- Email: [email protected]
Optical coherence tomography to detect macular edema in the presence of asteroid hyalosis
REFERENCES
1. Lois N, Halfyard AS, Bunce C, et al. Reproducibility of fundus autofluorescence measurements obtained using a confocal scanning laser ophthalmoscope. Br J Ophthalmol 1999;83: 276 –279. 2. Kitagawa K, Nishida S, Ogura Y. In vivo quantitation of autofluorescence in human retinal pigment epithelium. Ophthalmologica 1989;100:116 –121. 3. Von Ru¨ ckmann A, Fitzke FW, Bird AC. Distribution of fundus autofluorescence with a scanning laser ophthalmoscope. Br J Ophthalmol 1995;79:407–412. 4. Framme C, Roider J. Fundus autofluorescence in macular hole surgery. Ophthalmic Surg Lasers 2001;32:383–390. 5. Von Ru¨ ckmann A, Fitzke FW, Gregor ZJ. Fundus autofluorescence in patients with macular holes imaged with a laser scanning ophthalmoscope. Br J Ophthalmol 1998;82:346 – 351.
T
Optical Coherence Tomography to Detect Macular Edema in the Presence of Asteroid Hyalosis David J. Browning, MD, PhD, and Christina M. Fraser, BA PURPOSE: To propose the use of optical coherence tomography as an effective diagnostic tool for identifying macular edema in patients with asteroid hyalosis obscuring the fundus view. DESIGN: Case report. METHODS: Review of clinical chart and images. SETTING: Private retina practice. PATIENT: One patient diagnosed with diabetic retinopathy and asteroid hyalosis, who was experiencing decreased visual acuity and whose fundus view was inadequate for diagnosis using customary techniques. RESULTS: Usual methods of diagnosis were ineffective until OCT obtained a clear image of the fundus and subsequent macular thickening with vitreomacular adhesion. CONCLUSIONS: Optical coherence tomography is an effective diagnostic tool for discovering macular edema in cases of dense asteroid hyalosis where traditional methods fail to obtain a clear image of the fundus. (Am J Ophthalmol 2004;137:959 –961. © 2004 by Elsevier Inc. All rights reserved.)
Accepted for publication Nov 10, 2003. From the Charlotte Eye, Ear, Nose, and Throat Associates, Charlotte, North Carolina The authors have no proprietary interest in any of the materials used in this study. Inquiries to David J. Browning, MD, PHD, 6035 Fairview Rd., Charlotte, NC 28210; e-mail: [email protected]
VOL. 137, NO. 5
FIGURE 1. Color fundus photograph of the left eye showing dense asteroid hyalosis, which prevents an adequate view of the macula to discern macular thickening.
HE DIAGNOSIS OF CLINICALLY SIGNIFICANT DIABETIC
macular edema is made by stereoscopic slit-lamp biomicroscopy of the fundus.1 In some patients with asteroid hyalosis, the reflecting calcium hydroxyapatite particles can be so dense that few fundus details are visible by slit-lamp biomicroscopy. In such patients with diabetic retinopathy, the usual methods for diagnosis of macular edema are inapplicable. This report documents the usefulness of optical coherence tomography (OCT) in such situations. A 68-year-old woman was first examined on 14 January 2000 for proliferative diabetic retinopathy diagnosed on routine screening examination by her optometrist. Her best-corrected visual acuity was 20/25 in the right eye and 20/32 in the left eye. She had 2⫹ nuclear sclerosis of her lens bilaterally. The vitreous cavity was clear in the right eye and neovascularization elsewhere was present in three quadrants. In the left eye, heavy asteroid hyalosis was present with an obscured fundus view, but one patch of neovascularization elsewhere could be discerned nasally. Panretinal photocoagulation was applied on two occasions to each eye. The right eye was treated on 21 January 2000 and 14 March 2003. The left eye was treated on 22 September 2000 and 6 February 2002. During follow-up, her vision remained stable in the right eye but dropped to 20/160 in the left eye from 4 February 2002 until 3 July 2003. The fundus view on the left was inadequate to allow detection of macular thickening (Figure 1). Fluorescein angiography revealed mild late macular hyperfluorescence on the left, and less than that present in late frames of the right macula, which was not clinically thickened. An OCT revealed macular thickening with vitreomacular adhesion (Figure 2a). From 3 July 2003 to 2 September 2003, the patient experienced a further decline in visual acuity from 20/160 to 20/400 in the left eye. Based on the OCT study and the clinical course, vitrectomy, membrane peeling, and intravitreal triamcinolone acetonide injection were
BRIEF REPORTS
959
FIGURE 2. (a) Optical coherence tomogram of the left eye preoperatively showing marked macular thickening with vitreomacular adhesion. (b) Optical coherence tomogram of the left eye postoperatively, showing resolution of the macular edema and vitreomacular adhesion.
