Appendix A — Screening examination protocol and form

SURVEY OF OPHTHALMOLOGY

VOLUME 24 l SUPPL . MAY-JUNE

1980

APPENDIX A - SCREENING EXAMINATION PROTOCOL AND FORM

In a large epidemiologicstudy such as that being conducted in Framingham there is great opportunity for potential errors to become manifest. This is particularly true when more than one examinerparticipatesin the study. A patient examination performed as part of an epidemiologic study must be conductedin a different fashion and different frame of mind than a clinical office examination. A study patient must be examinedaccording to a set procedurethat cannot vary from patient to patient or with time. The technique of examination and criteria for tilling out the examinationform must be identical for all examiners participating in the study. The protocol must be strictly adheredto, and extreme care must be taken in examining the patient and filling out the form. It is recommendedthat the protocol be reviewed periodically to keep the points fresh in your memory. The protocol is necessarilylong in order to maintain consistencyand reducethe examiner variability to a minimum. When filling out the form, pleaseuse ink, and specificallydo not useeither pencil or red ink. Pencil marks tend to blur with use, and red will be used by personnelreviewing the forms. Although throughout this protocol there will be referencesto “circle both” or “circle absent,”etc, it is written to clearly indicate the substanceof what is wanted. In fact, circle the appropriate-number but not the entry correspondingto the number. Care must be taken not to circle more than one number for each item. When errors in re cording are made, do not write over the initial entry, but cross it out and write the new 517

entry above or to the side. The same should be done for a number that is circled; draw a seriesof lines through the incorrect entry and then circle the correct entry. If an entry becomestoo confusing for the coder to understand, make a comment to the side describingthe correct entry. At the completionof eachpatient examination, that patient’s forms will be reviewedby the clinic secretaryfor completenessand appropriatenessof entries. The patient should not leave the examining site until the forms have been reviewed and all questionsraised by the secretary satisfactorily answeredby the examiner. Pleaseassisther in every way becauseit will be difficult or impossibleto obtain the missing information at a later date. Patient Identification: The examinee’s full name, Framingham Record Number, date of birth, age in completed years, date of examination, sex, place of examination, and the name (and address,if not local) of examinee’s private ophthalmologist and -family physician will be filled in by the secretarywhen the patient is first registered for the eye examination. Under place of examination, “clinic” refers to the Boston University Medical Center (BUMC) examining rooms across from the Framingham Union Hospital; “local” refers to any exam done by the BUMC staff outside the “clinic,” e.g., in the examinee’shome, nursing home, hospital, etc; “elsewhere” refersto an exam done on individualswho are unable to return to the Framingham area for examination. [It was proposed that people distant from Framingham might have their

(11 :l-22)

518

Surv Ophthalmol

24 (suppl) May-June

LEIBOWITZ

1980

own ophthalmologists conduct the examinations. This was never implemented.] The last name of the examiner will be filled in by the examining ophthalmologist.

HISTORY (11:23-40) The questionnaire section of the Screening Protocol will be administered by the clinic nurses according to the following procedure. [Prior to October 29, 1973 the examining ophthalmologist took the history.] The questionnaire will be completed after the subject is registered, and prior to being seen by the screening ophthalmologist. The interview should take place in the designated area; the nurse interviewer will return the patient to the waiting area after completion of the interview. All questions about history of cataract, macular degeneration, or glaucoma relate to the history of such findings by an ophthalmologist. If the patient was told he had one of these conditions by an internist or optometrist and it was never verified by an ophthalmologist, it is to be counted as negative. If the patient is reasonably sure an ophthalmologist diagnosedthe condition, record the history as positive. If the patient isn’t sure but thought such a diagnosis might have been made, record the history as questionable. The history should also be recorded as questionable if it is uncertain that the condition was reported by an ophthalmologist. Record the time of diagnosis on the form precisely as it is given by the examinee; for example, if the examinee says that his ophthalmologist reported he had cataracts 15 years ago, then write in “ 15 years ago.” Do not make the mental calculation of the patient’s age 15 years ago. When the patient is unable to specify when he first was told of his condition an age or time range will be acceptable, e.g., entries such as “age 60-65” or “ 15-20 years ago” are satisfactory.

Cataract (11:23) Cataract: Ask “Have you ever had a cataract removed from either eye?” Pause . . * “Have you ever been told by an eye doctor that you have a cataract or a lens opacity in either of your eyes?” Negative The subject has never been examined by an ophthalmologist or has never been

ET AL

told by an ophthalmologist that he has one of the above conditions. Questionable - The subject thinks that he might have been told by an ophthalmologist that he has one of the above lens conditions or thinks it may have been an ophthalmologist who told him, but is not sure. Positive - The subject is certain that he has been told by an ophthalmologist that he has a cataract or lens opacity in one or both of his eyes, or has had a cataract removed.

Macular Degeneration (I 1:26) Macular degeneration: Ask “Have you ever been told by an eye doctor that you have a degenerative or aging change in the back of your eye which has causedyou to permanently lose vision?” Negative The subject has never been examined by an ophthalmologist or was never told by an ophthalmologist that he has the above condition. Questionable - The subject thinks that he might have been told by an ophthalmologist that he has degeneration or aging changes in the back of an eye causing him to lose vision, or was definitely told this but is not sure it was an ophthalmologist who told him. Positive - The subject is certain that he has been told by an ophthalmologist that he has degenerative or aging changes in the back of his eye causing a permanent loss of vision.

Glaucoma (11:29) Glaucoma: Ask “Have you ever been treated by an eye doctor for glaucoma?” Pause . . . “Were you treated with eye drops or pills or an eye operation?” If yes, ask: “Are you taking any medication now for the glaucoma?” Negative - The subject has never been treated by an ophthalmologist for the above condition. Questionable - The subject received medical treatment for glaucoma in the past which was not continued to the present, and has not been operated upon for his condition, or is taking some eye medication at present which he thinks may be for glaucoma, but is not sure. Positive - The subject is certain that he had been told by an ophthalmologist that he had glaucoma, or increased pressure in his eye, for which he is receiving medicine or had received surgical treatment. If he had not received surgical treatment for the condition in the past, he must be under medical treatment at the present time. Include in this history any form of glaucoma, i.e., chronic open angle, narrow angle, congenital, or secondary glaucoma. Medical treatment only - The subject is

FRAMINGHAM

519

EYE STUDY

currently receivingtreatment in the form of eye drops (e.g., pilocarpine,echothiophateiodide, or epinephrine) or oral medication (e.g., acetazolamide)and has not beensurgicallytreated for glaucoma. Surgical treatment - The subjecthas received ocular surgical treatment for any type of glaucoma. Include any of the following as glaucoma operations: filtering procedures, peripheral iridectomy, cyclodialysis, cryotherapy, or diathermy. Treatment unknown - The patient thinks he was told that he had glaucoma but does not know either his past or present treatment.

Diabetes Mellitus (11:32) Diabetes mellitus: Ask “Have you ever been treated by a physician for sugar diabetes?” If yes, ask: “What treatment are you receiving now for the diabetes?” Negative - The subject has not been told that he has diabetes, nor been treated for it. Questionable - The subject has been told that he has diabetes e.g., sugar in the urine, but other tests were negative, or he was not treated, or the treatment was not continued to the present. Pos,itive - The subject is being treated for sugar diabetes at the present time. This treatment may include insulin, oral hypoglycemic agents, or diet alone. Whenever the subject gives a

“questionable” or “positive” history of diabetes mellitus, ask “How old were you when the diabetes was first diagnosedby your physician?” (I 1:35) Present treatment: If “questionable” or “‘positive” history of diabetes mellitus is circled, ask about the present treatment regimen. None - The subject is not being treated for diabetes at the present time. Diet alone - The subject’s diabetes is presently

managedby low carbohydrateand/or low caloric diet, or by omission of specific food items. Oral medication without insulin - The subject’s diabetes is presently managed by oral hypoglycemic agents, e.g., tolbutamide, tolazamide, actohexamide, chlorpropamide, phenformin, hydrochloride, etc. Oral medication plus insulin - The subject’s diabetes is presently managed by oral medication plus insulin, e.g., regular, protamine zinc, globulin, insulin NPH, insulin Lente, etc. In&in without oral medication - The subject’s diabetes is presently managed by insulin without oral hypoglycemic agents.

