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Br J Ophthalmol 1999;83:759761 759

The support of the Joint Research Board of St somewhat bemused by the notion that the pas-
Bartholomews Hospital is gratefully acknowledged. sage of time invariably invalidates good clinical
MAILBOX K J MANSFIELD
J E WILSON
studies. Our editorial did not go into detail
about VEPs and CVI because of space
Biological Services Unit, Medical College of St limitations and the focus of that editorial. We
Bartholomews Hospital, Charterhouse Square,
meant only to imply that VEPs had been less
A new substrain of the non-obese London EC1M 6BQ
useful than we all hoped they would be in
diabetic mouse which develops cataracts P POZZILLI evaluating this diYcult group of visually im-
(NOD/Ba/Lop19) P E BEALES paired children. We do not disagree with Clarke
Department of Diabetes and Metabolism,
and Mitchell that intact flash VEPs usually
EDITOR,The non-obese diabetic (NOD) St Bartholomews Hospital, London EC1A 7BE
imply a better visual outcome than if the VEPs
mouse is a spontaneous model of type 1 (insu- Correspondence to: Dr P E Beales. are abnormal or absent. Similar results have
lin dependent) diabetes mellitus, frequently been reported by Taylor and McCulloch.1
1 Mansfield KJ, Beales PE, Williams AJK, et al.
used in diabetes research.1 The colony at the Housing, production and life-maintenance of Regrettably, in our studies of children with cor-
medical college of St Bartholomews Hospital the non-obese diabetic (NOD) mouse. Animal tical visual impairment the group of patients
(NOD/Ba) was established in 1987 and some Technology 1992;43:2937.
2 Pozzilli P, Signore A, Williams AJK, et al. NOD with intact flash VEPs represents only a small
55% of females and 15% of male mice sponta- mouse colonies around the worldrecent facts portion of those we care for. In the remaining
neously develop diabetes by 30 weeks of age.2 and figures. Immunol Today 1993;14:1936. larger group of patients with abnormal VEPs
Cataracts are not a characteristic normally 3 Scarpitta AM, Perrone P, Sinagra D. The we have not found good correlation with the
found in NOD mice but were observed during diabetic cataract: an unusual presentation in a
young subject: case report. J Diab Comp ultimate visual outcome. Moreover, in children
routine inspection in 1988. All animals in the 1997;11:25960. with neurological disorders, flash VEPs are
substrain NOD/Ba/Lop19 now spontaneously 4 Williams D. Laboratory animal often abnormal even when the patient is well
develop cataracts in both eyes (typically at 104 ophthalmologyan overview. Animal Technology
1992;43:14765. sighted.2 The problem then is how to interpret
199 days of age). There are diVerences between 5 Carroll PB, Herskowitz RD, Goodman AD, et al. an abnormal VEP in a child with CVI. This is
NOD/Ba/Lop19 and the other mice of the Rapid onset of severe retinopathy, cataracts and where VEPs have been disappointing and
colony with puberty, gestation period, teeth neuropathy in young patients with diabetes mel- frequently misleading. VEP mapping may be a
eruption, and eye opening all taking place later. litus. Acta Paediatr 1992;81:3558.
significant improvement over standard flash
Cataracts of the type seen are often the result of VEPs. Witing et al 3 reported that VEP
metabolic disturbances; however, although Cortically visually impaired children mapping in 50 children with permanent CVI
blood glucose levels greater than 12 mmol/l are was always abnormal and showed good correla-
known to cause cataracts in experimental EDITOR,While Hoyt and Fredrick rightly tion with computed tomography results,
models,3 their development in NOD/Ba/Lop19 state the heterogeneous aetiology of cortical whereas the conventional VEP recordings were
is not related to the development of diabetes visual impairment (CVI) in children,1 we were abnormal in only 50% of cases and with much
(normally at 112133 days) as they occur disappointed in their bland and unjustified less good correlation. We, therefore, look
before blood glucose levels exceed 11.5 mmol/l. dismissal of the value of electrophysiological forward to further studies of VEPs demonstrat-
This is unusual in that cataract formation in studies in these cases. They fail to quote any ing improved techniques that provide better
other susceptible laboratory rodents usually electrophysiological studies more recent than prognostic value when evaluating the abnormal
precedes the development of a general disease 1979 in their review, of which there have been VEP in a child with CVI.
