JAMA Ophthalmology Online First

Plus Disease in Retinopathy of Prematurity Qualitative Analysis of Diagnostic Process by Experts Plus Disease in Retinopathy of Prematurity

Hewing NJ, Kaufman DR, Chan R, et al. — Thu, 23 May 2013 00:00:00 GMT

Importance

Plus disease is the most important parameter that characterizes severe treatment-requiring retinopathy of prematurity, yet diagnostic agreement among experts is imperfect and the precise factors involved in clinical diagnosis are unclear. This study is designed to address these gaps in knowledge by analyzing cognitive aspects of the plus disease diagnostic process by experts.

Objective

To examine the diagnostic reasoning process of experts for plus disease in retinopathy of prematurity using qualitative research techniques.

Design

Cognitive walk-through, with qualitative analysis of videotaped expert responses and quantitative analysis of expert diagnoses.

Setting

Experimental setting in which experts were videotaped while reviewing study data.

Participants

A panel of international retinopathy of prematurity experts who had the experience of using qualitative retinal features as their primary basis for clinical diagnosis.

Intervention

Six experts were video recorded while independently reviewing 7 wide-angle retinal images from infants with retinopathy of prematurity. Experts were asked to explain their diagnostic process in detail (think-aloud protocol), mark findings relevant to their reasoning, and diagnose each image (plus vs pre-plus vs neither). Subsequently, each expert viewed the images again while being asked to examine arteries and veins in isolation and answer specific questions. Video recordings were transcribed and reviewed. Diagnostic process of experts was analyzed using a published cognitive model.

Main Outcome and Measures

Interexpert and intraexpert agreement.

Results

Based on the think-aloud protocol, 5 of 6 experts agreed on the same diagnosis in 3 study images and 3 of 6 experts agreed in 3 images. When experts were asked to rank images in order of severity, the mean correlation coefficient between pairs of experts was 0.33 (range, −0.04 to 0.75). All experts considered arterial tortuosity and venous dilation while reviewing each image. Some considered venous tortuosity, arterial dilation, peripheral retinal features, and other factors. When experts were asked to rereview images to diagnose plus disease based strictly on definitions of sufficient arterial tortuosity and venous dilation, all but 1 expert changed their diagnosis compared with the think-aloud protocol.

Conclusions and Relevance

Diagnostic consistency in plus disease is imperfect. Experts differ in their reasoning process, retinal features that they focus on, and interpretations of the same features. Understanding these factors may improve diagnosis and education. Future research defining more precise diagnostic criteria may be warranted.

Giant Conjunctival Nevus Clinical Features and Natural Course in 32 Cases Giant Conjunctival Nevus

Shields CL, Regillo AC, Mellen PL, et al. — Thu, 23 May 2013 00:00:00 GMT

Importance

Conjunctival nevus is the most common tumor of the ocular surface and we selected the largest nevi to evaluate for clinical features and outcomes.

Objective

To describe the clinical features and outcomes of giant (≥10 mm diameter) conjunctival nevus.

Design, Setting, and Patients

Retrospective case series of 618 patients with conjunctival nevus, 32 of which had giant conjunctival nevus, treated at an ocular oncology service between July 1, 1974, and June 30, 2012.

Exposures

Observation, excisional biopsy, and cryotherapy.

Main Outcomes and Measures

Management, nevus recurrence, and nevus transformation into melanoma.

Results

Of 618 patients with conjunctival nevus, 32 (5%) were classified as having giant conjunctival nevus. The mean patient age at diagnosis was 34 years. Of those with giant conjunctival nevus, a history of an increase in nevus base or thickness was noted in 15 cases (47%) and an increase in color intensity in 2 cases (6%). The giant nevus involved cornea in 11 cases (34%), limbus in 23 (72%), bulbar conjunctiva in 31 (97%), fornix in 9 (28%), tarsus in 3 (9%), semilunar fold in 10 (31%), and caruncle in 7 (22%). The nevi had mean diameter of 16 mm and mean thickness of 2 mm. On slitlamp examination, intrinsic cysts were identified in 25 cases (78%), intrinsic blood vessels in 26 (81%), and feeder vessels in 22 (69%). Management included excisional biopsy with cryotherapy in 23 cases (72%) and observation in 9 cases (28%). Amniotic membrane graft reconstruction was used following excision in 3 cases (13%). Malignant melanoma developed within the giant nevus in 1 case after 23 years of observation. Postexcisional biopsy, nevus recurrence was detected in 4 cases (17%), pseudopterygium in 1 (4%), dry eye in 1 (4%), and eyelid blepharoptosis in 1 (4%).

Conclusions and Relevance

In an ocular oncology practice, giant conjunctival nevus represents 5% of conjunctival nevi. This benign tumor rarely transforms into conjunctival melanoma. Management alternatives include observation or wide excisional biopsy, cryotherapy, and reconstruction, possibly with amniotic membrane graft.

Oral Glucosamine Supplements as a Possible Ocular Hypertensive Agent

Murphy RK, Ketzler L, Rice RE, et al. — Thu, 23 May 2013 00:00:00 GMT

The Centers for Disease Control and Prevention report that osteoarthritis affects 27 million adults in the United States. Glucosamine sulfate is a naturally occurring substance found in human cartilage and a precursor for glycosaminoglycans (GAGs). A combination of supplements, glucosamine and chondroitin sulfate, was shown in the Glucosamine/Chondroitin Arthritis Intervention Trial to aid moderate to severe osteoarthritic knee pain.

Spectral-Domain Optical Coherence Tomographic Appearance of Acute Multifocal Retinitis

Yew Y, Subrayan V. — Thu, 23 May 2013 00:00:00 GMT

Acute multifocal retinitis, previously termed acute multifocal inner retinitis by Foster et al in 1991, is a very rare presentation of multiple transient, self-limiting posterior uveitis involving the superficial inner aspect of the retinal layer. Very few cases pertaining to this condition have been reported in the literature. It typically affects both eyes of healthy, immunocompetent individuals having previously experienced flulike viral prodrome that subsequently resolves over weeks to months, with the patient regaining normal vision. Although it is idiopathic, some have regarded it as an unusual manifestation of ocular bartonellosis (cat-scratch disease) or a variant of ocular syphilis. We report a case of a rare uveitis entity with its spectral-domain optical coherence tomographic (SD-OCT) appearance to highlight its pathological feature.

Progression of Diabetic Retinopathy in the Hypertension Intervention Nurse Telemedicine Study

Muir KW, Grubber J, Mruthyunjaya P, et al. — Thu, 23 May 2013 00:00:00 GMT

Interventions to improve glycemic control reduce the progression of diabetic retinopathy. Additionally, pharmacologic reduction of blood pressure (BP) in patients with diabetes mellitus and poorly controlled hypertension reduces the risk of worsening diabetic retinopathy. Despite pharmacologic improvements, hypertension remains poorly controlled in approximately half of Americans with it. The Hypertension Intervention Nurse Telemedicine Study (HINTS) investigated a telemedicine-mediated medication management and behavioral intervention for hypertension. Participants in HINTS (including nondiabetic individuals) with poor BP control who received combined medication and behavioral management demonstrated mean decreases in systolic BP of 15 mm Hg and 8 mm Hg at 12 and 18 months, respectively. The purpose of the current analysis was to determine whether the interventions influenced the progression of diabetic retinopathy in participants with diabetes.