If on oral medication or insulin, inquire about the type and amount of medication used, if known.

(I 1:36-38) Diabetic coma: If “questionable” or “‘positive” history of diabetes mellitus is circled, ask “Have you ever had any episodes of unconsciousnesswhich were said by your doctor to be due to the diabetes?” Negative - The subject has not been in any coma related to his diabetic condition. Questionable - The subject thinks he might have been in a coma in the past, or definitely was in a coma but is not sure if it was related to his diabetic condition. Positive - The subject is sure he has been in a coma and that the coma was due to diabetes.

If “questionable” or “positive” history of diabetic coma, inquire about the type or types of coma that may have occurred at any time in his past. To identify Hypoglycemic coma, ask “Was the episode of unconsciousness less than five hours duration?’ Pause . . . “Were you put in the hospital because of the coma?’ Pause . . . “Were you in the hospital for less than 24 hours?” A positive answer to either of the above will be accepted as hypoglycemic coma. To identify Hyperglycemic coma, ask “Was the episode of unconsciousness more than five hours duration?” Pause . . . “Were you admitted to the hospital for more than 24 hours because of this condition?” A positive response to either of the above will be accepted as hyperglycemic coma.

Note: Conflict in the above answers with respect to a single episode, i.e., “unconsciousnesslasted two hours but I was in the hospital for two days,” will be considered as type unknown. When the subject reports a “questionable” or “positive” history of diabetic coma, ask, “How many years has it been since the last episode of unconsciousness?”In every instance, report exactly what the patient says, e.g., if the examinee reported 15 years ago, then write in “15 years ago;” if the examinee said that he was about 60-65 years of age write in “60-65.”

Loss of an Eye (11:40) Loss of an eye: Ask “Have you ever had an eye removed?” If the subject says that he has had an eye removed, determine which eye and the reason for removal. Enter the reasonfor removal at the bottom of thefirst page.

VISUAL ACUITY (11:41-72) In testing and recording visual acuity, all extraneous light must be turned off in the room except for the cabinet light, and the

520

Surv Ophthalmol

24 (suppl) May-June

1980

shades closed. If distance glasses are available, check and record the acuity with the distance glasseseven if uncorrected acuity is better. Do not test near vision. Begin with the 20/30 line if acuity seems to be good and present increasingly smaller lines until a complete line cannot be read correctly. Use isolated lines on the acuity chart rather than isolated letters or multiple lines when determining the visual acuity. When a letter is missed on a line, ask the subject to read the complete line again, more closely. If the missed letter or letters are correctly identified on the second reading, that line will be accepted as correctly read. When the subject volunteers two or three alternative designations of the letter, ask the subject to commit himself to a definite answer. If on the second reading a different letter is now read wrong, do not give him credit for this letter or any others that are guessedwrongly on the second reading. The vision will be recorded as the smallest complete line read correctly by the examinee, with the letters on a lower line written as plus, e.g., 20/25 + 3. Sometimes the examinee will miss several letters on increasingly smaller lines due to astigmatism. In this case record the visual acuity as the next largest line above the smallest line where most of the letters are read and give the examinee credit for the letters correctly identified on the lower line. In cases where the distance vision is less than 20/400, have the patient walk toward the screen until the 20/400 line can be first read or until the one foot mark is reached. If the examinee cannot discern the 400 symbol at one foot, record as hand motion (H.M.), light projection (L.P.P.), light perception (L.P.) or no light perception (N.L.P.). Light projection should be tested in a darkened room using the direct ophthalmoscope light at about one-foot distance from the eye. The rheostat should be turned on highest power. Light perception should be tested by directing the light of the indirect ophthalmoscope on the examinee’s eye at about a one-foot distance. If the best acuity for an eye is 20/25 or worse, retest the acuity for that eye using a pinhole placed directly in front of the examinee’s glasses. Note: Ignore the plus subscript here (and in criteria for refraction, which follows), i.e., an eye with 20/25 + 4 should have pinhole examination and an eye with 20/30 + 4 after pinhole should be

LEIBOWITZ

ET AL

refracted. Determine the pinhole acuity by the previously described technique. When the pinhole decreasesacuity rather than improves it, record the acuity found without the pinhole as the pinhole acuity. At this point, place the examinee’s glasses prescription in the lensometer and record distance correction. Do not record prescription if the glasses are for reading only and were not used in obtaining distance visual acuity. Instructions for operating the lensometer will be posted near the instrument. If the best visual acuity is 20/30 or worse in either eye including pinhole test, do a manifest refraction, using glassesprescription or retinoscopy as a base. Use k.25 diopter increments for sphere and f.25 diopter increments for cylinder. Check astigmatism axis by f 5’ increments. Record the new prescription and the acuity found with it. Also record the spherical equivalent (sphere plus half the cylinder) of the manifest refraction. If no manifest refraction was needed,record the spherical equivalent of the patient’s existing distance correction. If no prescription has been determined, leave the space for spherical equivalent blank.

ANTERIOR SEGMENT (12: 1 l-52) (12:11-23) Cornea1Changes Direct hand-light illumination will be used to examine for arcus senilis. [Prior to May 21, 1974, examination for arcus senilis was performed with the 16D power of the Zeiss slit lamp only.] Additional cornea1screening will be done using the 16D power of the Zeiss slit lamp; this includes examinations for marginal degeneration, peripheral neovascularization, stromal opacity, cornea guttata and pigment granules. [Prior to September 17, 1973, screening was done with the 10D power and higher powers only if pathology was suspected.] (12:ll) Arcus Senilis presentsas a dirty white hazy ring of the peripheral cornea but separatedfrom the limbus by an area of clear cornea. In early stages the haze may be quite faint and difficult to perceive. In order for arcus senilis to be considered present, you must identify or find an infiltrate in the peripheral cornea, distinctly demarcated from the adjacent cornea1stroma, and separated from the limbus by an area of clear stroma. It may be found in any sector of the cornea.

