Many screening methods are available for detecting diabetic retinopathy. However, once patients develop retinopathy, it is unclear as to what method should be used for their review. We describe a novel and integrated system for the screening and treatment of diabetic retinopathy using high street optometrists for primary screening and digital imaging as a secondary screening tool, with referral to a joint retinal clinic only where ophthalmological intervention may be required. Of 3586 patients screened by optometrists, 328 were classified as having moderate/severe pre-proliferative retinopathy or diabetic maculopathy. Patients with proliferative retinopathy (1% of the total) were recalled directly to the joint retinal clinic. A consecutive sample (281) of these patients, together with a further 100 classified by the optometrists as having no or background retinopathy were compared using digital images and standard 35 mm colour transparencies. These, together with the original optometrist reports, were reviewed independently and individually by an ophthalmologist. A further sample of 124 patients who had undergone both digital imaging and ophthalmologist slit-lamp examination were also compared. Comparison of 35 mm colour transparencies with optometrist reports showed the latter had a sensitivity for detecting sight-threatening retinopathy (STR) of 62%, a specificity of 84%, and a kappa score of 0.62. The results for digital images were 90%, 97%, and 0.90, respectively, although the extent of retinopathy was under-reported in 10 patients. With ophthalmologist slit-lamp examination as the gold standard, the sensitivity of digital imaging was 90% with a substantial level of agreement between them (kappa 0.61). We conclude that digital images provide an efficient method for the follow-up of patients with established or previously treated retinopathy.

Sir, Central serous chorioretinopathy and antiphospholipid antibodiesFresults of a pilot study Central serous chorioretinopathy (CSCR) normally occurs in otherwise healthy individuals. It is characterised by the development of a serous detachment of the neurosensory retina at the macula. Bilateral disease has been reported in about 23% of cases. 1 The condition is normally selflimiting with good visual recovery. However, up to 30% of cases may develop recurrent episodes and require photocoagulation therapy. 2 Stress has been implicated, but not conclusively proven to be an aetiological factor in CSCR. 3 The aetiology of CSCR has been the subject of much speculation, but remains unknown. There is evidence of abnormal perfusion of the choriocapillaris in CSCR. 4-6 There is also evidence of an association between serous retinal detachment and raised serum antiphospholipid antibodies. 7 Furthermore, raised antiphospholipid antibodies are seen in 42% of patients with systemic lupus erythematosus (SLE) 8 and an association between SLE and CSCR has been observed. 7,9,10 Antiphospholipid antibodies are associated with thrombophilia 11,12 and could, in theory, lead to localised thrombosis in the choriocapillaris resulting in the perfusion abnormalities found in CSCR. We performed a pilot study to begin to investigate possible evidence for a direct association between CSCR and raised levels of antiphospholipid antibodies (anticardiolipin, and anti-b2 glycoprotein-1). The prevalence of such antibodies in the normal population is reported to be approximately 6%. 13 A total of 20 patients (13 M, 7 F) presenting with a clinical diagnosis of CSCR to one unit between September 1999 and December 2000 underwent analysis of their clotting profiles and serum testing for the presence of antiphospholipid antibodies. General health was assessed and any features specific for the primary antiphospholipid syndrome were recorded. None of the patients who presented had clinical features of the primary antiphospholipid syndrome. Two patients showed minor abnormalities in their clotting profiles. In one patient, this was transient and the other was lost to follow-up. No patients had persistently elevated levels of antiphospholipid antibodies, although IgM anti-b2 glycoprotein-1was transiently elevated in one patient. In conclusion, this study did not suggest an association between raised antiphospholipid antibodies and central serous chorioretinopathy. It would appear that antiphospholipid antibodies are unlikely to be directly implicated in the aetiology of CSCR.

This case report highlights the successful management, by vitrectomy alone, of a case of chronic phacolytic glaucoma secondary to a dislocated hypermature lens in the vitreous of a patient with ectopia lentis et pupillae (ELP). The features and complications of ELP are discussed.

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