Punctal occlusion is safe and efficient for the treatment of keratoconjunctivitis sicca in patients with ocular GvHD

The use of punctal plugs in the treatment of keratoconjunctivitis sicca (KCS) in inflammatory eye disease remains controversial because of the potentially increased retention time of tears enriched with inflammatory cytokines that may aggravate eye inflammation. We describe the safety and efficacy of punctal occlusion in a retrospective analysis of 19 patients (16 men) with KCS due to chronic GvHD (cGvHD). Efficacy and safety were assessed by subjective and objective criteria (symptoms, corneal fluorescein staining, tear film break-up time (BUT), Schirmer I test, Jones test and visual acuity). Follow-up was from plug insertion until maximum one year after punctal occlusion. After punctal occlusion, patients reported a significant increase in subjective comfort (1.10 vs 0.59 on a scale ranging from no symptoms (0) to severe impairment (2), P<0.001). Pathological corneal fluorescein staining decreased significantly (P<0.001) and tear film BUT remained unchanged (5.98 vs 4.0?s, P=0.79). Measurement of tear secretion or retention time showed a non-significant trend for improvement in the Schirmer I (3.0 vs 3.40?mm, P=0.08) and Jones (1.36 vs 2.8?mm, P=0.08) tests. The logMAR visual acuity remained unchanged. Punctal occlusion achieved a significant improvement in subjective symptoms and objective findings in ocular GvHD without increasing ocular inflammation.     

角膜异物合并感染愈后泪膜稳定性临床分析

目的观察角膜异物合并感染治愈并停用药物后患眼主观不适感和泪膜、眼表结构的改变。方法入选73例(146眼)确诊为角膜异物合并感染的患者,常规治疗自然病程内痊愈并停用药物后,排除其他影响泪膜稳定性的因素,分别于愈后0、10、30、60d复诊并行泪液分泌试验(ST)、角膜荧光素染色(FL)、泪膜破裂时间(BUT)测量。患眼为患病组,对侧健康眼为对照组。结果角膜异物感染治愈后83.6%(61例)患者有类似干眼症的眼部不适,愈后60d恢复正常(P>0.05)。患眼泪膜稳定性低于对照组,各观察指标恢复时间和恢复曲线有差别,ST结果在愈后60d时与对照组无明显差别(P>0.05),而FL分值和BUT结果恢复较快,愈后30d已达正常水平(P>0.05),虽然ST愈后30d较愈后初始时已经明显好转(P<0.05),但测量值却仍低于对照组(P<0.05)。结论角膜异物合并感染治愈后泪膜稳定性下降,对协助了解其恢复过程及指导后续处理具有重要的参考价值。     

Dry Eye in Vernal Keratoconjunctivitis: A Cross-Sectional Comparative Study

The purpose of this comparative cross-sectional study was to investigate the use of standardized clinical tests for dry eye in pediatric patients with active and quiet vernal keratoconjunctivitis (VKC) and to compare them with healthy children.We recruited 35 active VKC, 35 inactive VKC, and 70 age-matched control healthy subjects. Each child underwent a complete eye examination, including visual analog scale symptoms assessment, biomicroscopy, fluorescein break-up time (BUT), corneal fluorescein and conjunctival lissamine green staining, corneal esthesiometry, Schirmer test with anesthetic, and meibomian glands inspection and expression.Active VKC patients showed significantly increased symptoms and signs of ocular surface disease, compared with the other 2 groups. Inactive VKC patients, compared with control subjects, showed increased photophobia (P < 0.05; Mann-Whitney U test), conjunctival lissamine green staining and Schirmer test values, and reduced BUT and corneal sensitivity [P < 0.05 by analysis of variance (ANOVA) least significant difference posthoc test for BUT and Schirmer; P < 0.001 by Mann-Whitney U test for lissamine green staining and corneal sensitivity].Our results confirm the association between VKC and short-BUT dry eye. This syndrome seems to affect the ocular surface in quiescent phases too, determining abnormalities in tear film stability, epithelial cells integrity, and corneal nerves function. The very long-term consequences of this perennial mechanism of ocular surface damage have not been fully understood yet.     