521

(12:13) Marginal Degeneration (ring ulcer,

gutter dystrophy) is a sterile melting of the epithelium, Bowman’s membrane and superficial stroma of the peripheral cornea. (12:15) Peripheral Neovascularization is new vesselformation beginningat the cornea1limbus and encroaching centrally. The vessels must extend beyond the limbus to be considered present. (l2:17) Stromal Opacity is any impairment of the normal clarity of the cornea which occurs at the stromal level. Even a small opacity, visible only by the slit lamp, should be included. (12:19-21) Cornea Guttata: The cornea will next be examined by the slit lamp to determine the presenceor absenceof cornea guttata. Cornea guttata are wartlike excrestenses of Descemet’s membrane extending toward the anterior chamber and displacing endothelial cells. They can usually be seen both by direct illumination of the slit lamp beam and by specularreflection; they must be distinguished from pigment granules on the endothelium which are frequently found in the presenceof cornea guttata. The brown color and nontransparencyof the pigment granules differentiates them from the clear semitransparentcornea guttata. Cornea guttata will be considered questionableif it cannot be decidedwhether or not they are present or if the examiner is uncertain whether they are pigment granules or cornea guttata. They will be considered presentif they have the appearanceof almost transparent, hyaline excrescenseson the posterior surface of the cornea that are directed toward the anterior chamber. One is sufficient for a diagnosisof present.Estimate whether the cornea guttata number less than ten or ten or more on eachcornea.[It was intended that only central cornea guttata be countedthough the protocol gave no such explicit statement.] If associatedwith cornea1 edema(increasedthicknessof stroma and/or microcystic or bullous edema of the epithelium) circle “with edema” without regard to the number of guttata. Two types of cornea guttata are usually distinguished:the Hassall-Henlebodieswhich occur peripherally and are associatedwith aging, and central cornea guttata which are associatedwith Fuchs dystrophy of the cornea. Differentiate betweenthe two locations for questionable or present cornea guttata. Divide t.he cornea1 diameter roughly into

--;

I I b u: _-,-- I

-+

I

Peripheral Central

;--

1

-y-t--

--t--t-

FIG. A.l. Cornea:centralvs. peripherallimits

quartersfrom external limbus to external limbus; consider the external portion of the cornea as peripheral,and the internal half as central, as diagrammed in Fig. A. 1. Occasionally the cornea guttata will be found both centrally and peripherally. If it cannot be determined whether they are located centrally, peripherally, or central and peripheral, then check “questionable” for cornea guttata-B. (12:23) Pigment Granules: While looking for cornea guttata, observe the presence or absence of pigment granules on the endothelium. They have the appearance of brown dust-like particles -adherentto the endothelium. One will be consideredsufficient for diagnosis. The occurrence of pigment granuleswill be consideredquestionableif the examiner is uncertain whether they are corneaguttata or granules,or if otherwiseuncertain that pigment granules are present. Estimate whether there are more or less than ten granules present; if ten or more, determine if enough granules are on the endothelium to form a Kruckenberg’s spindle. A spindlewill be considereddefinitely present if enoughgranulesare on the endotheliumto give a shape consistent with a spindle. The spindle will be consideredquestionableif a large number of granules are present, but there are not enoughto be definite about the spindle configuration. The spindle configuration may vary from a small central band of concentratedpigment to a diffuse deposit of pigment granules. These are shapedlike an inverted “V” with its apex at the center of the cornea and they spread downward to cover most of the inferior third of the cornea.

522

Surv Ophthalmol

24 (suppl) May-June

1980

(12:25-27) Iris The iris should be examined for atrophy by directing the slit lamp beam through the pupil into the posterior chamber. The room should be darkened, and the iris evaluated for transmission of light from the interior of the eye through atrophic iris. Atrophy will be considered questionable if it is not possible to distinguish atrophy from ocular albinism. If any light from the posterior chamber can be visualized through the iris, atrophy will be considered present. Differentiate between light transmitted through portions of the pupil margin, the most common situation (circle “pup. margin”) and that transmitted through the body of the iris (circle “stroma”). If appropriate circle “both.” Any small patch of marginal atrophy either pre- or postdilatation will be considered present. Pupillary reaction can be determined by observing the changein pupil size when directing the light beam of the slit lamp toward the pupil and simultaneously opening the aperture to its maximum. Reaction time should be differentiated as none, sluggish, or brisk (normal). Any delay in pupil responsewill be considered sluggish. Pupil reaction should be considered brisk when there is a prompt, obvious constriction when the slit aperture is widened.

(12:30-44) Tonometry Use applanation tonometry as the preferable method for measuring the intraocular pressure. A questionably reliable applanation pressure is preferable to a Schiotz measurement. Schiotz should be tried only when the applanation method is unavailable or judged unreliable. In all cases record three measurements with the same instrument, and circle the appropriate reliability for that instrument. Do not record the measurements of both instruments. Applanation tonometry will be performed on subjects in the following manner. Instill one drop of combined proparacaine and fluorescein into the lower fornix of each eye. Avoid touching lashes or lid margins with dropper tip and throw the bottle away if contamination is suspected. Set the slit lamp magnification at 10X. The illuminating aperture should be opened fully and positioned at about 60” angle to the slit lamp. Turn the measuring scale to 10 mmHg. Bring the prism in contact with the cornea -

LEIBOWITZ

ET AL

the point at which the limbus shines with a bluish light (observed by the naked eye from the side opposite to the illumination). Correct the position so that the two semicircles are of equal size and located in the middle of the field of view. It is important that the mires be of medium width. If the examiner has the impression of thick mires, the following procedure should be followed in sequenceuntil the mires are of required width: a - Check that the upper lid is not resting on tonometer. b - Pull back the tonometer and reposition. c - Blink eyes. d - Wipe tonometer head. e - Blot lacrimal lake of lower fornix. When the mires are too thin after administering the first drop of combined proparacaine and fluorescein, administer a second drop. If the mires are then too broad, use the corrective measures outlined above. Three readings will be taken on each eye, beginning with the right eye. The readings will be consecutive on each eye. Remove the tonometer from contact with the eye, turn the measuring scale to 10 mmHg and reposition the tonometer between each reading. To determine the intraocular pressure turn the measuring drum on the tonometer until the inner borders of the two fluorescein rings just touch each other at the midpoint of the ocular pulse, as illustrated in Fig. A.2. The mires should both overlap and separate with the pulse swing. When the swing is equidistant on either side of the midpoint record the pressure from the measuring drum to the nearest millimeter of mercury. The measuring dial should not be observeduntil the endpoint is reached:the purpose of this is to keep the measurement objective. Note the instrument used and record the approximate time that tonometry was done, circling “a.m.” or “p.m.,” whichever is appropriate. Applanation tonometry should not be considered reliable if it is necessary to hold the lids open (unless very soft droopy lids that can be easily held open without counterresistance from the examinee) because of squeezing or general nervousnessof the examinee, or if the upper lid rests on the tonometer and exerts some resistance against the scale. It should also be consideredunreliable if the endpoint is not clearly visualized. However, the tension should be recorded in these instances, even

FRAMINGHAM

523

EYE STUDY

FIG. A.2. Mires: applanation tonometry Systolic

Midpoint

Diastolic

cornea1thickness, the examinee should be gonioscoped by the screening ophthalmologist at this point. In addition, prior to dilation, all subjects should be asked about symptoms related to angle closureglaucoma, (such as severeheadache,usually in the evening and associatedwith blurring of vision). If symptoms suggestiveof acute glaucoma are present, the subject should also be gonioscoped. The angles need to be graded only as to width at this time. The narrowestwidth of the angle in any quadrant should be recorded. Gonioscopywill be done using the Goldmann gonioprism with methylcelluloseafter topical anesthesiawith 1% proparacaine. Enter the gonioscopic findings as the estimated angle (12:46) Estimation of Angle Depth size in degreesusing the guide shown in Fig. The technique for estimating the angle A.3. If the angle is estimatedat 10”or lessin depth is taken from: van Herick W, Shaffer any quadrant, do not dilate, but attempt to RN: Estimation of width of angle of anterior continue the examination through an unchamber; Incidence and significance of the dilated pupil. narrow angle.Am J Ophthalmol68.426629, LENS (12:56-13:21) 1969. The slit beam of the Zeiss slit lamp is (1236-58) Pupil Dilatation placedalmost perpendicularto the peripheral and Examination cornea1 surface and the angle opening is Dilate both eyes with one drop of 10% viewed at a 60” angle from the light beam. The slit beam shouldbe as narrow as possible, phenylephrine and one drop of 1% and the area of measurementis located just tropicamide. This may be repeatedonce after before the point of disappearanceof the ten minutes. While the eyes are dilating, the corneal-iris space at the periphery. The cor- patient may go back to a central waiting area. neal section width is used as the unit for es- After a period of Yzhour to 45 minutes, when timating the anterior chamber angle width, which should be reported as a percentageof cornea1thickness.The angleshouldbe viewed with the slit lamp magnification set at 16D. d,OO L 300 [Prior to September 17, 1973 10D power was use&] The temporal anterior chamber angle at either the 3 o’clock (OD) or 9 o’clock (OS) / meridian should be the approximate area evaluated. though “not reliable” is also circled. Schiotz tonometry may be used in instanceswhere applanation tonometry is not possible. The examinee should be in the supine position on the examination table. Proparacaine hydrochloride-l .O% should be instilled, the eye directed straight upward, and the lids immobilized against the orbital rim. Use the 7.5 gm weight; if a reading of 3 scale units or lower is obtained then the 10.0 gm weight should be used. Record the measurementas unreliable if the lids touch the tonometer or the examinee squeezeshis lids. Convert scale readings to mmHg. The zero reading of the Schiotz tonometer should be checkedbefore each use.

