Showing papers in "Archives of Ophthalmology in 2004"

Causes and prevalence of visual impairment among adults in the United States.

Abstract: Objectives To estimate the cause-specific prevalence and distribution of blindness and low vision in the United States by age, race/ethnicity, and gender, and to estimate the change in these prevalence figures over the next 20 years. Methods Summary prevalence estimates of blindness (both according to the US definition of Results Based on demographics from the 2000 US Census, an estimated 937 000 (0.78%) Americans older than 40 years were blind (US definition). An additional 2.4 million Americans (1.98%) had low vision. The leading cause of blindness among white persons was age-related macular degeneration (54.4% of the cases), while among black persons, cataract and glaucoma accounted for more than 60% of blindness. Cataract was the leading cause of low vision, responsible for approximately 50% of bilateral vision worse than 6/12 (20/40) among white, black, and Hispanic persons. The number of blind persons in the US is projected to increase by 70% to 1.6 million by 2020, with a similar rise projected for low vision. Conclusions Blindness or low vision affects approximately 1 in 28 Americans older than 40 years. The specific causes of visual impairment, and especially blindness, vary greatly by race/ethnicity. The prevalence of visual disabilities will increase markedly during the next 20 years, owing largely to the aging of the US population.

Prevalence of age-related macular degeneration in the United States.

Abstract: Objective: To estimate the prevalence and distribution of age-related macular degeneration (AMD) in the United States by age, race/ethnicity, and gender.Methods: Summary prevalence estimates of drusen 125 pin or larger, neovascular AMD, and geographic atrophy were prepared separately for black and white persons in 5-year age intervals starting at 40 years. The estimated rates were based on a meta-analysis of recent population-based studies in the United States, Australia, and Europe. These rates were applied to 2000 US Census data and to projected US population figures for 2020 to estimate the number of the US population with drusen and AMD.Results: The overall prevalence of neovascular AMD and/or geographic atrophy in the US population 40 years and older is estimated to be 1.47% (95% confidence interval, 1.38%-1.55%), with 1.75 million citizens having AMD. The prevalence of AMD increased dramatically with age, with more than 15% of the white women older than 80 years having neovascular AMD and/or geographic atrophy. More than 7 million individuals had drusen measuring 125 pin or larger and were, therefore, at substantial risk of developing AMD. Owing to the rapidly aging population, the number of persons having AMD will increase by 50% to 2.95 million in 2020. Age-related macular degeneration was far more prevalent among white than among black persons.Conclusion: Age-related macular degeneration affects more than 1.75 million individuals in the United States. Owing to the rapid aging of the US population, this number will increase to almost 3 million by 2020.

The prevalence of diabetic retinopathy among adults in the United States.

Abstract: Objective: To determine the prevalence of diabetic retinopathy among adults 40 years and older in the United States.Methods: Pooled analysis of data from 8 population-based eye surveys was used to estimate the prevalence, among persons with diabetes mellitus (DM), of retinopathy and of vision-threatening retinopathy-defined as proliferative or severe nonproliferative retinopathy and/or macular edema. Within strata of age, race/ethnicity, and gender, US prevalence rates were estimated by multiplying these values by the prevalence of DM reported in the 1999 National Health Interview Survey and the 2000 US Census population.Results: Among an estimated 10.2 million US adults 40 years and older known to have DM, the estimated crude prevalence rates for retinopathy and vision-threatening retinopathy were 40.3% and 8.2%, respectively. The estimated US general population prevalence rates for retinopathy and vision-threatening retinopathy were 3.4% (4.1 million persons) and 0.75% (899000 persons). Future projections suggest that diabetic retinopathy will increase as a public health problem, both with aging of the US population and increasing age-specific prevalence of DM over time.Conclusion: Approximately 4.1 million US adults 40 years and older have diabetic retinopathy; 1 of every 12 persons with DM in this age group has advanced, vision-threatening retinopathy.

Prevalence of open-angle glaucoma among adults in the United States.

Abstract: Objective: To estimate the prevalence and distribution of open-angle glaucoma (OAG) in the United States by age, race/ethnicity, and genderMethods: Summary prevalence estimates of OAG were prepared separately for black, Hispanic, and white subjects in 5-year age intervals starting at 40 years The estimated rates were based on a meta-analysis of recent population-based studies in the United States, Australia, and Europe These rates were applied to 2000 US census data and to projected US population figures for 2020 to estimate the number of the US population with OAGResults: The overall prevalence of OAG in the US population 40 years and older is estimated to be 186% (95% confidence interval, 175%-196%), with 157 million white and 398000 black persons affected After applying race-, age-, and gender-specific rates to the US population as determined in the 2000 US census, we estimated that OAG affects 222 million US citizens Owing to the rapidly aging population, the number with OAG will increase by 50% to 336 million in 2020 Black subjects had almost 3 times the age-adjusted prevalence of glaucoma than white subjectsConclusions: Open-angle glaucoma affects more than 2 million individuals in the United States Owing to the rapid aging of the US population, this number will increase to more than 3 million by 2020