原发性干燥综合征眼科诊断试验的评价

目的:在我国患者中重新评价原发性干燥综合征(PSS)眼科诊断试验的临床价值。方法:用Schirmer试验、BUT试验和角膜荧光素活体染色试验。在112例PSS患者和185例对照者中,评估上述试验的敏感度和特异度及其主要影响因素。结果:Schirmer、角膜荧光素活体染色和BUT试验的特异度分别为43.8％、93.5％和31.4％,敏感度分别为91.7％、50.0％和87.5％。统计分析显示Schirmer试验和BUT试验的特异度与年龄呈负相关(P<0.001),而敏感度与年龄呈正相关(P<0.05)。在55岁以上的患者,除角膜荧光素活体染色试验外各项试验的诊断价值有限。按目前我国诊断KCS的标准,上述三项试验中两项或两项以上异常,诊断的敏感度和特异度分别为84.8％和49.7％。结论:有持续性眼干患者并Schirmer试验(<5mm/5min)和(或)角膜荧光素活体染色试验阳性可明显提高临床诊断的敏感度(79.5％)和特异度(97.8％)(P<0.001)。     

What may be gained from standard photocoagulation during early worsening of diabetic retinopathy? An observational study in type-1 diabetic patients after tightening of glycaemic control.

OBJECTIVE: To assess the outcome of laser photocoagulation treatment for rapidly progressing diabetic retinopathy, socalled early worsening, subsequent to a rapid improvement of glycemic control. For the purpose of this study, early worsening was defined as any incidence or progression of retinopathy that followed a reduction in HbA1c by > 2% within 6 months.MATERIAL AND METHODS: Retrospective observational study in type-1 diabetic patients in a university diabetes center.PATIENTS: 23 patients with early worsening were identfied during a 16-year period, with a mean age of 25 years, duration of diabetes of 12 years, and glycated hemoglobin HbA1c of 12.4%; retinopathy was absent or mild nonproliferative at baseline. Focal, and/or panretinal laser coagulation was performed according to standard ETDRS criteria. Retinal pathology and visual acuity was followed-up for 12-120 months.RESULTS: Improving metabolic control induced mild non-proliferative retinopathy without macular edema in 4 patients, which regressed without treatment. In 19 patients, symptomatic diabetic maculopathy developed with macular edema, resolving by focal coagulation in 3 patients. Of the remaining 16 patients, 14 developed proliferative retinopathy (7 of whom despite focal, grid or scatter coagulation pretreatment), and were treated by full panretinal coagulation. In 7 of the 14 patients with proliferative retinopathy, vitreous hemorrhages occurred requiring pars plana vitrectomy. Proteinuria, polyneuropathy, and impaired vision prior to laser treatment were indicative of poor prognosis. Visual acuity > 0.3 in at least one eye was preserved in 22 of the 23 patients.CONCLUSIONS: In patients with type-1 diabetes mellitus and early worsening of diabetic retinopathy, the benefit of standard laser photocoagulation was limited, and particularly in the presence of symptomatic macular edema.     

糖尿病白内障患者晶体乳化术后泪膜功能变化及干眼综合征

目的观察糖尿病患者白内障术后泪膜的变化。方法随机抽取合并糖尿病的白内障患者112例（130只眼）行超声乳化白内障吸除术,对照组为随机选取的单纯老年性白内障患者50例（50只眼）。分别于术前及术后1d、7d、30d、90d进行症状、角膜荧光素染色（FL）、泪膜破裂时间（BUT）、基础泪液分泌试验（SIt）调查。结果两组术后1d、7d、30d干涩、异物感加重,与术前比较BUT明显缩短,SIt分泌增加,FL染色率明显增多,差异均有统计学意义（P〈0．01）。术后90d两组BUT及SIt逐渐恢复到术前水平。结论糖尿病患者白内障术后可致泪膜稳定性下降。术后补充人工泪液,促使泪膜功能恢复,对糖尿病患者尤为重要。     