state.4 a not inconsiderable number. As for our own We apologise for any confusion caused by
The cataracts initially take the form of a vis- work we have found that a normal flash VEP the terseness of our discussion. We encourage
ible dense white sclerotic central area (see Fig indicates statistically and clinically a better Clarke and Mitchell to continue their VEPs of
1), accompanied by clouding of the lens itself, prognosis in blind babies with non-ocular children with CVI and look forward to reading
which becomes denser over a few days. Both visual impairment even though we would con- their results in the future.
eyes are usually aVected within 5 days of each cede that in some cases flash VEPs can be
CREIG S HOYT
other. Back cross breeding experiments show normal in CVI.2 It is therefore clinically useful DOUGLAS R FREDRICK
the Mendelian inheritance patterns typical of to perform evoked potential studies in these San Francisco, California
a single recessive gene. It has been suggested children, a position endorsed by the commen-
that there may be a subset of young diabetic tary in the same issue of BJO,3 which states 1 Taylor MJ, McCulloch DL. Prognostic value of
VEPs in young children with acute onset of cor-
patients with unusual susceptibility to cata- that electrophysiological investigations are tical blindness. Pediatr Neurol 1991;7:11115.
racts and other complications of diabetes mandatory in the investigation of babies with 2 Taylor MJ. Evoked potentials in pediatrics. In:
aVecting the eye5 and NOD/Ba/Lop19 could poor visual contact. We endorse this sentiment Halliday AM, ed. Evoked potentials in clinical test-
ing. 2nd ed. London: Churchill Livingstone,
act as a specific model for this group. If the and although accepting the limitations of the 1992.
mechanism by which cataract formation technique, feel that VEP investigations pro- 3 Witing S, Jan JE, Wong PKH. Permanent cortical
occurs in NOD/Ba/Lop19 mice could be vide valuable objective information in the visual impairment in children. Dev Med Child
established then it could prove useful to deter- assessment of these infants. Hoyt and Freder- Neurol 1985;27:7309.
mine if any diabetic patients who develop ick rightly point out that further work is
cataracts have the same genotypic and/or required in the evaluation of infant CVI but Automated perimetry by optometrists in
metabolic characteristics. This then raises the not even to attempt any review of work within
patients at low risk of glaucoma
possibility of preventative treatment. the past 20 yearsnever mind the most
recentis at best misleading and at worst EDITOR,The letter by Dayan et al 1 raises
scientifically unacceptable. some interesting questions regarding the
M P CLARKE examination and referral of patients by
K W MITCHELL optometrists for further investigation in rela-
Department of Ophthalmology, tion to open angle glaucoma.
University of Newcastle, While the authors base their comments
Royal Victoria Infirmary, upon largely anecdotal evidence from a series
Newcastle upon Tyne NE1 4LP
of only 11 subjects from one referral source,
there are nevertheless some important points
1 Hoyt CS, Fredrick DR. Cortically visually
impaired children: a need for more study. Br J to be answered from these comments.
Ophthalmol 1998;82:12256. Firstly, the College of Optometrists guide-
2 Clarke MP, Mitchell KW, Gibson M. The prog- lines oVer guidance based on clinical evidence
nostic value of flash evoked potentials in the to optometrists conducting eye examinations.
assessment of non-ocular visual impairment in
infancy. Eye 1997;11:398402. They specifically encourage optometrists to
3 Casteels I, Spileers W, Missotten L, et al. The conduct the appropriate tests on any individual
baby with poor visual contact. Br J Ophthalmol patient as a matter of best practice. In the case
1998;82:12289.