recommended to the patient for the left eye and were performed on 22 September 2003. The intraoperative findings corroborated the OCT image showing tractional membranes attached to the macula. At postoperative follow-up on 31 October 2003, best-corrected visual acuity was 20/100 in the left eye. The OCT was repeated on this date and revealed resolution of the macular edema and vitreomacular traction (Figure 2b). Asteroid hyalosis occurs when noninflammatory deposits of calcium oxalate and hydroxyapatite combine with complex phospholipids along collagen strands of the vitreous humor.2,3 The prevalence of asteroid hyalosis in the general population is 0.5% to 0.9%.4,5 Although patients 960
AMERICAN JOURNAL
with the condition are usually asymptomatic, the collection of deposits can become so dense as to prevent accurate examination of the fundus by the physician, can prevent treatment of retinopathy with laser or cryotherapy, and, if severe enough, can blur the patient’s vision.2,4,5 Vitrectomy has been used in such cases to restore vision.4,5 Fluorescein angiography often reveals details not appreciated by ophthalmoscopy. This condition may cause incorrect biometry readings when calculating intraocular lens implant power in cataract surgery. The cause of asteroid hyalosis is unknown, but studies suggest that exogenous sources provide the matter, as the vitreous is considered deficient in the substance of the asteroid bodies. OF
OPHTHALMOLOGY
MAY 2004
We are unaware of previous reports examining the performance of OCT in the setting of dense asteroid hyalosis based on a PUBMED search of the terms optical coherence tomography and asteroid hyalosis from 1990 to 2003. Knowledge of the excellent imaging characteristics of OCT in the face of asteroid hyalosis should be useful knowledge to clinicians managing similar cases.
REFERENCES
1. Early Treatment Diabetic Retinopathy Study Research Group. Photocoagulation for diabetic macular edema. Arch Ophthalmol 1985;103:1796 –1806. 2. March WF, Shoch D. Electron diffraction study of asteroid bodies. Invest Ophthalmol Vis Sci 1975;14:399 –400. 3. Yazar Z, Hanioglu S, Karakoc G, Gursel E. Asteroid hyalosis. Eur J Ophthalmol 2001;11:57–61. 4. Renaldo DP. Pars plana vitrectomy for asteroid hyalosis. Retina 1981;1:252–254. 5. Feist RM, Morris RE, Witherspoon CD, et al. Vitrectomy in asteroid hyalosis. Retina 1990;10:173–177.
Is Adjustment of National Eye Institute Visual Function Questionnaire Scores for General Health Necessary in Randomized Trials? Pa¨ ivi H. Miskala, PhD, Neil M. Bressler, MD, and Curtis L. Meinert, PhD PURPOSE: To assess whether treatment comparison of National Eye Institute Visual Function Questionnaire (NEI-VFQ) scores in a clinical trial is influenced by general health to warrant adjusting for it. DESIGN: Two randomized pilot trials. METHODS: Patients enrolled in two randomized pilot trials of submacular surgery versus observation for choroidal neovascularization had quality of life interviews (NEIVFQ and the Short Form-36 Health Survey) 24 months
Accepted for publication Nov 3, 2003. From the Department of Ophthalmology (P.H.M., N.M.B.), The Johns Hopkins University School of Medicine, and Department of Epidemiology and Department of Biostatistics (C.L.M.), The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland The Submacular Surgery Trials Pilot Study was supported by numerous private and public sources that have been published previously Am J Ophthalmol 2000;130:408). Funding sources are listed on the first page of the article. Inquiries to Pa¨ ivi H. Miskala, PhD, Submacular Surgery Trials Coordinating Center, Wilmer Clinical Trials and Biometry, 550 N Broadway, 9th Floor, Baltimore, MD 21205–2010; fax: (410) 955-0569; e-mail: [email protected]
VOL. 137, NO. 5
after enrollment. Information on comorbidities was collected through chart reviews. Data from 120 patients were analyzed using linear regression methods. RESULTS: Adjustment for comorbidities did not change the magnitude of the treatment effect on NEI-VFQ scores. However, adjustment for Short Form-36 physical and mental component summaries produced changes in the estimated treatment effect when NEI-VFQ scores were compared. CONCLUSIONS: Adjustment of NEI-VFQ scores for general health may be advisable. The Short Form-36 summary scores may be appropriate for this purpose. (Am J Ophthalmol 2004;137:961–963. © 2004 by Elsevier Inc. All rights reserved.)
