Update on depression and age-related macular degeneration

The impact of NF-κB on inflammatory and angiogenic processes in age-related macular degeneration

Age-related macular degeneration (AMD) is a prominent cause of vision loss, characterized by two different types, dry (atrophic) and wet (neovascular). Dry AMD is distinguished by the progressive deterioration of retinal cells, which ultimately causes a decline in vision. In contrast, wet AMD is defined by the abnormal development of blood vessels underneath the retina, leading to a sudden and severe vision impairment. The course of AMD is primarily driven by chronic inflammation and pathological angiogenesis, in which the NF-κB signaling pathway plays a crucial role. The activation of NF-κB results in the generation of pro-inflammatory cytokines, chemokines, and angiogenic factors like VEGF, which contribute to inflammation and the formation of new blood vessels in AMD. This review analyzes the intricate relationship between NF-κB signaling, inflammation, and angiogenesis in AMD and assesses the possibility of using NF-κB as a target for therapy. The evaluation involves a comprehensive examination of preclinical and clinical evidence that substantiates the effectiveness of NF-κB inhibitors in treating AMD by diminishing inflammation and pathological angiogenesis.

Smaller-Incision new-generation implantable miniature telescope: Three-months follow-up study

PURPOSE

To evaluate three months follow-up of SING IMT implant in patients affected by late-stage AMD.

DESIGN

Prospective cohort study.

SUBJECTS

In a total of 80 eyes of 40 patients who underwent the enrollment tests, 11 patients' eyes affected by late-stage AMD matched the inclusion criteria and underwent SING IMT implant from February to June 2022.

METHODS

Before surgery, each patient underwent the enrollment examination to verify inclusion and exclusion criteria.

MAIN OUTCOME MEASURES

BCVA for distance and for near, IOP, ACD and ECD were evaluated at 1 and 3 months follow up. Also quality of life in doing the activities of daily life was evaluated.

RESULTS

BCVA for distance and for near improved from baseline to 3 months follow up (23.91 ± 9.418 ETDRS letters and 59.09 ± 11.58 ETDRS letters respectively (p < 0.001). An endothelial cell loss was shown (p < 0.001), with a rate of cell density reduction around 8.3% (baseline vs 3 months).

CONCLUSIONS

SING IMT could be a valid surgical device to improve patients' sight and quality of life which have been deteriorated by late-stage macular degeneration. Further studies with more patients and longer follow up are needed to confirm our results.

Enhancing the Functional Performance of Patients with Late-Stage Age-Related Macular Degeneration Implanted with a Miniature Telescope using Rehabilitation Training

INTRODUCTION

In this work, our aim is to report the functional outcomes of cataract surgery with smaller-incision new-generation miniature telescope (SING IMT) implantation followed by rehabilitation training in patients with central visual loss due to late-stage age-related macular degeneration (AMD).

METHODS

This retrospective study included patients who were monocularly implanted with SING IMT and then followed a rehabilitation program based on 6 biweekly sessions focused on visual abilities, reading, writing, visual motor integration and mobility. A total of 11 participants were included in this study. Reading acuity (RA), reading speed (RS), and fixation stability (FS) were assessed biweekly at 6-, 8-, 10-, 12-, 14-, and 16-week follow-up visits after SING IMT implantation and at a final assessment at 24 weeks. Best-corrected distance visual acuity (BCDVA) was also measured at baseline and at the same postoperative timepoints.

RESULTS

Mean baseline BCDVA was 12.5 ± 8.6 letter score. Both RA and RS were found to be significantly improved from the first rehabilitation session (6 weeks after surgery) to the last session (24 weeks after surgery). At the end of the rehabilitation program, mean RA was 0.45 ± 0.19 LogMAR and mean RS was 30.9 ± 17.6 words per minute. Moreover, all patients achieved a FS of 15 s or more after the last rehabilitation session. Most patients (55%) achieved an improvement of 15 letters in BCDVA at the end of the study.

CONCLUSIONS

This study suggests that rehabilitation training can improve visual functions of patients with late-stage AMD implanted with SING IMT in real-world tasks such as reading skills.

Understanding barriers and enablers to participation in a proposed online lifestyle intervention for older adults with age-related macular degeneration to guide programme implementation

Age-related macular degeneration (AMD) is a blinding condition associated with depression, loneliness and unhealthy lifestyle behaviours which drives AMD progression. We have proposed the first online lifestyle intervention for AMD, called Movement, Interaction and Nutrition for Greater Lifestyles in the Elderly (MINGLE) to promote positive lifestyle changes and reduce loneliness. This qualitative grounded-theory study explored enablers and barriers to future participation in MINGLE for older adults with AMD. Thirty-one participants were interviewed and thematic analysis revealed nine themes. Enablers to participation were: socialising and learning about AMD, motivation to improve health, programme accessibility and structure. Barriers were: lack of time, technology, limited knowledge regarding holistic interventions, vision-related issues, mobility and negative perception of group interactions. These factors must be considered when developing lifestyle interventions for AMD patients to maximise participation. Supporting technology use and raising awareness about benefits of healthy lifestyle behaviours for AMD may help overcome these barriers.

Daily Functionality of People with Low Vision: The Impact of Visual Acuity, Depression, and Life Orientation-A Cross-Sectional Study

Background

Low vision (LV) has a significant negative impact on the activities of daily life as well as on the psychological health of patients.

Objectives

The objective of this study is to investigate psychological, clinical, and demographic factors that may impact the daily functionality of patients with LV.

Methods

A convenience sample of 53 patients, meeting the WHO criteria for LV, was recruited. Questionnaires on daily functionality, depression, and life orientation (in terms of optimism/pessimism) were administered along with a semistructured personal interview. Key Findings. The main results revealed a significant negative correlation between daily functionality and depression (r = -0.423, p < 0.001). Conversely, there is a positive correlation between daily functionality and visual acuity (r = 0.415, p < 0.001), while years since diagnosis were negatively correlated with depression (r = -0.345, p < 0.001). Depression seems to be a moderate predictor of a person's daily functionality (β = -0.389, p < 0.002), followed by visual acuity (β = -0.344, p = 0.006), explaining the 31.1% of the total variance.

Conclusions

The study supports a correlation between daily functionality and both depression and visual acuity. Optimism as a personality characteristic did not factor into the prediction model for daily functionality, but it showed a strong correlation with lower levels of depressive symptoms. This highlights the potential for developing coping strategies for chronic disease management. Recommendations. The study could serve as a useful guide and may urge clinicians to pay attention to the psychological evaluation of these patients, supporting their unique emotional needs. Mental health professionals can use patients' positive resources to provide appropriate counseling and embrace the coping skills that encourage their engagement in activities of daily life.

Assessment of vision-related quality of life and depression in patients with age-related macular degeneration

PURPOSE

To evaluate the effect of age-related macular degeneration (AMD) on vision-related quality of life (VRQOL) and depression levels.

METHODS

This cross-sectional study included 143 patients who are being followed up with a diagnosis of AMD. The Turkish versions of the National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25) and Geriatric Depression Scale-15 (GDS-15) were directed to the patients. The questionnaire results were analyzed based on the severity, treatment procedures for AMD, and sociodemographic characteristics of patients.

RESULTS

The subscale scores obtained from the NEI VFQ-25 ranged from 47.54 for "near activities" to 84.02 for "color vision." Of the patients, 59.4% (85/143) were compatible with depression according to the GDS-15 questionnaire. There was no significant difference in the NEI VFQ-25 subscale scores between the gender groups (P > 0.05), whereas females were statistically significantly more depressive than males (P < 0.05). There were no significant differences between the injection (anti-vascular endothelial growth factors [anti-VEGF]) group and the non-injection group in terms of subscales of the NEI VFQ-25 questionnaire (P > 0.05). The depression ratio in the non-injected group was statistically significantly higher (P < 0.05).

CONCLUSION

According to the present study, the association between depression and AMD is a fact that should be highlighted. Patients with depression had lower scores on the quality of life (QOL) test. Previous intravitreal injection did not affect NEI VFQ-25 scores. Female patients with AMD had higher rates of depression and lower visual acuity levels.

Efficacy, Durability and Safety of Faricimab in Neovascular Age-Related Macular Degeneration and Diabetic Macular Oedema: Lessons Learned from Registration Trials

INTRODUCTION

This review aims to assess the efficacy, durability and safety of faricimab-a dual vascular endothelial growth factor and angiopoietin 2 inhibitor-in patients with neovascular age-related macular degeneration (nAMD) and diabetic macula oedema (DMO). It summarises the findings of current studies on faricimab and discusses whether this new drug may fill a gap in current treatment options.

METHODS

We performed a search of the PubMed, Cochrane, Web of Science and EMBASE databases for publications on faricimab between 29 November 2022 and 10 May 2023, and a search of ClinicalTrials.gov for the protocols on clinical trials for this review. We included clinical trials, case-control studies and observational studies.