Evaluation of Dry Eye Using Anterior Segment Optical Coherence Tomography in Patients With End-Stage Renal Disease Undergoing Hemodialysis

The aim of the present study was to evaluate dry eye parameters with conventional tests and tear meniscus with Anterior Segment Optical Coherence Tomography (AS-OCT) in patients with end-stage renal disease (ESRD). Thirty-eight ESRD patients undergoing hemodialysis, and 40 healthy individuals were enrolled. An ocular surface disease index questionnaire (OSDI) was administered. Before conventional dry eye tests, tear meniscus were evaluated using AS-OCT. After a complete ocular examination, Schirmer and break-up time (BUT) tests were performed and probable corneal staining was investigated. Schirmer test and BUT values were significantly lower in ESRD patients (P < 0.05). OSDI scores and corneal staining scores were significantly higher in ESRD patients (P < 0.05). Tear meniscus height, tear meniscus depth, and tear meniscus area, which were obtained by AS-OCT were significantly lower in patients with ESRD (P < 0.05). Tear meniscus evaluation using AS-OCT is an effective and non-invasive method to assess tear meniscus in patients with ESRD. Patients with ESRD undergoing hemodialysis should obtain regular ophthalmic examination, especially for dry eye.     

Plasma fibronectin in diabetic retinopathy and macroangiopathy

To establish the relation between plasma fibronectin (PF) and vascular complications of diabetes mellitus, we studied 163 normotensive diabetic outpatients, of whom 53 were treated with insulin (15 type I, 38 type II) and 110 with sulfonylureas, and compared them to 34 control subjects. Diabetic patients were divided, according to their therapy, into four groups: with retinopathy (classified as background or proliferative) detected by fluorescein angiography (m), with macroangiopathy, assessed by clinical criteria (M), with both vessel complications (mM) and without vascular disease (N). PF was not related to glycosylated hemoglobin (HbA1) in each treatment group (r = 0.26; P = 0.051 in the insulin treated patients and r = 0.09; P = 0.356 in the group on oral drugs). PF levels were similar in M groups, either on insulin or sulfonylureas and in controls. Both m and mM subsets of patients were, conversely, characterized by significantly raised mean PF concentrations when compared to N subjects or controls, but proliferative retinopathy was not associated with a significant PF increase compared to background retinopathy. The differences of PF levels among m, mM and N groups remained significant after processing the data by means of stepwise discriminant analysis with age, duration of diabetes, body weight and HbA1 entering the model as covariates. We conclude that diabetic macroangiopathy is not associated with modifications of mean PF levels, which, on the contrary, appear increased only in diabetic patients with retinopathy, regardless of their therapy.     

Long‐term review of driving potential following bilateral panretinal photocoagulation for proliferative diabetic retinopathy

Aim To determine the necessity for repeated Driver and Vehicle Licensing Agency (DVLA) visual field testing in people with diabetes who have had bilateral panretinal photocoagulation (PRP) for proliferative diabetic retinopathy. Methods A questionnaire survey was conducted of driving history in a cohort of people with diabetes who had been treated with bilateral PRP for proliferative retinopathy between 1988 and 1990. In addition, all similarly eligible subjects attending the diabetic retinal review clinic over a 12‐month period who had had laser between 1991 and 2000 were questioned as to their driving status. Results Forty‐five surviving patients from the 1988–1990 cohort were eligible and 25 returned the questionnaire (55%). Eight had never driven and 15 (13 with Type 1 diabetes) still held a valid licence, having passed the DVLA field test on a number of occasions. Neither of the two patients who had stopped driving reported failing the DVLA field test as the reason for stopping. All 12 of the patients directly questioned in the clinic were still driving and had passed at least one repeat DVLA test. Conclusions People with Type 1 diabetes who have no further laser treatment for proliferative diabetic retinopathy can expect to retain their UK driving licence for at least 15 years following small‐burn PRP, provided they maintain sufficient acuity.     