Current Concepts in the Pathogenesis of Age-Related Macular Degeneration

Abstract: Objective To review and synthesize information concerning the pathogenesis ofage-related macular degeneration (AMD). Methods Review of the English-language literature. Results Five concepts relevant to the cell biology of AMD are as follows: (1)AMD involves aging changes plus additional pathological changes (ie, AMD isnot just an aging change); (2) in aging and AMD, oxidative stress causes retinalpigment epithelial (RPE) and, possibly, choriocapillaris injury; (3) in AMD(and perhaps in aging), RPE and, possibly, choriocapillaris injury resultsin a chronic inflammatory response within the Bruch membrane and the choroid;(4) in AMD, RPE and, possibly, choriocapillaris injury and inflammation leadto formation of an abnormal extracellular matrix (ECM), which causes altereddiffusion of nutrients to the retina and RPE, possibly precipitating furtherRPE and retinal damage; and (5) the abnormal ECM results in altered RPE-choriocapillarisbehavior leading ultimately to atrophy of the retina, RPE, and choriocapillarisand/or choroidal new vessel growth. In this sequence of events, both the environmentand multiple genes can alter a patient's susceptibility to AMD. Implicit inthis characterization of AMD pathogenesis is the concept that there is linearprogression from one stage of the disease to the next. This assumption maybe incorrect, and different biochemical pathways leading to geographic atrophyand/or choroidal new vessels may operate simultaneously. Conclusions Better knowledge of AMD cell biology will lead to better treatmentsfor AMD at all stages of the disease. Many unanswered questions regardingAMD pathogenesis remain. Multiple animal models and in vitro models of specificaspects of AMD are needed to make rapid progress in developing effective therapiesfor different stages of the disease.

Racial variations in causes of vision loss in nursing homes: The Salisbury Eye Evaluation in Nursing Home Groups (SEEING) Study.

Abstract: Objective To determine the prevalence and causes of low vision in a large sampleof nursing home residents. Methods Twenty-eight nursing homes on the Eastern Shore of Maryland and Delawarewere enrolled in a clinical trial to assess the impact of vision restoration/rehabilitationon nursing home residents. Visual acuity was measured using both recognitioncharts and preferential looking techniques. An ophthalmologist examined allresidents with visual acuity worse than 20/40 in the better-seeing eye anddetermined the primary cause for decreased vision. Results are reported forthe better-seeing eye. Results Of 2544 eligible residents, 1591 (63%) participated, but 286 residentswere unable to respond to visual acuity testing. Of the remaining 1307 residents,496 (37%) had best-corrected visual acuity worse than 20/40 in the better-seeingeye. Causes were ascribed for 412 subjects. Rates of low vision were similarbetween African American subjects and white subjects (39% and 38%, respectively;age-adjusted P = .18). Cataract was the leading causeof low vision, responsible for 37% of low vision among white subjects and54% of low vision among African American subjects. Macular degeneration wasresponsible for 29% of low vision among white subjects but only 7% among AfricanAmerican subjects. Glaucoma caused low vision in 4% of white subjects and10% of African American subjects. Refractive error was not a frequent causeof low vision in nursing home residents. Conclusions Low vision is highly prevalent among nursing home residents, with 37%having visual acuity worse than 20/40 in the better-seeing eye. Differencesin causes of low vision between African American subjects and white subjectswere noted, with African American subjects more likely to have vision losson the basis of cataract, a readily treated condition. Appropriate interventionsfor nursing home residents, who face significant obstacles in accessing eyecare services, have the potential to improve the quality of life of this at-riskolder population.

The prevalence of refractive errors among adults in the United States, Western Europe, and Australia

Abstract: Objective: To estimate the prevalence of refractive errors in persons 40 years and older.Methods: Counts of persons with phakic eyes with and without spherical equivalent refractive error in the worse eye of +3 diopters (D) or greater, -1 D or less, and -5 D or less were obtained from population-based eye surveys in strata of gender, race/ethnicity, and 5-year age intervals. Pooled age-, gender-, and race/ethnicity-specific rates for each refractive error were applied to the corresponding stratum-specific US, Western European, and Australian populations (years 2000 and projected 2020).Results: Six studies provided data from 29281 persons. In the US, Western European, and Australian year 2000 populations 40 years or older, the estimated crude prevalence for hyperopia of +3 D or greater was 9.9%, 11.6%, and 5.8%, respectively (11.8 million, 21.6 million, and 0.47 million persons). For myopia of -1. D or less, the estimated crude prevalence was 25.4%, 26.6%, and 16.4% (30.4 million, 49.6 million, and 1.3 million persons), respectively, of whom 4.5%, 4.6%, and 2.8% (5.3 million, 8.5 million,and 0.23 million persons), respectively, had myopia of -5 D or less. Projected prevalence rates in 2020 were similar.Conclusions: Refractive errors affect approximately one third of persons 40 years or older in the United States and Western Europe, and one fifth of Australians in this age group.

Prevalence of cataract and pseudophakia/aphakia among adults in the United States.

Abstract: Objectives: To determine the prevalence of cataract and pseudophakia/aphakia in the United States and to project the expected change in these prevalence figures by 2020Methods: Summary prevalence estimates of cataract and of pseudophakia/aphakia were prepared separately for black white and Hispanic persons (for whom only cataract surgery data were available) in 5-year age intervals starting at 40 years for women and men The estimates were based on a standardized definition of various types of cataract: cortical, greater than 25% of the lens involved, posterior subcapsular, present according to the grading system used in each study; and nuclear, greater than or equal to the penultimate grade in the system used Data were collected from major population-based studies in the United States, and, where appropriate, Australia, Barbados, and Western Europe The age-, gender-, and race/ethnicity-specific rates were applied to 2000 US Census data, and projected population figures for 2020, to obtain overall estimatesResults: An estimated 205 million (172%) Americans older than 40 years have cataract in either eye, and 61 million (51%) have pseudophakia/aphakia Women have a significantly (odds ratio=137; 95% confidence interval, 126-150) higher age-adjusted prevalence of cataract than men in the United States The total number of persons who have cataract is estimated to rise to 301 million by 2020; and for those who are expected to have pseudophakia/aphakia, to 95 millionConclusion: The number of Americans affected by cataract and undergoing cataract surgery will dramatically increase over the next 20 years as the US population ages

The artificial silicon retina microchip for the treatment of vision loss from retinitis pigmentosa.