(12:52) Conioscopy If the temporal anterior chamber angle width was estimatedto be lessthan 30% of the

Lzoo FIG. A.3. gonioscopy

Estimation

L

of angle width

400 by

524

SW

Ophtholmol

24 (suppl) May-June

1980

the eyes are fully dilated, the examinee will be brought back by the nurse for the remainder of the screening examination. Dilation will be considered adequate when approximately two-thirds of the diameter of the anterior surface of the lens can be visualized while examining the eye with the Zeiss slit lamp. If pupil constriction occurs to the point that this portion of the lens cannot be visualized, give the examinee an additional round of drops and wait another 5-10 minutes before continuing the examination. (12:58) The lens examination will be considered adequate if at least two-thirds of the anterior surface can be visualized with the slit lamp. More peripheral portions of the lens can then be visualized by angling either the examinee’s eyes or the slit lamp direction. The lens examination will be considered inadequate if the examinee cannot maintain fixation so as to allow a careful and adequate evaluation of the lens. The lens examination will be first carried out using direct and retroillumination with the slit lamp at 10D. If pathology is seenwith the magnification set at this low level, it may be increased to better observe the abnormality. This is followed by direct ophthalmoscopy.

LEIBOWITZ

ET AL

Definitions for lens changesas they will be used in the present study are given as follows: (1252-68) Early Senile Changes: Vacuoles, waterclefts, spokes, and lamellar separation must have a distinct edge or border before they can be called present. These presenile lens changes should only be reported on the exam form if they occur in the anterior cortex. (12.62) Vacuoles -

appear as small round to oval optically empty spacesin the lens cortex. The vacuole borders appear darker than the interior lighter portions. Vacuoles occurring in the posterior subcapsular area will be designated as posterior subcapsular senile lens changes. (12:64) Waterclefs - appear as empty spaces in the lens cortex, with the base directed peripherally and the apex centrally. (12.66) Spokes - waterclefts in which the fibers of the wall and contents of the media have become slightly cloudy and opaque. They can be visualized better in retroillumination and have a “knobby” appearance. Spokes are differentiated from cortical cuneiform changes by the fact that cuneiform changesare spokes that are cloudy enoughto be visualized by direct observation. (12:68) Lamellar separations - are the result of diffuse water absorption of the corLens Changes Present tex causing separations of the lamellae of the (12:60) Early senile changes, senile lens cortex, resulting in foldlike parallel lines. This changes, other lens changes consistent with is not to be confused with congenital lamellar cataract, and aphakia will be sought. cataract, where ringlike opacities deep in the Aphakia refers to any lens that has been cortex concentrically surround the nucleus. operated upon, even if lens remnants are pres- (13:11-19) Senile Lens Changes (13:ll) Pseudoexfoliation - a flaking off ent. For the purpose of this study it also includes a subluxated or dislocated lens. If any of the exterior surface of the lens capsule by one of the above abnormalities is found, mechanical rubbing of the iris. The central check “present” or “aphakia,” as ap- pupillary area contains a homogeneous propriate. If changes are indefinite but greyish disc on the lens capsule. A clear area nevertheless suggestive of any of the above separates this central disc from a ragged findings, check “questionable.” If ques- greyish peripheral change. Lens flakes may tionable or present changes are found, com- be observedon the iris surface. This condition plete the remaining questions on the lens. For must be differentiated from true exfoliation this study, do not include as lens changes such as occttrs in glassblowers and others. In Mittendorf dot, small axial embryonal these instances the flaking of the capsule is sutural opacities, or other small dot opacities irregularly located. [Pseudoexfoliation rather that cannot be visualized by direct than true exfoliation is the item of interest ophthalmoscopy. Do not consider small here. Though the definition implies that both punctate dot-like opacities as cataractous result from a flaking of the lens capsule, the origin of the deposits of pseudoexfoliation is changes. If neither lens opacities nor aphakia are not known.] (13:13) Corticul cuneiform - large white questionable or present, skip the remainder of the lens examination for that eye and proceed flat radial wedge-shaped opacities located peripherally in the cortex of the lens and to the fundus portion of the exam.

FRAMINGHAM

525

EYE STUDY

directed centrally. They can be seen well in direct illumination as contrasted with spokes. These opacities may be continuous with waterclefts or lamellar separation. (13:lS) Decreased lucency of nucleus - a diffuse increase in the optical density of the lens nucleus (sclerosis) when compared to the adjacent cortex; the color may vary from a slight. yellowish tinge to a dark yellow, to reddish-brown, to black. Because of the gradual transition from normal to sclerosis in the older population it is often difficult to determine when changes are present. Circle present when nucleus is definitely faintly brown and interrupts the slit lamp beam. Circle questionable if not certain that sclerosis is present. (13:17) Posterior subcapsular - vacuolar or granular-appearing opacity located subcapsularly in the posterior axial region. It frequently has a saucer-like shape. Vacuoles appearing in the posterior subcapsular area will ble designated as posterior subcapsular senile lens changes. (13:19) Other senile lens changes- circle if lens opacities other than above are questionable or present and are possibly related to senile degeneration. Briefly comment on these changeson the bottom of page 3. Coronary type of opacities should be included under other senile lens changes. (13:21) Other Lens Changes refers to lentitular changes other than early senile and senile lens changes,or aphakia. The opacities should be observed with both the slit lamp and with the lO+ diopter lens of the direct ophthalmoscope (or appropriate lens for the examiner). The opacity must be large enough to visualize with the direct ophthalmoscope. This will exclude such common minor opacities as stellate opacities, punctate dotlike opacities, and cystoid spaces. However, this category can include congenital and secondary types of cataract. (Briefly note on the bottom of page 3 the other lens changes found. ) For any of the above changes,questionable should be reported if there is doubt about the presence of the lens finding.

FIG. A.4. Posterior fundus

macula and posterior fundus (area included within the second major branching of the major blood vessels) are seenclearly with the direct opthalmoscope.If the area of the fundus shown in Fig. A.4 cannot be adequately visualized, the fundus examination will be considered inadequate. Indirect ophthalmoscopy is to be used in estimating cup/disc ratio (14D lens), for peripheral visualization of the fundus (20D lens), and for other aspects of the fundus examination when opacification of the media prevent good visualization with the direct ophthalmoscope. The direct ophthalmoscope must be used for evaluation of the disc (other than cup/disc ratio), macula, and posterior retina for microaneurysms. Record the type of instrument used.