Retinal neovascularisation without ischaemia in the spontaneously diabetic Torii rat

Aims/hypothesis The spontaneously diabetic Torii (SDT) rat has recently been established as a model of type 2 human diabetes mellitus. Male SDT rats develop severe diabetic ocular complications. This study investigated the nature of the ocular complications in this model and addressed the question of whether the SDT rat is a good model of human proliferative diabetic retinopathy.Methods Male SDT rats aged 50 weeks were studied for a period of 8 months. Under deep anaesthesia, one eye of each animal was enucleated following perfusion with fluorescein dextran and a retinal flat mount was prepared to study vascular structure. The other eye was enucleated and investigated histologically by haematoxylin–eosin and azan staining and by immunohistochemistry using antibodies against vascular endothelium (Griffonia simplicifolia isolectin B4 antibody) and vascular endothelial growth factor (VEGF).Results From the vascular structure study, 17 of 32 rats (53%) showed proliferative retinopathy without vascular non-perfusion. The histological study revealed traction retinal folds in rats with proliferative retinopathy. Azan staining showed some proliferative matrix in rats with normal retinal structure and those with proliferative retinopathy compared with normoglycaemic controls. Staining with Griffonia simplicifolia isolectin B4 antibody showed no specific vascular changes in any of the rats, while VEGF staining revealed higher immunoreactivity in the retina of rats with normal retinal structure and those with proliferative retinopathy, but only low immunoreactivity in the control animals.Conclusions/interpretation There appear to be differences between the SDT rat model of diabetic retinopathy and human proliferative diabetic retinopathy, as the SDT rat develops retinal neovascularisation without retinal ischaemia. This very unique display of ocular neovascularisation may be caused by increased expression of VEGF.     

Residual B-cell function in insulin-dependent (type I) diabetics with and without retinopathy

Summary In order to evaluate if residual B-cell function is a protecting factor against the development of diabetic retinopathy in type I diabetics we measured C-peptide levels before and after glucagon stimulation (1 mg i.v.) in 74 type I diabetics. In all patients retinopathy was assessed by fluorescein angiography and retinal lesions were classified as: grade 0, normal; grade 1, background retinopathy; grade 2, proliferative retinopathy. We then correlated the degree of retinopathy to sex, age, duration of diabetes, smoking, percentage of ideal body weight, systolic and diastolic blood pressure, serum cholesterol, triglycerides, creatinine and C-peptide by means of multiple linear regression analysis. Twenty-three out of 74 type I diabetics had retinopathy. In all 7 subjects with proliferative retinopathy duration of diabetes exceeded 10 years. There was significant correlation between retinopathy and duration of diabetes (r=0.373, p<0.001). No correlation was found between retinopathy and all the other variables, in particular between retinopathy and basal C-peptide or C-peptide increment (Δ). An inverse correlation was found between the increment of C-peptide and duration of diabetes (r=−0.404, p<0.01). Our data show that residual B-cell function cannot be considered a protecting factor against the development of diabetic retinopathy.     

Biochemical markers of type III and I collagen: association with retinopathy and neuropathy in type 1 diabetic subjects.

AIMS: Connective tissue alterations may contribute to the development of diabetic long-term complications in eyes, kidneys and peripheral nerves. Collagen deposition may be increased in micro- and macrovascular disease in diabetic subjects. We tested whether biochemical markers of type III and I collagen metabolism are associated with retinopathy and neuropathy in Type 1 diabetes. METHODS: A total of 28 patients, mean age 43.4 +/- 9.5 (sd) and duration of diabetes 25.2 +/- 9.7 years, were studied. Stereoscopic colour fundus photographs were taken for assessment of retinopathy which was classified as no, background or proliferative. Concentrations of aminoterminal propeptide of type III procollagen (PIIINP), carboxyterminal propeptide of type I procollagen (PICP) and carboxyterminal cross-linked telopeptide of type I collagen (ICTP) in serum and urinary excretion of cross-linked N-telopeptides of type I collagen (NTX) and deoxypyridinoline crosslinks (DPyr) into urine were measured. RESULTS: Average serum PIIINP was higher in subjects with proliferative (3.2 +/- 1.1 microg/l) than without proliferative retinopathy (2.5 +/- 0.6 microg/l) (P = 0.03). Average serum PICP was higher in subjects without retinopathy (181.7 +/- 19.5 microg/l) than in subjects with background retinopathy (132.1 +/- 42.7 microg/l) (P = 0.02). Concentrations of other collagen markers were not different in subjects with or without retinopathy. No association between collagen markers and neuropathy was found. CONCLUSIONS: The increased synthesis of type III collagen, reflecting deposition of matrix and basement membrane connective tissue, may be involved in the pathogenesis of proliferative retinopathy in Type 1 diabetic subjects. On the other hand, we observed decreased synthesis of Type I collagen, which can result in weakened vascular integrity in subjects with retinopathy.     