Abstract: Objective To determine the safety and efficacy of the artificial silicon retina(ASR) microchip implanted in the subretinal space to treat vision loss fromretinitis pigmentosa. Methods The ASR microchip is a 2-mm-diameter silicon-based device that containsapproximately 5000 microelectrode-tipped microphotodiodes and is powered byincident light. The right eyes of 6 patients with retinitis pigmentosa wereimplanted with the ASR microchip while the left eyes served as controls. Safetyand visual function information was collected. Results During follow-up that ranged from 6 to 18 months, all ASRs functionedelectrically. No patient showed signs of implant rejection, infection, inflammation,erosion, neovascularization, retinal detachment, or migration. Visual functionimprovements occurred in all patients and included unexpected improvementsin retinal areas distant from the implant. Main Outcome Measures Subjective improvements included improved perception of brightness,contrast, color, movement, shape, resolution, and visual field size. Conclusions No significant safety-related adverse effects were observed. The observationof retinal visual improvement in areas far from the implant site suggestsa possible generalized neurotrophic-type rescue effect on the damaged retinacaused by the presence of the ASR. A larger clinical trial is indicated tofurther evaluate the safety and efficacy of a subretinally implanted ASR.

Comparison of the GDx VCC scanning laser polarimeter, HRT II confocal scanning laser ophthalmoscope, and stratus OCT optical coherence tomograph for the detection of glaucoma.

Abstract: Objective: To compare the abilities of current commercially available versions of 3 optical imaging techniques: scanning laser polarimetry with variable corneal compensation (GDx VCC), confocal scanning laser ophthalmoscopy (HRT II [Heidelberg Retina Tomograph]), and optical coherence tomography (Stratus OCT) to discriminate between healthy eyes and eyes with glaucomatous visual field loss. Methods: We included 107 patients with glaucomatous visual field loss and 76 healthy subjects of a similar age. All individuals underwent imaging with a GDx VCC, HRT II, and fast retinal nerve fiber layer scan with the Stratus OCT as well as visual field testing within a 6-month period. Receiver operating characteristic curves and sensitivities at fixed specificities (80% and 95%) were calculated for parameters reported as continuous variables. Diagnostic categorization (outside normal limits, borderline, or within normal limits) provided by each instrument after comparison with its respective normative database was also evaluated, and likelihood ratios were reported. Agreement on categorization between methods (weighted ) was assessed. Results: After the exclusion of subjects with unacceptable images, the final study sample included 141 eyes of 141 subjects (75 with glaucoma and 66 healthy control subjects). Mean±SD mean deviation of the visual field test result for patients with glaucoma was �4.87±3.9 dB, and 70% of these patients had early glaucomatous visual field damage. No statistically significant difference was found between the areas under the receiver operating characteristic curves (AUCs) for the best parameters from the GDx VCC (nerve fiber indicator, AUC=0.91), Stratus OCT (retinal nerve fiber layer inferior thickness, AUC=0.92), and HRT II (linear discriminant function, AUC=0.86). Abnormal results for each of the instruments, after comparison with their normative databases, were associated with strong positive likelihood ratios. Chance-corrected agreement (weighted ) among the 3 instruments ranged from moderate to substantial (0.50-0.72). Conclusions: The AUCs and the sensitivities at high specificities were similar among the best parameters from each instrument. Abnormal results (as compared with each instrument’s normative database) were associated with high likelihood ratios and large effects on posttest probabilities of having glaucomatous visual field loss. Calculation of likelihood ratios may provide additional information to assist theclinicianindiagnosingglaucomawiththeseinstruments.

Risks of progression of retinopathy and vision loss related to tight blood pressure control in type 2 diabetes mellitus: UKPDS 69.

Abstract: Objective To determine the relationship between tight blood pressure (BP) control and the different aspects of diabetic retinopathy in patients with type 2 diabetes mellitus (DM). Setting Nineteen hospital-based clinics in England, Scotland, and Northern Ireland. Design Outcome of retinopathy status assessed by 4-field retinal photography related to allocation within a randomized controlled trial comparing a tight BP control policy aiming for a BP less than 150/85 mm Hg with a less tight BP control policy aiming for a BP less than 180/105 mm Hg. Subjects One thousand one hundred forty-eight hypertensive patients with type 2 DM were studied. These patients had type 2 DM for a mean duration of 2.6 years at the inception of the Hypertension in Diabetes Study, had a mean age of 56 years; and had a mean BP of 160/94 mm Hg. Seven hundred fifty-eight patients were allocated to a tight BP control policy with angiotensin-converting enzyme inhibitor or beta-blockers as the main therapy; 390 were allocated to a less tight BP control policy. Main outcome measures Deterioration of retinopathy (>/=2-step change on a modified Early Treatment Diabetic Retinopathy Study [ETDRS] final scale), together with end points (photocoagulation, vitreous hemorrhage, and cataract extraction) and analysis of specific lesions (microaneurysms, hard exudates, and cotton-wool spots). Visual acuity was assessed at 3-year intervals using ETDRS logarithm of the minimum angle of resolution charts. Blindness was monitored as an end point with the criterion of Snellen chart assessment at 6/60 or worse. Results By 4.5 years after randomization, there was a highly significant difference in microaneurysm count with 23.3% in the tight BP control group and 33.5% in the less tight BP control group having 5 or more microaneurysms (relative risk [RR], 0.70; P = .003). The effect continued to 7.5 years (RR, 0.66; P /=6/60) in 1 eye was 18/758 for the tight BP control group compared with 12/390 for less tight BP control group. These equate to absolute risks of 3.1 to 4.1 per 1000 patient-years, respectively (P = .046; RR, 0.76; 99% confidence interval, 0.29-1.99). There was no detectable difference in outcome between the 2 randomized therapies of angiotensin-converting enzyme inhibition and beta-blockade. Conclusions High BP is detrimental to each aspect of diabetic retinopathy; a tight BP control policy reduces the risk of clinical complications from diabetic eye disease.