(13:27-41) Disc

(13:27-3 1) Estimation of cup/disc ratio will be done using the indirect ophthalmoscope and the 14D Nikon lens. No other instrument should be used in making this estimation. The ratio is to be measured in two meridians, horizontal and vertical. The horizontal cup/disc ratio, to be recorded in tenths, is the estimate of the ratio of the broadest horizontal diameter of the cup to the diameter of the disc in that same axis. A similar estimate will be made for the vertical cup/disc ratio. This estimate will be made on the basis of cup shape rather than cup color in this study. Occasionally, cup size will be the same extent FUNDUS EXAMINATION as the white color of the base of the cup, but color should not be the basis for estimating (13.23-25) The fundus examination will be cup width - the estimate should be made on considered adequate if performed through a contour alone. The diameter of the disc will dilated pupil, and all features of the disc, be measured from its point of junction with

526

Surv Ophthalmol

24 (suppl) May-June

1980

LEIBOWITZ ET AL

Transition Zone (Estimated Nasal b_ljMldpoint)/empora’

IM

\

FIG. AS. zones

Optic cup: transition

Sclera

the sclera. The s&al edgeis frequently difficult to determine, but can often be visualized as a slightly yellowish white rim surrounding the disc. The disc edge is consideredthe inner border of sclera. The diameter of the cup will be estimated from the point at which the relatively flat or sloping disc surface makes its first definite discernible transition posteriorly toward the depth of the cup. Since this transition zone is not always a point transition, it will be necessaryin many casesto use the midpoint of this sharp transition as the endpoint - as diagrammed in Fig. AS. The nasal edge of the cup usually has a sharply defined margin where the relatively flat surface of the disc makes a fairly abrupt turn posteriorly. Occasionally the nasal blood vessels will protrude from the surfaceof the disc into the cup and the nasal edge of the cup must be mentally gaugedas to whereit would lie if the vesselswere not present. In a myopic cup where the posterior edge slopes nasally beneath the anterior edge, still consider the nasal edge of the cup as the sharp transition zone of the anterior surface of the disc. The temporal edgeof the cup is frequently much more difficult to define becauseof the sloping nature of the temporal disc, par: titularly in myopes. However, in most discs, althoughthe slopemay be considerable,there is usually some point at which the surfaceof the disc makes a sharper direction posteriorly. The midpoint of this zone will be designatedas the edgeof the cup. If a transition zone is consideredquestionable,it should still be used in estimating cup/disc ratio. If a cup is seen but no transition zone can be found, report the cup/disc ratio as 99 (code for unknown). In observingand estimating cup/disc ratio with indirect ophthalmoscopy, it will be necessaryto move the parallax in various directions in order to better stereoscopically

visualize the cup. Reference Slides for Esther cUa/* Ratio: Stereo photographs of a range of

cup/disc ratios will be provided in each examining room. These should be used for reference.The slides are labelled 0.0 to 0.9 corresponding to the horizontal cup/disc ratio in the Table on the next page.[SeeFundus Photographs l-10.1 (13:35-41) Evalrrting the Disc: In evaluatingthe disc, when the cup/disc ratio is “0” leavethe rest of the cup evaluationblank. When the cup/disc ratio is 0.1 or greater in any meridian, then all the following parts of the disc evaluation need to be completed. In this situation the depth of cup (13:37)cannot be “0” (none). (13:35) Estimate whether the cup touches the sclerain any meridian. If it does,then indicate whether the cup touchesthe horizontal or vertical rim. The horizontal meridian is consideredto be locatedwithin 45” aboveand below a horizontal line drawn through the center of the disc, nasally and temporally. The vertical meridian is the remaining 90” of margin above and below (seeFig. A.6). If Vertical

Horizontal

FIG. A.6. meridians

Optic

cup: horizontal/vertical

FrAMINGHAM

Horiz. c/d ratio

527

EYE STUDY

(Vert. c/d ratio)

Description of slides

0.0

(0.0) Gentle temporal slope directed nasally toward blood vessels; no distinct cup characterized by sharper posterior bending of anterior surface of disc.

0.1

(0.1) Very small dimple where blood vessels enter cup substance; contour and shape are almost equal in this cup.

0.2

(0.2) Gentle sloping temporal disc with abrupt posterior bending of anterior surface; well demarcated edgesof cup.

0.3

(0.3) Deep cup with sharp borders.

0.4

(0.5) Periphery of disc surrounded by wide band of whitish yellow sclera except for superonasal edge. Vertical borders well defined; gentle slope of temporal retina with sharp posterior bend more centrally.

0.5

(0.5) Difficult to determine edges of cup inferiorly and vertically because of ill-defined borders; the cup edge in this case is located slightly wider than the white base.

0.6

(0.6) Temporal and superior margin of cup wider than white base; inferior cup border has gentle slope before sharp posterior bend.

0.7

(0.7) Temporal margin of cup close to rim of disc and seemsto slope to base of cup. (0.9) Nasal cup at edge of disc while other areas of cup have thin edge of disc between it and rim. (0.9) Nasal cup at edge of disc; very thin rim of disc between it and rim.

0.8 0.9

the cup touches the vertical and horizontal rim, circle “both.” Circle “questionable” if in doubt as to whether the cup actually touches the rim.

the optic nerve rim into clear focus. Note the lens power. Reduce the plus lens power (increase the minus power) until the floor of the cup is clearly visible. Again, increase the plus (13:37) Separate discs into those in which a power until the floor is just blurred, and then cup is questionable, those in which a cup is reduce the plus power one diopter so that the present but lamina cribrosa not visible, and floor is clearly visible. Note the lens power. those in which the lamina cribrosa is visible in The difference between the lens power noted the depth of the cup. The lamina cribrosa, for for rim and the floor should be recorded in the purposes of this study, is defined as “lack whole diopters. of homogeneity of base of the cup.” This (13:41) For the purposes of this study, might be characterized as small roundish grey myopic cup will be considered present only if lacunae in the base of the cup. If only one of both a temporal slope and undermining of the these apparently different spots is observed nasal aspect of the disc are observed. circle lamina cribrosa visible. If a cup is “Absent” indicates the cup is not myopic. present but the examiner is not sure whether Circle “questionable” if a cup is observedand the base of the cup has a homogeneous it may possibly be myopic in configuration. appearance or not, circle “2” (lamina Try not to let the refractive error influence cribrosa not visible). If a cup/disc ratio is es- your judgment. timated as 0.1 or more, the cup should be considered as “questionable” or “present.” (13:43-55) Macula (13:39) The depth of the cup should be estimated as the dioptric difference betweenthe The macula is defined, for the purpose of rim of the cup and the floor. The examiner this study, as the area of brownish black should first focus on the rim of the disc with pigmentation surrounding the foveola; it is the direct ophthalmoscope, increase plus lens usually slightly larger than 1 disc diameter in power until the rim is slightly blurred, and size, and usually slightly larger than the then reduce plus power by 1 diopter to bring vascular free zone of the posterior fundus.

528

Posterior

Surv Ophthalmol

24 (suppl) May-June

1980

LElbOWlTZ

ET AL

Pole

FIG. A.7. Posterior pole

The macular pigment is frequently difficult to visualize in the aged fundus and the edges frequently blend into the surrounding pigment epithelium (see the diagram of the posterior fundus, Fig. A.4). The macula and posterior pole should be examined using the direct ophthalmoscopeonly. (13A3-45) Pigment Disturbance includes any changes in the regularity of the epithelium (atrophy, migration, mottling, granularity) from any causeif it occurswithin the defined area of the macula or posterior pole. This includes conditions such as chorioretinitis, traumatic maculopathy, exudative maculopathy, and others. Aging changesof the macular pigment epithelium are often characterized by either a slight graininess or a decreasein the density of pigmentation. Occasionally the aged macula will be void of clinically apparent pigment. Do not classify these aging changesas pigment disturbance. A set of fundus slides illustrating pigment disturbance of the macula are in each examiner’s room for reference. [See Fundus Photographs1l-15.1 They are labelled O-4 as follows:

atrophy, migration) that are present but not very noticeable. These defects would not be usually ap parent at first observation but visualized after closer scrutiny of the macula. 3- “Obvious” pigment disturbance. The pigment disturbance can be easily visualized. There would be no question about the certainty of macular changes being present. 4 - “Severe” pigment disturbance. The pigment disturbance is so marked that a recognizable macula is no longer observed.