Familial clustering of diabetic retinopathy in South Indian Type 2 diabetic patients.

AIM: The aim of the study was to determine whether there is familial clustering of diabetic retinopathy among South Indian Type 2 diabetic subjects. METHODS: During the period September 1991 to September 1997, 322 families with at least two diabetic siblings who were registered at our centre and had undergone a retinal examination were selected for the study.The sibling with the longest duration of diabetes was defined as the proband. The prevalence of retinopathy was compared between the siblings of probands with and without retinopathy. RESULTS: Diabetic retinopathy was diagnosed in 11.2% of the siblings of the probands without diabetic retinopathy and in 35.3% of the siblings of the probands with diabetic retinopathy (P < 0.0001). The increased prevalence of retinopathy among siblings of probands with retinopathy represented all grades of retinopathy, namely non-proliferative diabetic retinopathy with and without maculopathy and proliferative diabetic retinopathy, although the latter did not reach statistical significance due to the small numbers. Hypertension, metabolic control and the duration of diabetes among the probands did not affect the clustering of retinopathy. The odds ratio for retinopathy in the siblings of probands with retinopathy after adjusting for age, glycosylated haemoglobin, duration of diabetes, proteinuria and other confounding variables was 3.37(95% confidence interval 1.56-7.29, P = 0.002). CONCLUSIONS: Familial clustering of diabetic retinopathy was three times higher in siblings of Type 2 diabetic subjects with diabetic retinopathy.     

Association of intercellular adhesion molecule 1 polymorphisms with retinopathy in Chinese patients with Type 2 diabetes.

AIMS: To investigate the relationship of the K469E and G241R polymorphisms of the intercellular adhesion molecule 1 (ICAM-1) gene with diabetic retinopathy in Chinese patients with Type 2 diabetes mellitus. PATIENTS AND METHODS: One hundred and seventy-two Chinese patients with Type 2 diabetes and 80 normal control subjects were recruited. Patients with diabetes were placed into two groups: the diabetic retinopathy (DR) group and the non-diabetic retinopathy (NDR) group. The DR group was subdivided into those with proliferative retinopathy (PDR) and non-proliferative retinopathy (NPDR). Genomic DNA was prepared using the hydroxybenzene-chloroform extraction method. Genotypes and alleles were detected by polymerase chain reaction-heteroduplex-single-strand conformation polymorphism (PCR-HA-SSCP) analysis combined with gene sequencing. RESULTS: The patients with retinopathy had an increased frequency of the K469K genotype compared with both the patients without retinopathy and the control subjects (61.4 vs. 40.0 and 35.0%, respectively; chi(2) = 8.280 and 13.952, respectively; P < 0.05). The frequency of the K allele in the DR group was higher than in the NDR group and control subjects (75.4 vs. 58.8 and 61.3%, respectively; chi(2) = 9.693 and 11.219, respectively; P < 0.05). Genotype and allele frequencies were similar in the NDR group and control subjects, and in the PDR and NPDR groups. CONCLUSION: The ICAM-1 gene K469E polymorphism is associated with diabetic retinopathy in Chinese patients with Type 2 diabetes. Patients with the K469K genotype were more likely to have diabetic retinopathy than patients with the K469E or E469E genotype.     

