FigureOcular disease diagnosis can be a tricky endeavor. Trivial conditions and potentially sight-threatening diseases may be hard to distinguish. The task is difficult and the stakes are often high. Constructing a list of possible causes (a differential diagnosis list) and testing for conditions on this list are an excellent ways to proceed toward an accurate understanding of patient problems. This textbook attempts to assist practitioners in this process. Jack Kanski is most recognized in optometric circles for his classic Clinical Ophthalmology, A Systematic Approach, which is currently in its seventh edition. More recently, Dr. Kanski released Signs in Ophthalmology: Causes and Differential Diagnosis. In the preface of this first edition, the author identifies his target audience as ophthalmologists in training and optometrists and states that the book's purpose is “to acquaint the reader with the salient characteristics, causes, and differential diagnosis of the many signs that may occur in ophthalmic disorders.” To this end, the book's chapters are organized by structure starting at the eyelids and ending with the fundus. There are also chapters on intraocular pressure, pupils, ocular motility, and systemic signs of health conditions with ocular manifestations. Each chapter is organized by clinical finding and a list of possible causes. For example, the Retina chapter has a Focal Elevated Lesion section, which contains the following differential diagnosis list: retinal astrocytoma, retinoblastoma, retinoma, and toxocara granuloma. Each item on the differential is described in brief outline-style text, which may include a definition, signs, causes, and associations to look for. Most conditions are accompanied by a high-quality, albeit small, color photograph, with most photos measure about 2 in2. Purchase grants you access to a web site where you may access an identical digital version and larger images can be viewed on the on-line copy. When appropriate, drawings, OCT scans, ultrasound scans, and fluorescein angiographic images are used, although the majority of figures are photos. There are over 1300 high-quality photos in Signs in Ophthalmology: Causes and Differential Diagnosis. This text does not contain references or suggested additional readings. I found Signs in Ophthalmology: Causes and Differential Diagnosis very accessible. The chapters are logically presented and it would be easy to use it as a quick reference guide in clinic. Clinicians less experienced in ocular disease are sure to appreciate material presented by clinical sign instead of by diagnosis. For example, if one were to note an unusual retinal vascular caliber, they would merely go the Retina chapter, find the Changes in Calibre section, and discover a concise list of conditions to consider. After reading the brief overview and examining the high-quality photos, our clinician is most likely headed in the right direction. However, thorough understanding will not be gleaned from this text and other resources then need to be used. The clinician well versed in ocular disease, however, might view this text differently. This book's subject matter is extensive and the information given is quite cursory and without reference. The differential diagnoses lists are accurate and include the most common possibilities but are far from inclusive. Interestingly, there seems to be much wasted space where more extensive text-based information or larger photos might have been included. In addition, certain common topics such as visual field anomalies are not to be found, while conditions seldom encountered by optometrists such as congenital craniofacial anomalies and signs of systemic disease are covered. In the final analysis, Jack Kanski should be congratulated on an excellent first edition of Signs in Ophthalmology: Causes and Differential Diagnosis. A text based on structure affected and clinical appearance will surely speed up a clinician's ability to accurately diagnose ocular disease. More experienced clinicians may appreciate it as an easily accessible but limited guide for use in clinic. Perhaps future editions will improve on this winning design. Carl H. Jacobsen Berkeley, California