RESULTS

In phase 3 trials of nAMD, the efficacy of faricimab was non-inferior to aflibercept (+ 5.8-6.6 vs. + 5.1-6.6 Early Treatment Diabetic Retinopathy Study [ETDRS] letters). At study end, 80% of faricimab-treated patients were on ≥ 12-week dosing intervals, and 44.9-45.7% of faricimab-treated patients were on 16-week dosing intervals. Total adverse events, as well as serious ocular adverse events, were comparable between groups. In phase 3 trials of DMO, efficacy of faricimab was non-inferior to aflibercept (+ 10.7-11.8 vs. + 10.3-10.9 ETDRS letters). At study end, > 70% of patients in the personalised treatment interval faricimab group were on ≥ 12-week dosing intervals, and 51-53% were on 16-week dosing intervals. Total adverse events were comparable between groups, although the rate of serious ocular adverse events was higher in the faricimab groups than in the aflibercept groups (1.9-3.1% vs. 0.6-1.9%, respectively). In real-world studies of treatment-resistant nAMD or DMO, faricimab demonstrated superior efficacy compared to aflibercept. In a real-world study of mostly previously treated nAMD, faricimab demonstrated some efficacy.

CONCLUSION

Faricimab demonstrated non-inferior to superior efficacy, strong durability and acceptable safety in treatment-naïve nAMD and mostly treatment-naïve DMO, as well as superior efficacy in treatment-resistant nAMD and DMO. However, further research is needed on faricimab in real-world settings.

One-year outcomes of resveratrol supplement with aflibercept versus aflibercept monotherapy in wet age-related macular degeneration

AIM

To determine the one-year outcomes of resveratrol oral supplement in patients suffering from wet age-related macular degeneration (AMD).

METHODS

Fifty naïve and previously untreated patients suffering from wet AMD, were randomly assigned in two subgroups of 25 patients each. All the participants were treated with 3 monthly intravitreal injections of 2.0 mg aflibercept (IAIs) followed by injections "according to need", while in one group the patients also received daily two tablets of resveratrol oral supplement. Prior to treatment initiation, a complete ophthalmological examination, including best corrected visual acuity (BCVA) and contrast sensitivity evaluation, optical coherence tomography (OCT) scans, fundus autofluorescence (FAF), fluorescein angiography, indocyanine green angiography, and OCT angiography (OCTA), was performed to every participant, while all of them completed the Hospital Anxiety and Depression Scale (HADS) questionnaire, in order to assess their quality of life (QoL) status. The patients were assessed monthly for 1y with FAF, and OCT or OCTA; the main endpoints were the number IAIs, the changes in BCVA, in contrast sensitivity, and in patients' QoL status.

RESULTS

No significant differences were present between the groups regarding the baseline demographic and clinical data. Over the 12-month period, a similar number of IAIs was applied in both groups (4.52±1.00 vs 4.28±0.90, P=0.38), while the rest of the clinical data also did not differ significantly after the completion of the study period. However, for HADS Depression (11.88±2.51 vs 8.28±1.54, P<0.001) and HADS Anxiety (11.92±2.52 vs 7.76±1.51, P<0.001) questionnaires values, the score was significantly better in patients who received resveratrol supplements. Moreover, a statistically significant difference was detected in the mean change from baseline values of contrast sensitivity (0.17±0.19 vs 0.35±0.24, P=0.005), HADS Depression (0.08±1.38 vs -3.88±1.48, P<0.001), and HADS Anxiety (0.36±1.98 vs -5.12±2.70, P<0.001) scores, in favour of the patients treated with resveratrol supplements.

CONCLUSION

The resveratrol oral supplement is a complementary treatment in cases of wet AMD, highlighting its effectiveness in improving patients' QoL status.

Mechanistic Insight into Age-Related Macular Degeneration (AMD): Anatomy, Epidemiology, Genetics, Pathogenesis, Prevention, Implications, and Treatment Strategies to Pace AMD Management

One of the most complicated eye disorders is age-related macular degeneration (AMD) which is the leading cause of irremediable blindness all over the world in the elderly. AMD is classified as early stage to late stage (advanced AMD), in which this stage is divided into the exudative or neovascular form (wet AMD) and the nonexudative or atrophic form (dry AMD). Clinically, AMD primarily influences the central area of retina known as the macula. Importantly, the wet form is generally associated with more severe vision loss. AMD has a systemic component, where many factors, like aging, genetic, environment, autoimmune and non-autoimmune disorders are associated with this disease. Additionally, healthy lifestyles, regular exercise, maintaining a normal lipid profile and weight are crucial to decreasing the risk of AMD. Furthermore, therapeutic strategies for limiting AMD should encompass a variety of factors to avoid and improve drug interventions, and also need to take into account personalized genetic information. In conclusion, with the development of technology and research progress, visual impairment and legal blindness from AMD have been substantially reduced in incidence. This review article is focused on identifying and developing the knowledge about the association between genetics, and etiology with AMD. We hope that this review will encourage researchers and lecturers, open new discussions, and contribute to a better understanding of AMD that improves patients' visual acuity, and upgrades the quality of life of AMD patients.

Through the Eyes of Patients: Understanding Treatment Burden of Intravitreal Anti-VEGF Injections for nAMD Patients in Norway

Purpose

Patients with neovascular age-related macular degeneration (nAMD) are treated with frequent intravitreal injections to maintain vision. The treatment frequency impacts the life of patients and caregivers and poses a major capacity challenge for Norwegian ophthalmic clinics. The purpose of this survey was to document patient-reported outcomes on how the disease and the treatment impact nAMD patients in Norway.

Methods

Norwegian nAMD patients voluntarily completed the survey. The patients reported the time spent on each treatment appointment, the need for caregiver support, treatment intervals, and the emotional impact of the treatment. There was no active selection of patients to the survey. Respondents had to confirm the nAMD diagnosis prior to submitting the response. All data was included in the analysis as submitted by the respondents. This survey was market research involving anonymous patient data, and no participants were identifiable.

Results

In total, 130 patients responded to the survey. The majority of patients reported to receive nine or more injections per year (48.8%), and many patients needed caregiver support for every treatment appointment (37.7%). Patients reported to be anxious one day (25.4%), two days (8.5%), one week (10.8%) or more than one week (3.1%) prior to treatment. The week before the treatment, 33.1% of patients reported to be stressed and 15.4% struggled to sleep. The majority of patients reported the treatment as uncomfortable (54.6%) or as somewhat painful (26.2%). The results on yearly number of injections, time used each treatment day and need for caregiver support suggested a variation between Norwegian hospital regions.

Conclusions

This survey uncovers how treatment with intravitreal injections represents a substantial burden for Norwegian patients with nAMD. Future research on how the treatment burden impacts nAMD patients may lead to more patient-centered care and help guide treatment decisions. New treatments with longer intervals between injections are likely to both reduce the treatment burden and improve capacity in ophthalmology clinics.

Biological factors influencing depression in later life: role of aging processes and treatment implications

Late-life depression occurring in older adults is common, recurrent, and malignant. It is characterized by affective symptoms, but also cognitive decline, medical comorbidity, and physical disability. This behavioral and cognitive presentation results from altered function of discrete functional brain networks and circuits. A wide range of factors across the lifespan contributes to fragility and vulnerability of those networks to dysfunction. In many cases, these factors occur earlier in life and contribute to adolescent or earlier adulthood depressive episodes, where the onset was related to adverse childhood events, maladaptive personality traits, reproductive events, or other factors. Other individuals exhibit a later-life onset characterized by medical comorbidity, pro-inflammatory processes, cerebrovascular disease, or developing neurodegenerative processes. These later-life processes may not only lead to vulnerability to the affective symptoms, but also contribute to the comorbid cognitive and physical symptoms. Importantly, repeated depressive episodes themselves may accelerate the aging process by shifting allostatic processes to dysfunctional states and increasing allostatic load through the hypothalamic-pituitary-adrenal axis and inflammatory processes. Over time, this may accelerate the path of biological aging, leading to greater brain atrophy, cognitive decline, and the development of physical decline and frailty. It is unclear whether successful treatment of depression and avoidance of recurrent episodes would shift biological aging processes back towards a more normative trajectory. However, current antidepressant treatments exhibit good efficacy for older adults, including pharmacotherapy, neuromodulation, and psychotherapy, with recent work in these areas providing new guidance on optimal treatment approaches. Moreover, there is a host of nonpharmacological treatment approaches being examined that take advantage of resiliency factors and decrease vulnerability to depression. Thus, while late-life depression is a recurrent yet highly heterogeneous disorder, better phenotypic characterization provides opportunities to better utilize a range of nonspecific and targeted interventions that can promote recovery, resilience, and maintenance of remission.

Psychiatric aspects of ophthalmic disorders: A narrative review

Ophthalmic disorders have psychiatric aspects associated with them at various levels. Psychological factors have a well-documented role in the causation, aggravation, and maintenance of various ophthalmic conditions, including glaucoma, central serous retinopathy, dry eye disease, and retinitis pigmentosa. Many ophthalmic conditions, including blindness, have psychological manifestations as well, which need to be addressed, in addition to the ophthalmic pathology. There is also significant overlap in the treatment of the two disciplines in many ways. For instance, many ophthalmic drugs have psychiatric side effects. Even ophthalmological surgeries have psychiatric aspects associated with them, which primarily include black patch psychosis and anxiety in the operation theater. This review will be useful for psychiatrists and ophthalmologists, for their clinical practice and research. Future research should focus on this interface to give it its well-deserved attention.