VISION 2020: The Right to Sight: a global initiative to eliminate avoidable blindness.

Abstract: An estimated 45 million people around the world are blind. 1 Most of them have lost their sight to diseases that are treatable or preventable. Eighty percent of them live in the lesser-developed world in countries where chronic economic deprivation is exacerbated by the added challenge of failing vision. Without intervention, the number of individuals with blindness might reach 76 million by 2020 because of a number of factors, primarily the rapid aging of populations in most countries.2 Since eye disease is seen largely in older people, the projected doubling of the world's population older than 50 years to 2 billion by 2020 has profound effects on the number of those with blindness and low vision.

Central corneal thickness as a risk factor for advanced glaucoma damage

Abstract: Objective To determine if central corneal thickness (CCT) is related to the levelof glaucoma severity at the initial examination. Methods The initial visit to a glaucoma specialist by consecutive patients withprimary open-angle glaucoma from 1997 to 2002 was reviewed retrospectively.Each patient's age, sex, race, family history of glaucoma, number of glaucomamedications, visual acuity, spherical equivalent, intraocular pressure, CCT,visual field data, and vertical and horizontal cup-disc ratios were analyzed. Results Three hundred fifty eyes of 190 patients met the inclusion and exclusioncriteria. Central corneal thickness was significantly lower in blacks (mean,537 µm) than in whites (mean, 556 µm). Lower CCT was significantlyassociated with worsened Advanced Glaucoma Intervention Study score, worsenedmean deviation of visual field, increased vertical and horizontal cup-discratios, and increased number of glaucoma medications. In multivariate analysis,lower CCT was significantly associated with worsened Advanced Glaucoma InterventionStudy score, worsened mean deviation of visual field, and increased verticaland horizontal cup-disc ratios. Conclusions Central corneal thickness is a powerful clinical factor in determiningglaucoma severity at the initial examination by a specialist. Measuring CCTmay aid the ophthalmologist in identification of glaucoma patients at highrisk for progression.

Optical coherence tomography findings in myopic traction maculopathy.

Abstract: Results: Epiretinal traction was found in 58 (46.4%) of 125 eyes and retinal damage, in 43 eyes (34.4%). Macular retinoschisis was the most frequent form of macular damage (25 eyes [58%]), followed by retinal thickening, lamellar hole, and shallow retinal detachment. Conclusions: Epiretinal traction is a frequent finding in degenerative myopia and, particularly if associated with the presence of staphyloma, can generate a form of macular damage unique to eyes with high myopia. This damage can affect up to one third of these eyes and should be considered as a separate cause of visual loss easily detected by optical coherence tomography at its early stages.

Safety of an intravitreal injection of triamcinolone: results from a randomized clinical trial.

Abstract: Objective: To determine the safety of a single intravitreal injection of triamcinolone acetonide (4 mg) in patients with subfoveal choroidal neovascularization caused by age-related macular degeneration. Methods: A double-masked, placebo-controlled, randomized clinical trial was conducted at a public tertiary referral eye hospital. Patients participating had agerelated macular degeneration with evidence of choroidal neovascularization, any part of which was classic; age older than 59 years; and best-corrected visual acuity of 20/200 or better. Eyes were assigned to active study treatment or to placebo. Intraocular pressure and cataract grading were performed every 6 months for 3 years. Adverse events, from mild to vision-threatening or lifethreatening, were recorded as procedure-related or corticosteroid-related. Results: Seventy-five eyes were assigned to study treatment and 76 eyes to placebo. There were no moderate or severe adverse events related to the surgical procedure in either group. Triamcinolone-treated eyes had a significantly increased risk of developing mild or moderate elevation of the intraocular pressure. Topical glaucoma medication reduced intraocular pressure to acceptable levels in all patients. There was significant progression of cataract in the triamcinolone-treated eyes. Conclusion: Despite a significant adverse event profile, intravitreal triamcinolone is generally well tolerated by the human eye as long as patients are carefully followed up by their surgeon and treated appropriately, when necessary. Arch Ophthalmol. 2004;122:336-340

Incidence of dry eye in an older population.

Abstract: Objectives To estimate the 5-year incidence of dry eye and to examine its associationwith risk factors. Methods The population of Beaver Dam, Wis, that was 43 to 84 years of age (n= 5924) was examined in the 1988-1990 (n = 4926), 1993-1995 (n = 3722), and1998-2000 study phases (n = 2962). At the 1993-1995 examination, when dryeye data were first collected, and the 1998-2000 examination, 2783 subjectsparticipated, and 44 were interviewed. Of these, 2802 provided dry eye history.The incidence cohort consisted of 2414 subjects not reporting dry eye in the1993-1995 examination. Risk factor information was ascertained at the 1993-1995examination and included demographics, medical history, cardiovascular diseaserisk factors, medications, and lifestyle factors. Results During the 5-year interval between examinations, a history of dry eyedeveloped in 322 of 2414 subjects, for an incidence of 13.3% (95% confidenceinterval [CI], 12.0%-14.7%). Incidence was significantly associated with age( P P P Conclusions Incidence of dry eye is substantial. However, there are few associatedrisk factors. Some drugs (eg, diuretics and antihistamines) are associatedwith a greater risk, whereas others (angiotensin-converting enzyme inhibitors)are associated with lower risk.