Essentials of Cataract Surgery Bonnie A. Henderson, ed. Thorofare, NJ: SLACK Inc.; 2007. $49.95.FigureIn 2005, Bonnie An Henderson, MD, created the first annual Harvard Medical School Intensive Cataract Surgical Training Course. This extensive course is offered free of charge to all US-based ophthalmology residents and is taught by physician/educators who have been nominated by their respective institutions as best cataract surgery teacher. The authors (30 total) of the textbook Essentials of Cataract Surgery are drawn from the distinguished faculty of this course. Ophthalmologists in training appear to be the target audience, although others may glean insight from the text as well. The implicit goal of this book is to assist the reader in mastering phacoemulsification surgery and also to serve as a reference after having gained surgical competence. As an optometrist, I will not be performing cataract surgery so I am clearly not part of the target audience. However, optometrists often work with cataract patients and frequently consult with cataract surgeons. This review is written from an optometrist’s perspective primarily for fellow optometrists. Essentials of Cataract Surgery ambitiously tackles a wide breadth of material in a relatively short text (33 chapters, 306 pages). This book is offered in paperback form with black and white photos and diagrams. After mild initial disappointment at the lack of color, I found the photos to be generally of good quality and the diagrams and tables to be clear and informative. Each chapter is logically organized, concisely written, and ends with a summary of key points. The editors have done a fine job in insuring a coherent style and layout throughout the text. The first three chapters cover screening and preoperative assessment. These cursory sections are full of useful optometric information but may offer little new information for optometrists who co-manage cataract patients. True to its title, this book is essentially about cataract surgery. Chapter topics include anesthesia, wound construction, viscoelastics, phacoemulsification techniques, alternative surgical techniques, surgical complications, intraocular lens design, suturing, and postoperative care. Additional chapters cover postoperative complications, cataract surgery in glaucoma and refractive surgery patients, and possible future surgical advances. There are also chapters on somewhat esoteric topics such as surgical blade design, which I found quite interesting. Although many sections will be pertinent only to those performing this procedure, I was surprised to find much of the text informative and eminently readable. The chapters did not always flow logically, but this is a minor criticism as most readers are likely to use Essentials of Cataract Surgery as a reference. Also, there can be drawbacks in covering such an extensive and complex body of information in a small text. To address this concern, each chapter is appropriately and extensively referenced. If a reader desires additional information or a more in-depth understanding, this book will point them in the right direction. Essentials of Cataract Surgery is a must-have book for the cataract surgeon in training. It is concise, comprehensive, well-referenced, and filled with practical surgical tips by renowned experts. This text is unlikely to be as directly useful to the practicing optometrist. However, for those optometrists who desire a richer understanding and appreciation of what happens when they refer their patients, Essentials of Cataract Surgery proficiently provides the surgeon’s perspective. Carl H. Jacobsen School of Optometry University of California Berkeley, California

PURPOSE To formulate and test a model to predict the development of local patches of nonproliferative diabetic retinopathy (NPDR), based on multifocal electroretinogram (mfERG) implicit times and candidate diabetic risk factors. METHODS mfERGs and fundus photographs were obtained from 28 eyes of 28 diabetic patients during an initial and 12-month follow-up examination. mfERG implicit times were derived at 103 locations using a template-stretching method, and a z-score was calculated in comparison with 20 age-matched normal subjects. Thirty-five nonoverlapping retinal zones were constructed by grouping two to three adjacent stimulated locations, and each zone was assigned the maximum z-score within it. Zones containing initial retinopathy were excluded from further analysis. The probability that new retinopathy would develop in the remaining zones by the follow-up examination was modeled based on the mfERG implicit time z-score for the zone and other candidate diabetic risk factors determined during the initial visit. Data collected from four previously untested diabetic subjects and the other eye of eight previous subjects during their second year follow-up were used to test the predictive model. RESULTS After 1 year, new retinopathy developed in 11 of the 12 NPDR eyes and 1 of the 16 eyes without initial retinopathy. After accounting for the correlation among zones within each eye, a predictive model was formulated with the variables mfERG implicit time, duration of diabetes, presence of retinopathy (NPDR or no retinopathy), and blood glucose level at initial visit. The area under the receiver operating characteristic (ROC) curve of this multivariate model is 0.90 (P <0.001). The predictive model has an expected sensitivity of 86% and a specificity of 84%, which was verified by the test data. CONCLUSIONS The development of diabetic retinopathy over a 1-year period can be well predicted by a multivariate model. The inclusion of local mfERG implicit times allowed the model to identify the specific sites of future retinopathy.