Branched-Chain Amino Acids Metabolism and Their Roles in Retinopathy: From Relevance to Mechanism

Retinopathy is one of the leading causes of irreversible blindness and vision loss worldwide. Imbalanced nutrients play important roles in the pathogenesis and pathophysiology of retinal diseases. Branched-Chain Amino Acids (BCAAs), as essential amino acids, perform a variety of biological functions, including protein synthesis, glucose metabolism, lipid metabolism, inflammation, and oxidative stress in metabolic tissues of diabetes and aging-related diseases. Recently, it has been shown that BCAAs are highly related to neuroprotection, oxidative stress, inflammatory and glutamate toxicity in the retina of retinopathy. Therefore, this review summarizes the alterations of BCAA levels in retinopathy, especially diabetic retinopathy and aging-related macular disease, and the genetics, functions, and mechanisms of BCAAs in the retina as well as other metabolic tissues for reference. All of these efforts aim to provide fundamental knowledge of BCAAs for further discoveries and research on retina health based on the sensing and signaling of essential amino acids.

Spiritual and religious perspectives in persons with visual impairment due to age-related macular degeneration

Introduction

Age-related macular degeneration (AMD) is one of the global leading causes of severe vision loss. Patients suffering from AMD face complex spiritual and mental challenges that have an impact on the course of their disease, their quality of life, and their relationship with their surroundings.

Methods

A survey was carried out using a 21-item questionnaire between August 2020 and June 2021 among 117 patients from different countries to investigate how spirituality, religion, and their way of practicing them affected the experiences and daily lives of patients suffering from AMD, and whether it helped them cope with the disease.

Results

Our study concluded that spirituality and religion are important factors that facilitate patients' ability to cope with a progressive degenerative disease such as AMD. Patients who are religious are more at peace with having AMD. Practices that contribute to patients being at peace in accepting the disease are regular prayers or meditation. Spirituality and religion are important components that promote a healthier and happier emotional state and mental wellbeing. In particular, by believing that death is not the end, patients feel more hopeful, which helps in their adjustment to a seemingly hopeless health condition. A significant number of AMD patients desire to talk about God with the medical staff. The profile of such patients could be those believing in a higher power, praying often, participating in religious services, being worried about the loss of vision, and needing assistance in daily life.

Discussion

An interdisciplinary and multidimensional team of medical health professionals including mental health workers and chaplains can be of great value in managing persons with AMD.

Trends and disparities in disease burden of age-related macular degeneration from 1990 to 2019: Results from the global burden of disease study 2019

Objectives

This study aims to estimate the trends and disparities in the worldwide burden for health of AMD, overall and by age, sex, socio-demographic index (SDI), region, and nation using prevalence and years lived with disability (YLDs) from Global Burden of Disease (GBD) study 2019.

Methods

This retrospective study presents the prevalent AMD cases and YLDs from 1990-2019, as well as the age-standardized prevalence rate (ASPR) and age-standardized YLD rate (ASYR) of AMD. To measure changes over time, estimated annual percentage changes (EAPCs) of the age-standardized rates (ASRs) were analyzed globally, then studied further by sex, SDI, region, and nation. We included data from the 2019 Global Burden of Disease (GBD) database to examine AMD prevalence and YLDs from 1990-2019 in 204 countries and territories, as well as demographic information such as age, sex, SDI, region, and nation.

Results

Globally, the number of prevalent AMD cases increased from 3,581,329.17 (95% uncertainty interval [UI], 3,025,619.4-4,188,835.7) in 1990 to 7,792,530 (95% UI, 6,526,081.5-9,159,394.9) in 2019, and the number of YLDs increased from 296,771.93 (95% uncertainty interval [UI], 205,462.8-418,699.82) in 1990 to 564,055.1 (95% UI, 392,930.7-789,194.64) in 2019. The ASPR of AMD had a decreased trend with an EAPC of -0.15 (95% confidence interval [CI], -0.2 to -0.11) from 1990 to 2019, and the ASYR of AMD showed a decreased trend with an EAPC of -0.71 (95% confidence interval [CI], -0.78 to -0.65) during this period. The prevalence and YLDs of AMD in adults over 50 years of age showed a significant increase. The prevalence and YLDs of AMD were significantly higher in females than males, overall. The ASPRs and ASYRs in low SDI regions was greater than in high SDI regions from 1990 to 2019. In addition, increases in prevalence and YLDs differed by regions and nations, as well as level of socio-economic development.

Conclusion

The number of prevalent cases and YLDs due to AMD increased over 30 years and were directly linked to age, sex, socio-economic status, and geographic location. These findings can not only guide public health work but also provide an epidemiological basis for global strategy formulation regarding this global health challenge.

What Advice Is Currently Given to Patients with Age-Related Macular Degeneration (AMD) by Eyecare Practitioners, and How Effective Is It at Bringing about a Change in Lifestyle? A Systematic Review

There is currently no treatment for early/intermediate Age-related Macular Degeneration (AMD) but Eye Care Professionals (ECPs) are recommended to advise patients about modifiable lifestyle factors, including dietary changes, that can slow disease progression. The aim of this review was to understand advice currently given to patients with AMD by ECPs and to evaluate evidence regarding patient compliance. A systematic review was conducted of literature published in electronic databases: CINAHL, MEDLINE, PsycINFO, PyscARTICLES, EMBASE, AMED. Methods followed PRISMA guidelines (PROSPERO registration number: CRD42020223724). Twenty-four reports were eligible for inclusion, 12 focused on ECP experience, 7 on patient experience, and 6 on impact of advice (one paper reported on the ECP and patient experience). Studies reported that a substantial proportion of patients did not recall receiving lifestyle modification advice from their ECP (57.95%, range 2-95% across patient based studies). Practitioners were most likely to provide advice about nutritional supplements (80%, range 67-93% across ECP studies), and least likely about smoking (44%, range 28-71% across ECP studies), however supplements advised did not always comply with evidence-based guidelines. The main reason for patients not following lifestyle advice was lack of provision by the ECP (54.5%, range 21-94% across studies on the impact of advice). The review highlighted a need for more studies to understand patient preferences for receiving advice and research on ECP perceived barriers to advice provision.

Eligibility for faricimab in a real-world neovascular age-related macular degeneration population: a cross-sectional study

OBJECTIVES

To investigate the eligibility of a real-world neovascular age-related macular degeneration (nAMD) population for the TENAYA and LUCERNE trials (testing faricimab), and to compare the eligible real-world patients to trial participants.

DESIGN, SETTINGS AND PARTICIPANTS

In this retrospective cross-sectional study, we used data from the Swedish Macula Registry (SMR) between 1 January 2017 and 31 December 2020. Persons were eligible if they fulfilled the main inclusion criteria in TENAYA and LUCERNE: (1) nAMD diagnosis, (2) treatment naïve, (3) ≥50 years and (4) best-corrected visual acuity (BCVA) of 78-24 letters.

MAIN OUTCOME MEASURES

Characteristics at the original visit of the eligible SMR population and baseline data from the clinical trials were compared.

RESULTS

In total, 27 962 individuals with nAMD were registered in SMR. A total of 15 399 (55%) individuals were treatment naïve; of these, 15 368 (55%) were ≥50 years and 13 265 (47%) also had BCVA of 78-24 letters and fulfilled eligibility. Among treatment-naïve individuals, 86% were eligible and the BCVA criterion was the most common reason for non-eligibility. The eligible SMR population was significantly older than either TENAYA or LUCERNE. SMR included more women and patients with worse visual acuity than TENAYA, while SMR patients were diagnosed more quickly than LUCERNE.

CONCLUSIONS

Almost half of the real-world nAMD population in SMR fulfilled the main inclusion criteria of the TENAYA and LUCERNE trials. Among treatment-naïve individuals, 86% were eligible. Marginally differences were shown between the eligible SMR population and the trial populations. The SMR population were older and more similar to the population in LUCERNE than TENAYA.

Increased probability of mood disorders after age-related macular degeneration: a population-based cohort study

We aim to investigate the association of mood disorders with age-related macular degeneration (AMD). This retrospective cohort study used data from 2000 and 2016 from National Health Insurance Research Database (NHIRD) in Taiwan. Patients with AMD diagnosis formed the exposed group, and an age- and sex-matched group without AMD served as the nonexposed group. Main outcomes were the incidence of mood disorders including psychological counseling, behavior therapy, sleep or anxiety-related disorders, and major depressive disorders (MDDs) in the exposed and non-exposed groups. The Cox proportional hazard regression analysis was used to evaluate the incidence and adjusted hazard ratio (aHR) of mood disorders. A total of 5916 and 11,832 individuals with and without AMD were enrolled into the exposed and nonexposed groups. There were 1017 (17.19%) and 1366 (11.54%) episodes of mood disorders occurred in the exposed and nonexposed groups, respectively. The aHRs of any psychological counseling, behavioral therapy, sleep or anxiety-related disorders, and MDD were significantly higher in patients with AMD than in those without AMD (all P < 0.05). Besides, patients with dry-AMD, participants aged 50-70 years, and women with AMD had a higher incidence of mood disorders (all P < 0.05) than did non-AMD individuals, patients > 70 years, and women without AMD. In conclusion, AMD occurrence leads to an increased rate of mood disorders, particularly among those with dry-AMD, middle aged participants (aged 50-70), and women.