Sunlight and the 10-year incidence of age-related maculopathy: the Beaver Dam Eye Study.

Abstract: Objective To examine the association of sunlight exposure and indicators of sunsensitivity with the 10-year incidence of age-related maculopathy (ARM). Design Population-based cohort study. Participants We included persons aged 43 to 86 years at the baseline examinationfrom 1988 to 1990, living in Beaver Dam, Wis, of whom 3684 persons underwent5-year follow-up and 2764 underwent 10-year follow-up. Methods Data on sun exposure and indicators of sun sensitivity were obtainedfrom a standardized questionnaire administered at baseline and/or follow-up.We determined ARM status by grading stereoscopic color fundus photographsusing the Wisconsin Age-Related Maculopathy Grading System. Main Outcome Measures Incidence and progression of ARM. Results While controlling for age and sex, we found that participants exposedto the summer sun for more than 5 hours a day during their teens, in their30s, and at the baseline examination were at a higher risk of developing increasedretinal pigment (risk ratio [RR], 3.17; 95% confidence interval [CI], 1.24-8.11;P= .01) and early ARM (RR, 2.14; 95% CI, 0.99-4.61;P= .05) by 10 years than those exposed less than 2 hoursper day during the same periods. In participants reporting the highest summersun exposure levels in their teens and 30s, the use of hats and sunglassesat least half the time during the same periods was associated with a decreasedrisk of developing soft indistinct drusen (RR, 0.55; 95% CI, 0.33-0.90;P= .02) and retinal pigment epithelial depigmentation(RR, 0.51; 95% CI, 0.29-0.91;P= .02). Participantswho experienced more than 10 severe sunburns during their youth were morelikely than those who experienced 1 or no burn to develop drusen with a 250-µmdiameter or larger (RR, 2.52; 95% CI, 1.29-1.71;P=.01) by the 10-year examination. No relationships were found between UV-Bexposure, winter leisure time spent outdoors, skin sun sensitivity, or numberof bad sunburns experienced by the time of the baseline examination and the10-year incidence and progression of ARM or its associated lesions. Conclusions Few significant relationships between environmental exposure to lightand the 10-year incidence and progression of ARM were found in the BeaverDam Eye Study. Consistent with results from the baseline and 5-year follow-upexaminations, significant associations were found between extended exposureto the summer sun and the 10-year incidence of early ARM and increased retinalpigment. A protective effect of hat and sunglasses use by participants whilein their teens and 30s against the 10-year incidence of soft indistinct drusenand retinal pigment epithelial depigmentation was also found, but only inthose who reported the highest amount of sun exposure during the same periods.

Determination of vitreous, aqueous, and plasma concentration of orally administered voriconazole in humans.

Abstract: plasma voriconazole concentration achieved in the vitreous and aqueous were 38.1% and 53.0%, respectively. Mean vitreous and aqueous minimum inhibitory concentrations for 90% of isolates (MIC90) were achieved against a wide spectrum of yeasts and molds, including Aspergillus species andCandida species, along with many other organisms. Conclusions: Orally administered voriconazole achieves therapeutic aqueous and vitreous levels in the noninflamed human eye, and the activity spectrum appears to appropriately encompass the most frequently encountered mycotic species involved in the various causes of fungal endophthalmitis. Because of its broad spectrum of coverage, low MIC90 levels for the organisms of concern, good tolerability, and excellent bioavailability with oral administration, it may represent a major advance in the prophylaxis or management of exogenous or endogenous fungal endophthalmitis.

Prospective study of intake of fruits, vegetables, vitamins, and carotenoids and risk of age-related maculopathy.

Abstract: Methods: We conducted a prospective follow-up study of women in the Nurses’ Health Study and men in the Health Professionals Follow-up Study. We followed 77562 women and 40866 men who were at least 50 years of age and had no diagnosis of ARM or cancer at baseline for up to 18 years for women and up to 12 years for men. Fruit and vegetable intakes were assessed with a validated semiquantitative food-frequency questionnaire up to 5 times for women and up to 3 times for men during follow-up. Results: A total of 464 (329 women and 135 men) incident cases of early ARM and 316 (217 women and 99 men) cases of neovascular ARM, all with visual loss of 20/30 or worse due primarily to ARM, were diagnosed during follow-up. Fruit intake was inversely associated with the risk of neovascular ARM. Participants who consumed 3 or more servings per day of fruits had a pooled multivariate relative risk of 0.64 (95% confidence interval, 0.44-0.93;P value for trend=.004) compared with those who consumed less than 1.5 servings per day. The results were similar in women and men. However, intakes of vegetables, antioxidant vitamins, or carotenoids were not strongly related to either early or neovascular ARM. Conclusion: These data suggest a protective role for fruit intake on the risk of neovascular ARM. Arch Ophthalmol. 2004;122:883-892

The relation of retinal vessel caliber to the incidence and progression of diabetic retinopathy: XIX: the Wisconsin Epidemiologic Study of Diabetic Retinopathy.

Abstract: greater 4-year progression of retinopathy. Larger venular diameters (RR, 4.28; 95% CI, 1.50-12.19; test of trend, P=.006) but not arteriolar diameters were associated with greater 4-year incidence of proliferative retinopathy. In multivariable analyses, arteriolar and venular calibers were not associated with the 4-year incidence of retinopathy. While adjusting for other factors, arteriolar and venular calibers were not associated with incidence of macular edema at 4 years. There were few associations of arteriolar or venular caliber with the 10- or 14-year incidence or the progression of retinopathy. Conclusions: Larger arteriolar and venular caliber, independent of retinopathy severity level, is related to the progression of retinopathy, and larger venular caliber is associated with the 4-year incidence of proliferative retinopathy. Caliber of retinal vessels is not associated with incident retinopathy. These data suggest a quantitative measure of retinal vascular caliber provides additional information regarding risk for progression of retinopathy.

