk reduction therapy if indicated. Future advances in digital retinal imaging technology will allow researchers and clinicians to better chart and monitor the vascular effects of hypertension.}, keywords = {Humans Hypertension/classification/*diagnosis/epidemiology Ophthalmoscopy/*methods Photography/*methods Retinal Diseases/classification/*diagnosis/epidemiology Signal Processing, Computer-Assisted}, year = {2006} } @article{wong3, author = {Wong, TY and Klein, R and Amirul Islam, FM and Cotch, MF and Couper, DJ and Klein, BE and Hubbard, LD and Sharrett, AR}, title = {Three-year incidence and cumulative prevalence of retinopathy: the atherosclerosis risk in communities study}, journal = {Am J Ophthalmol}, volume = {143}, number = {6}, pages = {970--976}, note = {0002--9394 (Print) Journal Article}, abstract = {PURPOSE: To describe the three-year incidence and cumulative prevalence of retinopathy and its risk factors. DESIGN: Population-based, prospective cohort study in four US communities. METHODS: In the Atherosclerosis Risk in Communities (ARIC) Study, 981 participants had retinal photography of one randomly selected eye at the third examination (1993 to 1995) and three years later at the fourth examination (1996). Photographs were graded on both occasions for retinopathy signs (for example, microaneurysm, retinal hemorrhage, and/or cotton-wool spots). Incidence was defined as participants without retinopathy at the third examination who developed retinopathy at the fourth examination, and cumulative prevalence was defined to include incident retinopathy as well as participants who had retinopathy at both the third and fourth examinations. RESULTS: The three-year incidence and cumulative prevalence of any retinopathy in the whole cohort was 3.8\% and 7.7\%, respectively. In multivariable analysis, incident retinopathy was related to higher mean arterial blood pressure (odds ratio [OR] 1.5, 95\% confidence interval [CI] 1.0 to 2.3, per standard deviation increase in risk factor levels), fasting serum glucose (OR 1.6, 95\% CI 1.3 to 2.1), serum total cholesterol (OR 1.4, 95\% CI 1.0, 2.0), and plasma fibrinogen (OR 1.4, 95\% CI 1.1 to 1.9). Among persons without diabetes, the three-year incidence and cumulative prevalence of nondiabetic retinopathy was 2.9\% and 4.3\%, respectively. Incident nondiabetic retinopathy was related to higher mean arterial blood pressure (OR 1.4, 95\% CI 0.9 to 2.3) and fasting serum glucose (OR 1.5, 95\% CI 1.0 to 2.3). Among persons with diabetes, the three-year incidence and cumulative prevalence of diabetic retinopathy was 10.1\% and 27.2\%, respectively. CONCLUSIONS: Retinopathy signs occur frequently in middle-aged people, even in those without diabetes. Hypertension and hyperglycemia are risk factors for incident retinopathy.}, year = {2007} } @article{wong4, author = {Wong, TY and Mitchell, P}, title = {Hypertensive retinopathy}, journal = {N Engl J Med}, volume = {351}, number = {22}, pages = {2310--2317}, note = {1533--4406 (Electronic) Journal Article Review}, keywords = {Blood Pressure Cerebrovascular Accident/etiology Coronary Disease/etiology Humans *Hypertension/complications/epidemiology/physiopathology/therapy *Retinal Diseases/complications/epidemiology/physiopathology/therapy Risk}, year = {2004} } @book{yogesan, author = {Yogesan, K and Kumar, S and Goldschmidt, L and Cuadros, J}, title = {Teleophthalmology}, publisher = {Springer-Verlag}, address = {Berlin}, year = {2006} }