Development, implementation and evaluation of the online Movement, Interaction and Nutrition for Greater Lifestyles in the Elderly (MINGLE) program: The protocol for a pilot trial

Introduction

People with age-related macular degeneration (AMD) are more likely to experience loneliness, have poorer diets and be less physically active than people without AMD. The online Movement, Interaction and Nutrition for Greater Lifestyles in the Elderly (MINGLE) program is a holistic evidence-based intervention aiming to support people with AMD by incorporating physical activity, social interaction and nutrition education components all delivered via a COVID-19-safe Zoom platform. This study will involve two phases: 1) a formative qualitative study with AMD patients to identify the barriers and facilitators to participating in the proposed MINGLE program; and 2) a 10-week pilot study to evaluate the feasibility, acceptability and preliminary efficacy of MINGLE.

Methods and analysis

Phase 1 involves AMD patients who will be recruited from an eye clinic in Western Sydney, Australia to participate in audio-recorded semi-structured interviews. Verbatim interview transcripts will be coded using the Capability, Opportunity, Motivation and Behaviour (COM-B) model and themes established. These themes will be used as a guide to specifically tailor the proposed MINGLE program to people with AMD. Phase 2 involves 52 AMD patients who will then be recruited from the same clinic to participate in the MINGLE program. Pre-post questionnaires will be administered to intervention participants to collect information on the following variables: demographics, socioeconomic status, vision function, loneliness, quality of life (including depression), falls risk, physical activity (level), and dietary intake. The acceptability and feasibility of the MINGLE program will also be evaluated using descriptive statistics.

Trial registration number

ACTRN12621000939897p.

Posttraumatic Growth Among Older Adults With Age-Related Macular Degeneration

Introduction: The term “post-traumatic growth” describes positive outcomes that accrue from the struggle with highly challenging life circumstances. The purpose of this study is to describe post-traumatic growth accruing from experience with vision loss caused by age-related macular degeneration (AMD) and to identify the relationships between depression, cognitive processing, social support, and post-traumatic growth. Methods: Individuals with vision loss caused by AMD completed an interviewer-administered composite questionnaire to identify elements of Tedeschi and Calhoun’s theoretical model of the process of posttraumatic growth, including measures of distress (depression), intrusive and deliberate rumination (cognitive processing), and social support (quality and quantity of social ties). Relationships were examined using path analysis. Results: Eighty-nine participants completed the questionnaire (mean age = 85.3 years, range = 74–98 years). All paths, including from depression to social support (β = –.363, p < .001), from social support to deliberate rumination (β = .233; p ≤ .01), and from intrusive rumination to deliberate rumination (β = .514, p < .01), were significant and consistent with the posttraumatic growth theoretical model. Deliberate rumination had a significant direct path to post-traumatic growth (β = .38, p = .001). Discussion: The findings may illuminate elements of the process of post-traumatic growth among those with AMD. We found that as social support increased, depression decreased. Increased social support seemed to encourage positive deliberate rumination, which led directly to post-traumatic growth. Although intrusive rumination is often associated with negative outcomes, the model demonstrates that it also stimulates engagement in deliberate attempts to process one’s experience. Deliberate cognitive processing is a direct precursor to post-traumatic growth. Implications for Practitioners: A focus on the process of growth and thriving can offer a broader view of the experience of living with vision loss. Interventions that foster post-traumatic growth among those with AMD should focus on enhancing social support and facilitating deliberate cognitive processing.

Chinese Version of the Vision-Related Quality of Life (NEI-VFQ-25) among Patients with Various Ocular Disorders: A Pilot Study

Background and Objectives: Subjective visual function is currently becoming an increasing appreciation in assessing the health-related quality of life. This study aimed to assess the vision-related quality of life (VRQOL) among patients with refractive errors, keratoconus, senile cataract, and age-related macular degeneration (AMD) using the Chinese version of the National Eye Institute Visual Function Questionnaire 25 (NEI-VFQ-25). Materials and Methods: The questionnaire of NEI-VFQ-25 was filled out in a clinical setting or by telephone/mail. Univariate and multivariate analyses were used to determine which factors are associated with the NEI-VFQ-25. Results: From June 2018 to January 2019, 28 patients with refractive error, 20 patients with keratoconus, 61 with senile cataracts, and 17 with AMD completed the questionnaire NEI-VFQ-25. There were significant differences in the NEI-VFQ-25 subscale of general vision (p = 0.0017), ocular pain (p = 0.0156), near activities (p = 0.0002), vision-specific social functioning (p = 0.007), vision-specific mental health (p = 0.0083), vision-specific dependency (p = 0.0049), color vision (p < 0.0001), peripheral vision (p = 0.0065), and total score (p < 0.0001) among four disease groups, respectively. The multiple linear regression revealed that the best-corrected visual acuity (BCVA) and disease group were important factors of the total NEI-VFQ-25. After adjusting for BCVA, patients with AMD had a worse total NEI-VFQ-25 score than patients with refractive error, keratoconus, or senile cataracts. Conclusions: Among the patients with four ocular disorders and a broad vision spectrum from normal, partial sight, low vision to legal blindness, the BCVA of their better eye was the most important factor in the VRQOL.

Patient-Reported Measures of the Effects of Vision Impairments and Low Vision Rehabilitation on Functioning in Daily Life

The quantification of vision impairments dates to the mid-nineteenth century with standardization of visual acuity and visual field measures in the eye clinic. Attempts to quantify the impact of vision impairments on patients' lives did not receive clinical attention until the close of the twentieth century. Although formal psychometric theories and measurement instruments were well developed and commonplace in educational testing, as well as in various areas in psychology and rehabilitation medicine, the late start applying them to clinical vision research created a vacuum that invited poorly developed and poorly functioning instruments and analytic methods. Although this research is still burdened with legacy instruments, mandates by regulatory agencies to include the patients' perspectives and preferences in the evaluation of clinical outcomes have stimulated the development and validation of self-report instruments grounded in modern psychometric theory and methods. Here I review the progress and accomplishments of applying modern psychometrics to clinical vision research. Expected final online publication date for the Annual Review of Vision Science, Volume 8 is September 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Elevated risk of mood disorders after the occurrence of recurrent retinal detachment: a population-based cohort study

INTRODUCTION

To investigate the risk of mood disorders in patients who experienced retinal detachment (RD) by using the National Health Insurance Research Database in Taiwan.

METHODS

Participants with a diagnosis of RD were regarded as the study group, and an age- and sex-matched group without a diagnosis of RD served as the control group. The outcomes related to mood disorders after RD included (1) psychiatric outpatient department visits; (2) behavioural therapy; (3) sleep or anxiety-related disorders; and (4) major depressive disorder (MDD).

RESULTS

A total of 4,129 participants diagnosed with RD and 16,516 non-RD individuals were enrolled in the study. There were no significant differences in the four mood disorder-related outcomes between the study and control groups. However, the patients with recurrent RD who received more than two treatments and female patients with RD who needed surgical treatment showed a higher probability of developing MDD than did the non-RD subjects (incidence rate: 0.96 versus 0.36; adjusted hazard ratio (aHR): 2.382, 95% CI: 1.032-5.496, log-rank P= 0.0325; and aHR: 6.895, 95% CI: 1.659-28.656, log-rank P= 0.0060, respectively).

CONCLUSION

Patients with recurrent RD and multiple surgeries and females with RD who needed surgical treatment were at greater risk for developing MDD.

Perspectives on Implementing the Patient Health Questionnaire-4 in Low-Vision Service Organizations to Screen for Depression and Anxiety

Purpose

To describe the process of implementing a screening questionnaire for depression and anxiety, the Patient Health Questionnaire-4 (PHQ-4), in low-vision service (LVS) organizations.

Methods

This study consisted of three parts: (1) a usability study combined with semistructured interviews, in which clients (n = 10) of LVS organizations expressed their preference for using the PHQ-4; (2) a feasibility study, in which the PHQ-4 was implemented on a small scale and its use was evaluated, involving health care providers (n = 6) and clients (n = 9); and (3) semistructured interviews to identify barriers and facilitators for implementing the PHQ-4 according to health care providers (n = 6) and managers (n = 4) of LVS organizations. Results were integrated into themes and linked to constructs of the Consolidated Framework for Implementation Research (CFIR).