Detection of diabetic foveal edema: contact lens biomicroscopy compared with optical coherence tomography.

Abstract: Objective To compare contact lens biomicroscopy with optical coherence tomography(OCT) for the detection of diabetic foveal edema. Methods Study participants consisted of a convenient cohort of consecutive patientswith diabetes mellitus seen at the Wilmer Eye Institute's Retinal VascularCenter, Baltimore, Md. Case characteristics were recorded and eyes were examinedby 1 of 4 retina specialists by means of contact lens biomicroscopy. Edemainvolving the center of the macula was assessed as definitely present, questionablypresent, or definitely not present. The OCT testing was performed and interpretedby trained technicians, masked to the physicians' assessment of foveal edema.Agreement between OCT and contact lens examination for the absence or presenceof foveal edema was evaluated. Results One hundred seventy-two eyes of 95 patients with diabetes were enrolledin August and September 2002. Foveal thickness was objectively measured byOCT in 170 (99%) of 172 cases. We found excellent agreement between OCT andcontact lens examination for the absence or presence of foveal edema whenOCT thickness was normal (≤200 µm) or moderately to severely increased(>300 µm). However, agreement was poor when foveal thickness was mildlyincreased on OCT (201-300 µm). Conclusions Agreement between contact lens examination and OCT for the detectionof diabetic foveal edema is poor when OCT thickening is mild. This suggeststhat contact lens biomicroscopy is relatively insensitive for the detectionof mild foveal thickening apparent on OCT. Additional studies are needed toinvestigate the natural course of cases with mildly increased foveal thicknesson OCT that do not appear thickened clinically.

Vitreous levels of vascular endothelial growth factor and stromal-derived factor 1 in patients with diabetic retinopathy and cystoid macular edema before and after intraocular injection of triamcinolone

Abstract: Background:Diffuse macular edema (DME) and/or aberrantneovascularization(NV)cancausevisionlossindiabetic retinopathy (DR) and may be modulated by growth factorsandchemokines.Thechemokinestromal-derived factor 1 (SDF-1) is a potent stimulator of vascular endothelial growth factor (VEGF) expression, the main effector of NV, and the key inducer of vascular permeability associatedwithDME.Circulatingendothelialcellprecursors migrating in response to SDF-1 participate in NV. Objective:ToinvestigatetherelationshipbetweenSDF-1 and (VEGF) in vitreous of patients with varying degrees of DR and DME before and after intraocular injection of triamcinolone acetonide, used to treat refractory DME. Methods:Inthisprospectivestudy,36patientswereincluded and observed for 6 months. Vitreous VEGF and SDF-1 levels were measured by enzyme-linked immunosorbent assay in samples obtained immediately before and 1 month after injection of triamcinolone. Results:BothVEGFandSDF-1weresignificantlyhigher (P.01) in patients with proliferative DR than in patients with nonproliferative DR. Levels of SDF-1 were markedlyincreasedinpatientswithDMEcomparedwith those without DME. Vascular endothelial growth factor correlated with SDF-1 levels and disease severity (r 2 =0.88). Conclusions:Triamcinolone administration resulted in dramatic reductions of VEGF and SDF-1 to nearly undetectable levels, eliminated DME, and caused regression of active NV. Our results support a role for SDF-1 and VEGF in the pathogenesis of the adverse visual consequencesofDRandsuggestthattheeliminationofDME with regression and/or initiation of fibrosis of NV after triamcinolone injection may be due to the suppression of VEGF and SDF-1.

Associations of mortality with ocular disorders and an intervention of high-dose antioxidants and zinc in the Age-Related Eye Disease Study: AREDS Report No. 13.

Abstract: OBJECTIVE To assess the association of ocular disorders and high doses of antioxidants or zinc with mortality in the Age-Related Eye Disease Study (AREDS). METHODS Baseline fundus and lens photographs were used to grade the macular and lens status of AREDS participants. Participants were randomly assigned to receive oral supplements of high-dose antioxidants, zinc, antioxidants plus zinc, or placebo. Risk of all-cause and cause-specific mortality was assessed using adjusted Cox proportional hazards models. RESULTS During median follow-up of 6.5 years, 534 (11%) of 4753 AREDS participants died. In fully adjusted models, participants with advanced age-related macular degeneration (AMD) compared with participants with few, if any, drusen had increased mortality (relative risk [RR], 1.41; 95% confidence interval [CI], 1.08-1.86). Advanced AMD was associated with cardiovascular deaths. Compared with participants having good acuity in both eyes, those with visual acuity worse than 20/40 in 1 eye had increased mortality (RR, 1.36; 95% CI, 1.12-1.65). Nuclear opacity (RR, 1.40; 95% CI, 1.12-1.75) and cataract surgery (RR, 1.55; 95% CI, 1.18-2.05) were associated with increased all-cause mortality and with cancer deaths. Participants randomly assigned to receive zinc had lower mortality than those not taking zinc (RR, 0.73; 95% CI, 0.61-0.89). CONCLUSIONS The decreased survival of AREDS participants with AMD and cataract suggests that these conditions may reflect systemic rather than only local processes. The improved survival in individuals randomly assigned to receive zinc requires further study.

Hypoxia-inducible factor 1alpha in the glaucomatous retina and optic nerve head.