No association between retinopathy and insulin resistance in type 1 diabetes

Intact endothelial cell function has been suggested to be important for insulin action. An association between retinopathy and insulin resistance has been found in type 2 diabetes. To evaluate, whether insulin resistance is related to retinopathy in insulin dependent diabetes, we examined 36 type 1 diabetic patients with various degrees of retinopathy: 7 patients had proliferative, 15 had background and 14 patients had no retinopathy. The three groups were matched for age, sex, body weight and insulin dose. Compared with patients with no retinopathy, those with proliferative retinopathy had a longer (P less than 0.05) duration of diabetes (13 +/- 3 vs 22 +/- 3 years for no vs proliferative retinopathy), and higher (P less than 0.05) serum creatinine (74 +/- 4 vs 97 +/- 8 mumol/l), triglyceride (0.69 +/- 0.04 vs 1.02 +/- 0.17 mmol/l) and diastolic blood pressure (77 +/- 3 vs 90 +/- 10 mmHg) levels. The rate of insulin-mediated glucose metabolism (1 mU euglycaemic insulin clamp) was virtually identical in each diabetic group (4.80 +/- 0.42, 4.90 +/- 0.36 and 4.98 +/- 0.74 mg/kg/min) and 40% below that in 8 matched normal subjects (7.53 +/- 0.53 mg/kg/min, P less than 0.001). In conclusion, proliferative retinopathy is related to long duration of diabetes, incipient nephropathy and hypertension. Insulin resistance characterizes the majority of patients with type 1 diabetes but is unrelated to retinopathy.     

Vascular Endothelial Growth Factor Inhibitors for Diabetic Retinopathy

The prevalence of diabetes is growing at epidemic rates in the USA. Diabetic retinopathy develops in a large proportion of patients and is a leading cause of blindness worldwide. Systemic management of diabetic retinopathy has included glycemic, hypertension, and lipid control. Local ophthalmic treatment in the form of focal/grid or panretinal laser photocoagulation has been shown to prevent vision loss in diabetic edema and proliferative diabetic retinopathy, respectively. The introduction of anti-vascular endothelial growth factor for diabetic macular edema and retinopathy has provided clinicians with improved clinical outcomes with potentially less damaging effects than laser.     

Tear production and corneal sensitivity in diabetes

AIM: Diabetic patients are at significant risk of developing corneal lesions such as superficial punctate keratitis, recurrent corneal erosions, persistent epithelial defects, and microbial keratitis. The aim of this study was to investigate whether diabetes mellitus is correlated with both reduced corneal sensation and reduced tear production. METHODS: In 25 type II diabetic patients with a history of retinopathy only and in 25 nondiabetic control subjects (age and sex matched), we performed noncontact corneal aesthesiometry and assessed basal tear production using Schirmer's test with topical anesthesia. The noncontact corneal aesthesiometer (NCCA) is a new noninvasive device for quantifying threshold corneal sensitivity. RESULTS: The diabetic patients demonstrated a significantly reduced Schirmer's test result (P<.001) and significantly reduced corneal sensitivity (P<.01). CONCLUSION: Our study supports previous reports of reduced basal tear production, lending more support to the theory of a peripheral neuropathy affecting lacrimal gland function in diabetes. We also confirmed reduced threshold corneal sensitivity in diabetic patients using the NCCA.     

Plasma concentration of pigment epithelium-derived factor in patients with diabetic retinopathy

CONTEXT: Pigment epithelium-derived factor (PEDF) is a strong inhibitor of angiogenesis. Eyes with diabetic retinopathy have low levels of ocular PEDF; however, the PEDF levels in the blood of diabetics have still not been determined. OBJECTIVES: Our objective was to determine the plasma levels of PEDF in diabetic patients and to determine the relationship with the stage of the diabetic retinopathy. DESIGN AND SETTING: This study was designed as a cross-sectional, institutional study. PATIENTS OR OTHER PARTICIPANTS: A total of 145 Japanese were studied; 112 had type 2 diabetes mellitus, and 33 were healthy controls. INTERVENTION: There was no intervention. MAIN OUTCOME MEASURES: The plasma level of PEDF was measured by ELISA, and the stage of diabetic retinopathy was determined by ophthalmic examinations. Clinical systemic status of diabetic patients was also examined. RESULTS: The plasma PEDF level in diabetic patients (6.68 +/- 0.54 microg/ml; mean +/- sem) was significantly higher than that in controls (4.38 +/- 0.59 microg/ml, P = 0.03), and the level was especially high in patients with proliferative diabetic retinopathy (7.78 +/- 0.98 microg/ml; n = 45; P = 0.005). The gender (P = 0.03), blood urea nitrogen (P = 0.005), and triglycerides (P = 0.04) were significant and independent determinants of plasma PEDF levels in diabetic patients. CONCLUSIONS: The PEDF level in the plasma was significantly elevated in diabetic patients, especially those with proliferative diabetic retinopathy. High levels of PEDF in the plasma may be related to the progression of diabetic retinopathy.     