of glaucoma, recommendations are made that
visual field tests should be conducted on
Reply subjects over the age of 40, those with a family
history of glaucoma, and those with suspicious
Figure 1 A NOD/Ba/Lop19 mouse with EDITOR,We thank Clarke and Mitchell for optic discs or other risk factors.2
cataracts. Note the thick band of sclerotic their thoughtful comments on our editorial on The majority of visual field tests used in
material on the right hand side. cortical visual impairment (CVI). We are optometric practice are based upon static
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760 Mailbox, Book review, Notices

perimetry (College of Optometrists annual be to apply it to a group with a higher pretest above which individuals should have their
clinical survey, 1998) and decisions then need probability of having pathologyfor example, visual fields tested at routine eye test appoint-
to be made on the results obtained. Therefore, patients over 60 years of age. We doubt that ments. Much of the misunderstanding regard-
if one or two points are missed on a central forthcoming technological developments will ing referrals in this area could then be
field test does that mean an abnormality is improve the trade oV between sensitivity and clarified.
present? The optometrist needs to make a specificity to a point where routine screening This is also relevant in light of the current
judgment on this issue in the light of the com- of patients over 40 can be justified. Further- review of the GOC referral guidelines to
plete clinical findings rather than simply exert more, a test of adequate positive predictive optometrists relating to the present obligation
a pass/fail criterion from a screening test. value is a prerequisite for a screening pro- to refer to a general practitioner when an
Not surprisingly most glaucoma patients in gramme not a post hoc modification. abnormal finding is detected in the routine eye
hospital clinics are referrals from optometrists With regard to the legal position, this has in test.
but evidently this is at the cost of a relatively part been created by the guidelines themselves RONALD STEVENSON
high false positive rate.3 Not surprisingly also, since a practitioner who does not comply with
visual field test designers are continually trying them can be held to have been negligent.
to develop programs with high specificity and The fault does not lie with individual 1 Dayan M, Gales K, GriYths PG. Automated
high sensitivity,4 which help the user to make an optometrists who cannot be blamed for mak- perimetry by optometrists in patients at low risk
appropriate decision regarding normal or ab- of glaucoma. Br J Ophthalmol 1998;82:1221.
ing the referrals; having identified a field 2 Crick RP, Tuck MW. How can we improve the
normal findings and thus referral. defect they have little option but to refer to the detection of glaucoma? BMJ 1995;310:5467.
Whether the optometrist refers a patient to hospital eye service. Informing the opto- 3 Theodossiades J, Murdoch I. Positive predictive
the general practitioner for further investigation metrist of the outcome of all referrals is value of optometrist initiated referrals for glau-
is influenced by a number of factors. Opto- coma. Ophthalmic Physiol Opt 1999;19:627.
undoubtedly good practice but we do not 4 Crick RP. What can we do about the detection of
metrists are legally required to refer patients if think it would have any significant impact on primary open angle glaucoma? Glaucoma Forum
an abnormality is suspected or found. the false positive referral rate. It is the 1999;1:1018.
Therefore, realistically, individual practi- guidelines themselves that are the problem.
tioners are more concerned about missing We note that there is some disquiet among
pathology than referring false positives. This Viscoelastic
optometrists as well as ophthalmologists
feeling is further strengthened by legal cases about the guidelines. This is a diYcult area in
reaching the General Optical Council where EDITOR,I was very disappointed to read in
practice and there are no easy answers; the BJO, a BMJ publication, an example of
optometrists have been sued (successfully) for however, it is time to review the cut oV age for
not detecting and referring ocular pathology. corrupt English usage. In the January issue, on
routine visual field screening. page 71, the term viscoelastic is freely used. I
This defensive attitude could be changed.