PURPOSE:To examine the potential of abnormal mfERGs to predict the development of diabetic retinopathy at corresponding retinal locations 1 year later.METHODS:One eye of 11 diabetic patients with nonproliferative diabetic retinopathy (NPDR) and 11 diabetic patients without retinopathy were retested 12 months after initial testing. At each time, mfERGs were recorded from 103 retinal locations, and fundus photographs were taken within 1 month of each recording. Local mfERG implicit times were measured and their z-scores were calculated based on results obtained from 20 age-matched control subjects. mfERG abnormalities were defined as z-scores of 2 or more for implicit time and z-scores of -2 or less for amplitude (P < or = 0.023). mfERG z-scores were mapped onto fundus photographs, and the relationship between baseline abnormal z-scores and new retinopathy at follow-up was examined.RESULTS:New retinopathy developed in 7 of the eyes with NPDR after 1 year. In these eyes, 70% of the mfERGs in areas of new retinopathy had abnormal implicit times at baseline. In contrast, only 24% of the responses in regions that remained retinopathy free were abnormal at baseline. Relative risk of development of new retinopathy over 1 year in the areas with abnormal baseline mfERG implicit times was approximately 21 times greater than that in the areas with normal baseline mfERGs (odds ratio = 31.4; P < 0.001). Eyes without initial retinopathy did not develop new retinopathy within the study period, although 4 of these 11 eyes had abnormal implicit times at baseline. mfERG implicit times tended to be more delayed at follow-up than at baseline in NPDR eyes, but not in eyes without retinopathy and control eyes. mfERG amplitudes had no predictive power.CONCLUSIONS:Localized functional abnormalities of the retina reflected by mfERG delays often precede the onset of new structural signs of diabetic retinopathy. Those functional abnormalities predict the local sites of new retinopathy observed 1 year later.

This study first compares two methods for measuring first order multifocal electroretinogram (mfERG) implicit time abnormalities in eyes with early diabetic retinopathy. Two analysis methods are used: template stretching (multiplicative scaling) of an 80 msec response epoch and template sliding (cross-correlation or additive scaling) of portions of responses containing the major waveform features. The study also compares the relative sensitivities of N1, P1 and N2 implicit time assessed by cross-correlation. The nature of the change in the mfERG waveform associated with diabetes is also assessed. MfERGs were recorded from 15 eyes of 15 individuals with diabetes and early non-proliferative retinopathy and 20 eyes of 20 healthy control subjects of similar age. Implicit time determined by template stretching is more frequently abnormal in the eyes of the diabetic subjects than the implicit time of any of the components assessed by template sliding. This is attributable to the lower variability of the template stretching implicit time measure in normals. Of the components, P1 is most often abnormal in the eyes of individuals with diabetes. Responses recorded from retinal areas with retinopathic signs are more often abnormal than those from other areas. Later components of the response are not delayed more than earlier ones. We conclude that template stretching is a sensitive measurement technique, but that it does not fully capture the effect of diabetes on the first order mfERG well.

Han, Ying MS; Bearse, Marcus Jr PhD; Schneck, Marilyn PhD; Barez, Shirin MD; Jacobsen, Carl OD; Adams, Anthony OD, PhD, FAAO Author Information

Epiretinal membranes are a common finding in older patients but are rare in young patients. Although they may be associated with other ocular conditions, most epiretinal membranes occur in the absence of ocular pathology. Patient symptoms range from asymptomatic to complaints of severe vision loss and metamorphopsia. Epiretinal membranes are commonly classified according to their density and contractile characteristics. In this review, cellophane maculopathy refers to thin, glistening membrane, surface wrinkling maculopathy is characterized by fine, superficial retinal folds and macular pucker is associated with a dense, grayish-white membrane causing a characteristic pattern of severe retinal distortion. With sufficient visual disturbance, epiretinal membranes may be treated by pars plana posterior vitrectomy and epiretinal membrane peeling.

Bullimore, Mark A. OD, PhD1; Twelker, Daniel J. OD1; Jacobsen, Carl H. OD1; Wood, Joanne M. OD, PhD2 Author Information

The sexually dimorphic area (SDA) of the gerbil hypothalamus is essential for male sexual behavior. To determine (a) if the SDA can affect mating via laterally projecting axons and (b) which SDA afferents might affect mating, male gerbils were given bilateral, parasagittal knife cuts lateral to the medial or lateral SDA. Others were given cuts with a knife coated with horseradish peroxidase to label cells of which axons were cut. Medial cuts eliminated mating and consistently labeled cells in the medial SDA. Lateral cuts did neither. Medial cuts also labeled more cells in the ventral part of the lateral septal nucleus, the encapsulated part of the bed nucleus of the stria terminalis, the medial nucleus of the amygdala, the amygdalohippocampal area, and the ventral premammillary nucleus than lateral cuts did. Thus, medial cuts may disrupt mating by severing SDA efferents or by severing SDA afferents from 1 or more of these 5 sites.