Abstract: Objective To examine tissue hypoxia in the retina and optic nerve head of glaucomatouseyes by the assessment of a transcription factor, hypoxia-inducible factor1α (HIF-1α), which is tightly regulated by the cellular oxygenconcentration. Methods Using immunohistochemical analysis, the cellular localization of HIF-1αwas studied in the retina and optic nerve head of 28 human donor eyes withglaucoma compared with 20 control eyes from healthy donors matched for severalcharacteristics. The relationship between the retinal regions that exhibitedimmunostaining for HIF-1α and functional damage was examined using visualfield data. Results There was an increase in the immunostaining for HIF-1α in theretina and optic nerve head of glaucomatous donor eyes compared with the controleyes. In addition, the retinal location of the increased immunostaining forHIF-1α in some of the glaucomatous eyes was closely concordant withthe location of visual field defects recorded in these eyes. Conclusions Because the regions of HIF-1α induction represent the areas ofdecreased oxygen delivery and hypoxic stress, information obtained from thisstudy provides direct evidence that tissue hypoxia is present in the retinaand optic nerve head of glaucomatous eyes, and hypoxic signaling is a likelycomponent of the pathogenic mechanisms of glaucomatous neurodegeneration. Clinical Relevance These findings support the presence of tissue hypoxia in the retinaand optic nerve head of glaucomatous patients.

Intravitreal triamcinolone for the treatment of macular edema associated with central retinal vein occlusion.

Abstract: Objective To investigate the safety and efficacy of intravitreal triamcinoloneacetonide as treatment for macular edema associated with central retinal veinocclusion (CRVO). Methods We reviewed the medical records of 13 consecutive patients (13 eyes)with macular edema associated with CRVO who were treated with an injectionof intravitreal triamcinolone acetonide (4 mg) at the University of Wisconsinand the Bascom Palmer Eye Institute. Each intravitreal injection was deliveredthrough the pars plana using a 27- or 30-gauge needle. Main Outcome Measures Change in Snellen visual acuity, clinical appearance of macular edema,measurement of foveal thickening with optical coherence tomography (OCT),and frequency of complications. Results The median age of the 13 patients was 67 years (interquartile range,57-77 years), and the median duration of symptoms before injection was 8 months(interquartile range, 4-9 months). Mean baseline visual acuity was 20/500in the affected eye. Mean visual acuity at the 6-month follow-up examinationwas 20/180 in the affected eye. All 13 patients completed the 6-month examination.Eyes with nonischemic CRVO (n = 5) demonstrated a significant improvementin visual acuity, whereas eyes with ischemic CRVO (n = 8) demonstrated a nonsignificantvisual acuity improvement. No patient had a decrease in visual acuity. Meanbaseline foveal thickness as measured by OCT was 590 µm (retinal thickening= 416 µm). Mean foveal thickness as measured by OCT at the 1-month follow-upexamination in 12 patients was 212 µm (retinal thickening = 38 µm).At the 3-month follow-up examination, mean foveal thickness as measured byOCT for 13 patients was 193 µm (retinal thickening = 19 µm). Betweenthe 3- and 6-month follow-up examinations, 4 patients developed a recurrenceof macular edema. Three of the 4 patients were retreated with a second injectionof triamcinolone. Two of these 3 patients experienced an improvement in visualacuity following retreatment. At the 6-month follow-up examination, mean fovealthickness as measured by OCT for 13 patients was 281 µm (retinal thickening= 107 µm). No adverse effects such as retinal detachment or endophthalmitisoccurred. One patient experienced an increase in intraocular pressure thatwas controlled with 2 aqueous suppressants. Conclusions Intravitreal injection of triamcinolone appears to be a possibly effectivetreatment in some patients with macular edema associated with CRVO. Patientswith nonischemic CRVO may respond more favorably than patients with ischemicCRVO, and retreatment may be necessary in some patients. In this case series,severe complications were not noted.

Vitreous and aqueous penetration of orally administered moxifloxacin in humans.

Abstract: Objective To investigate intraocular penetration of moxifloxacin hydrochloride after oral administration. Methods Prospective study of 15 patients scheduled for vitrectomy between September and November 2004 at the Barnes Retina Institute, St Louis, Mo. Aqueous, vitreous, and serum samples were analyzed from 15 patients after oral administration of 2 tablets containing 400 mg of moxifloxacin. Assays were performed using high-performance liquid chromatography. Results The mean ± SD moxifloxacin concentrations in plasma (n = 15), vitreous (n = 13), and aqueous (n = 13) samples were 3.56 ± 1.31 μg/mL, 1.34 ± 0.66 μg/mL, and 1.58 ± 0.80 μg/mL, respectively. Mean ± SD sampling times after oral administration of the second moxifloxacin tablet for plasma, vitreous, and aqueous were 2.94 ± 0.81 hours, 3.77 ± 0.92 hours, and 3.71 ± 0.89 hours, respectively. The percentages of plasma moxifloxacin concentration in the vitreous and aqueous were 37.6% and 44.3%, respectively. Minimal inhibitory concentrations against 90% levels were exceeded against a wide spectrum of gram-positive and gram-negative pathogens in the vitreous and aqueous. Conclusions Moxifloxacin has a spectrum of coverage that encompasses the most common organisms in endophthalmitis. The pharmacokinetic findings of this investigation reveal that orally administered moxifloxacin achieves therapeutic levels in the noninflamed eye. Because of their broad spectrum of coverage, low minimal inhibitory concentration against 90% levels, good tolerability, and excellent oral bioavailability, fourth-generation fluoroquinolones may represent a major advance for managing posterior segment infections.