Clearly, ophthalmologists do not wish to PHILIP G GRIFFITHS presume the term is addressing the properties
spend clinical time seeing large numbers of Newcastle upon Tyne Hospitals NHS Trust, Royal of a substance which has both viscous and
normal eyes although there must be a grey Victoria Infirmary, Queen Victoria Road, elastic properties. The words viscous and
Newcastle upon Tyne NE1 4LP elastic are adjectives describing the property
area where a patient will be referred with a
reasonable measure of doubt as to the of a substance. It is therefore incorrect to use
presence of an abnormality. What is an the terms as nouns. American English has
Authors reply coined the word viscoelastic and through
acceptable false positive rate with respect to
referrals to a hospital eye clinic? common usage is encouraging others to adopt
EDITOR,I thank Dr GriYths for his reply to
One of the main ways in which the referral it. However, surely we should expect a native
my original comments. However, I would like
process could be improved is by a formal noti- British journal to set a better example by using
to answer some of the points that he raises. technically correct terminology.
fication system from ophthalmologists to opto- The use of visual field screening in patients E S ROSEN
metrists to let individual optometrists assess the above the age of 40 in optometric practice is 10 St John Street, Manchester M3 4DY
accuracy of their clinical findings/decisions/ based upon the fact that the incidence of glau-
results of the cases that they refer. The health coma increases above that age. Therefore,
service referral forms are designed to allow this measuring intraocular pressure and visual
to happen since the patient can be asked to sign fields and combining this with assessment of
giving consent to the general practitioner or the optic disc is highly relevant in that group
ophthalmologist to pass information back to
the referring optometrist. Ideally the ophthal-
of the population. The highest positive predic- BOOK REVIEW
tive value (PPV) is demonstrated when infor-
mologist will send a copy of the reply to the mation on all three factors is included.2 3
general practitioner and to the referring opto- Logically it follows that the PPV of visual
metrist. Currently and historically this process fields as a stand alone test increases if it is Ida and the Eyea Woman in British
does not happen in many areas of the country only used in a group with a higher cut oV Ophthalmology. Ed Elizabeth Imlay Buck-
(personal communication with members). agethat is, 60 years of age as suggested by ley, Dorothy Usher Potter. Pp 322; 18.
RONALD STEVENSON GriYths, given the age related nature of many Speldhurst, Kent: Parapress, 1998. ISBN
Professional adviser, College of Optometrists, ocular conditions including glaucoma. This 1-898594-63-5.
42 Craven Street, London WC2N 5NG approach is likely to miss a significant number
of possible early chronic simple glaucoma The editors of Ida Manns autobiography,
1 Dayan M, Gales K, GriYths P. Automated cases. Conditions other than glaucoma may Elizabeth Buckley and Dorothy Potter, have
perimetry by optometrists in patients at low risk also be detected by routine visual fields undertaken a task of a true devotion. Through
of glaucoma. Br J Ophthalmol 1998;82:1221. testing, a point made in GriYthss original
2 College of Optometrists Guidelines. The routine their long standing respect and admiration for
eye examination. London: College of Optom- letter. this giant of 20th century ophthalmology, the
etrists, September, 1997. The legal position of the college guidelines authors have successfully brought together an
3 Bell, OBrien C. Accuracy of referral to a may be misunderstood by GriYths in that, by
glaucoma clinic. Ophthal Physiol Opt 1997;17:7 excellent book which reviews the somewhat
11. not complying with them, he suggests that a meandering autobiography which Ida Mann
4 Henson DB, Spry PG, Spencer IC, et al. practitioner may be held negligent. This is not herself wrote.
Variability in glaucomatous visual fields: impli- the case since the guidelines are not set by the For those who are interested it is an
cations for shared care schemes. Ophthal Physiol General Optical Council as law but are simply
Opt 1998;18:1205. extremely fascinating account of individuals
College of Optometrists professional guide- who helped to form Ida Manns career from
lines given to members to represent current her early days at Moorfields and Oxford onto
Reply best practice. her period in Australia and the continuing
Most optometrists feel that if they receive research that she did there on Aboriginal
EDITOR,We thank Dr Stevenson for his feedback on referrals to indicate a high false demographics.