Categorizeall questionable,subtle,obvious or severepigment changesas to location; i.e., whether the pigment changesare confined to the macula, the posterior pole, or both. The posterior pole is defined for the purposesof this study as the area of the fundus enclosed by the major temporal vascularsystemand its imagined closure by extension of vesselsas shown by dotted line in Fig. A.7. (13:47-51) Macular Drwsen: Drusen are located deep in the retina, at Bruch’s membrane level, and displacepigment epithebum. They can vary from what appearssimply as defects in the pigment epithelium, to small yellow colloid-like dots, to larger yellow softer lesions. [See Fundus Photographs 16 and 17.1 “Questionable” drusen would be similar Grade 0 - “No” pigment disturbance. Although there to the defects seen in the photograph is no fovea1 reflex in this fundus and a suggestion “questionable” macular pigment disturof granularity in the superior temporal segment of bance. Differentiate the drusen into “small” the macula, there is essentially no pigmentary yellow type and the “large” soft type. Do not change. Any eye with this fundus picture should be include retinal changes known as fundus reported as pigment disturbance - “none.” flavimaculatus as drusen. 1 - “Questionable” pigment disturbance. The If questionable or present drusen are slight mottling and suggestion of defect in the pigobserved, categorize as to location, Le., ment epithelium should not be calledpresent. 2- “Subtle” pigment disturbance. The defects “macula,” or “peripheral,” or “both.” For in pigment epithelium are clear and distinct, but 13:49 “peripheral” means posterior pole (as are minimal at best. “Subtle” defect refers to in macular pigment disturbance) excepting macula. If questionableor present, estimate macular pigment changes (mottling, granularity,

FRAMINGHAM

529

RYE SYUDY

the total number in the posterior pole and macula. When only a few drusen are observed count them to determine if more or less than ten. Estimate whether more than ten and less than 100, or more than 100. (13~53)The macula should also be observed for th.e presence of elevation of the pigment epithelium or the neurosensoryepithelium by serum, hemorrhage, or proliferated scar tissue. Circle “questionable” if it appearsthat the macula might be elevated, and “present” if the macula is obviously elevated. Be careful to exclude edema of the nonsensory retina from this category. Circle questionable or present if the elevation occurs within the macula, or in the perimacular area within one disc diameter from the edge of the macula. (13:55) Perimacular Circinate Exudatesare hard yellow in character and located within the retinal tissue. Circle “questionable” if these hard yellow exudates are found in the perimacular area but not of sufficient number to classify as circinate. Circle “present” if at least one-quarter of the macula is surrounded by these exudates or sufficient number are found to give a circinate appearance. [See Fundus Photograph 18.1

that the individual is to be referred for “questionable” or “present” findings as listed in each disease category.

Glaucoma (13:60) Criteria for referral for definitive glaucoma evaluation are a history of previous diagnosis or treatment (definite only); an average pressure of 22 mmHg or more in either eye; an averagepressuredifference of 3 mmHg or more between eyes and 16 mmHg or more in the eye with the greater pressure;a cup/disc ratio 0.5 or greater in either meridian; or the cup/disc ratios differ by 0.2 or more in a given meridian between eyes. Refer for glaucoma evaluation, if any of below are entered: a) history of previousdiagnosisor treatment 11:29 code 2, 3, 4 b) averagepressureof 22 mmHg or more 12:30, 12:34, 12:38 averageOD 2 22, and/or

12:32,12:36,12:40averageOS 2 22 c) averagepressuredifferenceof 3 mmHg or more betweeneyesand 16 mmHg or more in eye with greaterpressure 12:30, 12:34, 12:38averageOD 1232, 1236, 1240 averageOS averageOD minus averageOS 2 3 mmHg, and averageOD or averageOS 2 16 mmHg (13:57) Retina d) cup/disc ratio 0.5 or greater (13:57) Microaneurysms and/or Dot 13:27or 13:31OD 2 0.5, and/or 13:29or 13:33OS 2 0.5 Hemorrhages [See Fundus Photographs 20 and 2 11: Clinically, microaneurysms and e) cup/disc ratio differs by 0.2 or more between small dot hemorrhages are frequently in- eyes 13:27(OD) minus 13:29(OS) 2 .02, and/or distinguishable and are considered together 13:31(OD) minus 13:33(OS) 2 .02 for diabetic retinopathy referral. Microaneurysms and/or dot hemorrhagesshould be (Note that criteria b and d differ from what is looked for throughout as much of the fundus given on the form.) as is observable with the direct ophthalmoCataract scope. If the subject has microaneurysms anywhere in the fundus, he should be referred (13.61) Cataract referral for lens opacities for definitive examination. Circle “ques- and macular referral for drusen or disturtionable” if not certain that small red dots are bance of pigment epithelium requires that a visible in the retina. Circle “present” if cer- visual acuity of 20/30 or worse be also prestain. ent in the same eye. The visual acuity of 20130 or worse need not necessarily be due to the cataract or macular changes. An individual with 20/30+ acuity (even though he REFERRALFOR DEFINITIVE may pick up letters on the 20/25 line) is to be EXAMINATION (1359-64) referred if one of these changes is found. (13:59) If the examinee is referred as a Refer for cataract evaluation, if any of the are entered: suspect for definitive exam, circle “yes” in following a) senileor other lensopacitiesandvisual acuity of (13:59) and complete the remainder of the 20130 or worse referral section. Fill out all referral sections OD - visual acuity (best of 11:42,11:52and even though the examinee is referred for only 11:62)20/30 or worseandcodes1 or 2 circled in one diseaseevaluation. Circle each finding for 12:62, 12:64, 12:66, 12:68, 13:11, 13:13, 13:15, which the individual is being referred. Note 13:17, 13:19, or 13:21,and/or

530

Surv Ophthalmol

24 (suppl) May-June

LEIBOWITZ

1980

ET AL

OS - visual acuity (best of 11:47, 11:57 and Diabetic Retinopathy 11:67) 20/30 or worse and codes 1 or 2 circled in (13:63) Every individual with a history of 12:63, 12:65, 12:67, 12:69, 13:12, 13:14, 13:16, diagnosis or treatment of diabetes mellitus is 13:18, 13:20 or 13:22 to have bilateral seven field stereo b) aphakia OD - 12:60 code 8, and/or photographs taken but is not referred for OS - 12:61 code 8 definitive examination unless microaneurysms or dot hemorrhages are found. All in-

dividuals screened as having microaneurysms and/or dot hemorrhages are to be (13:62) Refer for drusen and pigment referred for photography and definitive exdisturbance of the macula only if these amination. changes are present in the defined area of ihe Refer for diabetic retinopathy evaluation, macula with or without posterior pole if any of the following are entered: changes. Do not refer for posterior pole a) history of diabetes mellitus (referred for seven changes alone without coexisting macular stereo fundus photographs only) 11:32 code 1 or 2 findings. Refer for macular degeneration evaluation, if any of the following are entered: b) microaneurysms or dot hemorrhages