Results

Six themes were derived from the substudies: (1) quality of the intervention, (2) applicability for clients of LVS organizations, (3) attitude and needs of clients, (4) attitude of health care providers, (5) support within LVS organizations, and (6) embedment in current practice. Results could be linked to 12 CFIR constructs. The constructs "relative advantage," "patient needs and resources," and "available resources" emerged most prominently in our themes as either barrier or facilitator.

Conclusions

The PHQ-4 seems an appropriate screening instrument for use in LVS organizations because of its quality and adaptable use. It might provide opportunities to timely detect depression and anxiety, but challenges in implementing the PHQ-4 should be considered.

Translational Relevance

Barriers and facilitators for implementing the PHQ-4 may also apply to implementing other questionnaires in LVS organizations.

Assessment of vision-related quality of life and depression and anxiety rates in patients with neovascular age-related macular degeneration

PURPOSE

To assess the vision-related quality of life and the depression and anxiety rates in patients with neovascular Age-Related Macular Degeneration (nAMD).

METHODS

A cross-sectional study of patients with nAMD treated with intravitreal injections was performed. The patients completed two validated questionnaires: the Visual Functioning Questionnaire (VFQ-25, score from 0 to 100), and the Hospital Anxiety and Depression Scale (HADS) questionnaire. Age, gender and visual acuity (VA) in the Early Treatment Diabetic Retinopathy Study (ETDRS) scale was registered.

RESULTS

Fifty-five patients with nAMD participated with a mean age of 80.9 ± 6.6 years-old (range 67-93) and a mean VA in the best eye of 73.5 ± 12.7 letters (range 44-95). The global VFQ-25 mean score was 57.4 ± 21.9 being 38.9 ± 13.2 for the general vision and 42.0 ± 19.5 for the general health. VA in the best eye was associated with the global score of the VFQ-25 scale (R = 0.608; P < .001), but no correlation was observed with general health (P = .936). In the HADS scale, 26.9% and 25.5% of patients had symptoms of depression and anxiety respectively. A negative correlation was found between the HADS and VFQ-25 scales for the general vision score (R = -0.438).

CONCLUSION

This study elucidates the impact of vision impairment and the visual functioning in nAMD, describing an important rate of depression and anxiety symptoms.

Prevention of the Onset of Age-Related Macular Degeneration

Age-related macular degeneration (AMD) represents the leading cause of irreversible blindness in elderly people, mostly after the age of 65. The progressive deterioration of visual function in patients affected by AMD has a significant impact on quality of life and has also high social costs. The current therapeutic options are only partially able to slow down the natural course of the disease, without being capable of stopping its progression. Therefore, better understanding of the possibilities to prevent the onset of the disease is needed. In this regard, a central role is played by the identification of risk factors, which might participate to the development of the disease. Among these, the most researched are dietary risk factors, lifestyle, and light exposure. Many studies showed that a higher dietary intake of nutrients, such as lutein, zeaxanthin, beta carotene, omega-3 fatty acids and zinc, reduced the risk of early AMD. Regarding lifestyle habits, the association between smoking and AMD is currently accepted. Finally, retinal damage caused by ultraviolet rays and blue light is also worthy of attention. The scope of this review is to summarize the present knowledge focusing on the measures to adopt in order to prevent the onset of AMD.

Association Between Visual Impairment and Depression in Patients Attending Eye Clinics: A Meta-analysis

IMPORTANCE

Given that depression is treatable and some ocular diseases that cause visual loss are reversible, early identification and treatment of patients with visual impairment who are most at risk of depression may have an important influence on the well-being of these patients.

OBJECTIVE

To conduct a meta-analysis on the prevalence of depression in patients with visual impairment who regularly visit eye clinics and low vision rehabilitation services.

DATA SOURCES

MEDLINE (inception to June 7, 2020) and Embase (inception to June 7, 2020) were searched.

STUDY SELECTION

Studies that obtained data on the association between acquired visual impairment and depression among individuals aged 18 years or older were identified and included in this review. Exclusion criteria comprised inherited or congenital eye diseases, review studies, unpublished articles, abstracts, theses, dissertations, and book chapters. Four independent reviewers analyzed the results of the search and performed the selection and data extraction to ensure accuracy.

DATA EXTRACTION AND SYNTHESIS

Meta-analyses of prevalence were conducted using random-intercept logistic regression models. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

MAIN OUTCOMES AND MEASURES

Proportion of depression.

RESULTS

A total of 27 studies were included in this review, and all but 2 included patients older than 65 years. Among 6992 total patients (mean [SD] age, 76 [13.9] years; 4195 women [60%]) with visual impairment, in 1687 patients with depression, the median proportion of depression was 0.30 (range, 0.03-0.54). The random-effects pooled estimate was 0.25 (95% CI, 0.19-0.33) with high heterogeneity (95% predictive interval, 0.05-0.70). No patient characteristic, measured at the study level, influenced the prevalence of depression, except for the inclusion of patients with cognitive impairment (0.33; 95% CI, 0.28-0.38 in 14 studies vs 0.18; 95% CI, 0.11-0.30 in 13 studies that excluded this with major comorbidities; P = .008). The prevalence of depression was high both in clinic-based studies (in 6 studies, 0.34; 95% CI, 0.23-0.47) and in rehabilitation services (in 18 studies, 0.25; 95% CI, 0.18-0.33 vs other settings in 3 studies, 0.15; 95% CI, 0.05-0.38; P = .17), and did not vary by visual impairment severity of mild (in 8 studies, 0.24; 95% CI, 0.14-0.38), moderate (in 10 studies, 0.29; 95% CI, 0.21-0.39), and severe (in 5 studies, 0.29; 95% CI, 0.12-0.56; P = .51).

CONCLUSIONS AND RELEVANCE

The results of this meta-analysis suggest that depression in patients with visual impairment is a common problem that should be recognized and addressed by the health care professionals treating these patients.

Economic Value of Anti-Vascular Endothelial Growth Factor Treatment for Patients With Wet Age-Related Macular Degeneration in the United States

Importance

Anti-vascular endothelial growth factor (anti-VEGF) is a breakthrough treatment for wet age-related macular degeneration (wAMD), the most common cause of blindness in western countries. Anti-VEGF treatment prevents vision loss and has been shown to produce vision gains lasting as long as 5 years. Although this treatment is costly, the benefits associated with vision gains are large.

Objective

To estimate the economic value of benefits, costs for patients with wAMD, and societal value in the United States generated from vision improvement associated with anti-VEGF treatment.

Design, Setting, and Participants

This economic evaluation study used data from the published literature to simulate vision outcomes for a cohort of 168 820 patients with wAMD aged 65 years or older and to translate them into economic variables. Data were collected and analyzed from March 2018 to November 2018.

Main Outcomes and Measures

Main outcomes included patient benefits, costs, and societal value. Each outcome was estimated for a newly diagnosed cohort and the full population across 5 years, with a focus on year 3 as the primary outcome because data beyond that point may be less representative of the general population. Drug costs were the weighted mean across anti-VEGF therapies. Two current treatment scenarios were considered: less frequent injections (mean [SD], 8.2 [1.6] injections annually) and more frequent injections (mean [range], 10.5 [6.8-13.1] injections annually). The 2 treatment innovation scenarios, improved adherence and best case, had the same vision outcomes as the current treatment scenarios had but included more patients treated from higher initiation and lower discontinuation.

Results

The study population included 168 820 patients aged 65 years at the time of diagnosis with wAMD. The underlying clinical trials that were used to parameterize the model did not stratify visual acuity outcomes or treatment frequency by sex; therefore, the model parameters could not be stratified by sex. The current treatment scenario of less frequent injections generated $1.1 billion for the full population in year 1 and $5.1 billion in year 3, whereas the scenario of more frequent injections generated $1.6 billion (year 1) and $8.2 billion (year 3). Three-year benefits ranged from $7.3 billion to $11.4 billion in the improved adherence scenario and from $9.7 billion to $15.0 billion if 100% of the patients initiated anti-VEGF treatment and the discontinuation rates were 6% per year or equivalent to clinical trial discontinuation (best-case scenario). Societal value (patient benefits net of treatment cost) ranged from $0.9 billion to $3.0 billion across 3 years in the current treatment scenarios and from $0.9 billion to $4.3 billion in the treatment innovation scenarios.

Conclusions and Relevance

This study's findings suggest that improved vision associated with anti-VEGF treatment may provide economic value to patients and society if the outcomes match published outcomes data used in these analyses; however, future innovations that increase treatment utilization may result in added economic benefit.

Age-Related Macular Degeneration

Age-related macular degeneration (AMD) is a leading cause of blindness. The main risk factor is advancing age, with the severity of vision loss ranging from mild to severe. There is a 25% risk of early AMD and 8% risk of late AMD in patients over the age of 75, with the number of cases expected to increase because of the aging population. Diagnosis of the disease requires a dilated fundus examination. Physicians should be aware of the symptoms, risk factors, and treatment options for AMD to refer appropriately for ophthalmologic evaluation. Early detection can be helpful to prevent disease progression.

Age-Related Macular Degeneration and Visual and Physical Disability in a Nationally Representative Sample from the United States

Purpose

Outline the association between age-related macular degeneration (AMD) and functional difficulty using novel item response theory (IRT) psychometric techniques, and highlight populations particularly at risk of functional impairment.