Diabetic retinopathy: current concepts of evaluation and treatment

Diabetic retinopathy is a common, and potentially blinding or visually disabling complication of diabetes. Nearly all diabetic subjects will have some degree of retinopathy after 20 years of diabetes, and 50% of those with insulin dependent diabetes will have proliferative retinopathy after 15 years. Macular oedema frequently produces central vision loss and legal blindness, most commonly in non-insulin dependent diabetics. In recent years, several therapeutic modalities have been demonstrated to be effective on the basis of large-scale randomized, controlled clinical trials. These include panretinal photocoagulation (PRP), using the argon laser or xenon arc, for proliferative retinopathy, and focal photocoagulation for macular oedema. Vitrectomy surgery is effective for diabetic vitreous haemorrhage and traction retinal detachment, producing improved vision in most patients, but only a relatively small percentage of patients so treated recover good visual acuity (greater than or equal to 6/12). Other therapeutic modalities, such as hypophysectomy for severe retinopathy, remain controversial, while still others, such as rigorous blood glucose control and aldose reductase inhibitors, are currently under investigation. The primary care physician who deals with diabetic patients should be familiar with the lesions of diabetic retinopathy and with current therapeutic modalities. He should perform an examination of the posterior retina with the direct ophthalmoscope on each diabetic patient at each visit, and should institute prompt referral to an ophthalmologist at the first sign of change. Periodic examination of all diabetic patients by an ophthalmologist should be conducted at the intervals recommended in the previous section. Definitive evaluation and treatment of diabetic retinopathy should be carried out by the ophthalmologist.     

A proposal of new ocular items in Sjögren's syndrome classification criteria

OBJECTIVE: To verify whether ocular surface tests other than those included in primary Sj?gren's syndrome (SS-I) classification criteria (Schirmer I, Break up Time, vital dye staining) may contribute to SS I diagnosis. METHODS: Two hundred and sixty-two patients (78 SS-1, 91 non-SS autoimmune diseases, 93 Sicca syndrome) filled a validated questionnaire on symptoms and were evaluated by Schirmer test without (Schirmer I) and with (Jones test) topical anaesthesia, Break Up Time (BUT), corneal aesthesiometry, tear clearance rate, vital dye (lissamine green) staining, impression conjunctival cytology, concentration of tear lysozyme and lactoferrin. Thresholds were selected from Receiver Operating Curves; sensitivity, specificity, likelihood ratio (LR+), predictive values were calculated for each test. A logistic regression model was constructed representing the best diagnostic index for SS. RESULTS: Data showed a poor diagnostic performance of Schirmer test I (LR+ 1.38) and BUT (LR+ 1.05); results from lissamine green staining may be unreliable due to incorporation bias. Tear lactoferrin (LR+ 4.52), Jones test (LR+ 6.24), tear lysozyme (LR+ 8.0), symptom questionnaire (LR+ 8.62), tear clearance rate (LR+ 18.73) and corneal aesthesiometry (LR+ 20.96) exhibited high diagnostic performance also taken together in the regression model. CONCLUSION: Because many of the tests we have screened in this study can be carried out by a trained ophthalmologist in any clinical setting, we recommend that ocular surface impairment is studied with the combination of tests proved to be helpful for the SS I diagnosis.