interest in our letter. Though he rightly com- positive referral rate, referral criteria would be The autobiography itself provides a unique
ments that our evidence is anecdotal there has modified to correct this problem. Recent oph- insight into the enormous energy, but even
been no systematic study to justify the use of thalmological opinion does suggest that feed- more so into the approach, which Ida Mann
routine visual field screening in patients over back on referrals would help case finding.3 4 took to her research work. Undoubtedly, these
40 attending their optometrist. Finally, I do agree that it would be welcome were driven by a great interest in her topics. In
The best way the improve the positive and timely to have dialogue between ophthal- addition, she paid great attention to detail and
predictive value of visual field screening would mologists and optometrists regarding the age this is highlighted in the book itself with some
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Mailbox, Book review, Notices 761

idiosyncratic but highly enjoyable personal Royal National Institute for the Blind 5175674/972-3-5140077; email: Eunos99@
references and even quotations which one A national conference of the Royal National kenes.com).
must assume represent the spoken word. Institute for the Blind will be held on 2223
There is also some rare insight into the poli- June 1999 at the Cedar Court Hotel, Wake-
tics involved in the emergence of early 20th field. Further details: Kristene Wilde, Confer- International Agency for the Prevention
century UK ophthalmology, with special refer- ence administrator, Royal National Institute of Blindness
ence to the diYculties and the advantages that for the Blind, RNIB Education Centre: North, The sixth general assembly of the Inter-
women may have in developing medical Grosvenor House, Grosvenor Road, Leeds national Agency for the Prevention of Blind-
careersparticularly in the field of ophthal- LS6 2DZ (tel: 0113-274 8855; fax: 0113-274 ness will be held on 56 September 1999 at
mology. 8800). the Conference Centre, Beijing Friendship
Overall, this is a very enjoyable read and it Hotel, Beijing, Peoples Republic of China.
can be recommended to all those interested in
Neglected Areas of Disease Burden: the The theme is The right to sight. Further
the history of ophthalmology.
details: IAPB Secretariat, LV Prasad Eye
JOHN V FORRESTER Biomaterials Challenge
A workshop will be held on 30 June 1999 at Institute, LV Prasad Marg, Banjara Hills,
the Society for Chemical Industry, 14/15 Bel- Hyderabad 500 034, India (tel: 091-40-
grave Square, London covering five areas: 215389; fax: 091-40-248271; email: IAPB@
ophthalmic, craniofacial, stroke, respiratory, lvpeye.stph.net).
renal, with a keynote address Artificial
NOTICES vision given by Professor Mark Humayun
(Baltimore, USA). Further details: Jeanette Ophthalmological Clinic, University of
Hawkes, The Biomaterials Partnership, LGC Creteil
(Teddington) Ltd, Queens Road, Teddington, An international symposium on the macula
Middx TW11 0LY (tel: 0181 943 7596; will be held on 12 October 1999 at the Oph-
Community based rehabilitation
The latest issue of the Community Eye Health fax: 0181 943 2767; email: biomaterials@ thalmological Clinic, University of Creteil.
(no 28) discusses community based rehabili- lgc.co.uk). Further details: Professor G Soubrane, Chef
tation in developing countries. For further de Service, Clinique Ophtalmologique Uni-
information please contact Community Eye versitaire de Creteil, Centre Hospitalier Inter-
XII Congress European Society of communal, 40 Avenue de Verdun, 94010
Health, International Centre for Eye Health,
Institute of Ophthalmology, 1143 Bath Ophthalmology Creteil, France (fax: 01 45 17 52 27).