Macular Degeneration

a) macular drusen and visual acuity of 20/30 or worse OD - visual acuity (best of 11:42, 11:52 and 11:62) 20/30 or worse and codes 1, 2, 3, 4 or 5 circled in 13:47 and codes 2, 4 or 9 circled in 13:49, and/or OS - visual acuity (best of 11:47, 11:57 and 11:67) 20/30 or worse and codes 1, 2, 3,4 or 5 circled in 13:48 and codes 2, 4 or 9 circled in 13:50 b) disturbance of macular pigment and visual acuity of 20130 or worse OD - visual acuity (best of 11:42, 11:52 and 11:62) 20/30 or worse and codes 1, 2, 3 or 4 circled in 13:43 and codes 2, 4 or 9 circled in 13:45, and/or OS - visual acuity (best of 11:47, 11:57 and 11:67) 20/30 or worse and codes 1, 2, 3 or 4 circled in 13:44 and codes 2, 4 or 9 circled in 13:46 c) serous, hemorrhagic or proliferative elevation of pigment or neurosensory epithelium OD - 13:53 code 1 or 2, and/or OS - 13:54 code 1 or 2 d) perimacular circinate exudates OD - 13:55 code 1 or 2, and/or OS - 13:56 code 1 or 2

OD - 13:57 code 1 or 2, and/or OS - 13:58 code 1 or 2

(13:64) The screenee should also be referred for definitive examination when any other significant pathology is suspected,particularly anything requiring medical care or treatment. Specify the reason for referral. Refer for other reasons if: the examiner circled “2” (yes) in 13:64.

OTHER OCULAR FINDINGS Record any other ocular abnormality observed that would be useful to record for future reference, and which will also be

relayed to the individual’s private physician or ophthalmologist. Separate these other findings as to whether in your judgment they cause vision loss or not.

PHOTOS TO BE TAKEN (13:65) This will be filled in by the clinic clerk according to information provided on the

photographer’s form and the list of random sample individuals.

FRAMINGHAM

531

EYE STUDY

NI&1897-1 REV.673

Form Approved O.M.B. 68-572011

FRAMINGHAMOPHTHALMOLOGY STUDY - SCREENING EXAMINATION

(11:l)

Name

Fram. Record No. (11:5)

Birth

date

_--_ -I-

(1-4) -I-

_

Ophthalmologist (11:ll) Family

(11:13)

physician

(11:19) (11:ZO)

Examiner

(11:X?)

Place of exam

local 2

clinic 1

Sex

Age

Exam date

(11-12)

-_ -I-

-I-

-

(13-18) (19)

3 Ezle

--

elsewhere 3

(S-10)

(20-21) (22)

1-1---~~=~~Ie=I~~~~--**---~~~~~==~=--=-----~~-~~=~--~-~.~.~=~~~~=~-~ Has an ophthalmologist treated of the following conditions? (11:23)

(11:26)

(11:29)

CATARACT neg. 0

(11:35)

(11:36)

(X1:37) (11:38) (11:40)

him he has any If ques. or pos. age first diag.

pos. 2

unk. 9

- --

(23-25)

MACULARDEGENERATION ques . pos. neg. 1 2 0

unk. 9

-

--

(26-28)

-

--

(29-31)

-

--

(32-34)

GLAUCOMA ques. 1

neg. 0 (11:32)

the examinee or told

ques. 1

med.& only 2

surg. Rx 3

DIABETES MELLITUS ques . neg. 1 0 (If negative, skip

unk. pos. 9 2 to 11:40)

Present treatment 0 None 1 Diet alone 2 Oral medication 3 Oral medication List medications Diabetic coma neg. ques. 0 1 If If

ques. or pos., ques. or pas.,

LOSS OF AN EYE OD absent neg. 2 0

hist. unk. 9

Rx unk. 4

4 Insulin w/o oral 5 Other 9 Unknown

w/o insulin plus insulin and amount pos. 2 type: years

unk. 9 bpo 2

since

OS absent 3

med.

(36) Wer 3

last

(35)

both 4

unk. 9

episode:

(38-39)

OU absent 4

FIG. A.8. Screening examination

(37)

form

532

Surv Ophthalmol

24 (suppl) May-June

1980

LEIBOWITZ ET AL -2-

(11:41)

How tested? (Use distance glasses if available) not done with diet. glasses w/o dist. glasses 2 3

(41)

Visual acuity found: (11:42) If V.a. 20/25 or worse, pinhole “.a. (11:52) If test included distance glasses, enter Rx: OD OS If pinhole acuity XI/30 or worse, enter Rx for manifest refraction and acuity after refraction: Rx: OD OS (11:62) (11:72)

Rx spherical

equivalent

--

--

----- I

OD

OS

0 ques. 1 abs.

2 &.;II:,~,

u;k.

unk. 9 9 9 9

ais.

Deck number

abs. ques. pres. 0 -1 -2 0 1 2 2 0 1 2 0 1

unk. 9 9 9 9

G~r~~~de,

u;k.

qufe.‘2

3 210 w/o edema 4 with edema

---_- /

s-w

OS

CORNEALCHANGES

OD abs. ques. pres. Arcus senilis 0 -1 - 2 Marginal degen. 0 1 2 Periph.neovasc. 0 1 2 Stromal opacity U I 2 Cornea1 guttata - A ,

----- I ----- I (42-61

(11:79)

(12:ll) (12:13) (12:lS) (X:17) (12:19)

----- I ----- I

-se

(79-80)

--1 1

-. -

-

(11-12) (13-14) (15-16) (17-18)

(19-20)

3 210 w/o edema 4 with edema

Cornea1 auttata - B OD unk. abs. ques. present 0 1 2 central 9 3 peripheral 4 cent.6 periph. (12:23) Pigment granules on cornea1 OD unk. present aba. ques. n_ 72---lO(ques.spin.) 5 zlO(def. spin.)

(62-71) (72-77)

(12:21)

(12:25)

I

abs. ques. 0 1

Iris

3 stroma

4 both Pupil none

reaction OD sluggish

brisk

unk.

Ullk.

(21-22)

9

endothelium

atrophy OD unk. abs. ques. aba. ques. present 0 1 2 pup. margin 9 0 1

(12:27)

OS present 2 central 3 peripheral 4 cent.6 periph.

abs. ques. 0 1

none

2 3 4 5

OS unk. present
(23-24)

OS unk. present 2 pup. margin 9 3 stroma 4 both

OS sluggish

brisk

(25-26)

unk.

-

FIG. A.& continued

-

(27-28)

FRAMiNGHAM

533

EYE STUDY -3-

TONOMETRY (12:29)

Instrument:

2 Schiots

1 Applanation

(29)

I ? 2 g tz 5 K

(12:30) (12:34) (12:38) (12:42) (12:44)

(12:46)

(12:52)

wg mHg -g

a.m. p.m. yes 0

OS ques. no 2 1

Gonioscopy for narrow angle suspects (AC depth/cornea1 thickness ~30%) Narrowest angle width OD

Pupil

--a --

(30-33) (34-37) 08-41) (42-43)

----

--

Estimation of angle depth as X of cornea1 (slit beam sign) OD OS x

PIP=-~PI=I=PS=-CIPPE=-~=~===-----=-I==-=e=EISE=i---._-__=ElilllSS=3~I5DL~~

(12:56)

OS OS OS

(a) OD =a (b) OD -dg (c) OD mm Time pressure taken Tension reliable? OD yes ques. no unknown 0 1 2 9

0

-----

unknown Y

-

(44-45)

-

thickness x

_--

0

OS

,---

--

--

(46-51)

(52-551

s==s=-_I=P==s=====T=---=

--------

dilatation OD inadequate 2

not done 8

adequate 0

OS inadequate 2

not done 8

(56-57)

Lens examination OD adequate inadequate 0 2

not done 8

adequate 0

OS inadequate 2

not done 8

(58-59)

adequate 0 (12:58)