Methods

This cross-sectional study included 5604 US adults. Primary outcomes were item response theory–adjusted visual and physical difficulty scores. Secondary analyses of AMD populations at highest risk of reporting greater functional difficulty were undertaken.

Results

In total, there were 386 participants with early AMD (mean presenting visual acuity [pVA], 0.12) and 55 with late AMD (mean pVA, 0.35). Those with late AMD reported substantially higher item visual difficulty, whereas those with both early/late AMD reported significantly higher item physical difficulty versus those with no AMD (P < .05). In univariate regression, only those with late AMD reported significantly higher visual difficulty versus those with no AMD (10.1 points [95% confidence interval (CI), 8.2–12.1 points] vs 7.1 points [95% CI, 7.0–7.2 points]; P = .003). Both early/late AMD reported higher physical difficulty versus those with no AMD (11.6 points [95% CI, 11.1–12.1 points; P = .005]; 13.4 points [95% CI, 11.8–15.0 points; P = .03], respectively, versus 11.0 points [95% CI, 10.9–11.1 points]. After adjustment for sociodemographic and medical variables (excluding pVA), only those with late AMD reported significantly greater visual and physical difficulty versus those with no AMD (10.0 points [95% CI, 8.2–11.9 points] vs 7.1 [95% CI, 7.0–7.2 points; P = .002]; and 12.7 points [95% CI, 11.3–14.0 points] vs 11.0 [95% CI, 10.9–11.1 points; P = .02], respectively); greater visual difficulty in those with late AMD persisted after additionally adjusting for pVA versus those with no AMD (9.1 points [95% CI, 7.6–10.6 points] vs 7.1 points [95% CI, 7.0–7.2 points; P = .01]). Among individuals with AMD, lower income, higher medical comorbidities, depression, and pVA predicted greater visual and physical difficulties.

Conclusions

AMD confers significant functional difficulty among US adults with sociodemographic characteristics influencing dysfunction; highlighting the value of alternatives to Snellen visual acuity in assessing visual characteristics. With aging populations and the increasing prevalence of AMD, health care professionals should be aware of the functional burden of AMD and recognize those at higher risk of functional difficulty.

Translational Relevance

Contemporary psychometric validation techniques can be effective in accurately describing the level of functional impairment for those with visual impairment.

Age-Related Macular Degeneration: Epidemiology and Clinical Aspects

Age-related macular degeneration (AMD) is a degenerative disease of the human retina affecting individuals over the age of 55 years. This heterogeneous condition arises from a complex interplay between age, genetics, and environmental factors including smoking and diet. It is the leading cause of blindness in industrialized countries. Worldwide, the number of people with AMD is predicted to increase from 196 million in 2020 to 288 million by 2040. By this time, Asia is predicted to have the largest number of people with the disease. Distinct patterns of AMD prevalence and phenotype are seen between geographical areas that are not explained fully by disparities in population structures. AMD is classified into early, intermediate, and late stages. The early and intermediate stages, when visual symptoms are typically absent or mild, are characterized by macular deposits (drusen) and pigmentary abnormalities. Through risk prediction calculators, grading these features helps predict the risk of progression to late AMD. Late AMD is divided into neovascular and atrophic forms, though these can coexist. The defining lesions are macular neovascularization and geographic atrophy, respectively. At this stage, visual symptoms are often severe and irreversible, and can comprise profoundly decreased central vision in both eyes. For these reasons, the condition has major implications for individuals and society, as affected individuals may experience substantially decreased quality of life and independence. Recent advances in retinal imaging have led to the recognition of an expanded set of AMD phenotypes, including reticular pseudodrusen, nonexudative macular neovascularization, and subtypes of atrophy. These developments may lead to refinements in current classification systems.

Determinants of concern about falling in adults with age-related macular degeneration

PURPOSE

To investigate the prevalence and level of concern about falling (CF) among older people with vision impairment due to age-related macular degeneration (AMD) compared to a visually normal control group, and to identify determinants of CF for the AMD group.

METHODS

Participants included 133 older people: 77 with AMD (mean age = 80.5 ± 6.2 years), and 56 controls (mean age = 75.4 ± 5.3 years). Binocular visual acuity, contrast sensitivity and visual fields were measured, and CF was assessed using the Falls Efficacy Scale - International (FES-I). Data were also collected for sensorimotor function (postural sway, sit-to-stand, knee extensions, walking speed, proprioception), and neuropsychological function (reaction time, symptoms of anxiety and depression) using validated tests and scales.

RESULTS

Concern about falling scores were higher for AMD participants compared to control participants (mean ± S.D. 24.6 ± 8.0 vs 21.6 ± 5.7, p = 0.02, respectively), although these findings failed to reach significance when adjusted for age (p = 0.16). Among AMD participants, multivariable models showed that greater CF was associated with reduced contrast sensitivity (p = 0.02), slower sit-to-stand times (p < 0.001) and higher anxiety scores (p < 0.001); these factors explained 40% of the variance in CF (p < 0.01).

CONCLUSION

Levels of CF in older people with AMD were not found to be elevated by their disease status alone, but rather by the extent of vision loss. Levels of CF in those with AMD were associated with various visual, sensorimotor and neuropsychological factors. These findings will assist clinicians in identifying those at greatest risk of developing high CF and inform the design of future intervention programmes for this population.

Pars plana vitrectomy relieves the depression in patients with symptomatic vitreous floaters

AIM

To investigate the depressive state among the patients with symptomatic vitreous floaters (SVF), as well as its change after SVF removal via vitrectomy surgery.

METHODS

Twenty-eight eyes of 28 patients who underwent 27-gauge pars plana vitrectomy (PPV) for SVF were included. Thirty-nine eyes of 39 age- and gender-matched healthy volunteers without SVF were also recruited as a healthy control. Center for Epidemiologic Studies Depression (CES-D) was used to assess volunteers and patients' depression (before and 1wk after PPV).

RESULTS

The CES-D score was 18.3±8.6 for patients, and was 12.4±6.0 for healthy control (P=0.003). Patients were significantly more likely to be in a depressive state (53.6%, defined as CES-D score ≥16) than the healthy control (20.5%, P=0.005). For patients with SVF, the CES-D score was negatively correlated with their age (r _s=-0.42, P=0.025). After PPV, both the CES-D score (11.9±5.4 vs 18.3±8.6, P<0.001) and proportion of depressive state (18.5% vs 53.6%, P=0.005) were significantly decreased.

CONCLUSION

This study suggests that symptoms of vitreous floaters have an apparently negative impact on patients' psychological state. The PPV can effectively relieve the depressive state for patients with SVF.

Why Miss the Chance? Incidental Findings while Telescreening for Diabetic Retinopathy

PURPOSE

To report on incidental pathological findings met while screening for Diabetic Retinopathy (DR) in Diabetes Clinics (DC) by ophthalmologist-graded digital fundus imaging.

METHODS

At the DC of Pescara (central Italy), for 3,859 eyes of 1,930 consecutive patients having not undergone fundus examination in the last year, two mydriatic fundus digital images, taken with a CenterVue DRS Digital Retinal Camera, were sent along with Best Corrected Visual Acuity, on a "store-and-forward" basis, to an ophthalmologist trained in DR screening, and graded according to the UK Diabetic Eye Screening Programme. Incidental fundus abnormalities other than DR were reported.

RESULTS

No adverse event to mydriasis was reported. One hundred and eighty eyes (4.66%) were ungradable. Among the 3,679 gradable ones, 1,105 (30.04%) showed different degrees of DR (R1 to R3), and 126 (3.42%) maculopathy (M1). Any Age-Related Macular Degeneration was present in 387 eyes (10.52%), any optic disc and parapapillary area features suspect for glaucoma in 562 eyes (15.27%), any hypertensive retinopathy in 1,263 eyes (34.33%), vitreoretinal interface disease in 252 eyes (6.84%), myopic choroidopathy in 92 eyes (2.50%), disc pallor in 31 eyes (0.84%). Mean time was 5 min for screening, 2 min for grading.

CONCLUSION

Teleretinography is a well-established, cost-effective procedure in DR screening. Along with increased attendance, locating a digital camera in a DC with a retina-specialist grader results in finding fundus pathologies also beyond DR, very similarly to fundus examination in an outpatient ophthalmic setting.

Depressive and Anxiety Symptoms in Older Adults With Auditory, Vision, and Dual Sensory Impairment

Objective: The objective of the study is to examine the association of auditory, vision, and dual sensory impairment with late-life depressive and anxiety symptoms. Method: Our study included 7,507 older adults from the National Health & Aging Trends Study, a nationally representative sample of U.S. Medicare beneficiaries. Auditory and vision impairment were determined by self-report, and depressive and anxiety symptoms were evaluated by the two-item Patient Health Questionnaire (PHQ-2) and two-item Generalized Anxiety Disorder Scale (GAD-2), respectively. Results: Auditory, vision, and dual impairment were associated with an increased risk of depressive and anxiety symptoms in multivariable analyses accounting for sociodemographics, medical comorbidity, and functional impairment. Auditory, vision, and dual impairment were also associated with an increased risk for depressive and anxiety symptoms that persist or were of new onset after 1 year. Discussion: Screening older adults with sensory impairments for depression and anxiety, and screening those with late-life depression and anxiety for sensory impairments, may identify treatment opportunities to optimize health and well-being.