Street, London EC1V 9EL. (Tel: (+44) 171 The XII Congress European Society of Oph-
608 6910; fax: (+44) 171 250 3207; email: thalmology will be held in Stockholm, Sweden
eyeresource@ucl.ac.uk) Annual subscription on 27 June1 July 1999. Further details: Con- Jules Franois Prize
25. Free to workers in developing countries. gress (Sweden) AB, PO Box 5819, S-114 86 The 2000 Jules Franois Prize of $100 000 for
Stockholm, Sweden (tel: +46 8 459 66 00; fax: scientific research in ophthalmology will be
+46 8 661 91 25; email: soe@congrex.se; awarded to a young scientist who has made an
Residents Foreign Exchange Programme http://www.congrex.com/soe/). important contribution to ophthalmology. All
Any resident interested in spending a period topics in the field of fundamental and/or clini-
of up to one month in departments of cal research in ophthalmology will be consid-
ophthalmology in the Netherlands, Finland, British Ophthalmic Photographic
Association ered. The application should be sent jointly
Ireland, Germany, Denmark, France, Austria,
The British Ophthalmic Photographic Associ- with a curriculum vitae, the list of all publica-
or Portugal should apply to: Mr Robert Ache-
ation (BOPA) will hold a workshop entitled tions, and three copies of the candidates 10
son, Secretary of the Foreign Exchange Com-
mittee, European Board of Ophthalmology, The other side of the chin rest on 10 July most relevant publications to Jules Franois
Institute of Ophthalmology, University Col- 1999 at the Southampton Eye Unit. Topics Foundation Secretary, Professor Dr M Hans-
lege Dublin, 60 Eccles Street, Dublin 7, include: consent; allergies and complications; sens, Dienst Oogheelkunde, de Pintelaan 185,
Ireland. living with visual impairment; and procedures. B-9000 Gent, Belgium. Deadline for applica-
Cost 20. Further details: Tim Mole (tel: tions 31 December 1999.
01703 798747).
12th Annual Meeting of German
Ophthalmic Surgeons XXXIV Nordic Congress of
The 12th annual meeting of German Oph- Vision 99: International Conference on Ophthalmology
thalmic Surgeons will be held on 1013 June Low Vision and Vision Rehabilitation The XXXIV Nordic Congress of Ophthal-
1999 at the Meistersingerhalle, Nrnberg, The International Conference on Low Vision mology will be held in Reykjavik, Iceland,
Germany. Further details: MCN and Vision Rehabilitation will be held on 1821 June 2000. This meeting celebrates the
Medizinische Congress-Organisation Nrn- 1216 July 1999 at the Waldorf-Astoria Hotel, 100 year anniversary of the Nordic Ophthal-
berg GmbH, Weilandstrasse 6, D-90419 New York City, New York. Further details: mology Conference. Further details: Iceland
Nrnberg, Germany (tel: ++49-911- Lighthouse International, 111 East 59th Incentives Inc, Hamraborg 13, Is-
3931621; fax: ++49-911-3931620; email: Street, New York, NY 10022-1202, USA (tel:
Kopavogur, Iceland (tel: +354 554 1400; fax:
doerflinger@mcn-nuernberg.de). (212) 821-9482; fax: (212) 821-9705; email:
+354 554 1472; email: incentiv@itn.is).
vision 99@lighthouse.org).

Continuing Medical Education DR-2000, International Forum on


The Tenth Annual Loyola Ophthalmology 4th Meeting of the European
Resident Alumni Day on the subject of Neuro-Ophthalmology Society Diabetic Retinopathy
corneal oedema will be held on 12 June 1999 The 4th meeting of the European Neuro- The International Forum on Diabetic Retino-
at Loyola University Medical Center, May- Ophthalmology Society will be held on 29 pathy will take place on 79 September 2000
wood, IL, USA. Further details: Russell August2 September 1999 in Jerusalem, at the Palazzo Reale, Naples, Italy. Further
Dolce, Department of Ophthalmology, Loyola Israel. Further details: Secretariat, 4th Meet- details: Francesco Bandello, Congress Secre-
University Medical Center, 2160 South First ing of the European Neuro-Ophthalmology tariat, MGR Congressi, Via Servio Tullio, 4,
Avenue, Maywood, IL 60153, USA (tel: (708) Society, PO Box 50006, Tel Aviv, 61500, 20123 Milano, Italy (tel: 39 02 430071; fax:
216-3408). Israel (tel: 972-3-514000; fax: 972-3- 39 02 48008471; email: dr2000@mgr.it).
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Cortically visually impaired children

M P CLARKE and K W MITCHELL

Br J Ophthalmol 1999 83: 759


doi: 10.1136/bjo.83.6.759a

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