(12:60)

Lens changes present OD abs. ques. present aphakic unk. 8 9 0 1 2 (If "0" or "an skip to FundusOD)

EARLY SENILE CHANGES OD abs. ques. pres. 1 2 (12:62) Vacuoles 0 1 2 (12:64) Waterclefts 0 I 2 (12:66) Spokes 0 1 2 0 (12:68) Lamellar

OS abs. ques. present aphakic unk. 8 0 1 2 Y If"O"or"8" skip to Fundus OS)

unk. 8 8 9 8

OS abs. ques. pres. 2 0 1 2 0 1 2 0 1 2 0 1 (12:79)

unk. 9 9 9 9

Deck number

-

-

(60-61)

(62-63) - (64-65) (66-67) (68-69) 12 (79-80) -I==I=PIPIPP__*=IoI_=_c ____ Fram.No. (l-4) --/--~--B.d.(5-10)

SENILE LENS CHANGES

FIG. A.8, continued

-

-

-

-

(11-12) (13-14)

-

-

(15-16) (17-18) (19-20)

534

Surv Ophthalmol

24 (suppl) May-June

1980

LEIBOWITZ

ET AL

-41 (13:23) m 3

Fundus examination OD adequate inadequate 0 2

not done 8

OS inadequate 2

notdone 8

OS indirect both Only 3 4

not done 8

adequate 0

(23-24)

D

z (13:25) 3 IA

Ophthalmoscope used OD Indirect direct only both 2 3 4

not done 8

I I j direct 2

------ - --- - - -‘---===-~-D=D=P=-===------S=============~=========-=---------~====-----~~= ICUP/DISC

(13:27) (13:31) (13:35)

(13:37)

RATIO (in Horizontal Vertical

-

(25-26)

4= =E~~EP1====~=C-----

----

tenths) OD OD

OS OS

Does cup touch edge of disc? OD yes unk. no ques. 2 verticallv 3 0 1 3 horizontally 4 both

_ _

(27-30) (31-34)

OS

no 0

I

ques. 1

yes 2 verticallv 3 horizontally 4 both

unk.8 9

-

-

(35-36)

-

-

(37-38)

-

-

(39-40)

-

-

(41-42)

Depth of cup

none ques. 0 1

(13:39)

-- -- -

I I ~ i-

unk. none ques. cup present 0 1 2 lamina crib. 9 not visible 3 lamina cribosa visible

Diopter measure between cup bottom OS OD

Myopic cup OD abs . ques . present 2 1 0

abs. 0

unk . 9

and top of disc

(13:41)

unk. 9

OS cup present 2 lamina crib. not visible 3 lamina cribosa visible

ques. 1

OS present 2

unk. 9

_---- ----======---=D1=---------

NIH-1897-l Rev. 4-11

FIG. A.8, continued

FRAMINGHAM

535

EYE STUDY -5-

1:13:43) PIGMENT DISTURBANCE OD none ques. present 0 1 2 subtle 3 obvious 4 severe (13:45)

If

questionable

If

ques . 1

questionable OD OS

(13:53)

I

none u

If

2 2

questionable x10 OD 2 OS 2

location: I

unk. abs. 9 0 I

or present, peripheral 3 3

location: both 4 4

OS post. pole both 4 3

ques . 1

(45-46)

OS present 2 small 3 large

unk. 9

(47-48)

(49) (50)

elevation

(51) (52) of pigment

abs. 0

ques. 1

OS present 2

unk. 8

(53-54)

circlnate exudates OD ques . present unk. abs . 2 9 1 0

ques. 1

OS present 2

unk. 9

(55-56)

ques. present 2 1

unk. 9

Perimacular abs. 0

Microaneurysms

and/or dot hemorrhages OD OS abs . ques . present unk. abs. ques. present 2 0 1 2 9 1 I 0 ---=P=-I-IS-SS-P--====5S=D9-D-CE-PDDSPCD--=--====~~~~*.**=--~~~~-, I= iif

Nltt

(43-44)

unk 9

unk . 9 9

ob -

9 (13:57)

unk. 9

or present, estimated number: 10-99 2100 unk . 3 4 9 3 4 9

Serous, hemorrhagic or proliferative or neurosensorv enithelium abs. 0

(13:55)

OS present 2 subtle 3 obvious 4 severe

ques. 1

unk. macula 9 I 2

OD present 2 small 3 large

macular

(13:51)

1

MACULARDRUSEN abs. 0

(13:49)

or present,

OD post. pole both 3 4

mculs 2 (13:47)

unk. 9

1897-l

Rev. r-73

FIG. A.8, continued

unk. 9

(57-58) - --P-CS-IL--*SI-PI=----

536

Surv Ophthclmol

24 (suppl) May-June

1980

LEIBOWITZ

ET AL

-6Referred for further any of the following (13:59)

exam if questionable in one or both ayes:

0 No - Skip to next page 2 Yes - Complete remainder

or definite

fo

(59)

of the form

Referred for GLAUCOMAEVALUATION - history of previous diagnosis or treatment - average pressure of 20 mmllg or more - average pressure difference of 3 mmRg between eyes and 16 mmllg or more in eye with greater pressure - cup/disc ratio 0.4 or greater - cup/disc ratio differs by 0.2 or more between eyes (13:60)

0 Wo 2 Yes

(60)

Referred for CATARACTEVALUATION - senile or other lens opacities 20/30 or worse - aphakia (13:61)

and visual

acuity

of

(61)

0 No 2 Yes Referred for MACULARDEGENERATIONEVALUATION - macular drusen and visual acuity of 20/30 or worse - disturbance of macular pigment and visual acuity of 20/30 or worse - serous, hemorrhagic or proliferative elevation of pigment or neurosensory epithelium - parimacular circinate exudates

(13:62)

0 No 2 Yes

(62)

Referred for DIABETIC RRTINOPATHY EVALUATION - history of diabetes mellitus (ref. for 7 photos - microaneurysms or dot hemorrhages (13:63)

0 NQ 2 Yes (7 photos without definitive exam) 3 Yes (7 photos and definitive exam) Referred

(13:64)

only)

for

other

raasons

(63)

(specify):

0 No 2 Yes

(64)

,EE==C*5SIIL=SI=S3=C==

NIH-1897-l Rev. r-79

FIG. A.8, continued

FRAMINGHAM

537

EYE STUDY -7-

m cl

Ocular findings present other than glaucoma, macular degeneration, or diabetic retinopathy, not cause loss of vision; please list.

z 0 z

OS

OD

u.

cataract, and which do

-

(L 4 -I 2 u 0

Ocular findings associated with loss of vision: If cause of decrease in visual acuity (best corrected visionworsethan 20/25 in either eye) is other than due to glaucoma, cataract, macular degeneration, or diabetic retinopathy, specify the condition.

ti I.0 I I-

OD

OS

O

_IIL-~.ISIEI=~EE=I--==~~~~=~~=~==~=~*~===~~=*=~=~~~====~~~=~~~=~-~~~*~=-~~~=~===~~~*~---~*.-~==~~ Photos taken (651 C None 0 2 2 fields sample selection + 3 7 fields, diabetes suspect 0 4 7 fields, sample and diabetes suspect I 5 7 fields, a 8 Other 9 Unknovn (79-80) (13:79) Deck number 1 3 a~~;r==nrpPsn~=E--=~==~=msE=====~~=~~~=~~~~~=====~~====~=-~~~~~=~~~~==~==-~=-===~--=====--=~-e’ Ln

(13:65)

Remarks :

Date

Coded by ;:p9

.

Verified

-1 -33

FIG. A.8. continued

by

Date