Artemisinin Protects Human Retinal Pigmented Epithelial Cells Against Hydrogen Peroxide-induced Oxidative Damage by Enhancing the Activation of AMP-active Protein Kinase

Dry age-related macular degeneration (AMD), a leading cause of blindness in aged population, is directly associated with oxidative stress induced damage of the retinal pigmented epithelial (RPE) cells. In the current study, we investigated the role of AMPK in the protective effect of artemisinin, an FDA approved anti-malarial Chinese herbal drug, on RPE cell line D407, against H₂O₂ induced oxidative stress. Our results showed that artemisinin promoted the survival of D407 cells from H₂O₂. Artemisinin reduced intracellular ROS generation and oxidative stress, decreased LDH release and the loss of mitochondrial membrane potential in D407 cells treated with H₂O₂. Western blotting showed that artemisinin concentration- and time-dependently stimulated the phosphorylation of AMP-activated protein kinase (AMPK) in D407 cells while AMPK inhibitor Compound C or knock-down of AMPK by si-RNA, inhibited the survival protective effect of artemisinin. More importantly, artemisinin produced a similar protective effect in primary cultured retinal pigment cells which was also blocked by inhibitors of AMPK. Taken together, these results suggested that artemisinin promotes survival of human retinal pigment cells against H₂O₂-induced cell death at least in part through enhancing the activation of AMPK. Therefore, artemisinin may be a beneficial therapeutic candidate for the treatment of age-related diseases, including retinal disorders like AMD.

Low vision rehabilitation services: Perceived barriers and facilitators to access for older adults with visual impairment

Introduction

The aim of this study is to describe the barriers and facilitators to accessing low vision rehabilitation services in Massachusetts, USA, and determine differences between communities with and without existing low vision rehabilitation services for older adults with visual impairment.

Method

A sample of older adults with visual impairment ( n = 64) from both communities participated in the study. Barriers and facilitators to accessing the services were explored through focus groups and prioritized during one-on-one interviews, which allowed for comparison between communities.

Results

Twelve themes were identified: (a) bureaucracy and funding (public policy); (b) public awareness and stigma (community); (c) services available, knowledge of providers, care coordination, transportation (organizational); (d) people and lack of awareness of family/friends (interpersonal); and (e) income, health status, knowledge, self-advocacy, and time (individual).

Conclusion

This study provides insights into the perceived barriers and facilitators of accessing low vision rehabilitation services for older adults with vision impairment living in Massachusetts, USA. Key findings indicate the need for improved awareness of these services at the provider and consumer level, coordinated care, increased education on the efficacy of occupational therapy low vision rehabilitation services, client-centered care provided when the client is ready to accept services, and service provision that addresses sociodemographic factors.

Age-related macular degeneration

Age-related macular degeneration is a leading cause of visual impairment and severe vision loss. Clinically, it is classified as early-stage (medium-sized drusen and retinal pigmentary changes) to late-stage (neovascular and atrophic). Age-related macular degeneration is a multifactorial disorder, with dysregulation in the complement, lipid, angiogenic, inflammatory, and extracellular matrix pathways implicated in its pathogenesis. More than 50 genetic susceptibility loci have been identified, of which the most important are in the CFH and ARMS2 genes. The major non-genetic risk factors are smoking and low dietary intake of antioxidants (zinc and carotenoids). Progression from early-stage to late-stage disease can be slowed with high-dose zinc and antioxidant vitamin supplements. Intravitreal anti-vascular endothelial growth factor therapy (eg, ranibizumab, aflibercept, or bevacizumab) is highly effective at treating neovascular age-related macular degeneration, and has markedly decreased the prevalence of visual impairment in populations worldwide. Currently, no proven therapies for atrophic disease are available, but several agents are being investigated in clinical trials. Future progress is likely to be from improved efforts in prevention and risk-factor modification, personalised medicine targeting specific pathways, newer anti-vascular endothelial growth factor agents or other agents, and regenerative therapies.

Determining Optimal Test Parameters for Assessing Dark Adaptation in People With Intermediate Age-Related Macular Degeneration

Purpose

The primary aim was to determine optimal test conditions for evaluating dark adaptation in intermediate age-related macular degeneration (iAMD) in order to minimize test time while maintaining diagnostic sensitivity.

Methods

People with AMD and age-similar controls were recruited (aged >55 years). Rod intercept time (RIT) was assessed after a 76%, 70%, and 65% rhodopsin bleach at 5° eccentricity and 76% and 70% bleach at 12°. Test order was randomized and a 30-minute washout period added between tests. Results were compared between control and iAMD groups and receiver operating characteristics (ROC) curves were constructed.

Results

A total of 26 participants with variable grades of macular health attended for two visits. There was a statistically significant difference in average RIT between the control and iAMD groups at 5° (median, IQR controls = 5.8 minutes, 3.8-7.5; iAMD = 20.6 minutes, 11.1-30.0; Mann-Whitney, P = 0.01) and at 12° (mean, controls: 4.54 minutes ± 2.12 SD, iAMD = 7.72 minutes ± 3.37 SD; independent samples t-test, P = 0.03) following a 76% bleach. Area under the ROC curves was 0.83 (confidence interval [CI]: 0.64-1.0) and 0.79 (CI: 0.59-0.99) for these two test conditions, respectively. Five participants (45%) in the iAMD group had RITs >20 minutes for 76% bleach at 5°, but none for any other test condition.

Conclusions

Nearly half of the participants with iAMD produced unacceptably long recovery times (>20 minutes) using a 76% bleach at 5° eccentricity. The 76% bleach at 12° provided almost equivalent separation between AMD and controls but recovery was achieved within 20 minutes.

Patient Awareness of Cataract and Age-related Macular Degeneration among the Korean Elderly: A Population-based Study

PURPOSE

Age-related eye disease is often considered part of natural aging. Lack of awareness of eye conditions can result in missed treatment. We investigated the rates of awareness of cataract and age-related macular degeneration, the most common age-related eye-diseases, and the associated factors among elderly Koreans.

METHODS

We identified 7,403 study subjects (≥40 years old) with cataract or age-related macular degeneration based on ophthalmic examination results during the 5th Korean National Health and Nutrition Examination Survey conducted between 2010 and 2012. We assessed whether patients were aware of their eye condition based on a previous diagnosis by a physician.

RESULTS

The average awareness rate over the 3-year study period was 23.69% in subjects with cataract and 1.45% in subjects with age-related macular degeneration. Logistic regression analysis showed that patients with cataract were more likely to recognize their condition if they had myopia (odds ratio, 2.08), hyperopia (odds ratio, 1.33), family history of eye disease (odds ratio, 1.44), or a past eye examination (odds ratio, 4.07-29.10). The presence of diabetes mellitus was also a significant predictor of patient awareness of cataract (odds ratio, 1.88).

CONCLUSIONS

Poor patient recognition of eye disease among the Korean elderly highlights the seriousness of this potential public health problem in our aging society. Pre-existing eye-related conditions and diabetes were significant predictors of awareness; therefore, patients in frequent contact with their doctors have a greater chance of detecting eye disease.

Low Vision Rehabilitation for Adult African Americans in Two Settings

PURPOSE

The Vision Rehabilitation for African Americans with Central Vision Impairment (VISRAC) study is a demonstration project evaluating how modifications in vision rehabilitation can improve the use of functional vision.

METHODS

Fifty-five African Americans 40 years of age and older with central vision impairment were randomly assigned to receive either clinic-based (CB) or home-based (HB) low vision rehabilitation services. Forty-eight subjects completed the study. The primary outcome was the change in functional vision in activities of daily living, as assessed with the Veteran's Administration Low-Vision Visual Function Questionnaire (VFQ-48). This included scores for overall visual ability and visual ability domains (reading, mobility, visual information processing, and visual motor skills). Each score was normalized into logit estimates by Rasch analysis. Linear regression models were used to compare the difference in the total score and each domain score between the two intervention groups. The significance level for each comparison was set at 0.05.

RESULTS

Both CB and HB groups showed significant improvement in overall visual ability at the final visit compared with baseline. The CB group showed greater improvement than the HB group (mean of 1.28 vs. 0.87 logits change), though the group difference is not significant (p = 0.057). The CB group visual motor skills score showed significant improvement over the HB group score (mean of 3.30 vs. 1.34 logits change, p = 0.044). The differences in improvement of the reading and visual information processing scores were not significant (p = 0.054 and p = 0.509) between groups. Neither group had significant improvement in the mobility score, which was not part of the rehabilitation program.

CONCLUSIONS

Vision rehabilitation is effective for this study population regardless of location. Possible reasons why the CB group performed better than the HB group include a number of psychosocial factors as well as the more standardized distraction-free work environment within the clinic setting.