B
ECAUSE THE NATIONAL EYE INSTITUTE VISUAL FUNC-
tion Questionnaire (NEI-VFQ)1,2 is a relatively new instrument, little is known about possible confounding factors that should be considered when estimating treatment effect in clinical trials. Our investigation has suggested that general health may influence interpretation of NEI-VFQ scores.3 The purpose of this study was to examine whether the estimated treatment effect on NEI-VFQ scores would be influenced by general health status. Data were pooled from two randomized pilot trials of submacular surgery versus observation in patients with subfoveal choroidal neovascularization due to age-related macular degeneration.4 Patients who had quality-of-life interviews (39-item NEI-VFQ and the Short Form-36 Health Survey5 [SF-36] as part of the pilot trials) and information on nonocular medical conditions (collected through chart reviews, as described elsewhere3) 24 months after enrollment in the pilot trials were included in the study. Local Institutional Review Boards approved the Submacular Surgery Trials (SST) pilot study protocol before enrollment began at each clinical center; additional approvals were obtained for the chart reviews. Cross-sectional data for 120 patients were analyzed using linear regression methods. The effect of treatment (surgery) with and without adjustment was estimated by comparison of estimated coefficients from regression models. The dependent variable for all linear regression models was the overall NEI-VFQ score or one of the subscale scores. The independent variable was treatment assignment or treatment assignment and general health status measured by medical conditions or standardized SF-36 physical component summary (PCS) and mental component summary (MCS). Median age was 77 years; 60% were women and 98% were non-Hispanic white. Fifty-two percent of patients were assigned to surgery and 48% to observation. Median PCS and MCS scores were 46 (range 18 to 60) and 57 (range 17 to 68), respectively. The most common medical conditions were hypertension (52%), arthritis or rheumatism (27%), heart attack or angina (26%), cancer (18%),
BRIEF REPORTS
961
1. Lois N, Halfyard AS, Bunce C, et al. Reproducibility of fundus autofluorescence measurements obtained using a confocal scanning laser ophthalmoscope. Br J Ophthalmol 1999;83: 276 –279. 2. Kitagawa K, Nishida S, Ogura Y. In vivo quantitation of autofluorescence in human retinal pigment epithelium. Ophthalmologica 1989;100:116 –121. 3. Von Ru¨ ckmann A, Fitzke FW, Bird AC. Distribution of fundus autofluorescence with a scanning laser ophthalmoscope. Br J Ophthalmol 1995;79:407–412. 4. Framme C, Roider J. Fundus autofluorescence in macular hole surgery. Ophthalmic Surg Lasers 2001;32:383–390. 5. Von Ru¨ ckmann A, Fitzke FW, Gregor ZJ. Fundus autofluorescence in patients with macular holes imaged with a laser scanning ophthalmoscope. Br J Ophthalmol 1998;82:346 – 351.
T
Optical Coherence Tomography to Detect Macular Edema in the Presence of Asteroid Hyalosis David J. Browning, MD, PhD, and Christina M. Fraser, BA PURPOSE: To propose the use of optical coherence tomography as an effective diagnostic tool for identifying macular edema in patients with asteroid hyalosis obscuring the fundus view. DESIGN: Case report. METHODS: Review of clinical chart and images. SETTING: Private retina practice. PATIENT: One patient diagnosed with diabetic retinopathy and asteroid hyalosis, who was experiencing decreased visual acuity and whose fundus view was inadequate for diagnosis using customary techniques. RESULTS: Usual methods of diagnosis were ineffective until OCT obtained a clear image of the fundus and subsequent macular thickening with vitreomacular adhesion. CONCLUSIONS: Optical coherence tomography is an effective diagnostic tool for discovering macular edema in cases of dense asteroid hyalosis where traditional methods fail to obtain a clear image of the fundus. (Am J Ophthalmol 2004;137:959 –961. © 2004 by Elsevier Inc. All rights reserved.)