Surgery for idiopathic full-thickness macular hole: two-year results of a randomized clinical trial comparing natural history, vitrectomy, and vitrectomy plus autologous serum: Morfields Macular Hole Study Group RAeport no. 1.

Abstract: Objectives To determine the benefits of idiopathic full-thickness macular hole(FTMH) surgery compared with observation and to evaluate the use of autologousserum as an intraoperative adjunct. Methods A randomized clinical trial was performed to evaluate the anatomic andvisual benefits of FTMH surgery for lesions of 9 months or less symptom durationand visual acuity of 20/60 or less. We compared surgery with natural historyand determined whether use of intraoperative adjunctive autologous serum improvesthe surgical outcome. Eyes were randomized to (1) observation, (2) vitrectomy,or (3) vitrectomy plus serum and were followed for 24 months to assess anatomicstatus and visual function. Results In total, 185 eyes of 174 patients were enrolled. In the observationgroup, spontaneous closure of the FTMH occurred in 7 (11.5%) of 61 patients,with little or no change in overall acuity levels in 24 months. In contrast,the surgical groups had an overall closure rate of 80.6% (100/124) at 24 months,with 45% of eyes achieving Snellen acuity of 20/40 or greater. Surgical eyeshad better median near acuity than observation eyes by 6 lines (N5 vs N14).Use of autologous serum did not seem to affect anatomic or visual results.At 24 months, 72 (58.1%) of 124 surgical eyes had undergone cataract extraction. Conclusions Surgery for FTMH is safe and effective and is associated with significantvisual improvement compared with the natural history. Autologous serum applicationdoes not enhance the results of surgery.

A randomized trial of the effects of rigid contact lenses on myopia progression.

Abstract: Results: The mean±SD spherical equivalent cycloplegic refractive error progressed –1.56±0.95 diopters (D) for RGP wearers and –2.19±0.89 D for the SCL wearers during the 3 years of the study (analysis of covariance [ANCOVA], P.001). The axial growth of the eyes was not significantly different between treatment groups (ANCOVA, P=.57). The steep corneal meridian of the RGP wearers steepened 0.62 ±0 .60 D, and that of the SCL wearers steepened 0.88±0.57 D during the 3 years (ANCOVA, P=.01). Conclusions: The RGP wearers’ myopia progressed less than that of the SCL wearers. The corneal curvature of the SCL wearers steepened more than that of the RGP wearers, but the axial growth was not significantly different between the groups. Most refractive error treatment effect was limited to the first year of the trial. The results of the study provide information for eye care practitioners to share with their patients, but they do not indicate that RGPs should be prescribed primarily for myopia control. Arch Ophthalmol. 2004;122:1760-1766

The prevalence of diabetic retinopathy among adult type 1 diabetic persons in the United States.

Abstract: Objective To estimate the US prevalence of diabetic retinopathy (DR) among personswith type 1 diabetes mellitus (DM). Methods Prevalence data from the New Jersey 725 and Wisconsin EpidemiologicStudy of Diabetic Retinopathy were used to estimate the prevalence of DR byage, gender, and race among persons 18 years and older having type 1 DM diagnosedbefore age 30 years. Severity of DR was determined via masked grading of 7-fieldstereoscopic fundus photographs. Any DR was defined as retinopathy severitylevel of 14 or more; and vision-threatening retinopathy, as retinopathy severitylevel of 50 or more, the presence of clinically significant macular edema,or both. The estimates of the prevalence of DR among persons with type 1 DMwere applied to the estimated number of persons with type 1 DM diagnosed beforeage 30 years in the 2000 US population to obtain prevalence estimates of DRdue to type 1 DM in the general population. Results Among 209 million Americans 18 years and older, an estimated 889 000have type 1 DM diagnosed before age 30 years. Among persons with type 1 DM,the crude prevalences of DR of any level (74.9% vs 82.3% in black and whitepersons, respectively) and of vision-threatening retinopathy (30.0% vs 32.2%,respectively) are high. The prevalence of DR due to type 1 DM diagnosed beforeage 30 years in the general population 18 years and older is estimated at767 000 persons having DR of any level (0.37%), and 376 000 personshaving vision-threatening retinopathy (0.18%). Conclusion Retinopathy due to type 1 DM is an important public health problem inthe United States, affecting 1 per 300 persons 18 years and older, and 1 per600 persons with advanced, vision-threatening retinopathy.

Conjunctival nevi: clinical features and natural course in 410 consecutive patients

Abstract: Objectives To describe the clinical features of a conjunctival nevus and to evaluatethe lesion for changes in color and size over time. Design Retrospective, observational, noncomparative case series. Participants Four hundred ten consecutive patients with conjunctival nevi. Main Outcome Measures The 2 main outcome measures were changes in tumor color and size. Results Of the 410 patients, 365 (about 89%) were white, 23 (about 6%) wereAfrican American, 8 (2%) were Asian, 8 (2%) were Indian, and 6 (1%) were Hispanic.The iris color was brown in 55% (229/418), blue in 20% (85/418), green in20% (83/418), and not indicated in 5% (21/418). The nevus was brown in 65%,tan in 19%, and completely nonpigmented in 16%. The anatomical location ofthe nevus was the bulbar conjunctiva (302 eyes, 72%), caruncle (61 eyes, 15%),plica semilunaris (44 eyes, 11%), fornix (6 eyes, 1%), tarsus (3 eyes, 1%),and cornea (2 eyes, Conclusions Conjunctival nevus is a benign tumor most often located at the nasalor temporal limbus and rarely in the fornix, tarsus, or cornea. Over time,a change in tumor color was detected in 13% (20/149) and a change in tumorsize was detected in 8% (12/149).