Economic evaluation of stepped-care versus usual care for depression and anxiety in older adults with vision impairment: randomized controlled trial

BACKGROUND

A stepped-care program was found effective in preventing depressive and anxiety disorders in older adults with vision impairment. However, before a decision can be made about implementation, the cost-effectiveness of this program should be investigated. Therefore, we aimed to compare the cost-effectiveness of stepped-care versus usual care within low vision rehabilitation.

METHODS

An economic evaluation from a societal perspective was performed alongside a multicenter randomized controlled trial. Data were collected by masked assessors during 24 months. Included were 265 older adults with vision impairment and subthreshold depression and/or anxiety. They were randomly assigned to stepped-care plus usual care (n = 131) or usual care alone (n = 134). Stepped-care comprised 1) watchful waiting, 2) guided self-help based on cognitive behavioral therapy, 3) problem solving treatment, and 4) referral to a general practitioner. Costs were based on direct healthcare costs and indirect non-healthcare costs. Main outcome measures were quality-adjusted life years (QALYs) and the cumulative incidence of major depressive, dysthymic and/or anxiety disorders. Secondary outcomes were symptoms of depression and anxiety.

RESULTS

Based on intention-to-treat, significant differences were found in the incidence of depressive/anxiety disorders (mean difference 0.17; 95% CI 0.06 to 0.29) and symptoms of anxiety (mean difference 1.43, 95% CI 0.10 to 2.77) in favor of stepped-care versus usual care; no significant difference was found for QALYs and symptoms of depression. Societal costs were non-significantly lower in the stepped-care group compared with the usual care group (mean difference: -€877; 95% confidence interval (CI): -8039 to 5489). Cost-effectiveness acceptability curves showed that the probability of cost-effectiveness was 95% or more at a willingness-to-pay of €33,000 per disorder prevented. The probability that stepped-care was cost-effective compared to usual care was 59% or more for a ceiling ratio of 0 €/QALY and increased to 65% at 20000 €/QALY.

CONCLUSIONS

This economic evaluation shows that stepped-care is dominant to usual care, with a probability of around 60%, due to its clinical superiority and its modest cost savings. However, it depends on the willingness-to-pay of decision makers whether or not stepped-care is considered cost-effective compared with usual care.

TRIAL REGISTRATION

identifier: NTR3296 , date: 13-02-2012.

Functional Outcomes of the Low Vision Depression Prevention Trial in Age-Related Macular Degeneration

Purpose

To compare the efficacy of behavioral activation (BA) plus low vision rehabilitation with an occupational therapist (OT-LVR) with supportive therapy (ST) on visual function in patients with age-related macular degeneration (AMD).

Methods

Single-masked, attention-controlled, randomized clinical trial with AMD patients with subsyndromal depressive symptoms (n = 188). All subjects had two outpatient low vision rehabilitation optometry visits, then were randomized to in-home BA + OT-LVR or ST. Behavioral activation is a structured behavioral treatment aiming to increase adaptive behaviors and achieve valued goals. Supportive therapy is a nondirective, psychological treatment that provides emotional support and controls for attention. Functional vision was assessed with the activity inventory (AI) in which participants rate the difficulty level of goals and corresponding tasks. Participants were assessed at baseline and 4 months.

Results

Improvements in functional vision measures were seen in both the BA + OT-LVR and ST groups at the goal level (d = 0.71; d = 0.56 respectively). At the task level, BA + OT-LVR patients showed more improvement in reading, inside-the-home tasks and outside-the-home tasks, when compared to ST patients. The greatest effects were seen in the BA + OT-LVR group in subjects with a visual acuity ≥20/70 (d = 0.360 reading; d = 0.500 inside the home; d = 0.468 outside the home).

Conclusions

Based on the trends of the AI data, we suggest that BA + OT-LVR services, provided by an OT in the patient's home following conventional low vision optometry services, are more effective than conventional optometric low vision services alone for those with mild visual impairment. (ClinicalTrials.gov number, NCT00769015.)

Experience of Anti-VEGF Treatment and Clinical Levels of Depression and Anxiety in Patients With Wet Age-Related Macular Degeneration

PURPOSE

To investigate detailed patient experiences specific to receiving vascular endothelial growth factor inhibitors (anti-VEGF) for wet age-related macular degeneration (wAMD), and to acquire a snapshot of the frequency of clinically significant levels of depression, anxiety, and posttraumatic stress among patients and levels of burden in patients' carers.

DESIGN

Observational cross-sectional mixed-methods study.

METHODS

Three hundred patients with wAMD receiving anti-VEGF treatment and 100 patient carers were recruited. Qualitative data on patients' experience of treatment were collected using a structured survey. Standardized validated questionnaires were used to quantify clinically significant levels of anxiety, depression, and posttraumatic stress, as well as cognitive function and carers' burden.

RESULTS

Qualitative data showed that 56% of patients (n = 132) reported anxiety related to anti-VEGF treatment. The main sources of anxiety were fear of going blind owing to intravitreal injections and concerns about treatment effectiveness, rather than around pain. From validated questionnaires, 17% of patients (n = 52) showed clinical levels of anxiety and 12% (n = 36) showed clinical levels of depression. Depression levels, but not anxiety, were significantly higher in patients who received up to 3 injections compared with patients who received from 4 to 12 injections (analysis of variance [ANOVA] P = .027) and compared with patients who received more than 12 injections (ANOVA P = .001).

CONCLUSIONS

Anti-VEGF treatment is often experienced with some anxiety related to treatment, regardless of the number of injections received. Clinical levels of depression seem to be more frequent in patients at early stages of anti-VEGF treatment. Strategies to improve patient experience of treatment and minimize morbidity are suggested.

Prevalence of depression, anxiety, adjustment disorders, and somatoform disorders in patients with age-related macular degeneration in Germany

Aims: The purpose of this study was to analyze the prevalence of depression, anxiety, adjustment disorders, and somatoform disorders in patients diagnosed with age-related macular degeneration (AMD) in Germany.

Methods: This study included 7,580 patients between the ages of 40 and 90 diagnosed with AMD between January 2011 and December 2014 in 1,072 primary care practices (index date). The last follow-up was in July 2016. We also included 7,580 controls without AMD, which were matched (1:1) to the AMD cases by age, sex, type of health insurance (private or statutory), physician, and Charlson comorbidity score as a generic marker of comorbidity. The outcome of the study was the prevalence of depression, anxiety, adjustment disorders, and somatoform disorders recorded in the database between the index date and the end of follow-up.

Results: The mean age among subjects was 75.7 years (SD=10.1 years), 34.0% were men, and 7.8% had private health insurance coverage. The Charlson comorbidity index was 2.0 (SD=1.8). Depression was the most frequent disease (33.7% in AMD patients versus 27.3% in controls), followed by somatoform disorders (19.6% and 16.7%), adjustment disorders (14.8% and 10.5%), and anxiety disorders (11.7% and 8.2%). Depression (OR=1.37, 95% CI: 1.27–1.47), anxiety (OR=1.50, 95% CI: 1.35–1.67), adjustment disorders (OR=1.50, 95% CI: 1.36–1.65), and somatoform disorders (OR=1.22, 95% CI: 1.12–1.32) were all positively associated with AMD.

Conclusion: Overall, a significant association was found between AMD and depression, anxiety, adjustment disorders, and somatoform disorders.

[Requirements for low vision magnification aids in age-related macular degeneration: Data from the Tübingen low vision clinic (comparison of 2007-2011 with 1999-2005)]

BACKGROUND

The purpose of this study was to investigate if there has been a change in requirements for low vision magnification aids in recent years.

PATIENTS AND METHODS

The collective data from age-related macular degeneration (AMD) patients from the Tübingen low vision clinic from the years 2007-2011 were compared with the patient collective from the years 1999-2005. Magnification needs and the prescribed magnifying aids for reading in the categories magnifying spectacles, hand-held magnifiers, monocular telescopes, electronic magnifiers and electronic reading devices were evaluated. In addition patients from 2010 and 2011 were divided into dry and neovascular AMD and the prescribed magnification aids were compared for these AMD forms.

RESULTS

There was no significant change in in the prescribed magnification reading aids for AMD patients between the years 1999-2005 and 2007-2011. An electronic magnifier was prescribed most often (both collectives 43 %), followed by hand-held magnifiers (32 and 29.5 %, respectively) and magnifying spectacles (17 and 18.8 %, respectively). Also the magnifying needs and mean age of the AMD patients did not change significantly between the two periods (2007-2011 versus 1999-2005). The detailed analysis for dry and neovascular AMD for the years 2010 and 2011 showed no significant differences for the most commonly prescribed low vision aids. The prescription of low vision aids is not influenced by the AMD classification (dry or neovascular), only by the magnification needs.

CONCLUSION

There is an unchanged and still high demand for rehabilitation aids of AMD patients, for dry as well as for neovascular AMD even after the introduction of anti-vascular endothelial growth factor (anti-VEGF) therapy.