Accepted for publication Nov 10, 2003. From the Charlotte Eye, Ear, Nose, and Throat Associates, Charlotte, North Carolina The authors have no proprietary interest in any of the materials used in this study. Inquiries to David J. Browning, MD, PHD, 6035 Fairview Rd., Charlotte, NC 28210; e-mail: [email protected]
VOL. 137, NO. 5
FIGURE 1. Color fundus photograph of the left eye showing dense asteroid hyalosis, which prevents an adequate view of the macula to discern macular thickening.
HE DIAGNOSIS OF CLINICALLY SIGNIFICANT DIABETIC
macular edema is made by stereoscopic slit-lamp biomicroscopy of the fundus.1 In some patients with asteroid hyalosis, the reflecting calcium hydroxyapatite particles can be so dense that few fundus details are visible by slit-lamp biomicroscopy. In such patients with diabetic retinopathy, the usual methods for diagnosis of macular edema are inapplicable. This report documents the usefulness of optical coherence tomography (OCT) in such situations. A 68-year-old woman was first examined on 14 January 2000 for proliferative diabetic retinopathy diagnosed on routine screening examination by her optometrist. Her best-corrected visual acuity was 20/25 in the right eye and 20/32 in the left eye. She had 2⫹ nuclear sclerosis of her lens bilaterally. The vitreous cavity was clear in the right eye and neovascularization elsewhere was present in three quadrants. In the left eye, heavy asteroid hyalosis was present with an obscured fundus view, but one patch of neovascularization elsewhere could be discerned nasally. Panretinal photocoagulation was applied on two occasions to each eye. The right eye was treated on 21 January 2000 and 14 March 2003. The left eye was treated on 22 September 2000 and 6 February 2002. During follow-up, her vision remained stable in the right eye but dropped to 20/160 in the left eye from 4 February 2002 until 3 July 2003. The fundus view on the left was inadequate to allow detection of macular thickening (Figure 1). Fluorescein angiography revealed mild late macular hyperfluorescence on the left, and less than that present in late frames of the right macula, which was not clinically thickened. An OCT revealed macular thickening with vitreomacular adhesion (Figure 2a). From 3 July 2003 to 2 September 2003, the patient experienced a further decline in visual acuity from 20/160 to 20/400 in the left eye. Based on the OCT study and the clinical course, vitrectomy, membrane peeling, and intravitreal triamcinolone acetonide injection were
BRIEF REPORTS
959
FIGURE 2. (a) Optical coherence tomogram of the left eye preoperatively showing marked macular thickening with vitreomacular adhesion. (b) Optical coherence tomogram of the left eye postoperatively, showing resolution of the macular edema and vitreomacular adhesion.
recommended to the patient for the left eye and were performed on 22 September 2003. The intraoperative findings corroborated the OCT image showing tractional membranes attached to the macula. At postoperative follow-up on 31 October 2003, best-corrected visual acuity was 20/100 in the left eye. The OCT was repeated on this date and revealed resolution of the macular edema and vitreomacular traction (Figure 2b). Asteroid hyalosis occurs when noninflammatory deposits of calcium oxalate and hydroxyapatite combine with complex phospholipids along collagen strands of the vitreous humor.2,3 The prevalence of asteroid hyalosis in the general population is 0.5% to 0.9%.4,5 Although patients 960
AMERICAN JOURNAL
with the condition are usually asymptomatic, the collection of deposits can become so dense as to prevent accurate examination of the fundus by the physician, can prevent treatment of retinopathy with laser or cryotherapy, and, if severe enough, can blur the patient’s vision.2,4,5 Vitrectomy has been used in such cases to restore vision.4,5 Fluorescein angiography often reveals details not appreciated by ophthalmoscopy. This condition may cause incorrect biometry readings when calculating intraocular lens implant power in cataract surgery. The cause of asteroid hyalosis is unknown, but studies suggest that exogenous sources provide the matter, as the vitreous is considered deficient in the substance of the asteroid bodies. OF
OPHTHALMOLOGY
MAY 2004
We are unaware of previous reports examining the performance of OCT in the setting of dense asteroid hyalosis based on a PUBMED search of the terms optical coherence tomography and asteroid hyalosis from 1990 to 2003. Knowledge of the excellent imaging characteristics of OCT in the face of asteroid hyalosis should be useful knowledge to clinicians managing similar cases.
REFERENCES
1. Early Treatment Diabetic Retinopathy Study Research Group. Photocoagulation for diabetic macular edema. Arch Ophthalmol 1985;103:1796 –1806. 2. March WF, Shoch D. Electron diffraction study of asteroid bodies. Invest Ophthalmol Vis Sci 1975;14:399 –400. 3. Yazar Z, Hanioglu S, Karakoc G, Gursel E. Asteroid hyalosis. Eur J Ophthalmol 2001;11:57–61. 4. Renaldo DP. Pars plana vitrectomy for asteroid hyalosis. Retina 1981;1:252–254. 5. Feist RM, Morris RE, Witherspoon CD, et al. Vitrectomy in asteroid hyalosis. Retina 1990;10:173–177.
Is Adjustment of National Eye Institute Visual Function Questionnaire Scores for General Health Necessary in Randomized Trials? Pa¨ ivi H. Miskala, PhD, Neil M. Bressler, MD, and Curtis L. Meinert, PhD PURPOSE: To assess whether treatment comparison of National Eye Institute Visual Function Questionnaire (NEI-VFQ) scores in a clinical trial is influenced by general health to warrant adjusting for it. DESIGN: Two randomized pilot trials. METHODS: Patients enrolled in two randomized pilot trials of submacular surgery versus observation for choroidal neovascularization had quality of life interviews (NEIVFQ and the Short Form-36 Health Survey) 24 months
Accepted for publication Nov 3, 2003. From the Department of Ophthalmology (P.H.M., N.M.B.), The Johns Hopkins University School of Medicine, and Department of Epidemiology and Department of Biostatistics (C.L.M.), The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland The Submacular Surgery Trials Pilot Study was supported by numerous private and public sources that have been published previously Am J Ophthalmol 2000;130:408). Funding sources are listed on the first page of the article. Inquiries to Pa¨ ivi H. Miskala, PhD, Submacular Surgery Trials Coordinating Center, Wilmer Clinical Trials and Biometry, 550 N Broadway, 9th Floor, Baltimore, MD 21205–2010; fax: (410) 955-0569; e-mail: [email protected]
VOL. 137, NO. 5
after enrollment. Information on comorbidities was collected through chart reviews. Data from 120 patients were analyzed using linear regression methods. RESULTS: Adjustment for comorbidities did not change the magnitude of the treatment effect on NEI-VFQ scores. However, adjustment for Short Form-36 physical and mental component summaries produced changes in the estimated treatment effect when NEI-VFQ scores were compared. CONCLUSIONS: Adjustment of NEI-VFQ scores for general health may be advisable. The Short Form-36 summary scores may be appropriate for this purpose. (Am J Ophthalmol 2004;137:961–963. © 2004 by Elsevier Inc. All rights reserved.)
B
ECAUSE THE NATIONAL EYE INSTITUTE VISUAL FUNC-
tion Questionnaire (NEI-VFQ)1,2 is a relatively new instrument, little is known about possible confounding factors that should be considered when estimating treatment effect in clinical trials. Our investigation has suggested that general health may influence interpretation of NEI-VFQ scores.3 The purpose of this study was to examine whether the estimated treatment effect on NEI-VFQ scores would be influenced by general health status. Data were pooled from two randomized pilot trials of submacular surgery versus observation in patients with subfoveal choroidal neovascularization due to age-related macular degeneration.4 Patients who had quality-of-life interviews (39-item NEI-VFQ and the Short Form-36 Health Survey5 [SF-36] as part of the pilot trials) and information on nonocular medical conditions (collected through chart reviews, as described elsewhere3) 24 months after enrollment in the pilot trials were included in the study. Local Institutional Review Boards approved the Submacular Surgery Trials (SST) pilot study protocol before enrollment began at each clinical center; additional approvals were obtained for the chart reviews. Cross-sectional data for 120 patients were analyzed using linear regression methods. The effect of treatment (surgery) with and without adjustment was estimated by comparison of estimated coefficients from regression models. The dependent variable for all linear regression models was the overall NEI-VFQ score or one of the subscale scores. The independent variable was treatment assignment or treatment assignment and general health status measured by medical conditions or standardized SF-36 physical component summary (PCS) and mental component summary (MCS). Median age was 77 years; 60% were women and 98% were non-Hispanic white. Fifty-two percent of patients were assigned to surgery and 48% to observation. Median PCS and MCS scores were 46 (range 18 to 60) and 57 (range 17 to 68), respectively. The most common medical conditions were hypertension (52%), arthritis or rheumatism (27%), heart attack or angina (26%), cancer (18%),
BRIEF REPORTS
961